How this TB triage tool experiment in Tamil Nadu reduced death by 20 per cent: Can it be used in national programmes?

Indian Express

a day ago

A simple five-question triage tool — without the need for any laboratory tests — may be the key to saving lives of people diagnosed with tuberculosis (TB). Within two quarters of implementation in Tamil Nadu, the tool resulted in a state-wide reduction of early TB deaths — deaths recorded within the first two months of initiating TB treatment — by 20 per cent.
In fact, two-thirds of the total districts in the state documented a 20 per cent to 30 per cent reduction in total deaths in 2024. Discussions are ongoing to implement a similar tool under the national programme. There were an estimated 28 lakh TB cases and 3.15 lakh deaths in India in 2023, according to the latest available data from the Global TB Report.
Health workers in the state record five key parameters for all TB patients in the state — height and weight for calculating the body mass index (BMI) which can flag undernutrition in TB patients, swelling of the leg by pressing it for 15 seconds, respiratory rate per minute in a sitting position, oxygen saturation on a pulse oximeter and ability to stand without support.
A patient is tagged severely ill if they have any one condition — severe undernutrition indicated by BMI of less than 14kg/m2, respiratory insufficiency as indicated by the respiratory rate and oxygen saturation, or poor performance status as indicated by their inability to stand. The 'severely ill' patients are immediately referred for comprehensive assessment and inpatient treatment.
'Immediate in-patient care can reduce the probability of early death in the severely ill patients between one per cent and four per cent. Otherwise, the probability of death in these patients is between 10 per cent and 50 per cent,' said Dr Hemant Shewade, senior scientist from the National Institute of Epidemiology, who has studied the implementation of the initiative called Tamil Nadu-Kasanoi Erappila Thittam (TN-KET).
The initiative, rolled out in 2022, is the first state-wide implementation of the country's differentiated treatment guidelines, which aims to provide more support to severely ill patients. The implementation over the last couple of years demonstrates the feasibility and effectiveness of differentiated care models. And, it goes a step beyond, to show that the triaging process can be shorter and quicker.
The tool used in Tamil Nadu depends on just five parameters, instead of the nationally recommended 16 parameters. The triaging is performed by the health workers in the state within a day of diagnosis, with 98 per cent of those confirmed to have severe illness admitted to a hospital within seven days of diagnosis.
While the tool can be used with just pen and paper, the TN government has a portal called Severe TB Web Application. 'Now, this portal will have a prediction of the probability of a patient dying when the parameters are entered. This will help guide the health workers to take immediate action and prevent TB deaths,' said Dr Manoj Murhekar, head of the National Institute of Epidemiology.
The research from the institute has not only led to successful reduction of deaths due to TB but also in several interventions that have now been included in the national programme. One such intervention was increasing the monetary nutritional support provided by the government from Rs 500 to Rs 1,000. Importantly, the first three instalments of this monetary support are provided at the time of diagnosis.
Dr Shewade said, 'Our research found that in many cases there were delays in providing the monetary support, with many experiencing adverse outcomes before they got the support. We know that half of all the TB deaths that have to happen, happen within the first two months. And, without proper nutrition, the treatments are not likely to be as effective. This was the evidence behind the change in policy.'
An evaluation of the national programme by the NIE showed that patients, on average, received the first instalment of their monetary nutritional support 91 days after the diagnosis. In fact, two thirds of the patients with an unfavourable outcome received the support after their outcome was declared, according to the evaluation. The evaluation also suggested doubling the monthly rations for those with severe and very severe under-nutrition — a suggestion that has not yet been implemented as part of the national programme.
Anonna Dutt is a Principal Correspondent who writes primarily on health at the Indian Express. She reports on myriad topics ranging from the growing burden of non-communicable diseases such as diabetes and hypertension to the problems with pervasive infectious conditions. She reported on the government's management of the Covid-19 pandemic and closely followed the vaccination programme.
Her stories have resulted in the city government investing in high-end tests for the poor and acknowledging errors in their official reports.
Dutt also takes a keen interest in the country's space programme and has written on key missions like Chandrayaan 2 and 3, Aditya L1, and Gaganyaan.
She was among the first batch of eleven media fellows with RBM Partnership to End Malaria. She was also selected to participate in the short-term programme on early childhood reporting at Columbia University's Dart Centre. Dutt has a Bachelor's Degree from the Symbiosis Institute of Media and Communication, Pune and a PG Diploma from the Asian College of Journalism, Chennai. She started her reporting career with the Hindustan Times.
When not at work, she tries to appease the Duolingo owl with her French skills and sometimes takes to the dance floor. ... Read More