An Observational Study of RNTCP and DOTS Strategy in Three Districts
Item
- Title
- An Observational Study of RNTCP and DOTS Strategy in Three Districts
- Creator
- Sunil Kaul
- Date
- 1998
- extracted text
-
5
AN OBSERVATIONAL STUDY OF RNTCP & DOTS
STRATEGY IN THREE 7 "STRICTS
January '98 — March'98
Dr Sunil Kaul
Voluntary Health Association of India
40, long.Swasthya llhawan, Institutional Area, South of IIT, New Delhi 110016 ■
A- •
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r
A
ACKNOWLEDGEMENTS
I must gratefully acknowledge VHAI for facilitating this brief study which-had been on
my plans for the past few years. The guidance provided by Dr Mira Shiva and the
doughty words of wisdom given by Dr Debabar Banerji helped me make the best
possible use of the short time available. I must also thaiik the Medico - Friends Circle
whose genuine concerns about the disease made me observe the RNTCP projects with
an open mind. Mr Ram Babu of Rajasthan Voluntary Health Association spent valuable
time with me during the Jaipur,leg for the study and used all Iris acquaintances to
facilitate the study. Mr Debasis of VHAI deserves my gratitude for helping me with
preparing parts of the report.
I am indebted to the project officers and staff at Mahesana, Gulabi Bagh, Delhi and at
Jaipur for going beyond the call of their duties for taking me around their areas,
allowing me to choose the sites for visits, and sharing their findings with me in as
transparent a manner as service conditions would allow them.
Last but not the least, 1 need to acknowledge all the TB patients whom 1 have known
over the years, and those whom I interviewed during the study for their insights and
their indomitable courage which overcomes most odds inspite of all our treatments - or
reservations about them.
i
RNTCP - A SHORT STUDY
The National Tuberculosis Control Programme was facing problems in its
implementation and for various reasons the case finding, case holding and cures
.'.chieved were far from satisfactory. After studying the deficiencies in the existing set
up. the programme was revised in 1993.
NGOs working in the field of TB in one of the rare im. iactions allowed by the Ministry
of Health in 1995 had demanded a visit to the pilot projects to confirm the announced
results of 80% to 95% cure rates. The demand for visits didn't even materialise in the
minutes of the interaction. A visit was out of question.
i here have been criticisms bv DOI'S - busters about the fact that the RNTCP and DOTS
v as pushed I y the mandarins in Nirman Bhavan under the influence of WHO and a
loan sought ficim World Bank( IDA) for the same. Between claims of success made by
one partv and criticisms on (he intentions and methodology of tackling TB under
'' I CP the issue ot the efficacy of the DOTS methodology was lost. And since the GO1
ui its wisdom has gone ahead any way, it was though. ■ . udent to see if the programme
on ground has been able to go beyond this wrangling and come up with something
better to suit Indian conditions. To study the merits and demerits of the methodology,
and to sei.1 if the same could be used by NGOs — who are largely accountable to their
society and can suit good ideas to their communities better than the government can —
in their areas of work, it was decided to directly observe for a short while a few of the
DOTS programmes and report back to an NGO group under the aegis of VHAI. The
.areas to be focused were to be :
•
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is DO I'S really directly observed, because the revi.% n revolves around this and the
investment is being justified on this ground alone ?
what is the universe of patients against which th. cure and.compliance rates are
being calculated?
what is the detection rate and does it come anywhere near the expected incidence of
Til (0.2%) in their populations?
is a strict vigil being maintained on the compliance because if not, the programme
would indeed be disastrously increasing the incidence of MDRTB?
what are the patients reactions?
how strictly are the technical guidelines for case detection and treatment being met ?
Given the constraints of funds and time, three centres were selected for the visit:
1. Gulabi Bagh in North Delhi, which is being flaunted as the most successful pilot
project in the entire country.
■ it&O 1 ■ .*
2. Mahesana district of Gujarat, which was the only rural area chosen under the pilot
phase programme.
