Revisiting the tuberculosis and leprosy sanatorium era: for the post COVID healthcare in India

Sir,

Leprosy and tuberculosis (TB) are ancient diseases. These have been referred to in the Vedas and Ayurvedic Samhitas too. As no chemotherapy was effective against these diseases till middle of the 20th century, the main line of treatment was good food, open air and dry climate. Open air sanatoriums were formed for treatment and isolation of TB patients. The first sanatorium was founded in 1906 in Tiluania, near Ajmer, followed by one in Almora two years later. In 1909, the first non-missionary sanatorium was built near Shimla. Similarly, social stigma was the reason for creation of leprosy sanatoriums. First leprosy sanatorium was opened in 1925 at The school of tropical medicine, Calcutta and in 1955 the first research centre; The Lady Willingdon leprosy sanatorium, Chingleput (presently central leprosy teaching and research institute). These centers also contributed to knowledge of natural history of the disease and treatment. Subsequently many sanatoriums were set up at geographical locations which were at outskirts of cities, or at hilly terrains.¹ One of the major reasons of setting up these sanatoria was to isolate the patients and prevent spread of disease further, in absence of medicines. Later on, many other infectious disease hospitals were also opened up, to cater to patients suffering from other infectious diseases.

The Bhore Committee, in its report in 1946, introduced concept of organized domiciliary service for TB treatment. By 1956 evidence was generated that domiciliary treatment was encouraging enough to warrant a shift of emphasis from hospitals and sanatoria to clinics without waiting for any further trials.² Later on, all the sanatoria were converted into general hospitals for sick patients. The practice of isolating the patients in sanatoria gave way to domiciliary treatment.

Recently, the world has seen an emergence of some newer communicable diseases. There is also a threat of re-emerging diseases. Notably, the novel corona virus (COVID 19) infection has spread in the world in a very short period. This was declared a pandemic by the world health organization (WHO) within a span of three months. COVID-19 transmission has primarily been attributed to the direct breathing of droplets expelled by someone infected with COVID-19.³ However, the exact natural history of the disease and its dynamics of transmission are not known. There is no known medicine and treatment remains empirical. A number of vaccines are also being developed.

The current corona virus disease pandemic has overwhelmed the health systems of countries across the globe and India is no exception.⁴ The ministry of health and family welfare, government of India has released a number of preventive guidelines to contain the spread of the COVID 19 pandemic in India. Three types of COVID dedicated facilities have been proposed and set up: a dedicated COVID care centre (DCCC) that caters to COVID infected patients who are asymptomatic or mildly symptomatic. Dedicated COVID health centers or DCHCs have been established to cater to COVID patients with moderate symptoms or patients with co-morbidities and immunocompromised patients. Dedicated COVID Hospitals are hospitals that offer comprehensive care for those who have been clinically assigned as severe. The Dedicated COVID Hospitals are either a full hospital or a separate block in a hospital.⁵

While TB, leprosy and COVID-19 spread by close contact between people the exact mode of transmission differs, explaining some differences in infection control measures to mitigate these conditions. Three characteristics are common among these diseases: the communicability, social stigma and isolation centers. Like TB and leprosy, isolating COVID patients in dedicated centers has been used as a strategy to prevent spread of the disease. Public health experts and policy makers need to appreciate age old concept of sanatoria for prevention and treatment of COVID 19. Tamil Nadu health department have started converting hospitals on the outskirts of cities into quarantine centers. The TB sanatorium in Tambaram and a similar hospital in Thoppur in Madurai has been equipped with critical care facilities including ventilators and infectious disease experts.⁶ The TB sanatorium of Kolar, Karnataka has also been converted into an isolation centre for COVID patients.⁷ The concept is being picked up by state health departments. The fight against COVID-19 is at global and national level. Hence instead of consuming health infrastructure and economy for already existing ailments; they are being spent on the new scare of the era. The existing sanatoria are a cost-effective measure for converting them into dedicated COVID health centre and hospital.

COVID-19 virus has a potential to be used as a biological weapon in future. With no vaccine and treatment available the situation is much like TB in 18th and 19th century. Also, the threat of other biological warfare and emerging/re-emerging diseases is always there. Isolation centers and dedicated Infectious disease hospitals catering to such eventualities is the need of the present times. Isolation remains a key measure to prevent transmission of such diseases, pending effective treatment and availability of vaccines. The policy makers and Public health experts need to recognize that isolation hospitals and infectious disease hospitals would be a health care reform in the country’s public health system that can have far reaching effects on the health system of India that caters to the rapidly changing disease scenarios.

REFERENCES

1. 1. Central Tuberculosis Division Government of India. National Tuberculosis Elimination Program: About us, Available at: https://tbcindia.gov.in/index4.php?lang=1&level=0&linkid=399&lid =2768. Accessed on 21 September 2020.
2. 2. Dharmendra. Leprosy work in India. J Assoc Physic India. 1970;18(1):155-72.
3. 3. World Health Organization. Corona virus pandemic. News room. Q&A: Tuberculosis and COVID 19, Available at: https://www.who.int/news-room/q-a-detail/tuberculosis-and-the-covid-19-pandemic. Accessed on 21 September 2020.
4. 4. Bhaduri SD. Post-COVID healthcare reform in India: What to expect? J Family Med Prim Care 2020;9:5427-31.
5. 5. Ministry of Health and Family welfare: Guidance document on appropriate management of suspect/confirmed cases of COVID-19, April, 2020. Available at: https://www.mohfw.gov.in/pdf/ FinalGuidanceonMangaementofCovidcasesversion. pdf. Accessed on 21 September 2020.
6. 6. Times News Network. March 7, 2020. Corona virus scare: TN Government to set up quarantine facilities in Chennai and Madurai. Available at: http://timesofindia.indiatimes.com/articleshow/74521322.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst). Accessed on 21 September 2020
7. 7. Times News Network. June 3, 2020. Karnataka: Kolar’s Kamala Nehru TB Sanatorium takes on COVID 19. Available at: https://timesofindia.indiatimes.com/city/bengaluru/kolars-kamala-nehru-tb-sanatorium-takes-on-covid-19/articleshow/76164040.cms). Accessed on 21 September 2020.