National Tuberculosis Elimination Programme Research Articles

Need for operational simplicity and timely disbursal of benefits—a qualitative exploration of the implementation of a direct benefit transfer scheme for persons with tuberculosis in India

BackgroundNi-kshay Poshan Yojana (NPY) is a direct benefit transfer scheme of the Government of India introduced in 2018 to support the additional nutritional requirements of persons with TB (PwTB). Our recent nationwide evaluation of implementation and utilization of NPY using programmatic data of PwTB from nine randomly selected Indian states, reported a 70% coverage and high median delay in benefit credit. We undertook a qualitative study between January and July 2023, to understand the detailed implementation process of NPY and explore the enablers and barriers to effective implementation and utilization of the NPY scheme.MethodsWe followed a grounded theory approach to inductively develop theoretical explanations for social phenomena through data generated from multiple sources. We conducted 36 in-depth interviews of national, district and field-level staff of the National Tuberculosis Elimination Programme (NTEP) and NPY beneficiaries from 30 districts across nine states of India, selected using theoretical sampling. An analytical framework developed through inductive coding of a set of six interviews, guided the coding of the subsequent interviews. Categories and themes emerged through constant comparison and the data collection continued until theoretical saturation.ResultsStakeholders perceived NPY as a beneficial initiative. Strong political commitment from the state administration, mainstreaming of NTEP work with the district public healthcare delivery system, availability of good geographic and internet connectivity and state-specific grievance redressal mechanisms and innovations were identified as enablers of implementation. However, the complex, multi-level benefit approval process, difficulties in accessing banking services, perceived inadequacy of benefits and overworked human resources in the NTEP were identified as barriers to implementation and utilization.ConclusionThe optimal utilization of NPY is enabled by strong political commitment and challenged by its lengthy implementation process and delayed disbursal of benefits. We recommend greater operational simplicity in NPY implementation, integrating NTEP activities with the public health system to reduce the burden on the program staff, and revising the benefit amount more equitably.

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

ABSTRACT 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.

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.

Clinicoradiological Profile of Patients Having Drug-Sensitive Pulmonary Tuberculosis With and Without Diabetes Mellitus in a Tertiary Care Hospital in Ahmedabad, Gujarat, India.

Background A significant effect of diabetes mellitus (DM) on the clinical and radiological features of tuberculosis (TB) has been reported. However, conflicting results have also been reported. Hence, a conclusion is yet to be drawn. This study aimed to analyze and compare the clinical and radiological features of drug-sensitive pulmonary TB with DM and without DM. Methodology A comparative, observational study was conducted between August and October 2023. Patients with drug-resistant TB, extrapulmonary TB, those on immunosuppressive drugs, and human immunodeficiency virus-positive individuals were excluded from this study. Pulmonary TB patients with DM were classified as the case group and those without DM were classified as the control group. Demographic details, clinical symptoms, detailed past and family histories of comorbid conditions, laboratory investigations, sputum acid-fast bacilli results, and chest X-ray findings were noted. The diagnosis of TB and grading of sputum smear results were done by following the National Tuberculosis Elimination Program guidelines. Results A total of 40 patients, 20 (50%) cases and 20 (50%) controls, were enrolled in this study. Clinical symptoms were almost similar in both groups except for dyspnea (80% vs. 40%) and hemoptysis (75% vs. 35%), which were significantly predominant in the case group. Lower zone involvement in chest X-ray was significantly (p = 0.0079) more in the case group (75%) compared to the control group (40%). Cavitary lesions were also significantly higher in the TB with DM group (p = 0.031). Bilateral lesions and multiple zone involvement were also more common in the case group, although no statistically significant difference was seen. Additionally, thehematological parameters of the two groups differed; however, the findings were not statistically significant. Conclusions Based on our findings, we recommend screening all TB patients for DM. Similarly, all high-risk DM patients should be screened for TB for early diagnosis and management, thereby reducing morbidity and mortality. Physicians should be aware that people with DM may present with pulmonary TB in an atypical manner.

