TB screening and doctor referrals increased eight times, microbiological confirmations for TB rose almost seven times and TB registrations were 62 times higher when those with symptoms visited pharmacies with trained staff compared to those without, said the study commissioned by BMJ Global Health, a repository of journals specialising in non-communicable diseases.

With 18% of the global population, India currently reports the highest incidence of TB in the world–23% or nearly a quarter of all cases.

The study was based on an intervention conducted in Patna, capital of the eastern state of Bihar, where 105 trained pharmacies successfully diagnosed 255 TB cases, three times the number of patients (83) identified with TB symptoms by 699 untrained pharmacies in the control group.

Retail pharmacies—around 750,000 nationwide—often provide the first point of medical contact for potential patients. Given that the treatment for TB, a curable disease, reaches only about 59% of patients, as IndiaSpend  reported in March 2017, pharmacies could play an integral role in India’s fight against TB.

“Pharmacies as ‘gatekeepers’ have a role to play in helping potential patients,” said Amrita Daftary, one of the authors of the study. “They are usually the first point of contact for many people. People go to them when they develop any medical condition.”

Patients who were referred by trained pharmacists visited doctors 42% more often than they otherwise would have, the study found, and TB registrations, mandatory for private medical service providers after a 2012 government directive, were 62 times higher among those referred by the intervention group.

Completion rates for chest-radiograph (chest X-ray), sputum smear and GeneXpert test—three important steps in TB diagnosis—were higher for those who received referrals from trained pharmacists by margins of 37%, 13% and 23%, respectively.

Why private sector participation

TB is among India’s most deadly infectious diseases, with an estimated 2.8 million confirmed cases in 2015, according to a World Health Organization (WHO) report. Caused by the Mycobacterium tuberculosis bacteria, its transmission is airborne and occurs when an infected person coughs or sneezes.

India’s TB burden is the highest in the world, as we mentioned earlier, followed by Indonesia (10%) and China (10%).

The National Strategic Plan for Tuberculosis Elimination launched in March 2017 gave particular importance to the role of the private sector in the eradication of TB in India. The screening and referral intervention involving private retail pharmacies is meant to be a critical part of this plan.

Public-health facilities that specialise in TB in India are already overstressed, with little political will to change the situation, said a 2011 study by the National Center for Biotechnology Information.

Rural areas have poor medical infrastructure to treat the disease and private healthcare units remain unregulated, said the 2011 study, which added that “irrational” use of first-line and second-line anti-TB drugs was the other problem with TB care in India.

Patna’s TB rate exceeds Sub-Saharan Africa’s

Along with lower-than-average rates of health, income and literacy, Patna reports a TB incidence rate of 326 per 100,000 population. This is well over the incidence rate of Sub-Saharan Africa (237) and higher than the Indian average of 204. This made the city an ideal location for the project.

The intervention was carried out within an ongoing “public-private mix programme” in Patna. “Piggybacking on the PPM provided access to a vast majority of the private pharmacy providers in Patna,” Daftary said.

Of 804 private pharmacies enrolled in the programme, a random sample of 105 participated in the pilot event. They were recruited in phases:
The first set of 30 pharmacists was trained in December 2015, the second in February 2016, and the last set of 45 pharmacists in May 2016.
Their training comprised five components: (i) identifying TB through tell-tale symptoms, screening and diagnostic testing, and stewardship of antibiotics, (ii) referring potential TB patients for doctor consultations and chest X-rays, (iii) offering a financial incentive of Rs 50 for every completed doctor referral and chest test, (iv) added incentive of Rs 200 for positively diagnosed cases, and (v) field support with SMS reminders to reinforce the pharmacists’ training and screening process.

In parallel, 699 of 804 pharmacies, which did not receive the training, were observed for referral rates.

Trained group spotted 725% more cases

During the 18-month pilot period, 81% or 84 pharmacies in the intervention group referred at least one customer for a TB screening, followed by one of two pathways: chest X-ray and a medical consultation, or a direct doctor consultation.

Overall, the trained group identified 1,674 potential TB patients based on their symptoms, while untrained pharmacists could only find 203 (fewer by 725%), according to the study. Of those identified,  255 cases referred by the intervention group and 83 cases from the control group respectively, were registered as confirmed TB notifications.

A TB notification is created when the doctor or diagnostician registers a person with symptoms on to the National TB Surveillance System, and then on to WHO.

The final stage of diagnosing TB involves the microbiological tests (MB) — the intervention group reported 24% MB positive cases (61), while the control group reported 11% MB positive cases (9).

Why the intervention worked

Periodic group discussions and private interviews helped improve the intervention programme for pharmacists, the study found. The newly acquired ability to ‘dispense’ a screening test gave trained pharmacists a greater sense of professional responsibility towards TB patients.

