A Study On Implementation Of Revised National Tuberculodsis Control Programme For The Community Of Dadu Majra Colony ,Ut Chandigarh.

http://doi.org/10.33698/NRF0117  – Hemlata,Kavita Narang ,Sushma Kumara Saini

Abstract : The revised strategy for control of tuberculosis was evolved by the Government of India in 1993 and implemented in 1997 encompassing DOTS (directly observed treatment, short course chemotherapy) component to combat the dreaded disease tuberculosis with high prevalence in low socio economic community and community with migratory population. It has been more than a decade since the launch of the programme and hence it is necessary to study the implementation of the programme in various settings especially in low socioeconomic community. For this reason Dadu Majra Colony, Chandigarh which is a low socio economic community was chosen to study the implementation of RNTCP. Data was collected from health care providers, TB patients and general population by using interview schedules. Observation checklists were made to study physical setup, materials, logistics, DOTS administration procedure and microscopy services. Record analysis was done to study documentation. Results revealed that Stock items, staff and physical set up were available as per recommendations of RNTCP. DOTS administration procedure, sputum collection and microscopy services were found to be satisfactory except few disparities. Supervisory visits of senior treatment lab supervisor were regular and documented but some of higher level supervisor’s visits were not documented. Records like laboratory register and transfer forms were filled completely and legibly. TB identity cards, treatment cards, laboratory forms, monthly reports were found incompletely filled. Performance indicators were as per the norms of RNTCP except few such as percentage of 3 month conversion rate of new smear positive patients cure rate of new smear positive cases. Knowledge and awareness of TB patients, DOTS providers and general population about RNTCP was found to be moderate. The study concluded that the overall implementation of RNTCP programme in Dadu Majra Colony was satisfactory except few disparities for which more supervision is required from district level supervisors to ensure better performance of the programme.

Key words : RNTCP DOTS, Peformance indicators

Correspondence at :

Hemlata,

Nursing Supervisor,

Inderprastha Apollo Hospital, New Delhi.

Background of the study

Tuberculosis or TB is a common and deadly infectious disease caused by mycobacterium tuberculosis.1 It usually attacks the lungs but can also affect other parts of the body. It spreads through the air, when people having the disease cough, sneeze or spit. Globally, there were an estimated 9.27 million incidence cases of TB in 2007. Most of the estimated numbers of cases in 2007 were in Asia (55%) and Africa (31%), with small propor tions of cases in the Eastern Mediterranean Region (6%), the European Region (5%) and the Region of the Americas (3%). The five countries that ranked first to fifth in terms of total numbers of cases in 2007 were India (2.0 million), China (1.3 million), Indonesia (0.53 million), Nigeria (0.46 million) and South Africa (0.46 million).2

Tuberculosis (TB) remains a major public health problem in India. India has more new TB cases annually than any other country. In 2008, out of the estimated global annual incidence of 9.4 million TB cases, 1.98 million were estimated to have occurred in India, of which 0.87 million were infectious cases, thus catering to a one fifth of the global burden of TB.2

In order to combat this problem the National Tuberculosis Programme of India (NTP) was initiated in 1962.The National programme was designed for domiciliary treatment using self administered standard drug regimens. Despite the existence of the NTP, there was little impact on burden of TB till 1992. Based on the recommendations of an expert committee, a revised strategy to control TB was pilot-tested in 1993 in a population of 2.35 million and thereafter increased in a phased manner. A full-fledged programme was started in 1997 and rapidly expanded with excellent results. The Revised National Tuberculosis Control Programme (RNTCP) uses the DOTS (Directly Observed Treatment, Shor t-course chemotherapy) strategy, which has been based on results of tuberculosis research done in India. The Goal of RNTCP is to decrease mor tality and morbidity due to TB and to reduce the transmission of infection until TB ceases to be a major public health problem. The goal is to be achieved through the following objectives.3

  1. To achieve and maintain a cure rate of at least 85% among newly detected infectious (new smear positive) cases
  2. To achieve and maintain detection of at least 70% of such cases in the population

Laboratory Diagnosis of Acid-fast bacilli by Sputum Smear Microscopy is an important component of Revised National Tuberculosis control Program (RNTCP). A study conducted in Karnataka during 2005 concluded that good quality Laboratory results are essential for proper initial categorization of the patients, decision to start the continuation phase and to declare the outcome of treatment as ‘cured’. False results in diagnosis either lead to unnecessary treatment of the patient with potentially toxic drugs and puts precious resources of the programme to the drain, increasing the health care costs (false positive results); or deprive the potentially infectious TB patients from the benefit of treatment and cure (false negative results). Errors in reading follow-up of treatment smears can result in patients being placed on prolonged treatment or re-treatment, or in treatment discontinued prematurely.4

