BACKGROUND: Addressing TB in India is critical to meeting global targets. With the scale-up of diagnostic networks and the availability of new TB drugs, India had the opportunity to improve the detection and treatment outcomes in drug-resistant TB (DR-TB).OBJECTIVE: To document how the introduction of new drugs and regimens is helping India improve the care of DR-TB patients.DESIGN: In 2016, India´s National TB Programme (NTP) introduced bedaquiline (BDQ) under a Conditional Access Programme (BDQ-CAP) at six sites after providing extensive training and strengthening laboratory testing, pre-treatment evaluation, active drug safety monitoring and management (aDSM) and follow-up systems.RESULTS: An interim analysis reflected earlier and better culture conversion rates: 83% of the 620 patients converted within a median time of 60 days. However, 248 serious adverse events were reported, including 73 deaths (12%) and 100 cardiotoxicity events (16.3%). Encouraged by the evidence of safety and efficacy of BDQ, the NTP took steps to systematically expand its access to cover the entire population by 2018.CONCLUSION: The cautious yet focused approach used to introduce BDQ under BDQ-CAP paved the way for the rapid introduction of delamanid, as well as the shorter treatment regimen and the all-oral regimen for DR-TB.

People living with the human immunodeficiency virus (HIV) (PLHIV) are at high risk for tuberculosis (TB), and TB is a major cause of death in PLHIV. Preventing TB in PLHIV is therefore a key priority. Early initiation of antiretroviral therapy (ART) in asymptomatic PLHIV has a potent TB preventive effect, with even more benefits in those with advanced immunodeficiency. Applying the most recent World Health Organization recommendations that all PLHIV initiate ART regardless of clinical stage or CD4 cell count could provide a considerable TB preventive benefit at the population level in high HIV prevalence settings. Preventive therapy can treat tuberculous infection and prevent new infections during the course of treatment. It is now established that isoniazid preventive therapy (IPT) combined with ART among PLHIV significantly reduces the risk of TB and mortality compared with ART alone, and therefore has huge potential benefits for millions of sufferers. However, despite the evidence, this intervention is not implemented in most low-income countries with high burdens of HIV-associated TB. HIV and TB programme commitment, integration of services, appropriate screening procedures for excluding active TB, reliable drug supplies, patient-centred support to ensure adherence and well-organised follow-up and monitoring that includes drug safety are needed for successful implementation of IPT, and these features would also be needed for future shorter preventive regimens. A holistic approach to TB prevention in PLHIV should also include other important preventive measures, such as the detection and treatment of active TB, particularly among contacts of PLHIV, and control measures for tuberculous infection in health facilities, the homes of index patients and congregate settings.

ObjectivesTo estimate out-of-pocket (OOP) expenditure due to hospitalisation from NCDs and its impact on households in India.MethodsThe study analysed nationwide representative data collected by the National Sample Survey Organisation in 2014 that reported health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private). The recall period for inpatient hospitalisation expenditure was 365 days. Consumption expenditure was collected for a recall period of 1 month. OOP expenditure amounting to >10% of annual consumption expenditure was termed as catastrophic. Weighted analysis was performed.ResultsThe median expenditure per episode of hospitalisation due to NCDs was USD 149 - this was similar to 3 times higher among the richest quintile compared to poorest quintile. There was a significantly higher prevalence of catastrophic expenditure among the poorest quintile, more so for cancers (85%), psychiatric and neurological disorders (63%) and injuries (63%). Mean private-sector OOP hospitalisation expenditure was nearly five times higher than that in the public sector. Medicines accounted for 40% and 27% of public- and private-sector OOP hospitalisation expenditure, respectively.ConclusionStrengthening of public health facilities is required at community level for the prevention, control and management of NCDs. Promotion of generic medicines, better availability of essential drugs and possible subsidisation for the poorest quintile will be measures to consider to reduce OOP expenditure in public-sector facilities.ObjectifsEstimer les depenses directes de la poche (DDP) liees a l'hospitalisation pour les maladies non transmissibles (MNT) et leur impact sur les menages en Inde.MethodesL'etude a analyse les donnees representatives a l'echelle nationale recueillies par la National Sample Survey Organization en 2014, qui a rapporte l'utilisation des services de sante et les DDP liees aux soins de sante par quintiles de revenus et par type d'etablissement de sante (public ou prive). La periode de rappel pour les depenses d'hospitalisation des patients etait de 365 jours. Les depenses de consommation ont ete recueillies pour une periode de rappel d'un mois. Les DDP representant > 10% des depenses annuelles de consommation ont ete qualifiees de catastrophiques. Une analyse ponderee a ete realisee.ResultatsLes depenses medianes par episode d'hospitalisation pour les MNT etaient de 149 USD, environ 3 fois plus elevees dans le quintile le plus riche par rapport au quintile le plus pauvre. Il y avait une prevalence significativement plus elevee de depenses catastrophiques dans le quintile le plus pauvre, et plus encore pour les cancers (85%), les troubles psychiatriques et neurologiques (63%) et les blessures (63%). Les DDP moyennes pour les hospitalisations dans le secteur prive etaient pres de cinq fois plus elevees que dans le secteur public. Les medicaments representaient 40% et 27% des DDP pour l'hospitalisation dans le du secteur public et prive, respectivement.ConclusionLe renforcement des etablissements de sante publics est necessaire au niveau communautaire pour la prevention, le controle et la prise en charge des MNT. La promotion des medicaments generiques, une meilleure disponibilite des medicaments essentiels et le subventionnement possible pour le quintile le plus pauvre sont des mesures a prendre en compte pour reduire les DDP dans les etablissements du secteur public.ObjetivosCalcular los gastos de bolsillo (GDB) por hospitalizacion de enfermedades no transmisibles (ENT) y su impacto sobre los hogares de la India.MetodosEl estudio analizaba a nivel nacional datos representativos recogidos por la Organizacion Nacional de Encuestas por Muestreo en el 2014 que reportaba la utilizacion de servicios sanitarios y atencion sanitaria relacionada con GDB segun el quintil de ingresos y el tipo de centro sanitario (publico o privado). El periodo de captacion de gastos para pacientes hospitalizados fue de 365 dias. Los gastos de consumo se recogieron para un periodo de un mes. Los GDB que representaban hasta >10% del consumo anual de gastos se consideraron catastroficos. Se realizo un analisis ponderado.ResultadosEl gasto medio por episodio de hospitalizacion debido a ENT era de USD 149 - esto era similar to 3 veces mas alto entre el quintil mas rico comparado con el quintil mas pobre. Habia una prevalencia significativamente mas alta de gastos catastroficos entre el quintil mas pobre, mas aun para cancer (85%), desordenes psiquiatricos y neurologicos (63%) y heridas (63%). La media de GDB por hospitalizacion en el sector privado era casi cinco veces mas alta que en el sector publico. Los medicamentos correspondian al 40% y al 27% de los GDB por hospitalizacion en el sector publico y privado respectivamente.ConclusionEs necesario fortalecer los centros sanitarios publicos a nivel comunitario para la prevencion, el control y el manejo de ENTs. Promover los medicamentos genericos, una mayor disponibilidad de medicamentos esenciales y el posible subsidio para el quintil mas pobre, serian medidas a considerar para reducir los GDB en los centros sanitarios publicos.

