Can We Beat Tuberculosis in Kashmir?
Dr. Abdul Rouf
The beautiful valley of Kashmir has long grappled with the burden of tuberculosis (TB), a deadly infectious disease that affects thousands of lives each year. Although as per recent Sub National certification for progress towards TB free status verification reports, the incidence of TB cases in Kashmir remains relatively low when compared to most of the other regions in India. But elimination of TB in this region is an uphill task.
3376 notified cases have been notified in 2022 in Kashmir division. A key concern is that, if we can end TB by 2025 under the Pradan Mantri TB Mukht Bharat Abhiyan (bringing incidence less than 44 cases per lakh population). The incidence of tuberculosis is decreasing at a rate of roughly 2% every year. However, in the pursuit of eliminating TB from the region, drop has to be around 10%. Tuberculosis Preventive Therapy (TPT) has emerged as a crucial tool to curb the spread of the disease and bring the valley closer to its goal of elimination, as it can raise the decline to 10% if executed in true spirit.
Tuberculosis Preventive Therapy, also known as TB preventive treatment, is a medical intervention aimed at protecting individuals at high risk of developing active TB from becoming infected with the bacteria or progressing to the active disease if they have latent TB infection. Latent TB is when a person is infected with TB bacteria but does not have active TB disease. TPT typically involves administering a course of antibiotics to prevent the latent infection from becoming active TB. TPT plays a vital role in the global efforts to eliminate tuberculosis, especially in India where there are about 40 % prevalence of latent TB infections, which can turn into active tuberculosis in 5 to 10 % of cases within two years of acquiring infection. Around 71% of household contacts (HHC) of pulmonary TB patients in India had baseline TBI. The risk of TBI increases significantly (16-21 times) in cases of HIV co-infection with or without ART. So, the target population for TPT includes people living with HIV, household contacts of pulmonary TB patients, and other high-risk groups.
To identify TB infection, Tuberculin Skin Test (TST) and Interferon-Gamma Release Assay (IGRA) are utilized, as there is currently no gold standard test to diagnose TBI or predict progression to TB disease. One of the key steps in TPT implementation is counselling eligible individuals and their families about TPT. Transparent information sharing regarding the treatment regimen, benefits, adherence support, and potential adverse events plays a vital role in ensuring patient compliance.
Before initiating TPT, healthcare providers conduct a pre-treatment assessment, which includes baseline investigations like liver function tests and evaluating personal history, ensuring safe administration. Two TPT dosage regimens are used based on age, weight, and medical conditions: 6 months of daily Isoniazid (6H) and 3 months of weekly Isoniazid and Rifapentine (3HP). But unfortunately, Rifapentine is not available in Valley and there is apprehension from some researchers and clinicians that monotherapy may lead to drug resistance. To support adherence and monitoring, digital platforms, tele/video calls, 99DOTS/MERM, and counting empty blisters are utilized. However, the availability and affordability of Rifapentine for the 3HP regimen remain a concern, requiring close monitoring and advocacy with drug manufacturers.
Moreover, to generate demand for TPT from the community, improved communication, and social mobilization activities are needed. Non-government organizations (like JEET) and community-based organizations can play a pivotal role in supporting demand generation for TPT services.
Here’s how TPT contributes to the fight against TB:
- Targeting Latent Infections: Latent TB infections act as a reservoir for active TB cases. By providing TPT to individuals with latent infections, the risk of progression to active TB is significantly reduced. This approach not only benefits the individual but also reduces the potential for further transmission of the disease in the community.
- High-Risk Populations: TPT is particularly valuable for individuals who are more susceptible to TB infection and disease progression. This includes close
contacts of active TB patients, people living with HIV, healthcare workers, and others with compromised immune systems.
- Reducing TB Incidence: By preventing latent TB infections from becoming active, TPT directly contributes to lowering TB incidence rates. This reduction in new cases is a crucial step towards TB elimination.
- Cost-Effective Intervention: Compared to the costs associated with treating active TB cases, providing TPT is a cost-effective approach. Early intervention through TPT can save substantial medical expenses and resources.
While TPT shows great promise, its successful implementation in Kashmir faces some challenges:
- Identification of High-Risk Individuals: Identifying individuals with latent TB infections can be challenging, as many may not present any symptoms. A comprehensive screening program, especially for high-risk groups, is necessary to identify latent cases. Non-availability of IGRA test which is more specific than TST in public sector is also one of the key concerns in Kashmir.
- Adherence to Treatment: Completing the full course of TPT is crucial for its effectiveness. Healthcare providers and community health workers should focus on education and support to ensure patients adhere to the prescribed regimen as per laid guidelines.