DOTS envisages strict supervision, adherence and high compliance that will result in high cure rates and less likelihood of emergence of drug resistance, thus DOTS strategy envisages greater importance to cure than detection.11 A study done in 2008 to examine delays experienced by patients in accessing directly observed treatment found that patient delays as well as diagnostic and treatment delays were minimal. Provider delays, however, contributed significantly to delayed entry into India’s Revised National TB Control Programme (RNTCP). Patients had to resor t to multiple contacts with providers due to limitations of these providers in diagnosing or directing patients to the RNTCP.5

A study conducted in 2007 to evaluate the Revised National Tuberculosis Control Programme (RNTCP) through assessment of performance, response and outcome of treatment of patients in Domjur Tuberculosis Unit of Howrah district, West Bengal found low sputum conversion rate after intensive phase of treatment, high defaulter rate and low cure rate among new sputum-positive cases in comparison to RNTCP norm. The study suggested that periodic re-orientation training of Medical Officers and DOTS providers, ensuring proper supervision from TU and district level, review of performance and timely feedback regarding performance of each health unit can be undertaken for improvement of performance.6

Tuberculosis is more prevalent in low socio economic communities and areas where migratory populations live. Since many years Revised National Tuberculosis Control programme is functional in India and hence it is necessary to study this programme in various settings especially in low socio economic community. Dadu Majra Colony, Chandigarh is a low socio economic community and researcher has personal interest to study this area due to familiarity of the area in clinical postings. In this colony there is designated microscopy centre covering population of 21000. The residents of Dadu Majra Colony are migrants from various states of India like Punjab, Haryana, Himachal Pradesh, Uttaranchal, Bihar and Rajasthan and even from neighboring country Nepal. The study of implementation of revised national tuberculosis control programme in this colony will provide baseline data so that necessary improvements can be done thereafter a study was conducted with the objective to study the implementation of Revised National Tuberculosis Control Programme for the community of Dadu Majra Colony, UT, Chandigarh.

Methodology

An exploratory research design was adopted to explore the implementation of Revised National Tuberculosis Control Programme convenient sampling was used to select the study setting as Dadu Majra Colony, Chandigarh owing to familiarity of the area to researcher. Under the setting 4 areas were studied and the sampling of the four areas was done as follows:

  1. All Health care providers (7) were interviewed
  2. All diagnosed TB patients(52) on DOTS treatment were interviewed
  3. Every 25 th house was selected by systemic random sampling from 3003 houses ie 114 By lottery method the first house was selected as house no.4 and one adult member was interviewed from each house.
  4. Physical setup, materials, logistics, DOTS administration procedure, sputum smear collection and preparation procedure were observed and record analysis was done for the all the records maintained in the microscopy

Guidelines were developed on the basis of guidelines given by RNTCP to study implementation of revised national tuberculosis control programme. Various components of RNTCP were included which are necessary to study the implementation of the programme such as performance indicators, physical facilities, stock, drugs and logistics, staff position and training, record and reports, DOTS administration procedure, sputum smear collection and preparation procedures, information, education and communication activities. These guidelines were used as a foundation to develop the tools.

The tools were prepared by review of literature related to goals, activities and standard guidelines of Revised National Tuberculosis Control Programme, consultation with experts in the field of public health and nursing and informal observation in the concerned setting. Three tools were prepared

Tool no. 1: Included record analysis. Part-A: Supervision register (Jan.08-Dec.08), Part-B: OPD register, Laboratory register, Monthly repor t and Treatment cards for calculation of indicators of RNTCP (Jan 2008- Dec.2008), Part-C: Patient’s TB identity card, Laboratory form for sputum examination, Referral form for treatment, Transfer form and Monthly repor t and Laboratory register (Jan.08-Dec.08) and Treatment cards of all T.B patients on DOTS (52)

Tool no. 2: Includes observation check lists i.e. Part-A: For Physical facility, staff and logistics in the designated microscopy center, Part-B: For DOTS provider to study DOTS administration, Part-C: For laboratory technician to study laboratory practices.

Tool no. 3: Includes Interview schedules i.e.Part – A : For all TB patients (52) on DOTS treatment in Dadu Majra Colony, Chandigarh to study knowledge of RNTCP, Part-B: For DOTS provider (7) to study knowledge of RNTCP and problems faced by them, Part-C: For General population (114) to study awareness of RNTCP

The tool was validated experts from the field of nursing and public health to check the clarity, understanding and for content validity of tools. Feasibility was assessed during pilot study in sector 38 dispensary.

