Kerala's multi-layered approach to #endTB

Shobha Shukla *

As part of the #EndTB Dialogues series launched in lead up to the 50th Union World Conference on Lung Health last month, we got an opportunity for exclusive interview with Dr M Sunil Kumar, State Tuberculosis Officer, Ministry of Health and Family Welfare, Kerala, and Dr Shibu Balakrishnan, World Health Organization (WHO) consultant with the Revised National TB Control Programme (RNTCP) in Kerala.

Kerala’s multilayered sustained model of TB care and control is reflected in the reduced incidence rate of disease which was measured at 44 cases per 1,00,000 people, against the national average of 199 cases per 1,00,000 people. The annual decline rate of TB incidence in the state is 3%, which, again, is much higher than the national average.

Kerala is equipped to offer universal DST to all the diagnosed TB cases in the private and public sector. It has achieved 69% universal DST for rifampicin with CBNAAT. Additionally, 5 districts offer universal DST for isoniazid also through line probe assay. Prevalence of rifampicin resistance in TB infected people in Kerala is 1% and isoniazid resistance is also less than 2%.

People’s movement against TB

Kerala’s TB elimination activities have grown into a people’s movement against TB. At the grassroot level there are self-help groups called 'Kurmishri' who are involved in the TB control programme. The healthcare portal of the Kurmishri network meets once every quarter.

Health inspectors attend these group meetings in their jurisdiction where health related issues are discussed and symptomatic TB patients are directed to public health system. Also district panchayats or the local self-governments provide nutritional and housing support to TB patients and their families.

TB mapping and active case-finding

In 2018, Kerala launched a house to house survey to test every resident of the state for TB and to map vulnerable populations with a view to monitor them regularly. 87% of the Kerala’s population - which means 2,45,00000 people - was mapped by trained healthcare workers (including local/ village level health workers, social health activists, medical staff, etc ). Out of these only 352 new cases of TB were found.

In this active case-finding exercise all persons were scored on 13 health parameters. The survey found that 3.5% of Kerala’s population is vulnerable to TB and 50% of Kerala’s active TB cases come from the pool of people with latent TB infection (LTBI). These people with LTBI are now screened for TB once every 3 months by the field staff.

A new surveillance system has been in place at the district level since the last 2-3 years under the leadership of district TB officers. Under this system, pharmacists have to maintain the records of sale of TB drugs and this data is collected from the pharmacies in every district.

At the state level, monthly sales data of TB drugs is obtained from the drug controller’s office of Kerala. Names of private doctors giving TB treatments are tracked and forwarded to the respective districts to ensure that TB cases of the private sector are notified. This helps in identifying the missing cases that are getting treatment outside the existing public health system.

Private sector participation:

Private sector involvement has been there since 2004 with support of the Indian Medical Association (IMA). Statewide trainings for IMA doctors have been organised to train them in standards of TB care and treatment protocols. Patients diagnosed in the private sector are offered free treatment in the public sector.

Another initiative for better engagement with the private sector is the opening of STEPS (System for TB Elimination in Private Sector) centres in private hospitals. These centres, launched in 2018 by the then WHO Deputy Director Dr Soumya Swaminathan (now Chief Scientist at WHO), act as a link between the public and private sector. They provide a single window for TB case notification, linkage to treatment support, and they also ensure that all public health and social welfare schemes offered to RNTCP patients are available to patients in the private sector too. This has helped in ensuring good treatment adherence in the private sector at par with the public sector.

Some other state wide initiatives:

- School children are provided with handkerchiefs and trained in cough etiquette. There is also a legislation against spitting in public places.

- Token system in hospitals controls overcrowding of patients in OPDs, as overcrowding in hospitals abets TB transmission. A fast tracking mechanism for presumptive TB cases or those diagnosed with TB is in place so that they are fast tracked to the doctor to reduce the time gap between diagnosis and treatment initiation.

- All TB patients are given a financial incentive of 1000 INR every month for nutritional support.

Prevent TB to end TB

Kerala has taken many initiatives to prevent the spread of TB infection and to promote air borne infection control measures in public places. With its successful mapping of vulnerable populations and surveillance system, the state is all geared up for programmatic management of LTBI. Its proposal for a pilot in at least two districts (Idukki and Wayanad) to diagnose and treat LTBI has been approved by the government of India.

The primary diagnostic test is interferon gamma release assay (IGRA) and primary treatment regimen is 3HP (once weekly dose of isoniazid–rifapentine for 12 weeks). It will be rolled out as soon as the national policy on LTBI management is announced.

NCDs are a major threat to TB control

A major hurdle which Kerala faces in its TB control efforts is the rising incidence of non-communicable diseases (NCDs). Around 44% of its TB patients suffer from diseases like diabetes, hypertension, etc. So now the thrust is on linking all TB patients with the NCDs control programme. Kerala started screening for diabetes in TB patients from 2003 onwards and TB diabetes bidirectional screening has been there since last 2-3 years.

Kerala has a robust general health system that is supported by political and administrative commitment. This, coupled with its high literacy rate and good health seeking behaviour of the people, is likely to make Kerala the first TB free state in the country and become a beacon of hope for other states.