rc Tuberculosis in Saharias (An information booklet based on research at ICMR-NIRTH, Jabelpur) NIRTH |JABALPUR ICMR-National Institute for Research in Tribal Health NIRTH Complex. Nagpur Raed P.O, - Garha, Jabelpur - 482.003, Madhya Predesh, INDIA Phone: - +91-761-2370800, 2370818 Fax: -+91-761-2672239, 2672835 E-mail: director(@nirthces.in Based on the research work conducted by: Dr VG Ra, Sieit'C° De. Tass Chalom, Siena? Dr Jyh Bi, Sei Dr RK Suma Sei D* % (Dr. M, Munizand, Scien “C* ent COR. hoEE Tuberculosis in Saharias INDEX * Executive summary 3 * Background 4 * Burden of TB in India 5 = TB situation in tribal populations 6 = Burden of TB in Saharia in Madhya Pradesh 7-8 © Burden over time and space © Burden in different age groups © Burden by Gender = TB infection in Saharia children 9 = Burden of drug resistant TB 10 = Health literacy on TB 11 "= Risk factors for TB 12-14 © Socio-economic risk factors © Clinical risk factors ‘© Lifestyle risk factors © Population attributable risk * Disease Intervention through IEC 15-16 = Cost to patient 7, © Total costs (diagnosis & treatment) © Catastrophic expenditure due to TB = Recommendations 18 = Supporting publication 19 —oExecutive summary This booklet summarizes TB situation among Saharia tribal population -a Particularly Vulnercble Tribal Group (PVTG) based on research studies carried out in Madhya Pradesh, India, particularly by Scientists at NIRTH, Jabalpur. The booklet also outlines the summary of risk factors, intervention and the recommendations. This include clarmingly high burden of tuberculosis among Scharia tribal population in terms of prevalence, drug resistant TB, health literacy, risk factors of TB, and costs incurred to TB patients. The information will throw light on evidence for action to contral and strengthen tuberculosis control in this vulnerable population. Further, this information booklet also provides information on effectiveness of interventions to deal with T3 in most vulnerable communities.Background i] Tuberculosis (TB) is a common opportunistic infection in developing countries and continues to remain one of the major public health problems in India. In general | in India are geographically and culturally isolated and depict varied social as well as | economic development. Moreover, their health problems differ fom area to area. A the impedime! number of commissions and committees have been appointed to ider to their development in the country and these committees have recommended a number ‘of measures to eliminate the socio-economic imbalances existing in the tribal Several programmes have been launched to remove these stumbling blocks to benefit the tribal population beginning ftom the first Five Year Plan. In spite of these efforts, the tribes show a great variation in their economie, social, political, educational and health spheres. There is @ consensus agreement that the health status of the tribal population has been consistently poor mainly among the Particularly Vulnerable Tribal Groups (PVTGs) because of illiteracy, isolation and remoteness. Saharia is one of the PVTG in Madhya. Pradesh with poor socio-economic and health indicators. This report summarizes the findings of the siudies on Tuberculosis conducted by ICMR-NIRTH, Jabalpur in Saharia Socio-economnic status * 84% illiterates = 93% labourers * 91% living in katcha houses * 89% single room houses = 96% without separate kitchen 79% below BPL. * 38% Tobaceo smoking * 36% Alcohol consumptionBurden of TB in India 2015, an estimated India accounts for more than one-fourth of the global TB burden. I out of total 104 lakh TB cases estimated 28 lakh TB new cases occurred in the counir globally. Though TB is preventable and completely curable, yet about 480,000 people died of TB in India, The figure below shows the estimated figures for TB burden globally and for India teported in WHO Global TB Report for the year 2016. Despite, drugs are available to cure most TB patients since the 1950s, yet TB remains still huge burden, in tesource-poor | settings and the world's most important cause of death especially in India. When s ntific knowledge is used to guide policy and practices. evidences are ranked