Module for Youth Volunteers: Basics of TB Disease

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Resources

• Global Tuberculosis Report, 2020; Geneva: World Health Organization, 2020
• Training Modules (1-4) for Programme Managers and Medical Officers India: Central TB Division, MoHFW, Government of India,July 2020

TB is one of the top burdensome infectious diseases in India. It is estimated that, around 1/4th (26%) of the world's TB cases are in India, translating to about 30 Lakhs new TB cases emerging each year (TB incidence). Against this estimated incidence the National TB Elimination program reported around 19 lakh new and relapse cases in the year 2021.

An estimated 5 Lakhs deaths occur due to TB each year in the country, translating to about 1 case of TB death every one-two minutes. Compared to this, there are only about 60 thousand deaths due to HIV and about 77 deaths due to Malaria each year.

TB diagnosis and treatment services although provided free of cost in the public sector, the cost of accessing these services and related loss of wages drive the affected people with poverty (catastrophic costs). TB also has a huge impact on the world's and the country's economy because of loss of workdays (100 million workdays per year).

Assessment

Resources:

• ^*WHO Global TB Report 2021
• ^{^}Status of National AIDS Response
• ^$PIB MOHFW

TB is caused due to the infection by a bacterium called Mycobacterium tuberculosis.

It often affects the lungs, and in such cases it is called Pulmonary Tuberculosis. But, it can affect almost any part of the body (except the hair and the nails), in which it is known as Extra-Pulmonary Tuberculosis.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

Determinants are any characteristics that affect the health of a patient.

TB can affect anyone but it is more prevalent in some communities which are vulnerable to TB disease due to various factors which are mentioned below:

Increased exposure of TB due to where they live or work

• prisoners
• slum dwellers
• miners
• hospital visitors
• healthcare workers

Limited access to Quality TB services

• Migrant workers
• Women in settings with gender disparity,
• Children
• Physically challenged
• Transgender population
• Tribal and population living in hard to reach areas
• Refugees or internally displaced people
• Illegal miners and undocumented migrants

Increased risk because of biological or behavioural factors that compromise immune functions in people who:

• People who live with HIV
• have diabetes or silicosis
• undergo immunosuppressive therapy
• are undernourished
• use tobacco
• suffer from alcohol use disorders.
• inject drugs 

Active TB disease has 4 major symptoms (the 4 Symptom complex). Presence of any one of these symptoms without any other reason warrants evaluation for TB. These are:

Figure: Signs and Symptoms of TB

People affected with TB may experience other symptoms as well. These may be based on the site that is affected with TB or other more non-specific symptoms of an infection. The physician or doctor would evaluate these symptoms in view of diagnosis of TB.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

Tuberculosis is transmitted mainly through the air via droplet nuclei generated when a TB patient coughs or sneezes. 

It is estimated that every sputum smear-positive patient spreads the infection to 10 – 15 persons annually, if untreated..

Figure: Transmission of TB bacteria through air via droplet

Resources:

• Technical and Operational Guidelines for TB Control in India 2016
• WHO - Fact sheet details on Tuberculosis

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After exposure to infective droplets containing M.TB, only a small proportion gets infected and further progresses to active TB disease.

• Majority of those that get infected persist in a stage of clinical latency known as TB infection (previously known as Latent TB infection). They do not have TB disease and do not show any symptoms of TB and no evidence of any TB related changes on chest X-ray.
• A small proportion of those with prior infection may progress to active TB disease due to various environmental/ agent/ host factors.

Figure: Flow chart for TB disease progression

Resources:

• Understanding delayed T-Cell Priming, Lung Recruitment, and AirwayLuminal T-Cell Responses in Host defence against Pulmonary Tuberculosis

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• TB Infection (or previously known as Latent TB infection) is a stage in between uninfected and having active TB. In this stage the person has no symptoms and can only be identified using laboratory tests.

• The vast majority of infected people may never develop TB disease. However, to achieve TB elimination, it is important to treat TB infection in people at risk of developing active TB disease.

• It is a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifested active TB.

• There is no single acceptable/reliable test for direct identification of Mycobacterium tuberculosis infection in humans. Tuberculin Skin Test (TST) and Interferon-gamma release assay (IGRA) are commonly used tests for identifying TB infection.

Resources:

• Latent Tuberculosis Infection Guideline

• Guideline for Programmatic Management of Tuberculosis Preventive Treatment in India

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

As TB is an airborne infection, TB bacteria are released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by taking simple precautions:

Figure: Measures for control and prevention of tuberculosis

TB Preventive Treatment(TPT) also has a very important role in prevention of TB. Presently, household contacts of sputum-positive TB patients are given TPT upon confirmation of TB infection and ruling our active Tuberculosis.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

What is Drug-Sensitive Tuberculosis (DS-TB)?

