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How Kerala is fighting TB, and winning

In 2016, 435,000 people in the country died of TB. Patients often incur financial distress due to catastrophic health expenses.

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World Without TB

Kollam, Oct 8 : Agathi mandiram (poor people’s home) in Kollam city was built to provide shelter to beggars. Today, its 123 residents are mostly homeless people with mental or physical disabilities, brought here when found wandering the streets.

In May 2018, the Tuberculosis (TB) Centre of Kollam district decided to screen every one of agathi mandiram’s inmates. Ordinarily, their in-house doctor, Shreekumar D., would identify those with TB-like symptoms and send their sputum samples for analysis to the state TB Cell a few times a year, leading to the identification of two or three cases each year.

For the first time this year, the centre sent a pulmonologist to examine every person in the home, as part of the Kerala TB Elimination Mission launched in March 2018 with the aim of reducing the number of TB cases to 2020 by the year 2020, and eliminating TB-related deaths altogether.

“It was challenging because the inmates often could not explain their symptoms nor give their sputum sample,” said P. Anish, a consultant chest physician who screened all the inmates. Deploying techniques not normally used to detect TB, such as the CT-Scan, he detected 22 cases.

This exercise was replicated across the state from April to June in an effort to screen every person in Kerala, after the state set its sights on eliminating TB, displaying confidence in its robust health system which has already delivered enviable indicators.

This confidence is why, for Kerala, eliminating TB is “low-hanging fruit”, as the state’s Health Secretary, Rajeev Sadanandan, puts it. “We are about the only state [that] is capable of eliminating this disease,” he told IndiaSpend.

Kerala’s strategy has implications for all of India, which has the world’s largest TB burden — 2.74 million or 27 per cent of the global total. Further, nearly 300,000 Indians fall through the surveillance system or do not complete their course of medication, prompting the rise of more virulent, drug-resistant strains. In 2016, 435,000 people in the country died of TB. Patients often incur financial distress due to catastrophic health expenses.

This is what makes TB a public health imperative that must be dealt with through early diagnosis, complete treatment and improved quality of care. And Kerala’s example is instructive.

“The reduction of TB cases in Kerala is dramatic,” said K.P. Aravindan, a retired professor from Kozhikode Medical College. “From a disease that was extremely common, it is now a rare disease.”

And what has helped is the state’s thorough implementation of the “active case-finding” strategy to test every resident and map vulnerable populations so as to regularly monitor, test and treat them.

Active case-finding involves health workers proactively screening people for TB, as opposed to people coming to health institutions with TB-like symptoms and getting screened, which has been the mainstay of the Revised National Tuberculosis Control Programme (RNTCP) for more than 15 years.

The Central TB Division, which works under the central health ministry and is responsible for implementing RNTCP, requires all state TB units to conduct an active case-finding exercise thrice a year among populations identified as vulnerable, such as those living in slums and labour camps, mine workers, tea garden workers and the homeless. This is typically done in an ad-hoc fashion and there is no consistent follow-up, mostly because the number of TB cases is high and resources are stretched thin.

Kerala, however, has improved an already robust healthcare system and a motivated workforce to implement active case-finding so thoroughly that each resident will be screened this year, with health workers going door-to-door to find cases. The persons identified as vulnerable will be followed-up on every three months.

These activities have increased the number of symptomatic patients tested per 100,000 from about 700 — close to the all-India figure — to nearly 1,250, according to the Kerala State TB Cell.

TB affects mostly young adults the world over. In Kerala, however, proportionally more people over 45 years have TB, data collected by the State TB Cell show. Between 2004 and 2014, the proportion of TB cases among those above 45 years increased by more than 10 per cent.

This suggested a link between chronic diseases such as diabetes, which affect older people more, and TB.

This led to a change in policy — first within the state starting 2012 and since 2017 across India — so that TB patients are as a rule tested for diabetes and vice-versa. Following Kerala’s example, all TB patients registered under RNTCP are supposed to be referred for screening for diabetes. Referral is the responsibility of the health institution where TB treatment is initiated.

