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.     

The poorest of the poor: a poverty appraisal of households affected by visceral leishmaniasis in Bihar, India

Objective  To provide data about wealth distribution in visceral leishmanisis (VL)-affected communities compared to that of the general population of Bihar State, India.
Methods  After extensive disease risk mapping, 16 clusters with high VL transmission were selected in Bihar. An exhaustive census of all households in the clusters was conducted and socio-economic household characteristics were documented by questionnaire. Data on the general Bihar population taken from the National Family Health Survey of India were used for comparison. An asset index was developed based on Principal Components Analysis and the distribution of this asset index for the VL communities was compared with that of the general population of Bihar.
Results  83% of households in communities with high VL attack rates belonged to the two lowest quintiles of the Bihar wealth distribution. All socio-economic indicators showed significantly lower wealth for those households.
Conclusion  Visceral leishmanisis clearly affects the poorest of the poor in India. They are most vulnerable, as this vector-born disease is linked to poor housing and unhealthy habitats. The disease leads the affected households to more destitution because of its impact on household income and wealth. Support for the present VL elimination initiative is important in the fight against poverty.     

印度德里地区公私合作项目促进结核病控制的可行性和有效性

背景：印度新德里。目的：评价公私结合项目(PPM)用于加强结核病(TB)控制的可行性，并确定其对病例发现、病例管理质量、治疗效果以及对病人就诊方便程度的影响。设计：(1)通过查阅病历资料监测病人发现工作；(2)对私人开业者(PPs)治疗的病人进行队列分析；(3)通过填写调查表对病人及私人开业者进行调查。结果：共检出612例病人，其中168例(27％)为新发涂阳病人。由于私人开业者的参与，新发病人的登记率增加了47％，新发涂阳病人的登记率增加了29％。登记病人在诊断和效果评价时的痰菌检查率分别是100％和84％。私人开业者的新发菌阳病人治疗成功率为81％，与公立卫生机构的86％无显著性差异。95％的病人采用了全面监督化疗方式。结论：本公私合作项目与修正国家结核病控制规程(RNTCP)的推荐内容相一致，是在政府资助下完成的，并在实施过程中得到一些政府和私人组织的支持。通过实施本项目提高了病例发现率，接受私人开业者全面监督化疗病人的治疗效果同样也令人满意。     

Feasibility and effectiveness of a public-private mix project for improved TB control in Delhi, India.

SETTING: New Delhi, India. OBJECTIVE: To assess the feasibility of a public-private mix (PPM) project for improved tuberculosis (TB) control and determine its impact on case detection, case-management quality, treatment outcome and patient convenience. DESIGN: 1) Monitoring of case detection through the review of record data; 2) cohort analysis of patients treated by private providers (PPs); 3) questionnaire-based surveys of patients and private providers. RESULTS: A total of 612 cases were detected, of whom 168 (27%) were new sputum-positive cases. Incremental case notification due to PPs was 47% for new cases and 29% for new sputum-positive cases. Sputum examination for diagnosis and evaluation was performed in 100% and 84%, respectively, of notified patients. The treatment success rate for new sputum-positive cases treated by PPs was 81%, which was not significantly different from the 86% in the public sector. Directly observed treatment (DOT) was confirmed by 95% of patients. CONCLUSIONS: This PPM project, carried out with government funding in accordance with the RNTCP recommendations and with the support from several government and private organisations, achieved improved case detection as well as acceptable treatment outcome for patients receiving DOT from PPs.     

