Caring for TB patients in the time of Corona

Caring for TB patients in the time of Corona

Dr KK Aggarwal

President CMAAO, HCFI and Past National President IMA

India continues to have the highest burden of both TB and drug-resistant TB in the world. India launched a TB Free India Campaign on March 13, 2018 at the Delhi End TB Summit and has set 2025 as the deadline of eliminating TB from the country.

Today, with much of the global focus, including resources, being shifted towards Covid-19, other diseases such as TB run the danger of being relegated to the background.

But, can we afford to do so? Not, if we are to meet the deadline, which is five years before the global target of 2030.

There are lessons to be learnt from Covid-19. Covid-19 has in a way shown us the path to control the TB burden in the country. Prevention is the key and this is what will bring us closer to our goal of making India TB-free.

Both Covid-19 and TB can have similar symptoms such as cough, fever and difficulty breathing. Do not ignore any patient with cough. The WHO recommends that tests for both conditions should be made available for individuals with respiratory symptoms.

TB is an airborne infection which spreads via droplet nuclei (< 5 µ in size) released into the air when the infected person coughs, sneezes, sings or even talks. Covid-19, though not yet known to be air-borne, spreads by large droplets (< 5 µ in size).

Open TB cases are infectious and just being within close proximity of an infected person may expose a person to the risk of acquiring the infection. The risk of disease transmission is particularly high in overcrowded conditions. Anybody could be harboring the infection and therefore could be the source of infection, which could also be Covid-19.

Measures must be put in place to limit disease transmission; protective measures such as basic infection prevention and control, hand hygiene, cough etiquette are common to both.

All household and close contacts of patients with infectious TB should be traced and tested and treated with a full course of ATT if found positive for TB. This also includes people living with HIV and other people at risk with lowered immunity or living in crowded settings. These groups are also at high risk of Covid-19. And if infected, they are at risk of developing severe disease.

Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment.

All TB patients, especially active and drug-resistant cases, should be isolated or self-quarantined for 14 days.

The CDC has defined the “minimum period of isolation of the patient – pulmonary tuberculosis (also includes mediastinal, laryngeal, pleural, or miliary). Until bacteriologically negative based on three appropriately collected and processed sputum smears that are collected in eight – 24 hour intervals (one of which should be an early morning specimen), and/or until 14 days after the initiation of appropriate effective chemotherapy, provided therapy is continued as prescribed, and there is demonstration of clinical improvement (i.e., decreasing cough, reduced fever, resolving lung infiltrates, or AFB smears showing decreasing numbers of organisms.” (Available at: https://www.cdc.gov/tb/programs/laws/menu/isolation.htm)

Every case of TB should be notified and diligently followed up during the course of its treatment. Public awareness at grass root level must be created to the scale similar to Covid-19.

Social distancing, adopted as preventive measure for Covid-19 may interrupt treatment of TB. The government must act to ensure availability of anti-tuberculosis treatment.

TB is a treatable condition. But, any disruption in treatment can result in drug-resistant TB.

The WHO has published an information note to assist national TB programs and health personnel to urgently maintain continuity of essential services (prevention, diagnosis, treatment and care) for people affected with TB during the COVID-19 pandemic. It has cautioned that during the Covid-19 pandemic, adequate stocks of TB medicines should be provided to all patients to take home to ensure treatment completion without having to visit treatment centers unnecessarily to collect medicines.

Following this call from the WHO, the government has said that it has enough drugs to last until March 2021 and India’s TB patients will not be affected. Drugs will be issued for a month in advance so that patients have enough medicines with them even case of a lockdown (https://www.indiaspend.com/covid19-could-disrupt-tb-drug-supply-hitting-those-most-vulnerable-to-the-virus/, March 24, 2020).

