Without a magic wand, India cannot eliminate TB by 2025

GeneXpert

Only 93,000 MDR-TB cases have been diagnosed till 2015 in India.

At the end of 50 years of tuberculosis control activities, the disease remains a major health challenge in India. As per new estimates, the number of new cases every year has risen to 2.8 million and mortality is put at 4,80,000 each year. These figures may go up when the national TB prevalence survey is undertaken in 2017-18. Against this backdrop, the Ministry of Health and Family Welfare, in its national strategic plan for tuberculosis elimination (2017-2025), has set a highly ambitious goal of “achieving a rapid decline in burden of TB, morbidity and mortality while working towards elimination of TB by 2025.”

Though the Revised National Tuberculosis Control Programme (RNTCP) has treated 10 million patients, the rate of decline has been slow. Providing universal access to early diagnosis and treatment and improving case detection were the main goals of the national strategic plan 2012-17. But the RNTCP failed on both counts, as the Joint Monitoring Mission report of 2015 pointed out. Going by the current rate of decline, India is far from reaching the 2030 Sustainable Development Goals — reducing the number of deaths by 90% and TB incidence by 80% compared with 2015. Yet, the latest report for TB elimination calls for reducing TB incidence from 217 per 1,00,000 in 2015 to 142 by 2020 and 44 by 2025 and reduce mortality from 32 to 15 by 2020 and 3 per 1,00,000 by 2025.

Incidentally, nearly 50% of people in India are latently infected with TB. According to CDC, 5-10% of infected people will develop TB disease at some time in their lives. “About half of those people who develop TB will do so within the first two years of infection,” the CDC says. With the latently infected people acting as a reservoir, it will be nearly impossible to eliminate TB in India by 2025.

Radical approaches are needed to come anywhere close to reaching these ambitious targets. Most importantly, the TB control programme plans to do away with the strategy of waiting for patients to walk in to get tested and instead engage in detecting more cases, both drug-sensitive and drug-resistant. The emphasis will be on using highly sensitive diagnostic tests, undertaking universal testing for drug-resistant TB, reaching out to TB patients seeking care from private doctors and targeting people belonging to high-risk populations.

The other priority is to provide anti-TB treatment — irrespective of where patients seek care from, public or private — and ensure that they complete the treatment. For the first time, the TB control programme talks of having in place patient-friendly systems to provide treatment and social support. It seeks to make the daily regimen universal; currently, the thrice weekly regimen is followed by RNTCP, and the daily regimen has been introduced only in five States. There will be a rapid scale-up of short-course regimens for drug-resistant TB and drug sensitivity testing-guided treatment. In 2013, India “achieved complete geographical coverage” for MDR-TB (multi-drug-resistant tuberculosis) diagnosis and treatment.  Yet, only 93,000 people with MDR-TB had been diagnosed and put on treatment till 2015; several MDR-TB cases are simply not diagnosed.

What next?

Though Bedaquiline, the drug for people who do not respond to any anti-TB medicine, is provided in six sites in the country, the number of beneficiaries is very small. It has been a battle to get the drug for treatment, as in the case of an 18-year-old who had to approach the Supreme Court for help. Yet, the report envisages a countrywide scale-up of Bedaquiline and Delamanid.

In a marked departure, the report underscores the need to prevent the emergence of TB in susceptible populations. One such segment is those in contact with a recently diagnosed pulmonary TB. Incidentally, active-case finding is already a part of the RNTCP programme but rarely implemented. It wants to increase active case finding to 100% by 2020. Since RNTCP expenditure has increased by 27% since 2012 and is inadequately funded, the Ministry proposes to increase funding to ₹16,500 crore.

Acknowledging that the business-as-usual approach will not get the Health Ministry anywhere close to the goals, it has earmarked critical components that will be addressed on priority. These include sending customised SMSes to improve drug compliance, incentivising private doctors to notify cases and providing free medicines to patients approaching the private sector, facilitating nutritional support to TB patients, including financial support, rewarding States performing well in controlling TB, and using management information systems to monitor all aspects of TB control. “The ultimate impact of this national strategic plan will be transformational improvements in the end TB efforts of India,” the report says. It plans to take a “detect-treat-prevent-build approach” in its war against TB.

