Tamil Nadu's TB care initiative records at least 38% reduction in deaths

NEW DELHI: Tamil Nadu recorded at least a 38 per cent reduction in its tuberculosis (TB) death rate across quarterly diagnosis cohorts between July 2024 and December 2025 under a statewide initiative that identifies severely ill patients at diagnosis and prioritises them for hospitalisation, according to a study.

As part of the study done by ICMR National Institute of Epidemiology (NIE) and Tamil Nadu State TB Cell, the reduction was observed under the Tamil Nadu Kasanoi Erappila Thittam (TNKET), a state-specific programme aimed at making the state TB-death-free, the researchers said.

The monitoring and evaluation framework used under TNKET has been published as a practice paper in BMJ Global Health on Saturday, November 7.

According to BMJ Global Health author guidelines, "practice papers give authors the opportunity to describe their experience of evaluation of field experience specific to a community, sub-national or national setting" that will guide high TB burden Indian states and countries in implementing and monitoring differentiated TB care (involving triaging for severe illness at diagnosis) to reduce TB deaths.

The initiative, described by the researchers as India's first statewide and state-specific differentiated TB care programme, was implemented from April 2022 to December 2025 and covered all adults aged 15 years and above diagnosed with drug-sensitive TB in the state. Tamil Nadu diagnoses approximately 60,000 adults with drug-sensitive TB annually in public health facilities.

Under TNKET, patients are assessed at the time of diagnosis using five clinical parameters -- body mass index (BMI), pedal oedema (swelling of the feet and ankles), respiratory rate, oxygen saturation and their ability to stand without support.

Patients identified as severely ill, including those with very severe undernutrition, respiratory insufficiency or poor physical performance, are prioritised for referral to hospitals and inpatient care.

The ICMR-NIE and Tamil Nadu State TB Cell paper presented a monitoring and evaluation framework to assess the programme's performance. It covers preparatory and input indicators, the patient-care cascade from initial triaging to hospital admission, admission-related outputs, quality of triaging and inpatient care, and the TB death rate as the eventual outcome.

The study found that it took two years of statewide implementation to minimise losses along the patient-care cascade while also improving the quality of triaging and inpatient care.

These improvements translated into sustained statewide TB death rate reduction across all quarterly diagnosis cohorts starting July 2024, the researchers said.

Against a reported death rate of 6.3 per cent at the start of TNKET, the reduction ranged from 38 per cent (6.3 per cent to 3.9 per cent) among those diagnosed in October-December 2024 to 56 per cent (6.3 per cent to 2.8 per cent) among those diagnosed in July-September 2025.

The findings from routine monitoring and evaluation have been confirmed after adjusting for potential effects of confounders and time through an individual-level and interrupted time series analysis.

However, the Tamil Nadu experience also identified significant gaps in follow-up after hospital discharge.

The systematic tracking of patients identified as severely ill at diagnosis at the two-month mark did not exceed 35 per cent in any quarter, indicating the difficulties in ensuring sustained post-discharge monitoring through routine public health systems, even in a state like Tamil Nadu that has one of the strongest public health systems in India.

The researchers said the TNKET monitoring and evaluation framework could be replicated in other high TB-burden states and countries, particularly those operating under resource-constrained healthcare settings.

The researchers identified three important lessons from the Tamil Nadu experience.

First, differentiated TB care requires sustained implementation over time to translate into a reduction in the statewide TB death rate, rather than expecting immediate results after its launch.

Second, triaging should be done at diagnosis based on simple clinical parameters that are easy to measure in routine healthcare settings, allowing health workers to identify high-risk patients without depending on sophisticated investigations.

Third, repeated follow-up assessments after hospital discharge may not be feasible to implement at scale and should not be made mandatory in resource-constrained health program settings, the researchers said.

The findings underline the importance of designing public health interventions around the operational capacities of healthcare systems, particularly in countries with a high burden of TB.

The TNKET initiative seeks to address the risk of high early mortality among TB patients by identifying those who are severely ill at the time of diagnosis and ensuring that they receive timely referral and inpatient care.

The findings from routine monitoring and evaluation suggest that TNKET reduced not only early TB deaths (referred to as deaths within two months of diagnosis) but also overall TB deaths (referred to as deaths within one year of diagnosis).

The five-parameter assessment is intended to help healthcare workers identify patients who require urgent attention, while the monitoring and evaluation framework tracks whether those identified actually reach hospitals and receive appropriate care.

Earlier, an ICMR-NIE-developed mortality prediction calculator, based on the same five clinical parameters, was reported to help identify adults with TB at higher risk of death.

"Now at diagnosis, using simple and easy-to-measure clinical parameters, we know who are more likely to die and take immediate action," the study said.

The researchers said the Tamil Nadu experience demonstrated that reducing TB deaths depended not merely on identifying high-risk patients but also on strengthening the entire chain of care, from diagnosis and triaging to hospital admission and quality inpatient treatment.

They said the experience could provide a practical model for other high TB-burden regions seeking to reduce deaths through differentiated care approaches adapted to their available healthcare resources.