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La situation es grave. Es un infection intestinal de bacteria. Se puede transmitir facilmente a persona a otra. Es muy grave ahora en Haiti. Los síntomas incluyen diarrea profusa y puede llevar a sed extrema. Pero hay una vacuna si quieres trabajar alla.

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La ONU trabaja para evitar la propagación del cólera en Haití

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De diciembre a la fecha se han registrado más de 2800 casos sospechosos, con 91 confirmados y 36 decesos. La mayoría de los casos están relacionados con asentamientos de desplazados. Las agencias de las Naciones Unidas implementan medidas de contención y preventivas, pero apenas cuentan con fondos para hacerlo al haber recibido solo el 9% de los recursos requeridos.

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Es una enfermedad grave y potencialmente mortal causada por un parásito de la picadura de mosquitos anopheles infectados. Los síntomas principales incluyen fiebre, escalofríos, dolores musculares y malestar general, similares a la gripe.

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Malaria-Malaria - Síntomas y causas - Mayo Clinic

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Aprende sobre los síntomas, las causas, el tratamiento y la prevención de esta enfermedad infecciosa que los mosquitos transmiten al ser humano a través de sus picaduras.

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En el Dominican Republic of Congo, malaria tienen una grande impactica. Lo es el principal causa de muerte y para ninos. Malaria causa encima 40% de clinica muertes para ninos baja cinco.

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La oncocercosis es una enfermedad infecciosa común en el África subsahariana. Es una enfermedad parasitaria causada por gusanos (Onchocerca volvulus). Su consecuencia más grave es la ceguera y es la segunda causa principal de ceguera por enfermedad. Los síntomas también pueden incluir picazón y protuberancias incómodas en la piel.

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Uche Amazigo, Mounkaila Noma, Jesse Bump, Bruce Benton, Bernhard Liese, Laurent Yaméogo, Honorat Zouré, Azodoga Seketeli

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Over the last 30 years a large international partnership has successfully attacked onchocerciasis. This partnership has defeated the disease in 10 of the 11 countries in West Africa and is making progress in the remaining endemic countries in central Africa and East Africa. The program, spanning 30 countries across Sub-Saharan Africa, encompasses more than 107 projects to create a comprehensive approach to eliminating the disease as a public health problem. The onchocerciasis control programs have yielded the following results:

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El Virus de la Inmunodeficiencia Humana (VIH)

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El Virus de la Inmunodeficiencia Humana (VIH)

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A finales de 2015, Africa Subsahariana fue la region mas afectada, con casi 1 de cada 25 adultos viviendo con VIH, de un total de 36,7 millones de personas en todo el mundo. En los países mas afectados, las ninas representan mas del 80 % de las nuevas infecciones por VIH entre los adolescentes, y a nivel mundial, las jovens de 15 a 24 anos tienen el doble de probabilidades que los jovens de estar en riesgo de VIH.

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El Zika es un virus que se pasa por la picadura de un mosquito. En pauses UN desarrollo, hay mas mosquitos, por eso El virus SE pueden extender mas rapido. Puede causar fiebre, sarpullido y dolor. En mujeres embrazadas, puede hacer dano Al bebe

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What we know

Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). These mosquitoes bite during the day and night.

Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects.

There is no vaccine or medicine for Zika.

Page last reviewed:

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Zika is spread mostly by the bite of an infected Aedes species mosquito. A pregnant woman can pass Zika to her fetus during pregnancy and a person with Zika can pass it to his or her sex partners.

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En Africa de sur, 17.7% de la population tienen HIV. 49,000 personas morien en 2023. Los sintomas incluyen fiebre, dolor de garganta, erupción, y etcétera.

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El cólera es una enfermedad infecciosa. Se transmite principalmente a traves de agua o alimentos contaminados. Provoca diarrea intensa y deshidratación, que pueden ser mortales si no tratan rapidamente. El tratamiento solo consistir en la hidratación y antibioticos. El cólera es mas comun en paises como Yemen ha tenido cólera mas del mundo, afectando a millones desde 2016.

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La enfermedad de Chagas hace originado de América Latina. Es un enfermedad que causa tú ojos hinchar y porque del parásito. 55% de la populación sufrir de esto enfermedad y puede esta mejorar o empeorar.

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La Peste Bubónica es un enfermedad causó por la infection bacterial por Yersinia Pestis. Se propaga a través de la picaduras de pulgas infectadas que se alimentan de roedores. En Mongolia se traves por la consumo de Las marmotas crudas. Las síntomas incluir ganglios negros inflamados, fiebre, dolor de cabeza, nauseas y vomitos, dolores musculares.

