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India will soon bridge the gap between the number of TB cases expected and those detected

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Operation ASHA, a non-profit, has taken TB treatment to the doorsteps of 10 million individuals living in disadvantaged areas across nine countries. Sandeep Ahuja, Co-founder and CEO, Operation ASHA, reveals more about its strategies to curb the rising incidence of TB in India, the treatment trends and long-term goals in interaction with Sanjiv Das

India is witnessing a rising incidence of TB. In 2019, 24.04 lakh patients were notified in the records of the MoH&FW, registering an increase of 11 per cent. What role is Operation Asha playing to tackle this surge?

Operation ASHA has been successful in taking tuberculosis treatment to the doorsteps of 10 million individuals living in disadvantaged areas across nine countries. This has been a significant achievement for us and, we remain committed to making TB treatment fully affordable and accessible to millions of people across the globe.

Tuberculosis has been around since millennia. Even in countries where it had been nearly eradicated, it is coming back with a vengeance in deadly drug-resistant forms. There is no doubt that it is curable, but it has emerged as the biggest infectious disease killer, even beyond HIV, a serious threat to human lives. In the past two centuries, more than two billion people have lost their lives – double the number of deaths caused by AIDS, smallpox, cholera, and Spanish flu put together. The biggest challenge here is the lack of technical expertise in identifying, tracking and providing long-term treatment to TB patients.

Therefore, at Operation ASHA, we ensure that tuberculosis treatment is available and accessible to all disadvantaged communities even in the remotest parts of the country. Our model is a scalable, replicable, low cost, community-driven, patient-centric and provides solutions for long term care. We rely on technology which helps us identify, track and provide last mile uninterrupted healthcare services. As a result, we have 100 per cent detection rate and treatment success rate of around 87 per cent. Also, technology helps us in maintaining electronic record and there are no chances of human error or inaccuracy.

What has been the impact of COVID-19 on TB patients? Did you reach out to your patients during the lockdown period? How are they coping? 

COVID and TB both affect the lungs. So, TB patients, whose lungs are already compromised, are more prone to COVID than others. This puts massive responsibility on Operation ASHA to ensure that its patients stay safe and continue TB treatment regularly and be cured of TB. At Operation ASHA, we have taken all necessary steps to ensure that the medicines available to the patients along with regular monitoring. We reach out to every patient within our radar telephonically, every day. We have also provided funds for food rations and rent etc., to those in need so they do not migrate to villages which will lead to an interruption in TB treatment. We are happy that practically all our patients are continuing their TB treatment. Also, we are making further changes in our tablet/mobile application from fingerprint and retina sensor to face recognition to ensure social distancing, while providing critical support even during the pandemic.

There are reports that patients who have been vaccinated for TB are less prone to coronavirus. Tell us more about how vaccination is playing a positive role in keeping the virus at bay? There are also report on mandatory vaccination? Do you think mandatory vaccination as a policy is a must for TB? 

Yes, there have been unverified reports that suggested that patients who are vaccinated for TB are less prone to coronavirus. However, the World Health Organization (WHO) refuted the studies suggesting that the Bacille Calmette-Guerin (BCG) vaccine may be effective in preventing the Coronavirus.  Further, there is no evidence that the BGC vaccine protects people against infection with COVID-19 virus.

Countries with mandatory policies to vaccinate against tuberculosis have reported fewer coronavirus deaths than countries that do not have these policies. In a few countries, BCG vaccine is provided to frontline workers and elderly people to see whether it can provide some kind of protection from the novel Coronavirus. However, we are yet to have any confirmation on this.

Missing patients have remained the bone of contention for the National TB Elimination Programme. What is the reason behind this disturbing trend?

India is on its path to bridge the gap between the number of tuberculosis cases estimated and those detected, and it could soon find all its missing million TB patients. Government figures show that the country is worst affected by the deadly bacterial infection, has added around six lakh tuberculosis patients to its data since 2016. In 2019, the detection of TB cases in India reached its highest ever at 23.5 lakh patients, against an estimated 26.9 lakh cases. These numbers do not suggest an increase in incidence, but the success of India’s drive to eliminate tuberculosis. Though, the medical journal The Lancet said that over a million TB cases may be missing from India’s official statistics.