In India, to increase tuberculosis (TB) case detection under the National Tuberculosis Programme, active case finding (ACF) was implemented by the Global Fund-supported Project Axshya, among high-risk groups in 300 districts. Between April 2013 and December 2014, 4.9 million households covering ~20 million people were visited. Of 350 047 presumptive pulmonary TB cases (cough of ⩾2 weeks) identified, 187 586 (54%) underwent sputum smear examination and 14 447 (8%) were found to be smear-positive. ACF resulted in the detection of a large number of persons with presumptive pulmonary TB and smear-positive TB. Ensuring sputum examination of all those with presumptive TB was a major challenge.

Data from surveys on knowledge, attitudes and practice (KAP) on tuberculosis (TB) conducted under the Axshya project at two time points (baseline 2010-2011 and midline 2012-2013) were analysed for changes in coverage and equity of TB awareness after project interventions. Overall coverage increased from 84% at baseline to 88% at midline (5% increase, P < 0.05). In comparison to baseline results, coverage at the midline survey had significantly increased, from 81% to 87% among the rural population, from 81% to 86% among women, from 73% to 85% in the >= 55 years age group, from 71% to 80% among illiterates and from 73% to 81% in the south zone (P < 0.05). The equity gap among the different study groups (settlement, sex, age, education and zones) decreased from 6-23% at baseline to 3-11% during the midline survey. The maximum decline was observed for type of settlement (rural vs. urban), from 10% to 3% (P < 0.05). This community-driven TB control project has achieved high and equitable coverage of TB awareness, offering valuable lessons for the global community.

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) jointly developed a new paradigm for operational research (OR) capacity building and started a new process of appointing and supporting OR fellows in the field. This case study describes 1) the appointment of two OR fellows in The Union South-East Asia Office (USEA), New Delhi, India; 2) how this led to the development of an OR unit in that organisation; 3) achievements over the 5-year period from June 2009 to June 2014; and 4) challenges and lessons learnt. In June 2009, the first OR fellow in India was appointed on a full-time basis and the second was appointed in February 2012-both had limited previous experience in OR. From 2009 to 2014, annual research output and capacity building initiatives rose exponentially, and included 1) facilitation at 61 OR training courses/modules; 2) publication of 96 papers, several of which had a lasting impact on national policy and practice; 3) providing technical assistance in promoting OR; 4) building the capacity of medical college professionals in data management; 5) support to programme staff for disseminating their research findings; 6) reviewing 28 scientific papers for national or international peer-reviewed journals; and 7) developing 45 scientific abstracts for presentation at national and international conferences. The reasons for this success are highlighted along with ongoing challenges. This experience from India provides good evidence for promoting similar models elsewhere.

The Revised National TB Control Programme (RNTCP), an application in India of the Directly Observed Treatment, Short Course (DOTS) strategy to control TB is being implemented in the country since 1997. The goal of the RNTCP is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India Since 1999, achievements of the RNTCP have largely determined the global DOTS progress. It has been cited as the fastest expansion in the history of DOTS and in terms of patients being treated, it is the largest programme in the world. More than 50-fold expansion in RNTCP coverage has occurred since 1998 thus making DOTS accessible to more than 83% of the country's population. Quality of services has been maintained during this rapid expansion. As a result, the proportion of sputum positive cases confirmed in the laboratory is on par with international standards. By September 2005, the programme has initiated more than 3.5 million patients on treatment, thus saving over 600,000 additional lives. In 2003, new sputum positive case detection rate of 69% was achieved against target of at least 70% and treatment success rate of 86% has been achieved above the target of 85% Aggressive steps are being taken to meet global TB control targets by covering the entire country with RNTCP by 2005. Despite these achievements, there are many challenges for the RNTCP. Implementing DOTS in a diverse and large country, maintaining the quality of services during rapid expansion phase, decentralization of programme management to the states and, widening the reach of the programme to reach all sections of the society are some of the major challenges.