Private Sector Involvement in Tuberculosis Control in An Urban City of Western India– A Cross-Sectional Study

Background: In India, TB diagnosis and treatment practices among Private Practitioners (PPs) vary widely and are not properly regulated by the national TB program. Despite their irrational and inequitable practises, PPs remain an important and preferred primary care provider for many people. The study was done to with the objectives to describe different diagnosis and treatment practices of Tuberculosis among private practitioners and their involvement in National Tuberculosis Elimination Program (NTEP). Material and Methods: A cross sectional study was performed among 303 PPs during October 2020 to March 2021 by using stratified random sampling to select private practitioners based on their speciality. Results: Most preferred investigation was Chest X ray (45.2%) followed by sputum smear microscopy (29.7%). Only 71.3% PPs practiced the correct regimen for new cases of Pulmonary TB according to NTEP. More than half of the PPs had TB training (59.7%). Majority of the PPs (90.1%) were involved in NTEP mainly by referral of TB patients to local government centres for treatment purpose. Conclusion: Preferred investigation for diagnosis of pulmonary TB was chest X-ray followed by sputum examination among PPs. The treatment regimen and duration of treatment varies among PPs as per their clinical judgement and practice.

IJCM_311A: Epidemiological profile of tuberculosis cases at an urban slum in a metropolitan city a cross sectional study

Background: The WHO Global Tuberculosis Programme works towards the goal of a world free of TB, with zero deaths, disease and suffering due to the disease. Tuberculosis (TB) is a preventable and usually curable disease. Yet in 2022, TB was the worlds second leading cause of death from a single infectious agent, after coronavirus disease (COVID-19). The reported global number of people newly diagnosed with TB was 7.5 million in 2022; this is the highest number since WHO began global TB monitoring in 1995. Around 87% of new TB cases occurred in the 30 high TB burden countries, with more than two-thirds of the global total in Bangladesh, China, Democratic Republic of the Congo, India, Indonesia, Nigeria, Pakistan and the Philippines. Objective: To study the epidemiological profile of tuberculosis cases in an urban slum of Mumbai. Methodology: A retrospective record-based analysis of secondary data on tuberculosis (pulmonary and extrapulmonary) reported on the NIKSHAY portal between January to December 2022 at an urban health training center in an urban slum in Mumbai. Results: The total number of drug sensitive TB cases reported in 2022 was 519. Males constituted 42% and females 58%. The most common age group affected was 20-29 years. Pulmonary cases comprised 66.9% of the cases. The total number of Drug resistant TB cases reported were 75, 53 were pulmonary & 22 were extrapulmonary. Conclusion: In contrast to Male predominance (52.26%) of cases in Maharashtra, the urban slum had 42% males affected. India grapples with multiple challenges in combatting tuberculosis (TB), marked by a high disease burden, diagnostic delays, drug resistance, and socioeconomic barriers. While significant strides have been made through programs like the National Tuberculosis Elimination Program, the path to eradication demands continued efforts.

IJCM_275A: Implementation of WHO recommended 4-Symptom Screening Tool for tuberculosis in Northern India