Permission to conduct the study was sought from different authorities’ viz. from state tuberculosis officer, Principal from National Institute of Nursing Education and concerned Medical Officer. Verbal consent was taken from each study subject for interviewing them and in case of minor subjects (<18 yr old) consent of the parent/ guardian were taken for interviewing the subjects and they were explained them that data collected would be used only for research purpose and confidentiality of information would be maintained. Subjects were empowered with full autonomy to participate in the research and withdraw at any time.

Data collection was done by records analysis of supervision register (Jan.08- Dec.08) and monthly entries were analyzed in the designated microscopy centre for 1 day. Data was collected from laboratory register, monthly report and treatment cards for calculation of indicators of Jan 2008- Dec.2008 in the designated microscopy centre (Dadu Majra colony) and tuberculosis unit (sec.45) for 1 day. In other records such as laboratory register 30 entries were randomly selected and analyzed. Treatment cards (52), TB identity cards (52) and monthly reports (12) as they were fixed in number were analyzed. There after 26 laboratory forms for sputum examination, 2 transfer forms, were analyzed as generated in designated microscopy centre for 1 week (Monday-Saturday from 9am -2pm).

Observations were done for physical facility, staff and logistics in the designated microscopy center for 3 days in a month first at the first week of month, second at the 15th of the month and third at the 30th of the month. Observations were made for TB health worker to study DOTS administration and for lab technician to study sputum collection and preparation of smear were done for 6 days during 9am-1 pm. Interviews of 52 TB patients on DOTS treatment were conducted, 7 DOTS provider and 114 subjects from General population were interviewed as per interview schedule. Record analysis was done to study the documentation and to calculate performance indicators of RNTCP.

Results

Physical facilities and stock at designated microscopy centre

Table 1 depicts Physical facilities and stock at designated microscopy centre. In patient waiting area hand washing facility and clean drinking water facility were available. Four fixed benches were available with a sitting capacity of 12 persons on each bench and 4 wall paintings/boards/posters related to DOTS were displayed in sitting area for patients as per recommendations of RNTCP. As per recommendations the stock, was available in the designated microscopy centre.

Table-1: Physical facilities and stock at designated microscopy centre

Sr.No 1. Variables Patients waiting area: Recommended Present
·          Hand washing facility Should be available Yes
·          Clean drinking water facility Should be available Yes
2. Sitting place for patients:
·          Chairs and benches for sitting Should be available 4 Benches
·          Wall paintings/boards/posters Should be displayed 4 Posters
related to DOTS
3. Stock
·          Binocular microscope 1 1
·          Separate boxes for positive and 1 1
negative smear slides
·          Spirit lamp or Bunsen burner 1 1
·          Glass rods 1 1
·            Bottles for reagents 6 6
·          Foot-operated bin 1 1

Table-2 depicts Consumables, drugs and stationary in the designated microscopy centre. As per the recommendations of RNTCP, all the consumable items were available. Other items like sputum containers, slides, broomsticks, syringes, needles and stationary items were also available. Out of 52 patient wise boxes 78.8% boxes were properly marked and stock in the 65.3% boxes tallies with the treatment card. Quantity of items (Methylene blue, sputum containers) increased at the end was due to indent received in between the month. It was further observed that reagent bottles were labelled and kept out of reach of public. Slides were clean.

Table-2: Consumables, drugs and stationary in the designated microscopy centre

Sr. No. Variables Recommended for 1 month 1st wk 15th day 4th wk
1. Consumables items
and disinfectants
·          Carbol fucshin 1.2l 5L 3L 1L
·          Methylene blue 75ml 5L 3L 5L
·          Sulphuric acid 1.25l 5L 2.5L 2.5L
·          Immersion oil 25ml 30ml 20ml 10ml
·          Methylated spirit 25ml 100ml 60ml 30ml
·          Phenol 3kg 1.5kg 2kg 2kg
2. Drugs
·          Patient wise boxes 1 for each patient registered 50 51 52
·          Inj. Streptomycin 24 for each Cat.II 24 18 12
patient registered
3. Stationary
·          Laboratory Register 1 1
·          Supervision register 1 1
·          Treatment Card 50 56 55 54
·          Identity Card 50 62 61 60
·          Laboratory Form 125 200 130 73
·          Monthly Report 5 30 30 27
·          Transfer Form 5 47 45 42
·          Referral form 5 18 18 15
4. Others
·          Sputum containers 275 480 340 512
·          Slides 275 300 160 46
·          Broomsticks 275 300 160 46
·          Syringes 24 for each Cat.II 24 18 12
patient registered
·          Needle 24 for each Cat.II 24 18 46
patient registered

* Reagents bottles were labeled and kept out of reach of public. Slides were clean As per staff position and training in designated microscopy centre there were one sanctioned post for each category of staff which included medical officer, laboratory technician, TB health visitor and multipurpose health worker. All the staff was sanctioned and trained in RNTCP at Community health centre Sec.22, Chandigarh.