3. Jaipur, which was taken up in the second phase and could represent the BIMAROU
(Bihar, MP, Assam, Rajasthan, Orissa, UP) area.
1'he selection of the centres was made on the basis of proximity and convenience and
the fact that these centres have been around long enough to make corrections
necessitated by field conditions.
The study is not going into the comparative efficacy of short course regimens of RNTCP
& NTP, but is only making observations and inferences on the RNTCP programmes
seen at the three programme sites. Neither is at an inquest. The author has run a TB
programme in Urmul Trust and has first hand experience in using the daily WHO
regimens for a long time. The author attempted to use his experience in digging into
data, recording procedures and regimentation procedures so as to check his own
doubts about the feasibility and replicability of the project.
Since ‘permission’ from DDG(TB) didn't arrive in more than a month, despite our
replying all their queries and misgivings, a direct liaison was established with the three
sites and the admittedly honest and cooperative attitude of the projebt staff at each
place helped the observational study.
Delhi
Mahesana
Jaipur
j
Project HQ, Gulabi Bagh
Field Centre, Sarai Rohilla
Field Centre, FI Block Ashok Vihar
Field Centre, Shakti Nagar Extn
29 Jan & 19 Feb 1998
Project HQ, Mahesana
PHCs Jagudan & Amabaliyasan
Vill Baliasana, Vill Akhaj
CHC Lanva & Sander
PHC Ranuj(Patan)
10 -11 Feb 1998
District TB Centre, SMS Hospital
DOTS Centre, Bani Park
TB and Chest Hospital
DOTS Centre, Jaipuriya Hospital
DOTS Centre Gandhi Ngr Dispen.
09&HMarl998
10 Mar 1998
10 Mar 1998
10 & 11 Mar 1998
11 Mar 1998
31 Jan 1998
19 Feb 1998
19 Feb 1998
11 Feb 1998
12 Feb 1998
There are some queries of mine which remain unanswered and I have taken the liberty
of posing them at the end of the study report. Some suggestions which come to my
mind have also been humbly added for whatever they are worth.
d
Note : Data received from the three project areas may not be comparable as the data
live! handed oxer to me have been al the discretion of the projects who have
perceptible risks to their careers. " Data from these projects is the property of the
World Bank ", confided one of the project officers.
Background:
It might be worthwhile to mention a few points about the RNTCP and the DOTS
regimen lor the uninitiated
in I1''.'! a nation wide survey was conducted bj' the GOI to review the National
1 uberculosis Programme with assistance from WHO and SIDA. Their salient findings
............. ■ :. .alini ni . amplviion.
a) iii.im'ipi.uv budgetary outlay anil shoi tage ol drugs
uni undue emphasis on X - Kay diagnosis.
. iv) poor quality of sputum microscopy.
(v) emphasis on case detection rather than cure.
(vi) poor organisational set up and support tor I’B.
ivii) multiplicity of treatment regimens.
K.N I s i ’ w as launched by the Government of India in 1993 with an emphasis on DOI'S Directly Observed 1'reatment - Short Course in pilot projects in 5 different parts of the
country. I he objectives of the revised strategy were:
a) empii.His on the cure of infectious and seriously ill patients of tuberculosis, through
admii i.'tration of supervised short course chemomerapy, to achieve a cure rale of at
least l>5 o.
b) augmentation of the case finding activities to detect at least 70% of estimated cases,
only after having achieved the desired cure rate.
1'he strategy involved :
• use of sputum testing as the primary method of diagnosis among self - reporting
patients.
• standardise treatment regimens.
• augmentation of the peripheral level supervision through the creation of a sub district supervisory unit.
- vi. -ui ing, a regular, uninterrupted supply of drugs unto the most peripheral level.
• augmentation oi organisational support at central and state levels for meaningful
co. ndination.
S
emphasise training Hit, operalion.il resear> h ami NCO involvement in the
programme.
increase the budgetary outlay.
After the CO1 was convinced of the efficacy of the approach, the project area was
progressively increased with an aim to cover 271.21 million population by the end of
phase 111 of the programme, i.e., by 1998.