according to the relative merits of different data. 120 100 Rest World sindia 80 60 Lakhs 40 0 Incidence of TB Mortaigyef TR InidenceofHIV- Mortality of TIV- MDR-TB cases Cases 1B 1B‘TB situation -Tr bal population There has been limited investigation on the prevalence of tuberculosis (TB) in tribal communities in India, a vulnerable section of Indian society. There is great heteroge city across different tribal groups. which include a sub-category of particularly vulne tribes known as primitive tribes now renamed as particularly vulnerable tribal group: (PVTG), The findings of the TB prevalence surveys conducted among different triba population in the country are given below. Author / year | Tribe Prev./ 100,000 Mayurnath S et al, 1984 Pahadis, Kashmir valley 260 indian I Med Res 80: 129-10) | Chakma Tet al, 1996 SahariagMPo | 1270 Narang P et al, 1999 Wardha district. Maharashtra 133 (toed Tuberetang Dis, $: 478-82) Datta M etal, 2001 Jawadhu tribals, Tamil Nadu 810 ned Tuberc mg Dis: 52409) Murhekar MV et al, 2004 Nicobares, A& N islands 740 (Bull World Heath Organ: 82: 83643) Bhat et al, 2009 “Tribal population M.P. 387 TB situation - PVTG Tribes 1600 1513 432 00. 146 Baiga Bharia SabariaBurden of TB in Saharia of Madhya Pradesh Burden over time and space Strategic framework for action on TB contol in indi the surveys by cataloguing the burden of TB in a society or community. Although. ‘community based surveys are costly and laborious, but they provide direct measurement of prevalence and trends, A series of community surveys among Sshariya. # primitive vulnerable tribal group (PVTG) of Madhya Pradesh were undertaken to assess the TB situation. The overall TB prevalence estimated in different time points in diferent areas genous communities has emphasized is given below.Burden in different age groups With respect to the age specific prevalence of TB. it increases as age inereases. Hix! TB prevalence was observed in older age groups, —£~ Gwalior(2013) | —®—Shivpuri 2014) Pooled 5000 4000 race per 100,000 3000 2000 1000 15.24 25.34 344 45-54 55+ Age Groups Burden by Gender A very high prevalence was observed among males compared to females. Male @Female mTotal 6000 5000 4000 3000 2000 Prevalence per 100,000 1000 Gwalior 2013) Shiypuri 2014) Pooled- >) children TB infection in Saha’ A cross-sectional tuberculin survey was carried out to estimate the prevalence of tuberculous infection and the annual risk of tuberculosis infection (ARTI) ame children of Saharia, A total of 1341 children aged 1-9 years were subjected to (ubereulin testing with | TU of PPD RT 23 and the reaction sizes were read after 72 h. The proportion of BCG scar-positive children was 34.6%. The frequency distribution of children by reaction sizes indicated a clear-cut anti-mode at 11 mm and a mode at 18 mm at the right-hand side of the distribution, The prevalence of infection among children remained high in studies conducted in 1991-92 (TB infection - 16.9. ARTI - 3.3%) and 2007-08 (TB infection - 20.4, ARTI - 3.9%) in the same areas. Study area Bee sie ARTI (%) Karhal Block, Sheopur district 1991-92 16.9 33 Karhal Block, Sheopur district | __ 2007-08. 204 [ 39 National ARTI range 10 to 1.9 in different zones of the countryBurden of drug resistant TB ote mali resistant Bee als (MDR-TB) was 2.2% among ses and 8.2% “Shivpuri district. Though the prevalence of TB in these high, the MDR-TB rates were more or less similar to national Drug susceptibility pattern Gwalior Shivpuri 21) Sensitive to all drugs Mono drug resistance Isoniazid (H) Streptomycin (S) Rifampicin (R) Ethambutol (E) Two drug resistance S+H HE Three drug resistance S+H+E S+H+R H+R+E MDR (H+R) Resistance to all four cragsGh ak. ~#~*~*~*~*W th literacy on TB Overall health literacy about TB was assessed based on the following items: (i symptoms of TB (persistent cough for 2 or more weeks, sputum with blood, chest pain i) recognize TB as a transmissible ‘weight loss, loss of appetite, fever. and night sweat), disease, (ii) enumerate correct mode of transmission of TB (cough/sputum from infected persons), (iv) TB is treatable. (v) TB diagnosis tests, (vi) effective allopathy treatment for TB, and (vii) correct preventive methods for TB (covering nose/moulh while sneezing/coughing, not spitting everywhere, BCG vaccination), It was observed that 52% of respondents had heard about TB, This is low as compared to the national average of 88%. But among those who had heard of TB, the most significant finding that respondents knew all the symptoms of TB and only one third mentioned any one preventive measure. Bo 90 80 0 Percent. 