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Mongolia issues bubonic plague warning after 22 dead marmots seized

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The warning came after 22 dead marmots were discovered and seized by police last week from a vehicle travelling from western provinces to the capital city of Ulan Bator.

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En sudafrica 60% de mujeres he jovenes tienen VIH.

Mujeres y jovenes anos 15-24 son Nuevo a VIH cada semana.

En Sudafrica 7.2 milones gentes vivan con VIH.

Llave razones esta sexo obreras, inseguro sexo, y drugas. Desafortunadamente mas hombre no van a clinicas para tratamiento porque no es un social norm. clinica necesita volverse mas common para La publica a salvar vidas.

https://www.csis.org/analysis/worlds-largest-hiv-epidemic-crisis-hiv-south-africa

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In some communities of KwaZulu-Natal Province, South Africa, 60 percent of women have HIV. Nearly 4,500 South Africans are newly infected every week; one-third are adolescent girls/young women (AGYW) ages 15-24. These are staggering figures, by any stretch of the imagination. Yet, the HIV epidemic is not being treated like a crisis. In February, we traveled to South Africa, to understand what is happening in these areas with "hyper-endemic" HIV epidemics, where prevalence rates exceed 15 percent among adults. We were alarmed by the complacency toward the rate of new infections at all levels and the absence of an emergency response, especially for young people.

This is no time for business as usual from South Africa or its partners, including the U.S. government through the U.S. President's Emergency Plan for AIDS Relief (PEPFAR). The epidemic is exacerbated by its concentration in 15-49-year-olds, those of reproductive and working age who are the backbone of South Africa. Without aggressive action to reduce the rate of new infections in young people, HIV will continue to take a tremendous toll on the country for years and generations to come. Collective action is needed to push beyond the complacency and internal barriers to implement policies and interventions that directly target HIV prevention and treatment for young people. PEPFAR should ensure its programs support those efforts.

South Africa remains the epicenter of the HIV pandemic as the largest AIDS epidemic in the world-20 percent of all people living with HIV are in South Africa, and 20 percent of new HIV infections occur there too. The country also faces a high burden of tuberculosis (TB), including multi-drug resistant TB, which amplifies its HIV epidemic. Of particular concern are South Africa's hyper-epidemics, many in KwaZulu-Natal and Mpumalanga provinces, and the concentration in specific populations like AGYW. Of the estimated 7.2 million South Africans living with HIV, nearly 60 percent are women over the age of 15. HIV prevalence in other key populations-female sex workers, men who have sex with men, transgender women, and people who inject drugs-remains unacceptably high, in some cases double the national prevalence rate of approximately 19 percent.

After the early years of denial, the South African government now finances close to 80 percent of the HIV response, an unparalleled commitment in sub-Saharan Africa, and provides more than 4 million people with life-prolonging anti-retroviral treatment (ART). In 2018, President Cyril Ramaphosa called for an increase of 2 million South Africans on ART by December 2020 through increased testing and treatment.

The problem facing South Africa's HIV response is that treatment scale-up has stalled, and while new infections have gone down by 42 percent, the rate is not fast enough to bend the curve of the epidemic. New infections in young men and women remain alarmingly high (nearly 87 percent of the total) and viral suppression rates, a key to preventing those living with the virus from passing it on, are under 50 percent for those 15-24 years old. With approximately 45 percent of the population under the age of 25, the sheer numbers of those becoming infected and overall prevalence of HIV will stay alarmingly high without a massive decline in the new HIV infection rate.

The central question is how to interrupt HIV transmission in young adults, and where and whom to target. One answer is to target AGYW who are at higher risk for HIV acquisition in South Africa, as they are elsewhere in sub-Saharan Africa. The reasons are both biological and social, including high rates of teenage pregnancy, an epidemic of gender-based and interpersonal violence; lack of quality education; and widespread poverty and unemployment. High rates of sexually transmitted infections (STIs) increase the risk of HIV acquisition, and mental health issues can lead to risky behaviors. Professor Olive Shisana, special adviser on social policy to President Cyril Ramaphosa, emphasized the urgency: "New infections are the highest in adolescent girls/young women. We need to close the tap. If we get to them early, we'll reduce the load on the nation and globally."

Addressing the range of social, economic, and health issues that put AGYW at risk is one approach. PEPFAR's DREAMS program-Determined, Resilient, Empowered, Aids-Free, Mentored, and Safe-includes a package of multisectoral interventions to be "layered" for a comprehensive benefit to the young woman. The importance of this layered approach led to DREAMS being adapted by the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the South African government in its She Conquers campaign. However, tracking the layering of those services has proven to be a challenge, as has widespread scale up.

