Health system resilience: Ensuring TB services during COVID-19 pandemic in Kerala, India.

COVID-19 pandemic has affected TB case detection and continuity of care globally. Kerala, the southern Indian state has experienced a reduction in TB notification during second and third quarter of 2020. Through (1) causal analysis (2) meticulous planning and establishment of systems (3) locally customised guidelines (4) better management of resources (5) integration with other programs and (6) good partnership with private sector, Kerala was able to catch up the TB notification and ensure that TB services remain intact even during the COVID-19 pandemic. Approach to catch up TB diagnosis included (1) Field based active case finding among the vulnerable individuals, (2) bilateral screening for TB and COVID-19, (3) enhancement of biosafety in laboratories, (4) strengthening of specimen collection and transportation systems, (5) targeted advocacy and communication to find out missed cases and (6) effective partnership with the private sector. Current experiences also show that TB case finding could be improved and delay in diagnosis could be averted by integrating TB case finding into the screening and testing systems established for COVID-19. The experiences of ensuring TB services during pandemic in Kerala also affirms the importance of maintaining an integrated and strong TB control component in the public health sector and vesting ownership of the TB control programme with the primary health care team. Community-based and community-led responses that take diagnosis, care, and support to the doors of those affected have much potential in delivering TB services in the subsequent years of pandemic.

Individuals' Vulnerability Based Active Surveillance for TB: Experiences from India.

Community-based active TB case finding (ACF) has become an essential part of TB elimination efforts in high-burden settings. In settings such as the state of Kerala in India, which has reported an annual decline of 7.5% in the estimated TB incidence since 2015, if ACF is not well targeted, it may end up with a less-than-desired yield, the wastage of scarce resources, and the burdening of health systems. Program managers have recognized the need to optimize resources and workloads, while maximizing the yield, when implementing ACF. We developed and implemented the concept of 'individuals'-vulnerability-based active surveillance' as a substitute for the blanket approach for population/geography-based ACF for TB. Weighted scores, based on an estimate of relative risk, were assigned to reflect the TB vulnerabilities of individuals. Vulnerability data for 22,042,168 individuals were available to the primary healthcare team. Individuals with higher cumulative vulnerability scores were targeted for serial ACF from 2019 onwards. In 2018, when a population-based ACF was conducted, the number needed to screen to diagnose one microbiologically confirmed pulmonary TB case was 3772 and the number needed to test to obtain one microbiologically confirmed pulmonary TB case was 112. The corresponding figures in 2019 for individuals'-vulnerability-based ACF were 881 and 39, respectively. Individuals'-vulnerability-based active surveillance is proposed here as a practical solution to improve health system efficiency in settings where the population is relatively stationary, the TB disease burden is low, and the health system is strong.

Estimation of tuberculosis incidence at subnational level using three methods to monitor progress towards ending TB in India, 2015-2020.

OBJECTIVES: We verified subnational (state/union territory (UT)/district) claims of achievements in reducing tuberculosis (TB) incidence in 2020 compared with 2015, in India. DESIGN: A community-based survey, analysis of programme data and anti-TB drug sales and utilisation data. SETTING: National TB Elimination Program and private TB treatment settings in 73 districts that had filed a claim to the Central TB Division of India for progress towards TB-free status. PARTICIPANTS: Each district was divided into survey units (SU) and one village/ward was randomly selected from each SU. All household members in the selected village were interviewed. Sputum from participants with a history of anti-TB therapy (ATT), those currently experiencing chest symptoms or on ATT were tested using Xpert/Rif/TrueNat. The survey continued until 30 Mycobacterium tuberculosis cases were identified in a district. OUTCOME MEASURES: We calculated a direct estimate of TB incidence based on incident cases identified in the survey. We calculated an under-reporting factor by matching these cases within the TB notification system. The TB notification adjusted for this factor was the estimate by the indirect method. We also calculated TB incidence from drug sale data in the private sector and drug utilisation data in the public sector. We compared the three estimates of TB incidence in 2020 with TB incidence in 2015. RESULTS: The estimated direct incidence ranged from 19 (Purba Medinipur, West Bengal) to 1457 (Jaintia Hills, Meghalaya) per 100 000 population. Indirect estimates of incidence ranged between 19 (Diu, Dadra and Nagar Haveli) and 788 (Dumka, Jharkhand) per 100 000 population. The incidence using drug sale data ranged from 19 per 100 000 population in Diu, Dadra and Nagar Haveli to 651 per 100 000 population in Centenary, Maharashtra. CONCLUSION: TB incidence in 1 state, 2 UTs and 35 districts had declined by at least 20% since 2015. Two districts in India were declared TB free in 2020.