“I feel good that I am able to serve my society,” said one unnamed pharmacist quoted in the study. “People are benefitting. We are able to provide care and people are getting better.”

Providers catering to customers in relatively poorer sections of the city reported a growing relationship with patients, often by way of repeated visits.

Successful doctor referrals were attributed to a sense of trust among customers for trained pharmacists. The free TB screening drove up chest X-ray referrals, and positive results from these, in turn, drove up doctor referrals.

These initiatives were seen as major facilitators for achieving a 81% referral rate among pharmacists, especially in comparison to similar studies in 2003, 2014, 2016 and 2018 which saw rather dismal referral rates of around 30-40%.

“This was a practical procedure nested into an ongoing PPM programme, providing access to their inventory of doctors and test labs,” Daftary explained. “Financial incentives were important to tap the private pharmacy sector. Individualised feedback systems for pharmacists with updates on successful doctor referrals and diagnosis also helped.”

What needs to change in the programme

Pharmacists in the study group sometimes delayed referrals to patients who demanded short-term antibiotic courses instead of sustained treatment. A solution to this could be the “creation of general public awareness about antimicrobial stewardship and the threat of drug resistance”, Daftary said.

Another roadblock was the documentation process. It was the standard practice in many pharmacies to verbally refer patients for doctor consultations. These cases did not find their way into the programme tally.

Some customers were also deterred by the distance they would have to travel to visit the contracted doctor or laboratory. “If I send [them] from here to [far], patients will say they may save money on test but transportation will cost them more (sic),” said a pharmacist quoted in the study. “So they feel better to get tested at a nearby lab.”

Some of the other barriers identified include increased workload for pharmacies, the absence of identifiable symptoms, doctor consultation fees and customer discomfort with the unknown doctor or lab they may be referred to, the study showed.

“The government should capitalise on the trust people place on pharmacies and chemists,” said Daftary. “There should be greater investment in pharmacy training to enable them to screen and refer potential TB patients.”

This story was first published here on HealthCheck.

(Saha, an MSc student at the Symbiosis School of Economics, Pune, is an intern with IndiaSpend.)

Courtesy: India Spend

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An infectious air-borne bacterial disease that mostly affects the lungs but is preventable and curable, TB kills 421,000 Indians every year. That is the equivalent of passengers dying in 2,100 Boeing 737 MAX (200-seater) crashes, or more than five such crashes a day.

Indian TB deaths represent 32% of global TB mortality, and from current trends the country is not likely to meet its 2025 target of eliminating the disease, said the report, Building a tuberculosis-free world: The Lancet commission on tuberculosis published in the medical journal Lancet on March 21, 2019. The global target for eliminating TB is 2030.

On 12 indicators of its battle against TB, India is on track on two (tobacco taxation and political will), approaching its target on three (children with TB, universal health coverage service score and prevalence of undernourishment), but trailing on seven, namely drug- and multi-drug-resistant TB, national public-health financing, social-protection system, catastrophic health expenditure, anti-retroviral treatment for HIV patients and air pollution.

India needs to provide better diagnostic and treatment services, prioritise private provider engagement, provide universal access to drug susceptibility testing at the time of diagnosis and invest in active case-finding strategies to reduce its TB burden, said the commission report, which was chaired by Eric Goosby, a professor of medicine and infectious diseases expert at the University of California, San Francisco.

The Lancet TB commission involved 37 TB commissioners from 13 countries and mapped out priorities in diagnosis, treatment, prevention and advocacy efforts to end tuberculosis by 2030.

Currently, 10% of India’s TB patients die because they do not go to a doctor or go too late. It takes them an average of 4.1 months to get to a doctor and 57% of patients do not reach a “high-quality treatment provider”, where they are most likely to be diagnosed and treated, said the Lancet report.

Bridging these “care cascade gaps”–or gaps in the steps that a patient takes in order to get cured–will reduce India’s TB incidence by more than a third (38%) between 2018 and 2035. For both TB burden and deaths, the most important factor is patients visiting the private health-care sector in India, said the report.

Improving the state’s engagement with the private sector, where 80% of India’s TB patients seek early care, can save up to 8 million lives by 2045, said the report.

It would cost India an additional $290 million (Rs 1,999 crore) to “engage with” the private sector, said the report. Although that is half the current national TB budget, it is 0.9% of what India’s TB mortality costs: $32 billion.

Each dollar invested in reaching TB targets would provide a return of $16 to $82, said the report.

A quarter of India’s TB budget was spent on addressing the quality of TB care in the private sector, union health minister JP Nadda wrote in the TB commission’s report. This included free diagnosis, including rapid molecular tests, financial incentives to private providers, web- and mobile-based TB notification systems, digital technology for treatment adherence, etc.