Another important approach is to reach young men. The Centre for the Aids Programme of Research in South Africa (Caprisa) has demonstrated that a particularly complicated cycle of transmission involves men ages 25-34 infecting adolescent girls/young women ages 15-24, who then go on to infect their longer-term male partners ages 24-35, and the cycle continues. Prevalence among 20-24-year-old women is three times higher than in men their age. Promoting prevention through behavior and voluntary medical male circumcision (VMMC) and getting those men who are already living with HIV on treatment and virally suppressed so they can't pass the virus to their partners are critical interventions.

The challenge is reaching the men. "Services are not geared for men and young people," acknowledged Dr. Yogan Pillay, the deputy director general for the National Department of Health. While adult women come to clinics when they are pregnant or for their children, young men rarely interact with the health system unless they have suffered a major injury. In general, men are less likely to know their HIV status than women or to seek care and treatment if they test positive. Health services seen as not "male friendly" and gender norms around masculinity that equate seeking health care with weakness are two factors. As a result, men 25-34 years old have the lowest viral suppression rates (41.5 percent) of any gender/age band in South Africa. Community outreach is one way to reach AGYW and their male partners, especially those out-of-school who have a substantially higher HIV risk and men older than 25 years, by bringing information and services to where they are. "If you think you can intervene by using the current approach to health delivery, it won't work," noted professor Quarraisha Abdool Karim, Caprisa associate scientific director.

For many young adults, HIV is often not seen as a crisis because they have bigger worries: extreme poverty, unemployment and lack of jobs, crumbling school infrastructure. When they live in a community with such high HIV rates, there is a fatalistic feeling that getting infected with HIV is inevitable. Girls and women also face an epidemic of rape and gender-based violence; many young women express more concerns about getting raped or getting pregnant than getting HIV. At one site we visited, the girls stated that getting raped was their number one fear.

Pre-exposure prophylaxis (PrEP) offers a tool to help break the transmission cycle. Oral PrEP taken once a day can reduce vulnerability to infection by 99 percent. In areas where there is so much HIV circulating, every sexual encounter is high risk, and widespread PrEP could be a prevention lynchpin. However, PrEP rollout has been slow and inadequate in South Africa since it was approved in national guidelines in 2016. There have been issues with messaging, health worker sensitization and training, and availability. PrEP scale-up will require extensive outreach to create demand, ensure adherence, and negate any stigma to ensure that all those at high risk can have access. Only an estimated 12,000 people are currently on PrEP at approximately 50 clinics nationwide-shy of the national target of more than 18,000. To put that in further perspective, 12,000 equates to only 5 percent of the 231,000 presumed to be at risk for new infections based on the 2017 rates.

Lack of knowledge can impact young adults' informed prevention and treatment choices. There has been an associated decline in HIV and treatment literacy, which means that young people often don't understand how the virus affects the body and the impact of lifelong ART. The most recent national survey data from 2017 shows the same low level of condom use among 15-24-year-olds as the last survey in 2012, an increase in sexual debut before the age of 15 for boys, and an increase in multiple sexual partnerships for women under 24.

One barrier is the provision of basic health education and service delivery in schools. While South Africa has a national policy on school-based health education, some provincial officials, school governing boards, and other gatekeepers often prevent services from being provided, even though the age of consent for health services is 12. Schools are an important entry point because there is a high rate of school retention in South Africa and, once out of school, it is difficult to reach young people.

While we met many dedicated HIV champions across South Africa, and there are commitments from national and provincial officials and existing national strategies, the health and education systems are not providing the necessary information and services for young people, and not enough investment is being made to empower communities and civil society organizations to launch more effective and sustainable responses. There is an absence of targeted outreach, media campaigns, and high-profile champions. Young South Africans told us repeatedly that they wanted more leadership and information on HIV and to see role models of healthy living that make HIV prevention and staying negative cool and demonstrate how to live positively with HIV.

The critical gap in South Africa is not between evidence and policy, but between policy and implementation. While the government is committed to supporting the national HIV treatment program and has issued enabling guidelines, it faces significant challenges to effective implementation. It lacks the resources for an overhaul of the public health infrastructure and to scale up and increase coverage of prevention programs like PrEP and broader programs to address the needs of young adults. In addition, health worker shortages and a rising non-communicable disease (NCD) burden are crippling already overstretched health facilities, and the decentralized health system requires political will at the provincial and district levels to implement services effectively.

Many politicians and local government officials are preoccupied with other issues, such as the economic crisis that has gripped the country in recent years, a legacy of corruption that has crippled the energy sector, and upcoming elections in May. The president's 2019 State of the Nation address called attention to corruption and gender-based violence, but in stark contrast to last year's treatment pledge, he did not once mention HIV.