STEPS - a patient centric and low-cost solution to ensure standards of TB care to patients reaching private sector in India.

BACKGROUND: More than half of the TB patients in India seek care from the private sector. Two decades of attempts by the National TB Program to improve collaboration between the public and private sectors have not worked except in a few innovative pilots. The System for TB Elimination in Private Sector (STEPS) evolved in 2019 as a solution to ensure standards of TB care to every patient reaching the private sector. We formally evaluated the STEPS to judge the success of the model in achieving its outcomes and to inform decisions about scaling up of the model to other parts of the country. METHODS: An evaluation team was constituted involving all relevant stakeholders. A logic framework for the STEPS model was developed. The evaluation focused on (i) processes - whether the activities are taking place as intended and (ii) proximal outcomes - improvements in quality of care and strengthening of TB surveillance system. We (i) visited 30 randomly selected STEPS centres for assessing infrastructure and process using a checklist, (ii) validated the patient data with management information system of National TB Elimination Program (NTEP) by telephonic interview of 57 TB patients (iii) analysed the quality of patient care indicators over 3 years from the management information system (iv) conducted in-depth interviews (IDI) with 33 beneficiaries and stakeholders to understand their satisfaction and perceived benefits of STEPS and (v) performed cost analysis for the intervention from the perspective of NTEP, private hospital and patients. RESULTS: Evaluation revealed that STEPS is an acceptable model to all stakeholders. IDIs revealed that all patients were satisfied about the services received. Data in management information system of NTEP were consistent with the hospital records and with the information provided by the patient. Quality of TB care indicators for patients diagnosed in private hospitals showed improvements over years as proportion of TB patients notified from private sector with a microbiological confirmation of diagnosis improved from 25% in 2018 to 38% in 2020 and the documented treatment success rate increased from 33% (2018 cohort) to 88% (2019 cohort). Total additional programmatic cost (deducting cost for patient entitlements) per additional patient with successful treatment outcome was estimated to be 67 USD. Total additional expense/business loss for implementing STEPS for the hospital diagnosing 100 TB patients in a year was estimated to be 573 USD while additional minimum returns for the hospital was estimated to be 1145 USD. CONCLUSION: Evaluation confirmed that STEPS is a low cost and patient-centric strategy. STEPS successfully addressed the gaps in the quality of care for patients seeking care in the private sector and ensured that services are aligned with the standards of TB care. STEPS could be scaled up to similar settings.

Using a Pharmacy-Based Surveillance System to Improve Standards for TB Care in Kerala, India.

