Averting catastrophic tuberculosis costs in an Indian state: integration of Ayushman Bharat Arogya Karnataka with National Tuberculosis Elimination Program.

The WHO's "End TB" initiative aims to reduce catastrophic expenses, incidence, and mortality by 90%, 80%, and 0%, respectively by 2030 and Government of India has committed to reaching these goals by 2025. Despite tremendous progress, tuberculosis (TB) remains one of the main public health issues. To limit TB transmission and expedite reduction in incidence, further measures are needed. These milestones and objectives remain aspirational until we achieve "Universal access" to high-quality TB diagnosis and treatment. The goals of the study include outlining the process of 'Ayushman Bharat-Pradhan Mantri Jan Arogya Yojana-Arogya Karnataka' (AB-PMJAY-ArK) integration with the National TB Elimination Program (NTEP) in Karnataka, the types of TB patients who used AB-PMJAY-ArK services, and calculating the cost per TB patient at primary, secondary, and tertiary healthcare facilities, both public and private, stratified by type of service. Increased coverage, elimination of treatment delays, early and free treatment, and prevention of missing patients are benefits of integrating NTEP with Ayushman Bharat-PMJAY.

Prevalence and risk factors of hypertension with thyroid dysfunction among indian adults: Synthesis from national family health survey (2015-16).

Background: Thyroid dysfunction (TD) is considered a common cause of secondary hypertension (HT). Therefore, correcting TD may help in quicker and sustained achievement of desired blood pressure goals. However, there is a paucity of literature from India which estimates the relationship of HT with TD. Objectives: The objective of the study was to estimate the prevalence of TD with HT and to identify associated factors among Indian population. Materials and Methods: The survey data of the National Family Health Survey 4 (NFHS-4), conducted in India during 2015-2016, were analyzed using R statistical software for estimating the relationship between a history of HT and TD among women (N = 687246) aged 15-49 years and men (N = 108492) aged 15-54 years. Descriptive statistical tests and logistic regression were applied. Results: Among the persons suffering from the TD, the prevalence of HT was 32.8%, which was significantly higher than the prevalence of HT (21.9%) in euthyroid individuals. Further, the prevalence of TD was higher among hypertensive adults (2.5%) compared to nonhypertensive (1.5%). Conclusions: The study reported a higher prevalence of TD among the hypertensive persons and higher prevalence of HT among cases of TD. Therefore, screening for thyroid disorders should be routinely considered for better management of HT.

Risk factors for the development of tuberculosis among the pediatric population: a systematic review and meta-analysis.

Pediatric tuberculosis is a major cause of mortality and morbidity in children due to high transmission, poor diagnostic tools, and various respiratory diseases mimicking TB. Identifying risk factors will provide evidence for clinicians to strongly relate their diagnosis to the associated pathology. Studies were retrieved from PubMed, Embase, and Google Scholar, systematically reviewed, and meta-analyzed for various risk factors and their association with pediatric TB. Meta-analysis depicted that four out of eleven risk factors were significant-contact with known TB cases (OR 6.42 [3.85,10.71]), exposure to smoke (OR 2.61 [1.24, 5.51]), overcrowding in the houses (OR 2.29 [1.04, 5.03]), and, poor household conditions (OR 2.65 [1.38, 5.09]). Although significant odds ratio estimates were obtained, we observed heterogeneity in the studies included.    Conclusion: The study findings demand the constant screening of risk factors such as contact with known TB cases, exposure to smoke, overcrowding, and, poor household conditions for the development of pediatric TB. What is Known: • Knowledge of the risk factors of a disease is of utmost importance in the planning and institution of its control measures. Well-established risk factors in the occurrence of TB in the pediatric group are HIV positivity, older age and close contact with a known case of TB. What is New: • In addition to what is already known; this review and meta-analysis has identified exposure to indoor smoking, overcrowding and poor household conditions as important risk factors for developing pediatric TB. • Implications of the study: The findings highlight that in addition to routine contact screening for the pediatric group, the children living in poor household conditions and getting exposed to passive indoor smoking demand more attention to prevent the development of pediatric TB.

Hypertension among women in reproductive age in India: Can we predict the risk? An analysis from National Family Health Survey (2015-2016).