The government has now allowed doorstep delivery of essential medicines during the 21-day national lockdown vide a notification dated 26^th March, “…in exercise of the powers conferred by Section 26B of the Drugs and Cosmetics Act, 1940 (23 of 1940), the Central Government hereby directs that in case any person holding a license in Form-20 or Form-21 under the Drugs and Cosmetics Rules, 1945 to sell, stock or exhibit or offer for sale, or distribute drugs by retail, intends to sell any drug including the drugs specified in Schedule H except narcotics, psychotropics and controlled substances as defined in the Narcotic Drugs and Psychotropic Substances Act, 1985 (61 of 1985) and the drugs as specified in Schedule H1 & Schedule X to the said rules, by retail with doorstep delivery of the drug, the licensee can sell such drugs subject to the condition that any such sale of a drug specified in Schedule H shall be based on receipt of prescription physically or through e-mail…” (https://www.mohfw.gov.in/pdf/Doorstepdelivery26B.pdf )

Today is World TB Day: Lesson from COVID 19

Today is World TB Day: Lesson from COVID 19

If we want to eradicate TB by 2025, we need to have lessons from COVIOD 19

Dr KK Aggarwal

President CMAAO, HCFI and Past national President IMA

·      Act early before it is too late

·      Create public awareness at grass root level

·      Have PM give National Appeals

·      Test Test and Test all close contacts and symptomatic cases

·      Detect asymptomatic cases

·      Trace all close contacts

·      Trace all household contacts of TB patients, people living with HIV and other people at risk with lowered” immunity or living in crowded settings.

·      Self-quarantine all infected and infectious cases for 14 days

·      Do not ignore any patient with cough

·      Notify every case of TB

·      Protect high risk cases ( uncontrolled diabetics, immune suppressant)

·      Invoke section 270 of IPC and treat every MDR and XDR case

CDC recommendations for screening and testing health care personnel for TB

A systematic review of evidence that was published after release of the 2005 CDC guidelines for preventing Mycobacterium tuberculosis transmission in health care settings found that a low percentage of health care workers have a positive tuberculosis (TB) test at baseline and upon serial testing. The CDC published its conclusions in the May 17 Morbidity and Mortality Weekly Report.

Health care workers should be considered to be at increased risk for TB if they answer “yes” to any of the following statements:

·         Residence for a month or more in a country with a high TB rate

·         Current or planned immunosuppression, including HIV

·         Receipt of an organ transplant

·         Treatment with a tumor necrosis factor-alpha antagonist, chronic steroids, or other immunosuppressive medication or

·         Close contact with someone who has had infectious tuberculosis since the last test.

The updated recommendations for testing US health care personnel include:

·         Screening for TB with an individual risk assessment and symptom evaluation at baseline (preplacement)

·         TB testing with a tuberculin skin test for people without documented prior latent TB

·         No routine serial TB testing at any interval after baseline in the absence of a known exposure or ongoing transmission

·         Encouragement of treatment for all health care personnel with untreated latent TB, unless treatment is contraindicated

·         Annual symptom screening for health care personnel with untreated latent TB, and

·         Annual TB education of all health care personnel.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Can VOT be a feasible alternative strategy to DOT for treatment of TB?

DOTS (Directly Observed Therapy Short Term) as a strategy (where the patient has to take the TB medication in the presence of a DOTS agent) has been successfully adapted in TB control programs worldwide, including India. Although, it can be administered in home settings as well, there is still some inconvenience involved with DOTS, both to the patient and the healthcare provider, which may affect adherence to treatment.

Video-observed therapy (VOT) has been explored as a possible alternative to DOT. The World Health Organization (WHO) also recommends VOT as an alternative to DOT to improve treatment adherence when the video communication technology is available and can be appropriately organized and operated by health-care providers and patients (WHO Guidelines for treatment of drug-susceptible tuberculosis and patient care 2017 Update).

Results of a multicenter, analyst-blinded, randomized-controlled superiority trial conducted in 22 clinics in England show that VOT was a more effective approach to observation of tuberculosis treatment than DOT

In the trial, 70% patients managed with video observed therapy (VOT; daily observation using a smartphone app) completed >80% of scheduled observations over two months compared to 31% patients who were managed with DOT (observations done 3-5 times per week in the home, community, or clinic settings).

·         VOT allowed higher levels of treatment observation, both over the first 2 months of treatment and throughout treatment vs DOT.

·         VOT also supported daily dosing and was effective for socially complex populations.

·         The drop-out rate was lower with VOT vs DOT.

·         VOT reduced staff time requirements, especially compared with home-based DOT, making VOT cheaper than DOT even after taking into account the costs of the telephones and data plans provided by the study.

