The Albany Gazette - Tamil Nadu's TB Initiative Cuts Deaths by 38% Through Early Triage

Tamil Nadu has recorded a significant decline in tuberculosis mortality, with death rates dropping by at least 38 percent across quarterly cohorts starting from July 2024. This reduction is attributed to the Tamil Nadu Kasanoi Erappila Thittam (TNKET), a statewide initiative that identifies severely ill patients at the time of diagnosis and prioritizes them for immediate hospitalization.

The findings, published on November 7 in BMJ Global Health, detail the results of a monitoring and evaluation framework developed by the ICMR National Institute of Epidemiology (NIE) and the Tamil Nadu State TB Cell. The study describes TNKET as India’s first statewide and state-specific differentiated TB care program, implemented from April 2022 to December 2025. The program covered all adults aged 15 years and above diagnosed with drug-sensitive TB in the state’s public health facilities, where approximately 60,000 such cases are reported annually.

Under the TNKET protocol, patients are assessed at diagnosis using five specific clinical parameters: body mass index (BMI), pedal edema (swelling of the feet and ankles), respiratory rate, oxygen saturation, and the ability to stand without support. Patients identified as severely ill—those exhibiting very severe undernutrition, respiratory insufficiency, or poor physical performance—are prioritized for referral to hospitals and inpatient care.

The researchers noted that it took two years of statewide implementation to minimize losses along the patient-care cascade while simultaneously improving the quality of triaging and inpatient care. These operational improvements translated into sustained reductions in the statewide TB death rate across all quarterly diagnosis cohorts beginning in July 2024.

At the start of TNKET, the reported death rate was 6.3 percent. The study found that for patients diagnosed between October and December 2024, the death rate fell to 3.9 percent, representing a 38 percent reduction. For those diagnosed between July and September 2025, the rate dropped further to 2.8 percent, marking a 56 percent reduction from the baseline.

These results were confirmed through an individual-level and interrupted time series analysis that adjusted for potential effects of confounders and time. The findings indicate that TNKET reduced not only early TB deaths, defined as those occurring within two months of diagnosis, but also overall TB deaths within one year of diagnosis.

The monitoring framework evaluated preparatory and input indicators, the patient-care cascade from initial triaging to hospital admission, admission-related outputs, and the quality of triaging and inpatient care. The study emphasized that reducing TB deaths depends 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.

An earlier ICMR-NIE-developed mortality prediction calculator, based on the same five clinical parameters, was designed to help identify adults with TB at higher risk of death. The TNKET initiative operationalizes this by enabling immediate action at the point of diagnosis.

"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 stated.

Despite the success in reducing mortality, the Tamil Nadu experience highlighted significant gaps in follow-up care after hospital discharge. The systematic tracking of patients identified as severely ill at diagnosis did not exceed 35 percent at the two-month mark in any quarter. This indicates persistent difficulties in ensuring sustained post-discharge monitoring through routine public health systems, even in a state with one of India’s strongest public health infrastructures.

The researchers outlined three key lessons from the TNKET experience for other high TB-burden states and countries, particularly those operating under resource-constrained healthcare settings. First, differentiated TB care requires sustained implementation over time to translate into a reduction in statewide death rates, rather than expecting immediate results upon launch. Second, triaging should be based on simple clinical parameters that are easy to measure in routine 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 findings underscore the importance of designing public health interventions around the operational capacities of healthcare systems. The TNKET monitoring and evaluation framework is proposed as a replicable model for other high TB-burden regions seeking to reduce deaths through differentiated care approaches adapted to their available resources.

(A.Johnson--TAG)