Private-sector engagement
As we said earlier, 80% of TB patients first seek care in the private sector, where 46% get all their treatment. However, the quality of treatment in the private sector can vary.

In a sample of TB patients from Mumbai, seeking care from both the public and private sector, the average time taken to diagnose and start drug-resistant TB treatment was 87 days. The shortest time to start treatment was one month and longest around eight months. For drug-sensitive TB, when first-line TB drugs were effective, the duration ranged from 28 to 42 days, depending on the patient’s previous history of TB and treatment, IndiaSpend reported in February 2019.

Before 2009, only 1.5% of state TB spending in India was set aside to engage NGOs and private providers. The National Strategic Plan for Tuberculosis Elimination (NSP 2017-25) promised increased funding and called for a six-fold increase in “notification”–as reporting of TB patients is called–to 2 million patients per year by 2020 from the private sector, which would represent 75% of all estimated TB patients.

In 2017, 1.8 million TB cases–21% from the private sector–were notified in the national electronic system, called Nikshay. In 2018, 2.1 million TB cases were notified, an overall increase of 17%, of which 24% came from the private sector.

However, only 35% TB cases were handled correctly by the private healthcare sector in Mumbai and Patna between November 2014 and August 2015, IndiaSpend reported in October 2018.

Implementation hurdles
Despite the government’s commitments and claims, uneven implementation has slowed progress.

For example, even though the private sector treated about 2.2 million patients, according to this 2016 study in The Lancet, only about 541,000 were notified, as per Nikshay records in 2019. That means 76% of TB patients from the private sector were not reported to the government.

India is still in the process of implementing a universal drug-susceptibility test (DST), which detects drug resistance on all TB samples, as it has committed to under the NSP 2017-2025.  Only 257 of India’s 712 districts offer the universal DST test, according to the India TB Report, 2018, and only about 32% of notified TB patients underwent universal DSTs, IndiaSpend reported in January 2019.

These testing failures could explain why no more than 28% of India’s 135,000 estimated drug-resistant TB patients were diagnosed and only 26% treated in 2017, according to the Global Tuberculosis Report 2018.

Despite 2018 WHO guidelines that make bedaquiline–a new drug for TB–part of the core regimen for 135,000 drug-resistant TB patients in India, only 3,000 received the drug till January 2019, we reported.

(Yadavar is a principal correspondent with IndiaSpend.)

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.

Courtesy: India Spend

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In 2017, India had the world’s highest share (27%) and over a quarter of all TB cases globally, 2.7 million, and accounted for 32% (421,000) of deaths due to the disease–nearly a third of all TB deaths–as IndiaSpend reported in January, 2019. An estimated 2.79 million TB patients are added annually, according to the ministry of health and family welfare’s National Anti-Tuberculosis Drug Resistance Survey, 2016.

India also has the highest share (24%) of drug-resistant TB cases, i.e. patients resistant to one or more first line drugs used to treat the more common, drug-sensitive TB. India had around 135,000 DR-TB patients in 2017–of whom 124,200 (92%) had multi-drug resistant TB. Among the latter, 31,547 (25.4%) had pre extensively drug-resistant (XDR) and 1,615 (1.3%) were XDR-TB patients, according to the PLOS study. Only 39,009 or 28% of DR-TB cases were diagnosed and only 35,950 or 26% were treated in India in 2017, leaving a large diagnosis and treatment gap, IndiaSpend reported.

Large metropolitan cities such as Mumbai have the lion’s share of DR-TB cases, according to the Central TB Division’s India TB Report 2018. This is mainly because almost 42% of Mumbai’s 12.4 million people live in congested conditions in slums, according to Census 2011, with poor access to healthcare facilities.

These large cities also have sizeable numbers of health care providers and diagnostic facilities, and approaches to both treatment and costs vary among these. India faces a dual challenge of treating increasing numbers of DR-TB cases and regulating private treatment facilities, says the PLOS study, aimed at highlighting the problems DR-TB patients face while seeking treatment.

To understand reasons for delays in TB diagnosis, PLOS undertook a survey among 46 DR-TB patients in Mumbai to examine their health seeking behaviour (HSB). Assessing HSB is increasingly recognised as an important tool for understanding people’s preferences and decision-making with regard to health care and the timing of seeking treatment across various health conditions, according to the PLOS study. Understanding HSB is essential to align public health practice and health service delivery models for better outcomes, says the study. PLOS examined the treatment options, or pathways, that DR-TB patients pursued to define their HSB.

Recognition of TB symptoms was low

Many of the patients interviewed knew of others affected by TB, in their neighbourhoods, workplaces and families. However, they lacked awareness about recognising symptoms and prompt health-seeking. Stigma around the disease also contributed to leaving patients in a situation of denial, fear and a feeling of powerlessness, said the study.

