Tuberculosis

Explaining the burden of Tuberculosis

Tuberculosis (TB) is a contagious disease caused by Mycobacterium tuberculosis. The bacteria is known to affect the lungs causing Pulmonary tuberculosis (pulmonary TB) but can also affect other sites also in which case it is referred to as extra-pulmonary TB. The disease spreads when a healthy individual comes in contact with the bacteria expelled into the air by a person infected with pulmonary tuberculosis (pulmonary TB) by coughing. However, it’s only 5-10% of the total population infected by M.tuberculosis which develops tuberculosis (TB). People infected with HIV show a higher incidence of the disease. Other risk factors for the disease include low-nutrition, diabetes, and prevalence of smoking and alcohol consumption.

Globally, tuberculosis (TB) is one of the top ten causes of death with the highest percentage of these deaths being reported from developing countries. According to the latest Global TB Report by WHO published in 2018, out of the 10 million people who developed tuberculosis (TB) in 2017 two-thirds were from eight countries with India being home to the highest percentage (27%) of persons affected by TB. India, thus, accounts for the highest TB burden globally. In view of the growing number of TB cases, Government of India aims at a TB-free India by the year 2025. However, the challenge to rid the nation of the TB burden is far greater than what can be assessed. The challenges on the way to eradicate the disease include poor or, a complete lack of primary health care system in rural areas, HIV induced TB incidences, lack of proper nutrition and hygiene and widespread poverty which inhibits access to education, awareness, and a proper healthcare regime. The enormity of the problem calls for a multi-stakeholder and multi-faceted approach which involves empowering the grassroots, creating awareness and education about the disease and its treatment, involvement of the Non-Government Organizations (NGO), medical professionals, and caregivers in not only curing the present cases of TB but in preventing the occurrence of new ones. An early diagnosis coupled with prevention of new cases is the key to tackling the TB menace that India is currently faced with.

TB – Prevention, Treatment, and Care

TB prevention begins at birth with the BCG vaccine which gives protection against TB for the first 15 years of life. However, it has limited efficacy in preventing TB, in adults exposed to the infection. Hence, an early diagnosis and continued treatment is the key to effective disease management and stalls further spread of the infection to other adults. It is estimated that a person infected with TB can infect up to 10-15 adults within a year. But within two weeks of diagnosis and start of the TB treatment, the person is no longer contagious. Thus, it is an early diagnosis and a continued treatment that are key to prevent further spreading of the TB bacteria.

Another factor that can play a pivotal role is that of awareness and education. It has been found that raising awareness about the symptoms and the treatment of TB helps individuals with signs of TB seek help and get treated. Awareness and education take center stage in TB prevention in rural areas and slums where both education and access to healthcare is limited or non-existent. Contact tracing, maintaining good personal hygiene and clean surroundings, and intake of nutritious food help in preventing and supporting TB treatment.

Role of GLRA-India in Tackling the TB Menace

GLRA-India had been working for leprosy affected individuals across India for almost 30 years when the dreaded disease of TB started raising its head and struck India in epidemic proportions, in the early 1990’s. Around the same time, leprosy was beginning to reduce its grip on the Indian population owing to the introduction of WHO’s Multidrug Therapy (MDT) in the year 1982. This helped us shift our focus and resources on tackling TB and serving those affected by it without compromising our on-going efforts on leprosy. Given the vast network in urban slums and rural areas that we had developed over the years, and the reach we had in the most remote areas in India, we were confident that we could help in fighting the disease and serve the under-served communities in the far-flung areas of India. Thus, began our association with individuals affected by TB.

However, GLRA-India’s approach in treating TB affected individuals goes much beyond just medical rehabilitation. Besides the active case identification, treatment suggestions, and follow-up, GLRA-India actively pursues the social re-integration of such individual who face alienation from the community owing to the infectious nature of the disease. Moreover, it is commonly seen that individuals affected by TB, if not detected early, lose their livelihood which acts as a further block towards their successful rehabilitation. It was therefore realized that as important as the medical rehabilitation, was the social reintegration of TB affected persons. In the wake of this understanding, GLRA-India has adopted the WHO-Community-based Rehabilitation (WHO-CBR) which ensures their participation and inclusion in the community after becoming free from TB. Though, the WHO-CBR guidelines were originally formulated for rehabilitation of the disabled, and for the continued care and support of such individuals to stimulate their participation in the society, GLRA-India is one of the few NGOs to adopt this for re-integration of TB affected individuals.

In the past, GLRA-India has been one of the implementing partners of the Global Fund Axshya India ACSM Project, and the USAID - supported IMPACT Project. In order to reach out to the grassroots, we support 20 NGO partners working on TB, across 11 states of India to implement innovative projects. Some of these projects include Home Based Care for MDR TB patients in slums of Jaipur and Delhi, TB control among prison inmates in Gujarat, e-compliance projects in Jaipur, and TB control among truckers in Delhi.

While each of the projects implemented so far and the work done on the ground has been a great learning experience but the TB projects undertaken in the state of West Bengal, India are a special case to mention. In the past 10 years through several projects in the state involving active case search, capacity building, engagement of non-qualified private providers, notifications and novel initiatives such as silico-tuberculosis and prison TB, we have been able to reach out to __ persons with TB in these underserved communities. Out of this number, __ have been successfully cured of the disease and are now back in the community leading a healthy life.