Background: World Health Organization (WHO) suggests using symptom- based screening tools to improve early detection of tuberculosis (TB). The WHO recommended 4-symptom screening (W4SS) is one such tool. Although, found to be effective in screening TB among HIV patients, its implementation among general patients have not been well-studied. Objectives: To assess the predictive value of W4SS in TB screening among outpatients and inpatients in North India. Methodology: A prospective cohort study starting July 1, 2023 included patients in the outdoor or indoor of any department (except Chest TB). Patients were screened with W4SS (cough > 2 weeks, fever > 2 weeks, significant weight loss, night sweats). A presumptive TB case (presence of any one symptom), was further examined by the Chest TB consultant, completing the diagnostic algorithm as per National Tuberculosis Elimination Program guidelines for final diagnosis. Data were collected using a semi-structured study proforma and analysed using JAMOVI version 2.0, an open-source software for statistical analysis. Results: During 5 months of data collection, 8609 patients were screened for TB using the W4SS. Of these, 201 (2.3%) were W4SS positive, and of W4SS positive, 25 had confirmed diagnosis of TB. The positive predictive value of W4SS was 12.4% (95% confidence interval 10.9% to 14.1%). Among W4SS positive patients, being unmarried (p value < 0.05), uneducated (p value < 0.05), family history of TB (p value < 0.01), fever (p value < 0.01), significant weight loss (p value < 0.01) and night sweats (p value < 0.01) were significantly associated with final diagnosis of TB. Age, gender, employment and presence of cough were not significantly associated with confirmed diagnosis of TB among W4SS positive patients. Conclusion: W4SS in its present form has limited usability in screening general patients for TB. A multi-centric study is required to improve the scale.

Does nutritional support under programmatic settings result in weight and body mass index changes among tuberculosis patients? Evidence on the impact of nutritional support through Pradhan Mantri Tuberculosis Mukt Bharat Abhiyan under national tuberculosis elimination programme from Ramgarh district of Jharkhand

Background: To increase community participation in tuberculosis (TB) elimination efforts, the government of India has launched ‘Pradhan Mantri TB Mukt Bharath Abhiyan’ (PMTBMBA) under the national TB elimination programme. The scheme allows interested parties (Ni-kshay mitras) to offer nutritional support to TB patients. This study aims to understand the impact of such a support in improving weight and body mass index (BMI) among TB patients as most available evidence comes from research settings. Methods: This is a retrospective cross-sectional study carried out in Ramgarh district of Jharkhand, India, for the period first quarter 2023. Relevant data was extracted from Ni-kshay web portal and TB treatment cards. The data is analyzed using excel 365. Results: Of the 114 participants, 69 received nutritional support during the entire duration of treatment and 45 received support partially. Single factor ANOVA on weight and BMI gain revealed statistically significant difference in mean weight/BMI between the two groups with F (1, 110)=35.4660, p=3.16×10-08 and F (1, 110)=22.9994, p=5.12×10-06. Correlation analysis showed a moderate correlation between the number of nutritional kits received and the weight/BMI gain with correlation coefficients r=0.5, p=1.07×10-07 and r=0.4, p=1.65×10-05 respectively. Conclusions: The study concludes that the impact of nutritional supplementation in programmatic setting is comparable with that of implementation research study settings.

Knowledge and practices of private healthcare providers regarding tuberculosis case notification in Rural Maharashtra

India carries the highest share of active and missing tuberculosis (TB) cases globally. The Government of India is prioritizing private sector engagement (PSE) in TB elimination activities, as most healthcare-seeking in the country happens in this sector. This study aimed to understand the knowledge and practices of private healthcare providers (PHP) on various aspects of TB case notification through the National TB Elimination Programme (NTEP). This cross-sectional study was carried out between Oct 2020 to April 2021 amongst PHPs in the Junnar Tuberculosis Unit (TU), Pune District, Maharashtra. Junnar Block has 299 PHPs who assess, diagnose, and/or treat TB cases. A total of 97 participants were enrolled in the study. About 89 (91.8%) PHPs are aware that TB case notifications are mandatory by law. However, 80.4% are unaware of the Ni-kshay portal (web-based case surveillance system) by NTEP. Similarly, 74 (76.3%) must be aware of incentives for PHPs to collaborate with the government healthcare delivery system. 82.8% of total Ayurveda, Unani, Naturopathy, Siddha, and Homeopathy (AYUSH) practitioners and 46.2% of Allopathic practitioners have poor knowledge about TB case notification, with a Chi-square value of 14.36 (p<0.01). Our study shows that the active engagement of private providers (PPs), especially AYUSH practitioners in rural areas, is a need of the hour in achieving TB elimination.

