TB control in India in the COVID era

COVID-19 pandemic has disturbed the delivery of health care in almost all countries of the world. This has affected mostly the public health control programs. Because of lock downs, restrictions in movement, psychological fear of contacting the disease in health care facilities, diversion of health care workers for containment and management of COVID-19, utilization of diagnostic facilities like CBNAAT machines for COVID work, conversion of hospitals for care of these patients, financial diversion etc has created issues in the NTEP to focuss on TB control in India. Case notification and other areas of the program to achieve End TB by 2025 have suffered. Various ways of overcoming these difficulties have been discussed.

Tuberculosis Pathways to Care and Transmission of Multidrug-Resistance in India

Rationale

India is experiencing a regional increase in cases of multidrug-resistant tuberculosis (MDR-TB).

Objectives

Given the complexity of MDR-TB diagnosis and care, we sought to address key knowledge gaps in MDR risk factors, care delays, and drivers of delay to help guide disease control.

Methods

From January 2018 to September 2019, we conducted interviews with adults registered with the National TB Elimination Program for MDR (n = 128) and non–MDR-TB (n = 269) treatment to quantitatively and qualitatively study care pathways. We collected treatment records and GeneXpert-TB/RIF diagnostic reports.

Measurements and Main Results

MDR-TB was associated with young age and crowded residence. GeneXpert rifampicin resistance diversity was measured at 72.5% Probe E. Median time from symptom onset to diagnosis of MDR was 90 days versus 60 days for non-MDR, Wilcoxon P < 0.01. Delay decreased by a median of 30 days among non-MDR patients with wider access to GeneXpert, Wilcoxon P = 0.02. Pathways to care were complex, with a median (interquartile range) of 4 (3–5) and 3 (2–4) encounters for MDR and non-MDR, respectively. Of patients with MDR-TB, 68% had their first encounter in the private sector, and this was associated with a larger number of subsequent healthcare encounters and catastrophic expenditure.

Conclusions

The association of MDR with young age, crowding, and low genotypic diversity raises concerns of ongoing MDR transmission fueled by long delays in care. Delays are decreasing with GeneXpert use, suggesting the need for routine use in presumptive TB. Qualitatively, we identify the need to improve patient retention in the National TB Elimination Program and highlight patients’ trust relationship with private providers.

Paradigm shift in efforts to end TB by 2025

TB is a deadly infectious disease, in existence since time immemorial. This article traces the journey of TB developments in the last few decades and the path breaking moments that have accelerated the efforts towards Ending TB from National Tuberculosis Control Program (NTCP 1962-1992) to Revised National Tuberculosis Control Program (RNTCP - 1992-2019) and to National Tuberculosis Elimination Program (NTEP) as per the vision of Honorable Prime Minister of India. From increased funding for TB, the discovery of newer drugs and diagnostics, increased access to health facilities, greater investment in research and expanded reach of public health education, seasoned with TB activism and media's proactive role, private sector participation to political advocacy and community engagement, coupled with vaccine trials has renewed the hope of finding the elusive and miraculous breakthrough to END TB and it seems the goal is within the realms of the possibility. The recent paradigm shift in the policy and the drive of several states & UTs to move towards TB free status through rigorous population-based vulnerability mapping and screening coupled with active case finding is expected to act as the driving force to lead the country towards Ending TB by 2025. Continued investments in research, innovations and availability of more effective drugs and the vaccines will add to existing armamentarium towards Ending TB.

Evolution of newer regimens in TB from RNTCP to NTEP

TB is a global disease and the leading cause of death among infectious diseases worldwide. TB was considered incurable till the mid 19th century. The major landmark in the treatment was the discovery of Rifampicin which has led to shorter courses of therapy as compared to the previous regimens which also consisted of injectables. Although, treatment for TB is evolving expeditiously today but a lot needs to be done as far as drug resistant TB (DRTB) is concerned. Non-standard regimens in private sector, lack of access to drug susceptibility testing, delay in the treatment, poor follow up and default in the treatment has led to emergence DRTB. Addition of newer drugs like bedaquiline and delamanid has made oral regimen possible in DRTB as well. Encouraging results of BPaL regimen for extensively drug resistant TB (XDR-TB) may prove to be a game changer. The target of TB elimination by 2025 is onerous considering the huge population, rising DRTB patients and private sector non engagement in the programme despite implementation of second largest national programme of the world.

Care of tuberculosis patients in the times of COVID-19

Globally during this time of Covid-19 pandemic health care services are overhelmed and it has negative impact on other diseases like Tuberculosis (TB). High TB burden countries like India despite being faced by several other problems in present times, is continuously trying to provide uninterrupted services to TB patients through the national programs. In this general perspective we have shared our opinion on problems faced by TB patients in the times of covid-19.