• DSTB is a case where a person is infected with TB bacteria that are susceptible to all first line anti-TB drugs. It means that all of the first line TB drugs will be effective as long as they are taken properly and regularly.

• This type of TB has the best prognosis and the shortest treatment duration.

• Patients diagnosed with TB are considered to be DS-TB case, till such time s/he detected with resistance to any anti-TB drugs.

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What is Drug-Resistant Tuberculosis?

• Drug-Resistant TB occurs when bacteria become resistant to the drugs used to treat TB. This means that the drug can no longer kill the TB bacteria.

• Multidrug-resistant TB (MDR TB) is a type of DR-TB where TB bacteria is resistant to both Isoniazid and Rifampicin, the two most potent anti-TB drugs.

                               Figure: High Risk for Drug-Resistant Tuberculosis (DRTB)

Resources:

• Guidelines for Programmatic Management of Drug-Resistant Tuberculosis in India, March 2021 
• WHO Consolidated Guidelines on Tuberculosis: Module 4-Treatment: Drug resistant TB Treatment, 2020

Tuberculosis(TB) is curable if patients are treated with effective, uninterrupted anti-tuberculous treatment. Treatment adherence is critical for curing individual patients, controlling the spread of infection in the community, and minimizing the development of drug resistance.

Adherence to treatment means that a patient follows the recommended course of treatment by taking all the prescribed medications for the entire length of time, as necessary. In other words, “right dose for the right duration”.

In Drug Sensitive Tuberculosis(DSTB), a TB patient completes 168 doses of TB treatment and adheres to TB treatment.

Adherence to tuberculosis(TB) treatment is important for promoting individual and public health. Poor adherence to TB treatment results in:

• More individual suffering and death,
• Costly treatment as treatment regimens lengthen and
• Increases the risk for Drug Resistant Tuberculosis

Proper treatment of all forms of TB is critical to reducing individual morbidity and mortality and to interrupting transmission among family and community members.

National Tuberculosis Elimination Programme (NTEP) is a centrally sponsored programme being implemented under the aegis of National Health Mission.

National Level: Managed by Central TB Division (CTD), the technical arm of the Ministry of Health and Family Welfare (MOHFW)

State Level: State TB Cell coordinates the overall TB elimination programme in state under the guidance of State Health Society. The training ,supervision, monitoring and evaluation NTEP at state level are looked after by STDC (State TB Training and Demonstration Centre).

District TB Centre (DTC) is the nodal point for all TB elimination activities in the district under the guidance of the District Health Society.

Tuberculosis Unit (TU) Level: NTEP activities at block/sub-district level are implemented through TU which comprises Designated Medical Officer (MO) supported by two full-time NTEP staff - STS (Senior Treatment Supervisor) & STLS (Senior TB Lab Supervisor).

PHI (Peripheral Health Institute): PHI is a health facility manned by a Medical Officer (MO). Some of the PHIs are also the Tuberculosis Diagnostic Centres, which are the most peripheral level laboratories in the NTEP structure. All the Private Health Facilities like Private Practitioners / Private Hospitals / Clinics / Nursing Homes are also PHI.

Figure: Organisational structure of NTEP

Resources:

• TB India Report 2021
• Technical and Operational Guidelines for TB Control in India 2016

Those who are suspected of having TB disease are first screened for symptoms like cough and fever for more than 2 weeks, blood stained sputum and weight-loss. If found positive on screening, then TB patients are referred for testing to the nearest health facility. If diagnosed with TB, then they are subsequently initiated on treatment. The TB patients initiated on treatment are regularly monitored with the help of field staff or digital interventions like 99DOTS and MERM (Medication Event Reminder Monitor) technology. NTEP staff also ensures that the TB patients are regularly followed up on monthly basis till their treatment completion.