2s ss 2 1 ese cous Cough with Blood Fever | Chest Pain Weakness Weight loss Breathless Less of Appetite Night SweatsRisk factors for TB The major risk factors for wberculosis in Saharias are Socio-economic risk factors Males (OR=3.85), sto workers (OR= housing and cook: ig inside the house w Characteristies OR (95% Cl) Pe 604 1 35, 143 Bl 1.06 (0.81 — 1.40) 0,737 Sex | Female 56 675 1 | Male 2 660 3.85 (2.82 - 5.27) 0.000 Education Mliterate 2u1 1029 0.73 (0.52 — 1.02) OBIS Primary 33 184 0.69 (0.43 — 1.11) 0.883 Middle & above 23 122 1 Occupation Unemployed 67 303 1 Farmer/Labour 174 980 0.80 (0.60- 1.09) 0.165 Stone crashing/ Others 26 2 2.26 (132-388) 0,003 Annual family income <10,000 226 1036 1.59(.11-2.27) 0.010 10,000 41 299 1 Housing Pucca 26 19 1 Keccha 634 201 2,30 (1.25-4.25) 0.006 Separate Kitchen Yes 6 8 A No 654 212 4.11 (1.41-11.99) 0.010 N 267 1335 1602Clinical risk factors Clinical risk factors such as malnutrition (OR=3.81). abnormal blood sugar (OR=1.76), history of asthma (OR=3.46) had increased risk of PTB. Prevalence of HIV wa among Saharia and there was no HIV positive individual ame “Characteristics Case Control OR (95% CI Body Mass Index i = Normal 228 sal ' Malnourished 34 178 3.81 2.61 ~5.56 0.000 Blood sugar Normal 228 194 1 Diabetic 33 98 L.76(1.16-2.68) 0.007 History of Asthma No 199 Is I Yes 68 120 5.46 (2.48-4.83) 0.000 factors Life style risk factors such as chewing tobacco, smoking tobacco and aleohol consumption were also studied. Among these, the risk of TB was higher in tobacco smokers (OR=1.64) and alcohol consumers (OR=1.49). Alcohol consumption and smoking was meagre in women. Characteristics Case Control ORO5% CI) P-value ‘Chewing tobaceo No 164 900 1 Yes 103 435 1.29 (0.99 - 1.70) 0.065 Smoking tobacco No 142 868 1 Yes 125 467 1.64 (1.23-2.13) 0,000 Alcohol use No 183 1020 1 Yes 8 315 1.49 (1.12 1.98) 0.007Population attributable risk Attributable proportions for the modifiable risk factors for TB such as nutritional status, Gintal family income, occupation, smoking tobacco, history of asthma, alcohol lculated. It shows that 50% cases were consumption, and blood sugar level were ca attributed to malnutrition, 31% attributed to low annual family income, 18% attributed te tobacco smoking: 18% attributed to asthma, 10% attributed 10 alcohol consumption, SY attributed to stone crashing work and $% attributed to abnormal blood sugar (Diabetics) ‘After adjusting (based on AOR) it was found that 44% attributed to malnutrition and 12% attributed to asthma.Disease Intervention through IEC In view of high TB burden and low awareness about disease in Saharia ( intervention study was undertaken in Saharia dominated Pohri Block of Shivpuri distric Chambal division of Madhya Pradesh. Various IEC activities undertaken were (raining grass root workers, health camps. community meetings, wall paintings. street plays/nuk natak. rallies involving community members and school children, film show involvement of TB “dot” The knowledge on TB was found to be low in the baseline. Overall awareness increased in both the areas but improvement in the intervention area was significant MBaseline mEndline 100 94.6 a0 78.8 80 - gos 60.4 = 60+ z 49.7 47.7 2 os1 « 46.2 = 40 30 20> 10 ‘ ae Ete bee Intervetion Control Total ‘The proportion of the respondents who reported cough as a major symptom of TB increased from 72.0% to 95.5% (p<0.001) in intervention area. Similar fit ing is also seen for other important symptoms of TB such as cough with blood, chest pain, fever, and weight loss.SS is =. Control Endtine Contd Baseline wleterveton Fndline —Intersetion Baseline eS The awareness among opinion leaders about the DOT centres increased from 36.0% to 84.4% in the intervention area (p<0.001). Awareness about the availability