South Africa's HIV epidemic needs to be treated as a public health emergency. After the elections in May, there is an opportunity for the government to re-commit to fighting HIV, at national, provincial, and district levels. Business as usual is not bringing down new infections or getting patients onto treatment. The government should go beyond strategies and push through barriers to actual implementation, get services into school, and re-educate South Africans about HIV. Enabling nationwide scale-up of PrEP for young adults and all who are at high risk would go along way toward protecting South Africa's future.

For South Africa's HIV partners, like PEPFAR, the post-election period also provides an opportunity to re-engage with the new government and focus on how to best support targeted interventions toward adolescents and young people. That includes listening to young people and communities, making sure services are available away from clinics in communities and schools, supporting provinces in service provision, and elevating prevention and treatment for young people. Turning the tide on the epidemic will require more than increasing the number of people on treatment; PEPFAR can provide unique support to South Africa to implement a multipronged strategy for young people as an urgent priority.
Sara M. Allinder is executive director and senior fellow and Janet Fleischman is senior associate with the Global Health Policy Center at the Center for Strategic and International Studies in Washington, D.C. This commentary is based on their visit to South Africa in February 2019.
Commentary is produced by the Center for Strategic and International Studies (CSIS), a private, tax-exempt institution focusing on international public policy issues. Its research is nonpartisan and nonproprietary. CSIS does not take specific policy positions. Accordingly, all views, positions, and conclusions expressed in this publication should be understood to be solely those of the author(s).
© 2019 by the Center for Strategic and International Studies. All rights reserved.

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The World's Largest HIV Epidemic in Crisis: HIV in South Africa

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South Africa remains the HIV pandemic epicenter. CSIS's global health policy experts argue that without aggressive action to reduce new infections, the HIV toll will continue for generations and that renewed commitment is needed.

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En India, su situación es muy mal. Este enfermedad afecta los pulmones y a veces otras partes del cuerpo. Tuberculosis es una enfermedad que se transmite por el aire. Este enfermedad en India es solo muy mal porque tienen una falta de acceso al tratamiento. Los síntomas incluyen tosiendo para tres semanas o más.

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Abstract

Undernutrition and tuberculosis (TB) are linked and have a bidirectional relationship. Undernutrition increases the risk of TB which in turn, can lead to malnutrition. Undernutrition not only is a risk factor for progression of latent TB infection to active disease, but also increases the risk of drug toxicity, relapse and death once TB develops. The dietary intake of TB patients in the country is inadequate. Nutritional supplementation in patients with TB is associated with faster sputum conversion, higher cure and treatment completion rates, significant gain in body weight and body composition as well as better performance status.

The Government of India has various social support schemes (including nutrition supplementation schemes) and policies, at the Centre as well as State levels. Here we discuss some successful examples and suggest a few solutions to address this gap; like considering TB patients as a vulnerable group for "Targeted Public Distribution System" and providing extra rations for the duration of treatment. Recommendations for the research community, civil societies, government organizations, non-governmental and corporate sector on the actions needed to achieve the goals of the End TB Strategy are also provided. Ultimately, reduction of TB burden in India and its elimination will require improving the nutritional status of the community as a whole.

Keywords: Nutritional supplementation, risk factor, social support, tuberculosis, undernutrition

Introduction

Nutrition plays a vital role in the causal chain of many diseases. Malnutrition is one of the leading causes of morbidity in humans - be it overnutrition as in obesity and its related complications or undernutrition as in Kwashiorkor or marasmus. The impact of nutritional status on the occurrence, morbidity and mortality pattern in infectious diseases like diarrhoea, tuberculosis (TB) and HIV has been well documented 1 but not given enough recognition. Tuberculosis and undernutrition are both problems of considerable magnitude and importance worldwide. Here we present the current situation of malnutrition and TB in India and the ways to deal with this double trouble in the country.

Situational analysis

Magnitude of TB disease in India

India one of the countries with the highest burden of TB in the world, accounts for approximately one fifth of the global incidence. In 2013, 2.1 out of the 9.0 million estimated global annual incidence of TB cases occurred in India 2. World Health Organization (WHO) estimates that in India approximately 300,000 people die from TB each year 3, while the Global Burden of Disease study (GBD 2013) estimates > 0.5 million deaths/year 4. It is also estimated that approximately 40 per cent of the Indians are infected with tubercle bacillus, Mycobacterium tuberculosis, the vast majority of whom have latent (dormant) TB infection rather than active disease 2.

