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Chadha VK. My tuberculosis epidemiology journey: Implications for TB program interventions, activities and strategy. Indian J Tuberc 2024; 71:476-480. [PMID: 39278683 DOI: 10.1016/j.ijtb.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 09/18/2024]
Abstract
Key learnings from some landmark studies that the author has been associated with and their implications on program strategies are highlighted. Learnings from prevalence surveys provide justification for active TB Case finding (ACF), role of Chest X-ray screening, justification of the elderly as a key vulnerable population and suggest re-think of the methods of sub-national certification for progress towards tuberculosis free status. Risk of infection studies suggest 14 million people acquiring new tuberculous infection each year in India suggesting a re-think on the targets for TB elimination. Justification is given for 'TB deaths averted' as a parameter for monitoring program impact, reviving risk of infection surveys using CyTB and higher emphasis on careful analysis of routine surveillance data for monitoring epidemiological trends rather than oft-repeated surveys. The modelling outputs suggest higher focus on reducing transmission of infection in urban and reducing treatment delay in rural areas and the need to scale up active case finding and TB preventive treatment in order to achieve End TB targets. Case finding studies justify upfront molecular diagnostics, need to confirm a single sputum result by another specimen or radiology during ACF and futility of X-ray based diagnosis during ACF. High rates of recurrence with intermittent treatment regimen providing evidence in favor of daily regimen, role of family centric approach to nutritional supplementation to prevent TB mortality and reduce TB incidence among household contacts are highlighted besides the need to address high proportion of families suffering catastrophic expenses during pre-treatment period.
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Affiliation(s)
- Vineet K Chadha
- National Tuberculosis Institute, No. 8, Ballary Road, Bengaluru, India.
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Shewade HD, Kiruthika G, Ravichandran P, Iyer S, Chowdhury A, Kiran Pradeep S, Jeyashree K, Devika S, Chadwick J, Wesley Vivian J, Tumu D, Shah AN, Vadera B, Roddawar V, Mattoo SK, Rade K, Rao R, Murhekar MV. Quality of active case-finding for tuberculosis in India: a national level secondary data analysis. Glob Health Action 2023; 16:2256129. [PMID: 37732993 PMCID: PMC10515680 DOI: 10.1080/16549716.2023.2256129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/03/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND India has been implementing active case-finding (ACF) for TB among marginalised and vulnerable (high-risk) populations since 2017. The effectiveness of ACF cycle(s) is dependent on the use of appropriate screening and diagnostic tools and meeting quality indicators. OBJECTIVES To determine the number of ACF cycles implemented in 2021 at national, state (n = 36) and district (n = 768) level and quality indicators for the first ACF cycle. METHODS In this descriptive study, aggregate TB program data for each ACF activity that was extracted was further aggregated against each ACF cycle at the district level in 2021. One ACF cycle was the period identified to cover all the high-risk populations in the district. Three TB ACF quality indicators were calculated: percentage population screened (≥10%), percentage tested among screened (≥4.8%) and percentage diagnosed among tested (≥5%). We also calculated the number needed to screen (NNS) for diagnosing one person with TB (≤1538). RESULTS Of 768 TB districts, ACF data for 111 were not available. Of the remaining 657 districts, 642 (98%) implemented one, and 15 implemented two to three ACF cycles. None of the districts or states met all three TB ACF quality indicators' cut-offs. At the national level, for the first ACF cycle, 9.3% of the population were screened, 1% of the screened were tested and 3.7% of the tested were diagnosed. The NNS was 2824: acceptable (≤1538) in institutional facilities and poor for population-based groups. Data were not consistently available to calculate the percentage of i) high-risk population covered, ii) presumptive TB among screened and iii) tested among presumptive. CONCLUSION In 2021, India implemented one ACF cycle with sub-optimal ACF quality indicators. Reducing the losses between screening and testing, improving data quality and sensitising stakeholders regarding the importance of meeting all ACF quality indicators are recommended.