DOTS administration procedure

Table-3 illustrates the findings related the observations of DOTS provider while providing medicines. Among 30 observations of DOTS administration procedure, documentation was done every time after administration of medicine to patients. One patient was getting streptomycin inj. so 3 observations made; on all occasions needle was cauterized with needle destroyer and put in a puncture proof container by DOTS provider after inj. administration. There were certain steps which were not followed in some of the observations which include DOTS provider tallies identification data from record with the patient during 63.3% observations and observing patient while taking medicine during 66.6% observations. Only 23.3% times it was enquired if patient had taken meal and 40% times the patient was reminded about the next visit

Tally identification data from record with the patient 19 (63.3)Sr. No   Observations                                                                                                 n(%)

  • Enquired about whether patient had taken 7 (23.3)
  • Observing patient is taking medicines 20 (66.6)
  • Cauterize the needle with needle destroyer and put in puncture proof 3 (100.0) container after administration
  • Reminding to the patient about next visit 12 (40.0)
  • Documentation done after administration of medicine 30 (100.0)

Table-4 depicts the findings related the observations of lab technician while collecting and preparing sputum smear. All the steps were followed by laboratory technician correctly as per recommendations of RNTCP during preparation of smears and examination of slides in all the observations. In sputum collection procedure, labeling of sputum container was done on side at all times, each set of sputum samples of patient was given same lab serial number, it was ensured sputum is collected in a open air/ room with open windows by laboratory technician. Some disparities were also present. More than half of the times lab technician examined the sputum to determine if it is sputum or saliva and only 32% times the reason for collecting sputum was explained to the patient. None of the times lab technician stood behind the patient during sputum collection and ensured that no one stands in front of patient during procedure and supervised the patient during on spot sputum specimen collection.

Table-4 : Observation of lab technician while collecting and preparing sputum smear

N=50

Sr. No Observations n(%)
 

1.

 Sputum-collection procedure

labeling of sputum container on side

  

50(100)
2. Each set of sputum samples of a patient assigned same Lab Serial Number 50(100)
3. Explains to the patient reason for collecting sputum 16(32)
4. Instruction given to rinse mouth before coughing out the sputum 10(20)
5. Stands behind the patient during sputum collection –
6. Sputum is collected in a open air/ room with open windows 50(100)
7. Ensure that no one stands in front of patient during procedure –
8. Supervision of patient during on spot sputum specimen collection –
9. Visual examination of sputum to determine if it is sputum or saliva 30(60)
10. Wash his hands with soap and water when handles contaminated material 50(100)
 

11.

 Preparing smears and examination of slides

Wears mask and gloves during procedure

  

50(100)
12. Uses new slide for each smear 50(100)
13. Labeling of slide with a grease marker 50(100)
14. Uses a different broom stick for each sputum smear 50(100)
15. Sputum smear made on the slide (2 cm X 3 cm) 50(100)
16. Slide is dried before heating for 15-30 min. 50(100)
17. Fixes the slide by heating 3-5times for 3-4sec.each time 50(100)
18. 1% filtered carbol fuchsin is poured to cover the entire slide 50(100)
19. Heats the carbol fuchsin (avoid boiling) and allow the slides to 50(100)
 

20.

 stand for 5 minutes

Tilts the slide after rinsing to remove excess water

  

50(100)
21. Allows Sulphuric acid to stand on the slide for 2–4 minutes 50(100)
22. Allows Methylene blue to stand on the slide for 30sec 50(100)
23. Examines the slide under the microscope using a drop of immersion oil 50(100)
24. All positive and negative slides are stored serially in the same slide-box 50(100)
25. Recording done in the Lab Form for Sputum Examination and in Lab Register 50(100)
26 Put sputum containers and lids along with the bamboo sticks, into a 10(100)
bucket containing 5% phenol , after 12 hours of immersion in it, put into a red bag

Record analysis of supervision Register (2008)

Senior treatment lab supervisor (STLS) visited the microscopy centre regularly as per recommendations of RNTCP and documented his visits regularly senior treatment supervisor (STS) documented his visits irregularly and they were not documented for the months of March and May- July. Visits done by district tuberculosis officer and medical officer- tuberculosis unit were not recorded. Comments written by STLS and STS were same in all the months i.e. examined 1 positive and 1negative slide randomly, no discordance found, microscope is in working condition.TB health visitor and lab technician however informed that they have visited the centre randomly but did not document their visits.