Data from the Revised National TB Control Programme (RNTCP), show a decline in the prevalence and mortality rates of TB in the past 10 years 3. However, the incidence is declining very slowly 5 and at least a million patients are being "missed" by the programme - being either undiagnosed and untreated or managed in the private sector with no notification to the programme. Studies point to the role of various social, behavioural, economic and environmental factors like undernutrition, indoor air pollution, smoking and alcohol addiction, ignorance and poverty as barriers to complete elimination of TB 6, 7, 8, 9. Of these, undernutrition is the single most important predisposing factor for TB in India, with a population attributable fraction of over 50 per cent in most States 10.

Magnitude of undernutrition in India

Despite the fast economic growth in the country, India continues to have a large number of undernourished and food insecure people. The Global Nutrition Report 2014, presenting the occurrence of undernourishment over a period of three decades in India, reports that though the rates of undernutrition have come down from 26 to 15 per cent, the period of progress over the decades is quite limited 11. National Family Health Survey (NFHS-3) reports that 33 per cent of women and 28 per cent of men are malnourished 12. In India, every third woman of reproductive age group is undernourished with a body mass index (BMI) less than 18.5 kg/m ² and they are most significantly observed in the lowest wealth index group, across the country ( Fig. 1) 13. Among under-5 children stunted growth was seen in 48 per cent (22% severely), 43 per cent were underweight (16% severely) and wasting was found in 20 per cent of children (8% severely) 12. Children from poor households are approximately three times more likely to be undernourished than those from wealthier families. Similarly, prevalence of undernutrition is higher in tribal and rural areas compared to urban, and is greater in women than in men 13.

Fig. 1.

Prevalence rate of undernourished women based on wealth quintile.

Source: Ref. 13, reproduced with permission.

Undernutrition and tuberculosis linked

The relationship between TB and nutrition is bidirectional, i.e. having active TB leads to loss of weight, and being underweight is considered a risk factor for developing TB, whether through reactivation of latent TB or developing progressive primary disease upon infection 14. Undernutrition also leads to worse treatment outcomes once TB has developed. A systematic review of literature showed that across a variety of settings with different levels of TB burden, a strong and consistent log-linear relationship existed between BMI and TB incidence - for each unit reduction in BMI the risk of TB increased by about 14 per cent ( Fig. 2) 15. In an analysis of NFHS and other available data, the distribution of undernutrition was highest among younger age groups, women, rural people, members of the scheduled tribes and people in the lower quintiles of the wealth index. A notable finding in this study was that among the youngest age group (15-19 yr), up to two-third of incident TB cases could be attributable to undernutrition 16. Modelling showed that in India, about 50 per cent of TB cases could be attributed to undernutrition, implying that improving nutritional status could have a dramatic impact on TB incidence 17.

Fig. 2.

Dose-response relationship between body mass index (BMI) and TB incidence in various studies.

Source: Ref. 15, reproduced with permission.

Data from the NIKSHAY portal (web-based tool that monitors TB patients in RNTCP) reveals that of the three million TB patients notified in the RNTCP, the median weight for adult men is 43 kg and for women 38 kg ( Fig. 3) (personal communication with Central TB Division, Directorate General Health Services, Ministry of Health and Family Welfare, Government of India).

Fig. 3.

A, B. Gender and age-wise weight of tuberculosis patients notified in the Revised National TB Control Programme [Analysis of patient-wise information from case based electronic information (NIKSHAY) with the median weight for adult men (43 kg) and women (38 kg)].

In many parts of India, patients with active TB, especially those with pulmonary TB, have co-existing undernutrition, which can be severe and life-threatening, but is under-recognized and ignored 18, 19. In a report from Chattisgarh State among 1695 adult pulmonary TB patients, 90 per cent were found to have some degree of undernutrition 20. At diagnosis, majority of patients (80% women and 67% men) had evidence of severe chronic undernutrition. Half of men had weight less than 42 kg while women were less than 34 kg. Many patients had levels of undernutrition that were incompatible with life. Nearly half of women had severe undernutrition at the end of treatment. Moreover, severe undernutrition at diagnosis has been shown to be associated with a 2-fold increased risk of death 20.

Undernutrition and TB mortality: Undernutrition as a risk factor for TB mortality has been documented in multiple studies across the world 21, 22, 23. A study among TB patients in south India reported high death rates among patients with low baseline weights, even among patients with smear negative TB; mortality was 14 per cent among those weighing <35 kg compared to 4 per cent among those weighing > 45 kg 21. In a population-based cohort study from Mumbai, underweight and smoking were attributable to around 27 per cent of male TB deaths, while use of smokeless tobacco with underweight attributed to 22 per cent of male and 37 per cent of female deaths 24. Undernourished patients also have increased severity of disease, which in turn increases the risk of mortality 25.