Background: Hypertension in women of reproductive age group is of special concern because of the vulnerability of women to pregnancy-induced hypertension apart from socio-cultural vulnerability. Aim: The objective of the study was to identify the predictors for hypertension among Indian women and to develop a risk score which would provide an opportunity for early detection and appropriate action. Material and Methods: This study was based on the data collected in National Family Health Survey in 2015-2016. Women in India of 15-49 years were the study population. Data were analysed using SPSS v17. Logistic regression analysis was carried and expressed as odds ratio with 95% confidence intervals to identify predictors of hypertension. The risk score for hypertension was developed after shrinkage of variables and by using regression coefficients obtained by standard Logistic Regression Model. Results: Among 6,87,230 women between 15 and 49 years, 77,788 (11.3%) were hypertensive. The study results revealed that there was an increasing trend in the prevalence of hypertension (26.5%) with increasing age, and with increasing weight (23.4%). Urban areas (12.3% vs 10.9%), alcoholics (19.2%) and various forms of tobacco users (14.8%) had more prevalence of hypertension. Conclusion: Age, residing in urban area, consuming tobacco products, consumption of alcohol, non-vegetarian diet and overweight, were found to be the significant predictor variables, and were used to develop the Risk Prediction score using logistic regression model.

Adherence to Prescribing Indicators at a District Hospital in Ghana: Do We Match WHO Standards?

(1) Background: Rational use of medicines (RUM) and their assessment are important to ensure optimal use of resources and patient care in hospitals. These assessments are essential to identifying practice gaps for quality improvement. (2) Methods: Assessment of adherence to WHO/International Network for Rational Use of Drugs core prescribing indicators among outpatients in 2021 was conducted at the University Hospital of the Kwame Nkrumah University of Science and Technology in the Ashanti Region of Ghana. We reviewed electronic medical records (EMR) of 110,280 patient encounters in the year which resulted in 336,087 medicines prescribed. (3) Results: The average number of medicines prescribed per encounter was three, with generics being prescribed in 76% of prescriptions. Injections were prescribed in 7% of encounters while 90% of medicines were from Ghana's Essential Medicines List, 2017. (4) Conclusions: With the exception of patient encounters with injections, none of the prescribing indicators assessed in this study met WHO optimum levels, providing targets for quality improvement in RUM. Implementing prescribing guides and policies, regular audits and feedback as well as continuous professional development training may help to improve prescribing practices in the hospital.

Screening for Severe Illness at Diagnosis Has the Potential to Prevent Early TB Deaths: Programmatic Experience From Karnataka, India.

Due to the coronavirus disease (COVID-19) pandemic and its associated response, TB deaths increased for the first time in a decade. In any potentially fatal illness, an assessment of severity is essential. This is not systematically done for adults with TB, mostly due to a lack of policy and/or limited availability of diagnostic and clinical capacity. We developed a screening tool using simple and easily measurable indicators that can be used by paramedical TB program staff to quickly identify people with severe illness. During October-November 2020 in Karnataka, India, the paramedical program staff from 16 districts screened people with TB (aged ≥15 years) notified by public facilities for "high risk of severe illness," which was defined as the presence of any of the following indicators: (1) body mass index (BMI) ≤14.0 kg/m2; (2) BMI ≤16.0 kg/m2 with bilateral leg swelling; (3) respiratory rate >24/minute; (4) oxygen saturation <94%; (5) inability to stand without support. In this cohort study, we determined the incidence of program-recorded early deaths (within 2 months) and its association with high risk of severe illness. Of 3,010 people with TB, 1,529 (50.8%) were screened at diagnosis/notification, of whom 537 (35.1%) had a high risk of severe illness. There were 195 (6.5%, 95% CI=5.7, 7.4) early deaths: 59 (30.2%) within a week and 100 (51.3%) within 2 weeks of treatment initiation. The incidence of early deaths was significantly higher among those with high risk of severe illness (8.9%) at diagnosis compared to those without (3.8%) [adjusted relative risk: 2.36 (95% confidence interval=1.57, 3.55)]. To conclude, early deaths were especially high during the first 2 weeks and strongly associated with a high risk of severe illness at diagnosis/notification. Screening for severe illness should be explored as a potential strategy to end TB deaths.

High Levels of Outpatient Antibiotic Prescription at a District Hospital in Ghana: Results of a Cross Sectional Study.

