INTERNSHIP REPORT

SUBMITTED FOR THE FULFILLMENT

OF THE DEGREE OF

MASTER OF PUBLIC HEALTH

ALL INDIA INSTITUTE OF MEDICAL SCIENCES

CHHATTISGARH, INDIA

SUBMITTED BY:
DR. NITIKSHA SINGH
MPH 2022 BATCH

1|Page
 DR NITIKSHA SINGH, MPH 2022 BATCH, AIIMS RAIPUR

2|Page
 ACKNOWLEDGEMENT
I extend my heartfelt gratitude to Dr Anil K Goel sir, Head, Department of
Pediatrics, course coordinator of School of Public Health, AIIMS, Raipur, who
played a pivotal role in providing me with the invaluable opportunity for an
internship at Jan Swasthya Sahyog (JSS), Ganiyari. This experience has been
instrumental in shaping my understanding of public health and has significantly
enhanced our career prospects. The exposure and hands-on learning at JSS have
been pivotal in fostering my passion for public health, and I am sincerely thankful
for the guidance and support provided by Dr Anil Goel sir.

I would also like to express our deep appreciation to Dr. Raman Kataria, the
Founding Member of JSS, who played a pivotal role in providing me with the
invaluable opportunity for an internship at Jan Swasthya Sahyog (JSS), Ganiyari.
Dr. Kataria's mentorship has been a guiding light, offering me a comprehensive
understanding of community- based healthcare interventions. Furthermore, I am
grateful for the accommodation facilitated by Dr. Kataria, which greatly
contributed to a seamless and enriching internship experience at JSS.

My sincere thanks go to Dr. Ravindra Kurbude, Dr. Pratishta Ragav, and Mrs.
Minal Madankar, the esteemed Program Coordinators at JSS. Their unwavering
support, coupled with their wealth of knowledge, significantly enriched my
internship experience. Their guidance has been instrumental in broadening my
perspectives on public health, and I am truly fortunate to have had the opportunity
to learn from such distinguished professionals.

DR. NITIKSHA SINGH

M.P.H. 2022 BATCH
SCHOOL OF PUBLIC HEALTH
AIIMS RAIPUR

3|Page
4|Page
 CONTENTS

PROLOGUE.................................................................................................................4

JSS: PROGRAMME STRUCTURE..........................................................................5

JSS: AREAS OF WORK.............................................................................................5

SUBCENTERS..............................................................................................................7

MATERNAL AND CHILD HEALTH..........................................................................8

DISEASE BASED PEER SUPPORT GROUPS...........................................................9

PHULWARI PROGRAM...........................................................................................10

VISIT TO ANC CLINICS..........................................................................................18

ASSIGNMENTS..........................................................................................................22

KEY LEARNINGS......................................................................................................38

5|Page
PROLOGUE

Jan Swasthya Sahyog (JSS) is a volunteer-driven, non-profit organization

comprised of healthcare professionals dedicated to operating a cost-effective and
impactful health program. Since the year 2000, JSS has been providing both
preventive and curative services to residents in the tribal and rural areas of
Bilaspur, Chhattisgarh. This initiative includes a comprehensive community health
program and a rural health center with an attached hospital. The diverse and skilled
team at Jan Swasthya Sahyog consists of specialists in Medicine, Paediatrics,
Public Health, Gynaecology, Surgery, ENT, Ayurvedic Medicine, and
Microbiology.

The organization's activities are dispersed throughout Bilaspur and Mungeli

districts, encompassing tribal and marginalized communities. The focused efforts
are concentrated in 72 villages situated in forest and forest fringe areas, with a
significant portion falling within the core zone of Achanakmar Tiger Reserve,
renowned for its abundant natural beauty.
Problems Identified

The health situation in rural India is precarious due to the decline of traditional
medicine and the inadequacy of modern healthcare for economically and socially
disadvantaged populations. High costs and limited accessibility lead to a
distressing cycle of debt and poverty, worsened by new government economic
policies. These policies, including drug privatization, further reduce healthcare
accessibility for the rural poor, intensifying health disparities and perpetuating the
cycle of poverty.

The tribal communities the JSS team works with are predominantly these:
Oraon
Gond Majhi

Kanwar Dhanuar

Kol Birhor

6|Page
JSS PROGRAMME STRUCTURE

TIER 3
Referral Centers

TIER 2
3 Sub-centers

TIER 1
144 Village Heath Workers for Forest & Forest Fringe Areas

JSS: AREAS OF WORK

Out-patient Clinic

Rural Out-reach Clinic Village Health Program

JSS

7|Page
Ganiyari Outpatient Clinic
The center accommodates an outpatient clinic equipped with a cost-effective
pharmacy along with specialisation in Family Medicine, Obstetrics and
Gynaecology, Surgery, Paediatrics, Ophthalmology, Dental, and Ayurveda. With a
well-equipped laboratory running 24*7 (including a microbio laboratory),
pharmacy with a range of medicines available at a marginal cost, an inhouse blood
storage unit, an HDU, three operation theatres, a newborn care unit and a labour
room.

Rural Outreach Clinics

Every week, three outreach clinics are conducted with a complete team of doctors,
laboratory technicians, and pharmacy staff at three different sub-centers situated up
to 60 km away from Ganiyari. These clinics specifically cater to isolated forest and
forest-fringe villages, serving numerous individuals from the Baiga tribe, a
marginalized community often underserved by modern facilities. The sub-centre
clinics maintain several laboratory testing capabilities and provide medications
similar to those available at the referral hospital. Here, individuals can receive both
acute and chronic care for various conditions. If necessary, they can be referred to
the Ganiyari hospital for a higher level of medical care.