Common symptoms like cough, fever, fatigue and loss of appetite did not trigger suspicions among patients that they could have TB. Even patients previously treated for TB were not alerted to the disease’s presence by such symptoms.

One patient thought her symptoms of cough, breathlessness and loss of appetite were mainly due to venturing outdoors in the rain. She was diagnosed with TB only on visiting a doctor.

Another patient interviewed was diagnosed with TB in 2014. He had taken the cough and mild fever which began during the previous winter, to be symptoms of common cold.

Some patients who had contracted TB previously reported being afraid to admit to themselves that they could have contracted the disease again, for fear of going through the experience of treatment again, the study observed.

‘Neighbourhood’ providers and facilities were favoured

Patient’s chosen TB care pathways almost always began with a neighbourhood health care service, which could be an unregistered practitioner, a municipal health centre, a private allopathic doctor or a practitioner of alternatives medicine such as ayurveda, yoga, unani, siddha or homeopathy (AYUSH), found the study. This was largely due to convenience and was the normative HSB in their community.
Patients preferred going to the neighbourhood private clinic for its familiarity and convenience since these clinics were open in the evening after work hours, were more accessible and were easy to use, compared to government facilities.

Early symptoms of TB which were not severe, were most often seen as ‘ordinary’. It was normal for patients with such ‘ordinary’ symptoms to visit the family doctor nearby to seek treatment.

Patients said going to municipal facilities cost money and took up an entire day. We need to go early in the morning to visit the municipal secondary care hospital, where they give us two tablets and ask us to visit again the next day, but an auto rickshaw to the hospital costs Rs 70-80 one way, said a patient.

“If you see the pathways and the distances travelled, the patients who are symptomatic first approach the provider who is closest to home, so that travel is less. They expect their symptoms to be relieved, be it in the public sector or the private sector. But usually there is a lack of facilities and poor infrastructure available locally, where the person resides,” Yatin Dholakia, co-author of the report, told IndiaSpend.

“The provider first approached should be knowledgeable and trained, aware of what diagnostic algorithms are currently being followed,” said Dholakia.

“People should not have to travel for long [to access treatment]. This happens more when trying to access the public health sector,” said Dholakia, “This is because they diagnose (the patient) in one place and refer them to another, depending on where the patient resides. In some cases, people have travelled for more than 200 km over 20-22 days. All this causes delay in diagnosis and increases transmission of tuberculosis.”

“Distances traveled varied depending on type of patients, the provider accessed (public or private), whether the patient suffered from drug-sensitive or drug-resistant TB and the number of providers accessed in the pathway,” said Dholakia. “One DR-TB patient traveled 184 km (1.6 for testing and 182.8 to visit health care providers). He spent 166 days till treatment initiation after visiting seven different providers.”

Diagnosis was usually delayed

Fifty-five percent of the patients interviewed faced delayed diagnosis. Health care providers spent six minutes on average with patients and their history-taking was sketchy, which lengthened the time between first seeking care and diagnosis. These delays could have been avoided if these providers had spent a little more time with patients, taken detailed case histories and looked for symptoms of TB among patients who came from high TB burden localities, said the PLOS study.

Patients also had to visit several providers/health facilities and laboratories before getting a diagnosis. A doctor who had already treated one patient for TB, failed to suspect that she was suffering from TB again. It was only after almost a year involving several visits to public sector facilities that she was diagnosed with XDR-TB.

“For the patients interviewed, the average time taken to diagnose and initiate DR-TB treatment was 87 days. The shortest duration was one month and longest around eight months. For drug-sensitive TB, the duration ranged from 28 to 42 days depending on the previous history of TB and treatment,” Dholakia told IndiaSpend.

Patients interviewed also expressed faith in the public health system. “The government has done extensive research on TB and there are medicines which cure TB. It (TB) is no longer a threat,” the parents of one patient were quoted by the study as saying.

Patients often switched health care providers, hoping they would be given ‘stronger’ medicine

No two patients from the same geographical area had similar avenues of treatment, even if they had started and finished treatment at the same facilities, the study found.

Some patients had changed providers because they did not get better in two or three days. In several cases, patients switched providers because they did not have the patience to wait or the luxury of time for getting better. They needed to go back to work, show up for family events in native villages, or attend school and prepare for exams. They hoped the next doctor would give them ‘stronger’ medicines to make them better, the study said.

At times, providers were changed due to a lack of clear communication about the need for a particular test or medicine, or the need for follow-up after completion of prescribed treatment. In such situations, the patients had assumed that the doctor’s treatment had failed and hence had switched to another.