BACKGROUND: Monitoring of antibiotic prescription practices in hospitals is essential to assess and facilitate appropriate use. This is relevant to halt the progression of antimicrobial resistance. METHODS: Assessment of antibiotic prescribing patterns and completeness of antibiotic prescriptions among out-patients in 2021 was conducted at the University Hospital of Kwame Nkrumah University of Science and Technology in the Ashanti region of Ghana. We reviewed electronic medical records (EMR) of 49,660 patients who had 110,280 encounters in the year. RESULTS: The patient encounters yielded 350,149 prescriptions. Every month, 33-36% of patient encounters resulted in antibiotic prescription, higher than the World Health Organization's (WHO) recommended optimum of 27%. Almost half of the antibiotics prescribed belonged to WHO's Watch group. Amoxicillin-clavulanic acid (50%), azithromycin (29%), ciprofloxacin (28%), metronidazole (21%), and cefuroxime (20%) were the most prescribed antibiotics. Antibiotic prescribing parameters (indication, name of drug, duration, dose, route, and frequency) were documented in almost all prescriptions. CONCLUSIONS: Extending antimicrobial stewardship to the out-patient settings by developing standard treatment guidelines, an out-patient specific drug formulary, and antibiograms can promote rational antibiotic use at the hospital. The EMR system of the hospital is a valuable tool for monitoring prescriptions that can be leveraged for future audits.

Era of TB elimination: Growing need to understand diversities of Mycobacterium tuberculosis lineages!

INTRODUCTION: The mycobacterium tuberculosis complex (MTBC) has highly clonal population structure which made the organism spread globally mirroring human migration out of Africa and resulted in the formation of seven lineages. We conducted this study to determine the proportion of spoligotype lineages and drug susceptibility profile of Mycobacterium tuberculosis isolates among smear positive TB patients attending a tertiary care hospital in Mysore, Karnataka, India. METHODS: It is a descriptive study conducted at JSS Hospital a tertiary care centre at Mysore, India during 2018-19. The sputum smear positive samples were subjected to solid culture and drug susceptibility testing and spoligotyping for identification of lineages. RESULTS: Of the 100 samples which were culture positive, 94 isolates were clustered into five spoligotype international types with SIT-126 (EAI-5) being the largest cluster of 46 (46%) isolates, followed by SIT-62 (H1) with 24 (24%), SIT -26 (CAS 1-DELHI) with 20 (20%), SIT-53 (T1) with 03 (3%) and SIT-482 (BOV-1) with 01 (1%). Among the remaining six isolates, two had unique Cameroon spoligotypes and four were orphans CONCLUSION: The study finding reveals that a diverse pattern of genotypes is circulating in the region of which EAI-5, Harleem (H1) and CAS-DELHI pattern forms the majority (88%). It is evident that there is a wide range of MTB genetic lineages in circulation and further research is needed to understand the diversity across the country.

Uptake of universal drug susceptibility testing among people with TB in a south Indian district: How are we faring?

BACKGROUND: India implements universal drug susceptibility testing (UDST) using rapid genotypic tests (cartridge-based nucleic acid amplification test CBNAAT - and line probe assay - LPA). to bridge the gap of diagnosis of multidrug/rifampicin-resistant TB. There is limited evidence assessing the implementation of UDST in India. We assessed the implementation among people with pulmonary TB notified from public facilities in October 2019 from Raichur (Karnataka), India. METHODS: A cohort study involving secondary data in routine programme settings was conducted. All people with TB underwent a rapid genotypic DST for rifampicin resistance followed by first line-LPA (FL-LPA) if sensitive and second line-LPA (SL-LPA) if resistant. RESULTS: Of 217 people, 15.7% (n=34) did not undergo rapid genotypic DST. Of 135 who were rifampicin-sensitive detected on CBNAAT, 68.1% (n=92) underwent FL-LPA, and out of the six rifampicin-resistant cases, 66.7% (n=4) underwent SL-LPA. Overall, 65.4% (142/217) completed the UDST algorithm. Children (aged <15 y) and people with bacteriological non-confirmation on microscopy were less likely to undergo rapid genotypic DST. Of 183 patients who underwent both rapid genotypic DST and sputum smear microscopy, 150 were bacteriologically confirmed and, of them, 9 (6%) were 'rapid DST-negative'. CONCLUSION: We found gaps at various steps. There were a significant number of 'rapid DST-negative, smear-positive' patients.