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Affiliation(s)
- Hemant Deepak Shewade
- Division of Health Systems Research, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - G. Kiruthika
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Prabhadevi Ravichandran
- Division of Health Systems Research, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Swati Iyer
- Tuberculosis, Office of the World Health Organization (WHO) Representative to India, New Delhi, India
| | - Aniket Chowdhury
- Tuberculosis, Office of the World Health Organization (WHO) Representative to India, New Delhi, India
| | - S. Kiran Pradeep
- Division of Health Systems Research, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Kathiresan Jeyashree
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - S. Devika
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Joshua Chadwick
- School of Public Health, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Jeromie Wesley Vivian
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
| | - Dheeraj Tumu
- Tuberculosis, Office of the World Health Organization (WHO) Representative to India, New Delhi, India
| | | | | | | | - Sanjay K. Mattoo
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Kiran Rade
- Tuberculosis, Office of the World Health Organization (WHO) Representative to India, New Delhi, India
| | - Raghuram Rao
- Central TB Division, Ministry of Health and Family Welfare, New Delhi, India
| | - Manoj V. Murhekar
- Division of Epidemiology and Biostatistics, ICMR-National Institute of Epidemiology (ICMR-NIE), Chennai, India
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Balakrishnan SK, Suseela RP, Mrithyunjayan S, Mathew ME, Varghese S, Chenayil S, Aloysius S, Prabhakaran T, Nair SA. Individuals' Vulnerability Based Active Surveillance for TB: Experiences from India. Trop Med Infect Dis 2022; 7:tropicalmed7120441. [PMID: 36548696 PMCID: PMC9781449 DOI: 10.3390/tropicalmed7120441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Community-based active TB case finding (ACF) has become an essential part of TB elimination efforts in high-burden settings. In settings such as the state of Kerala in India, which has reported an annual decline of 7.5% in the estimated TB incidence since 2015, if ACF is not well targeted, it may end up with a less-than-desired yield, the wastage of scarce resources, and the burdening of health systems. Program managers have recognized the need to optimize resources and workloads, while maximizing the yield, when implementing ACF. We developed and implemented the concept of 'individuals'-vulnerability-based active surveillance' as a substitute for the blanket approach for population/geography-based ACF for TB. Weighted scores, based on an estimate of relative risk, were assigned to reflect the TB vulnerabilities of individuals. Vulnerability data for 22,042,168 individuals were available to the primary healthcare team. Individuals with higher cumulative vulnerability scores were targeted for serial ACF from 2019 onwards. In 2018, when a population-based ACF was conducted, the number needed to screen to diagnose one microbiologically confirmed pulmonary TB case was 3772 and the number needed to test to obtain one microbiologically confirmed pulmonary TB case was 112. The corresponding figures in 2019 for individuals'-vulnerability-based ACF were 881 and 39, respectively. Individuals'-vulnerability-based active surveillance is proposed here as a practical solution to improve health system efficiency in settings where the population is relatively stationary, the TB disease burden is low, and the health system is strong.
