Ground zero: Frontline champions lead the fight to #endTB as global meet opens in India
Shobha Shukla – CNS
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.
Shobha Shukla, CNS (Citizen News Service)
(Shobha Shukla is the Managing Editor of CNS (Citizen News Service) and Coordinator, APCAT Media (Asia Pacific regional
media network to end TB & tobacco, and prevent NCDs). Follow her on Twitter @shobha1shukla or visit www.citizen-news.org)
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