Chennai city’s new strategy to eliminate TB


Thanks to the Zero TB Cities project, if everything works to plan, Chennai may drastically reduce TB mortality, shrink the number of new cases annually and impact TB prevalence in the city in a matter of 3-5 years.

Chennai has been chosen as one of two cities in the world where the Zero TB Cities project will try to create an “island of elimination”; Lima in Peru is the other city. The project will be formally launched in Chennai in a few months’ time.

The project will be implemented by the Municipal Corporation of Chennai with the Chennai-based REACH and the National Institute for Research in Tuberculosis (NIRT) assisting it.

“Our U.S.-based team partnered with the Clinton Health Access Initiative (CHAI) India, to do extensive scoping missions across major Indian cities starting in 2014. Over the course of several visits, Chennai came out as the strongest site to explore a Zero TB City approach in India,” Tom Nicholson associate in research at the Duke Center for International Development (DCID), Durham, and who is heading the new project said in an email to The Hindu .

The very objective of the project is that other cities in India and elsewhere take the initiative in a similar way and tackle their own TB epidemics urgently. “When the municipal authorities in Lima or Chennai stand up and identify TB as a priority public health menace that needs to be tackled, other locations may follow suit, and build their own locally appropriate plans to more toward ultimate elimination of TB. If we can help, we will of course find a way to do so,” Mr. Nicholson said.

“The goal is to help communities move to zero deaths from tuberculosis in their own way, and create “islands of elimination”, which will hopefully reverse the overall tuberculosis epidemic,” Pamela Das, Executive Editor and Richard Horton, Editor-in-Chief, note in an Editorial in The Lancet.

The flicker of hope shines brightly amidst the gloomy and grim tuberculosis scenario in the country — 220,000 avoidable TB deaths in 2014 in people who were HIV negative and 2.2 million new TB cases, accounting for 23 per cent of the global total. The country today faces the world’s greatest TB crisis despite halving TB prevalence and the mortality rate in the last 25 years.

“Business as usual can no longer be an option in the fight against tuberculosis” as the global decline in the number of new TB cases every year has been extremely slow in the last 25 years. At this rate, it will take another two centuries to eliminate the disease, The Lancet notes .

The Zero TB Cities project that began in 2014 and launched in active form last month has earnestly embraced the Zero TB Declaration in 2012 that calls for a “new global attitude” in the fight against TB.

“In India, there is evidence that transmission of TB is much higher in cities, and cities are often the source of infection for rural communities. So, getting to zero in cities will eliminate important reservoirs of TB,” , Deputy Executive Director of Stop TB Partnership, Geneva said in an email to The Hindu .

Making a marked departure from the current highly ineffectual methods used to tackle the disease, the project envisages a comprehensive tuberculosis elimination strategy at the community level by using all the currently available arsenals. The “island of elimination” strategy does not call for any breakthroughs but only requires a change of mindset and better use of methods and tools that already exist.

To cut the transmission cycle and reduce mortality, the project intends to fight the TB war in Chennai by actively searching for people with TB disease, providing preventive therapy to people infected with TB and belonging to high-risk groups, controlling TB transmission by routinely using efficient tools for early and accurate diagnosis and providing appropriate therapy immediately, and finally by making sure the right supportive programmes are in place to keep patients on therapy.

Fortunately, the Revised National Tuberculosis Control Programme (RNTCP) guidelines are very forward looking and already advocate most of the strategies to be adopted by the Zero TB Cities project.

Though how soon the initial objective will be reached will depend on how quickly and how well the programme is rolled out, Chennai already enjoys a head start. Together with other stakeholders — NGOs, private practitioners, pharmacies, deans of medical colleges and NIRT — the Corporation has already initiated some measures that will form the “key focus” of the project.

For instance, the gaps in fighting the disease have already been identified by the Chennai Corporation, and ruling out TB in HIV positive adults using an advanced tool (GeneXpert) has been going on since June this year. Actively tracing and testing people living in the same household as a recently diagnosed TB patient and therefore at high risk of contracting the disease is already being done. “From Stop TB we are already supporting a TB REACH project in Chennai which among other things is focussing on how to implement contact investigation better,” said Dr. Sahu.

“The city is planning to go beyond household contacts to look for hotspots of transmission in slums and poverty pockets, and to implement active case finding in such settings,” said Dr. Sahu.

Seamless integration between public and private sectors for TB care will be less challenging in Chennai as the Corporation and REACH already work closely with the private sector to make case notification more effective and to address the issue of availability of TB medicines to people approaching private practitioners. In a small way, REACH already has a public-care representative embedded in private hospitals to facilitate medicine availability to poor patients.

“We see “Zero TB” as a long term goal, a catch-all way of saying we are moving in an accelerated fashion toward the pre-elimination phase, which is seen in wealthy health systems where TB exists but is no longer an urgent public health problem,” Mr. Nicholson said. “Realistically we expect that any city can expect to reach pre-elimination phase with the comprehensive approach.” Only after the infrastructure is in place to search, treat and prevent will moving toward the more ambitious goals of zero deaths, zero transmission, and ultimately zero patients be even conceptually possible.

Despite the disease being airborne and presence of a large population infected with TB bacteria (latent TB) acting as a reservoir, Mr. Nicholson is confident that TB can be and has been controlled in thousands of settings in the past.

While referring to the problems posed by migration of people into the city from high-burden settings Mr. Nicholson said: “The Zero TB Cities approach needs to be part of a larger movement and cannot fully succeed in isolation in India in terms of getting to the final “zeros” in Chennai.”

The Project is a collaborative effort between Harvard’s Department of Global Health and Social Medicine, Duke University’s Sanford School of Public Policy and Duke Center for International Development. Stop TB Partnership provides the operational and strategic collaboration.

Published in The Hindu on November 23, 2015