Is the clock really ticking !

World TB Day (WTBD) is observed on March the 24th every year to commemorate the date when Dr. Robert Koch announced his discovery of Mycobacterium Tuberculosis, the bacillus that causes TB.  According to WHO website “The theme of World TB Day 2021 is – ‘The clock is ticking’ –conveys the sense that the world is running out of time to act on the commitments to end TB made by global leaders. This is especially critical in the context of the COVID-19 pandemic that has put End TB progress at risk, and to ensure equitable access to prevention and care in line with WHO’s drive towards achieving Universal Health Coverage”.

A significant proportion of TB cases access care from private sector in Jammu Kashmir. The UT has pioneered private- public partnership in TB control during the early days of RNTCP[ Revised National Tuberculosis Control Program]  which is now known as NTEP [National Tuberculosis Elimination Program]. With support from various stakeholders, the state program was able to sensitize and train private practitioners and establish  designated microscopy center’s .Many of the smear negative and extra-pulmonary cases are also being contributed by private sector in JK.

After TB was made notifiable by the executive order of Government of India in May 2012, there were concerted efforts to sensitize practitioners. This led to increased notification from the private sector. Project JEET [Joint effort for elimination of tuberculosis] started work in 2018 and after that the number of cases from private sector has increased many folds However, there were a number of challenges to achieve 100% notification from the private sector, which I will discuss later in my article as my article is not about stats but strategies.

New focus and challenges.

1. Migration: Massive on the job migration is an important challenge to achieving TB elimination in JK. Migrants often would have acquired TB infection, due to higher infection rates in their state of origin. They have an increased risk of developing active TB disease, depending on factors such as conditions of their migration, occupation involved in, and due to socioeconomic vulnerability augmented by stressful migration conditions. Migrant workers also have a higher risk for not completing treatment once started. This is not restricted to migrants from other states only but within districts of Jammu and Kashmir.

2. Vulnerable groups: TB has been concentrated in certain vulnerable groups, such as the poor, the homeless, migrants, tribals. The factors that make these groups vulnerable operate through two principal pathways: increased risks for exposure and infection and an increased risk for progression from infection to active disease

3. Diabetes Epidemic: Jammu & Kashmir is witnessing an ever increasing and alarming trend of diabetes prevalence. Diabetes plays an important role in the development of TB disease. Any patient having other disease which reduces immunity like cancer, drug abuse or dialysis must be screened for Tuberculosis.

SOLUTIONS

Tools for active cases search: A sensitive tool for screening symptoms in the form of a questionnaire embedded in the computer/mobile application should be deployed by the health workers/asha responsible for the periodic screening.

Cartridge based nucleic acid amplification test, known as CBNAAT is latest diagnostic tool in fighting tuberculosis. It not only confirms TB but also confirms resistance to Anti Tuberculosis drug Rifampcin, results take 3 hours to maximum of one day. CBNAAT machines are deployed in all districts. Optimal access to CBNAAT should be ensured by logical deployment of machines for geographic and population coverage. Mapping of vulnerable population would enable in logical deployment of CBNAAT. To balance the use of CBNAAT in view of cost-benefit indicators, complex logistics in terms of specimen transportation, workload of laboratory human resource, chest radiography should be deployed generously and judiciously. X-ray facility should be made available at least for every 100,000 population, in close proximity to the designated microscopy centres either by procurement of new machines or outsourcing to private sector.

Establish robust TB surveillance and surveillance linked to action

Surveillance is one of the fundamental public health activities necessary for the control and elimination of TB. A robust surveillance system should be able to identify individuals with risk to develop TB and monitor them lifelong for developing TB disease. Notifying a confirmed patient is the easiest step in surveillance, however, that too is complex due to a number of influencing factors. A complete surveillance system should be able to capture all TB cases and actively look for symptoms to trigger diagnosis.

Surveillance of TB disease:

This includes identification individuals belonging of key populations (clinically, socially and geographically vulnerable). Risk factors, social determinants and co-morbidity of TB cases will be incorporated. A case based surveillance with an electronic data flow will be initiated in districts reporting lesser number of cases.

Active Case Finding includes symptomatic screening of individuals mapped by health system. A database of vulnerable individuals by name and unique identification details is to be maintained for this purpose at health centre/ sub centre level. Surveillance Linked action at this level would include linking up and facilitating confirmatory tests for diagnosis and appropriate Drug Susceptibility Testing in diagnosed cases.

Mandatory notification of TB by all health care providers

All Health care providers (formal or informal) must notify TB.

Benefits to Patients and Doctors: Each patient who is notified is paid a sum of Rs 500 per month till completion of treatment as a form of nutritional support called Nikshay Poshan Yojana and tribal patients Rs 700 per month. Private sector TB care doctors will be given Rs 500 on notification of a case diagnosed as per standards for TB Care in India (SCTI) and Rs 500 on completion of treatment. That means any doctor having private practice will get rupees one thousand per patient. All patients have choice to purchase medicine at various pharmacies or get it free from government centres

Provider Mapping

Mapping of all health care providers irrespective of their system of medicine, including unqualified providers should be done. This is to ensure that all care points that a patient is likely to access services from are included. ‘TB care provider’ is a subset of this universe that gets registered in the program of RNTCP, provide an opportunity for active case finding.

Definition of provider should not be limited to clinical practitioners, but should cover clinical and pathological laboratories and chemists shops.

Engaging providers through formal linkages

a. Assigning a nodal person for notification in each provider setting linked to the personnel responsible for surveillance at the PHC/HSC

b. Channelizing all program services to the patients through the private provider. An ‘after sale care model’ may be tried instead of program directly providing those services.

Enacting and Enforcement

ENACTING: Enacting notification at state level already exists in JK, work of NTEP, STO is exemplary.

ENFORCEMENT: Validate laboratory and drug sale data in schedule H1 register with Nikshay notification data. TB program authorities need to verify H1 registers and compare TB drug sale data with notification data from the prescriber. Compliance should be acknowledged with certification/recognition. Non-compliance should attract penal action.

Management of co-morbidities

Management of co-morbidities is must. Non-communicable diseases like diabetes, chronic respiratory diseases, cardiovascular diseases, and cancers do significantly lower the favorable outcomes of TB treatment. With prompt linkages among respective disease control programs, patients could be ensured of cure and better quality of life.

Lastly NGOs must be involved in following

a. Awareness in medical camps.

b. Providing enablers to travel when necessary.

c. Mechanisms for sputum collection and transportation

d. Administration of drugs at home

e. Early identification of malnutrition and preventive and therapeutic nutrition

f. Support for airborne infection control in households

g. Early detection and management of comorbidities

Depression and TB:  Many studies have shown that many patients of TB suffer from mild to moderate depression, counselling has improved compliance of medicine intake by patients.