Undernutrition and post-TB treatment: Patients with a poor nutritional status at the end of treatment are likely to have poor performance status because of poor muscle strength. These patients also have a higher risk of TB relapse after completion of therapy 26.

Undernutrition and paediatric TB:(i) Young children are at risk of developing primary progressive disease with the risk being higher among malnourished children and children under-3 years of age 27. A study that conducted TB screening of severe acute malnourished children attending a nutritional rehabilitation centre in Karnataka 28, demonstrated that 4 per cent of the 460 children were diagnosed with TB when they were actively screened for TB, using the diagnostic algorithm of National TB Programme while only 0.3 per cent of 763 children were diagnosed with TB when active case finding was not done.

(ii) Malnutrition can also impair the protective efficacy of Bacillus Calmette-Guerin (BCG) vaccine among a nutritionally deficient vaccinated population. In a study done in the 1960s it was shown that following BCG vaccination, malnourished children were twice as likely to develop TB as their well nourished peers 29.

(iii) Undernourished contacts of drug-resistant TB patients showed a higher risk of developing active disease 30.

(iv) Malnutrition is considered to be a marker of severity of TB-HIV disease, and is associated with higher rates of unfavourable treatment outcome, including death, among drug-resistant and HIV co-infected children 31.

Effect of undernutrition on anti-TB drugs: (i) Undernourished patients have been shown to have poor bioavailability of key drugs like rifampicin which can contribute to treatment failure and development of multi-drug resistance 32.

(ii) Undernourished patients have higher risk of hepatotoxicity, which is a major side effect of TB therapy and can contribute to default 33.

Nutrition, TB and diabetes: Dye et al 34 calculated the expected changes in TB incidence between 1998 and 2008 among rural and urban adult population of India accounting for the temporal changes in BMI, prevalence of diabetes and population age structure. As a result of rapid urbanization, increasing life expectancy, body mass index and rising prevalence of diabetes, TB incident cases would have increased 28 per cent, from 1.73 million to 2.11 million, faster than population size, generating an increase in TB incidence per capita of 5.5 per cent in 10 years 34.

Nutritional status and immune functions: The link between poor nutritional status and malfunctioning of the immune system has been well established. Both macro- and micronutrient deficiencies affect the immune system. Undernutrition compromises mucosal barrier function, allowing microbial translocation and weakening of immune system (especially cell mediated immunity) thus reducing the ability of the patient to remove the pathogens once they enter the body 35. Conversely, repeated infections can worsen nutritional status due to reduced appetite, lower intake and poor absorption, increased nutrient requirements as well as loss of nutrients. Thus, infections contribute to malnutrition leading to a vicious cycle, making the link between nutrition and health inextricable 35.

Evidence of food and nutritional supplementation in tuberculosis: Although it is known that patients with TB suffer from malnutrition related to macronutrients, micronutrients and minerals, studies on the effect of nutritional supplements on patient outcomes have been limited and have shown varying results. The earliest study of the role of a nutritious diet was during the landmark Madras trial of sanatorium vs. home therapy, which showed that at 12 months weight gain in the sanatorium group was double than that of the home group, but the difference in the sputum culture conversion did not differ significantly 36. In a re-analysis of the data, it was found that patients in the sanatorium group had a shorter time to sputum conversion (3 months in the sanatorium group as compared to 4 months in the home group), and a higher rate of persistent bacteriological cure (89.7 vs.74.7%) 37.

In a clinical trial of nutritional supplementation among sputum positive TB patients with or without HIV co-infection at Vellore Tamil Nadu, India, poor outcome to treatment was observed among 1 of 35 (2.9%) in the supplemented and 5 of 42 (12%) in the unsupplemented group at the end of treatment. Among TB-HIV co-infected individuals, 4 of 13 (31%) in the supplemented and 3 of 7 (43%) in the unsupplemented group had poor outcomes. These differences were more marked after one year of follow up 38. A recent randomized trial of nutritional supplements done on 100 patients in India showed that nutritional supplementation was associated with significant improvements in sputum conversion, cure rates, treatment completion rates, and performance status 39. In a non-randomized interventional study of supplementation in TB/HIV and HIV-infected patients, at the end of six months of supplementation significant gains in body weight, mid-arm circumference, body mass index, fat-free mass, and body cell mass were observed in the supplemented group as compared to the control group; gains were greater in patients with severe immunodeficiency 40.