Record analysis of records of microscopy centre

Table –5 depicts record analysis of records of microscopy centre. Laboratory register and transfer forms were filled completely and legible. In laboratory register 30 entries were randomly checked and analyzed; all of them were filled completely and legible.

Table -5 Record analysis of various records maintained at microscopy centre

Records No. of entries/ records checked(N) Total columns in record Columns filled n(%)
Laboratory register 30 12 12 30(100)
TB Identity Card 52 14 12 24(46.2)
13 20(38.5)
14 8(15.4)
Laboratory form 26 21 16 1( 3.8)
18 3(11.5)
19 6(23.0)
20 16(61.5)
Transfer form 2 17 17 2(100)
Monthly report 12 50 <20 4(33.3)
21-30 3(25.0)
31-40 1( 8.4)
41-50 4(33.3)
Treatment card 52 37 33 1( 1.9)
34 2( 3.8)
35 16(30.8)
36 20(38.5)
37 13(25.0)

Among 2 transfer forms, all the columns were filled completely. Out of 52 TB Identity Card and treatment cards only 15.4% and one fourth treatment cards were filled completely. Out of 26 laboratory forms and 12 monthly repor ts all of them were incompletely filled. Common columns blanks in all the records were TB number, retrieval action for missed doses and remarks.

Performance indicators of RNTCP in Dadu Majra colony (Jan 2008-Dec.2008)

Table-6 illustrates key indicators of performance of RNTCP. Percentage of smear positive diagnosed, treatment completion rate and default rate of new smear positive patients were as per the norms of RNTCP. Some of the indicators though not equal but were very close to their recommendations such as percentage of 3 month conversion rate of new smear positive patients was 87.1% near to its expected level >90%. Cure rate of new smear positive cases was 82.5% which is also near to its expected level >85%. Some of the indicators were higher than expected such as percentage of new smear positive out of total new pulmonary cases was higher (69.6%) than expected (50%). Outpatient examined percentage was also higher (7.28%) than expected level (2-3%). Percentage of retreatment cases out of all smear positive cases was 23.5%.There was a large difference between expected (10-15%) and present (41.6%) percentage of new extra pulmonary cases out of all the new cases. Transfer out rate for new smear positive cases was quite high (7.6%) as compared to its expected level <3%. There are indicators of treatment outcome for retreatment (cat.II) and extra pulmonary cases for which expected percentage is not mentioned in the programme but they are in the list of indicators and indicator percentage is as follows. Cure rate for retreatment cases was 25%. Treatment completion rate for category II cases was 33.3% and for extra pulmonary cases was 97.5%. Default rate for category II patients was 16.6%. For retreatment cases transfer out rates was 16.6%. Death rate of retreatment cases was 8.3% and failure rate of extra pulmonary cases was 2.5%. Knowledge and problems of DOTS provider about RNTCP

Table-7 shows knowledge and problems of DOTS provider about RNTCP. All

  • subjects had knowledge about most infectious form of B, total duration of DOTS and no. of sputum samples to be taken for diagnosis of TB. Five percent knew about vaccine for prevention of TB in children, type of room best suited for TB patients and time period for patient’s address verification between diagnosis and treatment initiation of patient. More than 5 of the subjects had knowledge about diet to be given to TB patient and what first action should be taken if patient does not come to take next dose in intensive phase and continuation phase of TB treatment. Only 1 subject knew about target age group for preventive treatment of TB in a family where an individual is having TB. Five of the subjects had faced no problem and rest of them felt that they had difficulty in handling RNTCP work along with their routine work as responded by ANM working in microscopy centre.