INTRODUCTION: Eleven anti-TB drugs were included in the Government of India's Schedule H1 drug regulations in 2014. The National Strategic Plan for TB Elimination in India 2017-2025 recognized the opportunity to strengthen the TB surveillance system and improve the quality of TB care by implementing the Schedule H1 regulation. However, there were no documented systematic large-scale efforts to use Schedule H1 regulation to support TB surveillance or improve the quality of care. We aimed to document the process of implementation of the Schedule H1 regulation to enhance the quality of TB care and strengthen the TB surveillance system in Kerala, India. METHODS: We conducted 33 in-depth interviews of the drugs control department enforcement officers, chemist shop owners, private-sector doctors, leaders of professional medical associations, and program managers and key staff of the TB Elimination Program in Kerala. Major themes identified were the process of implementation of Schedule H1 and how the National TB Elimination Program used the information. Findings from the qualitative interviews were corroborated with the quantitative information from the annual program performance reports and anti-TB drug sales data. RESULTS: The TB Elimination Program of Kerala used the information from the Schedule H1 drug register to identify the missing TB cases and strengthen TB notification, identify providers for engagement and extend support to them for ensuring standards of TB care, and provide feedback to providers regarding prescription practices. Stakeholders felt that implementation of Schedule H1 surveillance has helped to improve TB patient notifications from the private sector, build better public-private partnerships, and improve the quality of TB diagnosis and treatment in Kerala. CONCLUSION: Pharmacy-based drug sales data collected either through regulatory or non-regulatory methods have immense potential to support TB elimination programs.

STEPS: A Solution for Ensuring Standards of TB Care for Patients Reaching Private Hospitals in India.

BACKGROUND: In India, the private sector diagnoses and treats more patients with TB than the public sector. Gaps in the TB care cascade were observed more among the patients diagnosed in the private sector. CONCEPT: The System for TB Elimination in Private Sector (STEPS) model evolved as a solution to address gaps in the quality of care for patients in the private sector by ensuring standards of TB care. STEPS has 3 components: a consortium of private hospitals, a coalition of all professional medical associations, and a STEPS center in each private hospital. STEPS centers act as a single window for notification, linkage for social welfare measures, contact investigation, chemoprophylaxis, direct benefit transfers, and treatment adherence support. INTERVENTION: STEPS was piloted in 14 districts in the state of Kerala. All 14 districts formed consortiums of private hospital management for policy support and a coalition of professional medical associations for advocacy with doctors. STEPS centers were established in 318 private hospitals. RESULTS: Notification to National TB Elimination Program from the private sector improved by 26% when compared to the previous year. Among the patients notified from the private sector, microbiologically confirmed cases increased by 81%, rifampicin resistance testing at baseline increased by 56%, and the percentage of those informed of their HIV status increased by 95%. The percentage of patients notified from the private sector with their treatment outcome reported improved from 39% (2018) to 99% (2019). CONCLUSION: The STEPS model demonstrated that a low-cost locally customized private sector engagement model is feasible and is beneficial to society. STEPS could be one of the major solutions for supporting patients reaching the private sector.

Ensuring TB Services During Major Floods - Kerala, India, August 2018.

Ensuring the successful treatment of tuberculosis (TB) is an essential public health responsibility of national TB programs. This case study describes how the Department of Health and Family Welfare, Kerala state, successfully prevented the disruptions in TB treatment when an unprecedented massive flood, declared as "a calamity of severe nature," completely disrupted normal operations in the state during August 2018. Unanticipated floods led to the displacement and relocation of more than 1.5 million citizens. The state has ensured continuity of TB treatment for all notified drug sensitive and drug-resistant TB patients (9608 and 434, respectively), including those who were displaced and relocated. A real-time web-enabled, case-based patient management information system has helped preserve the entire patient information, available at multiple levels. Routine strength of the program, including good rapport with patients, frontline multipurpose health workers and treatment supporters, high literacy rate of general population, and well-integrated primary health care system delivering TB services, enabled ensuring continuity of care during the disaster situation. The success of the post-flood TB control measures in Kerala affirms the importance of maintaining an integrated and strong TB control component with general health system ownership.

Population Attributable Risk of Tuberculosis Vulnerabilities in Kerala, India.