Village Health Program

A comprehensive community health program is implemented in 72 villages
situated in the forest and forest fringe areas of Mungeli and Bilaspur districts in
Chhattisgarh. The initiative aims to bring healthcare services closer to the homes of
people, minimizing the need for extensive travel. The 146 Village health workers,
spread in each hamlet, are the backbone and serve as the first contact for all the
health needs, including identifying and treating common illnesses in the villages.

8|Page
Sub-Centres

Three different sub-centres Semariya, Shivtarai and Bamhni are located up to 60

kilometres from Ganiyari. Clinics serve many members of the Baiga tribe, a
marginalized minority that is frequently excluded from modern services. Many of
the laboratory testing facilities and drugs accessible at the referral hospital are
retained at sub-centre clinics. Individuals can receive both acute and chronic care
for a variety of ailments at the sub-centres, and if necessary, they can be referred to
Ganiyari Hospital for a higher level of care.

Sub-centre boasts a significant healthcare provision in the form of a mobile clinic

held every Tuesday. This initiative ensures uninterrupted access to healthcare
services, with the health team from JSS Ganiyari, comprising a doctor, two senior
health worker, delivering consultations, treatments, and necessary referrals. The
team also distributed medicines based on diagnoses, conducted sample collections,
and needful referrals to JSS for further investigations and management.

9|Page
Maternal & Child Health
In 2004, antenatal care (ANC) clinics were launched in six distinct villages within
the Bilaspur district to enhance mother and child health services in the area. The
ANC clinics were established with the subsequent objectives:

1. To recognize high-risk pregnancies;

2. To guarantee early pregnancy registration;
3. To encourage institutional delivery
4. To avoid problems before, during, and after childbirth

Pregnant women are checked at ANC clinics to make sure the foetus is developing
normally and the mother's health is still intact. They also learn the significance of
proper nutrition throughout pregnancy and how to recognize warning signs
for pregnancy complication.

In addition, regular Dai trainings are conducted to traditional birth attendants

(TBAS), teaching them safe home delivery techniques and appropriate referral
procedures. Because of persistent advocacy efforts, referral services and
emergency transportation have significantly improved in recent years.
Additionally, a government ambulance is currently stationed in one of our distant
villages for prompt access in an emergency.

10 | P a g e
Disease Support Peer Group
First peer support group thus started in February 2013 with 11 patients with sickle
cell disease. Between February and September 2013, groups had formed for sickle
cell disease, epilepsy, diabetes, major psychiatric illnesses, alcohol dependence,
airborne contact dermatitis, hypertension, chronic arthritis, and asthma and chronic
lung diseases. Physical activity was woven into sessions as games or exercise.
Each group got a small allowance for tea and snacks of 250 rupees. Each group
selected a chairperson and secretary among the participants who organised the
meeting and agenda.

Greater adherence has resulted from peer groups being able to support and
motivate members. Peer support promotes self-care and improved disease
outcomes.

11 | P a g e
Phulwari Program
Jan Swasthya Sahyog (JSS) Health Centre is located in Ganiyari, Chhattisgarh and
its community health programs are accessed by people from surrounding 2500
villages of north and central Chhattisgarh and eastern Madhya Pradesh for their
health needs. It is a healthcare initiative dedicated to promoting public health in the
Chhattisgarh region. Committed to community well-being, it focuses on providing
healthcare support, raising awareness, and implementing programs to address
health challenges. With a holistic approach, JSS strives to create a healthier and
more resilient community through its various healthcare initiatives.

Overview of the program:

A vital part of the JSS activity is to improve the nutritional status of children under
three years of age utilizing the local resources and these centers are called
phulwaris (or creches) which is a comprehensive initiative catering to children
aged 6 months to 3 years. Through this program, JSS not only provides crèche
facilities but also supplements nutritional needs and fosters cognitive
development. By aligning with the broader goals of JSS, the Phulwari program
contributes significantly to the organization's commitment to enhancing public
health and
well-being in this region.

Local community-selected women manage the crèches, overseeing up to ten

children individually. In some villages, multiple crèches exist, each managed by a
different worker(s) according to the number of children. Furthermore, supervisor
visits phulwari to ensure proper functioning of the same and monthly meetings
review crèche functioning, replenish supplies, and include health teachings.
Children at the daycare centers are provided with khichdi twice a day, "sattu" and
iron syrup once daily, and receive eggs three times a week, with malnourished
children receiving six eggs per week. Food preparation by women's groups (Self
Help Groups) in a village cluster is overseen by JSS. Crèches are equipped with
toys to support learning. The working hours are generally 9a.m to 5p.m and the
timing can vary from 6a.m to 4p.m according to the work timing of MNREGA.
Mothers with infants often return twice daily to breastfeed their children.

12 | P a g e
13 | P a g e
The Project:

Phulwaris are community-run creches that were started ten years ago by Jan
Swastha Sahyog (JSS). The principal goal of the Phulwari program is to combat
malnutrition in children between the age group of 0.5-3 years.
By providing a reliable day-care service to the rural poor, the Phulwari program
has not only helped alleviate child malnutrition, but has also solved other social
problems like dropping out of older kids from school and staying back of women
from work to take care of their infants and even improved the inter-caste social
dynamics.

