Missed chances in Maharashtra's TB preventive care cascade

Tuberculosis infection is a condition when a person harbours the bacilli without having signs of active disease. That hidden infection matters because household members of people with pulmonary tuberculosis are at particularly high risk: in India, approximately 70% of household contacts of people with pulmonary tuberculosis have the infection. The national tuberculosis elimination programme recommends preventive treatment to household contacts of all people with pulmonary tuberculosis after ruling out active disease. To understand how well this recommendation is working in practice, programme staff in Maharashtra analysed state data for the year 2023. Maharashtra is one of the bigger states in India with high tuberculosis burden, so its performance can highlight real challenges. The study, led by corresponding author Anuj Mundra, tracked the tuberculosis preventive treatment care cascade: from identifying household contacts to screening, determining eligibility, starting treatment, and recording outcomes. By following the cascade through the routine programme records, the team aimed to identify where people are being lost and where the system could do better at preventing tuberculosis before it becomes active disease.

The researchers examined routine programme data for all notified people with pulmonary tuberculosis in Maharashtra in 2023. Contact tracing was done for 84% of the 133,167 notified people with pulmonary tuberculosis. From those index patients, a total of 406,291 household contacts were enlisted, out of whom 386,224 (95%) were screened for symptoms of tuberculosis. Of the screened contacts, 185,502 (45%) were listed as eligible for tuberculosis preventive treatment, and 101,325 (55%) of those eligible were initiated on tuberculosis preventive treatment. Among people who started treatment, 41,480 (41%) successfully completed it. Treatment outcomes were not recorded for around 57,191 (56%) of those who started treatment. The analysis also showed that tuberculosis preventive treatment completion as well as recording of treatment outcomes was lesser for 6H regimen, among contacts of those seeking care from private sector and clinically diagnosed people with tuberculosis. These program-level numbers map the major drop-offs in the cascade.

The findings point to clear missed opportunities: many household contacts who could benefit from preventive treatment never start it, and among those who do start, outcome information is often missing. The authors call for work to identify and address the reasons for losses in the cascade, and they flag missing data as a key obstacle to understanding programme performance. Practical steps suggested in the analysis include training and using frontline workers to capture real time data using simpler tools, and improving capacity building, monitoring, and supportive supervision across the programme. The paper also recommends aligning the annual India TB report with the guidelines by including household contacts of all notified persons with pulmonary tuberculosis instead of only microbiologically positive ones, which may improve treatment outcome recording among clinically diagnosed cases. Taken together, these measures aim to strengthen delivery and tracking of tuberculosis preventive treatment so more household contacts can be protected from developing active disease.