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.
A significant proportion of TB cases access care from private sector. The state has pioneered private- public partnership in TB control during the early days of RNTCP. With support from various stake holders, the state program was able to sensitize and train private practitioners and establish designated microscopy centres .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] and CHRI 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.
Drug sales in the private sector
While number of patients registered under RNTCP declines on one side, private drug sales also declines. A published study in Lancet shows in 2014, there was decline of approximately 20% in drug sales compared to 2013. Now department of RNTEP in India has been renamed as NTEP[ National Tuberculosis Elimination Programe]
The following challenges may be expected.
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.
2. Vulnerable groups: TB has been concentrated in certain vulnerable groups, such as the poor, the homeless, migrants, people with harmful alcohol and other marginalized groups like tribal. 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.
4= Abortions due to TB in JK is now also being reported.
4. State specific data on TB burden.
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
Optimal access to CBNNAT 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.
4. 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. Further details of including ICT supported active case finding is discussed under the specific section below.
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. The strategy to ensure 100% notification has three specific steps.
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 centers. Step1. 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 MIS. Others 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.
Step2. 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.
Lack of formal linkages should not undermine the statutory responsibility if any, to notify TB.
Step3. Enacting and Enforcement
ENACTING: Enacting notification at state level
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.
Extra steps to facilitate notification
An extra step may further promote notification that requires wider discussion and action; hence not elaborated here. This step is ensuring availability of anti-TB drugs in open market only through a notification triggered outlet.
While active surveillance among vulnerable population leads to active case finding and notification of TB cases, complete notification by private sector will take care of the spill-overs and complete the surveillance circle.
Management of comorbidities
Management of comorbidities is discussed with more relevance elsewhere. Noncommunicable 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.
TB among tribal may be managed as a special project. An ethnicity sensitive intervention is required for ending TB in tribal population. It is characterized by
a. Limiting travel to access care
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.
Author worked in a project for elimination of TB and can be mailed at
arifmaghribi@yahoo.com