Objectives:

a. To provide a safe, secure, and stimulating environment for young children,

6 months to 3 years of age, when their parents are out for work

b. To demonstrate to mothers that older infants (beyond 6 months) can

consume and digest food other than breast milk, and that they thrive on
it.

c. To prevent malnutrition among this age group and where children

are malnourished, to improve their nutritional status.

d. To help older siblings who have dropped out of school, for the care of
the younger child, to return to school.

e. To allow parents to go out for work and increase their income that
accrues out of it.

Nutrition:
Under-nutrition in children below 3 years of age is a very serious problem among
the poor. Under-nutrition can lead to increased chances of falling ill and sometimes
even dying. It certainly causes poor intellectual development in a child affecting
his/her cognitive capacities. Under-nourished children grow into under-nourished
adults with poor working capacity and hence earning capacity, keeping them in a

14 | P a g e
15 | P a g e
poverty trap. Undernourished girls grow up into weak mothers and give birth
to under-weight babies, thus maintaining the vicious cycle of ill health.
To combat this issue, Phulwaris provide wholesome meals consisting of sattu
(wheat, barley and peanuts), khichdi (rice and lentils) and boiled eggs along with
clean water. The Phulwaris also provide nutritional supplements (iron and folic
acid), together with essential vaccines. They also have separate playing and
napping areas for the children. Crèche workers are trained in basic hygiene,
childcare and nutrition and in managing common illnesses like fever and diarrhea.

A network of health workers is also present in each village that monitors the
children’s health on a weekly basis and take care of more serious illnesses.

The diet at the centre consists of the following:

 9 am: Snack of Sattu– 60gm per child per day (A mixture of wheat (50%),
barley (25%) and peanuts (25%) are cleaned, roasted and ground together.
200 gms of this is added to 100 gms of sugar to make a packet of 300 gm
of sattu). One packet of sattu is served to five children each day.

 12 noon: Meal of Khitchdi– Rice:Daal 5:1 (125 gm of rice and 25 gm of

daal is cooked per child per day. Half of this is served at noon, with 5 ml
of oil is added on top of the food after it is served onto the child’s plate).

 3pm: Second meal of Khitchdi– same as the lunchtime meal.

 A boiled egg is provided to every child thrice a week.

Early Child Care & Education:

Since 2014, JSS has also started an ‘early child care and education’ program in
some existing phulwaris wherein they provide educational toys and games. Crèche
workers are trained to engage in games/songs to stimulate learning in the children.
In the future, JSS plans to expand the reach of the Phulwari program to about 10
new crèches per year while also augmenting the infrastructure of the existing
phulwaris. They are also planning to build 2 model phulwaris for demonstration
and training purposes.

16 | P a g e
Growth monitoring:
Anthropometric measurements are monitored every month by the Phulwari
supervisor and undernourished children are given special attention– an additional
ration of khitchdi. If there is no improvement in weight, the senior health worker
examines the child and refers it to the subcentre clinic on the day the doctor visits.
Those who are severely malnourished and need further investigation are referred to
Ganiyari.

Capacity Building:
A Phulwari unit has one caretaker for ten children. Sometimes this goes up to 12
children. But any centre that has 13 or more children has two women to take care
of them. These caretakers are from the same village community, and have
received training in basic child care, hygiene, nutrition and health. Their skills are
being upgraded periodically in facilitating early child learning and play.

Location of Phulwari:
A large village may have more than one Phulwari so that the centre is close to the
children’s homes since parents are unwilling to send children far from the home to
the centre. Parents drop the child off and collect them at the end of the day.
The crèches normally function out of a rented room– sometimes two rooms are
made available. The room needs to be large enough for the number of children,
easy to clean, and in a safe location (as in, not located right next to a pond for
instance). Cooking is not done in the same room where the children are kept: it is
in another room, or in the open air. The crèche is not run in the home of the crèche
worker unless no other space is available.

Policy changes:
The problem of under-three malnutrition has been highlighted time and again by
JSS over the last two years. As a result of their successful advocacy at the national
level, Public Health Resource Network has launched a similar program in
Jharkhand, Bihar, Chhattisgarh and Orissa under the project AAM (Action Against
Malnutrition) in collaboration with JSS and some other NGOs. With the support of

17 | P a g e
JSS, the Madhya Pradesh government has also launched its own Anaganwadi-cum-
creche scheme on a pilot basis in 100 Anganwadis. Many more organizations have
approached JSS to get training in running rural crèches and have gone on to start
their own.
Impact:

 Steep reduction in malnourishment in under 3 children

 Enables both parents to work without worry
 Enables older sibling to attend school and not having to care for the
younger ago

A Visit to Phulwaris Located In Shivtarai

On the 28th of August 2024, we visited 2 phulwaris in Shivtarai (Karka &

Kewrapara) to gain insights into its operations and services. The Karka phulwari
has enrolled thirteen children and Kewrapara phulwari has enrolled seventeen
children ranging in age from more than six months to 36 months. The phulwaris
are managed by two workers.

Operating from 9 a.m. to 5 p.m., the phulwari workers follow a structured routine.
They commence the day by administering iron-folic acid syrup to the enrolled
children. Subsequently, the children are provided with sattu once and khichdi twice
a day. Additionally, an egg is incorporated with the khichdi three times a week,
while malnourished children receive double the amount of eggs received by the
normal child. The workers actively promote handwashing with soap and water.