The successful implementation of the revised strategy is expected to achieve:
• a cure rate of at least 85%.
• case detection of at least 70 % of the expected.
• rate of reduction in the annual risk of infection from the current 2 to 2.5 % to 8 to 10
%.
• reduction in mortality to about 20 per 1,00,000 population.
reduction in relapse to less than 5% from current figure of 20 %.
WHO had given its treatment guidelines for national tuberculosis programmes in 1993
which had four regimens of treatment based on categories of patients which were:
CATI-
CATHCAT III -
CAT IV-
Sputum positives New cases; but even widespread sputum negative cases
were to be included, e.g., serious TB patients like TO meningitis etc.
Sputum positive Retreatment cases on account of relapses, treatment
failures or default. Even sputum negative cases could be considered but
after exercising a lot of care.
Sputum negative cases and non serious extrapulmonary cases were to be
considered.
Chronic cases.
Treatment was based on the priority for treatment on which basis they were to be
categorised. Sputum positive meant that at least two sputum smear specimens are
detected positive out of three sputum samples which include at least one overnight
sputum. However, one sputum sample positive is considered sufficient if X-Ray is
consistent with active pulmonary TB.
Sputum is the most important aspect of the approach. Before a diagnosis is to be made
in symptomatic patients, at least three samples of sputum are to be examined, one of
which has to be an overnight sample, Follow up samples are to be done of overnight
samples, once at the end of intensive phase — at the end of two months for Cat 1 and Cat
III patients, and at the end of three months for Cat II patients -- and later every two
months till the duration of treatment is completed. For details, please see Appendix A.
To further emphasise on the Sputum status, a 1:1 monitoring standard of Sp positive to
Sp negative has been insisted in each project so as to minimise the X-Ray dependence.
6
Binocular microscopes and training of Lab personnel to enhance microscopic accuracy
have been made part ol the !Togramme. X-Ray Chest may be done, but is not obligatory
lor Sputum positive patient.':
The idea of DOTS is to ensure that each and every dose is supervised from a centre
close to the patient. This helps the patient to 'remember the intake, cuts down cost of
default, cuts down incidence of MDRTB and is reassuring to the patient/ By the time
this study has been conducted, the programme has already unofficially sanctioned
POTS, i.e., Partially Observed Treatment Short Course. During the Intensive Phase(IP),
the patient has to come to the centre for the thrice "'eekly intake of drugs in single daily
dose blister combi - pack, but during the Continuation Phase(CP) the patient has to
collect the drug only once a week in weekly blister combi - pack dosages of which s/he
has to take only the first of the three doses in front of the TB worker. In toto, of the 2-1 IP
doses and 18 CP doses, 24 II’ and. (> CP doses require observation.
V»cighi iccoidings have to
made at eu<h visit. lire lust one oi tco buses ma\ be
given to the patient before the complete box of drugs for the CAT I /ll/lll reaches the
patients field centre close to his/her house in blister combi - packs. The dosages are
calculated on the basis of the initial weight recording in accordance with the following
chart:
Drug dosages for RNTCP (tin ice weekly):
Drug Name
Children and Adults
30kg
Adult
30-60
_____
Rifampicin
10 mg/kg body weight
450 mg
INH_________
5 mg/kg body weight600 mg
Ethambutol'
15 mg/kg body weight1200 mg
PyraZinamide 30 mg/kg body weight
^00 mg
Streptomycin* 15 mg/kg body weight
0.75 gm
* Ethambutol is not given to children below slx
six years of age.
agi
# Streptomycin is not to be administered to pregna it women.
Adult >60 kg
600 mg
600 mg
1200 mg
1500 mg
0.75 gm
The DOTS methodology has been reported to i • very successful in a number of
countries including China and US. The four/five -drug short course regimens do hot
require introduction. However, the changes from daily regimens to thrice weekly
regimens during the Intensive Phase does require explanations. The flow charts giving
the complete RNTCP methodology are given in appendices A to G.