These findings suggest VOT as a more acceptable, effective, and cheaper option for supervision of daily and multiple daily doses than DOT.

(Source: Lancet. 2019 Mar 23;393(10177):1216-1224)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

24th March is World TB Day (2)

Face masks and respirators: Personal respiratory protective equipment for TB prevention

As per the CDC, there are three levels of TB infection control in health-care settings.

The first level “administrative controls” should minimize the number of areas where exposure to Mycobacterium tuberculosis may occur.

The second level “environmental controls” should reduce the concentration of airborne TB bacteria in areas where exposure may occur.

The third level is the use of “personal respiratory protective equipment” by persons entering the areas where exposure to airborne TB bacteria may occur.

Personal respiratory protective equipment include face masks and respirators.

·         Face masks are cloth or paper masks e.g. surgical masks, which prevent the spread of micro-organisms from the user to other people by capturing large wet particles near the source (mouth and nose), but it does not provide sufficient protection from inhaling airborne infections.

·         Respirators are special type of closely-fitted mask with the capacity to filter particles 1 micron in size to protect from inhaling infectious droplet nuclei.

The respirator has tiny pores, which block droplet nuclei and forms an air tight seal around the entire edge. On the other hand, a face mask has large pores and lacks air tight seal around edges and therefore do not prevent leakage around the edge of the mask when the user inhales.

N95 masks are particulate respirators and filter particles ≥1 micrometer in diameter with at least 95% efficiency given flow rates up to 50 L/min. But, to be effective, N95 masks must fit the face with less than 10% seal leakage. Adjustable nose clip helps in obtaining a secure seal. All require fit-testing and must be adjusted to the face to provide the intended effectiveness of filtering 95% of particles with mass median diameter of 0.3 micrometers.

They are not designed for children or people with facial hair. Because a proper fit cannot be achieved on children and people with facial hair, so the N95 respirator may not provide full protection.

N95 respirators can be surgical or industrial types. The ones used in hospitals are surgical ones and the one used in the industry are industrial certified and are used in construction and other industrial type jobs that expose workers to dust and small particles.

All respirators must be put on and taken off in an area outside of the contaminated area. Putting a respirator on or taking it off even for a few seconds in a contaminated area can expose the wearer to significant levels of hazards.

All patients with cough (TB suspects on screening) should be provided with simple mask at the reception of a hospital to cover their mouths and noses. They should be advised about respiratory hygiene and cough etiquettes. They should be instructed to cover their mouths and noses when coughing or sneezing.

Use of a face mask does not protect health care workers from TB.

Doctors and other health care workers should wear N95 mask for TB prevention.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Why universal medical insurance is on the way

Dr KK Aggarwal

Universal health care (universal health coverage, universal coverage, universal care, or socialized health care) is a national health care system that provides health care and financial protection to all citizens of a country. It provides a specified package of benefits to all members of a society with an aim of providing financial risk protection, improved access to health services, and improved health outcomes. The health care does not cover everything for everyone.

The critical components are

·         Who is covered?

·         What medical services are covered?

·         How much of the cost is covered?

As part of Sustainable Development Goals (SDGs), United Nations member states have agreed to work toward worldwide universal health coverage by 2030.

In India with a population of 133.92 crores, Ayushman Bharat will cover 50% of the population (40% or 50 crore people in conventional scheme + additional 10 % people with income less than 8 lakh per annum). For them insurance premium will be paid and shared by the central government (60%) and state government (40%) from the central and state taxes collected from the people.

Another 32% of the population is medically covered by Employee State Insurance (ESI) (8% employees + 10% unrecognised sector); Railway (9%); Defence (1.1%), state health insurance schemes (1%), Municipal corporations (1%); CGHS (36,67,795 people) and PSUs (0.75 crore family beneficiaries) [1%] another 1% is covered through private companies (corporates).

The remaining 18% of the population comprises people with annual income of more than 8 lakh per annum who can easily afford individual private insurance.

To make universal coverage possible the options include:

·         The government should make it mandatory to have insurance for those not covered by any government, PSU or NGO scheme.

·         Like ESI, it should be mandatory to have the employee insured by the employer as part of his or her salary package.

·         Around 41% of the population has some life cover, which should provide some medical cover.

