Background: A robust disaggregated understanding of the determinants of tuberculosis (TB) in each local setting is essential for effective health system and policy action to control TB. Objectives: The objective of the study was to identify population attributable risk (PAR) for TB disease based on the locally available evidences for Kerala, India. Methods: Systematic review was done for risk factors of TB in the state. The second set of searches was done to understand the prevalence of the identified risk factors in general population in Kerala. With all available studies and reports, an expert group consensus was made to finalize state-specific prevalence of risk factors. Population attributable fractions were calculated for identified risk factors. Results: PAR for TB disease in Kerala obtained was 24% for undernutrition, 15% for diabetes, 15% for tobacco use, and 1% for HIV. Conclusion: Kerala state's PAR for TB was comparatively lower for HIV but higher for diabetes mellitus. Similar exercises for summarizing population risk factors need to happen at all states for making plans to effectively combat TB.

Ensuring the successful treatment of tuberculosis (TB) is an essential public health responsibility of national TB programs. This case study describes how the Department of Health and Family Welfare, Kerala state, successfully prevented the disruptions in TB treatment when an unprecedented massive flood, declared as “a calamity of severe nature,” completely disrupted normal operations in the state during August 2018. Unanticipated floods led to the displacement and relocation of more than 1.5 million citizens. The state has ensured continuity of TB treatment for all notified drug sensitive and drug-resistant TB patients (9608 and 434, respectively), including those who were displaced and relocated. A real-time web-enabled, case-based patient management information system has helped preserve the entire patient information, available at multiple levels. Routine strength of the program, including good rapport with patients, frontline multipurpose health workers and treatment supporters, high literacy rate of general population, and well-integrated primary health care system delivering TB services, enabled ensuring continuity of care during the disaster situation. The success of the post-flood TB control measures in Kerala affirms the importance of maintaining an integrated and strong TB control component with general health system ownership.

<sec> <title>SETTING:</title> The southern Indian state of Kerala has implemented ‘Kerala Tuberculosis Elimination Mission’ as ‘People’s Movement against TB’ under the stewardship of local governments (LGs). The state has been certified by the Government of India for being on track to attain the UN Sustainable Development Goals related to TB elimination. </sec> <sec> <title>OBJECTIVE:</title> To document the role of LG stewardship in the successful implementation of the TB elimination activities in Kerala. </sec> <sec> <title>DESIGN:</title> 1) Key informant interviews with four state officials, 2) desk review of available documents, 3) in-depth interviews with seven LG leaders, three mid-level programme managers and three health department field staff. </sec> <sec> <title>RESULTS:</title> LG involvement led to the establishment of solutions based on local problems, enhanced outreach of services to the socially vulnerable individuals, improved treatment support to patients with TB, increased community ownership of TB elimination activities, reduced TB-related stigma and social determinants being addressed. Institutional mechanisms such as LG TB elimination task forces, formal guidance in planning interventions and appreciation of their performance in the form of awards were facilitators for LG involvement. </sec> <sec> <title>CONCLUSION:</title> LG stewardship can accelerate TB elimination. A good plan for engagement and institutional mechanisms are crucial for LG involvement. </sec>

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