The TB-undernutrition syndemic: Evidence from the RATIONS trial of nutritional supplementation in Jharkhand, India
This seminar will discuss The Reducing Activation of Tuberculosis by Improvement Of Nutritional Status (RATIONS) trial. This was a multi-institutional cluster randomised trial, supported by the Indian Council of Medical Research, conducted between 2019 -2022 in four districts of Jharkhand. It was the first trial globally to aim for a reduction of tuberculosis (TB) incidence by improving the nutritional status of those at risk, and it was the largest cohort study of patients with TB who were given nutritional support to improve TB treatment outcomes.
The trial enrolled 2800 patients with microbiologically confirmed TB and their 10,345 household members. The household contacts in the clusters in the intervention arm received a food basket and patients as a cohort in both the arms received a food basket during the treatment period. The trial was conducted in a population with high rates of malnutrition in contacts and very severe undernutrition in patients (1 in 6 patients had a BMI of less than 14).
In household members, the TB incidence was reduced by nearly 40-50%, while in the case of patients with TB, there was 35-50% lower mortality, better weight gain, low rates of loss to follow up and high rates of return to normal work.
Madhavi Bhargava, Associate Professor in the Deptartment of Community Medicine, Yenepoya Medical College; Deputy Head, Center for Nutrition Studies, Yenepoya (Deemed to be University), Mangaluru
Madhavi was first trained as an ENT surgeon, despecialised to work as a primary care physician as well as a general surgeon in rural areas of Chhattisgarh for a decade. She then did a second post-graduation in her 40s and now teaches Community Medicine to undergraduates and postgraduates in Mangalore. Her work focuses on primary care, social determinants of health, adolescent and maternal nutrition and investigating the links between undernutrition and TB. She was the co-principal investigator of the RATIONS trial in Jharkhand. She contributes to several journals as an editor and a reviewer. She is passionate about teaching and mentoring students in research and socially relevant pursuits. Lately, she is also involved in developing narrative-based medicine as a tool for reflection in students.
Anurag Bhargava, Professor in the Department of Medicine, the Head of the Center for Nutrition Studies at Yenepoya (Deemed to be University) & Adjunct Professor in the Department of Medicine at McGill University
Anurag Bhargava trained in Internal Medicine at AIIMS, and in Epidemiology at McGill University. His work over the past 33 years across all levels of care in India, has spanned co-founding a non-profit providing service to rural underserved communities, teaching Medicine to undergraduates and residents, research on tuberculosis, acute febrile illnesses and contributing to policy development for nutritional care of patients with TB. He has been a persistent advocate of improving access and lowering costs of essential medicines in India. His work along with his wife Madhavi Bhargava has brought to attention the strong yet ignored connections between undernutrition and TB in India. He was the Principal Investigator of the RATIONS trial in Jharkhand, the first RCT to prove that addressing undernutrition can lead to substantial decline in TB incidence and TB mortality. He is a member of numerous advisory groups including the WHO Geneva’s Strategic Technical Advisory Group for TB. He was awarded the 2021 PRJ Gangadharam Endowment Award for a lifetime contribution to TB control by the Mahatma Gandhi Institute of Medical Sciences, Wardha.
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