Published in The Hindu on March 19, 2017

Time India got serious about fighting TB

GeneXpert

The number of estimated TB deaths in India shot up from 220,000 in 2014 to 483,000 in 2015

Pushed to a corner owing to lack of political will on the part of countries with a high burden of tuberculosis, the World Health Organisation has called for the first United Nations General Assembly session on the disease. The fight against TB cannot be won as long as the high-burden countries, particularly India which has the highest TB burden in the world, do not galvanise their government machinery effectively. While the number of deaths caused by TB and the incidence rate had been consistently dropping from the historical highs globally, there has been a recent uptick that is much larger than previously estimated. The primary reason is the sharp increase in the incidence estimate from India — from 2.2 million cases in 2014 to 2.8 million in 2015. Ironically, the revised disease burden estimate for India is an “interim” one; the actual burden, which could be much higher, will be known only when the national TB prevalence survey that is scheduled to begin next year is completed. The number of estimated deaths caused by TB more than doubled from 220,000 in 2014 to 483,000 in 2015. As in the case of incidence, the revised estimate for deaths could also be an underestimation.

The increase in incidence owes to a 34 per cent rise in case notifications by health-care providers in the private sector between 2013 and 2015. Yet, in 2015 notifications by doctors in the private sector comprised only 16 per cent of the total. Though notification was made mandatory in 2012, only 1.7 million incident TB cases in the public and private sectors were notified in 2015. Thus the fate of 1.1 million patients is simply not known: they have fallen off the radar. For an effective fight against TB, the control programme needs to be aware of every single patient diagnosed, and offer treatment to all. If there are only about 50 per cent of the patients approaching the private sector who successfully complete treatment, a recent study has shown that in 2013 only about 65 per cent of the 1.9 million who approached the public sector completed the treatment regime. The crisis has been aggravated with the disease becoming more expensive and difficult to treat and the number of people with drug-resistant forms increasing. The national TB control programme is behind schedule with respect to critical programmes including the expansion of the GeneXpert pilot programme, scaling up of drug sensitivity testing, and the introduction of a child-friendly paediatric TB drug. Only sustained action on several fronts can help bring TB under check. The global war will not be successful till India wins the battle within its own boundaries first.

About 0.5 million TB patients approaching RNTCP centres are not treated

GeneXpert

In 2013, only 39 per cent of 2.7 million TB patients in India had one year of recurrence-free survival.

In 2013, India had about 2.7 million people with TB, which is 23 per cent of the global burden of TB. India also accounted for 27 per cent (760,000) of the world’s “missing” patients — those may not have received effective TB care or may have received potentially suboptimal TB care in India’s private sector.

According to estimates by a team of researchers, of 2.7 million patients, only 72 per cent were evaluated at RNTCP facilities, about 60 per cent successfully diagnosed, 53 per cent registered for treatment, and 45 per cent completed treatment.  In all, only 39 per cent of 2.7 million patients achieved optimal outcome of one-year recurrence-free survival. The results of study that looked at TB cascade of care at RNTCP were published on October 25 in the journal PLOS Medicine.

“Though most of 27 per cent of “missing” patients are being treated in the private sector; a smaller percentage may not have received any care for TB, though it is hard to know how large this untreated population is. The WHO’s revision of India’s TB burden, released last week, would suggest that this percentage of patients who don’t come into contact with RNTCP TB services is larger than we have estimated,” says Dr. Ramnath Subbaraman from the Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard Medical School, Boston, U.S and the first author of the paper.

The bottom line is that about 500,000 patients (one-fifth of all TB patients) who interfaced with government TB clinics are either not successfully diagnosed or are diagnosed with TB but lost to follow-up before starting treatment.

If only 1.3 per cent of TB smear-positive patients who reached RNTCP diagnostic centres were not correctly diagnosed, 38 per cent of new smear negative patients and 27 per cent of retreatment smear negative patients were not diagnosed. So of all TB patients seeking care at government TB facilities, 16 per cent are not successfully diagnosed.

Soumya Swaminathan. - Photo R. Prasad

We need to know more about how anand where patients seek care, says Dr. Soumya Swaminathan.

“To reach all TB patients and avoid delays in diagnosis, TB services must be available where patients seek care. We need to know more about how and where patients seek care,” says Dr. Soumya Swaminathan, Director-General of ICMR and one of the authors of the paper. “Active case finding in vulnerable populations, use of molecular diagnostics and more suspicion of extrapulmonary TB by doctors are needed to improve TB diagnosis. Attention has to be paid to all steps of cascade.”