To enhance cognitive development, the phulwari features a sand playground

named "Ret Aangan." For elementary education, educational charts depicting
various flowers and animals are displayed. The phulwari also features a kitchen
garden where brinjal, spinach, radish, carrot, and other vegetables are cultivated.
These homegrown produce items are later utilized in the preparation of nutritious
khichdi, ensuring a wholesome diet for the enrolled children.

18 | P a g e
Learnings:

Community Engagement: Through the visit, we discovered that village health

workers actively mobilize children, ensuring regular nutrition and follow-ups at
the Phulwaris.

Understanding Village Life: Exposure to village life revealed crucial issues like
malnutrition, electricity and school accessibility, emphasizing the challenges faced
by the villagers.

Nutrition Initiative - Poshan Badi: The Poshan Badi initiative in Phulwari,

focusing on locally cultivated vegetables for nutrition, was recognized as a positive
and sustainable effort

Adaptability: Learning to work in adverse conditions with minimal resources

showcased the importance of adaptability.

19 | P a g e
20 | P a g e
21 | P a g e
 Antenatal Care (ANC) Visit

Cluster-Based Approach to Healthcare

JSS divides the regions it serves into clusters to improve healthcare access and
organization. The Tendukona cluster, which includes the villages of Semariya and
Shivtarai, has a dedicated subcenter that provides various healthcare services, with
a particular focus on maternal and child health. This cluster-based approach allows
JSS to ensure that even the most remote populations have access to essential
healthcare.

Figure 1 : Registration counter

Importance of ANC in Rural Areas

In rural settings like Semariya and Shivtarai, access to healthcare is often limited
due to geographical and socio-economic factors. ANC services are vital for
monitoring the health of pregnant women, ensuring early detection of
complications, providing nutritional support, and promoting safe childbirth
practices. These clinics help in reducing preventable deaths among mothers and
infants.

22 | P a g e
Objective of the Visit

The purpose of this visit was to observe the operations of ANC clinics in Semariya
and Shivtarai villages, which fall under the Tendukona cluster of JSS. The aim
was to understand how ANC services are provided in these subcenters and to
assess the impact on maternal health in rural areas.

Observations at Subcenter

The Semariya subcenter is a small, basic facility located within the village, easily
accessible to the local population. It is staffed by a dedicated team of healthcare
workers, including a general nursing and midwifery (GNM), senior health
worker(SHW), and a visiting doctor. Despite limited resources, the subcenter is
functional and well-organized to deliver basic healthcare services.

Antenatal Care Services

During the ANC clinic, several pregnant women attended for their regular
checkups. Services provided included routine health monitoring (blood pressure,
weight checks, and fetal assessments), nutritional counseling, and the distribution
of iron and folic acid supplements. Immunizations, such as tetanus shots, were also
administered. The clinic focused on preventive care, educating mothers on the
importance of nutrition and hygiene during pregnancy.

Diagnostic service at ANC

The ANC clinic in both Semariya and Shivtarai includes a range of essential
diagnostic tests aimed at ensuring the health of both the mother and the baby.
These tests include urine analysis to detect infections or abnormalities,
hemoglobin (Hb) tests to assess for anemia, and blood sugar tests to monitor
gestational diabetes. Additionally, screenings for sickle cell disease, blood group
typing, and crucial infectious diseases like HIV, hepatitis B (HBV), and malaria
are conducted. These tests help in early detection and management of potential
health risks during pregnancy, contributing to safer maternal outcomes.

23 | P a g e
Health Education and Counseling

During our visit, the healthcare workers were actively engaged in a health
awareness session focusing on malaria and diarrhea. They emphasized preventive
measures, such as the importance of using mosquito nets, keeping living areas
clean, and seeking timely medical help. For diarrhea, the discussion highlighted
the need for proper sanitation, safe drinking water, and the use of oral rehydration
solutions (ORS) to prevent dehydration. This session aimed to equip the
community with practical knowledge to reduce the incidence of these common but
serious health issues.

Figure: Health awareness session conducted by SHW

24 | P a g e
 Figure: Laboratory

Figure: Labour room

25 | P a g e
 Assignment
TITLE: Study on Intra-Familial Transmission of Tuberculosis (TB) in
Ganiyari, Chhattisgarh

RATIONALE
Tuberculosis (TB) continues to be one of the most significant public health
challenges globally, particularly in low- and middle-income countries like India,
where rural areas such as Ganiyari in Chhattisgarh are disproportionately affected.
TB is a contagious disease primarily spread through airborne transmission, often
within close-contact environments such as households. Intra-familial transmission,
wherein one family member infects another, is particularly common due to the
prolonged exposure that occurs in shared living spaces. This study focuses on
intra-familial transmission as a critical factor in the persistence and spread of TB
within communities like Ganiyari.

The rural population of Ganiyari faces several socio-environmental challenges that

exacerbate the spread of TB within families. Poor housing conditions, including
overcrowding, inadequate ventilation, and substandard sanitation facilities,
contribute significantly to the risk of transmission. These conditions allow the
bacterium Mycobacterium tuberculosis to spread more easily through air droplets
expelled by coughing, sneezing, or speaking. Overcrowded homes, common in
rural settings, increase the risk of exposure, especially when infected individuals
are not isolated effectively.

