Population Attributable Risk of Tuberculosis Vulnerabilities in Kerala, India

Short Comprehensive Multimodal Behavioural Intervention for Tuberculosis-Can It Be Effectively Incorporated in Tribal Health?

BACKGROUND

Tuberculosis management in tribal areas is a major challenge to the National Tuberculosis Elimination Program in India. There is need for culturally appropriate interventions for bridging the gaps existing in the current system. There is paucity of research in this vulnerable group; hence, a study was undertaken to determine the effect of a Short Comprehensive Multimodal Behavioural Intervention in tribal colonies of Kerala.

METHODS

The study used before-after design to assess the effectiveness of a Short Comprehensive Multimodal Behavioural Intervention for tuberculosis knowledge and voluntary reporting among residents of tribal colonies. The intervention included individual, small group, and large group education, with verbal, printed, and performance methods. Public-private partnership with community participation was emphasized to encourage the residents to approach public health system for managing tuberculosis.

RESULTS

Ten tribal colonies from two districts were included with 104 participants. There was significant improvement in the proportion of participants with knowledge regarding different aspects of tuberculosis such as aetiology, symptoms, transmission, and treatment. The overall knowledge score had a significant improvement [median (range) 3.0 (0-9) to 7.0 (0-11), p < 0.001] when assessed one month consequent to the intense period of group education.

CONCLUSION

Short-term health behavioural intervention package appropriate for the target group, implemented with public-private partnership and community participation of trained local volunteers, proved effective in improving the knowledge regarding tuberculosis and thereby health-seeking behaviour in detection. This can be tested for scaling up, and replication in other tribal health issues.

Individuals' Vulnerability Based Active Surveillance for TB: Experiences from India

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.