Sometimes, patients were forced to change providers because they could not afford the cost of the tests advised or the medicines prescribed.

Treatment pathways were often circuitous

Diagnosis and treatment processes were often circuitous, which confused patients. They did not understand why they were made to undergo the same tests at different places and at different times, were referred to different facilities and subjected to changes in their treatment in their extremely weakened state.

To minimise patient movement between providers and thus promote patient adherence, referral systems need to be redesigned, said the study. This would involve simplifying processes in the diagnosis and treatment of DR-TB.

The Municipal Corporation of Greater Mumbai (MCGM) decided to integrate the private sector for effective treatment of TB and hence started the Public Private Interface Agencies (PPIA) in 2014.

Patients in Mumbai often chose to go to a specific facility for ease of navigation and convenience. However all the providers and facilities accessed by the patients from a particular area did not function as part of the integrated system. This was because the PPIA had brought in only 41% of the mapped doctors and chemists in the wards it was implemented in, into its network.

One patient’s private provider was a part of the PPIA network, hence he was diagnosed with DR-TB and referred to the correct public sector facility within a month. But for another patient, it took six months for him to be diagnosed with XDR-TB, after visiting six different providers and various facilities.

Varying approaches to costs and payment also complicated diagnosis and treatment

Patients also faced dilemmas of costs and payments, as no two facilities operated similarly. For example, directly approaching a private laboratory for diagnostic tests cost money, but going through the MCGM’s PPIA network made tests free, or subsidised, depending on the tests.

Patients had no access to clear information about which facilities or providers served patients free or at subsidised rates.

Many patients being treated for DR-TB in the private sector had to stop treatment or move to the public sector, as they could not afford the treatment.

In some cases, the provider warned patients after they were diagnosed with DR-TB that it would be better to move to the public sector to receive free treatment.

“I was spending Rs 4,000 on medicines on a regular basis. I had come from the village and did not have so much money. After this someone suggested I go to government facilities where I will get free treatment,” the study quoted one patient as saying.

“We have not assessed the costs to the patients. However the cost of diagnosis of DR-TB ranges from Rs 2,500 to Rs 18,000, depending on the tests done. Additionally, periodic tests, x-rays and doctors’ consultation fees need to be considered. Incidental travel and nutrition supplement costs and medicines for management of adverse drug events and reactions need to be taken into account,” says Dholakia.

“If facilities are placed under one roof close to residential areas, and if doctors are trained in appropriate diagnosis and treatment management tools, it would bring down costs for patients. The government does not support travel costs for patients,” he added.

Experts say India can’t end TB without engaging and regulating the private health care sector

When asked whether the patterns found in this study were representative of the situation in all of India, Dholakia said, “Wherever there is a large [unregulated] private sector, there is a delay in diagnosis. Unless these private sectors are involved in Public Private Mix Programs, where the government or public health system sensitises them to the problem of TB, and talks to them about the various facilities available under government programs, there will be problems. This is true for other countries also and not only for India,” says Dholakia.

“This study, along with similar studies published previously all point to the same key messages and tortuous pathways DR-TB patients navigate. The pattern is much worse with drug-resistant TB, which is harder to diagnose and treat,” Prof Madhukar Pai, professor of epidemiology at McGill University in Montreal, told IndiaSpend.

“Since nearly 80% of Indians seek private/informal healthcare, India cannot end TB without engaging with this large, dominant private health sector. The experience in Mumbai, Patna and Mehsana suggests that private providers can be successfully engaged to improve quality of TB care, and to link privately treated patients with free government goods (e.g. including drugs) and benefits (e.g. nutrition supplements). India needs to scale up such private provider engagement models, increase notifications (of TB diagnoses) from the private sector, and improve quality of care in the private sector,” says Pai.

(Kashyap is an intern with IndiaSpend.)

Courtesy : India Spend
 

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In May 2018, the Tuberculosis (TB) Centre of Kollam district decided to screen every one of agathi mandiram’s inmates for TB. Ordinarily, their in-house doctor, Shreekumar D., would identify those with TB-like symptoms and send their sputum samples for analysis to the state TB Cell a few times a year, leading to the identification of two or three cases each year.

For the first time this year, the centre sent a pulmonologist to examine every person in the home, as part of Kerala TB Elimination Mission launched in March 2018 with the aim of reducing the number of TB cases to 2020 by the year 2020, and eliminating TB-related deaths altogether. “It was challenging because the inmates often could not explain their symptoms nor give their sputum sample,” said P. Anish, a consultant chest physician who screened all the inmates. Deploying techniques not normally used to detect TB, such as the CT-Scan, he detected 22 cases.