Dr PK Sen TAI gold medal oration

The current write-up is for Dr P.K.Sen TAI Gold Medal Oration Award for 2020 conferred to Dr Rupak Singla and delivered on 19 th December 2020. The title chosen for the oration was "Introduction and scale up of new anti-TB drugs in India: role of NITRD.ˮ However, in the oration the role this institute has played for overall scale up of Drug-resistant TB services in India under National Tuberculosis Elimination Programme (NTEP) at different times from the beginning of national TB programme has also been presented. National Institute of TB and Respiratory Diseases has travelled with our country from beginning of DR-TB care. It demonstrated for the first time use of a Standardized Treatment Regimen with second line drugs for MDR-TB in field conditions. NITRD assisted NTEP for the concept of DST guided treatment. This institute guided NTEP for the management of MDR-TB failure patients with Pre-XDR and XDR-TB. Also, NITRD assisted India for the introduction of newer DR-TB drugs and scale up of newer drugs across the country. The strength of NITRD include clinical expertise, laboratory support and training division. NITRD commitment is strong and will continue to support NTEP for all endeavors in future also.

Effect of pandemic on DOTS treatment during COVID-19 lockdown- A cross-sectional study

BACKGROUND

Tuberculosis (TB) is still the most common infectious disease globally, affecting 1.5 million people per year. Prior to COVID-19 outbreak, India was struggling with a rampant attack of Tuberculosis. With the surge of COVID-19 implementation of all national health programs including NTEP was disrupted. Prioritization of services, the challenges to reaching all types of communities and the role of stigmatization, and the possibility of increased disease transmission were few problems in the implementation of DOTS during the lockdown.

AIM

To assess effect of pandemic on DOTS treatment during COVID-19 lockdown.

METHODS

A cross-sectional study was conducted among 254 tuberculosis patients who were under DOTS during Covid-19 lockdown in Belagavi district. Participants who were on DOTS during 2019-2021 period.

RESULT

Of 254 participants, only 5 (2.0%) were supervised while taking drugs, 67 (26.4%) of subject's empty blister packs were taken back by health personnel and 106 (41.7%) participants were regularly followed up for treatment by health department. The variables like gender, literacy status, socioeconomic status, and occupation were all significantly associated with hampered access to DOTS during the lockdown period at p < 0.05.

CONCLUSION

This study concluded that the participants had hampered accessibilities to DOTS during lockdown.

Outcome of patients with tuberculosis managed under NTEP through STEPS in a private hospital in India

OBJECTIVE

As the global health care commits to the ambitious goal of TB elimination, System for TB Elimination in Private Sector (STEPS) was introduced to provide appropriate standards of TB care to all patients. This study aims to assess the outcome of TB patients treated under STEPS programme in a Private hospital and find any significant factors in determining favourable and unfavourable outcomes.

SETTING

Private Quaternary care hospital in South India.

DESIGN

Retrospective study which included 163 patients diagnosed with Pulmonary and Extra-Pulmonary Tuberculosis from January 2020 to June 2022. Details like clinical profile, type and site of tuberculosis, modification of ATT regimen, adverse effects and outcomes were recorded.

RESULTS

The study population included 62.6% males. 45.3% had Type-2 Diabetes mellitus. More than half of the cases were Extra-Pulmonary TB (52.2%) and 54.6% had microbiological confirmation. The Cure Rate in Pulmonary and Extra-Pulmonary TB cases were 76.7% and 79.2% respectively. 29 patients expired during TB treatment out of which 41.3% had renal failure. Advanced age and chronic kidney disease as a co-morbidity were significant in causing unfavourable outcomes.

CONCLUSION

Proper implementation of STEPS can help in 100% TB notification and effective care of TB patients.

A latent scale model to minimize subjectivity in the analysis of visual rating data for the National Turfgrass Evaluation Program

Introduction

Traditional evaluation procedure in National Turfgrass Evaluation Program (NTEP) relies on visually assessing replicated turf plots at multiple testing locations. This process yields ordinal data; however, statistical models that falsely assume these to be interval or ratio data have almost exclusively been applied in the subsequent analysis. This practice raises concerns about procedural subjectivity, preventing objective comparisons of cultivars across different test locations. It may also lead to serious errors, such as increased false alarms, failures to detect effects, and even inversions of differences among groups.