Currently, smear-negative TB patients are diagnosed using a multi-step diagnostic workup. As a result, at least 60-80 per cent of patients with negative sputum smear never complete the workup. “While the RNTCP is trying to implement a new diagnostic algorithm for smear-negative TB, the best solution for diagnosing more smear-negative patients would probably be use of new but more expensive diagnostic tests such as Xpert MTB/Rif, which diagnoses a substantially greater percentage of patients with smear-negative TB,” Dr. Subbaraman says.

Ironically, 13 per cent (over 200,000) patients who were diagnosed were lost before the start of treatment — about 16 per cent of smear-positive TB patients and about 10.5 per cent of smear-negative patients.

Pai

Only 11 per cent of MDR-TB patients survived for one year after treatment, says Prof. Madhukar Pai

“There are many reasons why diagnosed TB patients don’t start treatment. But the bottom line is that better record keeping and aggressive tracking of newly diagnosed patients might help to reduce the number of patients who are diagnosed but not enrolled in TB treatment,” says Dr. Subbaraman.

“For patients with MDR-TB, out of the 61,000 who reached government TB clinics, only about 11 per cent completed appropriate treatment and survived for one year after treatment without experiencing disease relapse, ” says Prof. Madhukar Pai, a TB expert from McGill University, Montreal, Canada and one of the authors of the paper.

“The major problem we highlight is not that MDR-TB patients are not seeking care. Rather, a very large percentage of them (59 per cent) were not successfully diagnosed in 2013. I should note that, since 2013, the number of MDR-TB patients diagnosed in the RNTCP has increased a bit in 2014 and 2015, but the percentage of MDR-TB patients successfully diagnosed is still probably abysmally low,” Dr. Subbaraman says.

“There is expansion of Xpert for diagnosing MDR-TB cases. But we need more decentralised rapid MDR diagnostics,” says Dr. Swaminathan.

Published in The Hindu on October 26, 2016

Trials with antibiotics lead to TB diagnosis delay

Pneumonia - Wikimedia Commons

Only occasionally do doctors ask for sputum smear and only after conducting blood tests and a chest X-ray

Tuberculosis patients in India who seek care in the private sector face a delay of as long as two months before they are diagnosed correctly — if at all — according to systematic reviews of Indian studies. This becomes alarming as private sector accounts for almost half of the TB care delivered in India. A larger group begins their pathway to care in the private and informal sector as they are often the first point of care for patients before TB patients eventually get treated in the public sector.

But despite the huge challenges posed by the private sector in TB diagnosis and treatment, only anecdotal evidence is available to explain the delay. Two studies published recently by Andrew McDowell, a medical anthropologist, and Madhukar Pai, a TB expert, from the McGill International TB Centre, McGill University, Canada, provide the much-needed insights into the cause of delay.

Besides interviewing private practitioners holding MBBS degrees and those practising alternative medicine such as Ayurveda, Unani and homeopathy, Dr. McDowell also conducted observations in the clinics of some of the doctors who were earlier interviewed, to understand the nuances of doctor-patient interactions including diagnostic or referral recommendations, prescriptions, and final diagnosis.

Experimenting with antibiotics

One study of 175 practitioners of Indian medicine published in the Transactions of the Royal Society of Tropical Medicine and Hygiene in March 2016 involved 400 interviews and 208 hours of observation, and 2,000 observed patient interactions in 10 clinics in Mumbai. One of the highlights of this study was that none of the 175 practitioners exclusively practiced their system of training. While allopathic medicines, including antibiotics, were prescribed for acute conditions, the physicians generally prescribed their system of medicine for chronic conditions.

Though all the physicians reported seeing at least one patient with typical TB symptoms for more than two weeks in the preceding year, the patient had to visit a doctor several times before he or she was suspected of having TB. The patients were treated with broad-spectrum antibiotics and other symptomatic drugs during the first few visits. Different antibiotics were prescribed during each visit. This process of experimentation using antibiotics usually lasted for 10-14 days.

A few doctors used at least one second-line TB drug when treating drug-susceptible TB.Though fever is common and not very specific to TB, and more than two weeks of cough is one of the main symptoms of TB, no physician ever asked for laboratory investigation on the first visit. Instead the focus was in managing symptoms using non-specific therapies.

