A detailed dissection of every tuberculosis-related death at the district level or a ‘TB death audit,’ much like the public health approach adopted by the Centre to reduce maternal deaths, will prove to be useful towards meeting India’s TB elimination goals, Soumya Swaminathan, Principal Advisor for the National TB Elimination Programme in India told The Hindu.
“Like COVID, TB is also a pandemic, but it has been around for a very long time. It affects the poor and vulnerable in every country. Even one dengue death gets picked up immediately by the media and gets reported. Still, 800 to 900 people die every day of TB in the country, but the news of a TB death hardly ever makes it to the newspaper,” she said.
Challenges facing NTEP
Dr. Swaminathan noted that among the challenges facing the National TB Elimination Programme (NTEP) is the further reduction in TB mortality rates to meet the End TB and Sustainable Development Goals (SDG) targets. From an estimated 35 deaths per 1,00,000 population in 2015, India has brought down this rate to 22 per 1,00,000 according to the latest official data. “However, we still have case fatality rates ranging from 5% to 10% in different states. These rates are higher for drug-resistant TB. These deaths are mostly happening in the economically-productive age group of 25 to 55 years,” she said.
Case fatality rate is the proportion of people who die from a specified disease among all individuals diagnosed with the disease over a certain period of time. It is calculated by dividing the number of deaths from a disease over a defined period of time by the number of individuals diagnosed with the disease during that time; the resulting ratio is then multiplied by 100 to yield a percentage.
TB Death Audit
India has significantly reduced its maternal mortality rate (MMR) by expanding the scope for institutional delivery, better antenatal and postnatal care and by undertaking district-wise maternal death audits, which are headed by the district collectors. “Everyone has to sit and explain why that (maternal) death happened and how it could have been prevented. Can we adopt a similar approach for TB?,” asks Dr. Swaminathan.
“The district collector should be aware of how many TB deaths occur, and non-programme partners should be engaged in audits of randomly selected cases. These could be community medicine departments of nearby medical colleges or public health institutes. It should not be the TB programme itself that does the death audits. TB deaths should be presented, analysed along with reasons, and the discussions could lead to improvements in service delivery,” she added. The deaths are most likely caused by a combination of complications due to TB, along with social and economic risk factors.
Citing an example, Dr. Swaminathan says that the National Institute of TB and Respiratory Diseases runs a ‘difficult to treat’ virtual TB clinic (using the ECHO platform), where cases are presented and discussed every month, for the benefit of doctors and nurses across the country. The case of a 19-year-old belonging to a poor migrant family who succumbed to TB in Delhi was presented. Her father had previously died of TB and her sister had also contracted the infection. “They worked as housemaids and had initially sought treatment with private doctors. By the time she got admitted to NITRD, she had extensive bilateral TB and was in respiratory failure. The fact that a 19-year-old girl died of drug sensitive TB points to the need for every patient to be notified and followed up by the TB programme. Any number of such cases are occurring every day. Are we paying attention and trying to improve the system?”
Soumya Swaminathan, Principal Advisor for the National TB Elimination Programme in India. File
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Ravindran R
Tamil Nadu model for reducing TB deaths
Tamil Nadu’s Kasanoi Erappila Thittam (TN-KET) meaning ‘TB death free project,’ was jointly started by the Indian Council of Medical Research’s National Institute of Epidemiology (NIE) and the State government for all aged 15 years and older with drug-susceptible TB notified by public facilities, with a goal to reduce deaths by 30% in this group.
According to NIE data, during April – June 2022, 14,961 TB patients were notified out of which 11599 (78%) were triaged. It was found that of these 1509 (13%) were at high risk of severe illness. Of these 48% were severely undernourished, another 50% had respiratory insufficiency, and 29% were unable to stand without support, with overlap between criteria. Of the 1509 patients, 1128 (75%) were assessed at a nodal inpatient care facility. Of these, 993 were confirmed as severely ill, and 909 (92%) were admitted. Of those admitted 4% patients succumbed to their illness. As a result of implementing TN-KET, Tamil Nadu now routinely captures BMI data for all adults with TB (notified from public facilities). The programme has also shone a light the need for capacity-building of TN-KET nodal inpatient care facilities in clinical management of very severe undernutrition in adults.
In the southern States, people have co-morbidities such as diabetes, alcoholism and in the north, there is severe malnutrition and severe anaemia, Dr. Swaminathan observed. In any case, every TB patient must be clinically evaluated for co-morbidities and risk factors and these should be treated too. At times, hospitals refuse admission to TB patients. “There has to be an order, where a TB patient cannot be refused admission and if patients are admitted to Pradhan Mantri Jan Arogya Yojana (PM-JAY) empanelled hospitals, the hospitals are compensated for admitting a severely ill TB patient,” she emphasised.
Dr. Swaminathan pressed on the need to prioritise reducing TB deaths, along with reducing prevalence, and incidence of the disease. “China has a death rate of 3 per 1,00,000 from TB, while India has a death rate of 22 per 1,00,000. We need to find gaps, address them and have an ambitious plan,” she said. “Our short-term focus, in the next National Strategic Plan is to reduce TB mortality. Incidence reduction will take time, whatever we do, because we don’t have a highly efficacious vaccine. Unless we start finding everyone and treating them, we will not have a rapid incidence reduction.”
Need for widespread screening
Dr Swaminathan said that the National TB prevalence Survey and State-specific Prevalence Surveys in Gujarat, Rajasthan and so on reveal that sub-clinical TB accounts for 40% to 50% of cases. “Which means, you will not pick them up with symptom screening and our national programme was entirely based on symptom screening. So, we were straightaway missing half of the active TB in population,” she said.
According to her, the solution is to have widespread use of X-ray backed up by an AI algorithm. “The hand-held X-ray technology with AI is green-lighted by the World Health Organization (WHO), STOP TB Partnership and ICMR. In fact, six government hospitals in Mumbai applied X-ray screening and their case notifications went up by 10% to 12%,” she stated.
Upfront molecular testing until last year in India was 30%. The 100-day TB elimination campaign aimed at strengthening diagnostics and linkage to treatment, as well as efforts by CTD to expand upfront molecular testing, should pay dividends this year, she added. Upfront molecular testing involves offering tests which can pick up TB as well as drug-resistance to TB bacteria leading to accurate treatment, which improves chances of the patient’s recovery.
Screening of household contacts should be made convenient, as they cannot be expected to spend days in going and getting themselves screened. This can happen now with the highly portable handheld X-ray devices, which many States have started using.
The crucial role of nutrition
She also emphasised on providing good nutrition to TB patients and their families. “The RATIONS trials led by Anurag Bhargava in Jharkhand among a population with BMI as low as 16 and 17 has demonstrated that almost 50% secondary household cases could be prevented just by providing good nutritional support. We don’t yet have a vaccine with 50% efficacy, so if we give adequate calories and protein, it acts like natural protector from bacteria.”
Commenting on the Ni-kshay Mitra Programme floated by the Centre for nutrition support to TB patients, Dr. Swaminathan said that while the goal was laudable, its success depends on volunteers coming forward to donate nutrition support and this may not be uniform across all geographies. “Also, the ability to deliver it (nutritional support) may be limited in remote areas,” she emphasised. The government’s move to double the amount meted out under the Direct Benefit Transfer (DBT) – (an earlier amount of Rs. 500 per month provided to TB patients during treatment, has now been increased to Rs. 1000) would go a long way towards meeting the patients nutritional needs, and more research is needed in ways to improve the family’s nutritional status, wherever needed.
