Screening for Severe Illness at Diagnosis Has the Potential to Prevent Early TB Deaths: Programmatic Experience From Karnataka, India

Abstract

Due to the coronavirus disease (COVID-19) pandemic and its associated response, TB deaths increased for the first time in a decade. In any potentially fatal illness, an assessment of severity is essential. This is not systematically done for adults with TB, mostly due to a lack of policy and/or limited availability of diagnostic and clinical capacity. We developed a screening tool using simple and easily measurable indicators that can be used by paramedical TB program staff to quickly identify people with severe illness. During October-November 2020 in Karnataka, India, the paramedical program staff from 16 districts screened people with TB (aged ≥15 years) notified by public facilities for "high risk of severe illness," which was defined as the presence of any of the following indicators: (1) body mass index (BMI) ≤14.0 kg/m²; (2) BMI ≤16.0 kg/m² with bilateral leg swelling; (3) respiratory rate >24/minute; (4) oxygen saturation <94%; (5) inability to stand without support. In this cohort study, we determined the incidence of program-recorded early deaths (within 2 months) and its association with high risk of severe illness. Of 3,010 people with TB, 1,529 (50.8%) were screened at diagnosis/notification, of whom 537 (35.1%) had a high risk of severe illness. There were 195 (6.5%, 95% CI=5.7, 7.4) early deaths: 59 (30.2%) within a week and 100 (51.3%) within 2 weeks of treatment initiation. The incidence of early deaths was significantly higher among those with high risk of severe illness (8.9%) at diagnosis compared to those without (3.8%) [adjusted relative risk: 2.36 (95% confidence interval=1.57, 3.55)]. To conclude, early deaths were especially high during the first 2 weeks and strongly associated with a high risk of severe illness at diagnosis/notification. Screening for severe illness should be explored as a potential strategy to end TB deaths.

FIGURE 1

Kaplan-Meier Failure Curve Depicting the Cumulative Proportion of Early Deaths (Within 2 Months) Over Time Among People With TB^a Notified by Public Health Facilities in 16 Districts in Karnataka, India From October 15 to November 30, 2020, N=3,010 ^a Age ≥15 years, all forms, without known drug-resistant disease at diagnosis.

FIGURE 2

Kaplan-Meier Failure Curves Depicting the Cumulative Proportion of Early Deaths (Within 2 Months) Over Time, Stratified by High Risk of Severe Illness Among People With TB^a Notified by Public Health Facilities in 16 Districts in Karnataka, India From October 15 to November 30, 2020, N=3,010 Abbreviation: RR, respiratory rate. Note: Very severe undernutrition is body mass index <14 kg/m² or 14–15.9 with bilateral leg swelling. Log rank P value <0.05 for all. ^a Age ≥15 years, all forms, without known drug-resistant disease at diagnosis.