MDR- and XDR-TB among suspected drug-resistant TB patients in a tertiary care hospital in India

Aim: To study the anti‐tubercular drug resistance pattern among suspected cases of drug‐resistant TB. Materials and Methods: First and second line drug susceptibility data were retrospectively analysed for all suspected cases of drug‐resistant tuberculosis (TB), presenting to the Pulmonary Medicine department of tertiary care hospital in South India from 2003 to 2007. Results and Discussion: Out of 177 cases of suspected drug‐resistant TB, 103 (58.2%) cases were multi‐drug‐resistant tuberculosis (MDR‐TB). Out of 75 cases of MDR‐TB for whom second‐line drug susceptibility test was performed, 45 (60.0%) cases met the criteria of extensively drug–resistant (XDR) TB, which is very high when compared with existing worldwide data on XDR‐TB (6.6% cases of MDR‐TB). In comparison with non‐MDR‐TB cases, MDR and XDR‐TB cases had a history of significantly higher duration of anti‐TB treatment (ATT) and significantly higher exposure to multiple ATT regimens. Past exposure to second‐line anti‐TB drugs was significantly high in XDR‐TB cases than in MDR‐TB and non MDR‐TB cases. Conclusion: This study highlights the high burden of XDR‐ and MDR‐TB among TB patients coming to tertiary care hospitals in India. Please cite this paper as: James P, Gupta R, Christopher DJ, Thankagunam B and Veeraraghavan B. MDR and XDR‐TB among suspected drug resistant TB patients in a tertiary care hospital in India. Clin Respir J 2011; 5: 19–25.     

Trends and sub-national disparities in TB notifications in India: Insights from HMIS data

Background/objectivesTuberculosis (TB) is a public health crisis across the globe, especially in the developing world including India. Around 27% of 10 million TB cases and 33% of 1.2 million TB deaths were contributed from India alone during 2018. Present study aims to estimate TB notification rates at national and sub-national levels up to District administrative blocks, which is very important with policy perspective.MethodsThe study mainly uses data from India's Health Management Information System (HMIS) for three consecutive years, 2017-18, 2018-19 and 2019-20. TB notification rates were calculated for India up to the lowest administrative level of health Districts. GIS maps were being used for mapping District-wise TB notification rates for 2017-18 and 2019-20.ResultsResults show that TB notification rates have increased from 152/lakh population in 2017-18 to 197 in 2019-20, an increase of 30%. Similarly, the increasing trends in TB notification rates were also observed at State as well as District level. However, wide rural-urban and public-private differences were observed in TB notification rates. Further, results illustrated huge inter-State and inter-District variations; and half of the TB cases in India were contributed only by six larger States.ConclusionsThe findings of the study shows the increasing notification in India since 2017-18, which is a clear indication of the efforts put in the TB program to achieve targets and goals committed to end TB by 2025. In this regard present estimates based on HMIS data significantly contributes to the policy formulation even at the lowest administrative level of health Districts.     

辽宁省鞍山市社区结核病防治探讨

目的探讨鞍山市社区防治管理办法。方法鞍山市结防所成立结核病防治服务科，管理社区防痨工作者和社区防痨工作志愿者，设置兼职社区监化点。加强社区宣传教育，加大政府干预措施。结果1999-2003年共建防痨网点280个，培训防痨工作者158名，招募防痨志愿者493名。大大提高结核病人的发现水平。同时扩大了市级防治半径，方便周边农村结核病人就诊。市民对结核病知晓率从2000年71．2％上升到2004年的95．6％。结论鞍山市充分发挥社区防痨工作者和防痨志愿者的作用，使居民结核病知晓率、肺结核的发现率和治愈率均有提高，是可行的方法。     

Poverty indicators and mental health functioning among adults living with HIV in Delhi,India

Poor mental health functioning among persons living with HIV (PLHIV) has gained considerable attention particularly in low-income countries that disproportionately carry the global HIV/AIDS burden. Fewer studies, however, have examined the relationship between poverty indicators and mental health among PHLIV in India. Based on this cross-sectional study of 196 HIV-seropositive adults who received medical services at Shalom AIDS Project in Delhi, India, structural equation modeling and mediation analysis were employed to estimate the associations between poverty indices (household asset index, food security, unemployment, water treatment, sanitation), HIV-health factors (illness in the past 3 months, co-morbid medical conditions), and psychological distress. In the final model, ownership of fewer household assets was associated with higher levels of food insecurity, which in turn was associated with higher psychological distress. Also, the household asset index, food insecurity, and unemployment had a larger effect on psychological distress than new opportunistic infections. These findings build on increasing evidence that support concerted efforts to design, evaluate, and refine HIV mental health interventions that are mainstreamed with livelihood programming in high poverty regions in India.     