The biggest reason for this kind of trend is the lack of last-mile connectivity in healthcare services. We do have free treatment for tuberculosis but the average cost for per person for commuting to hospitals and labs is more than $500. This is one of the major reasons for the patients to withdraw themselves from long-term treatment since the majority of patients are daily wage earners.

Operation ASHA plays an important role in reaching out to the disadvantaged communities with the help of community health workers and volunteers. Community health workers are familiar with local customs and languages which help us in communicating and educating the masses about the disease. This also helps break the stigma and myths around TB. Additionally, the patient is tracked with our electronic applications coupled with GPS, fingerprint, and retina scanner, ensuring transparency in the whole process.

How does Operation Asha ensure that all TB patients complete the full treatment process?

Our model works on empowering communities. The first point of contact with any patient is a local community health worker who is able to educate the people and eliminate the myths and stigma associated with tuberculosis. These CHWs are semi-literates who are given two-weeks training by our organization on tuberculosis, technology, and nutrition. These volunteers and CHWs work on incentives. This way our model becomes very cost-effective.

Secondly, technology helps us in ensuring that every patient completes the full treatment process. To encourage transparency, we have fingerprint and retina sensors which ensure that the medicines and health care reach the concerned person.

Is there any improvement in TB diagnostics trend in India?

TB diagnostics in India has improved immensely in the last decade. Innovations in diagnostic technologies have reduced costs and helped improve TB care and treatment.

To ensure that Operation ASHA detects all TB patients in an area, we employ our technological tool, e-Detection. e-Detection is a screening tool based on the symptoms of a disease. It guides CHWs to ask key questions. Thus, it is easy for CHWs to find people with symptoms of TB, and then send them for testing. The application directs CHWs to give proper advice. It follows a step by step process for detection. It improves detection, improves the productivity of CHWs and brings down costs. Operation ASHA’s detection rate, mentioned by a Government Study Team is ‘240 TB patients per 100,000 population’, which is 2.4 times the average detection in the country at that time, and these results have been achieved because of the e-Detection software.

Operation ASHA is dedicated to providing tuberculosis treatment to the remotest villages in India with the help of technology. What type of technology are you talking about? Which remote locations have you set up your base?

Operation ASHA trains local CHWs rigorously and empowers them at every step with various technology applications. These applications have been developed in collaboration with Central and state governments, target communities, CHWs, beneficiaries, technology experts and psychologists.

Currently, Operation ASHA makes use of mobile/ tablet applications to track and support TB treatment and ensure that the treatment is carried out in a seamless manner. The applications help our community health workers as well as bring transparency to the whole process. We are extensively using data analytics for high-quality visualisation of data to improve results and outcomes. Operation ASHA has developed a mobile app using Tableau software to help significantly increase detections in the field. We are also using Tableau technology to analyse data to improve the efficiency of our TB program. Some of our applications are mentioned below:

e-Compliance: This is a biometric tracking technology. Whenever a patient takes a dose or visits a centre or meets the CHW, both have to give their fingerprints or iris scans. This registers their presence/ meeting, time and GPS location. There is real-time information if a patient has missed a dose so that the CHW can immediately follow up and visit the patient and give the medicine. This ensures that every dose is taken, thus ‘turning the tap off’ on Drug-Resistant TB.

e-Detection: e-Detection is a screening tool based on the symptoms of a disease. The algorithm is loaded onto the tablet. It guides CHWs to ask key questions to find people with symptoms of TB, and then send them for testing. The application directs CHWs to give proper advice. It follows a step by step process for detection. The questionnaire can be modified to screen for any disease apart from TB. We have used this application for TB, haemophilia, diabetes and mental health issues.

e-Counselling: This consists of a series of animated counselling videos covering all aspects of TB. This ensures high-quality comprehensive counselling of patients and their families before starting treatment. The software has been built in such a way that CHWs cannot fast forward the videos; every video must be played and seen. The algorithm requires fingerprints of the patients and CHW at regular intervals. Treatment cannot be started without providing counselling.

e-Alert: Here a computer application mimics a manual lab register. Whenever there is a positive report to the TB test which has been entered in the computer, the eAlert app sends test results via a text message to the CHW, patient and physician.

