Keeping Drug-Resistant TB Patients on Treatment Through COVID-19 in Dharavi, Mumbai

Mumbai, India's second-largest city, has one of the world's highest rates of drug-resistant tuberculosis (DRTB) — TB that resists isoniazid or rifampin, and sometimes other drugs. Treating it takes longer and is harder than ordinary TB: second-line drugs, more side effects, more relapse and higher mortality. In Dharavi, the largest slum in Asia — about 1 million people in 0.8 square miles (2.1 km²), many of them workers from across India — about 300 people are diagnosed with DRTB each year, and historically fewer than half finished treatment.

Then came the lockdowns

India's nationwide travel restrictions ran March 23–May 31, 2020 and January 27–April 30, 2021; Maharashtra extended them to June 15, 2021. Without wages, many migrant workers left Dharavi for their home towns — on foot, by train or by bus — often in the middle of DRTB treatment.

The program

Mumbai's municipal corporation (Brihanmumbai Municipal Corporation), CDC and the nonprofit SHARE India built a program into routine TB services to keep patients on treatment:

• Risk assessment: for every patient, addresses (including their permanent home), phone numbers of family and close contacts, and likely travel routes, with destinations and transit routes mapped.
• Field coordinators — exempt from travel restrictions — made calls and home visits every 2 weeks for 2 months, then monthly, counseled on adherence, and actively checked for side effects.
• Medicine: a 3-month supply for self-administration while clinics were disrupted, and a 1-month supply for anyone about to travel.
• Handover: patients who left were linked to TB programs at their destination, and those who had already gone were helped to restart treatment there.
• Support: every patient was enrolled for government cash assistance and referred for nutritional support.

Results, May 2020–September 2022

• 973 people began or continued DRTB treatment (average age 28, range 4–88; 56% female).
• 255 (26%) relocated during treatment, to 14 states and union territories, traveling a median 662 miles (1,065 km) — most often in May–June 2020 and April–June 2021.
• 540 patients reported 2,592 episodes of side effects; all but 101 (4%) were resolved.

Patient relocations, travel restrictions and COVID-19 cases in Dharavi. Image from CDC's report

Outcomes as of January 25, 2023

Only 3% of patients were lost to follow-up — against 18% before the pandemic — and the rate stayed low among those who moved and returned and those who moved away for good alike.

Why it worked

Instead of waiting for patients to come to the clinic each month and report problems, the program went to them: frequent contact, active monitoring and quick answers to concerns, mostly by telephone, which nearly every patient, relative or neighbor had. It also tackled the reason people left — lost wages — by linking them to aid. As in TB programs that kept going through floods in Kerala, hurricanes in the U.S. and Puerto Rico, and Haiti's earthquake, coordination, good contact information and extra medicine made the difference. Mumbai has since used the approach in other dense, poor neighborhoods.

Limits: phone follow-up may overstate adherence, and delayed lab results may have affected how outcomes were classified.

Sources

Based on Mangala D. Gomare, Sampada Bhide, Rajesh Deshmukh and others, "Retaining Patients with Drug-Resistant Tuberculosis on Treatment During the COVID-19 Pandemic — Dharavi, Mumbai, India, 2020–2022," MMWR, volume 72, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The report gives the same 70/185 split both for migrants who told staff they were leaving and for those who later left for good or returned; only the second, which its table confirms, is used here.