In addition to increased surveillance, the state has deployed more diagnostic tools such as the Cartridge-based Nucleic Acid Amplification Test (that can detect TB bacilli in very small amounts of sputum), X-Ray and CT-scan during active case-finding, as at agathi mandiram in Kollam.

“We have reached a saturation point in detecting TB using sputum microscopy,” said Kumar, referring to the technique in which the laboratory technician looks for TB bacilli in sputum — a mixture of saliva and mucus a subject has coughed up — using a microscope. “It is now time to use other techniques.”

Complementary programmes underway in some other districts engage with treatment support groups and with the private sector to increase reporting of cases (private-sector cases are typically under-reported, so that official TB statistics reflect mostly incidence, prevalence, treatment and cure figures reported by the public sector). From January to July 25, 2018, there have been 2,672 notifications from the private sector and 10,200 from the public sector, Balakrishnan said.

Across India, about 20 per cent of the total reported cases were in the private sector, while in Kerala, the figure was 36 per cent.

For two decades now, children living with infected adults have been given preventive drugs and are monitored as part of a protocol called chemoprophylaxis. Now, the state has decided to give infection-control kits to TB-positive patients, said Kumar, consisting of masks, disposable spittoons and disinfectant solution to protect TB from spreading to family members.

The department has found just 352 new cases of TB all over the state — in a population of 38 million — during the active case-finding and vulnerability mapping exercise so far, Balakrishnan said.

Kerala’s TB incidence is estimated to be 67 cases per 100,000, less than half the 138 per 100,000 pan-India. Since 2009, when Kerala began active case-finding, the TB notification rate in the state’s public sector has been falling by about three per cent every year. This is despite the fact that the number of people being tested for TB has remained constant, Balakrishnan said.

The proportion of TB in children under 15 years has consistently fallen in Kerala. In 2016, 6.3 per cent of TB cases were among children (under 14 years), down from 8.7 per cent in 2008.

Fewer children are being affected because primary transmission has gone down, state TB officer Sunil Kumar told IndiaSpend. This could mean that direct transmission of the disease from the environment or from other TB patients has reduced.

The biggest lesson Kerala holds for the rest of the country lies in the basic implementation of the programme — treating the TB patient who comes to the hospital appropriately, said Yogesh Jain, a founder member of Jan Swasthya Sahyog, a community hospital in Bilaspur.

The importance of following the “old-fashioned” guidelines from RNTCP related to early diagnosis, completion of treatment and other protocols cannot be overstated. “There are no magic bullets here. Kerala is showing a mirror to the rest of the country that we have to do what we are supposed to do well,” he said.

While Kerala’s example may not be entirely replicable across India — given the vast population, paucity of resources, and lack of infrastructure, capability and preparedness — much can be done with the existing resources too.

Aravindan pointed out that even in low-resource states such as Odisha and Chhattisgarh, some programmes work. “It is political will that makes programmes work,” said Aravindan.

(In arrangement with IndiaSpend.org, a data-driven, non-profit, public interest journalism platform. Menaka Rao is a an independent journalist based in Delhi. The views expressed are those of IndiaSpend. Feedback at [email protected])

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Obituary – Ex-Aus batsman Dean Jones had a love affair with India

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Dean Jones

For some strange reason, a 51-second video clip of Dean Jones being bowled neck and crop for a duck by the legendary Kapil Dev in a Test against Australia went viral on Wednesday, with a commentator uttering the words “that’s the end of Dean Jones”. And, on Thursday Jones died of a cardiac arrest, aged 59 years and 184 days, in Mumbai.

Jones, who was in India to honour his contract with a broadcaster for the IPL, was close to many Indian players, like Kapil Dev and Dilip Vengsarkar, and was a regular visitor to India for cricket-related work.