Screening People with Tuberculosis for High Risk of Severe Illness at Notification: Programmatic Experience from Karnataka, India.

Due to limited availability of diagnostics and capacity, people with tuberculosis do not always undergo systematic assessment for severe illness (requiring inpatient care). In Karnataka (south India), para-medical programme staff used a screening tool to identify people at 'high risk of severe illness', defined using indicators of very severe undernutrition, abnormal vital signs and poor performance status (any one): (i) body mass index (BMI) ≤ 14.0 kg/m2 (ii) BMI ≤ 16.0 kg/m2 with bilateral leg swelling (iii) respiratory rate > 24/min (iv) oxygen saturation < 94% (v) inability to stand without support. Of 3020 adults notified from public facilities (15 October to 30 November 2020) in 16 districts, 1531 (51%) were screened (district-wise range: 13-90%) and of them, 538 (35%) were classified as 'high risk of severe illness'. Short median delays in screening from notification (five days), and all five indicators being collected for 88% of patients, suggests the feasibility of using this tool in programme settings. However, districts with poor screening coverage require further attention. To end tuberculosis deaths, screening should be followed by referral to higher facilities for comprehensive clinical evaluation, to assess the need for inpatient care. Future studies should assess the validity (especially sensitivity in picking severely ill patients) of this screening tool.

Engaging Informal Private Health Care Providers for TB Case Detection: Experiences from RIPEND Project in India.

BACKGROUND: Informal (unqualified) health care providers are an important source of medical care for persons with presumptive TB (PPTB) in India. A project (titled RIPEND) was implemented to engage informal providers for the identification of PPTBs and TB patients in 4 districts of Telangana State, India, during October 2018-December 2019 project period. Engagement involved sensitizing the informal providers about TB, providing them financial incentives to identify PPTBs, and linking these PPTBs to diagnostic and treatment services provided by the Government of India's National TB Elimination Programme. OBJECTIVES: To describe (a) the characteristics of the informal providers, along with their self-reported practices on TB diagnosis, treatment, and challenges encountered by the RIPEND project staff in engaging them in the project and (b) the outputs and outcomes of this engagement. METHODS: We used a combination of one-on-one interviews with informal providers, group interviews with RIPEND project staff, and secondary analysis of data available within the project's recording and reporting systems. RESULTS: A total of 555 informal providers were actively engaged under the project. The majority (87%) had a nonmedicine-related graduate degree and had been providing medical care for more than 10 years. Most (95%) were aware that a cough for 2 weeks or more is a symptom of pulmonary TB and that such patients should be referred for sputum-smear microscopy at a government health facility. Challenges in engaging the informal providers included motivating them to participate in the study, suboptimal mobile usage for referral services, and delays in providing financial incentives to them for referring PPTBs. During the project period (October 2018-December 2019), 8342 PPTBs were identified of which 1003 TB patients were detected and linked to TB treatment services. CONCLUSION: This project showed that engaging informal providers is feasible and that a large number of PPTB and TB patients can be identified through this effort. The Government of India should consider engaging informal providers for the early diagnosis of TB to reduce the missing TB cases in the country.

Clinical profile and risk factors for mortality among COVID-19 inpatients at a tertiary care centre in Bengaluru, India.

COVID-19 is an emerging viral disease affecting more than 200 countries worldwide and it present with varied clinical profile throughout the world. Without effective drugs to cure COVID-19, early identification and control of risk factors are important measures to combat COVID-19.  This study was conducted to determine the clinical profile and risk factors associated with mortality among COVID-19 patients in a tertiary care hospital in South India. This record-based longitudinal study was conducted by reviewing the case records of COVID-19 patients admitted for treatment from June 2020 to September 2020 in a tertiary care centre in South India. The clinical details, discharge/death details, were collected and entered in MS Excel. Potential risk factors for COVID-19 mortality were analysed using univariate binomial logistic regression, generalized linear models (GLM) with Poisson distribution. Survival curves were made using the Kaplan-Meier method. Log-rank test was used to test the equality of survivor functions between the groups. Out of 854 COVID-19 patients, 56.6% were men and the mean (standard deviation) age was 45.3(17.2) years. The median survival time was significantly lesser in male COVID-19 patients (16 days) as compared to female patients (20 days). Increasing age, male gender, patients presenting with symptoms of fever, cough, breathlessness, smoking, alcohol consumption, comorbidities were significantly associated with mortality among COVID-19 patients. Patients with older age, male gender, breathlessness, fever, cough, smoking and alcohol and comorbidities need careful observation and early intervention.  Public health campaigns aimed at reducing the prevalence of risk factors like diabetes, hypertension, smoking and alcohol use are also needed.