This exercise at agathi mandiram was replicated across the state from April to June 2018, in an effort to screen every person in Kerala, after the state set its sights on eliminating TB, displaying confidence in its robust health system which has already delivered enviable indicators.

This confidence is why, for Kerala, eliminating TB is “low-hanging fruit”, as the state’s health secretary, Rajeev Sadanandan, puts it. “We are about the only state [that] is capable of eliminating this disease,” he told IndiaSpend.

Kerala’s strategy and potential success has implications for all of India, which has the world’s largest TB burden–2.74 million or 27% of the global total. Further, nearly 300,000 Indians fall through the surveillance system or do not complete their course of medication, prompting the rise of more virulent, drug-resistant strains. In 2016, 435,000 people in the country died of TB in India. TB patients often incur financial distress due to catastrophic health expenses.

“While ridding people of the burden of any disease is a worthy goal by itself, TB elimination provides perhaps one of the strongest cases for public intervention from an economic point of view,” as this March 2017 World Bank report noted. “Reducing TB incidence could generate benefits of $33 per dollar spent,” the report cited The Economist as saying.

If infected patients cannot access treatment or fail to complete the regimen, they can infect many others, often with more resistant and virulent forms of the disease. This is what makes TB a public health imperative that must be dealt with through early diagnosis, complete treatment and improved quality of care. And Kerala’s example is instructive.

“The reduction of TB cases in Kerala is dramatic,” said K.P. Aravindan, a retired professor from Kozhikode Medical College. “From a disease that was extremely common, it is now a rare disease.”
In a four-part series on Kerala’s ambitious plans, IndiaSpend will examine how Kerala’s policies are showing results and what lessons they could offer India. In this first part, we shine the spotlight on Kerala’s thorough implementation of the active case-finding strategy to test every resident of the state and to map vulnerable populations so as to regularly monitor, test and treat them.
Active case-finding

Active case-finding involves health workers proactively screening people for TB, as opposed to people coming to health institutions with TB-like symptoms and getting screened, which has been the mainstay of the Revised National Tuberculosis Control Programme (RNTCP) for more than 15 years. (India has had a National TB Programme since 1962, the “revised” version of which has been deployed since 1997.)

Kerala started active case-finding in health institutions as early as 2009 and in the community in 2014, something started at the national level only in 2017.

The Central TB Division, which works under the central health ministry and is responsible for implementing RNTCP, requires all state TB units to conduct an active case-finding exercise thrice a year among populations identified as vulnerable, such as those living in slums and labour camps, mine workers, tea garden workers and the homeless. This is typically done in an ad-hoc fashion and there is no consistent follow-up, mostly because the number of TB cases is high and resources are stretched thin.

Kerala, however, has improved an already robust healthcare system and motivated workforce to implement active case-finding so thoroughly that each resident will be screened this year, with health workers going door-to-door to find cases. The persons identified as vulnerable will be followed-up on every three months.

These activities have increased the number of symptomatic patients tested per 100,000 from about 700–close to the all-India figure–to nearly 1,250, according to the Kerala State TB Cell.

Bidirectional screening
TB affects mostly young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the State TB Cell show. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10%, according to State TB cell data.

This suggested a link between chronic diseases such as diabetes, which affect older people more, and TB.

Kerala and some other south Indian states such as Andhra Pradesh, Goa and Tamil Nadu and the union territory of Puducherry report higher blood sugar levels, which are indicative of diabetes, as compared with the national average, as per the National Family Health Survey 2015-16.

A 2012 study supported by the Kerala government found that 44% of TB patients had diabetes. Moreover, 21% of TB patients were found to have undiagnosed diabetes.

This led to a change in policy–first within the state starting 2012 and since 2017 across India–so that TB patients are as a rule tested for diabetes and vice-versa. Following Kerala’s example, all TB patients registered under RNTCP are supposed to be referred for screening for diabetes. Referral is the responsibility of the health institution where TB treatment is initiated.

Vulnerability mapping
Health workers tasked with diagnosing TB during door-to-door visits are given a checklist. Depending on the boxes ticked, a vulnerability score is calculated–the most vulnerable are household contacts of TB patients, followed by those on immunosuppressant medicines, the malnourished, healthcare workers, and those with diabetes, organ disorder, etc. Those considered vulnerable are kept under surveillance, with follow-up checks every three months.

In addition to increased surveillance, the state has deployed more diagnostic tools such as the Cartridge-based Nucleic Acid Amplification Test (that can detect TB bacilli in very small amounts of sputum), X-Ray and CT-scan during active case-finding, as at agathi mandiram in Kollam. “We have reached a saturation point in detecting TB using sputum microscopy,” said Kumar, referring to the technique in which the laboratory technician looks for TB bacilli in sputum–a mixture of saliva and mucus a subject has coughed up–using a microscope. “It is now time to use other techniques.”
Complementary programmes underway in some other districts engage with treatment support groups and with the private sector to increase reporting of cases (private-sector cases are typically underreported, so that official TB statistics reflect mostly incidence, prevalence, treatment and cure figures reported by the public sector). From January to July 25, 2018, there have been 2,672 notifications from the private sector and 10,200 from the public sector, Balakrishnan said.