Table-6 Key indicators of performance of RNTCP (From Jan 2008-Dec.2008)

Indicator Expected Present
Outpatient examined percentage 2-3% 7.28%
Percentage of smear positive diagnosed >10% 11.2%
% new smear positive out of total new pulmonary cases 50% 69.6%
% of new extra pulmonary cases out of all new cases 10-15% 41.6%
% of retreatment cases out of all smear positive cases – 23.5%
% of 3 month conversion rate of new smear positive patients >90% 87.1%
Treatment outcomes for new smear positive cases

·           Cure rate

  

>85%

  

82.5%
·           Completion rates >3% 7.6%
·           Default rates <5% 2.5%
·           Transfer out rates <3% 7.6%
Treatment outcomes for retreatment cases( Cat.II)
·           Cure rate – 25.0%
·           Completion rates – 33.3%
·           Default rates – 16.6%
·           Transfer out rates – 16.6%
·           Death rates – 8.3%
Treatment outcomes for extra pulmonary cases
·           Completion rate – 97.5%
·           Failure rate – 2.5%

Table-7 : Knowledge and problems of DOTS provider about RNTCP                                N=7

Sr. no Variables                                                                                                      n

Related to knowledge of RNTCP
1. Mode of transmission of tuberculosis 5
2. Most infectious form of T.B 7
3. Part of body is commonly affected in T.B 6
4. No. of Sputum samples taken for diagnosis of TB 7
5. Total duration of DOTS 7
6. Target age group for preventive treatment of TB in a family where an individual is having TB 1
7. Effect of not taking all drugs in TB treatment 7
8. Category of TB patients follow up sputum sample should be taken after 2 months 2
9. Category of TB patients follow up sputum sample should be taken after 3 months 4
10. Diet to be given to TB Patient 4
11. Vaccine for prevention of TB in children 5
12. Type of room is best for TB patients 5
13. Time period for patient addresses verification between diagnosis and treatment initiation of patient 5
14. First action should be taken if patient does not come to take next dose in intensive phase of TB treatment 4
15 First action should be taken if patient does not come to take next dose in continuation phase of TB treatment 4
16. Problems faced in the implementation of RNTCP

·       No problem

  

5
·       Difficulty in handling both work as respond by ANMs 2

Knowledge and practice of TB patients undergoing DOTS treatment about RNTCP

Table-8 depicts knowledge and practice of TB patients about RNTCP All 52 patients had knowledge about what is to be done with the empty leaves of medicine. Most of them knew about that TB is an infectious disease and about total duration of TB treatment and effect of not taking all drugs of TB treatment. Half of the study subjects had knowledge about prevention of spread of TB to family members and diet to be taken during treatment of T.B. Only 1 subject knew about vaccine for prevention of T.B in children. Related to practice of RNTCP all of the subjects had 7days time gap for initiation of treatment and sputum microscopy and had given 2-3 samples for diagnosis of TB. Majority of them felt that the DOTS centre is convenient in terms of location and timings as well. All of the patients responded that they had not paid money for investigations or treatment in the health facility, most of them had faced no problem regarding diagnostic procedure and treatment schedule and any other problem in the health facility. Some of the patients faced problems i.e. 9.6% patients felt that information given by health care providers was not proper and rest 1.9% patients respond privacy was not maintained during injection administration.

Table-8: Knowledge and practice of TB patients undergoing DOTS treatment about RNTCP          N=52

Related to knowledge of RNTCPVariables                                                                                        n (%)

T.B. is an infectious disease                                                                                                           46(88.5)

Symptoms of TB                                                                                                                           10(19.2)

Mode of transmission of tuberculosis                                                                                           20(38.5)

No. of Sputum samples taken for diagnosis of T.B.                                                                     43(82.7)

Total duration of TB treatment                                                                                                      51(98.1)

Days in a week medicines are given in DOTS                                                                            50(96.2)

What is to be done with the empty leaves of medicine                                                                52(100)

Precautions during TB treatment                                                                                                    20(38.5)

What should be done if TB symptoms subside, after 2 months of TB treatment                          36(69.2)

Effect of not taking all drugs of TB treatment                                                                                  51(98.1)

Method of disposal of sputum                                                                                                         16(30.8)

Prevention of spread of TB to family members                                                                               24(46.2)

Diet to be taken during T.B treatment                                                                                                29(55.8)

Appropriate room for TB patient                                                                                                          5(9.6)

Vaccine for prevention of T.B in children                                                                                           1(1.9)

Related to practice of RNTCP

Within 7days time gap for initiation of treatment and sputum microscopy                                     38(100%)

Addresses verified before initiation of treatment                                                                              28(53.8)

2 or 3 Sputum samples given for diagnosis of T.B.                                                                           38(73.1)

Treatment taken for TB (24 -36doses) under direct observation of health worker                             37(71.2)

DOTS centre convenient in terms of location                                                                                    42(80.8)

DOTS centre convenient in terms of timing                                                                                         46(88.5)

Money paid for investigations or treatment in health care facility          – Problems faced by TB patient in the health facility

  • No problem 46(88.5)
  • Not explaining properly 5(9.6)
  • Not maintaining privacy during injection administration 1(1.9)

Knowledge score of various subjects about RNTCP

Table-9 depicts knowledge score of various subjects. Among the 52 TB patients, half of them had good knowledge, 51.9% had moderate knowledge and only 1.9% subjects had poor knowledge about RNTCP. Majority of DOTS providers had good knowledge and 14.3% subjects had moderate knowledge about RNTCP.