Assessing the social burden of tuberculosis and trends in TB targets: A focus on sustainable development goals

BackgroundTuberculosis (TB) is a serious public health issue that is linked to social burden and unfavourable health outcomes. With regards to the Sustainable Development Goals (SDG) targets, this study evaluated the social burden endured by patients and analyzed catastrophic costs, and measured TB incidence and death rates. MethodsCross sectional study, with 312 TB patients registered with the National Tuberculosis Elimination Programme (NTEP) were studied. Social burden, direct and indirect costs, and catastrophic costs were evaluated. TB incidence and death rates are calculated. ResultsThe majority of participants (70.8%) were men and married. Patients in substantial numbers reported losing their jobs and having limited access to community events. While divorcees, older age groups, and women were more likely to experience direct catastrophic costs, men and 33–44 years age group were more likely to experience indirect catastrophic costs. The overall catastrophic expenses exceeding 20% of income were observed in male patients, those over 55 years, and patients from nuclear families. The TB incidence rate decreased by 1.8% between 2017 and 2019, with a substantial reduction among males but an alarming increase among females. The death rate experienced a slight rise of 0.27%, with higher rates observed in females compared to males. ConclusionPersistent social stigma and the presence of catastrophic costs associated with tuberculosis remain prevalent issues. A multifaceted approach, including enhancing access to healthcare services, implementing awareness campaigns aimed at reducing stigma, expanding TB control and prevention programs is needed. Government interventions aimed at alleviating financial burdens are crucial.

Urinary lipoarabinomannan in individuals with sputum-negative pulmonary tuberculosis.

Tuberculosis (TB) is a major global cause of ill health. Sputum microscopy for confirmation of presumptive pulmonary TB (PTB) has a reportedly low sensitivity of 22-43 per cent for single smear and up to 60 per cent under optimal conditions. National TB Elimination Programme in India recommends the use of cartridge-based nucleic acid amplification test (CBNAAT) and culture for microbiological confirmation in presumptive PTB individuals with sputum smear negative test. The use of lateral flow urine lipoarabinomannan (LF-LAM) is usually recommended for the diagnosis of TB in HIV-positive individuals with low CD4 counts or those who are seriously ill. The objective of this study was to detect urinary LAM using cage nanotechnology that does not require a physiologic or immunologic consequence of HIV infection for LAM quantification in human urine in 50 HIV-seronegative sputum smear-negative PTB individuals. To study the diagnostic value of urinary LAM in sputum smear negative PTB individuals, a cage based nanotechnology ELISA technique was used for urinary LAM in three different groups of participants. Fifty smears negative PTB clinically diagnosed, 15 smear positive PTB and 15 post TB sequel individuals. Sputum was tested by smear, CBNAAT, and culture along with urine LAM before treatment. The results were interpreted by ROC curve in comparison to the standard tests like CBNAAT and culture. The mean urinary LAM value was 0.84 ng/ml in 37 culture-positive [Mycobacterium tuberculosis (M.tb)] and 0.49 ng/ml in 13 culture-negative (M.tb) smear-negative individuals with PTB, respectively. In 47 smear-negative PTB cases with microbiologically confirmed TB by CBNAAT, the mean urinary LAM was 0.76 ng/ml. The mean urinary LAM in post-TB sequel individuals was 0.47 ng/ml. As per the receiver operating characteristic curve, cut-off value of urinary LAM in individuals with smear-negative PTB microbiologically confirmed by: (i) CBNAAT was 0.695 ng/ml and (ii) culture was 0.615 ng/ml. The findings of this study suggest that individuals with smear-negative PTB and a urinary LAM value of >0.615 ng/ml were most likely to have microbiological confirmed TB while those with a LAM value <0.615 ng/ml >0.478 ng/ml are less likely and those with a value <0.478 ng/ml are unlikely to have microbiological confirmed TB.