Tuberculosis (TB) intervention model targeting mobile population of truckers in Delhi,India

Collaborative TB and HIV prevention and management activities are essential for reducing the burden of TB disease and achieving favorable outcomes by ensuring early initiation of antiretroviral therapy in the comorbid patients. The Mobile population of truckers and helpers is at higher risk of HIV and also TB infection.ObjectiveThe present study assessed the feasibility and opportunities for integrating TB screening and anti-tubercular drug dispensation services to truckers as an additional service utilizing the existing infrastructure and human resources of a targeted intervention (TI) based STI (Khushi) clinic and an integrated counseling and testing center (ICTC) operating at a transport hub and transshipment site in Delhi, India.MethodsThis exploratory operational research study was conducted at the Sanjay Gandhi Transport Nagar (SGTN), off the GT-Karnal highway, in North-west district of Delhi, the Indian capital city during May–Nov’ 2016.The proposed methodology for integration of comprehensive TB services within the existing STI/HIV services for the trucker population included a prevention and awareness component using interpersonal sessions, transporter meeting, one-on-one group session and IEC/BCC sessions utilizing a surround and engage technique. TB diagnostic testing and treatment services were provided through the collaboration with the TI/Khushi clinic and ICTC center staff aided by the field assistants.ResultsOverall, a total of 833 activity sessions were conducted during the study period among the truckers at the SGTN. During these sessions, 14644 truckers and 1444 other individuals were covered. A total of 297 truckers and 30 other people were referred for testing out of which 283 truckers and 33 others were tested for TB. Of these, ten truckers and four other individuals were found positive for TB.DiscussionThe present study provides the first patient (truckers) level evidence from India that routine, provider-initiated voluntary TB testing of truckers coming to avail services at STI and ICTC clinics for prevention and screening of HIV-AIDS is possible. The current practice of referral of HIV patients from the ICTC center to the chest clinic is inefficient since the opportunity costs and financial implications involved may deter patients from testing while the HIV negative but presumptive TB patients are likely to be missed. However, for this collaborative partnership to be successful, further investment regarding human and financial resources is necessary. Existing staff needs sensitization, training and proper incentives for conducting TB related IEC/BCC activities along with that for HIV-AIDS. Furthermore, the deployment of additional personnel is preferable for sputum collection and TB testing with the availability of early reporting at site.     

辽宁省鞍山市社区结核病防治探讨

目的探讨鞍山市社区防治管理办法。方法鞍山市结防所成立结核病防治服务科,管理社区防痨工作者和社区防痨工作志愿者,设置兼职社区监化点。加强社区宣传教育,加大政府干预措施。结果1999—2003年共建防痨网点280个,培训防痨工作者158名,招募防痨志愿者493名。大大提高结核病人的发现水平。同时扩大了市级防治半径,方便周边农村结核病人就诊。市民对结核病知晓率从2000年71.2%上升到2004年的95.6%。结论鞍山市充分发挥社区防痨工作者和防痨志愿者的作用,使居民结核病知晓率、肺结核的发现率和治愈率均有提高,是可行的方法。     

The performance and limitation of T-SPOT.TB for the diagnosis of TB in a high prevalence setting

Background

Tuberculosis (TB) diagnosis remains difficulty. The previous reports have shown that the T-SPOT.TB assay may be a more promising diagnostic tool for TB, however, it needs a further study to evaluate the diagnostic value of T-SPOT.TB for the specific populations in a high prevalence setting.