Table-9: Knowledge score of various subjects

S.no. Knowledge score (15) TB patients(52) DOTS provider(7)
1 Good knowledge (10.1-15) 24(46.2) 6(85.7)
2 Moderate knowledge(5.1-10) 27(51.9) 1(14.3)
3 Poor knowledge(<5) 1(1.9) –

Awareness of General population about RNTCP

Among 114 subjects all the subjects had awareness about TB disease.

Table-10: Awareness of General population about RNTCP                              N=114

Awareness about TB disease 114(100)Sr.no         Variables                             n(%)

2             Source of information about TB

  • Dispensary/hospital 11(9.6)
  • Media 61(53.5)
  • Neighbors/relatives 34(29.8)
  • Combined above sources 8(7)
  1. Awareness about posters or hoardings of TB disease in their locality 47(41.2)
  2. Information of TB patient in their locality 12(10.5)
  3. Mode of transmission of TB 50(43.9)
  4. Symptoms of TB 84(73.6)
  5. Prevention of TB 44(38.5)
  6. Availability of TB treatment 102(89.5)
  7. Availability of TB treatment centre 82(71.9)
  • Treatment available free of cost 47(41.2)

Most of the subjects knew about the availability of TB treatment (89.5%),/treatment centre (71.9%) in their locality. Three fourth subjects had awareness regarding the symptoms of TB. Nearly half of the subjects knew that TB treatment available free of cost and mode of transmission of TB. Regarding the source of information about TB, more than half of subjects had information from media and only 9.6% subjects had information from dispensary/hospitals. Awareness about posters or hoardings related to TB in their locality was 41.2%. Information of method of prevention of TB responded as vaccine availability or maintains distance from patient was 38.5%.Information regarding TB patient in their locality was only 10.5%

Discussion

Tuberculosis is a major health problem of enormous magnitude, not only in India but also in other countries of the South East Asia region. Since 1993 the Government of India has been implementing the WHO- recommended DOTS strategy via Revised National Tuberculosis Control Programme (RNTCP). The revised strategy was pilot- tested in 1993 and launched as a national programme in 1997. By March 2006, the programme was implemented nationwide in 633 districts, covering 1114 million (100%) population. Phase II of the RNTCP started from October 2005, which is a step towards the achievement the TB-related targets of the Millennium Development Goals.

The programme has treated over 8 million TB patients, with nearly 1.5 million registered for treatment in 2007 alone. Despite the rapid expansion of RNTCP for more than a decade tuberculosis is still prevalent in low socio economic communities where migratory populations live. The area chosen for the study was Dadu Majra Colony, Chandigarh which is a low socio economic community and hosts migratory population from various states of India like Punjab, Haryana, Himachal Pradesh, Uttaranchal, U P, Bihar and Rajasthan and even from neighboring country Nepal. The setting was also chosen because of convenience and familiarity of the area to the researcher. In Dadu Majra Colony services of RNTCP are provided through a centre named as designated microscopy centre covering population of 21000.

Data was collected to assess the knowledge of health care providers, TB patients and general population through interview schedules. Skills of trained staff regarding DOTS administration, sputum smear collection and preparation, physical setup, materials, logistics were assessed through observation checklists. Record analysis was done to study the documentation and to calculate performance indicators of RNTCP.

All the physical facilities and stock items were available as per recommendations of RNTCP in designated microscopy centre at Dadu Majra Colony, Chandigarh. A study conducted in Habra tuberculosis unit in 2004 had found that 28.3% centers lacked expected facilities as per recommendations of RNTCP. A study conducted in Dahod district in 2004 had found inadequate stock of slides and sputum cups in the visited designated microscopy centres. There was no drug store at Tuberculosis Unit-Devgadhbaria and Tuberculosis Unit –Dahod.7

In the present study all the trained staffs were available as per recommendations of RNTCP but contrary results were found in a study conducted in Dahod district where posts of pharmacists were vacant in 11 PHCs and in all CHCs except 2. Staff nurses not trained for RNTCP were managing the drug stores in the remaining centers. The posts of 2 senior treatment supervisors and 1 TB Health visitor were vacant.7