of free DOTS medicine increased from 40.0% to 84.4% and 25.8% to 33.3% respectively in intervention (p<0.001) and control area (p<0.001). Knowledge that TB will not cure without full treatment increased from 36.0% to 65.6% in the inte-vention area (p<0.001). ControlEndline EControlBaseline intervetionEndline _ Intervetion Baseline ‘TB will not cure without fulltreamtret Medicine freeat DOTS. 84 ee 40 q 33 DOTS is sure way to cure TB re EE 36 33 Heard about DOT centres. aim oy —————— o 20 40 oo 80 100Costs to patients Total costs (diagnosis and treatment) It was estimated that direct. indireet and total costs were averaged Rs. and Rs. 2466 respectively. Proportion of patients incurred indirect costs was higher than the proportion of patients incurred direct costs in both before and afte diagnosis of TB. 6000 2 | 2 gy MDI! einen Tot 4 2000 ¢ Diagnosis Treatment Total Catastrophic expenditure due to TB Majority getting treatment free of costs and those who incurred costs, they faced catastrophic TB care expenditure amounted to 10%, which is the proportion of various costs in relation to annual family income. 15000 10000 es I mi Income eon BIncome after costs detection _™ Costs. -19000Recommendations Urgent need to initiate intensified TB control activities Need for contact screening for all TB patients Focused active case finding Health system strengthening by filling in vacancies, improving diagnostic facilities, sensitizing health care providers. etc. Chemoprophylaxis for the children under 5 years involving local communities Intensified awareness activ Nutrition support for TB patients till treatment completion and promotion of the concept of Kitchen garden Need for improved housing with better ventilation and sanitation Provision of solar chulhas Smoking and alcohol cessation activities including social mobilization as part of TB Control Program. Inter-sectoral coordination involving all concerned departments. Genetic susceptibility studies may be undertaken Community participation for sustainabilitySupporting publications from ICMR-NIRTH, Jabalpur Rao VG. Gopi PG, Yadav R, Sadacharam K. Bhat J, Subramani R. Anvikar AR. Tiwari BK, Vasantha M, Bhondeley MK, Gadge V, Fusuff SI, Shukla GP. Tuberculosis infection in Saharia, a primitive tribal community of Central India. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2008 Sep:102(9):898-904 Rao V.G., Gopi P.G., Bhat J., Selvakumar N. Yadav R.. Tiwari B.K...Gadge V., Bhondeley M.K.. ‘Wares D-F. Pulmonary tuberculosis: public health problem amongst Saharia. a primitive tribe of Madhya Pradesh, central Indi, Intemational Joumal of Infectious Diseases.2010; 14: 713-2716 Rao VG, Gopi PG, Bhat J, Yadav R, Selvakumar N. Wares DF, Selected risk factors associated with pulmonary tuberculosis amongst Saharia tribe of Madhya Pradesh, central India, European Journal of public health 2012 Apr:22 (2):271-3. . Rao VG, Bhat J, Yadav R, Muniyandi M, Sharma R & Bhondeley MK. Pulmonary tuberculosis - a health problem amongst Saharia tribe in Madhya Pradesh. Indian J Med Res 141; May 2015: 630-635. niyandi M, Sharma R, Karfarma C & Luke C. Situation of ‘Saharia trite of central India. Indian J Med Res 141; May ‘Muniyandi M, Rao VG, Bhat J,Yadav R, Sharma RK & Bhondeley MK. Health literacy on tuberculosis amongst vulnerable segment of population: special reference to Saharia tribe in central India, Indian J Med Res 141; May 2015: 640-647. 10 PY, Pall S, Kaushal LS. Datta M, Tiwary 4. RS. Survey of pulmonary a primitive tribe of Madhiya Pradesh. Indian J Tuberc 1996; 43 : 85-9. Bhat J, Rao VG, Gopi PG, Yadav R, Selvakumar N, Tiwari B, 20. ef al. Prevalence of pulmonary tuberculosis amongst the tribal population of Madhya Pradesh, central India. Jnt J Epidemiol 2009; 38 : 1026-32 “Jyothi Bhat, VG Rao, M. Muniyandi . Rajiv Yadav, MK Bhondley. Study on “risk factors for pulmonary tube ‘A case-control study among Saharia tribe in “Madhya Pradesh, India. Indian J Med Res.(In press). 7 at J, Yadav R, Muniyandi M, Sharma R, ae MK. Risk factors for e ni oa " nee i sis amongst the Saharia tril : population based case RK,‘Atypical suhariavilage ir Madtyo Pradesh, Irie ICNR-NIRTH, Fobalpur, Madhya Pradesh, Tadic