Despite being the most populous district of Himalayan state of Himachal Pradesh in India, Kangra has also led from the front in caring for largest number of people with TB in the state. Compared to the national average in India, Kangra offers TB tests to 3-4 times more people per 100,000 population.

Good news is that TB rates have been consistently declining in the past three years. More importantly, Kangra has made the steepest stride in making the greatest number of village-panchayats’ TB free in the state (81 out of 559 panchayats are declared TB free already).

Indian government has made a radical shift in finding, treating, and preventing more TB recently. It launched a 100-days campaign last month to focus on those who have a higher TB risk and offer them state-of-the-art artificial intelligence enabled and computer-aided TB detection by an ultraportable handheld X-ray and offer WHO recommended upfront molecular test to those who are presumptive for TB.

Another policy change is to screen everyone and not just those with TB symptoms (as almost half of TB patients were asymptomatic and could be found early only through an X-ray in national and sub-national TB prevalence surveys of Indian government). Finding people with TB (early and accurately) and offering them effective TB treatment also stops further spread of pulmonary TB, so treatment is prevention too.

Also, those found without active TB disease in high TB risk populations are to be tested for latent TB - and if found positive for it they are being offered TB preventive therapy (TPT).

As part of its fifteen years old End TB Dialogues series, CNS spoke to Dr Rajesh Kumar Sood, who has served in government health services in Dharamshala, Kangra for three decades now and has been making stellar contribution towards strengthening people-centred health responses. He serves as District TB officer of Kangra for National TB Elimination Programme (NTEP) and as the District Programme Officer of National Health Mission in Kangra.

Dr Sood agrees that the 100 days campaign has accelerated efforts to find more people with TB, treat more of them and prevent TB too.

It is estimated that almost one third of the population may have latent TB in India – which means they have the TB bacteria but not active TB disease. People with latent TB cannot spread it to others (latent TB is not infectious). But there is a risk of latent TB to progress into active TB disease. Every case of active TB disease (and infectious lung TB) comes from this big pool of people with latent TB.

Biggest campaign to prevent TB in India

“100 days campaign is the biggest campaign in the history of India to find, treat and prevent TB among high-risk populations. We are not only finding more people with active TB disease and linking them to care but also those who have latent TB and offering them TB preventive therapy. This is a real game changer,” said Dr Sood. “It is like turning the tap off while we find and treat those with the disease.”

Dr Sood’s team in Dharamshala Kangra identified those who are at a higher TB risk. These included those who are malnourished; use tobacco or alcohol; have diabetes or HIV; those who have suffered from TB and completed treatment in last five years (as there could be relapse cases); contacts of TB patients in the last two years; those above the age of 60 years (as senior citizens have almost double TB risk); those who are living in crowded settings such as prisons, shelter homes for migrant workers, orphanages, hostels, etc; tribals; tea garden workers; brick kiln workers; people who use drugs; cancer patients or those who are immunologically suppressed; COPD (Chronic Obstructive Pulmonary Disorder) patients; pregnant women; women exposed to indoor air pollution because of using firewood as cooking fuel; among others.

Identifying people who are higher risk was made possible with the incredible support of over 1800 female voluntary healthcare workers called ASHA - Accredited Social Health Activists- and 300 community health officers, along with others.

Reaching the unreached people in Dharamshala Kangra

Two specialised vans (called Ni-Kshay Vahan) equipped with battery-operated, ultraportable handheld X-rays and battery operated, laboratory independent and point-of-care WHO recommended molecular test Truenat is going to remote areas – thus bringing the lab closer to the people who are at a higher risk of TB. Innovative awareness campaigns with banners, slogans and other materials further help amplify the efforts to mobilise communities. Ni-Kshay is a Sanskrit language word which implies being TB free (“Ni” means “not having” and “Kshay” means TB).

Healthcare workers including ASHA workers are doing house-to-house TB screening and offering an X-ray to all.

“Here comes the real challenge. In Kangra district we have only 18 functional X-ray machines to cater to 260,000 people who are at higher risk of TB (often referred to as key and other vulnerable populations). In addition, we have 3 handheld X-ray machines - one such AI-enabled X-ray (called Prorad which is made in India by Molbio Diagnostics) was given to us under CSR by Power Grid Corporation of India (a public sector undertaking), another handheld X-ray was provided courtesy Tong-Len Charitable Trust, and a third handheld  X-ray machine was made possible due to Indian Council of Medical Research (ICMR),” said Dr Sood.

Only Prorad X-ray is AI-enabled in Kangra as of now. AI-enabled computer aided detection of TB using X-rays was recommended by the World Health Organization (WHO) in 2021 (as AI outperformed radiologists in lung TB detection in studies). Radiology experts are limited (and very busy) in most health services. As these X-rays are battery-operated, AI-enabled ones have made it possible to find TB in remote areas at the doorstep of people (or as close as possible to them) and offer them an upfront battery-operated molecular test Truenat for confirming TB. Lacking such devices or their shortages will not only make it cumbersome for people to go for TB screening, but also far more time consuming.

“My district is fortunate enough to have a Truenat molecular test machine in every block,” said Dr Sood. However, more battery-operated molecular test machines need to be deployed for diagnosing TB in the field.

“Using handheld X-ray machines, we can do around 70-100 X-rays in a day (around 3000 X-rays in a month) in Kangra. The highest we could do was 199 X-rays in a day, Healthcare workers are under immense work pressure. Often, they leave their homes at sunrise and queues of people to get an X-ray often do not clear up till 7pm in the evening. As these X-ray machines are battery operated, we charge them over night so that the equipment is ready for use the next day," said Dr Sood.