Methods

We reviewed this problem, identified sources of subjectivity, and presented a model-based approach to minimize subjectivity, allowing objective comparisons of cultivars across different locations and better monitoring of the evaluation procedure. We demonstrate how to fit the described model in a Bayesian framework with Stan, using datasets on overall turf quality ratings from the 2017 NTEP Kentucky bluegrass trials at seven testing locations.

Results

Compared with the existing method, ours allows the estimation of additional parameters, i.e., category thresholds, rating severity, and within-field spatial variations, and provides better separation of cultivar means and more realistic standard deviations.

Discussion

To implement the proposed model, additional information on rater identification, trial layout, rating date is needed. Given the model assumptions, we recommend small trials to reduce rater fatigue. For large trials, ratings can be conducted for each replication on multiple occasions instead of all at once. To minimize subjectivity, multiple raters are required. We also proposed new ideas on temporal analysis, incorporating existing knowledge of turfgrass.

Reasons and extent of delay in the diagnosis of pulmonary tuberculosis after the appearance of symptoms

Objective

Delay in the diagnosis of tuberculosis (TB) is a significant problem at both individual and community levels. Delayed diagnosis of TB contributes to more severe disease manifestations, higher risk of death, and higher disease transmission in the community. We conducted this study to assess the extent and associated reasons for delay in diagnosis of pulmonary TB.

Methods

This study was conducted in the Department of TB and Respiratory Diseases, J. N. Medical College, Aligarh, from June 2020 to May 2022. A total of 2053 new pulmonary TB patients, who first consulted any private healthcare provider (HCP) for treatment, were enrolled in the study. The required information was collected by interview technique using a predesigned questionnaire.

Results

A total of 2053 patients were enrolled in the study. There was a significant delay of more than 2 weeks in the diagnosis of pulmonary TB after the onset of symptoms in 94% of patients. The extent of delay ranged from 8 days to 240 days with a mean of 36.33 days. The delay in visiting the HCPs by the patient was not significant. Only 5.85% of patients had a significant delay of more than 2 weeks in seeking any health care after the appearance of symptoms. A delay by HCP contributed to a greater portion of the total delay, with a mean of 31.77 days. The main reason for the delay by HCPs was not investigating TB. The hospital delay was not significant. The mean hospital delay was 5.82 days.

Conclusion

The delay in the diagnosis of TB in India is very high. A delay by HCPs contributes to a greater portion of the total delay. Information, Education and Communication (IEC) activities will play an important role in reducing the delay. All HCPs should be actively involved in subjecting the suspects to TB diagnosis at the earliest possible as per National Tuberculosis Elimination Programme (NTEP) guidelines.

India marching towards TB elimination: How far we are

Tuberculosis continues to be the leading cause of death worldwide. India shares twenty five percent of total tuberculosis population. Programmatic approach to fight against tuberculosis started in this country in the form of National Tuberculosis Program (NTP). In due course of time India adopted many strategic changes in its fight against tuberculosis. The current program named National tuberculosis elimination program (NTEP) has been set up to eliminate TB by 2025. There are some challenges which India need to overcome to achieve its target five years ahead of the sustainable development goals. Insufficient budget, inadequate diagnostic facilities, under-reporting, low success rate, high dropout rate, social stigma are some of the major challenges in the path to achieve a TB elimination status. Besides that, all the backlogs demand for swift performance in identification, notification, and treatment of TB cases. India has all the potential to eliminate tuberculosis. Strengthening of health system, mainstreaming of private sectors, enhancing diagnostic facilities, inclusion of latest diagnostic techniques, addressing social hindrances, and advocacy for higher budget are some of the program strengthening measures, if followed properly, can take India towards a TB free status.

Assessment of treatment outcomes of daily fixed-dose combination therapy among drug-sensitive pulmonary tuberculosis patients: A prospective study from Bengaluru, India

Context

The annual incidence cases report depicts India as having the highest tuberculosis (TB) burden globally. Following a programmatic change, the daily fixed-dose combination (FDC) anti-TB treatment regimens were introduced by the Indian government's National Tuberculosis Elimination Program (NTEP).

Aims

The aim of the study was to assess the treatment outcomes among drug-sensitive pulmonary TB patients receiving daily FDC drugs and the associated factors influencing the treatment outcomes.

Settings and Design

A prospective study was conducted among 300 drug-sensitive pulmonary TB cases in the Bruhat Bengaluru Mahanagara Palike (BBMP) area.

Materials and Methods

The TB units and designated microscopic centers (DMCs) were selected by multistage random sampling. Data were collected through a pre-tested and semi-structured questionnaire. Patients were followed up until treatment completion.

Statistical Analysis Used

Data were compiled and analyzed using IBM Statistical Package for Social Sciences (SPSS) statistics version 20.0. Descriptive statistics and the Chi-square test were used for interpretation. A P-value less than 0.05 was considered statistically significant.

