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Bringing dramatic drop in TB deaths, how TN set an example for rest of India with one-of-a-kind model
While TB-related death simply refers to a death among a person with TB within 12 months of notification (diagnosis), early TB death refers to deaths that happen within two months, often within the first few weeks of the notification. It is estimated that around 70 percent of TB deaths in the state are early TB deaths.
An analysis by the agencies implementing the Tamil Nadu Kasanoi Erappila Thittam (TN-KET, which means TB death-free project) has shown that within six months of the launch of the initiative in April 2022, overall TB-related deaths have come down by nearly 10 percent while early TB fatalities reduced by nearly 20 percent.
Chennai: A first-of-its-kind statewide differentiated tuberculosis (TB) care initiative in Tamil Nadu has significantly brought down TB deaths in the state, prompting researchers to pitch it as a model that can be replicated across the country.
These results from TN-KET hold significance for India which continues to report the highest burden of TB and TB-related mortalities globally despite making significant strides in curbing the burden of the bacterial disease over the last several years.
India is considered a TB endemic country, a highly infectious disease caused by a bacteria called Bacillus Mycobacterium Tuberculosis, which is spread when people who are sick with TB expel the pathogen into the air, mostly by coughing.
Spearheaded by the Tamil Nadu State TB Cell and Indian Council of Medical Research-National Institute of Epidemiology (ICMR-NIE), the TN-KET initiative involves triaging (preliminary assessment) adults with TB at diagnosis, and those identified as severely ill based on specified indicators are prioritised immediately for referral, comprehensive assessment, and inpatient care.
'The key aim is to gauge or predict the patients who are likely to die due to the infectious disease while first identifying the disease in them and immediately offer them hospitalised care to treat the severe symptoms they have,' said ICMR-NIE director Dr Manoj Murhekar.
The initiative, also supported by the World Health Organisation (WHO) India and the ICMR National Institute for Research in TB (ICMR-NIRT), has been implemented in all 38 districts of Tamil Nadu, except for Chennai.
'This initiative has shown that it is possible to bring down TB-related deaths remarkably by following some scientifically designed tools and methods. Severe illness can be quickly identified through triaging and they can be promptly admitted after diagnosis,' Dr Hemant Deepak Shewade, a senior medical scientist with ICMR-NIE who is associated with the initiative, told ThePrint.
While the impact of the project in the first year has been analysed, the analysis of the second year (2023-24) is still underway but the early indications from routine monitoring of TN-KET suggest that it is even better than the previous results, Shewade said.
'We feel that scaling the model across India will be beneficial in bringing down the number of people dying every year due to the disease,' he added.
The senior scientist, however, cautioned that such an initiative could only bring down TB-related deaths by up to 30 percent, and measures like detecting all TB incidents, early detection, comorbidity management, universal health coverage, among others, were crucial to further reduce TB deaths in the country.
Dr Asha Frederick, Tamil Nadu's State TB Officer, said that district TB officers and Nodal physicians have played a key role in the implementation of the initiative. 'We recommend that these triage variables are captured elsewhere including other Indian states and high TB burden countries to guide patient management,' Dr Frederick said.
On the future plans for the TN-KET, the state has started identifying other severe comorbidities like uncontrolled Diabetes (requiring insulin) among people with TB. 'If this goes well, we plan to cover other severe comorbidities like severe addiction to alcohol and tobacco,' Frederick added.
According to the World TB report 2024 by the WHO, there were an estimated 28 lakh incident people with TB in 2023, 26 percent of global TB burden. Also, the country had an estimated 3.1 lakh TB deaths that year which was 29 percent of all TB mortalities globally.
Tamil Nadu is among the states with high TB burden in the country.
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How the strategy works
As part of the project, health workers triage every new TB-diagnosed adult (all above 15 years) for very severe undernutrition, respiratory distress or poor physical condition on five variables—body mass index (BMI), pedal oedema (swelling of feet and ankles), respiratory rate, oxygen saturation, and ability to stand without support.
This is carried out as a health system initiative in routine operational settings by existing health workforce.
Whether or not a patient is severely ill is confirmed by entering the details into a software application TB SeWA (Severe TB Web Application). All those identified as severely ill are then prioritised for in-patient care by nodal physicians in nodal inpatient care facilities of the districts, using TN-KET case record form and in-patient care guides specifically developed for such patients.
A study published on the early implementation of the project and its feasibility underlined that 80-90 percent of severely ill patients (as per triage tool) are getting detected and admitted within one day of diagnosis.
The admission of severely ill patients (triage-positive) has improved over the years: 67 percent in 2022, 86 percent in 2023 and 91 percent in 2024. The median admission duration was five days in 2022 and this has improved to seven days in 2023 and 2024.
Over the years, the focus has been to ensure quality comprehensive assessment and inpatient care during the admission of the severely ill patients with focus on therapeutic nutrition for very severely undernourished patients as half of those eligible for admission have very severe undernutrition.
Between April 2022 and June 2023, as per details shared by ICMR-NIE scientists, 66,765 of 72,404 notified adults were triaged, and 7,950 were triage-positive (identified as severely sick due to TB).
Among these, 5,870 (or 74 percent) patents were referred and admitted. The analysis later showed 21 percent decline in early TB death rate and 11 percent reduction in overall TB death rate during treatment.
By improving the admission among triage-positive patients, there is scope to further reduce TB death rate, the researchers noted, adding that once the goal of 30 percent mortality rate reduction among notified TB patients using this strategy is achieved, they will consider adding follow up triaging for all patients at two months for further reduction in mortality rate.
As per the Sustainable Development Goals (SDG), India has to eliminate TB by 2030.
(Edited by Ajeet Tiwari)
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