Strenthening TB management in India

Dr Ashok Sahni discusses critical issues and recommendations for strengthening TB management

Tuberculosis (TB) is one of India’s major public health problems. Out of the 15 million TB patients in the world, more than four million are in India (26.6 per cent). About 38 per cent of the people of all ages are infected with the disease. Infection among males above 40 years of age runs as high as 70 per cent. Every year, two million people in India develop the disease, half of whom, more than 2000 patients everyday, have infectious and often fatal TB.

Adults in India die more from TB than from any other infectious disease, one every minute and more than 1000 everyday, a grim statistics that has changed little in the past two decades.

On March 26, 1997, India formally launched the Revised National Tuberculosis Programme (RNTCP) with phased coverage in various states throughout India. In 1998 and early 1999, Directly Observed Treatment Shortcourse (DOTS) covered a population of about 140 million. The RNTCP began rapid expansion thereafter. By early 2003, the programme had already covered over 650 million people.

Studies show that patients with symptoms of TB in India seek care promptly. Where services are better, patients seek care even more promptly. However, more than 80 per cent of chest symptomatics contact the private facilities. Between 60-80 per cent of the medical institutions are in the private sector. The message of RNTCP may not have reached these and the patients may not be benefiting from the RNTCP.

Keeping the above situation in view, there is a need to build health sector capacities:

a) To implement the national TB programme strategy and to overcome the present barriers that impede the programme

b) To build partnerships with the private sector, medical schools, NGOs, business, and industry

c) To address the emerging issues of HIV-associated TB, drug resistant TB, and TB control in high endemic states

The difficult areas for coverage with the RNTCP are: Assam, Bihar, Jammu and Kashmir, Karnataka, Madhya Pradesh, Meghalaya, Mizoram, Punjab, Uttar Pradesh

Keeping the above critical situation of TB Management in India in mind, Indian Society of Health Administrators (ISHA) had organised two national level meetings during July 2002 and June 2003 focussing on TB Management in India-diagnosis, treatment, and rehabilitation, which was attended by 51 experts at national level

Policy issues

1.(a) Case finding under RNTCP needs improvement. (b) Study of behaviour pattern of chest symptomatics (CS) has shown that 70 per cent of them take action within 15 days, with 40 per cent doing so within one week.

2. The above study also showed that 30 per cent of CS had cough alone (ie, without any other symptom of tuberculosis). A National Tuberculosis Institute (NTI) study has shown that the proportion of cases among those with cough alone was negligible. Examining them is a waste.

Recommendations

1. To prevent denial of the diagnostic test to CS taking early action, which has resulted in unpopularity of service providers, and for improving case finding under RNTCP, sputum should be examined for all CS with symptoms for at least two weeks, to start with.

2. Desirability of ordering sputum examination for all CS with cough and one more symptom of tuberculosis for one week or more (40 per cent took action within one week) deserves to be studied, to get maximum case detection among early action takers with minimum of sputum examinations

Treatment issue

1. Multiplicity in treatment regimen used all over India by general hospitals and private medical practitioners

2. The drug is wasted because drugs for both initial and continuation are in the same box, though drugs for the latter phase need more shelf life. Imported drugs/drug components have limited shelf life when drugs reach the patient. Because of committed patientwise boxes, drug for defaulters is wasted, new patients are not offered treatment sometimes, in the absence of fresh boxes.

Recommendations

1. Use of RNTCP regimen should be made mandatory.

2. Use 2 boxes, one for each phase. 3. Delayed issue of drugs to patients for continuation phase to overcome problem of shelf life.

4. Produce drugs/drug components in India

5. Support research to increase shelf life of drugs to two-and-a-half years, at least.

Use drugs for long-term defaulters for new patients (if needed), and use the new spare drug boxes for these new patients to reconstitute drug box for defaulters, if and when necessary.

Availability issues

1. 10 TU and 15 TU are available 2. Production of 1 TU is being stopped

3. No uniform practice for incentives to DOT workers

Recommendations

1. 10 TU and 15 TU should be removed from the market by legislation

2. Production of 1 TU should not be stopped

3. Frame and implement a national policy for incentives to DOT workers

Education and training issues

1. IEC activities for developing support from private practitioner (PP) need to be improved.

2. All DOTs workers are not adequately trained

3. IEC have been devised without involving professionals in social sciences. 4 Currently formulated IEC does not adequately address social and general issues that are appropriate for both community and service providers.

