Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

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ABSTRACT

Background: The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices.

Objectives: To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice.

Methods: From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project’s core activities and outcomes.

Results: In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice.

Conclusions: OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

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Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence

Catherine Stevenson, Nita Forouhi, Gojka Roglic … (2007)

Background Tuberculosis (TB) remains a major cause of mortality in developing countries, and in these countries diabetes prevalence is increasing rapidly. Diabetes increases the risk of TB. Our aim was to assess the potential impact of diabetes as a risk factor for incident pulmonary tuberculosis, using India as an example. Methods We constructed an epidemiological model using data on tuberculosis incidence, diabetes prevalence, population structure, and relative risk of tuberculosis associated with diabetes. We evaluated the contribution made by diabetes to both tuberculosis incidence, and to the difference between tuberculosis incidence in urban and rural areas. Results In India in 2000 there were an estimated 20.7 million adults with diabetes, and 900,000 incident adult cases of pulmonary tuberculosis. Our calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) tuberculosis. We estimate that the increased diabetes prevalence in urban areas is associated with a 15.2% greater smear-positive tuberculosis incidence in urban than rural areas – over a fifth of the estimated total difference. Conclusion Diabetes makes a substantial contribution to the burden of incident tuberculosis in India, and the association is particularly strong for the infectious form of tuberculosis. The current diabetes epidemic may lead to a resurgence of tuberculosis in endemic regions, especially in urban areas. This potentially carries a risk of global spread with serious implications for tuberculosis control and the achievement of the United Nations Millennium Development Goals.

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Influence of diabetes mellitus on the immunity to human tuberculosis.

Pavan Kumar Nathella, Subash Babu (2017)

Type 2 diabetes mellitus (DM) is a major risk factor for the development of active pulmonary tuberculosis, with development of DM pandemic in countries where tuberculosis (TB) is also endemic. Understanding the impact of DM on TB and the determinants of co-morbidity is essential in responding to this growing public health problem with improved therapeutic approaches. Despite the clinical and public health significance posed by the dual burden of TB and DM, little is known about the immunological and biochemical mechanisms of susceptibility. One possible mechanism is that an impaired immune response in diabetic patients facilitates either primary infection with Mycobacterium tuberculosis or reactivation of latent TB. DM is associated with immune dysfunction and alterations in the components of the immune system, including altered levels of specific cytokines and chemokines. Some effects of diabetes on adaptive immunity that are potentially relevant to TB defence have been identified in humans. In this review, we summarize current findings regarding the alterations in the innate and adaptive immune responses and immunological mechanisms of susceptibility of DM patients to M. tuberculosis infection and disease. This article is protected by copyright. All rights reserved.

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From Where Are Tuberculosis Patients Accessing Treatment in India? Results from a Cross-Sectional Community Based Survey of 30 Districts

Srinath Satyanarayana, Sreenivas Nair, Sarabjit Chadha … (2011)

Background Tuberculosis (TB) notification in India by the Revised National TB Control Programme (RNTCP) provides information on TB patients registered for treatment from the programme. There is limited information about the proportion of patients treated for TB outside RNTCP and where these patients access their treatment. Objectives To estimate the proportion of patients accessing TB treatment outside the RNTCP and to identify their basic demographic characteristics. Methods A cross sectional community-based survey in 30 districts. Patients were identified through a door-to-door survey and interviewed using a semi-structured questionnaire. Results Of the estimated 75,000 households enumerated, 73,249 households (97.6%) were visited. Of the 371,174 household members, 761 TB patients were identified (∼205 cases per 100,000 populations). Data were collected from 609 (80%) TB patients of which 331 [54% (95% CI: 42–66%)] were determined to be taking treatment ‘under DOTS/RNTCP’. The remaining 278 [46% (95% CI: 34–57%)] were on treatment from ‘outside DOTS/RNTCP’ sources and hence were unlikely to be part of the TB notification system. Patients who were accessing treatment from ‘outside DOTS/RNTCP’ were more likely to be patients from rural areas [adjusted Odds Ratio (aOR) 2.5, 95% CI (1.2–5.3)] and whose TB was diagnosed in a non-government health facility (aOR 14.0, 95% CI 7.9–24.9). Conclusions This community-based survey found that nearly half of self-reported TB patients were missed by TB notification system in these districts. The study highlights the need for 1) Reviewing and revising the scope of the TB notification system, 2) Strengthening and monitoring health care delivery systems with periodic assessment of the reach and utilisation of the RNTCP services especially among rural communities, 3) Advocacy, communication and social mobilisation activities focused at rural communities with low household incomes and 4) Inclusive involvement of all health-care providers, especially providers of poor rural communities.

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Author and article information

Journal

Journal ID (nlm-ta): Glob Health Action

Journal ID (iso-abbrev): Glob Health Action

Journal ID (publisher-id): ZGHA

Journal ID (publisher-id): zgha20

Title: Global Health Action

Publisher: Taylor & Francis

ISSN (Print): 1654-9716

ISSN (Electronic): 1654-9880

Publication date Collection: 2018

Publication date (Electronic): 19 March 2018

Volume: 11

Issue: 1

Electronic Location Identifier: 1445467

Affiliations

[a ] Department of Tuberculosis and Communicable Diseases, International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office , New Delhi, India

[b ] Centre for Operational Research, International Union Against Tuberculosis and Lung Disease , Paris, France

[c ] Independent Senior Public Health Consultant , Nilgiris, Tamil Nadu, India

[d ] Division of Global HIV and Tuberculosis, US Centers for Disease Control , Atlanta, GA, USA

[e ] Epidemiology and Research Division, National Tuberculosis Institute , Bangalore, India

[f ] Department of Community Medicine, ESIC Medical college and PGIMSR , Bangalore, India

[g ] Department of Community Medicine, Government Medical College and SSG Hospital , Vadodara, India

[h ] National Tuberculosis Institute , Bangalore, India

[i ] World Health Organisation India Country Office , New Delhi, India

[j ] Central Tuberculosis Division, Ministry of Health and Family Welfare, Government of India

[k ] The Global Fund to fight AIDS, Tuberculosis and Malaria , Geneva, Switzerland

[l ] Médecins sans Frontières, Brussels Operational Center (LuxoR) , Luxembourg City, Luxembourg

[m ] International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office , New Delhi, India

Author notes

CONTACT Karuna D Sagili drkarunas@ 123456gmail.com Technical Advisor-Research, The Union South East Asia Office , New Delhi, India

[*]

These authors contributed equally to this work.

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Patrick K Moonan http://orcid.org/0000-0002-3550-2065

Article

Publisher ID: 1445467

DOI: 10.1080/16549716.2018.1445467

PMC ID: 5912428

PubMed ID: 29553308

SO-VID: 68906fde-5bcf-4751-b6c3-b025c7acadc0

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 01 December 2017

Date accepted : 09 February 2018

Page count

Figures: 2, Tables: 4, References: 70, Pages: 13

Funding

Funded by: The Union South East Asia office

This article was prepared as part of Global Fund grant implemented by The Union South East Asia office, India. The co-authors from CDC were supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention.

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

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Point-Of-Care Testing for Tuberculosis

Most cited references 50

Diabetes and tuberculosis: the impact of the diabetes epidemic on tuberculosis incidence

Influence of diabetes mellitus on the immunity to human tuberculosis.

From Where Are Tuberculosis Patients Accessing Treatment in India? Results from a Cross-Sectional Community Based Survey of 30 Districts

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