b’or effective management, some indicators have been passed down to all'levels so as to
allow self evaluation. These are:
Case Finding and Case Management Indicators
Proportion of symptomatic patients who are smear positive
No. of smears taken from suspect cases
Percent smear positives among new TB cases
Value
8 -12 %
3
50 %
Value
Case Finding and Case Management Indicators
Proportion of new smear positive patients found in the Laboratory
>95%
Register being on treatment (in TB Register)
> 90%
Proportion of new smear positive cases placed on DOTS
Sputum conversion for new smear - positive TB cases at
> 85%
3 months
> 90 %
DOT treatment given in the initial phase
>85%
Percent of new smear-positive patients who are cured
Programme management Indicators
Value
113 supervisors and laboratory supervisors in place
Training activities according to plan
Registers , reports, etc. In place
No. Of supervisory visits done by the
Central unit
•
Number of supervisory visits by the STO
No. of supervisory visits by the DTO
> 80 %
>75%
100%
Every site at least
twice
Every site quarterly
Each microscopy
unit quarterly
Adequately thugs and laboratory supplies, with stock at each
level
Complete reports received within the quarter
Integration indicators
Process initiated to enhance integration with other programmes
anti other relevant institutions
3
R
> 90%
> 95%
Delhi — Chest Clinic Gulabi Bagh
Population of project area : 1 million as of now
: Gulabi Bagh
HQ
: 10
Field Centres
: 1 (HQ) + 2(field)
Microscopy Centres
Project Officer
: Dr R K Mehra
Interviews of Dr RK Mehra, Dr Ghanshyam Singh, Mr Anand, Mr Ajay & Mr Naresh
taken during the course of the visit. Visits made fi.cn the Hqs to Sarai Rohilla TT3
Centre, and the ones at Ashok Vihar Phase I and Shakti Nagar Extension.
Manpower & Infrastructure
The Chest Clinic, Gulabi Bagh(CCGB) has been running for a long time and is well
known in the area as " I'/> kn aspalul" even though there are only a lew beds. CCGB
started the pilot project in Oct 19l>3 and established K) Drug Distribution Centres and 10
Microscope Centres. The Municipal Committee of Delhi extended the already existing
infrastructure ot CCGB and deputed its manpower for the project. For the field centres,
space was provided for the TB centres within already existing school/ government
buildings. 1'he World Bank money coming directly to the project — via the District TB
society formed now — meets the-costs of all consumables (except drugs and films),
laboratory reagents, microscope maintenance, maintcm... e of vehicles and vehicle hire,
and for contractual staff. CCGB has hardly got any contractual staff on their rolls.
Funding
When the programme started, the funding was received from SIDA and ten microscopy
centres(MCs) were started along with the drug distribution centres. But during the
switchover from SIDA to World Bank, eight of these have had to be closed down. AU
the microscopes of the MCs are centrally used at CCGB and replacements for the two
field microscopy centr es are provided from these oarb.
But the funds are clearly not enough to meet the expectations of the staff. Rumours
about motor cycles being given, and cribbing about promised incentives not being paid
for freshly detected sputum positives abound. Repeated demands for small items like
felt pens and tumblers shows that the project does have t. scrounge for money.
° • -'W
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lhe feeder population of the area varies from the upper £r upper middle class .families, ,
of posh areas of Pritampura to the migrant labour populations of Jhuggi Jhopri (shanties)
colonies in Shastri Nagar and Sarai Rohilla.
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Accessibility
Distances from the farthest point in each locality to the drug distribution centre range
from three to four kilometres. This translates into a maximum of twelve rupees by
rickshaw each wax- for a patient who cannot walk it to the centre.
Case Finding
There is only a passive surveillance for newer cases. Initially, there was a problem in
getting patients, and the project resorted to active case finding. Each case of sputum
positive TB attracted an incentive of hundred rupees and the health workers spent a lot
of energy in urging all 'TB looking people' to cough out their sputum and in making
slides on the spot. There are no official figures available, but around a hundred new
cases were discovered. The scheme fizzled out because finally the promised incentive
was never paid to the workers.