Community-based Advocacy Communication Social Mobilization (ACSM) intervention by empowering key community leaders: Evaluation using the RE-AIM framework.

Based on the theme of World Tuberculosis (TB) Day 2018-"Wanted Leaders for TB free world," various studies and country-level project have witnessed how training leaders on TB has helped enhance TB awareness in the community. This study was conducted to evaluate the effectiveness of Advocacy Communication and Social Mobilization (ACSM) intervention strategy through key community leaders, using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. This study was undertaken by the Department of Community Medicine, Sri Manakula Vinayagar Medical College and Hospital (SMVMCH), Puducherry, in the field practice area of Primary Health Centre (PHC), Thirubuvanai. The STOP TB, ENGAGE-TB, and National TB Elimination Program (NTEP) guidelines were used for interventions. Key community leaders (KCL) list (N = 117) was obtained from Mannadipet commune panchayat and PHC. The study was conducted in four phases: phase 1 (baseline): quantitative data: proportion of presumptive TB cases from notification register; phase 2 (intervention): training program for staff nurses, auxiliary nurse midwife (ANM), Accredited Social Health Activist (ASHA), and Anganwadi workers (group activity), participatory rural appraisal (PRA) activity for self-help group (SHG) leaders, and health education session for religious leaders and ex-panchayat leaders; phase 3: strengthening of ongoing activity: health education session and active case finding for TB; and phase 4: end line: outcome of the intervention, evaluated using the RE-AIM framework. As an outcome of the intervention, there was a marginal increase (21 cases) in the proportion of presumptive TB cases when comparing before (2018) and after (2019) intervention. The proportion of presumptive TB cases identified and referred by KCL was 312. A total of 77 presumptive TB cases were identified through community-based active case finding (ACF). Two sputum samples (on the spot early morning) were collected and sent for Cartridge-based nucleic acid amplification testing (CBNAAT), of which three cases were positive. This study was community led and involved leaders from diverse backgrounds, optimizing the chance of success. For sustainability, we have initiated TB support group.

Direct benefit transfer for nutritional support of patients with TB in India—analysis of national TB program data of 3.7 million patients, 2018–2022

BackgroundPatients with TB have additional nutritional requirements and thus additional costs to the household. Ni-kshay Poshan Yojana(NPY) is a Direct Benefit Transfer (DBT) scheme under the National Tuberculosis Elimination Programme(NTEP) in India which offers INR 500 monthly to all notified patients with TB for nutritional support during the period of anti-TB treatment. Five years after its implementation, we conducted the first nationwide evaluation of NPY.MethodsIn our retrospective cohort study using programmatic data of patients notified with TB in nine randomly selected Indian states between 2018 and 2022, we estimated the proportion of patients who received at least one NPY instalment and the median time to receive the first instalment. We determined the factors associated (i) with non-receipt of NPY using a generalised linear model with Poisson family and log link and (ii) with time taken to receive first NPY benefit in 2022 using quantile regression at 50th percentile.ResultsOverall, 3,712,551 patients were notified between 2018 and 2022. During this period, the proportion who received at least one NPY instalment had increased from 56.9% to 76.1%. Non-receipt was significantly higher among patients notified by private sector (aRR 2.10;2.08,2.12), reactive for HIV (aRR 1.69;1.64,1.74) and with missing/undetermined diabetic status (aRR 2.02;1.98,2.05). The median(IQR) time to receive the first instalment had reduced from 200(109,331) days in 2018 to 91(51,149) days in 2022. Patients from private sector(106.9;106.3,107.4days), those with HIV-reactive (103.7;101.8,105.7days), DRTB(104.6;102.6,106.7days) and missing/undetermined diabetic status (115.3;114,116.6days) experienced longer delays.ConclusionsThe coverage of NPY among patients with TB had increased and the time to receipt of benefit had halved in the past five years. Three-fourths of the patients received at least one NPY instalment, more than half of whom had waited over three months to receive the first instalment. NTEP has to focus on timely transfer of benefits to enable patients to meet their additional nutritional demands, experience treatment success and avoid catastrophic expenditure.