Another key factor is the weakened immune systems of certain household

members, such as the elderly, young children, and individuals with pre-existing
health conditions like diabetes or HIV. These individuals are not only more
susceptible to contracting TB but also face more severe forms of the disease. In
older populations, co-morbidities like chronic obstructive pulmonary disease
(COPD) and diabetes complicate TB management and often lead to delayed
diagnosis and treatment. This delay increases the risk of continued transmission
within the household before the disease is detected and treated.

26 | P a g e
Moreover, limited access to healthcare and health-seeking behaviors in rural
areas hinder early diagnosis and treatment, further exacerbating the problem. Many
individuals in Ganiyari may not seek medical care due to a lack of awareness,
financial barriers, or physical distance from healthcare facilities. This delay in
diagnosis allows TB to spread unchecked within households, affecting multiple
family members before treatment begins. In some cases, socio-cultural factors such
as stigma associated with TB prevent individuals from disclosing their symptoms
or seeking timely medical help, thus increasing the transmission risk.

Intra-familial transmission is a multifaceted issue, influenced by both

environmental and behavioral factors. Inadequate ventilation in homes, for
instance, makes it harder for airborne pathogens like TB to disperse, increasing the
likelihood of infection among household contacts. Additionally, behavioral factors
such as smoking, alcohol consumption, and poor nutritional status further weaken
the immune system, rendering individuals more vulnerable to infection.

The study aims to identify key factors responsible for intra-familial TB

transmission to inform prevention strategies. This includes assessing housing
conditions, household demographics, co-morbidities, and access to healthcare
services. By understanding these dynamics, targeted interventions—such as
improving living conditions, promoting health education, and ensuring timely
healthcare access—can be designed to reduce transmission within households.
Additionally, early diagnosis of TB through regular screening of household
contacts can significantly reduce transmission rates and improve treatment
outcomes.

Ultimately, prevention strategies that focus on environmental modifications (e.g.,

improving ventilation and reducing overcrowding), along with health interventions
(e.g., screening programs, vaccination, and treatment adherence support), can help
contain intra-familial transmission. This study is crucial in addressing the gap in
TB control, particularly in rural areas where resources are limited, but the burden
of disease is high. Addressing intra-familial transmission not only protects
vulnerable household members but also contributes to broader TB control efforts in
the community.

This detailed exploration of intra-familial TB transmission highlights the

importance of addressing environmental, behavioral, and healthcare access issues
to prevent further spread and reduce the overall TB burden in regions like
Ganiyari.

27 | P a g e
 REVIEW OF LITERATURE

S. No. Title of Study Author’s Name Type of Study Result

1. Active case Chawla et al. Community-based Chawla et al. (2020) found

finding of (2020) cross-sectional that 1.97% of household
tuberculosis study contacts of TB patients were
among household diagnosed with tuberculosis.
contacts of newly Symptom screening identified
diagnosed 12.1% of contacts with TB
tuberculosis symptoms, and 18.9% of those
patients: A tested were confirmed to have
community-based the disease. The study
study from highlighted those factors like
southern Haryana lower BMI, increased contact
hours with the index case,
smoking, and diabetes
significantly increased the risk
of TB among household
contacts.
2. Pulmonary Raj Kumar, M. Cross-sectional The study, conducted among
tuberculosis Saran, B. L. observational 1810 contacts of tuberculosis
among contacts of Verma, and R. N. study (TB) patients, found that the
patients with Srivastava (1984). overall prevalence of
tuberculosis in an radiologically active
urban Indian tuberculosis was 2.9%, and
population bacteriologically confirmed
tuberculosis was 1.1%. The
prevalence was significantly
higher in household contacts
(5.4% radiologically active,
2.6% bacteriologically
confirmed) compared to
neighborhood contacts (2.3%
radiologically active, 0.8%
bacteriologically confirmed).
The study also highlighted the
need for screening not only the
family members but also
neighborhood contacts for TB
detection.
3. Tuberculosis Velayutham B, prospective cohort HHC information was
screening in Jayabal L, Watson study documented for 93%
household B, Jagadeesan S, (1268/1364) of Index PTB

28 | P a g e
 contacts of Angamuthu D, patients. The main reasons of
pulmonary Rebecca P, et al. non-listing of HHC in 96 PTB
tuberculosis (2020) patients were HCW non-
patients in an availability or non-co-
urban setting operation of the HHC. There
were 2150 (80%) contacts who
were screened for TB.
Inconvenient time, feeling
healthy, stigma, out-station
visit were the main reasons for
537 contacts not undergoing
TB screening. Anti-TB
treatment was initiated in 21
(1%) of contacts diagnosed
with TB. Preventive therapy
was initiated in 59% (81/138)
of contacts aged
4. Prevalence and M Singh, M L prospective, : Tuberculin test was positive
risk factors for Mynak, L Kumar, J hospital based, in 95 of 281 contacts (33.8%),
transmission of L Mathew, S K descriptive study of which 65 were contacts of
infection among Jinda (2005) was conducted sputum positive patients, while
children in over a period of 30 were contacts of sputum
household contact 18 months negative patients. Nine of
with adults having these children were diagnosed
pulmonary as having tuberculosis based
tuberculosis on clinical features and/or
recovery of acid-fast bacilli;
seven were in contact with
sputum positive adults. The
important risk factors for
transmission of infection were
younger age, severe
malnutrition, absence of BCG
vaccination, contact with an
adult who was sputum
positive, and exposure to
environmental tobacco smoke
5. History of H. D. Shewade, V. Limitations notwithstanding,
household Gupta,S. this analysis presents potential
member with Satyanarayana, S. information to programme
tuberculosis or S. Chadha, S. managers regarding the
related death in Pandurangan,2S. population-level benefit of
newly diagnosed Mohanty, A. M. V. TPT among all household
patients in India Kumar contacts in marginalised and
(PUBLISHED 21 vulnerable populations in
JUNE 2020) India. This is important