By now, people in the area have heard of the programme, and when they learn that they
have TB, they report to the nearest centre or to the CCGB— usually the latter. All eight
patients whom I interviewed had gone for their cough to some private practitioner - a
few to some government hospital as well— and after an X-ray, had been started on
ATT. Even according to the programme staff, about 90% of patients have already
started treatment before reaching the RNTCP. Yet, it must be said to the credit of the
programme that most of these patients have reached the programme within a month of
starting treatment, i.e., they are within the definition limits of "new case."
Diagnosis
Such patients are given a sputum cup - these are plastic cups with screw-on lid and
have also never been in short supply — and asked to go to the microscopy centre with
rm overnight sample. The only patient I observed was sent off with bare minimum
instructions, and was not given adequate instructions to produce sputum as described
in the technical manual.
Since there are only three microscopy centres in the project area, patients are referred to
such centres alone, where a 'spot specimen' is collected along with the overnight
sample. They are asked to come again the next day and-another spot sample is taken. If
they come directly to one of the MCs, as is the case usually because of the "baile doctor
sahib Cailabi Bagh me baithte hain" knowledge, a spot sample is taken and a cup given to
the patient to get an overnight sample which the patient gives the next day along with
yet another spot sample. The result is given on the next programme day and the
treatment started il required.
Incineration
There are no incineration facilities at the field microscopy centres. This may have to be
looked into. 'There were a number of sputum cups which were not yet completely burnt
although the stall al the centre had tried to burn them crudely. The lack of ventilation
in
in the microscopy centre is also something which may've to be looked into, given the
high rates of MDRTB reported in North India latch/
Registration
Before starting treatment, patients are asked to show their ration cards or proof of
residence so as to avoid patients outside the project area trying to get 'good medicines'.
Along with, the patients are also required to gel a guarantor, like the local health
worker, or anganwadi worker to ensure that the patient shall visit the centre thrice a
week and shall not default. Any default here, and one doesn't get medicine. Patients
diagnosed TB but failins' this 'future compliance lest' are asked to approach other I B
hospitals for their treatment.
Drug Supply
Drug supplies have been regular and have never failed — according to the programme
handlers, and to the
patients interviewed. This must be one oi the major
accomplishments ol the programme. Earlier the orders weic to have a box of drugs per
patient, but was given up in between. The 'box' concept has been reintroduced since the
past six months and was seen to be religiously implemented, the name of each patient
has to be written on the box and the box then reserved for him/her. During the days
the system had been changed, drugs were being given to many patients from the same
box and the logistics of sorting them out in reporting procedures has been a tiring
exercise for the workers. Most field centre reported a lack of storage space for the
'boxes' concept.
There have been problems with the drugs changing their packaging though. 'Earlier,
they were imported, but now they are poor quality' from India', said a worker. Till they
are given out of one packet alone, there is no problem but if the packaging keeps
changing, the patients tend to feel that the drugs have been changed. This doesn't go
well with many of them because they feel that the drug that they were doing well, on
has been changed and this has been the cause of default in a few patients.
Young children have the privilege of getting Riiampicin in syrup form and small kid
tablets of ATT procured specially for the program ne. Age specific doses were found to
be accurately entered and adhered to in all the treaBnent cards.
DOTS
In both the functioning field TB centres that I visited — one had moved in only the
precious day
I couldn't find any water source. The patients had to go out of the
centre premises to a roadside hand-pump and then fetch water in the glasses which had
been provided at the centre. The'small room had little space, so all the patients who
were given the drugs shelled out from’ the combi-pack swallowed the drugs outside the
room. Since the next patients standing at the counter were blocking the health workers
view and attention, the drugs which were swallowed, were not under direct observation.
n
f
’ ■riWWi;
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Worse still, two relatives came to collect the drugs in my presence and were given
medicine -- good by my way of thinking but definitely against the DOTS concept ! I
could observe only one patient swallowing the drug in front of the DOTS worker.
