Table 2

Potential challenges and solutions to tuberculosis preventive treatment implementation, India

Major challengesPotential solutions
Political will and leadershipUnprecedented attention to the urgent global response to end tuberculosis. United Nations General Assembly meeting will take place in September, 2018*
Prime Minister Narendra Modi pledges to eliminate TB by 2025 in India (10 years in advance of global targets)†
Leveraging the international community to negotiate ‘patient-friendly’ pricing for newer drugs, especially for low income families suffering from TB
Ability to rule-out TB diseaseAdopting international screening algorithms to the local context (with and without chest radiographs)‡
Availability and use of Xpert MTB/RIF testing (Cepheid, Sunnyvale, California, USA)§
Availability and use of chest radiography. India has a robust health system; however, access to care is asymmetrical between rural and urban populations. The forthcoming ‘Ayushman Bharat Yojana’ (National Health Protection Mission)¶ holds promise to increase access to diagnostic services
Acceptance, adherence and completion of tuberculosis preventive treatmentAvailability and use of shorter, ‘patient-friendly’, TPT regimens. This includes proper government approval and procurement of rifapentine at price affordable to low-income persons
Patient-centric motivational counselling, mHealth solutions (eg, SMS reminders), social support and networking
Treatment-positive messaging and training of all partners supporting TPT implementation. Utilisation of ECHO platform for building a community of practice with regards to TPT**
Programmatic reporting of TPT activities, including patient outcomes
Monitoring treatment-related adverse eventsAdopting treatment screening algorithms for the selection of treatment; screening for appropriate TPT exclusion criteria
Patient and provider education on TPT adverse events
Programmatic reporting of TPT activities, including patient outcomes
Availability and use of the national target spontaneous reporting pharmacovigilance system††
Procurement and supply chain managementAccurately estimating the burden of latent infection at subnational levels
National-level and state-level coordination and forecasting
Utilisation of Global Drug Facility technical assistance and procurement and supply management tools‡‡
Implementation researchEstablishing a reliable, cost-effective test to rapidly detect tuberculosis infection, and identify those most likely to benefit from preventive treatment in the India context
Establishing TPT regimens that are most effective in India, with careful consideration of posology and duration for children and adults
Designing of effective, targeted, TPT interventions tailored to local epidemiology and programme performance
Assessing treatment cascades among persons with a high likelihood of progressing to active disease
Understanding transmission dynamics in a population with a high likelihood of repeated exposures
  • *United Nations, General Assembly. Draft resolution submitted by the President of the General Assembly. UN 72 Session.103

  • †Narendra Modi address at the End TB Summit. Delivered on March 13, 2018.104

  • ‡Systematic Screening for Active Tuberculosis: Principles and Recommendations. Geneva: World Health Organization; 2013.105

  • §Central TB Division. TB India 2017: Revised national tuberculosis control program annual status report. New Delhi: Government of India; 2018.90

  • ¶Government of India. Ayushman Bharat.106

  • **Struminger B, Arora S, Zalud-Cerrato S, Lowrance D, Ellerbrock T. Building virtual communities of practice for health. Lancet. 2017;390(10095):632–4.107

  • ††Thota P, Thota A, Medhi B, et al . Drug safety alerts of pharmacovigilance programme of India: A scope for targeted spontaneous reporting in India. Perspect Clin Res. 2018 Jan–Mar;9(1):51–5.108

  • ‡‡StopTB Partnership. Procurement and Supply Management (PSM) Tools.109

  • ECHO , Extension of Community Healthcare Outcomes; SMS, Short Message Service; TPT, Tuberculosis Preventive Treatment.