BACKGROUND: A robust disaggregated understanding of the determinants of tuberculosis (TB) in each local setting is essential for effective health system and policy action to control TB. OBJECTIVES: The objective of the study was to identify population attributable risk (PAR) for TB disease based on the locally available evidences for Kerala, India. METHODS: Systematic review was done for risk factors of TB in the state. The second set of searches was done to understand the prevalence of the identified risk factors in general population in Kerala. With all available studies and reports, an expert group consensus was made to finalize state-specific prevalence of risk factors. Population attributable fractions were calculated for identified risk factors. RESULTS: PAR for TB disease in Kerala obtained was 24% for undernutrition, 15% for diabetes, 15% for tobacco use, and 1% for HIV. CONCLUSION: Kerala state's PAR for TB was comparatively lower for HIV but higher for diabetes mellitus. Similar exercises for summarizing population risk factors need to happen at all states for making plans to effectively combat TB.

Lung Health Care pilot project trims patient pill load and antibiotic prescription in primary health care settings in Kerala, India.

INTRODUCTION: Kerala, the southern Indian state piloted Lung Health Care Project (LHCP) which is a locally adopted version of WHO recommended Practical Approach to Lung health (PAL). The current study assessed the impact of the project on the prescribing practices of doctors and consumption of antibiotics and other drugs. METHODS: This study compared performance of primary health care institutions with regard to drug prescriptions and consumptions before and after the implementation of the project. Chronic respiratory disease (CRD) patients in institutions implemented the project were interviewed in the OPD at exit and their prescriptions were documented at baseline and after six months. Focus group discussions were conducted with doctors to explore the reasons behind changes in drug consumption pattern. RESULTS: In the project implementing institutions, mean number of drugs prescribed for CRDs was 3.88 (SD 1.50) and 2.73 (SD 1.18) at baseline and after six months respectively (p < 0.001). Adjusted odds ratio for prescribing an antibiotic and injection to a CRD patient during impact assessment at institutions implementing project was 0.34 (95% CI 0.15-0.75 p 0.008) and 0.39 (95% CI 0.20-0.74 p 0.004) respectively, as compared to baseline. The factors which helped in reducing antibiotic and injection use as felt by the doctors were presence of a protocol, good quality trainings, supportive supervision and monitoring, availability of alternate drugs and good participation of staff nurses especially in-patient education. CONCLUSION: Strict adherence to diagnostic and management algorithms of Lung health care project in a primary health care setting in India helped in reducing pill burden to patients and prescription of antibiotics and injections.

Ocular adverse events in drug sensitive TB patients on daily fixed dose combination anti-TB drugs: A record review study from Kerala, India.

BACKGROUND: Government of India's Revised National TB Control Programme (RNTCP) has begun implementing daily fixed dose combination (FDC) anti-TB treatment regimen for drug sensitive TB patients in which ethambutol is given for six months. Prolonged ethambutol use is known to cause ocular adverse drug events (ADE). OBJECTIVES: To assess the magnitude of ocular ADEs in adult drug sensitive TB patients initiated on daily FDCs and to describe the demographic and clinical profile of patients with ocular ADEs. METHODS: We conducted a retrospective cohort study involving review of RNTCP records of all adult (age >14 years) drug sensitive TB patients initiated on daily FDCs between1st January 2018 and 31st July 2018 in Thiruvananthapuram district, Kerala State, India. RESULTS: 714 patients were initiated on daily FDCs during the study period. It was unknown whether all patients had undergone assessment for ocular ADEs. However, of these 714 patients, 8 patients (1.1%) were documented to have had ocular ADEs. Seven of these 8 patients had received ethambutol more than 15 mg/kg body weight and had developed ocular symptoms (decreased/blurring of vision) 3 months after TB treatment initiation. Ethambutol was stopped in all these 8 patients. In 5 patients it was recorded that ocular ADEs had resolved following stoppage of ethambutol and in the remaining it was unknown. CONCLUSION: The study confirms the occurrence of ocular ADEs among drug sensitive TB patients on daily FDCs and recommends strengthening of systems for assessing, documenting and managing ocular ADE.

Higher risk of developing active TB among adult diabetics exposed to TB during childhood: A study from Kerala, India.