At least four patients in the continuation phase who were asked to eat the drug then
and there questioned the worker to confirm the instruction. "Is it necessary to eat the
drugs now?" This left me to infer that many of such patients had been allowed, earlier
to take the drugs away without insisting on the first dose to be taken under direct
observation and my presence probably was the reason for the insistence of DOTS and
the inquiry!
The thrice weekly regimen has been staggered for some centres. Most centres usually
function on Mondays, Wednesdays and Fridays - unless one of them is a holiday, in
which case the routine is changed in anticipation to Tuesday, Thursday, Saturday for
the coming week. This also helps in adjusting leave and vacations of field staff whereby
a shift of duties prevents centres from closing down on DOTS days.
All the patients whom I interviewed while taking the DOTS dose had taken at least
some kind of food in the last one hour 'to avoid vomiting'. "We have been told to take it
one hour after food — well it is almost an hour, isn't it?" Given the fact that the centre
opened only at nine-thirty and functioned till twelve noon, one can't blame the patients
for not remaining empty stomach till the drug is swallowed. But it may be a better idea
to aim that these antibiotics have their full effect.
i
Adverse Drug Reactions
i >o patients vomit the medicine often ? " Yes, they do. And see, if they vomit inside the
centre, who will mop the floor? As it is, we get only forty rupees a month for the
sweeper. That is why we avoid patients taking the drugs inside the centre. But the
authorities cannot understand." The staff hasn't seen any other reactions. However, a
levs jaundice cases apart from several temporary gastritis patients have been seen by the
medical oiricers. :>mcc there are no records maintained, it is difficult to quantify the
reactions.
Staff confidence in DOTS
fhe two medical officers seem to be very enthusiastic about the DO'FS regimen. Having
dealt with unending non - compliant patients earlier in the NTP, they are sure that this
is much better. " This requires us to work doubly hard, but the results are so
giati tying!''
Most of the workers were sensitive to the problems faced by the patients and their
relations in attending the DOTS clinic and were strident in their criticism. Two of them
even told me that the doctors also are unhappy about it but have to follow the system
because of pressure from above. One teenage girl who was sodll and emaciated that she
1?
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had to be helped by her mother in coming to the cenii a and was accompanied by the
father also, told me that her family had spent twelve rupees for the rickshaw one way
from their home. Tire father pleaded the worker to hand over the drugs directly to them
as it was costly and very difficult to manage the trip thdee a week. The latter looked at
me for 'permission'. I told him that I was nobody to give permission, although I would
appreciate such a consideration. The worker, sensing some official problems told them
that he can't hand it to them directly, but will go to their house and personally
■ lmii'i-:ii r th.' doses every alternate day I le was surely going out of his way and it was
most heartening to see a government worker responding from his heart!
1 ater, he and one of his colleagues who had closed lus centre and come over, vented
their frustration. " It is in the first two - three month' .hat these patients are so weak
that thev can't work or walk. Coming to the centre with their relatives is like adding
fuel to the liri'. As it is they are poor, and the disease period lakes away the chance of
i amine.
-cage. I'hev do not mind doming even eveiy day to the centre during the
• onlinualion phase. It is the initial period which is tough and is made tougher because
>>1 the IX>I o strategy.'’
I . ■ inplimenled them for displaying a good heart to the emaciated girl. How do they
h.mdm such cases usually, 1 inquired. Don't such patients default ?
vs llu"c io.' And how do they .prevent it ?
V/e I,’, ,md screen out all patients who are likely
lefaull. And do not start the
treatment at all in such patients." And how many paints are left out on reasons of
‘.mlilady compliance of 1X t IS ?
.Almost twenty five percent." 'Maybe even thirty, add. the other.'
According to a slogan in the CCGB OPD, it is better not to take anti TB drugs than to
take them irregularly or half way. One agrees with the message. But you can't leave so
many patients out of the programme simply because they do not fit into the RNTCP
system.