Recommendations

1. Continuing medical education is a must for all doctors. 2. DOTs training should be made more effective and extensive.

3. .Involve social science institutions and individual social scientists with requisite experience for developing IEC. 4. Give adequate emphasis on IEC appropriate to both community and service providers.

Intersectoral co-ordination and community involvement

There are various other issues surrounding the management of TB programme. For example, the programme is more or less run on vertical lines and is seen as a health issue only. We need to develop and implement effective strategies for intersectoral co-ordination and community involvement on a contextual basis.

Case finding and treatment

Case finding under NTP/RNTCP is not adequate because about 50% of CS go to PPs 2. Attempts made so far have resulted only in isolated pockets of success. To solve this extensive dialogue with PPs has to be made with an open mind and flexible approach. Innovative ideas deserve to be encouraged at all levels.

Initial sputum negatives are x-rayed if symptoms persist after an antibiotic course for 10 days and put on treatment on the basis of x-ray result. Instead of taking x-ray, three more sputum specimens should be examined after the 10-day course. X-ray should be taken only if the sputum is still negative and symptoms persist.

About 50% of patients do not return for 2nd and 3rd specimen examination. A printed note, which explains the need for repeated sputum examination and emphasises its importance should be shown, explained and handed over to the patient at the time of first visit.

Category II patients are treated virtually with one additional drug, without nformation about his drug sensitivity pattern. We must provide facilities for drug sensitivity testing at district level and refer category II patients to the district facility. Or, ascertain average drug sensitivity in different regions/zones for different drugs and use these as a guide for choosing the appropriate additional drug.

Monitoring and evaluation

ARI of 1.75 is being used for monitoring indices. This is being revised to ARI of 1.5. This should be replaced by regional values of ARI and be selected and used by regional monitoring committees.

The report of the JPR 2000 (WHO) shows many contradictions, particularly between executive summary and the detailed report. Important comparative findings from NTP and RNTCP have not been presented. While carrying out fresh (impending) review, care must be taken to remove the wrong impressions and lack of adequate comparisons in the earlier review.

Research

Research Institutions have been kept out of RNTCP whereas problems under RNTCP should be studied in detail, with the involvement of research institutions.

TB cases with less than 5,000 bacilli are not diagnosed on direct smear. Since diagnosis by culture is not practicable, it is important to develop a more sensitive method of direct microscopy. Studies should be carried out to develop a more sensitive method of direct microscopy.

Results of one study presented showed that M.Bovis is common. This might be a reason for lack of protection by BCG. Studies on prevalence of infection with M.Bovis should be undertaken in different regions

Miscellaneous

MOs are not staying in the quarters allotted to them and are frequently not available at the work spot. Staying in allotted quarters must be insisted upon to ensure all-time availability of health care.

The amount of Rs 500 given to TU worker for field work is inadequate. This should be enhanced, on a contextual basis.

On completion of treatment (6 months), the treatment record is not handed over to the patient. Treatment register at TU level is taken to district centre for safekeeping. Thus, if and when a patient comes back, his earlier details are not available for us. Treatment records should therefore not be disturbed. It should be kept along with the laboratory register.

BCG is used as a diagnostic test by paediatrician and should be discouraged through IEC, CME, professional meetings and scientific articles. Quality control of BCG used in UIP is not carried out. BCG vaccination is administered by MPWs and ANMs. In a recent study, it was found that their knowledge base is inadequate and administrative support weak.

Quality control in preservation and transport of BCG has to be enforced. Competency building programmes for skills development of MPWs, ANMs and private practitioners need to be initiated. 27. Studies have shown that (eg. ICORCI Study), patients with symptoms of TB in India seek care promptly but in both public and private systems, they are neither reliably diagnosed nor effectively treated. Despite eight encounters with the health system and expenditure of upto six months wages, only one-third of patients with symptoms of TB had undergone even a single sputum examination for Tuberculosis. Health System’s response to the behaviour of patients needs to be changed. System needs to be decentralized to reach out to the poor and unreachables.

The writer is professor and hon executive director, Indian Society of Health Administrators, Bangalore