29 | P a g e
 considering the high mortality
observed in these TB-affected
households. Targeted TPT (if
implemented in a phased
manner) among female
household contacts may be
explored after considering
other factors such as TB
incidence among female
household contacts when
compared to males. Future
studies from other low to high
prevalence settings of India
may include i) subgroup data
on diabetes and other chronic
diseases, ever use of tobacco
and alcohol, and residence in
slums, and ii) timing of
household TB exposure and
TB-related death.
6. Identificationof Gry Klouman Nested within a : Of 525 HHCs, 29 were Mtb-
subclinical Bekken et al. large prospective culture positive and 96.6% of
tuberculosis in (2020) study in these asymptomatic. The TCS
household household and the Infectivity Score
contacts using contacts (HHCs) associated with positive
exposure scores of smear positive Tuberculin Skin Test and
and contact pulmonary TB QuantiFeron TB-Gold In-tube
investigations cases in South- assay (QFT) results in
India conducted multivariate analyses (TCS:
2010–2012 ORTST 1.16, 95% CI: 1.01,
1.33; ORQFT 1.33 95% CI:
1.16, 1.51. Infectivity Score:
ORTST 1.39, 95% CI: 1.10,
1.76; ORQFT 1.41 95% CI:
1.16, 1.71). The Infectivity
Score showed a moderate
capability to identify
subclinical TB (AUC of 0.61,
95% CI: 0.52, 0.70).
7. Partitioning the McIntosh AI, observational Key findings include:
risk of Jenkins HE, epidemiological Community transmission
tuberculosis Horsburgh CR, study was higher in Uganda than in
transmission in Jones-Lo´pez EC, Brazil, with probabilities
household contact Whalen CC, ranging from 0.21 to 0.69 in
studies Gaeddert M, et al. Uganda and 0.13 to 0.50 in
(2019) Partitioning Brazil. Adults were more

30 | P a g e
 the risk of likely to acquire TB from the
tuberculosis community than children.
transmission in Household transmission was
household contact more common for children
studies than adults, indicating that
children are more likely to be
infected by someone within
the household.
HIV status influenced
transmission, with household
contacts of HIV-negative
index cases more likely to be
infected through community
sources than those in contact
with HIV-positive index
cases.
Risk factors for transmission
within households included
close proximity to the index
case, advanced disease, and
the presence of lung
cavitations in the index case.

8. Transmission of Leonardo Systematic Key results include:

Mycobacterium Martinez*, Reviews and Children exposed to a
tuberculosis in Ye Meta- and Pooled household member with TB
Households and Shen, Ezekiel Analyses were 3.79 times more likely to
the Community: A Mupere, Allan be infected compared to those
Systematic Kizza, Philip C. unexposed.
Review and Meta- Hill, and Younger children (0-4 years)
Analysis Christopher C. had a higher risk of infection
Whalen (2016) compared to older children.
The risk was higher if the
index case (the initial TB
patient) was smear-positive
for TB, indicating more
infectiousness.
Although household
transmission is significant,
only about 11.3-14.1% of
overall TB transmission in
communities can be attributed
to household exposure,
meaning most transmission
occurs outside the home.

31 | P a g e
9. Tuberculosis Mercedes C retrospective 693 households of index
burden in Becerra, Sasha C cohort study of patients with MDR
households of Appleton, Molly F household tuberculosis were enrolled in
patients with Franke, Katiuska contacts of the study. In 48 households,
multidrug- Chalco, Fernando patients treated for the Mycobacterium
resistant and Arteaga, Jaime MDR or XDR tuberculosis isolate from the
extensively drug- Bayona, Megan tuberculosis in index patient was XDR. Of the
resistant Murray, Sidney S Lima, Peru, in 4503 household contacts, 117
tuberculosis: a Atwood, Carole D 1996–2003 (2·60%) had active
retrospective Mitnick (2010) tuberculosis at the time the
cohort study index patient began MDR
tuberculosis treatment—there
was no diff erence in
prevalence between XDR and
MDR tuberculosis households.
During the 4-year follow-up,
242 contacts developed active
tuberculosis—the frequency of
active tuberculosis was nearly
two times higher in contacts of
patients with XDR
tuberculosis than it was in
contacts of patients with MDR
tuberculosis (hazard ratio
1·88, 95% CI 1·10–3·21). In
the 359 contacts with active
tuberculosis, 142 (40%) had
had isolates tested for
resistance against fi rst-line
drugs, of whom 129 (90·9%,
95% CI 85·0–94·6) had MDR
tuberculosis
10. Transmission Jun Chen, Lifeng cohort study The time interval between the
of multidrug- Chen, Meng Zhou , index patients and the
resistant Gang Wu, Fenglian secondary patients ranged
tuberculosis Yi , Chen Jiang , from half a month to 110
within family Qionghong Duan months. Thirteen secondary
households and Meilan Zhou patients developed active
by DTM-PCR (2022) MDR-TB within two years
and MIRU-VNTR and accounted for 50% (13/26)
genotyping of all secondary patients.
Among eleven pairs of MDR-
TB families, six pairs had
identical genotypes, the cluster
rate was 54.5% (12/22); three
pairs had a single MIRU-