·         Any individual with salary up to Rs 21,000 per month is entitled for ESI insurance; this should also be allowed for all those will salaries less than Rs 8 lakh per annum.

·         Ayushman Bharat provides coverage for up to 5 lakh for the family. However, most packages are capped, and the average expenditure is only Rs 18000/- per admission. Till today in the last 4 months, only 10 lakh people have been treated with an expenditure of only Rs 1800 crores (@ Rs 18000/- per person). At this rate, the annual expenditure will be only Rs 7200 crore (shared by center and state in a ratio of 60:40). This amounts to very little for the country.

·         If required, the government can cover additional 18% of the population also. With this the government will be able to ensure coverage for 100% population and provide general ward basic and emergent treatment to all admissions

For this to happen the government must also ensure affordable health care by implementing one company - one drug - one price policy; incentives to open Ayushman-only hospitals by small healthcare doctor-owned setups and capping the prices of National List of Essential Drugs, devices, reagents, investigations, equipment and disposables.

The government should also make it mandatory for all establishments to provide 10% beds for Ayushman patients.

The cost of providing universal national immunization; “nationalizing” diseases and health issues of national importance like TB, AMR, Leprosy, cancer, dialysis and providing free treatments to all should continue via the national health annual budget, which itself should be raised by another 25% to be made around Rs 75000 crores. This budget should cover the proposed 1.5 lakh wellness centers.

To further improve the health budget, the total budget for environmental pollution (air, water, earth); budget for women and child health, mid-day school meal, Swachh Bharat, road safety, pharma sector, food industry etc. should be merged with an aim to reduce the disease burden.

The government should provide coverage only for general ward treatment. There will still be enough business left for private and national insurance companies for additional insurance coverage for private wards and diseases not covered under Ayushman Bharat.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

It is time to revisit the ‘GTN’ approach to end TB

Dr KK Aggarwal

Padma Shri Awardee

TB is a preventable and curable disease and yet despite advances in TB care, India continues to have the highest burden of both TB and MDR TB patients and accounts for about a quarter of the global TB burden. An estimated 1.3 lakh incident multi-drug resistant TB patients emerge annually in India, which includes 79000 MDR-TB Patients estimates among notified pulmonary cases. India bears second highest number of estimated HIV associated TB in the world (TB India 2017).

Globally, the incidence of TB has been declining at about 2% per year. But, this decline is not enough to achieve the first 2020 milestone of the End TB Strategy and the target of ending the TB epidemic by 2030 under the Sustainable Development Goals (SDG 3). TB cases have to decline by 4-5% to achieve this target.

India also has the dubious distinction of being among the top three countries, where the gap between estimated TB incidence and reported cases is the highest: India (25%), Indonesia (16%) and Nigeria (8%). Ten countries accounted for 75% of the incidence-treatment enrolment gap for drug-resistant TB; again India along with China accounted for 39% of the global gap.

This wide gap in the incidence of TB and the reported cases highlights the IMA End TB Strategy of “GTN”, where G stands for GeneXpert test (sputum diagnosis), T for Trace (contacts) and Treat. N is to Notify the disease at Nikshay (mandatory).

India has set 2025 as deadline to be free of TB. Although preventing and controlling TB is a collaborative effort, doctors are major stakeholders in the control of TB.

Control of TB depends on early detection, which means early and better treatment to prevent further spread of TB. Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment.

All household and close contacts of patients with infectious TB should be traced, screened and treated with a full course of ATT if found to have TB.

A household contact is a person who has shared the same enclosed living space for one or more nights or for frequent or extended periods during the day with the index case during the 3 months before starting the current treatment. A close contact is a person who is not in the household but has shared an enclosed space, such as a social gathering place, workplace or facility, for extended periods during the day with the index case during the 3 months before initiation of the current treatment episode (WHO 2012).

Most of us regularly treat many patients of TB. And, there can be no time better than today, World TB Day, to reiterate our commitment to ‘GTN’ and file our returns.

Ask yourself, how many GeneXpert tests you have ordered… how many contacts you have traced and screened for TB…and how many TB patients you have notified at Nikshay.

You can notify even today, if not done earlier. It is not necessary to notify the day you diagnose the patient as having TB.

Dr KK Aggarwal

Padma Shri Awardee
Vice President CMAAO
Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA