Introduction
TB is considered a social disease and has a devastating psychosocial and economic effect on affected people. It is a disease of international concern and a public health emergency. The Hon. Prime Minister of India has expressed a vison to eliminate TB from India by 2025, 5 years ahead of the United Nations Sustainable Development Goals of 2030. To fulfil PM’s auspicious desire, in 2017 Central TB Division of India launched the National Strategic Plan 2017-2025, achieving a goal of "TB free India”, with strategies under the broad themes of "Prevent, Detect, Treat and Build pillars.1 To achieve this target in short span of time, it is required to explore new innovative approaches for early diagnosis.
It is established that Diabetes increases the risk of Tuberculosis2 and negatively affects the treatment outcomes.3 It also has a negative impact on immune response of TB patients4 and mortality.5 In 2019, WHO has prepared a collaborative framework for care and control of TB in Diabetes particularly for high burden diabetic countries. After China, India stands second for the prevalence of Diabetes.6, 7 Mumbai is a major metropolitan city in India and is densely populated. It showcases huge burden of Diabetes as well as TB. Mumbai has reported more 60000 cases of TB in 2021, making the burden of TB more than 400 cases per lakh.8
Brihanmumbai Electric Supply and Transport Undertaking (BEST) is one of the largest public sector companies of India, serving people of Mumbai city since 1874. It provides safe, affordable, and efficient bus services to more than 3 million commuters on daily basis and provides un-interrupted power supply to more than 1 million consumers. BEST has deployed a team of more than 30,000 employees, majority of whom are working on field with direct contact and exposure from people, putting them at additional risks for infectious diseases. About 1400 employees of BEST are diabetic, aggravating the risk of developing active TB disease further.
To mitigate the impact of TB on employees, BEST has started “Standard of TB Care”9 initiative since 2011 and has exhibited rigorous and sustainable efforts to screen and treat TB patients. The Central TB division has also established the Employer Led Model for Tuberculosis Care and Prevention in 2019 to alleviate occupational risks.10 BEST has adopted, implemented, and demonstrated Employer led Model for TB care and embraced WHOs recommendations for screening and diagnosis. This study aims to demonstrate implementation of Employer led model for TB and intensified collaborative activities for TB and Diabetes care.
Methodology
It is a descriptive study with cross-sectional design. A comprehensive intensified case finding was planned by BEST under WHO's aforesaid recommendations11 with support from Mumbai District TB Control Society of MCGM, between November 2021 to June 2022. 1400 Diabetic employees were counselled about importance of pulmonary health and regular screening of infectious diseases. They were given awareness talks of benefits of early diagnosis and treatment of TB and about National TB Elimination Program. They were made to understand the risks and benefits of tests. Out of 1400 employees, 1127 diabetic employees gave verbal consent to undergo clinical evaluation and Xray. All 1127 employees participated in the study. No sampling was done amongst the consented employees. Data was collected in predesigned pretested questionnaire. TB screening by clinical evaluation and Xary was carried at all 26 depots for the employees of BEST. Screening of TB was part of regular medical activity and was voluntary after consistent advocacy amongst employees. All employees showing abnormal lesions were further subjected to detailed clinical examination and sputum examination through NAAT. Data analysis was done using appropriate statistical software.
Result
BEST has more than 30000 employees who are given benefit of employer’s medical dispensaries spanned across Mumbai. There are around 1400 employees of BEST who are diabetic. They are eligible to seek treatment from any of the BEST dispensary. All diabetic employees were counselled about importance of pulmonary health and regular screening for infectious diseases. A total of 1127 diabetic employees volunteered for screening including clinical examination, and Xray chest PA view. There were 11(1%) diabetic employees whose Xray showed abnormality. All employees with abnormal Xray were followed up and their sputum samples was collected for CBNAAT. The employees were also clinically evaluated to rule out any other respiratory disease. Of the 11 samples 10 samples came negative for Mycobacterium TB. 1 patient came positive for Mycobacterium TB and was put on treatment immediately.
On detailed exploration of medical history, 9 of 10 diabetic employees with abnormal Xrays gave previous history of TB disease. On further evaluation they did not show any signs and symptoms of active TB disease, nor did it indicate any evidence of reactivation. These employees were counselled for diet, lifestyle, and importance of control of Diabetes. They were also instructed about signs and symptoms of TB and seeking immediate medical advice if any associated symptoms of TB or any infectious disease develops. These employees are regularly monitored at BEST dispensaries. One diabetic employee with abnormal Xray did not give any history of TB. The Xray of this employee showed lower lobe lesions in the lung along with exhibition of active signs of TB. On further careful evaluation and ruling out other differential diagnosis this patient was put of empirical Anti TB treatment and is closely followed up. (Figure 1)
A total of 2 patients were put on Anti TB treatment immediately after diagnosis and closely monitored. Sound advice on diet, lifestyle, positive thinking, and counselling was provided to these patients. They were also given benefit of sick leave of 180 days under the protocol followed by BEST. The patients demonstrated good adherence to treatment and showed significant improvement clinical and radiologically. One patient was considered cured as his microbiological confirmation was possible, while the other was considered as Completed treatment according to predefined definition of NTEP making both outcomes favourable at the end of treatment.
Discussion
BEST has a presence of medical officers in 26 depots. Most of the employees of BEST seek treatment at these dispensaries for their ailments. BEST runs all the national programs through these dispensaries. Medical facilities at BEST follow an integrated approach, where all diseases are treated under one roof. BEST has a close collaboration with Brihanmumbai Mahanagar Palika. If a patient requires further investigation or specialised treatment, they are further referred to any Brihanmumbai Mahanagar Palika Medical college or hospital. BEST has adopted many public health programs and implemented it for its employees. It has further promoted workplace interventions. It promotes well being of its employees and conduct routine screening camps for early diagnosis and treatment. Diabetes is one of the diseases which is managed at BEST dispensaries. A holistic approach is adopted by BEST for management of diabetes, which also includes prevention and treatment of infectious diseases including Tuberculosis as per National framework for joint TB-Diabetes collaborative activities.12
BEST has a total of 1400 diabetic employees, who are on treatment. WHO recommendations11 of intensified screening of these employees was planned at their respective workplaces spanned across Mumbai over the period of November 2021 to June 2022. After repeated counselling 1127 employees volunteered for Xray and further clinical evaluation for lung health. Standard of TB care in India and PMDT guidelines 2021 highlighting the integrated diagnostic and treatment algorithm13 were carefully followed for appropriate diagnosis and treatment of TB. 1127 diabetics volunteered for screening is credited to the fact that BEST has implemented workplace intervention and as employer led model successfully consistently for TB diagnosis and care.
From the entire exercise 2 diabetic employees were diagnosed as TB and immediately started on treatment. Both these employees had not sought active medical care as they did not have any symptoms of TB, thus their diagnosis was purely attributed to the screening activities of BEST.
With intensified case finding of BEST, 2 TB patients were diagnosed, who would have gone undiagnosed otherwise. As one of them was bacteriologically confirmed pulmonary, it posed to be of infectious potential.14 Early diagnosis has potential to not only help the TB patient with initiation of appropriate regimen but also restricts the spread of infection further. Both these employees demonstrated successful outcomes, and this is also attributed to early diagnosis and treatment initiation.15 Metanalysis has shown that diabetic people have a 1.5-fold increased risk of developing active TB vs. those without DM.16
In the entire exercise only 2 patients came positive for TB, among 1127 diabetics, which when roughly generalised to one lac diabetics comes to 177. The burden of TB in Mumbai in general population is 400 per lac.8 Through 2015 to 2021, BEST identified a total of 395 TB cases and has shown a 55% reduction in incident cases. However, the percentage of TB patients having Diabetes has increased from 2015 to 2021 from 28% to 51%. (Figure 2) This low number of TB patients amongst diabetes patients is credited of the rigorous, regular, and sustained medical services provided by BEST. A holistic workplace intervention with integration of TB-Diabetes collaborative activities has successfully affected the incidence of TB in diabetic BEST employees.
Conclusion
BEST model for TB-DM collaboration has demonstrated successful reduction of TB cases amongst their employees. It has also demonstrated the success of an employer led model and showcased that if organisations take up the health aspect of its employees, especially infectious disease like TB amongst its vulnerable groups, then the incidence of TB significantly reduces and improves outcome of diagnosed patients. BEST promotes other organisations to adopt the Employer led model, TB-DM collaborative activities. It also advocates undiluted implementation of Standards of TB care of India and strategies documented in National Strategic Plan 2017-2025. In the backdrop of aforesaid observation, it is suggested to screen TB among Diabetic patients with clinical examination, X-ray/ Sputum examination/ IGRA Test at regular intervals to accelerate National TB Elimination Program 2025.
Article DOI