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Affiliation(s)
- Shibu K. Balakrishnan
- World Health Organization Technical Support Network (NTEP), Thiruvananthapuram 695001, India
| | - Rakesh P. Suseela
- World Health Organization Technical Support Network (NTEP), Thiruvananthapuram 695001, India
- Correspondence:
| | - Sunilkumar Mrithyunjayan
- State TB Elimination Program, Kerala State Health Services Department, Directorate of Health Services, Thiruvananthapuram 695001, India
| | - Manu E. Mathew
- World Health Organization Technical Support Network (NTEP), Thiruvananthapuram 695001, India
| | - Suresh Varghese
- State TB Elimination Program, Kerala State Health Services Department, Directorate of Health Services, Thiruvananthapuram 695001, India
| | - Shubin Chenayil
- State TB Elimination Program, Kerala State Health Services Department, Directorate of Health Services, Thiruvananthapuram 695001, India
| | - Suja Aloysius
- State TB Elimination Program, Kerala State Health Services Department, Directorate of Health Services, Thiruvananthapuram 695001, India
| | - Twinkle Prabhakaran
- State TB Elimination Program, Kerala State Health Services Department, Directorate of Health Services, Thiruvananthapuram 695001, India
| | - Sreenivas A. Nair
- Country and Community Support for Impact, Stop TB Partnership Secretariat, 1218 Geneva, Switzerland
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Garg T, Chaisson LH, Naufal F, Shapiro AE, Golub JE. A systematic review and meta-analysis of active case finding for tuberculosis in India. THE LANCET REGIONAL HEALTH. SOUTHEAST ASIA 2022; 7:100076. [PMID: 37383930 PMCID: PMC10305973 DOI: 10.1016/j.lansea.2022.100076] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Background Active case finding (ACF) for tuberculosis (TB) is the cornerstone case-finding strategy in India's national TB policy. However, ACF strategies are highly diverse and pose implementation challenges in routine programming. We reviewed the literature to characterise ACF in India; assess the yield of ACF for different risk groups, screening locations, and screening criteria; and estimate losses to follow-up (LTFU) in screening and diagnosis. Methods We searched PubMed, EMBASE, Scopus, and the Cochrane library to identify studies with ACF for TB in India from November 2010 to December 2020. We calculated 1) weighted mean number needed to screen (NNS) stratified by risk group, screening location, and screening strategy; and 2) the proportion of screening and pre-diagnostic LTFU. We assessed risk of bias using the AXIS tool for cross-sectional studies. Findings Of 27,416 abstracts screened, we included 45 studies conducted in India. Most studies were from southern and western India and aimed to diagnose pulmonary TB at the primary health level in the public sector after screening. There was considerable heterogeneity in risk groups screened and ACF methodology across studies. Of the 17 risk groups identified, the lowest weighted mean NNS was seen in people with HIV (21, range 3-89, n=5), tribal populations (50, range 40-286, n=3), household contacts of people with TB (50, range 3-undefined, n=12), people with diabetes (65, range 21-undefined, n=3), and rural populations (131, range 23-737, n=5). ACF at facility-based screening (60, range 3-undefined, n=19) had lower weighted mean NNS than at other screening locations. Using the WHO symptom screen (135, 3-undefined, n=20) had lower weighted mean NNS than using criteria of abnormal chest x-ray or any symptom. Median screening and pre-diagnosis loss-to-follow-up was 6% (IQR 4.1%, 11.3%, range 0-32.5%, n=12) and 9.5% (IQR 2.4%, 34.4%, range 0-86.9%, n=27), respectively. Interpretation For ACF to be impactful in India, its design must be based on contextual understanding. The narrow evidence base available currently is insufficient for effectively targeting ACF programming in a large and diverse country. Achieving case-finding targets in India requires evidence-based ACF implementation. Funding WHO Global TB Programme.
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Affiliation(s)
- Tushar Garg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Lelia H. Chaisson
- Division of Infectious Diseases, Department of Medicine, University of Illinois at Chicago, Chicago, IL, United States
| | - Fahd Naufal
- Wilmer Eye Institute, Johns Hopkins Medicine, Baltimore, MD, United States
| | - Adrienne E. Shapiro
- Department of Global Health and Department of Medicine, University of Washington, Seattle, WA, United States
| | - Jonathan E. Golub
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, United States