Figure: Patient Flow

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After Installing the App, all users will have access to the static content of the App which includes useful information around TB and its diagnosis. It covers the following sections:

Figure: Informative Page in TB Aarogya Sathi Application

• Information on TB - Provides basic information on TB. Useful to create awareness of TB and remove misconceptions/stigma among the general public.
• Symptoms - Provides information on the common symptoms of TB.
• Side Effects - Provides basic information on side effects due to Anti TB treatment; Helps to remove misconceptions.
• Health Facilities - Provides details of the health facilities which are providing TB Services.
• BMI Assessment - Provides Nutritional Assessment of the user based on Body Mass Index(BMI).
• Nikshay Sampark - The toll-free TB Helpline is accessed directly from the application.
• Nutrition Advice - Guides the user on the importance of good nutrition for prevention of TB and risk of TB due to malnutrition.
• Useful Links - Awareness materials on various aspects of TB, including nutritional support, mitigating stigma, incentives etc.
• Social Support - Provides information on various Direct Benefit Transfer Schemes available under NTEP.
• About NTEP - Provides a brief history of the National TB Program in the country and its aims and objectives.

Presumptive TB case refers to a patient who presents with symptoms or signs suggestive of TB disease (previously known as a TB suspect) and where further diagnostic workup including bacteriological investigation is required.

 Presumptive TB can be categorized into

1. Presumptive Pulmonary TB (P TB) - Symptoms are directly related to lungs (Cough, hemoptysis)

2. Presumptive Extra Pulmonary TB (EP TB) - Symptoms/ signs are specific to an extra pulmonary site (example: Lymph node swelling)

3. Presumptive Pediatric TB - Symptoms of TB in young children are more difficult to identify and can be more general (fever, weight loss) 

Resources:

• Technical and Operational Guidelines for TB Control in India 2016
• Definitions and reporting framework for tuberculosis

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Pulmonary TB(PTB) is primarily involves lungs. Screening should be done for the following symptoms:

Figure: Signs and Symptoms of active TB

Regular screening of Presumptive TB cases with unexplained cough of any duration should be done and checked for:

• History of close contact with known active TB case 

• Whether the patient has developed Presumptive/confirmed extrapulmonary TB(EPTB)

• High-risk groups: PL HIV, Diabetics, Malnourished, Cancer patients, patients on immunosuppressive therapy or steroids

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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National Tuberculosis Elimination Programme (NTEP) strives for all presumptive TB patients to be microbiologically confirmed. Under NTEP, the acceptable methods for microbiological diagnosis of TB are: 

Rapid diagnostic molecular test: Rapid molecular tests that use techniques like NAAT are very specific. They amplify the genomic material in the patient sample and hence enhances detection

• Nucleic Acid Amplification Test (NAAT) e.g., GeneXpert, TrueNat

  

  Figure: Genxpert Machine for CBNAAT

  

  Figure:  Truenat Machine

• Line Probe Assay

For laboratory diagnosis of TB, different biological specimens are used.

Pulmonary TB: Sputum sample is used. Sputum is a thick fluid produced in the lungs and in the adjacent airways. Normally, a spot sample and a fresh morning sample is preferred for the bacteriological examination of sputum.

Extra Pulmonary TB:

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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Presumptive TB patients attending the TB Diagnostic centre (TDC) will be referred for sputum examination at the same facility. The patients are given the sputum container with laboratory serial number written on its side. The patient is:

Figure: Sputum Collection Process

• Provided with the labelled sputum cups and demonstrated how to open and close the container.
• Given a labelled container with instructions to cough out sputum into the container early in the morning after rinsing the mouth with water. This is the early morning specimen. This is labelled as Specimen ‘b’.
• Ensure collection of sputum samples in an open, well-ventilated area designated for this purpose.
• Given a sputum container with instructions to collect an early morning specimen and go with the sputum specimen to the TDC(if the health facility is not a TDC) where the spot specimen can be collected. If the patient cannot travel to the TDC, then the spot specimen could be collected at the nearest health facility or sputum collection centre and transported to the TDC.

Video: Process of sputum collection 

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

• Community Health Volunteers play a significant role in increasing awareness regarding the burden of TB and the importance of preventing it and regularly screening the population.
• Community Health Volunteers should use the various platforms in the communities, such as the PRI meetings, school meetings etc., for spreading the information on TB. Using such media, the Community Health Volunteers should focus on building community awareness to improve the patients' health-seeking behaviour.

• Community Health Volunteers should screen the vulnerable population for Tuberculosis during the Active Case Finding Campaign. Positive TB suspects identified should then be referred for testing, post which, if diagnosed with TB, should be initiated on treatment.
• Community Health Volunteers should also ensure that those TB patients initiated on treatment adhere to the treatment.
• Community Health Volunteers should also record the population screened; sputum examined cases, diagnosed cases and patients initiated on treatment.
• Community Health Volunteers should also confirm the patient's address in their respective locality for correct patient identification.