INTRODUCTION: Factors associated with tuberculosis (TB) in Kerala, the southern Indian state that notifies approximately 33 microbiologically confirmed new cases per 100,000 population every year for the past two decades, are still unclear. We did a community-based case-control study in Kollam district, Kerala, to identify the individual-level risk factors for TB. METHODS: Structured questionnaire was applied to 101 microbiologically confirmed new TB cases registered under Revised National Tuberculosis Control Program and 202 age- and gender-matched neighborhood controls without present or past TB. Information was sought on socioeconomic status (SES), smoking, consumption of alcohol, close contact with active TB during childhood or recent past, diabetes mellitus (DM), and other comorbid conditions. RESULTS: Close contact with TB during childhood [odds ratio (OR) 15.88, 95% confidence interval (CI) 3.21-78.55], recent close contact with TB (OR 4.81, 95% CI 2.09-11.07), DM (OR 1.64, 95% CI 1.04-3.06), SES (OR 2.16, 95% CI 1.16-4.03), smoking more than 10 cigarettes/beedis per day (OR 3.32, 95% CI 1.27-8.96), consuming more than 10 standard drinks per week (OR 2.91, 95% CI 1.33-6.37), and the interaction term of having close contact with TB during childhood and DM at present (OR 7.37, 95% CI 1.18-50.29) were found to be associated with TB. CONCLUSION: Close contact with a case of TB, presence of DM, lower SES, smoking, and alcohol consumption were associated with active TB in Kollam. Having close contact with a case of TB during childhood and development of DM in later life together are significantly associated with active TB in the study population. The findings also direct further studies to confirm and explore mechanisms of interaction of diabetes with childhood exposure to TB.

Health benefits of Practical Approach to Lung health (PAL) experienced by patients with chronic respiratory diseases - Results from PAL pilot project in primary health care setting in Kerala, India.

Government of Kerala state had implemented a pilot project of the World Health Organisation recommended Practical Approach to Lung health (PAL) strategy, with an intention to improve the quality of diagnosis, treatment and management of common chronic respiratory diseases (CRD) in primary health care settings. The current study was done as a part of implementation of PAL pilot project and was intended to assess the benefits of PAL for the individual patients with CRDs accessing services from primary health institutions. Exit interviews were conducted at the baseline and for impact assessment after six months of pilot project by interviewing patients with CRD attending primary health institutions implementing PAL and control institutions. A total of 94 and 100 CRD patients were interviewed at baseline and after six months in the PAL implementing institutions, and 88 and 96 CRD patients were interviewed at the control institutions. Reduction in number of medical consultation, hospital admissions and exacerbations among CRD patients were 5.03, 3.20 and 2.24 times higher in PAL implementing institutions as compared to the control institutions. PAL pilot project in India implemented in an area with a reasonably sound primary health care system has proved that it might be beneficial for the patients with CRD as it reduces frequency of exacerbations, hospital visits and frequency of medical consultations.

Prevalence of chronic respiratory diseases from a rural area in Kerala, southern India.

BACKGROUND: Chronic lung diseases are one of the leading causes of morbidity in developing countries. A community based survey was undertaken with an objective to estimate the prevalence of chronic respiratory diseases and to describe the profile of people with CRDs in the rural area Nilamel health block in Kollam district, Kerala, southern India. METHODS: A household information sheet and a translated respiratory symptom questionnaire based on International Union against Tuberculosis and Lung Disease (IUATLD) bronchial symptoms questionnaire was administered to 12,556 people above 15 years, selected randomly from Nilamel health block. RESULTS: Prevalence of self reported asthma was 2.82% (95% CI 2.52-3.12) and that of chronic bronchitis was 6.19% (95% CI 5.76-6.62) while other CRDs which did not fit to either constitute 1.89%. Prevalence of asthma among males was 2.44% (95% CI 2.05-2.85) while that of females was 3.14% (95% CI 2.71-3.57). Chronic bronchitis prevalence was 6.73% and 5.67% among males and females respectively. CONCLUSION: Although India has devised a programme to combat cancer, diabetes, cardio vascular disease and stroke, none have been devised for chronic respiratory illness till date. Considering high prevalence and its contributions to morbidity and mortality, a comprehensive programme to tackle chronic respiratory diseases is needed.