Impact of diabetes mellitus on tuberculosis treatment outcomes: a cohort study in Bengaluru, India

Background: Tuberculosis (TB) remains a significant global health challenge, particularly in regions with a high prevalence of diabetes mellitus (DM). This study aims to evaluate the impact of DM on the treatment outcomes of TB patients in Bengaluru, India. Methods: In this cohort study, we examined 592 patients with smear-positive pulmonary TB, half of whom had a comorbid diagnosis of DM. Conducted in the Bruhat Bengaluru Mahanagara Palike area, the study included patients registered under the national TB elimination programme (NTEP). Data were collected on demographic characteristics, treatment adherence, sputum positivity, and treatment outcomes over six months. Results: The study revealed a high prevalence of DM among TB patients. Significant associations were observed between DM and various challenges, including higher rates of sputum positivity, poor adherence to anti-TB and anti-diabetic medications, increased adverse drug reactions (ADRs), and a higher default rate. TB patients with DM had a 1.5 times higher risk of unsuccessful treatment outcomes compared to non-diabetics. Furthermore, the risk of poor outcomes, particularly relapse, increased substantially in the TB-DM group during the six-month follow-up. Conclusions: Our findings highlight the crucial need for integrated TB and DM management strategies. This includes routine DM screening for TB patients, personalized treatment regimens, and enhanced patient education and support. These measures are essential for improving treatment outcomes in TB patients with comorbid DM.

"I Would Rather Die Drinking than take the Medicine": Role of Alcohol Use Disorder in Loss-to-follow-up of Tuberculosis Treatment in a Rural Area of Ballabgarh, Haryana.

Alcohol use disorder (AUD) is a significant risk factor for tuberculosis (TB) treatment loss-to-follow-up (LTFU). This field-based study was undertaken to understand the role of AUD and TB treatment LTFU and the reasons behind this association in a rural area of Ballabgarh, Haryana. TB patients who had completed their treatment and who had been LTFU were included in the study, along with the National TB Elimination Program (NTEP) staff, healthcare providers, family, and community members from Ballabgarh block of the north Indian state of Haryana. In-depth interviews (IDIs) and focused group discussions (FGDs) were conducted to gauge the perceptions of stakeholders regarding reasons for LTFU, especially in the context of alcohol use. Inductive analysis of the transcripts was done in keeping with the grounded theory, and themes with their sub-themes were identified. A conceptual framework of TB-AUD was constructed, and potential areas for intervention were determined. Fifty-eight IDIs and four FGDs were conducted in mid-2018. Almost all key informants and many patient participants believed that alcohol use makes TB patients highly susceptible to treatment LTFU. Key themes identified were shared personality traits and attitudes, combined side effects of anti-tubercular drugs and alcohol use, lack of family support, and an adverse financial situation. These findings call for a change in NTEP's approach to AUD-TB. Interventions may include collecting alcohol use information at patient enrolment and closure, integrating brief interventions for alcohol cessation in NTEP, and linking patients to deaddiction centers with the provision of appropriate dietary and financial support.

Financial hardship of tuberculosis patients registered under National Tuberculosis Elimination Programme (NTEP) in rural India: A longitudinal study

