50 Years of Tuberculosis Control in India: Progress, Pitfalls and the Way Forward.

India established the National Tuberculosis Control Project (NTCP) 50 years ago and re-designed it as Revised NTCP (RNTCP) 19 years ago. Tuberculosis (TB) control was beset with obstacles — BCG vaccination was found ineffective in TB control in 1979; human immunodeficiency virus began spreading in India since 1984 with TB as the commonest opportunistic disease; multi-drug resistance was found to be prevalent since 1992. The World Health Organization declared TB as global emergency in 1993. Yet, RNTCP was extended to the whole nation very slowly, taking 13 years from inception. The first objective of RNTCP, namely 85% treatment success has been achieved and case-fatality had dropped by 90%. Still, TB burden continues to remain huge; about half the cases are not getting registered under RNTCP; pediatric TB is neglected; TB drains national economy of US$ 23 billion annually. Therefore, TB control is in urgent need of re-design and re-invigoration, with additional inputs and system re-organization to cover all such gaps. We highlight the need for Public Health infrastructure under which all vertical disease control projects such as RNTCP should be synergized for better efficiency and for establishing Public Health Surveillance for collecting denominator-based data on incidence and prevalence to guide course corrections. India ought to spend 3 to 5 times more on TB control than at present. Control needs clear epidemiologic definition and measurable parameters for monitoring the level of control over time. TB control is both a measure of, and a means to, socioeconomic development.

Clinical & pathological features of acute toxicity due to Cassia occidentalis in vertebrates.

Cassia occidentalis is an annual shrub found in many countries including India. Although bovines and ovines do not eat it, parts of the plant are used in some traditional herbal medicines. Several animal studies have documented that fresh or dried beans are toxic. Ingestion of large amounts by grazing animals has caused serious illness and death. The toxic effects in large animals, rodents and chicken are on skeletal muscles, liver, kidney and heart. The predominant systems involved depend upon the animal species and the dose of the beans consumed. Brain functions are often affected. Gross lesions at necropsy consist of necrosis of skeletal muscle fibres and hepatic centrilobular necrosis; renal tubular necrosis is less frequent. Muscle and liver cell necrosis is reflected in biochemical abnormalities. The median lethal dose (LD 50) is 1 g/kg for mice and rats. Toxicity is attributed to various anthraquinones and their derivatives and alkaloids, but the specific toxins have not been identified. Data on human toxicity are extremely scarce. This review summarizes information available on Cassia toxicity in animals and compares it with toxic features reported in children. The clinical spectrum and histopathology of C. occidentalis poisoning in children resemble those of animal toxicity, affecting mainly hepatic, skeletal muscle and brain tissues. The case-fatality rate in acute severe poisoning is 75-80 per cent in children.

The prevention and control of human leptospirosis.

Human leptospirosis is prevalent in several states in India, sporadically or as outbreaks, especially during rainy seasons. It affects predominantly male adults who work in agriculture, causing severe morbidity and unnecessary mortality. Yet, there is no systematic leptospirosis prevention and control programme in the country, as it is not identified as priority under the national health policy. Therefore states with leptospirosis ought to establish public health programme for its prevention and control, as part of building a comprehensive initiative for the control of all-important infectious diseases. After establishing disease surveillance and laboratory support service, the disease burden must be monitored before and during interventions for control. The District is the ideal unit of activity, with full participation of the State Government and Local Panchayati raj. The public health staff must give technical leadership and the risk factors of human leptospirosis must be identified and specific interventions targeted against them. Action must be local-area-specific and coordinated between the Departments of Health, Agriculture, Animal Husbandry, Environment and Forestry. A model leptospirosis control programme has been formulated in Kerala State and is awaiting implementation. A state level Diagnostic and Epidemiology centre has been established to provide technical leadership. This model must be implemented and also replicated in other states. The most important ingredient for the control of infectious diseases is the 'political will'.