Integrated care: India must go beyond diagnosis in its fight against TB

Thirty-eight-year-old Sukhu, in a remote tribal village in Jharkhand, was given monthly food baskets in our RATIONS trial but, strangely, did not gain any weight. When we visited him to understand why, Sukhu had the answer: “I was found to have diabetes but was told to go to a community health centre 60 km away to start treatment. Without diabetes control, how will I gain weight?” 

Shankar, 52, weighed only 31 kg, could not stand without support and had severe anaemia, breathlessness and low oxygen levels. These features, part of the screening tool we implemented in the RATIONS trial, helped health workers flag Shankar as being at high risk of death. They referred him immediately for inpatient care at the district hospital. He recovered remarkably with treatment of TB, anaemia and undernutrition.

Asif, who was being treated for lung TB at a primary health centre (PHC), brought his wife, the mother of a seven-month-old child. She was underweight and had fever, headache, vomiting, and drowsiness. She was later diagnosed with TB meningitis and had not received TB preventive treatment. 

It is estimated that one-fifth of Indians harbour a TB infection, and 2.8 million develop TB disease annually, with more than 300,000 deaths. The development of TB disease depends not just on the presence of the TB germ but also on impaired immunity due to undernutrition, HIV, uncontrolled diabetes, alcohol, or tobacco use. These risk factors increase the risk of active TB, severe disease, death, and recurrence. The poor often find it challenging to adhere to the treatment, and families descend deeper into poverty and food insecurity due to the economic and social costs of the disease. Persons with TB often experience disability, recurrence, and higher mortality after successful treatment. More than 10% develop disease recurrence within two years in India. 

These true-life stories illustrate that
an effective model of TB care and prevention must be comprehensive and integrated, addressing not only the TB germ
but also the clinical, social and health system dimensions. 

Patients with TB often have coexisting controllable conditions such as undernutrition, diabetes, HIV, tobacco, and alcohol use, which are risk factors for disease and poor treatment outcomes. India has successfully integrated HIV screening and management in the TB programme, and a similar initiative for undernutrition, diabetes, and other risk factors is needed. India has the monthly direct benefit transfer under the Nikshay Poshan Yojana – with a monthly benefit of Rs 1,000– and the Nikshay Mitra Yojana for in-kind nutrition support to address undernutrition. However, these schemes face challenges of universal coverage and timely disbursement. Weight gains must be recorded and reported to assess the impact of these initiatives on TB treatment outcomes. 

Like Sukhu, almost one in seven persons with TB have diabetes (one in two in Kerala) with poor rates of control. Better control of diabetes could prevent TB occurrence. Decentralised diabetes care at the PHC level – with trained primary care providers for diagnosis, counselling, initiation and follow-up care – along with brief interventions for substance use and mental health problems and efforts to address stigma and discrimination, will improve treatment outcomes, reduce deaths and recurrence, and reinforce faith in the programme. Historically, TB programmes have strengthened primary care by making diagnostic tests and therapy available at points of first contact; decentralised, integrated care of persons with TB could similarly make the detection and treatment of non-communicable diseases more accessible.

Patients do not die of tuberculosis per se, but of severe disease and its complications; care must therefore be differentiated as per disease severity. Screening at diagnosis for high-risk features (very severe undernutrition, inability to stand, severe anaemia, breathlessness or low oxygen levels) can identify those at greater risk of death, which can be mitigated through appropriate inpatient care, as seen in Shankar’s case. The national programme has launched differentiated care guidelines to identify seriously ill patients for referral and in-patient care to reduce the currently unacceptably high rate of TB-related deaths. This will require an adequate number of beds and trained staff, as well as the capacity to manage severe disease and undernutrition. The TN-KET initiative in Tamil Nadu has shown that this is feasible.

Families share vulnerabilities and risk factors, of which undernutrition is the most prevalent in India. Families should be considered the unit of TB care and prevention, including screening, diagnosis, and treatment. Prevention of TB in the family rests on administration of TB-preventive treatment and/or provision of nutritional supplementation. TB preventive treatment is now recommended for all household contacts of patients with lung TB. The RATIONS trial in Jharkhand demonstrated a 40-50% reduction in new TB cases among families living with food insecurity, and this has influenced new WHO recommendations on nutritional support for such families. The meningitis in Asif’s wife could have been prevented through either TB preventive treatment or nutritional support. 

The provision of decentralised comprehensive care, differentiated care, and family-centred care could be transformative in India’s mission to reduce new TB cases, improve outcomes and prevent TB deaths.

(Anurag is a professor in the Department of Medicine, Kasturba Medical College, Mangaluru, and Madhavi is a professor in the Department of Community Medicine, Yenepoya Medical College, Mangaluru)