32 | P a g e
 VNTR locus variation. If a
single MIRU-VNTR locus
variation was tolerated in the
cluster defnition, the cluster
rate raised to 81.8% (18/22)

OBJECTIVES
How much family transmission has happened?
What are the factors responsible for intra-familial transmission and what can be
done to prevent intra-familial transmission, and facilitate early diagnosis of intra-
familial TB transmission?

METHODOLOGY
Study Design: Retrospective Cohort Study
Sampling Technique: Convenient sampling
Study population:
The study conducted in two clusters of Ganiyari district (Semariya, Shivtarai),
Chhattisgarh, chosen based on their diverse demographic and socioeconomic
characteristics.
Inclusion Criteria:
 Individuals diagnosed with TB in the past 20 years.
 Residing in any of the two clusters of Ganiyari district, i.e., Semariya, &
Shivtarai.
Exclusion Criteria:
 Individuals with significant cognitive impairment that prevents participation
in the study.
 Individuals who do not provide consent for participating in the study.

DATA COLLECTION TOOLS

Structured questionnaires will be used to collect data on socio-demographic
characteristics, history of present illness, and environmental factors.

33 | P a g e
34 | P a g e
DATA COLLECTION PROCEDURE

Data collectors visited participants’ houses in all the clusters of Ganiyari district.
Ensure confidentiality and obtain informed consent before administering the
questionnaire.
The structured questionnaires administered face-to-face by data collectors to assess
the intra-familial transmission of tuberculosis, and potential ways to ensure early
diagnosis of intra-familial transmission.

DATA ANALYSIS PLAN

The quantitative data collected during the study period entered into an excel sheet
and analysed using an analysis software and the qualitative data analysed using
thematic analysis method.

35 | P a g e
Conceptual Framework for Intra-Familial Transmission of
Tuberculosis

36 | P a g e
IMPACT OF THE STUDY

1. Public Health Impact

Enhanced TB Control Strategies: The study provides critical insights into the
factors contributing to intra-familial TB transmission, enabling the design of
targeted interventions to prevent and control TB within households. This can lead
to improved TB control strategies, especially in rural and resource-limited settings.
Reduction in TB Transmission Rates: By identifying high-risk groups (e.g.,
elderly, children, individuals with comorbidities) and implementing early
screening and prevention strategies, the study can help reduce TB transmission
rates among household contacts.
Better Understanding of TB Dynamics in Rural Areas: The study sheds light on
how socio-environmental factors like overcrowding, poor ventilation, and limited
healthcare access contribute to TB spread. This understanding can inform public
health policies focused on rural areas where these challenges are more pronounced.

2. Healthcare System StrengtheninG

Improved Community-Based TB Care Models: The findings can help in

developing and refining community-based TB care models, such as home-based
care and integrated care approaches that address TB along with other chronic
conditions. This could lead to better treatment adherence and outcomes.
Empowerment of Community Health Workers (CHWs): Engaging CHWs to
conduct systematic screening, contact tracing, and providing home-based care can
empower them and enhance their role in TB prevention and control, creating a
more resilient healthcare workforce.

3. Policy and Programmatic Impact

Informing TB Control Programs: The study’s findings can influence TB control

programs like the National TB Elimination Program (NTEP) in India to adopt
more focused and localized strategies for rural settings, such as Ganiyari. Policies
can be refined to incorporate environmental modifications (e.g., improving
ventilation), awareness campaigns, and nutritional support initiatives (e.g., Nikshay
Poshan Yojana).
Resource Allocation: Understanding the specific challenges and facilitators in
rural settings can guide more effective allocation of resources, ensuring that
interventions reach the most vulnerable populations.

37 | P a g e
 4. Social Impact

Reduced Stigma and Improved Awareness: By identifying barriers such as

stigma and lack of awareness, the study can help develop educational and
advocacy campaigns that reduce stigma associated with TB and encourage health-
seeking behavior. Increased awareness can lead to earlier diagnosis and reduced
intra-familial transmission.
Behavioral Changes: The study can promote healthy behaviors that reduce TB
risk, such as the use of masks, improving ventilation, avoiding smoking, and
maintaining better nutritional status.

5. Research and Knowledge Impact

Contribution to Scientific Knowledge: The study adds valuable data on intra-

familial TB transmission dynamics, particularly in rural and underserved settings.
This can serve as a basis for further research on TB transmission patterns,
prevention strategies, and the effectiveness of interventions.
Evidence for Multisectoral Approaches: The findings highlight the need for
multisectoral approaches that address environmental, social, and health system
factors. This evidence can be used to advocate for integrated strategies that go
beyond the health sector alone.

6. Long-term Impact

Sustainable TB Control: With a better understanding of the intra-familial

transmission, there can be a shift towards more sustainable TB control practices
that reduce the burden on healthcare systems and communities over the long term.
This can contribute to India's goal of TB elimination by 2025 and ultimately reduce
the global TB burden.
Overall, the study has the potential to make significant contributions to TB control
efforts by addressing intra-familial transmission, particularly in resource-limited
rural settings, thereby improving both individual and community health outcomes.

