Kollam, Pathanamthitta, Idukki (Kerala): Agathi mandiram (poor people’s home) in Kollam city was built after Independence to provide shelter to beggars. Today, its 123 residents are mostly homeless people with mental or physical disabilities, brought here when found wandering the streets.

In May 2018, the Tuberculosis (TB) Centre of Kollam district decided to screen every one of agathi mandiram’s inmates for TB. Ordinarily, their in-house doctor, Shreekumar D., would identify those with TB-like symptoms and send their sputum samples for analysis to the state TB Cell a few times a year, leading to the identification of two or three cases each year.

For the first time this year, the centre sent a pulmonologist to examine every person in the home, as part of Kerala TB Elimination Mission launched in March 2018 with the aim of reducing the number of TB cases to 2020 by the year 2020, and eliminating TB-related deaths altogether. “It was challenging because the inmates often could not explain their symptoms nor give their sputum sample,” said P. Anish, a consultant chest physician who screened all the inmates. Deploying techniques not normally used to detect TB, such as the CT-Scan, he detected 22 cases.

This exercise at agathi mandiram was replicated across the state from April to June 2018, in an effort to screen every person in Kerala, after the state set its sights on eliminating TB, displaying confidence in its robust health system which has already delivered enviable indicators.

This confidence is why, for Kerala, eliminating TB is “low-hanging fruit”, as the state’s health secretary, Rajeev Sadanandan, puts it. “We are about the only state [that] is capable of eliminating this disease,” he told IndiaSpend.

Kerala’s strategy and potential success has implications for all of India, which has the world’s largest TB burden--2.74 million or 27% of the global total. Further, nearly 300,000 Indians fall through the surveillance system or do not complete their course of medication, prompting the rise of more virulent, drug-resistant strains. In 2016, 435,000 people in the country died of TB in India. TB patients often incur financial distress due to catastrophic health expenses.

“While ridding people of the burden of any disease is a worthy goal by itself, TB elimination provides perhaps one of the strongest cases for public intervention from an economic point of view,” as this March 2017 World Bank report noted. “Reducing TB incidence could generate benefits of $33 per dollar spent,” the report cited The Economist as saying.

If infected patients cannot access treatment or fail to complete the regimen, they can infect many others, often with more resistant and virulent forms of the disease. This is what makes TB a public health imperative that must be dealt with through early diagnosis, complete treatment and improved quality of care. And Kerala’s example is instructive.

“The reduction of TB cases in Kerala is dramatic,” said K.P. Aravindan, a retired professor from Kozhikode Medical College. “From a disease that was extremely common, it is now a rare disease.”

In a four-part series on Kerala’s ambitious plans, IndiaSpend will examine how Kerala’s policies are showing results and what lessons they could offer India. In this first part, we shine the spotlight on Kerala’s thorough implementation of the active case-finding strategy to test every resident of the state and to map vulnerable populations so as to regularly monitor, test and treat them.

Active case-finding

Active case-finding involves health workers proactively screening people for TB, as opposed to people coming to health institutions with TB-like symptoms and getting screened, which has been the mainstay of the Revised National Tuberculosis Control Programme (RNTCP) for more than 15 years. (India has had a National TB Programme since 1962, the “revised” version of which has been deployed since 1997.)

Kerala started active case-finding in health institutions as early as 2009 and in the community in 2014, something started at the national level only in 2017.

The Central TB Division, which works under the central health ministry and is responsible for implementing RNTCP, requires all state TB units to conduct an active case-finding exercise thrice a year among populations identified as vulnerable, such as those living in slums and labour camps, mine workers, tea garden workers and the homeless. This is typically done in an ad-hoc fashion and there is no consistent follow-up, mostly because the number of TB cases is high and resources are stretched thin.

Kerala, however, has improved an already robust healthcare system and motivated workforce to implement active case-finding so thoroughly that each resident will be screened this year, with health workers going door-to-door to find cases. The persons identified as vulnerable will be followed-up on every three months.

These activities have increased the number of symptomatic patients tested per 100,000 from about 700--close to the all-India figure--to nearly 1,250, according to the Kerala State TB Cell.

Bidirectional screening

TB affects mostly young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the State TB Cell show. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10%, according to State TB cell data.

This suggested a link between chronic diseases such as diabetes, which affect older people more, and TB.

Kerala and some other south Indian states such as Andhra Pradesh, Goa and Tamil Nadu and the union territory of Puducherry report higher blood sugar levels, which are indicative of diabetes, as compared with the national average, as per the National Family Health Survey 2015-16.

A 2012 study supported by the Kerala government found that 44% of TB patients had diabetes. Moreover, 21% of TB patients were found to have undiagnosed diabetes.

This led to a change in policy--first within the state starting 2012 and since 2017 across India--so that TB patients are as a rule tested for diabetes and vice-versa. Following Kerala’s example, all TB patients registered under RNTCP are supposed to be referred for screening for diabetes. Referral is the responsibility of the health institution where TB treatment is initiated.

Vulnerability mapping

Health workers tasked with diagnosing TB during door-to-door visits are given a checklist. Depending on the boxes ticked, a vulnerability score is calculated--the most vulnerable are household contacts of TB patients, followed by those on immunosuppressant medicines, the malnourished, healthcare workers, and those with diabetes, organ disorder, etc. Those considered vulnerable are kept under surveillance, with follow-up checks every three months.