- Overcoming Stigma and Misconceptions: Like active TB, TPT may also face stigma and misconceptions among the population. Public awareness campaigns can help dispel myths and encourage acceptance of preventive therapy.
- Strengthening Healthcare Infrastructure: To implement TPT successfully, the healthcare infrastructure needs strengthening. Access to diagnostics, drugs, and trained healthcare professionals is essential.
The Road Ahead: Tuberculosis preventive therapy is a powerful tool that, if effectively deployed, can aid in eliminating TB from Kashmir. To make this a reality, collaboration between the government, healthcare organizations, non-governmental agencies, and the community is indispensable. Investing in robust
screening programs, enhancing public awareness, and ensuring access to quality healthcare services are all critical steps on the path to a TB-free Kashmir. Although stakeholders have taken into account the majority of the factors, external quality assurance (EQA) implementation is still crucial if you want to achieve the intended results. Implementing external quality assurance in tuberculosis preventive treatment (TPT) in Kashmir, or any other region, is crucial to ensure the accuracy, reliability, and effectiveness of the program. EQA helps to identify gaps and weaknesses in the system and improves overall patient outcomes.
The following measures can be taken to achieve external quality assurance for TPT:
Government and Stakeholder Engagement: Engage with the local government health authorities, international organizations, NGOs, and other stakeholders involved in TB control. Seek their support and collaboration to set up an EQA program.
Developing Guidelines and Protocols: Establish clear guidelines and protocols for TB preventive treatment, based on the World Health Organization (WHO) recommendations and national guidelines. This ensures consistency in the delivery of care.
Training and Capacity Building: Conduct comprehensive training programs for healthcare professionals involved in TPT, including doctors, nurses, lab technicians, and community health workers. Training should cover case detection, treatment initiation and completion, monitoring, and reporting.
Laboratory Support and Accreditation: Ensure that laboratories responsible for diagnosing TB and monitoring treatment have appropriate equipment and trained staff. Work towards obtaining relevant laboratory accreditations.
Monitoring and Evaluation (M&E) System: Set up a robust M&E system to track TPT program performance regularly. Monitor key indicators such as the number of people screened, the number initiated on preventive treatment, treatment completion rates, and adverse events.
Site Visits and Audits: Conduct regular site visits and audits by independent experts or supervisors to assess the quality of TPT services. Identify areas for improvement and provide feedback to healthcare providers.
External Review Panels: Establish external review panels comprising experts from Community Medicine Departments of Medical Colleges and Public Health experts in TB control and TPT. These panels can periodically review the program’s performance, assess adherence to guidelines, and recommend improvements.
Patient Feedback and Support: Gather feedback from patients who have undergone TPT to understand their experiences and challenges. Implement mechanisms for patient support and address their concerns promptly.
Peer Review and Collaboration: Encourage peer review and collaboration among healthcare providers. Regular case conferences and discussions can improve knowledge sharing and adherence to best practices.
Data Management and Reporting: Implement a standardized data management system to ensure accurate and timely reporting of TPT outcomes. Monitor data regularly to identify trends and potential issues.
Quality Improvement Initiatives: Use the findings from audits, reviews, and data analysis to develop and implement quality improvement initiatives. Continuous quality improvement is essential for enhancing TPT services.
Public Awareness and Advocacy: Raise public awareness about TB and the importance of preventive treatment. Engage in advocacy efforts to garner support for TB control programs and external quality assurance.
Research and Innovation: Encourage operational research and innovation in TB preventive treatment to stay up-to-date with the latest developments and best practices.
Remember that establishing an effective EQA program requires continuous dedication, collaboration, and adaptability. Regularly reassess the program’s effectiveness and make adjustments as necessary to improve TPT outcomes in Kashmir.
So, to conclude, Tuberculosis Preventive Treatment is crucial to reducing TB burden, transmission and to achieve elimination. Proper implementation, monitoring, and collaboration between healthcare sectors are essential to achieving the goal of ending TB. No one is safe until everyone is screened and treated to stop the spread of TB infection and #EndTB. Addressing challenges requires a multi-faceted approach involving strong political commitment, collaboration between different stakeholders, community engagement,
innovative strategies for reaching high-risk populations, and ongoing monitoring, evaluation of program performance and external quality assurance. By overcoming these obstacles, UT of Jammu and Kashmir can enhance the impact of TPT and move closer to achieving TB elimination goals.
Authors is working in the Department of Community Medicine, Government Medical College Srinagar and can be reached at [email protected]
