BOTTLENECKS OF TB CONTROL IN INDIA AND SOLUTIONS

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BOTTLENECKS OF TB CONTROL IN INDIA AND SOLUTIONS
K.A.P STUDY ON FRONTLINE HEALTH WORKERS

Dr. A.K. AVASARALA MBBS,
M.D. PROFESSOR HEAD DEPT OF COMMUNITY MEDICINE
EPIDEMIOLOGY PRATHIMA INSTITUTE
OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA
91505417 avasarala_at_yahoo.com
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PROMPT FOR THIS LECTURE
TUBERCULOSIS IN INDIA IS STILL A MAJOR PUBLIC
HEALTH PROBLEM EVEN AFTER 43 YEARS OF CONTROL
PROGRAM . WHY?

• I AM VERY MUCH WORRIED, SINCE A LONG TIME, DUE
  TO THE VERY SLOW RESPONSE IN
  REDUCTION OF TUBERCULOSIS IN INDIA
  IN SPITE OF EFFECTIVE DOTS EXPANSION.

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LEARNING OBJECTIVES

• PRESENTING MAGNITUDE OF THE TUBERCULOSIS
  PROBLEM IN INDIA, (SLIDES 5-11)
• DISCUSSING ITS CONTROL ASPECTS (SLIDES 12-30)
• IDENTIFYING THE BOTTLENECKS AND THE EXTRA NEEDS
  FOR THE CONTROL BY MEANS OF K.A.P.STUDY
  (SLIDES 31-35)
• DISCUSSING THE SOLUTIONS
  (SLIDES 36-42)

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PERFORMANCE OBJECTIVES

• CAN LEARN PROBLEM - ANALYSIS BY MEANS OF K.A.P
  STUDY
• LEARNER CAN DEVELOP DIFFERENT MODELS OF
  ALTERNATE COSTEFFECTIVE CHANNELS OF
  IMPLEMENTATION BASING ON THE RESPONSES

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STORY OF THIRTY YEARS BEFORE DOTS (1962-1992)

• NTCP (NATIONAL TB CONTROL PROGRAM) 1962-1992
  FOUND THAT ONLY 30 OF THE ESTIMATED NUMBER OF
  PATIENTS WERE BEING DIAGNOSED AND OF THOSE
  TREATED ONLY 30 COMPLETED THEIR TREATMENT

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THIRTEEN YEARS AFTER DOTS

• ESTIMATED 3.5 MILLION CASES ARE SPUTUM POSITIVE.
• TUBERCULOSIS (TB) ESTIMATED ANNUAL INCIDENCE IS
  2.2 MILLION, OF WHICH ABOUT 1 MILLION ARE
  INFECTIOUS.
• 0.5 MILLION PEOPLE IN INDIA DIE FROM TB EVERY
  YEAR.

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WHO PROJECTION COMING TRUE
A majority of deaths from TB occur in India (4).
India faces growing mortality from TB.
8
TB/HIV CO-INFECTION

• About half of the tuberculosis patients are
  affected by HIV infection and vice versa in
  India and
• making things complicated for the patient, the
  treating doctor, the patients family
  particularly his children and for his community
  and the health manager.

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TB IN CHILDREN

• OVER 100,000 CHILDREN MAY NEEDLESSLY DIE FROM TB
  THIS YEAR.
• HUNDREDS OF THOUSANDS OF CHILDREN WILL BECOME TB
  ORPHANS THIS YEAR.
• OVER 300,000 CHILDREN ANNUALLY HAVE TO LEAVE
  SCHOOL AS A RESULT OF THEIR PARENTS TB

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EMERGENCE OF MDR-TB

• Irregular callous use, misuse and over use of
  anti-tuberculosis drugs is the most common
  practice among both the qualified and
  unqualified medical practitioners (allopathic
  non allopathic )in India.
• Non adherence to the regimens by the doctors
  while prescribing drugs, is very common
• Poor patient-compliance of Tb regimens and
  increased defaultering of treatment by patients
  is another cause leading to drug resistance.

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TB IN PRISONS

• The level of TB in prisons has been reported to
  be up to 100 times higher than that of the
  civilian population.
• Cases of TB in prisons may account for up to 25
  of a country's burden of TB.
• Late diagnosis, inadequate treatment,
  overcrowding, poor ventilation and repeated
  prison transfers encourage the transmission of TB
  infection.