38 | P a g e
Annexure 1

Questionnaire

Section A: Environmental and Housing Factors

1. Housing Conditions

1.1 What is the average number of people living in your household?

1.2 How many rooms are there in your house?
1.3 Does your house have proper ventilation (e.g., windows, exhaust fans)?
1.4 How often do you keep windows and doors open for ventilation?
1.5 What type of materials is your house constructed from?

2. Overcrowding

2.1 How many people usually sleep in one room in your household?
2.2 How often do you have visitors staying overnight in your home?

3. Sanitation and Cleanliness

3.1 Do you have access to clean drinking water? (piped, borewell, or surface
water sources)
3.2 How often do you clean your living spaces?
3.3 What type of toilet facility does your household use?

Section B: Migrant Factors

4. Migration Patterns

4.1 Have you or any of your household members migrated to another area for
work?
4.2 If yes, how long do they typically stay away?
4.3 Where do they migrate to for work? (Nearby town/city, Another state,
Another country, Other)

39 | P a g e
5. Living Conditions During Migration

5.1 What type of accommodation do they typically live in while working away?
(Rented room, Shared dormitory, Temporary shelter, Other)
5.2 How many people usually share the accommodation with them?
5.3 Are there adequate sanitation and ventilation facilities at their place of stay?

6. Health and TB Awareness Among Migrants

6.1 Do the migrating members of your household have access to healthcare in

the area where they work?
6.2 Have they ever been screened for TB during their stay away from home?
6.3 How often do they return home to visit?
6.4 Do they bring any health issues when they return home?

7. Social and Cultural Factors

7.1 Are there any local beliefs or stigma related to TB and migration?

Section C: Healthcare Access

8. Availability of Healthcare Services

8.1 How far is the nearest healthcare facility from your home?
8.2 What type of healthcare facility is it?
8.3 How often do you visit a healthcare facility for health check-ups or
treatment?

9. Accessibility and Affordability

9.1 How do you usually travel to the healthcare facility? (walk, cycle, public
transport, private vehicle, others)
9.2 Are there any financial barriers that prevent you from accessing healthcare
services?
9.3 How much do you typically spend on healthcare services (including travel)
per visit?

10. Quality of Healthcare Services

10.1 How long does it usually take to receive treatment after a TB diagnosis in
your area? (Immediately, Within a week, More than a week, Others)

40 | P a g e
 10.2 Have you or anyone in your household faced any challenges in receiving
TB treatment?

11. TB Awareness and Health Education

11.1 Have you received any information or education about TB from healthcare
providers?
11.2 Do you know where to get tested for TB in your area?
11.3 Are there any TB awareness programs in your community?

Section D: Socioeconomic and Behavioral Factors

12. Socioeconomic Status

12.1 What is the primary source of income for your household? (Agriculture,
daily wage, salaried, others)
12.2 What is your average monthly household income?
12.3 Does your income level affect your ability to seek timely medical care?
12.4 Have you ever had to choose between healthcare and other basic needs
(e.g., food, education)?

13. Behavioral Factors

13.1 Do you or anyone in your household use tobacco or consume alcohol?

14. Health-Seeking Behavior

14.1 How soon do you seek medical help when you or someone in your
household shows symptoms of TB (e.g., persistent cough, weight loss)? –
immediately, after a day, after a week, others
14.2 What is your main reason for delaying medical help? (Lack of awareness
about TB symptoms, Fear of diagnosis, Financial constraints, No nearby
healthcare facility, Others)

15. Social and Cultural Factors

15.1 Is there any stigma associated with TB in your community?

15.2 How does stigma affect your willingness to seek treatment for TB?
(prevents, delays)

41 | P a g e
 15.3 Are there any traditional beliefs or practices in your community that affect
how TB is perceived or treated?

42 | P a g e
KEY LEARNINGS

During the internship period, I gained valuable insights into the intricacies of
providing comprehensive healthcare to marginalized populations with minimal
costs. The experience illuminated the importance of creating health awareness
initiatives that effectively motivate individuals to actively seek healthcare services.
Engaging in the proper training of tribal communities emerged as a critical
component in fostering their participation in health awareness and screening
programs, thereby reinforcing their health-seeking behavior.

The internship further enhanced my proficiency in designing different types of

studies and formulating interview guides. This skillset is pivotal in conducting
research that delves into the nuanced aspects of public health, ensuring a holistic
understanding of the diverse needs and challenges faced by communities.

The hands-on involvement in the research study on Tuberculosis transmission

provided a nuanced comprehension of the factors involved in the transmission and
its significance in the context of public health. This knowledge not only enriched
my academic repertoire but also holds substantial relevance for my career
prospects, as it equipped me with practical insights into community-based health
interventions.

Moreover, immersing in the rural milieu allowed me to grasp the intricacies of

village life, understanding the intricacies of their lifestyles, and identifying
prevalent health issues. This experiential understanding is invaluable for
formulating future policies that address the unique health concerns of rural
communities. The exposure to diverse perspectives and challenges during the
internship has undoubtedly contributed significantly to my academic and
professional growth, providing a solid foundation for my future endeavors in the
field of public health.

43 | P a g e
44 | P a g e