Patients' perception towards directly observed treatment - A qualitative study from Kollam district, Kerala, southern India.

BACKGROUND: The Direct Observation of Treatment (DOT) is an important component of the country's TB Control strategy. Standards of TB care in India and the End TB strategy emphasised the importance of a patient-centered approach to foster adherence. A qualitative study was conducted to explore the perception of people with Tuberculosis in Kerala regarding DOT, mechanisms to make the treatment of TB more patients centered and to identify the preferable mechanisms to ensure adherence. METHODS: Six focus group discussions were conducted - two among people with TB from rural area, two among people with TB in urban area, one among multipurpose health workers of rural area and one among key field staff of TB control in urban area. RESULTS: Patients who were on a strict DOT were unhappy about the issues of confidentiality, patient inconvenience and provider centered approach. A flexible, patient centered approach were a family member can act as the DOT provider with guidance from a trained health worker was evolved as the most acceptable and comfortable mode of treatment to majority of the TB patients. They felt that a strict external monitor as a DOT provider was not a necessity in majority of the cases. Only practical way to effectively incorporate ICT in monitoring patient compliance in current scenario was identified as daily phone call reminders. Patients also expressed their concerns in keeping the medicines for entire duration at home. CONCLUSION: A flexible patient wise individualized system based on patient's behavior, literacy and awareness along with attitude of family members is needed to ensure adherence to anti TB drugs.

TB management by private practitioners - Is it bad everywhere?

INTRODUCTION: Poor prescribing practice is alleged to be one of the major factors fuelling the drug-resistant tuberculosis (DR TB) emergence. A study in Mumbai revealed the extent of inappropriate tuberculosis (TB) management practices of private practitioners and discussed that with the context of high DR TB. Kerala is rated among the well performing States in India as far as TB control is concerned with evidences for a lower level of TB transmission and DR TB. The current study was done in Kerala State to assess the prescribing practices of private sector doctors in the treatment of TB. METHODS: Survey questionnaire to write a standard prescription for treating TB was administered to private practitioners dealing with TB, who attended continuing medical education programme on TB at two major cities in Kerala. RESULTS: Responses from a total of 124 questionnaires were studied. None of them prescribed anti-TB regimen for less than 6 months. Only 7 (5.6%) prescribed a regimen without complete four drugs (H, R, Z, E) in the intensive phase. Out of the 81 doctors who prescribed private anti-TB regimen, 67 (82.7%) had of the opinion that not less than 80% of their patients complete the treatment for the prescribed duration. CONCLUSION: The current study reports a reasonable TB management practice among the private sector doctors from a State with a low prevalence of DR TB and compliments the argument that effective treatment of TB following the principles of standards for TB care can prevent the emergence of DR TB.

Directly observed treatment short course for tuberculosis. What happens to them in the long term?

BACKGROUND: Though Directly Observed Treatment Short course (DOTS) is found effective in many controlled trials, few studies have examined its effectiveness under programmatic conditions. DOTS based Revised National TB Control Programme (RNTCP) was initiated in Ernakulam district of Kerala state in June 2000. It now covers all of India. It now seems appropriate to do an evaluation of RNTCP at field level. AIM: This study aims to document impact of DOTS in providing productive life to tuberculosis patients and measure rate of clinical recurrence under program conditions. METHODS: Retrospective cohort study using interview with structured, peer reviewed and validated questionnaire among cohort of new smear positive patients registered in RNTCP from January 2002 to December 2003 and declared cured/Treatment completed. We have contacted 1173 patients (62.2% of the cohort) for the study at their homes by devising a strategy to identify and trace patients from address given in TB registers. RESULTS: Mean age of identified patients is 51.9 years. 82.4% were males. 79% patients report full supervision in the intensive period. After seven years 64.1% are healthy, work and earn; 29.8% report residual respiratory problems; 0.3% of symptomatic patients were diagnosed with smear positive pulmonary tuberculosis. Relapse calculated as worst case scenario for full target population (dead and migrated inclusive) is 9.27%. Age specific mortality is 4-6 times higher than in a comparable general population. CONCLUSIONS: DOTS treatment under program conditions makes a measurable reduction in tuberculosis morbidity. Though high proportion of patients remains productive after DOTS, a significant proportion complains of residual respiratory symptoms. Age specific mortality of Post tuberculosis patients is high compared to general population. Close follow up irrespective of duration of symptoms may help to determine the causes of high residual morbidity and mortality rates.