BackgroundIndia shares a significant proportion of the Tuberculosis (TB) burden of the world. TB diagnosis, treatment, and success are complicated by the chronic nature of the disease as well as additional stressors including financial, psychological, and social hardships, adverse events associated with management, and poor compliance towards anti-tuberculosis medications. MethodsThis is a longitudinal study conducted in the Tuberculosis Units (TUs) of rural field practice areas of the Department of Community Medicine and Family Medicine in a tertiary care hospital in Odisha. 168 diagnosed TB patients from the TUs were enrolled after registration in NTEP and were followed up every month for 6 months or treatment completion. TB patient's cost estimate tool was used to collect data regarding the cost incurred by the patients before and during the diagnosis as well as in the post-diagnosis or treatment period. Results and conclusionOut-of-pocket expenditure was calculated as direct, indirect, and total cost in the pre and post-diagnostic phases of the disease. The median pre and post-diagnosis direct, indirect and total costs were ₹ 12,805, ₹ 16,960 and ₹ 31,192, respectively, with almost 62 % of participants spending more than 20 % of their annual income. In this study, 41 % of participants had to stop working for more than 60 days, and 53.1 % faced distress financing due to the disease. Through this study, we found that more than half of rural TB patients still visit private health facilities, and 20 % start anti-TB drugs by purchasing them from private pharmacies, which incur substantial out-of-pocket expenditure. Most participants faced catastrophic costs associated with hospitalisation, lower family income, and a delay in disease diagnosis.

Rifampicin-induced Pancytopenia in Pulmonary Tuberculosis Patient: A Rare Presentation

Tuberculosis (TB) is prevalent throughout the world and is a major public health problem in most developing countries. In India, standardised and Directly Observed Treatment (DOT) under National Tuberculosis Elimination Programme (NTEP) is being recommended currently for drug-sensitive pulmonary TB. TB being a major health issue in developing nations like India, causes enormous death and morbidity every year. Anti-Tuberculosis Treatment (ATT) given for TB has been highly effective in fighting the disease and is generally well tolerated, with few minor side-effects. We report a 76-year-old male who was diagnosed with pulmonary TB and was on first-line four-drug anti-tubercular therapy ATT since seven days. He presented to the emergency department with loss of weight and appetite, chest tightness and vomiting. Liver Function Tests (LFT) was deranged, suggesting ATT-induced hepatitis. After normalisation of LFT, rifampicin reintroduction was initiated. Complete Blood Count (CBC) revealed pancytopenia. In bone marrow biopsy, normoblastic maturation with few micronormoblasts and megaloblast picture was seen that did not reveal any granuloma, thereby ruling out the presence of Mycobacterium tuberculosis (MTB). Iron profile and vitamin B12 levels were within normal limits. Rifampicin-induced pancytopenia is rare but its possibility should always be kept in mind while treating with ATT.

Readiness, acceptability, and feasibility of differentiated TB care for COVID-positive pulmonary tuberculosis patients diagnosed in a district in South India: Mixed methods study.

Differentiated tuberculosis care (DTC) approach is the need of the hour to mitigate those risks and provide better treatment outcomes to reduce both mortality and morbidity. Before implementing such an approach, there should be adequate literature on healthcare facility assessment along with qualitative exploration on readiness and acceptability among various stakeholders that are currently needed to fill the gaps in National Tuberculosis Elimination Program. Our study objectives were to assess the availability of equipment, treatment, and investigations for managing patients under the DTC approach, to explore the readiness, acceptability, and feasibility of the DTC approach among healthcare providers involved in TB care provision, and to determine the knowledge regarding DTC approach among healthcare providers delivering TB care for COVID-positive pulmonary TB patients. All Peripheral Health Institutes (PHIs) in two randomly chosen blocks within the Tiruchirappalli district's health units were selected for the healthcare facilities assessment. By the universal sampling method, all the stakeholders were included. The study population was assessed for their knowledge regarding DTC. Checklist-based assessment of the feasibility of healthcare services followed by a questionnaire-based knowledge assessment was done. An in-depth interview-based exploration of readiness and acceptability of the DTC approach was conducted. This study was conducted among various stakeholders involved in TB care in selected PHIs of Tiruchirappalli from July 2022 to October 2022. The majority of healthcare workers (HCWs) are unaware of bidirectional screening (89.0%) and lack training in providing TB care to COVID-co-infected patients (87.8%), although the majority were aware of risk stratification for TB patients (90.2%) and are linking TB with other co-morbidities (82.9%). About 62.2% of HCWs claimed they are not using information communication technology-based services to receive lab findings from public scans and laboratory centers, and more than one-third were unaware of these facilities. Based on the qualitative assessment, most of them were willing to undergo periodic training to improvise their approach and treatment. Also, most of the HCWs felt manpower can be increased for the specific care of the patients. The research suggests that with sufficient training and upskilling of the HCWs, DTC is almost feasible and that HCWs will accept it if specific strategies are used. More studies like these in assessing the feasibility and acceptability of this DTC approach and exploring the challenges and solutions will help the policymakers in finding the lacunae before implementing this DTC model in various states across India.