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DOTS ACHIEVEMENTS

• DOTS IS NOW EXPANDED TO ALMOST ENTIRE INDIA(
  2005)
• NEW CASE DETECTION IS INCREASING?
• PREVLENCE SEEMS TO BE DECREASING
• FULL SUPPLY OF DRUGS ARE AVILABLE
• ADDITIONAL INPUTS LIKE MEDICAL OFFICERS (RNTCP)
• WHO ASSISTANCE IN PROGRESS

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DOTS ACHIEVEMENTS

• TO DATE, RNTCP HAS CONSISTENTLY SHOWN TREATMENT
  SUCCESS RATES OF AROUND 85, WHILST CASE
  DETECTION RATES HAVE GENERALLY RISEN TO NOW STAND
  AT AROUND 60.
• INDIA HAS DEMONSTRATED TO THE WORLD THAT WITH THE
  RIGHT COMBINATION OF POLITICAL COMMITMENT,
  ADHERENCE TO TECHNICAL STANDARDS, MANAGERIAL
  EXCELLENCE AND PARTNERSHIP, RAPID LARGE-SCALE
  EXPANSION OF SERVICES WITH GOOD RESULTS ARE
  POSSIBLE IN TB CONTROL. INDIAS ACHIEVEMENT IN TB
  CONTROL HAS BEEN ACKNOWLEDGED GLOBALLY.

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DELAYED POLICY REVISION AND DOTS INITIATION

• 30 YEARS HAVE LAPSED BEFORE DOTS IS IMPLEMENTED
  IN 1992. WHY? WHY THE POLICY WAS NOT REVISED
  MUCH EARLIER KNOWING THAT RESULTS ARE NOT GOOD
  WITH PREVIOUS NTCP? WHY WE HAVE WAITED AND
  WASTED 30 YEARS?

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WHICH ONE IS DEFECTIVE?

• DOTS STRATEGY
  (DOTS FIVE COMPONENTS)
• DOTS IMPLEMENTATION IN INDIA

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WEAK POLITICAL COMMITTMENT

• POLITICAL COMMITMENT, THE FIRST
  REQUISITE OF DOTS MANAGEMENT IS ONLY ON PAPER.
• POLITICIANS ARE NOT SERIOUS AND NOT ACTIVELY
  INVOLVED IN THE CRUSADE AGAINST TUBERCULOSIS.

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INAPPROPRIATE POLICY

• Policy of sputum testing among self referrals is
  very inappropriate .
• Tb is still a poor man's disease in India.
• It is hard to expect these patients to come for
  sputum testing on their own and that too spending
  their money for travel. These poor and ignorant
  people often go to quacks (unqualified medical
  parishioners) at the first instance and the
  patients believe them. One has to understand this
  treatment seeking behavior of the poor while
  dealing with tuberculosis.

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INAPPROPRIATE MILLENNIUM DEVELOPMENT GOALS

• UN Millennium Development Goals,
• the four principal targets for global TB control
  are
• to detect 70 of new smear-positive patients
  arising each year by 2005,
• and to successfully treat 85 of these patients
  by 2005
• to halve TB prevalence and deaths rates by 2015,
  as compared with 1990.

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BARRIERS FOR DOTS

• INCREASING POVERTY, SOCIAL UPHEAVAL AND CROWDED
  LIVING CONDITIONS IN DEVELOPING COUNTRIES
• INADEQUATE HEALTH COVERAGE AND POOR ACCESS TO
  HEALTH SERVICES
• INEFFICIENT TB CONTROL PROGRAMMES, WITH LOW CURE
  RATES, BECAUSE OF INADEQUATE AND INTERRUPTED
  TREATMENT

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DOCTORS APATHY

• EVEN ALLOPATHIC DOCTORS, BOTH IN PUBLIC SECTOR
  AND PRIVATE SECTOR , ARE NOT SERIOUS IN
  IMPLEMENTING DOTS.
• DOTS AWARENESS IS POOR IN BOTH OF THEM.
• ALL DOCTORS, SOME KNOWINGLY AND SOME
  UNKNOWINGLY ARE PRESCRIBING ANTI-TUBERCULOSIS
  DRUGS AS THEY LIKE. EVEN PULMONOLOGISTS ARE NOT
  STICKING ON TO DOTS REGIMENS AS RECOMMENDED IN
  THE NATIONAL PROGRAM.
• QUACKS (UNQUALIFIED PRACTITIONERS) ARE MISUSING
  THE DRUGS.

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POOR PATRONAGE OF DOTS REGIMENS BY PHYSICIANS

• Most Indian doctors/health workers are not aware
  of DOTS, its success in TB control in other
  countries and how it is being implemented in the
  country.
• The professional organization has not come
  forward to adopt DOTS and popularize it amongst
  their members.
• India has a large private health sector and ways
  and means to reach have not been identified.