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As TB is an airborne infection, TB bacteria are released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by taking simple precautions:

Figure: Measures for control and prevention of tuberculosis

TB Preventive Treatment(TPT) also has a very important role in prevention of TB. Presently, household contacts of sputum-positive TB patients are given TPT upon confirmation of TB infection and ruling our active Tuberculosis.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

Community-based TB activities are conducted outside the premises of formal health facilities (e.g. hospitals and clinics) in community-based structures (e.g. schools and places of worship) and homesteads. Community health workers and community volunteers carry out community-based TB activities. Both can be supported by nongovernmental organizations and/or the government.

Community Engagement is a cost effective intervention to improve health service coverage and deliver accessible and people-centered integrated care.

Figure: Importance of Community Engagement

Stigma is when someone sees you in a negative way.

Discrimination is when someone treats you in a negative way.

TB patients face various forms of stigma and discrimination in the community

Figure: Stigma towards TB Patients in the community

At Individual Level

• Lack of self-esteem and confidence
• Increased sense of emotional isolation, feeling of guilt and anxiety
• Physical as well as financial debilitation
• People, more often women, are forced to leave their homes
• Concealing symptoms and hesitancy in seeking medical care making disease management more difficult
• Delayed diagnosis, interrupted treatment that can lead to further transmission and DRTB
• Vulnerability increases, can lead to suicidal thoughts due to isolation and shame

At Family and Community Levels

• Loss of household earnings
• Exposure of caregivers to the risk of infection that lowers productivity and cycle of poverty further gets perpetuated
• Isolation and stigmatization of infected persons often by people of their community
• Deep-rooted lack of knowledge and misconceptions among the affected and infected within their cultural and religious environment
• Loss of status and negative impact on those with the disease, their caregivers, family, friends and communities
• Perceived and internalized stigma of the community due to socio-cultural values that TB is punishment for sins or transgression

Awareness should be generated in the community for promoting various health programmes, health seeking behaviours, screening of TB cases etc. by involving and sensitizing community influencers including PRI members and treatment support groups.

Figure: Activities for awareness generation in community

Interaction with the patients and their families is crucial to gauge a patient's understanding of the disease he/she is suffering from and the course of treatment to be followed.

Aspects to be considered during a Home visit:

• First home visit should be completed within 7 days of the patient's diagnosis.
• Patients who have Adverse Drug Reaction(i.e. ADR) / interrupted treatment /Loss to follow up /Repeat episode, interrupted the treatment should be given preference and would be preferable if the In-charge of the health facility accompany the team during home visit.

Figure: Precautionary measures to be advised to patient during home visit

A TB Champion is a person who has been affected by TB and successfully completed the treatment.

TB Champions, in their capacity as survivors, are role models and can provide valuable support to those with TB and their families.

Figure: Roles of TB Champion

Community Health Volunteers should identify TB Champions and engage them to provide their support to the patient in activities like:

Figure: Help to TB Patients by Community Health Volunteers

A Treatment Supporter can be any person such as a Medical Officer, MPWs, community volunteers working with the program etc. Even a patient’s relative or family member can be a Treatment Supporter.

As per NTEP guidelines, salaried NTEP/General Health System staff may also be assigned as treatment supporters for a patient.  However, they will not be eligible for any honorarium.

A patient can only be linked to one treatment supporter at a time in Nikshay.

Treatment supporters are eligible for Honorarium at the end of TB patients treatment, only if the patient's treatment outcome has been declared either as "Cured “or "Treatment Complete".

The eligible amount of honorarium is

• Rs. 1,000 for DSTB Patients and for
• Rs. 5,000 for DRTB patients. 

These benefit amount are processed through Nikshay and below are the prerequisite conditions that needs to be met in Nikshay, for generating incentive

• Treatment supporter should be registered and enabled for receiving honorarium from Nikshay.
• Bank details of Treatment supporter should be submitted to the nearest NTEP health facility staff.
• In Nikshay, this is the only scheme where benefits are generated manually by TU users - STS
• Nikshay will allow NTEP TU users to generate benefits, only if
  • ​Treatment Outcome has been declared as "Cured “or "Treatment Complete"
  • Patient duplication status should be Unique i.e. Nikshay marks the patient duplicate based on Gender and Mobile Number
• For DSTB patient, one benefit of maximum amount of Rs. 1,000 can be created if outcome is updated as “Cured” or “Treatment Completed
• For DR TB patients two benefits can be generated in Nikshay:
  • First benefit of maximum amount Rs. 2,000 can be created at end IP - Intensive Phase (i.e. Initiation Date + 6 months)
  • Second benefit of maximum amount Rs. 3,000 can be created if Outcome is updated as “Cured” or “Treatment Completed”