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Sagili KD, Muniyandi M, Shringarpure K, Singh K, Kirubakaran R, Rao R, Tonsing J, Sachdeva KS, Tharyan P. Strategies to detect and manage latent tuberculosis infection among household contacts of pulmonary TB patients in high TB burden countries - a systematic review and meta-analysis. Trop Med Int Health 2022; 27:842-863. [PMID: 35927930 PMCID: PMC9825928 DOI: 10.1111/tmi.13808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To summarise latent tuberculosis infection (LTBI) management strategies among household contacts of bacteriologically confirmed pulmonary tuberculosis (TB) patients in high-TB burden countries. METHODS PubMed/MEDLINE (NCBI) and Scopus were searched (January 2006 to December 2021) for studies reporting primary data on LTBI management. Study selection, data management and data synthesis were protocol-driven (PROSPERO-CRD42021208715). Primary outcomes were the proportions of LTBI, initiating and completing tuberculosis preventive treatment (TPT). Reported factors influencing the LTBI care cascade were qualitatively synthesised. RESULTS From 3694 unique records retrieved, 58 studies from 23 countries were included. Most identified contacts were screened (median 99%, interquartile range [IQR] 82%-100%; 46 studies). Random-effects meta-analysis yielded pooled proportions for: LTBI 41% (95% confidence interval [CI] 33%-49%; 21,566 tested contacts); TPT initiation 91% (95% CI 79%-97%; 129,573 eligible contacts, 34 studies); TPT completion 65% (95% CI 54%-74%; 108,679 TPT-initiated contacts, 28 studies). Heterogeneity was significant (I2 ≥ 95%-100%) and could not be explained in subgroup analyses. Median proportions (IQR) were: LTBI 44% (28%-59%); TPT initiation 86% (60%-100%); TPT completion 68% (44%-82%). Nine broad themes related to diagnostic testing, health system structure and functions, risk perception, documentation and adherence were considered likely to influence the LTBI care cascade. CONCLUSION The proportions of household contacts screened, detected with LTBI and initiated on TPT, though variable was high, but the proportions completing TPT were lower indicating current strategies used for LTBI management in high TB burden countries are not sufficient.
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Affiliation(s)
- Karuna Devi Sagili
- International Union Against Tuberculosis and Lung DiseaseSouth East Asia OfficeNew DelhiIndia
| | - Malaisamy Muniyandi
- Indian Council of Medical Research (ICMR)National Institution for Research in TuberculosisChennaiIndia
| | | | - Kavita Singh
- International Union Against Tuberculosis and Lung DiseaseSouth East Asia OfficeNew DelhiIndia
| | | | - Raghuram Rao
- National TB Elimination Program, Central TB DivisionMinistry of HealthNew DelhiIndia
| | - Jamhoih Tonsing
- Technical Advice and Partnerships DepartmentThe Global FundGenevaSwitzerland
| | - Kuldeep Singh Sachdeva
- International Union Against Tuberculosis and Lung DiseaseSouth East Asia OfficeNew DelhiIndia
| | - Prathap Tharyan
- Clinical Epidemiology UnitChristian Medical CentreVelloreIndia
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Digital Storytelling and Community Engagement to Find Missing TB Cases in Rural Nuh, India. Trop Med Infect Dis 2022; 7:tropicalmed7030049. [PMID: 35324596 PMCID: PMC8955008 DOI: 10.3390/tropicalmed7030049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/22/2022] [Accepted: 02/24/2022] [Indexed: 02/05/2023] Open
Abstract
Nuh, Haryana, is one of India’s least developed districts. To improve TB case notifications, ZMQ carried out an active case-finding (ACF) intervention conducted by community health workers (MIRAs) using a digital TB storytelling platform to create TB awareness in the community. The combined storytelling and ACF intervention were conducted house-to-house or in community group settings. Steps included (A) the development of digital TB awareness-raising stories using a participatory approach called Story Labs; (B) the implementation of the intervention; and (C) process, outcome, and impact evaluation of these activities. Six digital stories were created and used during ACF in which 19,345 people were screened and 255 people were diagnosed with TB. Of 731 participants surveyed, the stories were well received and resulted in an increase in TB knowledge. ACF activities resulted in a 56% increase in bacteriologically confirmed TB and an 8% decrease in all forms of TB compared to baseline. All form notifications may have been impacted by COVID-19 lockdowns. Digital TB storytelling can improve TB awareness and knowledge, particularly for low-literacy populations. The use of these tools may benefit ACF campaigns and improve TB case finding.
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Holistic Approach to Tuberculosis Detection, Treatment and Prevention: Emerging Evidence and Strategies from the Field. Trop Med Infect Dis 2022; 7:tropicalmed7030036. [PMID: 35324583 PMCID: PMC8955418 DOI: 10.3390/tropicalmed7030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 02/04/2023] Open
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