Nikshay Poshan Yojana (NPY) for tuberculosis patients: Early implementation challenges in Delhi, India.

BACKGROUND: Nutrition support is one of the essential factors for envisioning Tuberculosis (TB) elimination in India by 2025. In this regard, Government of India introduced Nikshay Poshan Yojana (NPY) through Direct Benefit Transfer (DBT) as monthly financial assistance towards nutrition for TB patients in April, 2018. Assessment of early implementation challenges of the scheme is essential. OBJECTIVE: (a) To determine the number (proportion) of TB patients who received the benefits (b) to explore the challenges encountered by the health care providers in delivering the NPY through DBT (c) to explore the ways the incentives were utilised by the patients. MATERIAL AND METHODS: It was a cross-sectional study conducted among patients registered for TB treatment at Ladosarai and Mehrauli DOTS centre between July-September, 2018.Health providers engaged in implementation of NPY at the study sites were also interviewed. The data were collected through structured questionnaires, double entered and analyzed in Epi Data. RESULTS: Out of 119 patients registered, we interviewed 57 (47.9%) patients. Of which, 30 (52.6%) had received NPY for 2 months in the fourth and fifth month of treatment. The health providers reported increased workload, lack of training and complex reporting formats as main hurdles in implementation of the scheme. While, the patients cited non-availability of bank accounts and unlinked bank account with Aadhar card as difficulties to receive NPY through DBT. CONCLUSION: Nearly half of the interviewed TB patients received nutritional incentives of NPY through DBT for 2 months. Non-availability of bank accounts and unlinked bank accounts were some challenges faced by both health providers and patient. It is recommended to address these implementation on time in order to reap the benefit of scheme in improving nutritional status of TB patients. Further studies are needed to determine the effect of nutrition support on TB patients.

Cost of Tuberculosis Care in Programmatic Settings from Karnataka, India: Is It Catastrophic for the Patients?

BACKGROUND: TB diagnostic and treatment services in India are provided free of cost in the programmatic context across the country. There are different costs incurred during health care utilization, and this study was conducted to estimate such costs. Methodology. A longitudinal study was conducted among patients of three urban tuberculosis units (TUs) of Davangere, Belagavi, and Bengaluru, Karnataka. Trained data collectors administered a validated questionnaire and recorded monthly costs incurred by the patients which are expressed in median Indian National Rupees (INR). The analysis was done using SPSS version 23.0. A p value of <0.05 was taken as statistically significant. RESULTS: Among 214 patients, about 37%, 42%, and 21% belonged to Davangere, Belagavi, and Bengaluru, respectively. Median total pre- and postdiagnostic costs incurred across the three TUs were 3800 and 4000 INR, respectively. The direct nonmedical cost was higher for accommodation (median cost of 800 INR) and direct medical cost for non-TB drugs (median cost of 2000 INR). However, maximum direct medical and nonmedical costs were attributed to hospital admissions (1200 INR) and accommodation costs (700 INR) in the postdiagnostic period, respectively. The median indirect cost incurred was 300 INR overall, and the maximum total indirect cost was 40000 INR in the postdiagnostic period. About one-third of patients faced loss of income and 19.6% faced coping costs. Patients spent about 6.7% (0.97%-52.3%) of their income on TB treatment. About 12.3% patients faced catastrophic expenditure. Median cost was significantly higher among those seeking private health care facilities (12100 INR in private vs. 6800 INR in public; p < 0.05) during the prediagnostic period. Prediagnostic and diagnostic out-of-pocket expenditures (OPE) were significantly higher across all the three centres (p < 0.05). CONCLUSION: The TB patients experienced untoward expenditure under programmatic settings. The costs encountered by one in eight patients were catastrophic by nature.