Results

Around 86.33% of patients were cured, 4% had completed treatment, and 1% had treatment failure. Older age, human immunodeficiency virus (HIV) reactive status, alcohol intake, tobacco use, and migrants were associated with poor outcomes.

Conclusions

The daily FDC regimen had better outcomes than intermittent regimens. Smokers, alcoholics, migrants, and patients with co-morbidity need to be given priority in management as they are prone to poorer outcomes.

Active Case Finding among Adults using an Individual's Vulnerability Score for Pulmonary Tuberculosis in a Rural Village of Goa: A Cross-sectional Study

Background

"Detect-Treat-Prevent-Build" to achieve tuberculosis (TB)-free India is envisaged in the National Tuberculosis Elimination Program (NTEP). To be able to achieve this, it is important to address the fact that the most vulnerable and hard-to-reach groups need to undertake screening. The present review aimed to examine the vulnerability in connection with TB disparities faced by distinct sub-populations generally viewed as vulnerable and follow these for testing.

Materials and Methods

The community-based cross-sectional study was conducted in the field practice area of sub-center Carambolim in a rural area of Goa for 3 months. The households were visited, and data collected via personal interviews were recorded on the questionnaire study tool. Based on the data, the participants' vulnerability mapping was done per the parameters identified.

Results

Among 223 households, 528 persons were screened for vulnerability. The 47 highly vulnerable participants were advised sputum CBNAAT, of which 9 (19%) tested positive for pulmonary TB, while of the 86 moderately vulnerable participants, 4 (5%) tested positive for pulmonary TB. Among the 34 with symptoms suggestive of TB, 3 (9%) tested positive for pulmonary TB.

Conclusions

The study detected 16 new TB patients from the population and found a higher incidence of pulmonary TB among the vulnerable group with no symptoms of Pulmonary TB. A further state-wide survey is recommended to diagnose such cases.

Psychiatric inconsistencies of technical epidemiological nexus codes used by the Brazilian Social Service to classify work-related disorders

This article aims to provoke discussions about technical inconsistencies in the technical epidemiological nexus framework used as part of Brazil’s social security regulations.

Verification of Sub-national Claim for 'TB-free' Status of Rajsamand District, Rajasthan, India-2020

Background

Tuberculosis (TB) caused by Mycobacterium tuberculosis is an opportunistic infection that affects the lungs in humans. Caseload of TB has been deemed it endemic in various regions of the world and India is on top of that list. The Government of India has set out a goal to eliminate tuberculosis in India by the year 2025 with the help of the National Strategic Plan (NSP) 2017-25. The objective of the index study was to verify the claim of Rajsamand district in Rajasthan, that it witnessed a >20% reduction in TB incidence between 2015 and 2020.

Methodology

This was a mixed-methods study. Quantitative component (cross-sectional study): Secondary data review (review of records from Nikshay notification systems and National tuberculosis elimination program (NTEP) reports, utilization of drugs in the public sector, and drug sales in the private sector). Primary data collection through survey. Qualitative component: nominal group technique and key informant interviews.

Result

Percentage decline of a ≥ 20% incidence in 2020 compared to baseline 2015 was not seen. The number needed to test (increased by 18.26% in 2020 as compared to the baseline of 2015. TB Score of Rajsamand district for the year 2020 was 68.34 out of 100.

Conclusion

Rajsamand district's claim of ≥20% reduction in TB incidence in the year 2020, was rejected.

TB free India: Reaching the unreached tribal population under National Tuberculosis Elimination Programme

India is the highest TB burden country in the world. The burden however is not uniform in different strata including tribal population - one of the key affected populations in the country. As the evidences from tribal population are hardly available, most of the policies and strategies implemented under National Tuberculosis Elimination Programme (NTEP) are usually based on the evidences from general populations. NTEP is continuously taking steps to strengthen TB services in tribal areas. The Social Action Plan including Tribal Action Plan is in place and the appropriate strategies are incorporated in the National Strategic Plan (NSP) to ensure universal access to quality TB services to vulnerable population groups. However, its implementation becomes challenging especially in tribal areas as different tribal groups have their own unique ways of dealing with health issues. These issues are therefore required to be addressed holistically involving all the stakeholders. In view of this a symposium was jointly organized by the Central TB Division (CTD), Govt. of India and ICMR - National Institute of Research in Tribal Health (NIRTH), Jabalpur on 17th and 18th December, 2019 at ICMR - NIRTH, Jabalpur. It provided an excellent platform for all the stakeholders from different parts of the country to share their experiences in tuberculosis particularly among marginalized populations. The recommendations emerged out of this interactive symposium highlight the sincere effort of NTEP to tackle TB situation in tribal population and show the way forward towards India's TB elimination goal by 2025 especially in hard to reach tribal areas.