Assessment of DOTS administration procedure revealed that all the steps were followed properly except few disparities in a few observations i.e. DOTS provider did not tally identification data from record of the patient, did not observe patient while taking medicines and did not enquire if patient had taken meal. While the results found in another study conducted in Delhi showed that 74 TB patients out of 99 were taking medicine in front of healthcare provider and rest of the patients took medicines to their homes.8

All the steps were followed correctly by laboratory technician in preparation of sputum smears except some disparities found in sputum collection procedure in some observations such as not ensuring no one stands in front of patient during procedure and not supervising the patient during on the spot sputum specimen collection. While contrary results were found in internal evaluation of Kheda district in which microscopy activities were poor at Radhu DMC – Haldarvas Tuberculosis Unit (smears being big sized and over-stained).9 Record analysis for supervisory visits of supervisors showed that senior treatment lab supervisor (STLS) visited and documented their visits regularly. Senior treatment supervisor’s (STS) visits were irregularly documented. Visits of district tuberculosis officer and medical officer- Tuberculosis unit were not documented at all though as per information given by lab technician they visited off and on. Different result was found in one of the study conducted in Rajkot, Gujarat in 2004 which showed that supervision by the STLSs was unsatisfactory in the centre.10

In record analysis laboratory register and transfer forms were filled completely and legibly and TB identity cards, treatment cards, laboratory forms and monthly reports were found incompletely filled ie some of the columns remain unfilled. Some disparities were also found in patient wise boxes. The boxes were not properly marked and stock in the boxes did not tally with treatment card. Parallel results were found in Kheda, Rajkot and Dahod district in 2004 i.e. treatment cards were found to be incomplete and incorrect, inconsistency was found between treatment cards and number of strips in the patient-wise boxes.7, 9,10

In the performance indicators of RNTCP percentage of smear positive diagnosed among the chest symptomatic, percentage of new smear positive cases out of total new pulmonary cases, treatment completion rate and default rate of new smear positive patients were as per the norms of RNTCP which signifies that the quality of sputum microscopy was satisfactory. Some of the indicators though not equal but were very near to its recommendations such as percentage of 3 month conversion rate of new smear positive patients and cure rate of new smear positive cases. Some of the indicators were higher than recommended such as outpatient examined percentage, percentage of new extra pulmonary cases out of all new cases, transfer out rates of new smear positive cases. Similar results were found in Kerala in 2003 and at Loni in 2008 such as percentage of new smear positive cases out of total new pulmonary cases and default rate were well performing and no single failure found among new smear positive patients.11,12 Contrary results were found in another study done in Howrah district, West Bengal in 2001 which showed sputum conversion rate and cure rate of the new sputum positive cases as not performing well.13

In present study knowledge and awareness of , DOTS providers was good. The level awareness of symptoms was relatively higher among TB patients than the other general community members. Similar study conducted in Maharashtra reflected that awareness of DOTS/RNTCP/Government’s TB programme was extremely low in general community and they perceived TB as curable but they were not aware about the reoccurrence of disease.14

The study concludes that overall implementation of the RNTCP programme in Dadu Majra Colony was satisfactory except few disparities. It is recommended that proper supervision from tuberculosis Unit and district level and in-service training for healthcare providers should be under taken. Such capacity building would ensure enhanced quality of services and better health outcomes in terms of less prevalence of tuberculosis in the community. Information, education and communication activities need to be strengthened to create awareness about RNTCP in the community.

References

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  1. Park Preventive and social medicine. 19th ed. Jabalpur: Banarasi Das Bhanot Publishers; 2007:352-360.
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  1. eport of “In depth review of RNTCP” in Rajkot, Gujarat. Available from URL: gujrat http:// gujhealth.gov.in/health_programmes/pdf/tb / Rajkot. pdf. Accessed on 15/11/09. Accesssed on 4/2/10
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12      Baburao PD, Bhaskar PS, Phalke D, Sharma YV. Study of Tuberculosis cases under RNTCP attending Designated Microscopy Centre at Pravara Rural Hospital, Loni. Pravara Medical Revision 2009; 4(4):7-11.

  1. Bisoi S, Sarkar A, Mallik S, Haldar A, Haldar DA study on performance, response and outcome of treatment under RNTCP in a tuberculosis unit of Howrah district, West Bengal. Indian Journal of Community Medicine 2007;32(4):245-248.
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