Though an X-ray should be used as a screening tool and sputum smear or GeneXpert as confirmatory tests, only 31 practitioners asked for sputum smear and only after conducting blood tests (i.e. blood cell counts and ESR) and a chest X-ray.

The good news is that 164 of the 175 AYUSH practitioners preferred to refer the TB patients to the public sector or to a chest physician and not treat the patients themselves. “Not treating TB patients could be due to a number of factors including uncertainty about treatment protocol, fear of MDR-TB, stronger messaging by RNTCP, fear of being exposed to TB themselves, and a desire to protect other patients in the waiting room from TB exposure,” Dr. McDowell says in an email to me.

However, some AYUSH practitioners did treat the TB patients who left the public sector. What is alarming is that about five per cent (nine AYUSH practitioners) used at least one second-line TB drug when treating drug-susceptible TB. “The key problem is that testing for resistance is very low. It would be unfair, however, to say that this issue is limited to AYUSH practitioners,” Dr. McDowell says. Adds Dr. Pai: “AYUSH doctors should not be treating any form of TB, and definitely not be using second-line anti-TB drugs.”

Chest X-ray and other lab tests were asked for only after months of fever.Lack of diagnostic tests

The second study was published in April 2016 in the International Journal of Tuberculosis and Lung Disease. It found private doctors using fever as a diagnostic criterion for TB due to “ubiquity of cough and paucity of sputum production by patients”. This study of 110 private doctors (MBBS and AYUSH) in Mumbai and Patna involving 143 interviews and 150 clinical observations in seven clinics found doctors from all systems of medicine treating patients symptomatically based on patient history and clinical observation without asking for diagnostic tests.

Patients were, however, asked for a chest X-ray and other lab tests when some doctors suspected TB, but “often after months of fever”. Even when patients had a history of cough, none of the practitioners of alternative medicine suspected TB on the first visit. “I will not think TB unless the problem persists for some time despite treatment,” one practitioner told the authors.

This empirical approach not only leads to delay in diagnosis and increase in the spread of TB but also exposes the patients to a broad-spectrum of needless antibiotics. Using drugs, particularly quinolones and amoxicillin-clavulanate, as diagnostic tools adds to the delay in diagnosing TB as these drugs tend to temporarily mask symptoms such as cough, fever, or sputum production. As the patients are poor and need immediate relief, the only way to reduce the experimentation with antibiotics is to work to reduce the cost of TB diagnostic tests.

The study reveals that the uptake of sputum smear testing is low in the private sector because it only confirms what the X-ray already suggests. Moreover, an X-ray presents a broader set of information about what is happening in the patients’ lungs.

The study found three reasons why doctors choose the ‘treat with antibiotics and wait’ approach while dealing with TB patients. First, there is a compulsion to provide rapid symptom relief; there is a risk of losing patients, especially when diagnostic tests are asked for during the first visit; there is the factor of financial capability of patients; and there is an easy availability of antibiotics. Second, there is a lack of clear and unique TB symptoms besides TB’s slow onset and progression. Finally, doctors perceive that many TB patients come without a cough or do not produce sputum.

These studies suggest the urgent need for the Indian TB programme to engage with private providers (allopathic and AYUSH) and change their traditional, empirical approach to dealing with TB. Ordering a chest X-ray early, a greater use of sputum TB tests (especially GeneXpert), and greater linkages and referrals to the public sector would be key issues for behaviour change management.


Related story and link:

The yawning gap in tuberculosis care in India

 

Published in The Hindu on July 19, 2016

India sets an example in subsidised TB diagnosis

genexpert

There is a bright spot in an otherwise gloomy TB scenario in India. Of the 12 high-burden countries where the private sector is a major player in providing health care, the Indian private sector offers the cheapest price for the WHO-approved Xpert MTB/RIF, a molecular test for diagnosing TB. India also has the highest number of private labs offering the test, with 113 labs offering it at a subsidised rate.

While it costs only Rs.2,000 in the 113 labs (with 5,200 collection centres) which are part of a novel initiative — Improving Access to Affordable & Quality TB Tests (IPAQT) — that was launched in India in March 2013, the charges are anywhere between Rs.3,500 and Rs.5,000 in labs that are not part of the IPAQT initiative. (The ipaqt.org site provides the details of other labs in the country that offer the WHO-approved subsidised tests.)

