Translating Evidence into Policy: The Case for INH Prophylaxis Programs for Health Care Personnel in India

“Care for the health of those who care for the health of others”
Lt Col (Dr) Rishi Raj, Dr. Hari Prasad, Dr. Bikas K Arya, Dr. T. Shyam, Prof. (Dr.) Sangeeta Das Bhattacharya
School of Medical Science and Technology, Indian Institute of Technology Kharagpur, India

1. Defining the problem 3. Construct the Alternatives Table 2. Cost of Isoniazid for preventive therapy and net savings for the health system 7. Decide
Estimated total Isoniazid Estimated net savings by What did the results show about the alternatives?
Health-care workers (HCW) in India are at high risk for occupational
Alternative I - Active Surveillance of Entry Level HCW cost to treat LTBI in HCW preventing active TB in HCW Fig 7. HCWs in India (National Health Profile 2007)
tuberculosis (TB) exposure. India needs a clear policy to check work-
o All health care workers at entry to the healthcare in India in USD ($) in India in USD ($)
place TB in the health-care sector.
sector will be screened with the tuberculin skin test Alternative 1
Fig 1. Incidence of active TB in HCW in India compared to general population 9,607,276 52,840,018
(TST) for latent Tuberculosis. IPT for entry level HCW
Alternative II - Active Surveillance of Veteran HCW Alternative 2
Per 100,000 population per year

o All health care workers who have served for 2-5 years IPT for Veteran HCW 54,255,850 340,726,738
in healthcare sector should be screened for latent working for 2-5 years
Tuberculosis by TST. Status Quo
- -892,514,800 (Total Loss)
Status Quo (Do Nothing) No IPT
o No Active surveillance or IPT treatment.
6. Confront the Trade-offs
Health-care workers having positive reaction in either alternatives I or II Fig 4. Risk of active TB and TB related mortality in HCW
In India, approximately 36 lakhs persons are employed in health-care
41% of Indian health care workers have a positive tuberculin skin test 4. will be screened for active tuberculosis by chest X ray, and if found
sector, of which approximately 22 lakhs (around 60%) have served for a
Indian health care workers have a higher risk of active TB than the suspicious for disease will be treated with full course DOTS.
duration of 5 years.
general population. Those found negative for active disease will be treated for a six month
Now it is clear that IPT programs for HCW with longer duration of
The incidence of active TB in Indian health care workers is between course of Isoniazid.
exposure to the health care sector will have maximum benefit in terms of
208-1260/100,000 per year, compared to the incidence of 168/100,000 This should be followed by every five yearly screening for Latent
prevention of active TB, TB related mortality, and the cost-savings to the

Per 1,000 HCW

per year in the general population. 1-3 Tuberculosis. 
health system.
Fig 2. Pulmonary and extra-pulmonary TB in different HCW groups 2 4. Evaluation Criteria 8. Tell Your Story
Based on a Markovian model of cost-effectiveness analysis of IPT IPT programs for health care personnel is an important part of India's’
programs in HCW the numbers needed to treat (NNT) to prevent a case strategy to combat TB.
of active TB was 25 to 23 and the NNT to prevent one TB related death “Care for the health of those who care for the health of Others”
was 446 to 417 depending upon the prevalence of positive TST. 6
We based the analysis of cost and savings from the cost-benefit References
1. Joshi R, Reingold AL, Menzies D, Pai M (2006) Tuberculosis among health-care workers in low and middle-
analysis of the IPT programs by Salpeter et al.6 income countries: A systematic review. PLoS Med 3(12):e494.
2. Gopinath KG, Siddique S, Kirubakaran H, Shanmugam A, Mathai E, et al. (2004) Tuberculosis among
Based on the literature Indian HCW at entry level have a prevalence Fig 5. Cost of IPT for HCW and net savings for the health system healthcare workers in a tertiary-care hospital in South India. J Hosp Infect 57: 339–342.
rate of TST positivity of 18 percent, whereas those who have served for 2 3. Rao KG, Aggarwal AM, Behera D (2004) Tuberculosis among physicians in training. Int J Tuberc Lung Dis 8:
2. Assembling the Evidence to 5 year have a prevalence rate of 29 percent.4 4.
1392–1394
Pai M, Gokhale K, Joshi R, et al. (2005) Mycobacterium tuberculosis infection in health care workers in rural
Population: Health care personnel with latent Tuberculosis Using the NNT, prevalence rate of TST positivity, life-time risks and India—Comparison of a whole-blood interferon gamma assay with tuberculin skin testing. JAMA 293: 2746–
2750.
Intervention: Prophylaxis with Isoniazid. number of health-care workers in India we calculated the evaluation 5. Smieja MJ, Marchetti CA, Cook DJ, Smaill FM. Isoniazid for preventing tuberculosis in non-HIV infected
Control: Placebo. criteria listed below.7 6.
persons. Cochrane Database Syst Rev. 2000 ;( 2):CD001363.
Salpeter SR, Salpeter EE. Screening and treatment of latent tuberculosis among healthcare workers at low,
Outcome: Incidence of active tuberculosis. Evaluation criteria moderate, and high risk for tuberculosis exposure: a cost-effectiveness analysis. Infect Control Hosp Epidemiol.
2004 Dec; 25(12):1056-61.
1.Estimated lifetime risk of active TB per 1000 HCW in 7. Field MJ (ed). Tuberculosis in the workplace. National Academy Press, 2001, p.153-154.
Does Isoniazid prophylaxis decrease the incidence of active TB in India 8. Human Resources in Health Sector. National Health Profile 2007.
health care workers with latent tuberculosis? 2.Estimated lifetime risk of death due to TB per 1000 HCW Acknowledgements
For this question of therapy a targeted search using the Haynes “5S” in India We are grateful to Dr. Ranjan Das, School of Medical Science and Technology and
model led to a systematic review in the Cochrane Database of 3.Estimated total Isoniazid cost to treat LTBI in HCW in Dr. Punyatma Singh, Rajiv Gandhi School of Intellectual Property Law for useful
5
Systematic Reviews by Smeja et al. (2000) . discussions and guidance throughout this work.
India in USD ($)
Eleven randomized control trials of IPT 4.Estimated net savings by preventing active TB in HCW in
o 73,375 patients India in USD ($)
o Mixed exposure risk
 Reduction in active TB over 2+ years
o Relative risk reduction: 0.40 (95% CI 0.31 to 0.52) 5. Project the Outcomes Fig 6. Cost of IPT for HCW and Loss due to active TB in Status Quo
o Absolute risk reduction: 0.01 ~ NNT 100
Table 1. Risk of active TB and TB related mortality in HCW
o No significant difference between 6 & 12 month course
Reduction in TB deaths Estimated lifetime risk of active Estimated lifetime risk of death due
No reduction in all-cause mortality TB per 1000 HCW in India to TB per 1000 HCW in India
INH hepatotoxicity Alternative 1
24.64 1.95
o 6 month regimen: 0.36% IPT for entry level HCW
o12 month regimen: 0.52% Alternative 2
IPT for Veteran HCW 16.32 1.50
Fig 3. Model of best evidence for questions of therapy
working for 2-5 years
Isoniazid for preventing 5. Status Quo
tuberculosis in non-HIV 26.20 2.04
infected persons No IPT

INH prophylaxis decreases the life-time risk of active TB for HCW from “From Buddha to Bardach”
26 to 16. This means a relative risk reduction of 39 percent.
“Knowing is not enough; we must apply.
INH prophylaxis decreases the life-time risk of death due to TB from 2 to
Willing is not enough; we must do.”
1.5. This means a relative risk reduction of 25 percent.
—Goethe