Implementing timeliness metrics for household contact tracing and TB preventive treatment through TB champions in the public sector, India: an explanatory mixed-methods study

Abstract

Objectives: A '7-1-7' timeliness metric, developed for hastening the response to infectious disease outbreaks/pandemics, was adapted to improve screening and managing household contacts (HHCs) of pulmonary tuberculosis (TB) patients. The feasibility, enablers, challenges and utility of implementing this modified metric through TB Champions (TB survivors) for HHC management were assessed.

Design: This was an explanatory mixed-methods study with a cohort design (quantitative) followed by a descriptive design with focus group discussions (qualitative).

Setting: The study was conducted within routine programmatic settings in public health facilities in six districts from three states of India.

Participants: In total, 595 drug-susceptible index pulmonary TB patients registered for treatment in the selected health facilities, and their listed 2108 HHCs were included in the study between December 2022 and August 2023. All 17 TB Champions involved in implementation participated in the focus group discussions.

Primary outcome measures: The primary outcome measures were the percentage of eligible participants receiving the desired service within the '7-1-7' timeliness metric and challenges in achieving the timeliness metrics.

Results: In 89% of 595 index patients, their HHCs were line-listed within 7 days of initiating anti-TB treatment ('First-7'). In 90% of 2108 HHCs, screening outcomes were ascertained within 1 day of line-listing ('Next-1'). In 42% of 2073 HHCs eligible for further evaluation, anti-TB treatment, TB preventive treatment (TPT) or a decision to not receive medication were made within 7 days of screening ('Second-7'). Barriers to TPT uptake included lack of money and daily wage losses for travelling to clinics, reluctance of asymptomatic contacts to take medication and fear of adverse events. TB Champions felt timeliness metrics improved performance in the systematic and timely management of HHCs.

Conclusions: TB Champions found '7-1-7' timeliness metrics were feasible and useful, and national TB programmes should consider their operationalisation.

Keywords: Family; International health services; Public health; Tuberculosis.

Figure 1. Overview of implementation of ‘7-1-7’ among household contacts of index pulmonary TB patients diagnosed in public health facilities in three states of India: December 2022 to August 2023. *Percentage calculated with total number of index patients registered as the denominator; #Percentage calculated with total number of household contacts listed as denominator; $Percentage calculated with household contacts for whom investigation/action data were available as the denominator. HHCs, household contacts; TB, tuberculosis; TPT, TB preventive treatment.

Figure 2. Facilitators (+) and barriers (-) at the various stages of implementing ‘7-1-7’ for index patients with PTB and their household contacts: Public health facilities in three states of India, December 2022 to August 2023. HHCs, household contacts; MO, medical officer; NTEP, National TB Elimination Programme; PTB, pulmonary tuberculosis; TBCs, tuberculosis champions; TPT, tuberculosis preventive treatment.

Figure 3. Daily cumulative achievement of outcomes for line-listing of household contacts of pulmonary TB patients, ascertainment of household contact screening outcomes and decisions/actions on anti-TB treatment, TPT or no drugs according to ‘7-1-7’ or ‘3-5-7’ time metrics: Public health facilities in three states of India, December 2022 to August 2023. ATT, anti-TB treatment; HHC, household contacts; TB, tuberculosis; TPT, tuberculosis preventive treatment. Note: a, line-listing of household contacts; b, screening of line-listed household contacts; c, decision or action on starting anti-TB treatment or TPT or no drugs in three study states; d, decision or action on starting anti-TB treatment or TPT or no drugs in two study states (Chhattisgarh and Odisha); in a and b, green indicates the ‘3-5-7’ timeliness metric proposed by the TB champions; peach indicates the ‘7-1-7’ timeliness metric; in c and d, the green with 42% and 66% achievement on day 7, respectively, applies to both the ‘3-5-7’ and ‘7-1-7’ timeliness metrics.