SHARE – Society for Health Allied Research Education

TB prevalence and interventions for reducing TB and LTBI in high-risk Key

Population of Rickshaw Drivers and Construction Workers

TB prevalence and interventions for reducing TB and LTBI in high-risk key population of rickshaw drivers and construction workers” is a SHARE INDIA project funded by Indian Council of Medical Research (ICMR). The project supports National TB Elimination Program’s (NTEP) existing guidelines to treat TB in high risk groups (socially vulnerable and clinically high risk) and to reach the unreachable for the screening of TB among rickshaw drivers and construction workers.

What we deliver

Key affected population especially rickshaw drivers and construction workers are disadvantaged group of people in comparison to the general population primarily on the account of their reduced access to medical services and the underlying detriments of health. Cycle rickshaw drivers do strenuous pedalling as compared to e-rickshaw drivers although both groups are exposed to environmental pollutants and workers at construction sites are exposed to silica containing dust at high and low pollution levels but may or may not be engaged in strenuous activities. This makes the rickshaw drivers and construction workers vulnerable, underserved and they are at risk of TB infection and illness constitute a challenge for TB control.Several studies have suggested that the TB burden in these groups is higher than the general population. Keeping this in mind SHARE INDIA enhanced outreach activities to detect TBand LTBI in these vulnerable groups.

We used a customised and cost efficient approach to conduct prevalence surveys that could inform the extend of gaps and unmet needs of these group. Through this project we intended to:

Reduce barriers for early TB case detection, including delay in presentation to NTEP facility, identification of rickshaw drivers’/ construction workers as presumptive TB and LTBI cases, timely diagnosis and subsequent treatment/TB preventative therapy among this high risk population
Pursue advocacy, communication, social mobilization and address the needs of high risk key population with TB
Foster community participation in TB care, prevention and health promotion
Promote the use of International standards for TB care among this high risk key population

Objectives

A project initiated the activity with the objective of detecting TB and LTBI as early as possible in the key population i.e. Rickshaw drivers and Construction workers to initiate the treatment/TB preventative therapy promptly.

The project’s objectives are as under:

Primary Objective:

Identifying the prevalence of TB and LTBI in rickshaw drivers and workers at construction sites exposed to silica containing dust at high and low pollution levels compared with those that are engaged in strenuous activities within these groups

Secondary Objectives:

1. Preventing development of active TB in infected individuals by chemoprophylaxis

2. Test and treat school children ferried to and from school by TB affected rickshaw drivers and the household contacts of children with active TB

Project Partners

State TB Office, Delhi and Karnataka-National TB Elimination Program
State TB Training & Demonstration Centre, Delhi and Karnataka-National TB Elimination Program
Indian CST, Bangalore, Karnataka
Ramaiah Medical College, Bangalore, Karnataka

Sensitization & Mapping Sites

Meeting with Rickshaw Drivers Owners/ Thekedars and Construction workers

One to one “pre-sensitization meetings were conducted at project sites with Fleet operators for e- rickshaws, rickshaw owners / thekedar and construction contractor or site engineer before the initiation of the study. These stakeholders were sensitized on the ICMR funded project, TB and LTBI, Goals of TB Elimination by 2025, planned survey to find TB and LTBI cases and data collection on tablets including cough sound, outcomes and expectation from the study.

Mapping of Rickshaw stands and Construction sites

The project study covered 5 zones of MCD for Delhi site and for Bangalore site study zones were selected based on Air Quality Index values from the 12 ambient air quality monitored sites from the Karnataka State Pollution Control Board (KSPCB)

Delhi-Zones (Rickshaw Drivers)

• Karol Bagh

• Central Delhi

• Sadar/ Paharganj

• Civil Lines

• East Delhi

Bangalore-Zones (Construction Workers)

• Bapujinagar

• BTM Layout

• Hombegowda Nagar

• Jayanagar 5th block

• Vijayanagar

• Chansandra

• City Railway Station

To study the prevalence of TB and LTBI in high-risk key population for Delhi and Bangalore zone, google maps were created and marked with location of study sites and presence of rickshaw stands and construction sites. The key work sites of cycle and e-rickshaw drivers like metro station, market, schools were mapped and routes of operation of rickshaw drivers have been mapped with key charging points for e- rickshaws.

Training of Project staff

Training of project staff to recognize the increased risk of TB and screening in these high riskpopulation for signs and symptoms suggestive of TB and LTBI and give special attention to syndromic disease surveillance.