'Have we missed reporting adverse drug reactions under Revised National TB Control Programme?' - A mixed method study in Bengaluru, India.

OBJECTIVE: Prompt identification, reporting and management of ADRs during anti tuberculosis treatment can ensure better compliance and treatment outcomes. The study was conducted to identify the gaps and associated factors in reporting of ADRs under RNTCP; assess knowledge, attitude and practice of RNTCP staff regarding pharmacovigilance programme and explore the barriers in reporting of ADRs from provider's perspective. METHODS: Mixed method research with sequential explanatory design was carried out in Tuberculosis Units of RNTCP administrative district of Bangalore city during July to December 2017. Quantitative study was carried out among 222 patients on intensive phase of Category I and Category II DOTS to study the incidence, severity and causality of ADRs; and records of these patients were analysed for gaps in reporting. Knowledge, attitude and practice (KAP) regarding recording and reporting aspect of pharmacovigilance programme was assessed among RNTCP staff. As part of the qualitative study, focus group discussion was carried out among RNTCP staff to study barriers for reporting ADRs from the provider's perspective. RESULTS: Record analysis at the time of recruitment showed documentation of ADRs in only five patients. Subsequent analysis of patient records during the middle and end of the intensive phase (IP) did not show documentation of any ADRs. Simultaneously interviews with patients revealed 116 (52.2%), 72 (32.4%) and 53 (23.8%) patients reported one or more symptoms of ADRs. The commonest ADR symptom reported were fatigability and gastrointestinal symptoms followed by musculoskeletal symptoms. KAP among 25 RNTCP staff showed that 96% of them felt reporting of ADRs was necessary and 92% reported the ADRs to their seniors, however 12% were scared to report. The main reason expressed for non-reporting was 'managing ADRs is more important than reporting' (52%). Also, 32% felt the need for retraining of staff on reporting and documentation. Barriers to reporting of ADRs were both health-system related like insufficient training and inadequate guidelines provided to RNTCP staff and patient-related factors like lack of awareness and reluctance to report ADRs. CONCLUSION: Successful implementation of RNTCP and achievement of TB elimination requires provision of adequate information regarding ADRs to patients and intense follow-up and probing at each contact by programme staff to effectively manage ADRs.

Enablers and Challenges in the Implementation of Active Case Findings in a Selected District of Karnataka, South India: A Qualitative Study.

BACKGROUND: Active case finding (ACF) for tuberculosis (TB) is a promising tool to enhance early case detection among marginalized populations. As opposed to passive case finding, it involves systematically searching for TB in individuals who would not spontaneously present for care. The National TB Program (NTP) of India has initiated ACF for TB through the existing general health system since the end of 2017. However, prior to scale-up, there is need for exploring the implementation challenges and solutions to improve the efficiency of this program. OBJECTIVES: (1) To explore the enablers and challenges in the implementation of ACF for TB by NTP in the Bengaluru rural district of Karnataka, South India, and (2) to explore the perceived solutions to improve the efficiency of ACF activity. METHODS: A qualitative descriptive study was conducted in the Bengaluru rural district during July 2018. In-depth interviews using purposively selected health care providers involved in active case finding (n = 9) and presumptive TB patients (n = 9) and presumptive TB patients (. RESULTS: The challenges in conduct of ACF were as follows: inadequate training of health care workers, shortage of staff, indifferent attitude of community due to stigma, lack of awareness about TB, illiteracy, inability to convince patients for sputum test, and delay in getting CBNAAT results. The field staff recommended the installation of mobile CBNAAT machine, involvement of general health staff in activity, training of health workers on counseling of patients, and issue of identity cards for community health workers/volunteers so that people recognize them. CONCLUSION: The health system challenges in conduct of ACF need to be addressed by training the health staff involved in activity and also improving the access to TB diagnostics.

Chest Radiography and Xpert MTB/RIF® Testing in Persons with Presumptive Pulmonary TB: Gaps and Challenges from a District in Karnataka, India.