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AN EYE OPENER AND TRUE

• THE KNOWLEDGE REGARDING THE TREATMENT GUIDELINES
  AMONG THE RESIDENTS AND CONSULTANTS IS LOW POINTS
  TO THE FACT THAT REEDUCATION OF FACULTY MEMBERS
  REGARDING RECENT TRENDS OR GUIDELINES IS
  ESSENTIAL IF WE WANT THIS KNOWLEDGE TO PERCOLATE
  TO THE PERIPHERY.

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LENGTHY TREATMENT

• CHEMOTHERAPY FOR SIX MONTHS DURATION IS STILL A
  PROBLEM FOR THE PATIENT TO COMPLY
• THERE IS AN URGENT NEED TO REDUCE THE DURATION OF
  TREATMENT IN VIEW OF PATIENTS COMPLAINCE AND
  SIDE EFFECTS OF DRUGS
• ULTRA- SHORT TREATMENT REGIMENS FOR THREE MONTHS
  DURATION USING QUINOLINES WITH RIFAMPICIN ARE ON
  THE ANVIL

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POOR MANAGEMENT

• CONTACT TRACING HIGH RISK GROUPS MANAGEMENT
  ARE NOT ADEQUATE
• INCREASING DEFAULTER RATE IS THE MAJOR OBSTACLE
  IN THE PROGRAM MANAGEMENT
• DEFAULTER CORRECTION ACTIVITIES ARE NOT EFFECTIVE

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PROBLEM WITH LARGE POPULATION

1. THE PROVISION OF QUALITY TB SERVICES TO A
   POPULATION OF OVER 1 BILLION IS A DIFFICULT TASK.
   
2. THIS MEANS PERFORMING ALMOST 100,000 SMEAR
   EXAMINATIONS EVERY DAY
3. PROVIDING AN UNINTERRUPTED SUPPLY OF ANTI-TB
   DRUGS TO MORE THAN 1.3 MILLION CASES EACH YEAR.
4. THIS REQUIRES THAT A LARGE AMOUNT OF RESOURCES TO
   BE MOBILIZED

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COMMUNITY INSENSITIVITY

• Indian society remains insensitive to the issue
  and continues to regard TB control, a government
  responsibility.
• Indian public has not been made aware of the
  magnitude of TB epidemic in the country.
  The national media, NGOs,
  politicians, professional organizations of
  doctors remain largely insensitive the issue.

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SOCIO ECONOMIC DETERMINANTS

• IT IS MAINLY A SOCIAL DISEASE WITH STRONG
  SOCIAL DETERMINANTS LIKE POVERTY, ILLITERACY,
  SUPERSTITIONS AND NEGATIVE LIFE STYLES

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SYSTEM HORIZONTAL OR VERTICAL?

• IN INDIA, WE DO HAVE DISTRICT TB ORGANIZATIONS
  AT DISTRICT LEVEL, BUT LESS STAFFED, LESS FUNDED
  AND LESS COMMITED.
• THESE VERTICAL ORGANIZATIONS CARRY OUT THEIR TB
  CONTROL WORK THROUGH THE HEAVILY WORK LOADED
  HORIZONTAL PRIMARY HEALTH CENTRES AND DEPEND
  UPON THEM.

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INFRASTRUCTURE WEAKNESS

• The public health system is unable to bear the
  entire burden of TB patients and they are forced
  to seek treatment from private doctors. Most of
  these 'doctors' are either unqualified (quacks,
  as we call them in India) or practitioners of
  other systems of medicine but practicing
  allopathic system.

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DOTS HURDLES

• VACANCIES OF KEY STAFF.
  Many states are facing an acute shortage of
  technical manpower
• LONG TREATMENT DURATION and the huge direct and
  indirect costs to patients due to TB
• COVERAGE NOT COMPLETE almost the entire country
  is under RNTCP but yet to cover uncovered
  districts
• ITS SUCCESSES HAVE YET TO REACH THE PUBLIC AT
  LARGE

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KAP STUDY ON FORTY-FOUR FRONTLINE WORKERS

• KAP study was performed on forty-four frontline
  workers (multipurpose health supervisors, health
  assistants, community health officers,
  pharmacists, anganwadi workers) engaged in
  control of tuberculosis just to have an idea of
  ground level situation.

