India's 2021 differentiated TB care guidance: Is it feasible to implement and act upon?

Background: In 2021, India's national tuberculosis (TB) elimination programme recommended severity assessment using 16 indicators (involving clinical, laboratory and radiological assessment) for all TB patients at diagnosis. Patients with a total score more than one or emergency criteria were eligible for referral and inpatient care (called as severely ill). This guidance is yet to be implemented statewide in India. Even in ideal settings, we wanted to understand the feasibility of implementing and acting upon the findings of severity assessment using 16 indicators. Specifically, how many would be assessed and eligible for inpatient care, followed by early deaths (within two months) among those with and without severe illness.

Methods: In this cross-sectional study, for a period of one month (June 5 and July 5, 2022), we intended to comprehensively assess all adults (≥15 y) with TB (drug-sensitive) notified from eight public teaching hospitals (tertiary care facilities) in Tamil Nadu (0.1 million TB notifications per year), a southern Indian state. We also followed them up for early deaths.

Results: Among 557 notified, 399 (71.6 %) were comprehensively assessed. Among 399, a total of 246 (61.7 %) were eligible for inpatient care. Early deaths were reported in 23 (9.3 %) of those with severe illness (n = 246), when compared to one (0.7 %) in those without (n = 153).

Conclusion: Even in facilities with clinical and diagnostic capacity, only seven in ten adults were comprehensively assessed. Nearly all the early TB deaths happened among those with severe illness. In future (especially in resource constrained settings), until clinical and diagnostic capacity improves up to the primary level, and bed and staff availability increase to admit every six in ten TB patients at diagnosis, implementing and acting upon the findings of severity assessment using 16 indicators appears non-feasible.