The mean price of the highly accurate TB test in Bangladesh is nearly $75, while it is $50 in the case of Afghanistan. It is as high as $155.5 in Philippines. Xpert is not commercially available in the private sector in six other high-burden countries.

These are some of the results of a study published today (January 26) in the journal Lancet Global Health.

The cost of the test will see a further drop if the Indian government waives off customs duty of 31 per cent levied on Xpert machine and reagents. “Nothing is preventing the government from waiving off the duty. There is a provision to waive import duties for life saving drugs and products, and HIV kits, for example, are duty-waived. Something similar is necessary for the WHO-endorsed TB tests,” Dr. Madhukar Pai, Professor at McGill University, Canada and one of the Governing Council Members of IPAQT and a coauthor of the paper said in an email to The Hindu.

As a result of the subsidised pricing agreement with the manufacturer, there has been an increase in the number of people in India accessing the highly accurate diagnostic test since 2013. From 15,190 people who availed the test between March and December 2013, it has gone up to 131,440 tests in 2015. The total number of tests done since March 2013 stands at 208,550.

“With a lot of effort, we have managed to keep the price manageable via IPAQT in India, and have shown that volumes can greatly increase. In other privatized countries, patients pay a lot, and have limited access to good tests,” said Dr. Pai.

Pai

Dr. Madhukar Pai. – Photo: R. Prasad

Access to accurate tests at subsidised price is very important in India as nearly 80 per cent of the population in the country first seek the private sector.  If one out of every four TB patients in the world is an Indian, one in eight TB patients in the world is a privately treated Indian patient.

Though the price is internationally set at $9.98 per cartridge, and the agreement allows for a 10 per cent variation in the exchange rate, the cost of the test has not been increased since January 2014 despite the rupee depreciating against the dollar in recent times. But the price may be revised if the rupee continues to depreciate, warns Dr. Pai.

Besides increasing the access to the highly reliable and sensitive test, all labs that become a member of the Initiative abide to ban the unreliable serological test. India banned serological test for TB in June 2012. Also, TB notification by the member labs has improved dramatically as IPAQT helps them with the process of notifying all TB cases.

While the sensitivity of smear microscopy is about 50 per cent, Xpert has 90 per cent sensitivity (in smear positive cases) and 98 per cent specificity. It can also indicate resistance to rifampicin — a first-line TB drug.

Published in The Hindu on January 26, 2016

‘India’s fight against TB lacks punch’

TB bacteria photo - Photo Credi -  Janice Carr, CDC

India’s TB policies have been found wanting on several counts. – Photo: Janice Carr, CDC

“TB is the leading infectious killer, yet countries still follow old and dangerous [TB diagnostic and treatment] polices,” MSF Access Campaign tweeted. In another tweet, MSF International said: “Outdated tuberculosis policies are risking further spread of drug-resistant TB.”

These tweets came soon after the “Out of Step 2015” report on TB policies in 24 countries, including India, was presented recently at the 46th Union World Conference on Lung Health in Cape Town, South Africa. The report was jointly prepared by Stop TB Partnership and MSF Access Campaign.

“The results of the survey show that many countries need to take bold steps to bring their policies up to date with the latest international standards,” the report noted. India’s TB policies have been found wanting on several counts.

For instance, unlike South Africa, Brazil and the Russian Federation which have recommended rapid molecular testing (Gene Xpert) instead of sputum smear microscopy as the initial diagnostic test for all presumptive TB cases, India has recommended its use only for people at risk of multidrug-resistant TB (MDR-TB) or HIV-associated TB, paediatric TB and extra-pulmonary TB cases. Even after limiting its usage, the roll-out has been “progressing slowly,” despite having in place “ambitious scale-up plans.”

Despite recording 71,000 MDR-TB cases (both new and retreatment) in 2014, the Indian TB policy continues to recommend the use of Category II treatment regimens containing streptomycin. It uses the drug “despite recommendations for drug susceptibility test for those at risk of MDR-TB,” the report noted.

Dr. K.S. Sachdeva, Additional Deputy Director-General, Central TB Division, Ministry of Health and Family Welfare, counters this. According to him, patients are first tested for MDR-TB and streptomycin is used only in those who do not have MDR-TB.

Published in the Hindu on December 9, 2015

Chennai city’s new strategy to eliminate TB

genexpert

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