A top order batsman, Jones, who was part of the second Tied Test in which he scored his maiden double century in 1986 in Madras, played 52 Tests and 164 ODIs between 1984 and 1994. He was a gutsy batsman and wasn’t scared of stepping out to play speedsters. His running between the wickets was very brisk. Jones is perhaps best known for his 210 in the Tied Test, his maiden double century at that level — an innings after which he was taken to a hospital and was put on a saline drip after he was dehydrated during his eight-and-a-half hours at the crease in hot and humid Madras, as Chennai was then called.”

A day that changed my life forever,” Jones tweeted on September 19, on the 34th anniversary of the Tied Test. Another tweet of his that day read:

“This Test was the Renaissance for Australian cricket. It was our Mt Everest moment. Under AB [Border] we started to believe that we can compete against the best. Great friendships started with the Indians. Our Journey had just begun!” Indeed, Jones’s friendship with Indians had well and truly begun in 1987, and some of his friends, like Kapil Dev, were in the team that played at Chepauk. India proved lucky for Jones as he was part of Allan Border’s team that won Australia their first ever World Cup, in 1987 at Eden Gardens, Kolkata. After retirement, Jones started getting TV work in India and was nicknamed ‘Professor Deano’. He even named his twitter handle @ProfDeano. Jones’s love affair with India continued both on and off the field. In Test cricket, although he played only three matches on Indian soil, his average here — 92.

75 — was the highest of the six countries he had played in. He played 18 ODIs in India and tallied 719 runs at 44.

94. The Aussie once also played alongside Indians in unofficial cricket. When a World XI gathered in England to celebrate the bicentenary of the Marylebone Cricket Club (MCC) in 1987, former India captain Dilip Vengsarkar partnered Jones in a game against Gloucestershire in Bristol.”

He was a very nice, jovial person. I was shocked when I heard this news today. I was absolutely devastated. Of course, we played against each other, representing India and Australia. We also played together once. It was one of the three matches played before the main five-day game between the MCC and Rest of the World XI at Lord’s in London. Dean and I had a 200-odd-run partnership. I scored 171 and he scored 70-odd in that match,” Vengsarkar told IANS. “Of course, I knew him very well. When he used to come to Mumbai for commentary etc, sometimes we used to meet. He was a good friend. And he used to play golf also. So, I was surprised that he collapsed and died today. It’s absolutely shocking,” he said. In mid-2000s, Jones also applied for the India coach’s job. Although he didn’t get the job, he became coach of the Islamabad franchise in the maiden Pakistan Super League in 2016 and guided the team to the title.

Jones played a prominent role in the revival of Australian cricket in late 1980s, especially during the 1987 World Cup and the 1989 Ashes Test series.

He went on to captain Victoria and Derbyshire. At times, Jones was too outspoken. As a commentator, he slipped a couple of times. In 2006, he called South Africa cricketer Hashim Amla a “terrorist”, a comment for which he had to pay a penalty. But he was accepted back into the commentary box while Amla forgave him. On Thursday morning, Jones reportedly greeted everyone when he was at the breakfast table in the hotel where he was staying in Mumbai. “When he went for breakfast, he was jovial and said ‘good morning boys, hope everything is fine’ to people present there,” a hotel source told IANS.

By Qaiser Mohammad Ali

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Obituary – MoS Railway Angadi will be remembered for warm gesture, smile

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Suresh Angadi,

New Delhi, Sep 23 : Minister of State for Railways Suresh Angadi, who passed away on Wednesday evening at a hospital here where he was being treated for Covid-19 will always be known for a big smile and warm gestures by his colleagues and friends.

Angadi was made the Minister of State for Railways in May last year by Prime Minister Narendra Modi.

Soon after his appointment as MoS for Railways, he knew that he has to meet the expectations of PM Modi to improve the train services.

During the inaugural run of second Vande Bharat Express train between New Delhi to Katra on October 4 last year, just two months after the abrogation of Article 370 from Jammu and Kashmir, he travelled in train with media persons to give a message that the government is standing with the people of J&K for the overall development of the region.

There were around 80 media persons along including the camerapersons to cover the inaugural run of the Vande Bharat Express.

During the trip, Angadi kept on interacting with the media about the plans of the Railway Ministry to bring development in erstwhile state of Jammu and Kashmir.

He gave interviews for four consecutive hours without any break and assured that he answered all the tough questions posed to him.

Speaking to IANS on the same trip, Angadi had said, the Indian Railways, which has witnessed delays in completion of several important projects, was aiming to finish all of them by 2022, on the occasion of 75th Independence Day.

He had also said that the national transporter sees the option of allowing private operators to run trains as an opportunity to provide world class services.

Angadi had said, “Prime Minister Narendra Modi has directed that all the pending projects and works be completed by 2022. We are focusing on completing pending works, like doubling and tripling of tracks, electrification, installation of CCTVs and signalling system upgrade.”

“New projects will be taken up only after completing them,” Angadi said.

He also favoured giving trains to private operators, and cited the example of private TV channels and said, “The entry of private players will generate more jobs and investment opportunities. In the long run, a lot of development will follow due to the competition.”

In countries like China trains run at 400 kmph. But in India trains were not running even at 160 kmph, he said.

“To compete with the world, we have to opt for investment from many sources. When a private company or people comes and invests in railways, it will create opportunities to develop economy,” he had said.

The railways had last year proposed to corporatise Rae Bareli Modern Rail Coach factory in UP.

On opposition of the Congress and other parties to corporatisation and privatisation of railways’ manufacturing units, the Minister said, “The Congress never thought about development. It has always opposed development.”

“We have not got to think of the Congress, but development and competition, and let the economy grow and create employment opportunities,” Angadi said.

Citing examples, he had said, the national highways remained undeveloped till the Atal Bihari Vajpayee government took it up and today even foreign countries were appreciating them.

Angadi in the railway ministry was also known as one of the most punctual minister. He always came to the ministry on time and ensured that the press briefing started on time.

Angadi represented Belagavi constituency of Karnataka in Lok Sabha.

He first won from the seat in 2004 and remained undefeated from the seat till 2019.

He was also known as a media man, who always remained responsive to the queries of media even late in night.

Following the news of gis death, Union Railway Minister Piyush Goyal said, “Deeply anguished at the unfortunate demise of Suresh Angadiji. He was like my brother. Words fall short to describe his commitment and dedication towards the people. My thoughts and prayers are with his family and friends in this hour of need. Om Shanti.”

Angadi Angadi admitted at AIIMS on September 11 after testing positive for Covid-19. He breathed his last on Wednesday evening.

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It was all about being ruthless: MI skipper Rohit Sharma

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Rohit Sharma

Abu Dhabi, Sep 24 : Rohit Sharma, on Wednesday, returned to his usual, elegant self with a masterful innings to lead Mumbai Indians to a 49-run win over Kolkata Knight Riders at the Sheikh Zayed Stadium in Abu Dhabi. Rohit scored 80 off 54 as MI scored 195/5. In reply, KKR managed to score 146/9.

Interestingly, this marked MI’s first ever victory in the United Arab Emirates (UAE), having lost all of their matches in 2014 when a part of the group stage was played in the UAE.

“It was only two players from the 2014 squad. It was all about how we executed our plans today, we never let it go. We were in good position throughout the game but it was all about being ruthless, getting as many (runs) as possible. We knew the wicket was good and dew was coming down,” said Rohit in the post-match presentation ceremony in which he was declared Player of the Match.

As the KKR bowlers fumbled with their line and length and gave Rohit short deliveries, the MI captain replied with his trade mark pull shots to deposit the ball over the boundary.

“I back myself to play (the pull shots), love playing it and practiced it quite a bit. Pretty glad it came out well, they were all good (laughs), can’t pick one. I haven’t played a lot of cricket in the last six months time and was looking to spend some time in the middle; it didn’t come out well in the first innings but glad to have done it tonight,” he said.

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