Enrolment of Rickshaw drivers and construction workers

Enrolment of Rickshaw drivers and construction workers

The project team engaged in one-to-one discussionsand group meetings with Rickshaw drivers and construction workers and they were provided TB education material in local language about importance of screening and testing for TB and LTBI. The rickshaw drivers and construction workers were explained to provide sputum sample if required for TB testing at NTEP facility in case they have signs and symptoms suggestive of TB or TST and X-ray diagnosis for LTBI diagnosis at NTEP facilities. All participants were well informed and consent was taken before enrolment.

Conducted field surveys

Conducted field surveys as per developed questionnaires

The project team equipped with pre-loaded questionnaires on tablets and printed consent forms and approached rickshaw drivers and construction workers. Survey questionnaires were designed in a manner to collect information based on all detriments of health including social determinants. The information that was collected was uploaded on the cloud in real time through a GPMS Tranportal supported by Indian CST–our project partner.

Linkage of TB affected participants

Linkage of TB affected participants to NTEP facilities

All study participants are linked to nearest NTEP facilities which will ensure confirmation of diagnosis thereby ensuring early detection of TB. The diagnosis of participant is done as per NTEP algorithm utilizing NTEP TB diagnostics available at the linked NTEP facilities.

Linkage of TB affected participants to Social Welfare schemes

The project is also linking all eligible TB affected participants to social welfare schemes including nutritional support as per NTEP guidelines.

Strengthening NTEP & Project Staff

Strengthening NTEP & Project staff for Detect – Treat – Prevent – Build approach with TST Training

The NTEP and the project staff is trained for Tuberculin Skin Test (TST) administration and Reading for LTBI at New Delhi Tuberculosis Centre (NDTB), New Delhi and STDC Karnataka. The training not only helps in building the capacity for TB elimination programs but also opens a new way for understanding LTBI burden that can contribute to new TB cases.

List of Documents prepared

Project specific survey questionnaires were prepared by SHARE INDIA in discussion with project investigators and project mentors. Subsequent to this, Indian CST digitized the survey questionnaires to collect data from surveys at Delhi and Karnataka sites.
Consent form for the participants for voluntary participation for the study.
Manpower roaster for field activities / survey for the project sites.
Participant Log Sheet / Record for all the diagnosis recommended by the NTEP facility.
Education material on TB.

List of Standard Operating Procedures developed

Two projects specific SOPs were prepared in consultation with all key project stakeholders; one each for Delhi and Karnataka
SOP on field activities
SOP on TST administration and Reading

Key Achievements

The Delhi Police joined hands with SHARE INDIA and supported survey teams by arranging camps in Rickshaw stands and garages and also helped in increasing awareness among rickshaw drivers for TB and LTBI testing. The Delhi Police played a key multiplier in our efforts during the field activities.
Leveraging on technology has enabled the participants to link them from rickshaw stands to the nearest NTEP facility. Social media platform such as WhatsApp messenger has been used to create groups for key population teams which enable the real time registration and prompt diagnosis on the basis of screening of the participant done by survey team. This initiative helped survey team to enrol all symptomatic participants hassle free to NTEP facilities so that finding missing Millions TB cases can be done.
Using TB as an entry point, this intervention has also increased the participants’ confidence to uptake other health services available at the nearest NTEP / Government facilities and diagnosis of diabetes, COPD and other health ailments (orthopaedic, general weakness etc.)

Way forward

As COVID-19 pandemic has hampered immunity at a large scale in the Indian communities there has been a large risk of acquiring the TB infection /breakdown of latent TB infection for immune compromised individuals especially among high risk key population of rickshaw drivers and construction workers.
During our study we found that 99% participants are migrant workers who work as Rickshaw puller/ driver and Construction workers in Metro cities such as Delhi and Bangalore. As TB is a silent epidemic, this would really help in formulating a policy on test and treat for TB and LTBI in Key population groups.
The dense growing urban environment facilitates, the transmission of TB especially among socially and clinically vulnerable group (Rickshaw drivers & Construction workers) and decades of unrestrained transmission has left hundreds of millions of this vulnerable group of people with Latent TB infection and almost the whole population needs to be reached every year for symptom screening and testing of over one crore symptomatic patients needed in the next three and a half years, so that the complete coverage for early diagnosis can be made to cut the chain of transmission. This survey will not merely address this issue but also help government on deciding policies for curtailing TB by 2025.
Sensitization and motivation of different service providers and stakeholders is the need of hour either through CMEs, personal communication, peer pressure or professional associations which need to be reformed.

SOCIETY FOR HEALTH ALLIED RESEARCH & EDUCATION INDIA (SHARE INDIA)

Prevalence of TB and LTBI in Key Population