Electronic Medical Record System (EMR): All applications (e-Compliance, e-Detection, e-Alert, etc.) are loaded on tablets which have Internet or SMS connectivity. All data is uploaded on a server, which collates it into various reports. Data is regularly analysed by supervisors within Operation ASHA.

Compliance Suite: e-Compliance suite enables various applications to speak to each other automatically, without human intervention. For example, the moment a lab technician enters a positive result in e-Alert, the resulting text message also goes to e-Detection, which interprets and immediately directs the CHW to recommend the patient to take the next step in the algorithm.

e-FAQ: FAQs are loaded onto the tablets as a searchable database. This eliminates the need for CHWs to depend on memory or sort through a sheaf of papers.

e-Survey: This tool is used to carry out surveys. It records The GPS location and time of every survey. So, a surveyor cannot ‘fill-up’ surveys sitting at one location. The application sends the data to the back-end, where it is collated automatically for use by researchers.

Mumbai has the highest incidence of TB patients in the country. What role is Operation Asha playing in this regard to prevent the spread?

In Maharashtra, we are working in Bhiwandi and Vasai. They are among the most congested places in the state and have been reporting an alarming rise in cases of drug-resistant tuberculosis. Operation ASHA conducts door-to-door visits in these areas to detect and treat TB. Additionally, we are educating communities and raising awareness about the disease in these communities.

A major hindrance in the detection of TB patients is poorly established specimen collection and suboptimal transportation systems. How can this challenge be overcome?

To ensure an effective specimen collection, it is essential to involve people who live in the same community as the patients and aid them with technology. Since patients have to either travel to the hospital or the health workers have to visit different places to collect the specimen, tracking becomes difficult.

Hence, we rely on health workers from one community and give them the means to find cases of TB within the community. The CHWs are sometimes former TB patients. They are provided with a tablet wherein they can feed all the procured information and report with the specimens to their area head.

You have your operations in Cambodia too. How has the country fared when it comes to TB prevention?

In Cambodia, Operation ASHA works closely with the National Tuberculosis Program, operating in 14 Operational Districts across six provinces and working with a total of 164 Health Centers. We serve 21 per cent of the country’s TB patients. Since starting operations in December 2010, we have enrolled more than 11,500 patients for tuberculosis treatment.

With tailored programmes for rural areas, Operation ASHA has been able to improve early detection of TB and has been effective in narrowing the gap of missing cases in Cambodia. Thus, it has supported the Cambodian TB Program, which is the best performing TB program globally.

What are the long-term plans of Operation Asha?

Operation ASHA works to eradicate tuberculosis across developing countries. Our vision is of a TB Free world.

Due to the pandemic, we have not been able to work on active case finding. We aim to resume that with updated technology. We are also bringing in face recognition technology to replace our fingerprint sensors to track the progress of current patients. This will be a breakthrough in TB care and treatment.

What about the funding for all your activities?

Our financial model is simple. The donors should pay for developing innovations, running pilots, research and upgrading the model. They include large foundations, multilateral organisations like the Global Fund and World Bank, bilateral donors like DFID and USAID, and foundations as well as individuals from India, US US, Europe, Hong Kong, Australia and other parts of the world.

But continuous long-term operation should be funded by the government. So, in Cambodia, most of our funding is provided by the Cambodian Government. In India also, we work in a similar way with funding from the National TB Elimination Program. This is likely to go up substantially with the focus the Prime Minister has brought on TB. We want to use such opportunities to make the world TB free, starting from India.

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