Tuberculosis Elimination in India: Where the Country Stands

Tuberculosis (TB) remains a significant public health challenge in India, with the country bearing the highest burden of TB cases globally. This article provides an overview of India's ongoing efforts towards TB elimination, highlighting both progress and persistent challenges. India's Revised National Tuberculosis Control Program (RNTCP), launched in 1997, has made remarkable strides in TB control. The introduction of the RNTCP and later its expansion as the National Tuberculosis Elimination Program (NTEP) in 2017, aimed to strengthen diagnostic and treatment services, with a focus on achieving universal access to TB care. DOTS (Directly Observed Treatment, Short-course) therapy has been a cornerstone of treatment, contributing to significant reductions in TB mortality. In recent years, India has made strides in adopting new technologies, including molecular diagnostics and telemedicine, to enhance TB case detection and patient care. The introduction of Bedaquiline and Delamanid, novel drugs for drug-resistant TB, has offered hope for patients with more resistant forms of the disease. However, the road to TB elimination in India is not without challenges. There is a pressing need for improved healthcare infrastructure, reduced stigma, and increased awareness among both the public and healthcare providers. The emergence of drug-resistant TB and the impact of the COVID-19 pandemic on TB services have posed additional hurdles. India's journey toward TB elimination is marked by significant progress and continued challenges. To achieve the ambitious goal of eliminating TB by 2025, concerted efforts are required to strengthen healthcare systems, improve diagnostic capabilities, and address social determinants of the disease.

Ni-kshay SETU, a Digital Health Intervention for Capacity Building in Tuberculosis under the National TB Elimination Program in India: A comprehensive mHealth app review

This mHealth application review explores the evolution, design, and impact of Ni-kshay SETU, a digital health intervention tailored for India's National Tuberculosis Elimination Program (NTEP). Faced with escalating TB incidences, the NTEP prioritized capacity-building, leading to the conception of Ni-kshay SETU. This review describes the narrative of Ni-kshay SETU's concept from the beginning to the present day. It starts with the National Strategic Plan 2017–25, which says that capacity building of health care workers is important for reduction of tuberculosis morbidity and mortality by 2025. The digital platform materialized as a web app with Android and iOS versions, constituting a user-friendly interface. The app, embodying a ready reckoner and decision-making tool, offers cadre-specific modules in local languages, promoting ease of comprehension and applicability. The app's development, rooted in a consultative process, aligns with the nuanced needs of healthcare personnel across various geographies and cadres. With more than 40,400 subscribers and 1,450,000 visits, Ni-kshay SETU serves as a notable example of digital health intervention, providing a comprehensive and context-aware approach to TB care. However, it's important to acknowledge the limitations of Ni-kshay SETU. While the app aims to address various challenges in TB care, its effectiveness is contingent on factors such as digital literacy and access to smartphones. Additionally, the app's success relies on consistent updates and continuous user engagement for its usage, posing potential challenges in sustaining the momentum. In summary, Ni-kshay SETU is not just a tool for building capacity but also acts as a driver for affordable digital solutions in areas with limited resources, aiming to strengthen healthcare systems on the path to eliminating TB.