Across India, about 20% of the total reported cases were in the private sector (384,000 private sector cases of a total 1.8 million) in 2017, while in Kerala, the figure was 36% (8,232 private sector cases of a total 22,754).

For the past two years, the Kerala TB Cell has pursued private sector practitioners to report their TB patients, giving their patients free medicines and leaving them free to go back to their private doctors. The government has also been training private doctors in TB treatment protocols for more than 10 years.

For two decades now, children living with infected adults have been given preventive drugs and are monitored as part of a protocol called chemoprophylaxis, according to the Kerala TB Elimination Mission Strategy document. Now, the state has decided to give infection-control kits to TB-positive patients, said Kumar, consisting of masks, disposable spittoons and disinfectant solution to protect TB from spreading to family members during the first two months of treatment when the disease is highly contagious.

The department has found just 352 new cases of TB all over the state–in a population of 38 million–during the active case-finding and vulnerability mapping exercise so far, Balakrishnan said. However, approximately 12% of Kerala’s screened population so far has been found highly vulnerable to TB, excluding those suffering from HIV.

Decrease in TB incidence
Kerala’s TB incidence is estimated to be 67 cases per 100,000, less than half the 138 per 100,000 pan-India, as per 2017 RNTCP figures. Since 2009, when Kerala began active case-finding, the TB notification rate in the state’s public sector has been falling by about 3% every year. This is despite the fact that the number of people being tested for TB has remained constant, Balakrishnan said.

Source: Kerala State TB Centre
Kerala registered a more than 20% decline in drug sales in the private sector in 2014 over 2013, a 2016 study found, indicating that the number of cases in the private sector had fallen too.
Kerala also has a lower rate of multi-drug resistant TB (MDR-TB, which is resistant to treatment with the first-line drugs rifampicin and isoniazid) and extensively drug-resistant TB (XDR-TB, resistant to treatment to a range of second-line as well as first-line drugs). Across India, 5.62% TB patients were detected with drug-resistant tuberculosis in 2017, while the figure in Kerala was 3.05%, as per 2017 RNTCP figures.

Idukki in central Kerala and Wayanad in north Kerala have shown the maximum decline in the number of TB cases, with a notification rate in the public health sector of just 51 cases and 44 cases, respectively, per 100,000 population, as per the Kerala TB Elimination Mission strategy document.

Low paediatric TB a major success
The proportion of TB in children under 15 years has consistently fallen in Kerala. In 2016, 6.3% of TB cases were among children (under 14 years), down from 8.7% in 2008.

Fewer children are being affected because primary transmission has gone down, state TB officer Sunil Kumar told IndiaSpend. This could mean that direct transmission of the disease from the environment or from other TB patients has reduced.

This has been achieved by pursuing RNTCP guidelines on giving chemoprophylaxis–drugs to prevent infection–to household contacts. The Kerala TB Elimination Mission Strategy document says it has given preventive drugs to children living with infected adults for two decades now.

This is not followed consistently all over the country, however, either because lack of awareness or unavailability of medicines.

The World Health Organization’s guidelines for countries with low incidence of TB warn that as TB caseloads reduce, it becomes even more important not to miss new patients.

“The idea is to maintain a surveillance system and testing more patients so that nobody is left out,” Kumar said.

Lessons for India
The biggest lesson Kerala holds for the rest of the country lies in the basic implementation of the programme–treating the TB patient who comes to the hospital appropriately, said Yogesh Jain, a founder member of Jan Swasthya Sahyog, a community hospital in Bilaspur. The importance of following the “old-fashioned” guidelines from RNTCP related to early diagnosis, completion of treatment and other protocols cannot be overstated. “There are no magic bullets here. Kerala is showing a mirror to the rest of the country that we have to do what we are supposed to do well,” he said.

“We may need to [implement] active case-finding of TB smartly,” said Nimalan Arinaminpathy, from the School of Public Health at Imperial College London, “As important as it is to go to slums and other disadvantaged communities, we also need to go to diabetics and smokers.”

While Kerala’s example may not be entirely replicable across India–given India’s vast population, paucity of resources, and lack of infrastructure, capability and preparedness–Arinaminpathy pointed out that much can be done with the existing resources too.