In addition to increased surveillance, the state has deployed more diagnostic tools such as the Cartridge-based Nucleic Acid Amplification Test (that can detect TB bacilli in very small amounts of sputum), X-Ray and CT-scan during active case-finding, as at agathi mandiram in Kollam. “We have reached a saturation point in detecting TB using sputum microscopy,” said Kumar, referring to the technique in which the laboratory technician looks for TB bacilli in sputum--a mixture of saliva and mucus a subject has coughed up--using a microscope. “It is now time to use other techniques.”

Complementary programmes underway in some other districts engage with treatment support groups and with the private sector to increase reporting of cases (private-sector cases are typically underreported, so that official TB statistics reflect mostly incidence, prevalence, treatment and cure figures reported by the public sector). From January to July 25, 2018, there have been 2,672 notifications from the private sector and 10,200 from the public sector, Balakrishnan said.

Across India, about 20% of the total reported cases were in the private sector (384,000 private sector cases of a total 1.8 million) in 2017, while in Kerala, the figure was 36% (8,232 private sector cases of a total 22,754).

For the past two years, the Kerala TB Cell has pursued private sector practitioners to report their TB patients, giving their patients free medicines and leaving them free to go back to their private doctors. The government has also been training private doctors in TB treatment protocols for more than 10 years.

For two decades now, children living with infected adults have been given preventive drugs and are monitored as part of a protocol called chemoprophylaxis, according to the Kerala TB Elimination Mission Strategy document. Now, the state has decided to give infection-control kits to TB-positive patients, said Kumar, consisting of masks, disposable spittoons and disinfectant solution to protect TB from spreading to family members during the first two months of treatment when the disease is highly contagious.

The department has found just 352 new cases of TB all over the state--in a population of 38 million--during the active case-finding and vulnerability mapping exercise so far, Balakrishnan said. However, approximately 12% of Kerala’s screened population so far has been found highly vulnerable to TB, excluding those suffering from HIV.

Decrease in TB incidence

Kerala’s TB incidence is estimated to be 67 cases per 100,000, less than half the 138 per 100,000 pan-India, as per 2017 RNTCP figures. Since 2009, when Kerala began active case-finding, the TB notification rate in the state's public sector has been falling by about 3% every year. This is despite the fact that the number of people being tested for TB has remained constant, Balakrishnan said.

Source: Kerala State TB Centre

Kerala registered a more than 20% decline in drug sales in the private sector in 2014 over 2013, a 2016 study found, indicating that the number of cases in the private sector had fallen too.

Kerala also has a lower rate of multi-drug resistant TB (MDR-TB, which is resistant to treatment with the first-line drugs rifampicin and isoniazid) and extensively drug-resistant TB (XDR-TB, resistant to treatment to a range of second-line as well as first-line drugs). Across India, 5.62% TB patients were detected with drug-resistant tuberculosis in 2017, while the figure in Kerala was 3.05%, as per 2017 RNTCP figures.

Idukki in central Kerala and Wayanad in north Kerala have shown the maximum decline in the number of TB cases, with a notification rate in the public health sector of just 51 cases and 44 cases, respectively, per 100,000 population, as per the Kerala TB Elimination Mission strategy document.

Low paediatric TB a major success

The proportion of TB in children under 15 years has consistently fallen in Kerala. In 2016, 6.3% of TB cases were among children (under 14 years), down from 8.7% in 2008.

Fewer children are being affected because primary transmission has gone down, state TB officer Sunil Kumar told IndiaSpend. This could mean that direct transmission of the disease from the environment or from other TB patients has reduced.

This has been achieved by pursuing RNTCP guidelines on giving chemoprophylaxis--drugs to prevent infection--to household contacts. The Kerala TB Elimination Mission Strategy document says it has given preventive drugs to children living with infected adults for two decades now.

This is not followed consistently all over the country, however, either because lack of awareness or unavailability of medicines.

The World Health Organization’s guidelines for countries with low incidence of TB warn that as TB caseloads reduce, it becomes even more important not to miss new patients.

“The idea is to maintain a surveillance system and testing more patients so that nobody is left out,” Kumar said.

Lessons for India

The biggest lesson Kerala holds for the rest of the country lies in the basic implementation of the programme--treating the TB patient who comes to the hospital appropriately, said Yogesh Jain, a founder member of Jan Swasthya Sahyog, a community hospital in Bilaspur. The importance of following the “old-fashioned” guidelines from RNTCP related to early diagnosis, completion of treatment and other protocols cannot be overstated. “There are no magic bullets here. Kerala is showing a mirror to the rest of the country that we have to do what we are supposed to do well,” he said.

“We may need to [implement] active case-finding of TB smartly,” said Nimalan Arinaminpathy, from the School of Public Health at Imperial College London, “As important as it is to go to slums and other disadvantaged communities, we also need to go to diabetics and smokers.”

While Kerala’s example may not be entirely replicable across India--given India’s vast population, paucity of resources, and lack of infrastructure, capability and preparedness--Arinaminpathy pointed out that much can be done with the existing resources too.

Having ASHAs monitor vulnerable groups every three months is a very good tactic, Arinaminpathy said, especially as this can be part of their routine work and cause no additional cost to the state.

Aravindan pointed out that even in low-resource states such as Odisha and Chhattisgarh, some programmes work. “It is political will that makes programmes work,” said Aravindan.

This is the first of a four-part series on Kerala’s fight against tuberculosis, and what it can teach India.

Next: How Once ‘Backward’ Idukki Is Leading Kerala And India In Ending TB

(Rao is a an independent journalist based in Delhi.)

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