Opportunities to prevent and manage undernutrition to amplify efforts to end TB.

The bidirectional relationship between TB and nutrition is well recognized - primary undernutrition is a risk factor for developing TB disease, while TB results in wasting. Although nutrition support is acknowledged as an important intervention in TB programmes, it is seldom afforded commensurate priority for action. TB incidence and deaths worldwide are falling too slowly to meet WHO End TB Strategy milestones, and the number of undernourished people is increasing, likely to be further exacerbated by the ongoing COVID-19 pandemic. Undernutrition needs to be more urgently and intensively addressed. This is especially true for the WHO South-East Asia Region, where the high rates of undernutrition are a key driver of the TB epidemic. The evidence base has been sufficiently robust for clear and workable programmatic guidance to be formulated on assessment, counselling and interventions for TB patients. Many high-burden countries have developed policies addressing TB and nutrition. Gaps in research to date have frustrated the development of more refined programmatic approaches related to addressing TB and malnutrition. Future research can be shaped to inform targeted, actionable policies and programmes delivering dual benefits in terms of undernutrition and TB. There are clear opportunities for policy-makers to amplify efforts to end TB by addressing undernutrition.

Urgent need to address the slow scale-up of TB preventive treatment in the WHO South-East Asia Region.

In September 2018, all countries made a commitment at the first ever United Nations High-Level Meeting (UNHLM) on TB, to provide TB preventive treatment (TPT) to at least 30 million people at high-risk of TB disease between 2018 and 2022. In the WHO South-East Asia Region (SEA Region), which accounts for 44% of the global TB burden, only 1.2 million high-risk individuals (household contacts and people living with HIV) were provided TPT (11% of the 10.8 million regional UNHLM TPT target) in 2018 and 2019. By 2020, almost all 11 countries of the SEA Region had revised their policies on TPT target groups and criteria to assess TPT eligibility, and had adopted at least one shorter TPT regimen recommended in the latest WHO TPT guidelines. The major challenges for TPT scale-up in the SEA Region are resource shortages, knowledge and service delivery/uptake gaps among providers and service recipients, and the lack of adequate quantities of rifapentine for use in shorter TPT regimens. There are several regional opportunities to address these gaps and countries of the SEA Region must make use of these opportunities to scale up TPT services rapidly to reduce the TB burden in the SEA Region.

Tuberculosis-tobacco integration in the South-East Asia Region: policy analysis and implementation framework.

SETTING: Despite overwhelming evidence for the association between tuberculosis (TB) and tobacco use, it remains neglected in the context of policy, planning and practice. There is limited evidence about the extent of integration of TB and tobacco control programmes in South-East Asia Region (SEAR) countries. OBJECTIVE: To assess the level of TB-tobacco integration in 11 SEAR countries. DESIGN: Cross-sectional study using a structured questionnaire addressed to TB and tobacco focal points at the World Health Organization Country Offices. RESULTS: Apart from India, no country in the SEAR has a formal coordination mechanism for national TB and tobacco control programmes or a system of referral for tobacco users among TB patients for treatment of tobacco dependence. There is no joint planning, joint training or joint supervision and monitoring in any country. CONCLUSION: There is poor integration between TB and tobacco control programmes in most SEAR countries. This assessment fed into the development of a regional framework for TB-tobacco integration, which outlines three strategies: 1) integrated patient-centred care and prevention; 2) joint TB tobacco actions covering policy development, planning, training and monitoring; and 3) research and innovation. Every country in the region should adopt the TB-tobacco integration framework to improve programme performance.

Involvement of private practitioners in RNTCP.

Private Practitioners are often the first point of conduct for a significant proportion of TB patients. For long-term success of RNTCP involvement of them is very essential. All Private Practitioners can support and encourage effective TB control by ensuring prompt referral, providing reassurance to patients, giving RNTCP recommended drug regimens and only starting treatment with rifampicin containing regimens if the full course of treatment can be ensured to be completed under direct observation. Schemes for Private Practitioners' involvement in RNTCP are: Scheme 1 referral services, scheme 2 provision of Directly Observed Treatment, scheme 3a designated MC--microscopy only, scheme 3b designated paid MC-microscopy and treatment, scheme 4a designated MC-microscopy only, scheme 4 b designated MC-microscopy and treatment. Nationwide Public--Private Mix (PPM) services involving 1500 private practitioners are providing RNTCP services successfully.

Medical colleges' involvement in the RNTCP: current status.

To widen access and improving the quality of TB services, involvement of medical colleges and their hospitals is paramount. The role of medical college professors in TB control as opinion leaders and role models for practising physician and as teachers imparting knowledge and skills and shaping the attitude of medical students cannot be underestimated. There is a pressing need for all medical schools to advocate DOTS and through this strategy provide the best opportunity for cure of patients. Priority activities to be undertaken by medical colleges are: (1) Training and teaching of RNTCP. (2) Service delivery of the RNTCP. (3) Advocacy of the RNTCP. (4) Operational research. A National Tast Force is being constituted comprising representatives from the zonal nodal centers, Central TB Institutes, and Central TB Division. With the establishment of zonal nodal centres and task forces at the different levels, it is envisaged that the movement will gain further momentum.