Ground zero: Frontline champions lead the fight to #endTB as global meet opens in India

Shobha Shukla *

Frontline champions lead the fight to #endTB

It was indeed a humbling experience for me to interact with a few frontline healthcare workers who are courageously fighting the #endTB battle on the ground in Hyderabad, India (the venue for the 50th Union World Conference on Lung Health). My day began with meeting G Swamy Reddy, project officer at Lepra Society in Hyderabad. He has been involved with leprosy and more recently TB care and control activities of Lepra since 1989.

Lepra has been working in the field of TB since 2002. It is now managing 5 out of the 53 Designated Microscopy Centres or DMCs (which are under the Indian government's Revised National Tuberculosis Control Programme - RNTCP) in the city of Hyderabad. About 1000 additional new TB cases get diagnosed and cared for due to these 5 DMCs every year.

We visited one such DMC situated in King Koti, where it was amazing to see the well-coordinated manner in which the work was being done. The laboratory technician of this DMC, Raj Shekhar, explained the treatment algorithm that is followed for all presumptive TB patients coming to the clinic.

Not only is their sputum microscopy done, their HIV status and blood sugar levels are also tested and a chest x-Ray taken - all of this on the patients' first visit to the centre on day-1. Moreover the sputum is also sent for CBNAAT testing (Cartridge Based Nucleic Acid Amplification Testing, such as Gene Xpert) and to Intermediate Reference Laboratory for TB drug resistance profiling.

Sputum test negative but Gene Xpert positive

He said that on an average 10-20% of the patients who test smear sputum negative by microscopy are diagnosed positive for TB by GeneXpert, due to the superiority of molecular testing. Also 4-5% of those who are diagnosed with TB, also test positive for HIV. All patients’ data is recorded meticulously for Nikshay (Indian government's real-time online data management system). Once diagnosis of TB is confirmed a health visitor visits the patient’s house and the patient is immediately put on appropriate TB treatment.

If the patient is from some other area (not under the jurisdiction of this DMC), he/ she is immediately referred to the concerned centre and records updated after confirmation is received. Patients are provided with 28 days supply of fixed dose combination pills as per their weight. Thus they have to visit the centre only once a month to collect their medicines.

Many patients from the private sector are also referred to this centre. I happened to meet one such female patient who was under treatment for extra-pulmonary drug sensitive TB. She was a student of B.Com but from her frail appearance looked to be no more than 13-14 years old and weighed less than 34 kg. Two months ago she had recurring low grade fever, weight loss and loss of appetite.

She showed herself to a private doctor who diagnosed TB of the lymph nodes and then referred her to this centre to avail of the free TB treatment in the public health system. Her intensive phase of treatment was about to end and she seemed happy with her progress.

There seemed to be a good collaboration with private doctors. G Swamy Reddy of Lepra informed that, “We have mapped all private doctors in the 5 DMC areas and we sensitise them and interact with them on a regular basis. They now refer many of their patients to us. Many of them have become DOTS providers also - we give them the DOTS boxes so their patients can take the free medications from them only."

TB, diabetes, HIV

But there are challenges too. Sometimes people wonder as to why their patients are tested for HIV and blood sugar also at the DMC (and not just for TB). So counselling is very important to tell the patients why it is important to test for HIV as well as for blood sugar.

Screening for diabetes started at the centre in 2018. Senior TB Supervisor Pallavi shared her worries about the rising incidence of diabetes even in the young patients. She told about a 25 years old female patient of extra-pulmonary TB who had elevated blood sugar levels. She was diagnosed with drug sensitive TB and put on a 6 months’ regimen. But her blood sugar levels continued to remain uncontrolled, despite taking diabetes treatment. During this period, she had recurrent glands.

After 6 months of treatment she tested positive for rifampicin resistant TB. She has since been put on MDR-TB treatment. Pallavi wondered whether diabetes interfered with her TB treatment, resulting in her TB becoming drug resistant; and also if TB prevented her blood sugar from declining. There were other similar cases of young patients with TB and diabetes. From Pallavi’s experience, some TB patients with thyroid problem also showed poor treatment outcomes.

According to G Swamy Reddy involvement of the community and of cured patients is important in the fight against TB. There is a need for more awareness and knowledge sharing at the grassroots level (that TB is treatable and curable) to dispel the myths and stigma around TB.

While providing nutritional support to TB patients is important, counselling should not take a backseat, he says. Also lab technicians must pay more attention to the quality and quantity of sputum collected so that the patient does not have to visit the clinic once again for diagnosis.

Another point of concern is that as of now latent TB is not on radar. There is very little knowledge about it even in the doctor community, let alone community. But Reddy is optimistic that it is only a matter of time when awareness about testing and treatment of latent TB will increase.

Local actions are building blocks

Keeping the team motivated and other partners fully engaged with the fight against TB is indeed key along with boosting morale of people with TB who are under care, says G Swamy Reddy. He shared humble and humane approaches that his team practices regularly in form of recognizing the contribution of medical, paramedical, private sector, patients, and other key actors who are helping shape progress in fight against the pandemic on the ground.