In Delhi, a randomized, blinded, placebo-controlled trial assessed the effect of micronutrient supplementation in 403 children treated with anti-tuberculosis therapy. It did not show any gain in weight or enhanced clearance of radiographic lesions in children with intrathoracic TB. However, over six months, children in the micronutrient supplement group had a faster height gain than those who did not receive the supplement (height-for-age, z score Δ = 0.08; P = 0.014) 41. However, a Cochrane review of 12 trials involving 3393 people on various types of nutritional supplements found only limited evidence to support the role of nutritional supplements in TB 42. This review shows that high energy supplements and combinations of zinc with other micronutrients like vitamin A may help TB patients to gain weight and reduce deaths in HIV-TB co-infection. In a systematic review on the effect of food assistance on enabling treatment adherence, eight of ten studies found that provision of food could improve adherence thus assist in treatment completion among both TB as well as HIV-TB co-infected patients 43. This emphasizes the fact that unresolved food insecurity could act as a barrier to adherence to TB treatment which in turn can adversely affect the completion and outcome of TB treatment.

World Health Organization (WHO) has brought out a set of guiding principles for the nutritional care and support of TB patients 44. These include:

(i)
Patients with active TB disease should receive prompt diagnosis and treatment should be initiated early based on WHO/RNTCP guidelines and the national standards of care. If malnutrition is identified at the time of TB diagnosis, it should be considered as a key causal factor to be addressed. Concerns about further weight loss from pre-treatment values or failure to gain weight during TB treatment should trigger detailed clinical re-assessment for co-morbid conditions (like glucose intolerance, HIV, etc.), poor adherence to treatment or development of resistance to anti-TB medications. Nutritional assessment should be done to identify the most appropriate interventions.

(ii)
An adequate diet (with all essential macro- and micronutrients), is mandatory for the health and well-being TB patients and also those with TB infection.

(iii)
As both undernutrition and TB have been shown to have a bidirectional causal link, nutritional screening, assessment and management must form an integral components of TB care and prevention.

(iv)
Poverty and food insecurity can be both cause and consequence of TB. Hence, these have to be recognized and addressed by those involved in the management of TB patients.

(v)
TB can also be accompanied by co-morbidities like diabetes mellitus, HIV, and habits like smoking, alcohol or substance abuse. These have their own nutritional implications and should be addressed while screening a TB patient for nutritional fitness.

Response analysis

(i) Existing nutrition-relevant policies/Schemes of Government of India

The Prime Minister's National Council for India's Nutrition Challenges provides reviews, policy directions, and coordinates amongst various programmes. For pregnant women, nursing mothers and children below six years of age supplementary feeding (as a gap filling measure) is provided as one of the services under the Integrated Child Development Services Scheme (ICDS). The "Midday Meal Scheme", in schools supplies free lunch on working days for children in primary and upper primary classes in Government, Government aided, Local Body, and Alternate Innovative Education Centers nationwide, to improve the nutritional status of school-age children. The Rajiv Gandhi Schemes for Empowerment of Adolescent Girls (RGSEAG), namely SABLA provides a package of services including health and nutrition to adolescent girls not currently studying in the school in age group of 11-14 yr, and nutrition for all girls between in 200 districts. Also, the Indira Gandhi Matritva Sahyog Yojana (IGMSY) provides cash assistance to pregnant and lactating mothers for improving health and nutrition and also supports to provide early and exclusive breastfeeding for the first six months of life. For general public, essential food items are available at subsidized cost through Targeted Public Distribution System (TPDS) 13.

The " Antyodaya Anna Yojana" (AAY), launched in December 2000, contemplates providing food grains (wheat and rice) at a highly subsidized rate for one crore poorest of the poor families amongst those below the poverty line within the States. The Government has also introduced the Food Security Bill. The National Food Security Act, 2013 (also Right to Food Act) aims to provide subsidized food grains to approximately two thirds of India's population. Under the provisions of this bill, beneficiaries of the public distribution system are entitled to 5 kg of cereals per person per month at subsidized rate. Pregnant women, lactating mothers, and certain categories of children are eligible for "take home rations" or daily free meals 45.

(ii) Response at State level to tackle undernutrition among tuberculosis patients

In Tamil Nadu, Chennai Corporation has been providing free breakfast for TB patients in certain DOTS centres, through the AMMA canteens. Under the Uzhavar Pathukapu Thittam (Farmer's benefit scheme) of the Government of Tamil Nadu, 1000 is provided monthly during treatment to all TB patients who have a farmer's card 46. Certain non-government organizations (NGOs) in Tamil Nadu provide nutritional aids to TB patients based on their socio-economic background. They provide health mix, dal to patients and this has resulted in improved adherence and treatment results 47. One such example is the REACH (Resource Group for Education and Advocacy for Community Health) organization. In 2008, REACH started to provide assistance of food supplements to deserving patients on individual case basis. Deserving TB patients were given five kg of rice; one kg of pulse ( dal) and some health mix every month till they completed their treatment. This support enabled patients to adhere regularly to treatment. A small study done by the same team on food insecurity among 72 TB patients revealed that nearly two-thirds of the families were food insecure 47.

