Since 2017, we have implemented the Zero TB in Kids (ZTB) project for schoolchildren and staff in India, employing a multi-pronged, multi-sectoral approach. Over 7 years of project implementation — encompassing the COVID-19 pandemic and an expansion to Nepal in 2020 — we have observed devastatingly high rates of tuberculosis (TB) infection and disease among children and adolescents residing in the congregate settings of schools, monasteries, and nunneries. Our service delivery model providing diagnostic, preventive, and treatment services in the community can overcome crucial logistical and societal barriers, appeal broadly to community members, and help improve stakeholder relations.
Combatting Infectious Disease
ZTB prevents, diagnoses, and treats TB in hard-to-reach settings, helping to eliminate the disease. In screening >20,000 schoolchildren and 4,600 adults in over 70 institutes for active and latent TB and providing TB preventive treatment (TPT), we have witnessed a reduction of TB incidence by 87% for Tibetan schoolchildren in the state of Himachal Pradesh, India. The majority of TB cases in these communities are subclinical, demonstrating a need for accelerated case-finding programs like ZTB.
Leveraging Transformative Technology
ZTB’s mobile teams of community-based physicians use cutting-edge diagnostic technology like ultraportable digital X-rays equipped with artificial intelligence (AI), potential field friendly TB infection screening tool such as the IGRA-based Qiareach, and molecular diagnostics. Its thorough monitoring and evaluation practices have produced robust, scientifically rigorous data that ZTB uses to generate new knowledge about the disease and best practices for its control — like by comparing the effectiveness of diagnostic tools in the field — as described in a use case report by the Data Foundation.
Engaging and Empowering Communities
ZTB is community-led, gender-inclusive, and driven by sustainability at all levels of leadership and programming. It has a strong foundation of trust and community ownership. This is reflected in ZTB’s health systems strengthening activities like introducing the workforce to new medical technology, as well as leadership training for women, girls, and gender-diverse people. Further, to overcome the effects of the COVID-19 pandemic, ZTB has incorporated mental health screening services as well as delivery of education for schoolchildren, rendering it a holistic child-centric program. Since 2021, we have also implemented the Smart Kids Initiative (SKI) to improve the wellness and education of Tibetan refugee children in India.
TB and Hepatitis B
Implementing tuberculosis preventive treatment in children and adults having hepatitis B has been a programmatic challenge given the hepatotoxic side-effects that were traditionally attributed to the anti-TB medicines. At ZTB, we have found that the overall prevalence of hepatotoxicity was less than 1% among all recipients of TPT. We are currently the feasibility and potential concerns associated with use of isoniazid or rifampin-based TPT for individuals with hepatitis B virus infection. The findings could inform guidelines on the use of TPT in patients with hepatitis B globally.
TB Transmission Dynamics
It is now understood that a significant proportion of TB transmission happens outside the household setting and in the community including schools. Deciphering the transmission dynamics and the hotspots shall inform appropriate public health measures for its interruption. At ZTB, we employ traditional, spatial and genomic epidemiology to map out tuberculosis transmission dynamics for pediatric population.
TB and Mental Health
Working with our partners, we have also accounted for mental health illness (MHI) across projects. Research suggests that MHI can be both a driver and byproduct of TB, creating a vicious cycle. Last year, adolescents and adult staff in the institutes were co-screened for mental health and TB by adapting the PHQ-9 tool. We found a high TB disease prevalence of 1,720/100,000 in adolescents with any MHI symptoms vs. 460/100,000 in those without (p=0.006), and 3,030/100,000 vs. 240/100,000 (p<0.001) in adults with and without MHI symptoms. Substance abuse associated with mental health is also becoming increasingly prevalent in adolescents. With Zero TB in Tibetan Kids, we have integrated screening for mental health in the ZTB community screenings in the schools, monasteries, and nunneries.