Methods

In this present study, we conducted stratified and comparable analyses to explore the clinical value and the limitation of T-SPOT.TB assay in TB diagnosis in a high TB prevalence setting, Southern China. A total of 413 subjects including 163 pulmonary TB (PTB), 39 extrapulmonary TB (EPTB), 106 non-TB pulmonary diseases (NTBPDs), 20 medical staff and 85 healthy controls were included in the study.

Results

According to T-SPOT.TB, there had a high incidence of latent TB infection (LTBI) in general population in Southern China, especially in the NTBPDS and medical staff. The T-SPOT.TB had a high performance in the diagnosis of active TB (ATB) in a lower risk of TB infection population such as the general population, however, the T-SPOT.TB for the diagnosis of ATB in the high risk of TB infection populations involving close contacts such as the patients with pulmonary diseases (PD) or medical staff isn’t reliable due to the interference by LTBI. Under this condition, the value of rule-out of the assay was seemed to be better than that of rule-in. We believed that the T-SPOT.TB is suitable for screening both the EPTB and the ATB combined with diabetes mellitus (DM). However, we found that the sensitivity of T-SPOT.TB in sputum smear-negative population wasn’t as high as that in smear-positive population.

Conclusions

The T-SPOT.TB testing results should be interpreted with caution combined with subject’s characteristics in a high prevalence setting.     

Impact of poverty on the prevalence of diabetes and its complications in urban southern India.

AIM: The impact of poverty on the profile of diabetes and its complications was studied. METHODS: A comparative study of low income group (LIG) (family income Rs. < 30,000/annum (approx. 432 pounds sterling) and high income group (HIG) (family income Rs. greater-than-or-equal 60,000/annum (approx. pounds sterling) subjects of > or = 40 years was done in Madras, India. By screening 1748 LIG subjects (M/W 844/904) 301 diabetic subjects were identified and 218 underwent tests for diabetic complications. Population data available in 635 (M/W 309/326) HIG subjects from the survey were used for comparison of glucose tolerance profile. Complications were studied in 221 diabetic HIG subjects. RESULTS: Age-standardized prevalences of diabetes (12.6% vs. 25.5%; chi(2) = 56.9, P < 0.0001) and impaired glucose tolerance (IGT) (8.9% vs. 19.0%) were significantly lower (chi(2) = 57.7; P < 0.0001) in the LIG. Hypertension was more common in LIG (53.7% vs. 40.0% in HIG; chi(2) = 34.9; P < 0.0001). LIG subjects were more physically active; 73.8% did not go to school. Parameters significantly associated with diabetes were body mass index (BMI), age, higher income, waist--hip ratio and physical inactivity. Higher income, BMI and age were associated with IGT. Diabetic LIG subjects had a higher prevalence of cardiac disease, neuropathy and cataract and a lower prevalence of retinopathy than HIG subjects. The risk variables such as hyperglycaemia, dyslipidaemia, hypertension, smoking and alcohol consumption were more in the LIG group. CONCLUSIONS: The urban poor in the developing world has a lower prevalence of diabetes than the urban poor in developed societies. However, they have higher rates of complications of diabetes.     

Adherence to Isoniazid Preventive Therapy among children living with tuberculosis patients in Delhi,India: An exploratory prospective study