Having ASHAs monitor vulnerable groups every three months is a very good tactic, Arinaminpathy said, especially as this can be part of their routine work and cause no additional cost to the state.
Aravindan pointed out that even in low-resource states such as Odisha and Chhattisgarh, some programmes work. “It is political will that makes programmes work,” said Aravindan.

This is the first of a four-part series on Kerala’s fight against tuberculosis, and what it can teach India.

(Rao is a an independent journalist based in Delhi.)

Courtesy: India Spend
 

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India boasts strong research expertise and technological and pharmaceutical capacity, yet lacks strong financial and political commitment from the government – to end the tuberculosis epidemic. (AP Photo/Rajesh Kumar Singh)

In 2015, there were an estimated 10.4 million new TB cases worldwide and 1.8 million TB deaths, according to the World Health Organization. And India is at the epicentre of this global epidemic, with half a million TB deaths annually. India also accounts for 16 per cent of the estimated 480,000 new cases of multi-drug-resistant TB.

Can India turn things around and control this epidemic?

The answer is a conditional yes. The Indian government has already taken several steps over the past few years to address it. This includes making TB a notifiable disease, developing the Standards for TB Care in India, introducing daily drug regimens and rolling out molecular and drug-susceptibility testing.

But there’s an opportunity to do more and better, and for India to assume a global leadership role.
 

India must back ambitions with rupees

Earlier this year, India’s Revised National TB Control Program published a draft of a new National Strategic Plan (NSP) for TB Elimination 2017-2025. The NSP, if fully funded and well implemented, could be a game changer in the fight against TB in India.

The plan aims to improve services and outcomes for the 1.5 million patients in the public system and to scale up access to new diagnostics and drugs. It also sets out a bold road map to reach private providers and support the millions of patients treated in the private sector.

Tuberculosis alone kills an estimated 480,000 people in India every year, according to the World Health Organization’s Global Tuberculosis Report 2016. (AP Photo/Rajesh Kumar Singh)

Building on promising pilot results, the NSP proposes to do so by providing incentives to providers — for following standard protocols for diagnosis and treatment as well as for notifying the government of cases. Patients referred to the government will in turn receive a cash transfer, to compensate them for direct and indirect costs of undergoing treatment and as an incentive to complete treatment.

The cost of implementing the new NSP is estimated at US$2.5 billion over the first three years, a big increase over the current budget. Historically, despite being a highly cost-effective program and despite having a high absorptive capacity, RNTCP has struggled to receive funding that is commensurate with the scale of India’s epidemic.

This simply cannot continue. India must start backing its ambitions with rupees. Therefore, the real test of whether the bold plan by the Health Ministry can be implemented will be whether enough resources can be mobilized — to find, treat and offer quality care to all TB patients, regardless of where they live.
 

Health spending an urgent priority

TB is one of many diseases that affect Indians, and India is clearly under-performing on several key health indicators, as shown by a recent report on attainment on health-related Sustainable Development Goals (SDGs) in 188 countries. This is an analysis from the Global Burden of Disease Study 2016, which measured 37 health-related indicators from 1990 to 2016.
India did very poorly in this analysis, ranking 127 among 188 countries. In fact, every single other BRICS country (Brazil, Russia, China and South Africa) ranked ahead of India.

A tuberculosis patient sits in the sun with her mother outside Lal Bahadur Shastri Government Hospital at Ram Nagar in Varanasi, India. (AP Photo/Rajesh Kumar Singh)

This analysis clearly shows that India’s economic progress is not reflected in the health of its people. India’s National Health Policy, approved this year, proposes to increase health expenditure by the government from the existing 1.15 per cent to 2.5 per cent of the GDP, by 2025.

Ensuring this increase should be an urgent priority for India, and an absolute requirement if India is to make progress towards universal health coverage.
 

A tradition of excellence

Are there areas of strength that India can leverage to fight TB?

India has made some impressive contributions in global health. India has been polio-free for more than five years and this success has propelled global efforts to eradicate polio. Indian biotech and drug manufacturers dominate the production of TB and HIV medications, accounting for more than 80 per cent of the global market.

The recent launch of a rotavirus vaccine produced in India has underscored the country’s leadership role in childhood immunization. India also has huge strengths in IT and software that can be leveraged. And India has a long tradition of excellence in TB research, highlighted by the creation of an India TB Research Consortium.

So, with its strong research expertise in TB, and technological and pharmaceutical capacity, India has the potential to make great progress against this disease.

What is essential is a strong financial and political commitment from Prime Minister Narendra Modi to end the TB epidemic, and an overall greater investment in health. When health becomes a priority for India, TB will naturally decline, as will many other conditions that currently make India rank so poorly in health-related SDGs.
 

Madhukar Pai, Director of Global Health & Professor, McGill University

This article was originally published on The Conversation. Read the original article.

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