Does Alcohol consumption during multidrug-resistant tuberculosis treatment affect outcome?. A population-based study in Kerala, India.

RATIONALE: India reports the largest number of multidrug-resistant tuberculosis cases in the world; yet, no longitudinal study has assessed factors related to treatment outcomes under programmatic conditions in the public sector. OBJECTIVES: To describe demographic, clinical, and risk characteristics associated with treatment outcomes for all patients with multidrug-resistant tuberculosis registered in the Revised National Tuberculosis Control Programme, Kerala State, India from January 1, 2009 to June 30, 2010. METHODS: Cox regression methods were used to calculate adjusted hazard ratios with 95% confidence intervals (CIs) to assess factors associated with an unsuccessful treatment outcome. MEASUREMENTS AND MAIN RESULTS: Of 179 patients with multidrug-resistant tuberculosis registered, 112 (63%) had successful treatment outcomes (77 bacteriologically cured, 35 treatment completed) and 67 (37%) had unsuccessful treatment outcomes (30 died, 26 defaulted, 9 failed treatment, 1 stopped treatment because of drug-related adverse events, and 1 developed extensively drug-resistant tuberculosis). The hazard for unsuccessful outcome was significantly higher among patients who consumed alcohol during treatment (adjusted hazard ratio, 4.3; 95% CI, 1.1-17.6) than those who did not. Persons who consumed alcohol during treatment, on average, missed 18 more intensive-phase doses (95% CI, 13-22) than those who did not. Although many patients had diabetes (33%), were ever smokers (39%), or had low body mass index (47%), these factors were not associated with outcome. CONCLUSION: Overall treatment success was greater than global and national averages; however, outcomes among patients consuming alcohol remained poor. Integration of care for multidrug-resistant tuberculosis and alcoholism should be considered to improve treatment adherence and outcomes.

Outcome of tuberculosis treatment in patients with diabetes mellitus treated in the revised national tuberculosis control programme in Malappuram District, Kerala, India.

SETTINGS: Kerala State, India has reported the greatest dual burden of Tuberculosis (TB) and Diabetes Mellitus (DM). Malappuram district in Kerala has monitored and recorded DM status and its control from 2010 under Revised National Tuberculosis Control Program (RNTCP). OBJECTIVES: To assess, under programme conditions, comprehensiveness of recording DM status among TB cases and the TB treatment outcomes among DM patients (disaggregated by glycemic control) and compare with-non DM patients. DESIGN: This retrospective record review included 3,116TB patients from April 2010 to September 2011.DM was defined as per international guidelines and TB treatment outcomes were categorized as favourable(cured and treatment completed) and unfavourable(death, default, failure and transfer out). Relative Risk (RR) and 95% confidence intervals(CI) were calculated to assess the risk of unfavourable outcomes. RESULTS: DM status was recorded in 90% of TB cases and 667 (24%) had DM. 17% of DM patients and 23% of patients with unknown DM status had unfavourable outcomes but this difference was not statistically significant. Unadjusted RR for poor glycemic control or unknown control status for unfavourable outcome were (2.00; 95% CI 0.97-4.13) and (2.14; 95% CI 1.11-4.13). CONCLUSION: This study could not confirm an adverse association between DM or its control during treatment and the course of response to TB treatment.DM screening in TB cases and recording of DM care needs to be improved to enable more conclusive evidence.