Some TB Projects undertaken by GLRA-India

Some of the projects presently underway in India are:

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DRTB Project in Sikkim

Sikkim has been one of the states of India that has received little attention for TB prevention and care. GLRA-India was one of the first NGO to start anti-TB projects in the state. We work in two of the four TUs of Gangtok. The DRTB project involves promoting adherence to DRTB treatments thus enabling better treatment outcomes in terms of decreased loss to follow-up. The project activities involve:

  • Providing early identification and appropriate referrals in case of drug side effects
  • Undertake family contact tracing
  • Providing counselling, and appropriate linkages to address co-morbidity such as diabetes mellitus, smoking, and alcohol use
  • Providing nutrition supplement to patients with BMI below 18.5
  • Patient Provider Meeting once in month
  • Undertake school-based IEC programs

The project had reached 76 persons affected by DRTB in the first six months of 2018 and efforts are underway to reach a larger beneficiary base.

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Project HOPE

Hospital-Based Care of Patients with Serious Forms of Extra-Pulmonary Tuberculosis

The project aims at reducing mortality & morbidity due to serious forms of Extra-pulmonary Tuberculosis (EPTB) through improved adherence to treatment & in-patient care. As ambulatory treatment is not suitable possible for persons suffering from EPTB, many of these patients require several months of hospitalization, which may not be possible in a government hospitals. Our implementing partner, Bantra St. Thomas Home Welfare Society, Howrah provides in-patient facility to such patients. Women who suffer from extra-pulmonary TB not only suffer the disease but also the mental burden of not being able to care for their family. Since, many of them are nit breadwinners for their families; the medical expenses are seen as an additional financial burden to take care of. Project HOPE aims at hospitalization and care of such women suffering from EPTB.

In the year 2018, a total of 24 women suffering from EPTB were admitted during which included 2 paediatric cases. More than 70% of them suffered from spinal TB. This was followed by TB meningitis (3) and lymph node meningitis (3) and abdominal TB respectively. The duration of treatment ranged from 3 to 20 months depending upon the case with no major side-effects reported during the period of hospitalization. 12 patients were discharged during the year in stable condition; out of these 3 had successfully completed treatment.

Home Based Care and Support to MDR TB patients – New Delhi

Drug Resistant TB (DR-TB) is a threat to effective TB control. As per WHO Global TB Report 2017, India has the largest number of drug-resistant TB cases in the world with an annual incidence estimated to be 147,000 (11 patients per 100,000 persons). This is much higher than the global estimate of 8.1 per 100,000 persons. With support of Else Kroner-Fresenius-Stiftung (EKFS), GLRA-India initiated treatment adherence project for DR-TB patients in the slums in the catchment areas of four chest hospitals, in close collaboration with Revised National Tuberculosis Control Programme (RNTCP) Delhi. The project aims to improve early initiation of MDR-TB treatment by contact screening, case holding through counselling at home, reduce loss of follow-up, enable early identification of adverse reactions and referral, infection control measures at patient and family level, and family counselling on nutrition.

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Project DISHA

Distinctive Integrated Sustainable Health Action

Project DISHA is one of its kind. It’s a CSR initiative of Apollo Tyres implemented in close collaboration with the Apollo Tyres Foundation. The project aims at sensitizing truckers and their allied population about TB and general health and hygiene. Despite the trucking industry being a large and important part of the economy, the truckers are a marginalised lot. Low level of education coupled with long hours on the road compromises food habits, hygiene, and family life making them an easy target for HIV and TB. Hence, awareness and education of this section of population was important.

Realizing the need to educate and inform this section of population, Project Disha was started in the Sanjay Gandhi Transport Nagar in New Delhi in the year 2017 and information was disseminated through pictorial hoardings, banners, and street plays to not only truckers but also to local shopkeepers, and dhaba-owners who interact with truckers on a regular basis.

Realizing the need to educate and inform this section of population, Project Disha was started in the Sanjay Gandhi Transport Nagar in New Delhi in the year 2017 and information was disseminated through pictorial hoardings, banners, and street plays to not only truckers but also to local shopkeepers, and dhaba-owners who interact with truckers on a regular basis.

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Project Nai-DISHA

New DISTINCTIVE INTEGRATED SUSTAINABLE HEALTH AND ACTION

Encouraged by the success of Project DISHA, Nai DISHA was launched in the year 2019 as DISHA came to a successful completion. A collaborative effort by, Bündnis Entwicklung hilft, Deutsche Bahn Stiftung and Deutsche Lepra- und Tuberkulosehilfe e. V. (DAHW), the project was launched in the Trans-shipment Locations (TSLs) of Lucknow, Agra and Jaipur regions of North India and a range of activities are carried out under the project. These include:

  1. Conducting routine outreach activities, follow-up with presumptive/patients, maintenance and validation of digital records, documentation and mobilization of the truckers/helpers to seek diagnosis and treatment for TB through linkage with the health system.
  2. Conducting different community outreach approaches like group meetings, one to one interpersonal interaction with truckers and labourers, community meetings at dhabas/eateries, active surveys, street plays and health awareness camps
  3. Communicating TB messages on hoardings/ banners with contact numbers of referral centres for seeking TB related services displayed at major eateries (dhabas), fuelling stations and mechanic/tyre repair shops along the most common routes in and out of the target TSLs.

The project activities, coverage, and quality is being monitored online through web-based mechanism, telephone and through on-site random physical validation by the Project Management Unit.