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ObjectivesWe verified subnational (state/union territory (UT)/district) claims of achievements in reducing tuberculosis (TB) incidence in 2020 compared with 2015, in India.DesignA community-based survey, analysis of programme data and anti-TB drug sales and utilisation data.SettingNational 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.ParticipantsEach 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 measuresWe 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.ResultsThe 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.ConclusionTB 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.

Background: In India, tuberculosis remains as a major public health problem amongst the tribal population. Poor physical access to diagnosis and treatment under the Revised National TB control programme (RNTCP) still remains the problem for the population. RNTCP implements Tribal Action Plan (TAP) for tribal patients. We conducted the study to determine the trends of financial utilisation for the special provisions available under tribal action plan like patient honorarium, incentive for sputum collection and transport, incentive for programme staff and incentive for vehicle maintenance. Methods: A cross-sectional study based on mixed method study approach was conducted in Chhattisgarh, India during Nov. 16 to Jun. 17. District TB Officers implementing TAP were interviewed telephonically using a semi-structured questionnaire to ascertain and analyse the reasons for low fund utilization in their districts. Retrospective financial data for five financial years from 13 TAP districts for 2012-2013 to 2016-2017 was collected, compiled and analysed. Results: Overall, the trends on states expenditure on tribal action plan in terms of absolute numbers has increased over the past five years; however, in terms of fund utilization against received ranges from 37% - 86% with the utilization rate less than 44% in the recent years (2014-2017). Conclusion: The trends of utilisation of TAP is less than 44% over the recent years. There is an urgent need for the administrators to intervene and improve the efficiency of fund utilisation at State and district levels.

Background: HIV is an important risk factor for the development of tuberculosis. People living with HIV are 21-34 times more likely to develop TB than their uninfected counterparts. Efficient approach for detecting more cases along with shortened duration of infectivity involves a systematic screening of pulmonary TB in settings where high risk groups are concentrated even before the diagnosis HIV infection. Lack of proper screening strategy for HRGs might result in their exclusion from timely intervention which may prove lethal without treatment.Methods: A cross sectional study was carried out in two districts of Chhattisgarh during September-December 2019.Training cum sensitization sessions were conducted for peer educators, outreach workers, counselors and project managers prior to the survey and were trained for systematic screening of pulmonary TB, sputum collection and transportation to GeneXpert®MTB/RIF lab and other relevant data collection for pulmonary TB diagnosis.Results: A total of 3963 HRGs were intended to be included in the study, 3418 were screened with 86.2% compliance rate. Out of all HRGs screened (3418), 81 (2.4%) were found presumptive pulmonary TB, of them 2 (0.05%) were microbiologically confirmed, 5 cases were found with incomplete treatment (all were IDUs). Prevalence of tobacco use, alcohol use, diabetes and hypertension were observed in 5.3% and 7.2%, 1.2% and 1.1 respectively.Conclusions: Although yield for pulmonary TB in this study was not much, the study has demonstrated that active case finding for accessing such a hidden population through existing manpower can assure better acceptability and feasibility in resource poor settings.

Rationale. Contact investigation is an established tool for early case detection of tuberculosis (TB). In India, contact investigation is not often conducted, despite national policy, and the yield of contact investigation is not well described.Objective. To determine the yield of evaluating household contacts of sputum smear-positive TB cases in Rajnandgaon district, Chhattisgarh, India.Methods. Among 14 public health care facilities with sputum smear microscopy services, home visits were conducted to identify household contacts of all registered sputum smear-positive TB cases. We used a standardized protocol to screen for clinical symptoms suggestive of active TB with additional referral for chest radiograph and sputa collection.Results. From December 2010 to May 2011, 1,556 household contacts of 312 sputum smear-positive TB cases were identified, of which 148 (9.5%) were symptomatic. Among these, 109 (73.6%) were evaluated by sputum examination resulting in 11 cases (10.1%) of sputum smear-positive TB and 4 cases (3.6%) of smear-negative TB. Household visits contributed additional 63% TB cases compared to passive case detection alone.Conclusion. A standard procedure for conducting household contact investigation identified additional TB cases in the community and offered an opportunity to initiate isoniazid chemoprophylaxis among children.

BackgroundThe World Health Organization (WHO) recommends same day sputum microscopy (spot-spot) in preference to conventional strategy (spot-morning) for the diagnosis of smear positive tuberculosis with the view that completing diagnosis on a single day may be more convenient to the patients and reduce pre-treatment losses to follow-up.MethodsWe conducted a cross-sectional study in seven selected district level hospitals of Chhattisgarh State, India. During October 2012 - March 2013, two sputum specimens (spot-early morning) were collected from consecutively enrolled adult (≥ 18 years) presumptive TB patients as per current national guidelines. In addition, a second sample was collected (one hour after the collection of first spot sample) from the same patients. All the samples were examined by ziehl-Neelsen (ZN) microscopy. McNemar's test was used to compare statistical differences in the proportion smear positive between the two approaches (spot-spot versus spot-morning).ResultsOf 2551 presumptive TB patients, 69% were male. All patients provided the first spot specimen, 2361 (93%) provided the second spot specimen, and 2435 (96%) provided an early morning specimen. 72% of specimens were mucopurulent in conventional strategy as compared to 60% in same day strategy. The proportion of smear-positive patients diagnosed by same day microscopy was 14%, as compared to 17% by the conventional method (pConclusionSame-day microscopy method missed 17% of smear-positive cases and contrary to prior perception, did not increase the proportion of suspects providing the second sample. These findings call for an urgent need to revisit the WHO recommendation of switching to same-day diagnosis over the current policy.

BackgroundEach follow-up during the course of tuberculosis treatment currently requires two sputum examinations. However, the incremental yield of the second sputum sample during follow-up of different types of tuberculosis patients has never been determined precisely.ObjectivesTo assess the incremental yield of the second sputum sample in the follow-up of tuberculosis patients under the Revised National Tuberculosis Control Programme (RNTCP) in Chhattisgarh, India.MethodologyA record review of tuberculosis (TB) patients registered in 2009 using a structured proforma from two sources, Tuberculosis and Laboratory Register, was undertaken in the six districts of Chhattisgarh, India.ResultsIn smear positive cases, of 10,048 follow-up examinations, 45 (0.5%) were found to be smear positive only on the second sputum when the result of the first sample was negative. In smear negative pulmonary and extra pulmonary TB patients, of 6,206 follow-up smear examinations, 11(0.2%) were found to be smear positive.ConclusionsThe incremental yield of a second smear examination was very low, indicating that examination of one sputum sample is enough during follow-up among TB patients. There is insufficient yield to support sputum smear microscopy for monitoring smear negative pulmonary TB and extra pulmonary TB patients. These results indicate that the follow-up smear microscopy can be substantially simplified with favourable resource implications.