What happens after a person gets an X-ray?

X-ray is provided to everyone from high TB risk communities. Those who are found to have presumptive TB are offered an upfront molecular test. ASHA workers collect sputum samples and transfer them to the nearest testing facility), and those who have active TB disease get an effective treatment (at most within a week).

Dr Sood’s team also ensures that every person with active TB disease is treated with medicines that work on the disease-causing TB bacteria (by testing that the TB bacteria is not resistant to any of the medicines used for treatment). This is made possible by sending samples for Line Probe Assay (LPA) drug susceptibility test. “There is only one facility for LPA test in the whole state of Himachal Pradesh. So, it takes around 10 days to get the LPA test results,” he said.

All patients are also provided nutritional support (INR 1000 is directly transferred to the bank account of the patient every month during the treatment by the government). Also, Ni-Kshay Mitra (‘Mitra’ means friend) initiative provides additional nutritional and psychosocial support to the patients. Kangra has prioritised people with drug-resistant forms of TB to receive such support.

People who are cured of TB are also championing the cause by helping support others with TB in Kangra. They are rightly called TB champions.

Not just TB, Dr Sood’s team is also helping manage TB related co-infections (like HIV) or co-morbidities (like diabetes) by proper linkage to care as per the guidelines.

Helping those who test TB negative to stay negative

“Those who test negative for presumptive TB in the X-ray screening or for active TB disease in the upfront molecular testing, are offered TB preventive therapy. These people are offered the latest skin test (called Cy-TB which is globally available as SIILTIBCY via Global Drug Facility of Stop TB Partnership. Cy-TB is made in India by Serum Institute of India). Those who test positive on Cy-TB are offered TB preventive treatment (called 3HP regimen of 3 months duration with isoniazid and rifapentine taken once weekly),” said Dr Sood.

All is not smooth: Important learnings

Implementing 100 days campaign (hope it continues and grows till India ends TB) is also yielding important learnings.

For example, it is not easy to convince seemingly healthy people (who do not have any TB symptoms yet) to take a TB test or a test for latent TB.

With limited number of AI-enabled handheld X-rays, people are escorted by ASHA or other healthcare workers to the nearest health facility with X-rays.

“When we do a TB camp in a village then people come forward to get their X-ray done and response rate is very high. But if there is no handheld ultraportable AI-enabled X-ray facility in the village, then we have to refer the people to a nearby health facility for X-ray which is very challenging and response rate is around 5% - 10%,” said Dr Sood. “In a public healthcare facility there could already be a queue of 100 people waiting to get their X-ray done (for reasons other than TB, such as, orthopaedics). So, TB asymptomatic person needs to stand in a queue to first get an OPD slip, then stand in another queue to get his/her/their prescription, then in the third queue to get a zero-billing done (as X-ray for TB is free) and then in the fourth queue to get the X-ray done. After this, the person has to go to the doctor with the report. It is not surprising that people are often reluctant to go through this cumbersome and time-consuming process, even if ASHA workers are helping them to navigate the hospital system.”

Critically important is to raise health and treatment literacy of people so that even when they are not TB symptomatic, they are willing to go through TB screening and testing process – and if eligible for TB preventive therapy, can adhere to the entire course of the treatment.

“If there is a person with active TB disease in the household, then the TB risk perception is likely to be high and people are more willing to accept TB preventive therapy to protect themselves from active TB disease. But if there is no one in the family with TB disease, then TB risk perception is often missing in key and other vulnerable populations, and so is the will to go for TB preventive services,” explained Dr Sood.

Another challenge is that ASHA workers have to bring people eligible for Cy-TB test to the nearest healthcare facility (wellness centre) and the person has to come again to get the results later. These multiple visits are a deterrent too and people may drop out of the care cascade.

“But we are making all efforts to mobilise more people and increase uptake of TB services. Our first supplies for Cy-TB have already exhausted and next supply is due,” shares Dr Sood.

There are technical challenges too. Indian government uses a very important online system with latest data of every person with TB enrolled in the programme, called Ni-Kshay portal. “Ni-Kshay platform despite being very well designed, is overwhelmed with the load it has to handle now. So due to increased load, the server has become very slow,” said Dr Sood. His team is also using other methods such as Google Forms or WhatsApp to collect and record data or information. “But eventually it is the Ni-Kshay platform where we need to maintain the complete database. We hope that this will stabilize shortly.”

Investing in TB free movement and health systems

“We need more mobile medical units (Ni-Kshay Vahans) equipped with ultraportable handheld AI-enabled X-rays and resources to support intensified efforts to find, treat and prevent more TB. The more outreach we can do and the more X-ray machines we have, the more TB we can find. Also, we need more trained and skilled human resources to carry on this work till we succeed in our mission to end TB,” says Dr Sood.

Point-of-care and battery operated WHO recommended molecular tests like Truenat should also be made more available so that those found with presumptive TB on X-rays can take a confirmatory TB test on the spot.

India’s 100-days campaign to find, treat and prevent more TB in high-risk people must continue beyond 100 days. This initiative is an important shift towards ending TB, but it would be “too late, too little” if it ends on the 100th day. Such a drive to find, treat and prevent ALL TB must continue and expand population-wide in high-risk settings till we end TB.