INH Preventive Therapy (IPT) substantially reduces the risk of incidence of TB disease in pediatric household contacts of TB patients. The National TB Elimination Program (NTEP) of India prescribes a daily regimen of Isoniazid to all under-6 pediatric contacts for 6 months duration.We conducted, this exploratory prospective study (June to Nov’ 2020) to assess adherence to IPT and reasons for nonadherence among child contacts of microbiologically confirmed, drug sensitive, non-PLHIV Tuberculosis patients in Delhi, India. The study outcomes included the initiation, adherence and completion of IPT. The caregivers of the child TB contacts were interviewed face to face by the field investigator. The data were entered on EpiData 3.1 and analysed with IBM SPSS 25.The INH adherence was assessed in a total of 86 household child TB contacts. IPT had been initiated in 62 (72.1%) child TB contacts of which 61 (98.4%) received INH within 1 month of starting of ATT-DOTS therapy in the index TB patient of the household. Furthermore, the failure to initiate IPT was reported by 24 (27.9%) child TB contacts. Within the cohort of child TB contacts who were not initiated with IPT, the ATT-DOTS duration in the index-TB patient was ≥5 months in 18 (75%) cases, 1–2 months in 3 (12.5%) cases, and <1 month in also 3 (12.5%) cases. Reasons for non-initiation (n = 24) were reported as refusal by the family in 12 (50%) cases mostly due to concern over side-effects of the drug, while non-provision of the drug by the DOTS provider was also observed in 12 (50%) cases.The mean (SD) INH adherence in the INH initiated cohort was 5.6 (2.0) (n = 62). Reasons for INH non-adherence were attributed to forgetfulness (n = 23, 37.1%), carelessness (n = 24, 38.7%), and intermittent stopping of the medication (n = 17, 27.4%) on the child falling sick, perceived drug side effects, and running out of drug stocks.INH non-adherence defined as at-least two missed INH doses in the previous 7 days was observed in 47 (54.7%) participants (n = 86). On bivariate analysis, none of the household sociodemographic characteristics showed any statistically significant association with the rate of INH non-adherence in the child TB contacts.The findings of the present study indicate the need to periodically assess adherence and persistence to IPT in the child TB contacts as high intermittent missed dosing rates can undermine the effectiveness of IPT in preventing incident disease.     

Tuberculosis control in India: Refocus on nutrition

Many western societies have eliminated tuberculosis years before the advent of potent anti-tuberculous drugs, as a result of the improved standards of living and good nutrition. But even with the availability of powerful anti-tuberculous drugs, India still has a long road ahead to reach the “End TB by 2025” goal. One of the major reason is that tuberculosis control program in India till now have focused primarily on case detection and medical treatment of active tuberculosis. Drug treatment alone does not completely prevent the occurrence of new infections in the community and also contributes to development of drug resistant strains if used improperly or incompletely. Although the treatment of active cases can reduce the period of transmission of disease, a significant amount of transmission to contacts occurs even before they have been diagnosed and treated. Additionally, this approach cannot prevent re-activation to active TB in the vast pool of persons with latent TB infection. Tuberculosis occurs in those with suppressed cell mediated immunity mainly due to poor nutritional status. Improving the nutritional status of the society by several social interventions hand-in-hand with utilizing the available anti-tuberculous drugs is possibly the only effective strategy. Promising programmatic guidance for nutritional support in TB patients have been formulated by the Central TB division of India but it needs a refocusing of TB control strategies towards nutrition at all levels and strong public health actions for effective implementation.     

The emergence of extensively drug-resistant tuberculosis (TB): TB/HIV coinfection, multidrug-resistant TB and the resulting public health threat from extensively drug-resistant TB, globally and in Canada

Resistance to anti-tuberculosis (TB) drugs continues to present a major challenge to global public health. Resistance usually develops due to inadequate TB management, including improper use of medications, improper treatment regimens and failure to complete the treatment course. This may be due to an erratic supply or a lack of access to treatment, as well as to patient noncompliance. However, the emergence and transmission of drug-resistant TB, including the recently detected extensively drug resistant TB (XDR-TB), is driven, in part, by the synergistic relationship between TB and HIV (TB/HIV coinfection). There is evidence that persons infected with HIV are more likely to experience XDR-TB. XDR-TB is virtually untreatable with available TB medications. XDR-TB presents a grave global public health threat, particularly in high HIV prevalence settings. The present commentary discusses the current status of XDR-TB and draws attention to the urgency in addressing this problem, for both the global and Canadian public health networks. XDR-TB and the apparent XDR-TB and HIV association warrants further study.