Epidemiology and effects of sociodemographic factors on extrapulmonary tuberculosis in Ambala, India

BACKGROUND

An ambitious plan was set into motion with the aim of TB elimination from India in 2025. To achieve this, it is high time to give emphasis on other prevalent forms of TB, such as extra pulmonary TB (EPTB).

OBJECTIVES

The study aims to discern the differences in patient characteristics and management practices between pulmonary TB and EPTB using data from district Ambala.

METHODS

This retrospective study used data of 12,985 TB patients from district Ambala, India. The differences in patient characteristics and management practices between pulmonary TB and EPTB were analyzed using the NIKSHAY database.

RESULTS

In the studied population, extra pulmonary TB (EPTB) formed 29.7% of all TB cases. Among all EPTB cases, pleural TB was found to be the most common form, accounting for 27%. The study also revealed that female gender, young age, non-diabetic status, and high BMI were associated with an increased propensity to have EPTB. Interestingly, unlike pulmonary TB, which had increased odds for contracting the disease in diabetic individuals (OR - 2.02), there were no increased odds for contracting EPTB in diabetic individuals. However, HIV infection significantly increased the odds for both pulmonary TB and EPTB. The results also showed diagnostic discrepancies between the private and public sectors, along with a low microbiological confirmation rate of 7.1% in EPTB cases.

CONCLUSION

The study highlights the importance of focusing on EPTB in addition to pulmonary TB for effective TB elimination in India. The differences in patient characteristics and management practices warrant further investigation and targeted interventions for both forms of the disease. Efforts should be made to improve diagnostic accuracy and reduce discrepancies between the private and public sectors.

New National Tuberculosis Elimination Program(NTEP) logo: Observation and comments

The new National Tuberculosis Elimination Program (NTEP) launched with its new logo in early 2020. Logo have been launched is circular with yellow and red colour. Name of program is in circular and with caption "TB Harega Desh Jeetega". There is red colour joyful person surrounded by National Flag with image of lung in the logo. Present letter highlights observation and comments on the new NTEP logo.

To study the impact of active case finding (ACF) among the TB patients detected in South Delhi

BACKGROUND

TB is one of the top 10 causes of death worldwide. The WHO adopted the End TB Strategy with ambitious goal of ending the global TB epidemic by 2030. The targets for this were 95% reduction in number of TB deaths, 90% reduction in TB incidence rate between 2015 and 2035 and to ensure that no family is burdened with catastrophic expenditure due to TB. Enhanced case detection is one of the components of End TB strategy adopted by WHO and within this Active Case Finding has an important place. However, its role in the Indian context needs to be assessed.

AIMS AND OBJECTIVES

To study the impact of Active Case Finding (ACF) in National Tuberculosis Elimination Program (NTEP) implementing area of National Institute of TB and Respiratory Diseases New Delhi in terms of case detection and treatment outcome.

MATERIALS AND METHODS

The TB patients detected during ACF through house to house survey in vulnerable population were identified, evaluated and followed up. Data from ACF records and TB treatment cards were filled in a pretested proforma and compared with passive case detection in the previous month from same area.

RESULTS

In December 2017 a total 8600 vulnerable population (living in slums, camps and night shelters) were screened over two weeks of whom 85 were found to have symptoms suggestive of TB of whom 19 were PTB that gives a case detection rate of 220 per lakh population. PTB case detection rate by passive case finding (PCF) in November 2017 from the same area of our study was found to be 63 per lakh population. This difference between the detection rate in ACF and passive case findings was statistically significant with Z proportion test and p value <0.00001. Treatment success rate was 75% and lost to follow up rate was 25% patients among the PTB patients detected in ACF. In passive case detection from the same area in November 2017 treatment success rate was 81.8% and lost to follow up rate (LTFU) was 18% in PTB patients. Even though LTFU rate was slightly higher but was not statistically significant.

CONCLUSION

ACF is an effective way to find additional cases of TB. ACF is more labour intensive than PCF but if judiciously used under national programme to target specific vulnerable population of society it can produce additional number of TB cases which otherwise would have gone undiagnosed. However, treatment outcome for these patients is below the target and hence to get the maximum impact of ACF there is a need to enhance the adherence to treatment through different methodologies. Poor treatment adherence will lead to increase transmission risk in communities and greater chance of developing drug resistance. Further studies with larger representative population should be undertaken in order to get more conclusive.