During 2010-2011 the TB Forum of Kasargod, Kerala, supported 101 deserving TB patients with a nutritional kit for six months 48. Deserving TB patients were selected based on their family condition and body mass index (BMI). The TB Forum identified a nutritional kit for the TB patients which included rice, green gram, groundnut, garlic, and ghee.

Brihanmumbai Municipal Corporation (BMC), Mumbai, provided calorie-rich food, in the form of Upma or Sheera, to all multi drug resistant and extensively drug resistant (MDR and XDR) TB patients under a pilot project mode in 36 centres of Mumbai 49. The initial response was good in terms of weight gain and treatment adherence though a few patients had expressed fatigue and monotony to the type of food given. Following the success of this model, food supplementation either as cooked food or additional monthly rations for drug-resistant TB patients is being planned to be replicated in other parts of the city 49.

Gap analysis

Despite many schemes to address undernutrition in India, nutrient gaps are still rampant across the country. The gaps observed in food and nutrient intake reveals that though average diet is adequate in cereals, it lacks adequate and good sources of quality protein such as pulses or dairy products, fat, fat-soluble vitamins A, D and K and micronutrients such as iron, zinc, folic acid and this gap widens as the wealth index of the population decreases 13. Decreased intake of micronutrients constitutes a major public health problem as it adversely affects the growth, survival and brain development of individuals 13.

Research needs to improve evidence for nutritional support for tuberculosis patients

There is not enough evidence to support the claim that nutritional management of patients with active TB should be in any way different from those individuals without active TB. Policymakers and stakeholders require evidence from basic and clinical sciences as well as at epidemiological and operational levels, on the need for additional nutritional supplement and support for patients with active TB disease. There are many unanswered questions in this field:

(i)
Is the resting energy expenditure different (more or less) between patients with active TB disease and those without TB?

(ii)
What is an optimal diet for a patient with active TB disease and for their close contacts with latent TB infection?

(iii)
Can macronutrient supplementation improve TB treatment outcomes among patients on treatment for active TB disease? Which group - children, adolescents, adults or pregnant and lactating women, will benefit the maximum by it?

(iv)
Is there a role for micronutrient supplementation for patients on anti-TB treatment? If so, which micronutrient (alone, combined or as multiple micronutrients) should be recommended?

(v)
Can population-level nutritional interventions reduce the progression from latent TB infection to active TB disease among close household contacts of patients with active TB disease?

(vi)
Is there an optimal BMI above which TB relapse can be prevented among individuals already treated for TB?

Suggested solutions/measures to address undernutrition in tuberculosis

Conclusions

The link between nutrition and tuberculosis is inextricable. The WHO End TB Strategy envisages a reduction in TB incidence of 75 per cent from current levels, by 2025 50. If India is to achieve this goal, the role of nutrition and food security as an important factor in both prevention and control of TB will need to be recognized and acted upon.

Acknowledgment

Authors thank Dr K.S. Sachdeva, ADDG, Central TB Division; Dr Kiran Rade, National Consultant, TB Epidemiologist, WHO/Central TB Division; Dr Shibu Balakrishnan, WHO-RNTCP Consultant, Kerala and Dr Jyothi Salve, WHO-RNTCP consultant, Mumbai for their inputs and comments in completing this review.

Footnotes

Conflicts of Interest: None.

References

Articles from The Indian Journal of Medical Research are provided here courtesy of Scientific Scholar

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Undernutrition & tuberculosis in India: Situation analysis & the way forward

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Undernutrition and tuberculosis (TB) are linked and have a bidirectional relationship. Undernutrition increases the risk of TB which in turn, can lead to malnutrition. Undernutrition not only is a risk factor for progression of latent TB infection ...

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En la India una enfermedad popular es la tuberculosis. La tuberculosis es una enfermedad infecciosa que afecta a los pulmones. Es causado por la bacteria en el aire de una persona afectada por toser, estornudos y hablar. En 2023, India contabilizó el 26% de los casos y las fallecidas mundial.

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La situacion es muy seria. Es un parasito infeccion causado por la besos bicho. Es no puede transmitir. Es muy grave en Argentina y otro pais en latino America. Mas de 1 millon y medio gente son afectadas. Los sintomas incluyen fiebre, diarrea profusa, sarpullido en cara, vomito, y muerte. Pero hay una tratamiento para la enfermedad.