BACKGROUND: In India, as per the latest diagnostic algorithm, all persons with presumptive pulmonary TB (PPTB) are required to undergo sputum smear examination and chest radiography (CXR) upfront. Those with sputum smear positive, sputum smear negative, but CXR lesions suggestive of TB or those with strong clinical suspicion of TB are expected to undergo Xpert MTB/RIF® assay test (also known as CB-NAAT (cartridge-based nucleic acid amplification test)). OBJECTIVE: To assess what proportion of PPTB who are undergoing sputum smear examination at microscopy centers of public health facilities have undergone CXR and CB-NAAT. To explore the barriers for uptake of CXR and CB-NAAT from the public health care provider's perspective. METHODS: We conducted a sequential explanatory mixed-methods study in Chikkaballapur district of Karnataka State, South India. The quantitative component involved a review of records of PPTB who had undergone sputum smear examination in a representative sample of seven microscopy centers. The qualitative component involved key informant interviews with four medical officers and group interviews with 9 paramedical staff. RESULTS: In February and March 2019, about 732 PPTB had undergone smear examination. Of these, 301 (41%) had undergone CXR and 49 (7%) had undergone CB-NAAT. The proportion of PPTB who had undergone CXR varied across the seven microscopy centers (0% to 89%). CB-NAAT was higher in PPTB from urban areas when compared to rural areas (8% vs. 3%) and in those who were smear positive when compared to smear negative (65% vs. 2%). The major barriers for CXR and CB-NAAT were nonavailability of these tests at all microscopy centers and patients' reluctance to travel to the facilities where CXR and CB-NAAT services are available. CONCLUSIONS: CXR and CB-NAAT of PPTB are suboptimal. RNTCP should undertake measures to address these gaps in implementing its latest diagnostic algorithm.

Active Case Finding for Tuberculosis through TOUCH Agents in Selected High TB Burden Wards of Kolkata, India: A Mixed Methods Study on Outcomes and Implementation Challenges.

Active case finding (ACF) for tuberculosis (TB) was implemented in 60 selected high TB burden wards of Kolkata, India. Community volunteers called TOUCH (Targeted Outreach for Upliftment of Community Health) agents (TAs) identified and referred presumptive TB patients (PTBPs) to health facilities for TB diagnosis and treatment. We aimed to describe the "care cascade" of PTBPs that were identified during July to December 2018 and to explore the reasons for attrition as perceived by TAs and PTBPs. An explanatory mixed-methods study with a quantitative phase of cohort study using routinely collected data followed by descriptive qualitative study with in-depth interviews was conducted. Of the 3,86242 individuals that were enumerated, 1132 (0.3%) PTBPs were identified. Only 713 (63.0%) PTBPs visited a referred facility for TB diagnosis. TB was diagnosed in 177 (24.8%). The number needed to screen for one TB patient was 2183 individuals. The potential reasons for low yield were stigma and apprehension about TB, distrust about TA, wage losses for attending health facilities, and substance abuse among PTBPs. The yield of ACF was suboptimal with low PTBP identification rate and a high attrition rate. Interviewing each individual for symptoms of TB and supporting PTBPs for diagnosis through sputum collection and transport can be adopted to improve the yield.

Co-existing Non-communicable Diseases and Mental Illnesses Amongst the Elderly in Punjab, India.

Background: There is scant literature from India assessing the burden of mental disorders among elderly patients with non-communicable diseases (NCDs). This study aimed to determine the prevalence of depression and generalised anxiety disorder (GAD) among the elderly population with diabetes and/or hypertension and risk factors for psychiatric morbidity. Methodology: A cross-sectional study was conducted between September-December 2017 by using a semi-structured questionnaire amongst an elderly population (n=320), who were attending an NCD clinic in a rural district in the northern state of Punjab, India. The Geriatric Depression Scale (30-item) and GAD-7 scale were used to assess depression and GAD. Result: Depression was found in 58.1% (95% confidence interval [CI] 52.6-63.4%) of the study participants; of whom, 34.1% had severe depression. The proportion of GAD was found to be 38.7% (95% CI 33.6-44.2%), with 19.7% scoring in the severe range. Both GAD and depression was found in 37.8% (95% CI 32.7-43.2%). Female gender, nuclear family, being single/separated/divorced/widowed, low-income status and comorbid NCDs (especially hypertension) were found to be risk factors associated with depression and GAD. Conclusion: NCDs with co-morbid mental illness are a growing public health problem amongst the elderly population of the country. The NCD programme should make immediate efforts to provide mental-health care as part of a holistic care package to elderly with NCDs.