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KAP FINDINGS -1

• A.1) CASE- FINDING DIFFICULTIES
  
• Outreach and distant areas -
  13 responses
• No immediate lab facility-
  14 responses
• Staff deficiency -
  11 responses
• Negligence on the part of
• chest symptomatics to report -
  12 responses
• Superstitions decreasing case finding - 09
  responses
• Illiteracy being the problem -
  10 responses
• Lack of involvement of
• the community leaders
  27 responses

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KAP FINDINGS - 2
B.1) DIFFICULTIES FACING DURING DOTS

• Irregular drug use -- 14 responses
• Side effects of drugs -- 11 responses
• Dots agent not serious -- 22 responses
• No direct observation , just handing over
  medicines responses -- 24 responses
• Quacks negative influence responses --
  22 responses

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KAP FINDINGS-3
EXTRA REQUIREMENTS

• Lab technician at local level , sub centre
  level -
• 14 responses
• One lab technician at PHC is not enough -
• 15 responses
• Lab technicians in villages with more number of
  cases - 31 responses
• Incentives to dots agents to be given - 32
  responses
• X-ray facilities at Primary health centres - 14
  responses.
• Village Tb clubs establishment - 16 responses

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PROBLEMS SUGGESTIONS FROM K.A.P. STUDY

• Outreach problems
• Diagnostic problems
• Side effects of drugs
• Transport problems
• Financial problems
• Community insensitivity
• Less self referral
• Quacks (unqualified medical practitioners)
  problem
• Lack of incentives
• Overburdened staff

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PROBLEM ANALYSIS

• POOR, ILLITERATE VAST POULATION WITH
  SUPERSTITIONS ABOUT BOTH THE DISEASE AND
  TREATMENT
• LIMITED RESOURCES WITH INADEQUATE TRAINED
  MANPOWER AND MONEY AND MISMANAGEMENT

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SOLUTIONS

• IT IS HIGH TIME FOR INTROSPECTION AS ALREADY 13
  YEARS HAVE ELAPSED AFTER DOTS WITHOUT MUCH
  EFFECT.
• 1st step Conduct in-depth epidemiological study
  to know -
• - interaction of various social and
  biological factors and the transmission
  potential in India
• - the prevalence, annual incidence and to
  measure transmission ,
• - to identify the modifiable or manageable
  determinants

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REALISTIC THINKING AND REALISTIC TARGETS

• QUALITATIVE STRATEGY IS URGENTLY NEEDED
• DOTS STRATEGY CONSISTS OF TWO MAIN COMPONENTS
• DIRECT OBSERVATION OF TREATMENT TO MINIMIZE
  DEFAULTERING AND DRUG RESISTANCE
• SHORT COURSE CHEMOTHERAPY
• . IF THESE TWO ARE NOT CARRIED OUT IN TRUE
  SPIRIT QUALITATIVELY, DISEASE REDUCTION WE CAN
  NEVER EXPECT

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PRIME TREATMENT

• FULL COURSE TREATMENT AS SOON AS THE NEW CASE IS
  ENCOUNTERED IS THE BEST WAY OF STOPPING THE
  SPREAD OF TB
• OPPORTUNITY TO TREAT A NEW CASE COMPLETELY AT
  THE FIRST INSTANCE OR CONTACT MUST BE RULE

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INCENTIVES

• FOOD FOR THE POOR TB PATIENT JUST LIKE FREE
  LUNCH FOR SCHOOL CHILDREN TO ATTRACT THEM TO
  ATTEND SCHOOLS MAY IMPROVE TREATMENT COMPLIANCE
• MONEY FOR THE DOTS OBSERVER MAY ALSO WORKOUT

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NEED FOR NEW AND EFFECTIVE EFFECTIVE VACCINE

• B. C.G VACCINE IS LESS PROTECTIVE FOR PREVENTING
  TUBERCULOSIS IN ADULTS
• NEW VACCINE IS ESSENTIAL FOR THIS HIGHLY
  COMMUNICABLE DISEASE WITH A LONG PERIOD OF
  COMMUNICABILITY

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REFERENCES

• WORLD TUBERCULOSIS DAY REPORT 2005
• WHO GLOBAL STAISTICS, 1996
• WHO GLOBAL TB SCENARIO-INDIA PROFILE
• TB control is not a public movement in India even
  18 months after the Amsterdam declaration-- DR.
  DINESH KUMAR, DIRECTOR,HEALTH AND DEVELOPMENT
  INITIATIVE-INDIA
• WHY BLAME PRIVATE PRACTIONERS? A letter to the
  editor published in Chest. (20011191288-1289
  2001 American College of Chest Physicians) from
  Ashish Bhalla