"
Patient compliance
I he patient compliance was generally good. Of the twe xntres where I could check out
till the closing time of the centre, one had one patient cut of twelve and tire other one
out of nine patients who were expected to make their collection that day but hadn't
done so. These patients were supposed to be followed up the next day by the health
visitor so as to ensure that there is no long break between two doses of drugs. Those
who are habitual of missing their turn at the centre . a counseled by more senior
members of the staff.
Once started, there seem to be few dropouts. Most of the male patients I met had learnt
to take the disease and the DOTS in their stride and would drop in at the centre on their
way to their work place. It was the women who fat .-.i a bit of a problem, but had
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adjusted their routine in such a lashion that they would come to the centre after having
dispatched their husbands and children for the day.
But how many are initial dropouts? Very few. As every health visitor has to report to
the CCGB after twelve every day, he or she can collect the treatment card and the drug
box of any new patient diagnosed earlier in the day. Such patients are followed up in
their homes if they do not report by the next DOTS morning. No drug is started till the
patient reaches the DOTS centre.
Record Maintenance
The record maintenance done is of an exceptionally high quality. The TB treatment
cards, which have so many columns and entries to be made, have few or no lapses at
all. Each of the project staff understands the value of each entry in the card and tries
hard to fill up each column. The registers kept at each centre are updated regularly by
the staff who fall back to the CCGB from their respective field centres after noontime.
Supervision
The supervision by the medical officers and the supervisors has been reasonably good
and has helped not only in keeping the field staff on their toes, but also in bringing
deficiencies to light very early, thus preventing material/ manpower failure.
'['here is a shortage of laboratory staff however, and it is not possible for the I.ab
Supervisor to follow the prescribed norms of checking 10 to 20% of slides for false
positives or false negatives.
Vital Statistics:
Cases Regd:
Total
Smear +vc
Smear -ve
X-Ray~
....... "Rolls' '
Total (Rs.)
Compliance
Rate (%)
Nov 92 - Oct 93
1994
1995
1996
2900
_408
2492
1303
758
545’
1214
859
355"
1177
806
371"
127
6350
40.50
73
3650
>90
67
3150"
>90
_75
3750
>90
Id
Cases Registered
Phase
Category
I______
(Oct93
Nov94)
II
TP
2
(Ian 95
Mar 97
ii
in
■ HP
; >
( Apr’”
: ii
Smear +ve.
Pul. ____
509_______
281
Smear -ve Extrapulmonary
Pul.
83____
89
5
11
Total
681
297
______ J
1053
807
165
7
310
28
1528
842
I -
304
23
3
195
82
0
499
456
294
145
149
293
I 351
i' 291
Dec 97
Tin”' siai ted v. <■! | , 2, 9b
XU ‘.he . aiegoi ies in the table hi.
a rough gender ratio oi 2:1.
Results of Sputum positive cas
lan 95 to Dec 95
' O'1'II
Total
'510
Cui ed
1 440
19
Expired
Failed
Is
i'•::!/
TlP
1 Maul!
Cme Rale
i 88%
I 34 I
'! 263 "
16
14
F
i'8 ! *:<>
I ical inent Results of Phase 1
Total
Cure
Cat 1
Pul Sp +ve
Pul Sp -ve
Extrapuhn
Cat II
Pul Sp +ve
509
83
89
476
281
222
Compliance
Expired
Failed
Tfr/
default
2
6
18
4
2
11
33
4
75
87
15
1 r- 1
15
Gujarat — Mahesana District RNTCP
I IQ
:
Population of project area :
Rural:
Urban
No of villages
PHIs used for DOTS
PHC
CHC
Gen Hosp
Dispensary
NGOs
Total
Sub - centres
Mahesana, Gujarat ■
Phase 1
(wef 02 Oct 93)
5,76,290
4,54,872
1,21,418
Phase II
(wef 15 Aug 95)
14,90,076
11,39,282
3,50,794
252
580
13
3
1
4
1
23
116
36
5
3
9
5
59
273
The entire project area has 36 microscopic centres and 3 ;X-Ray centres. 15 more PHCs
have been designated Microscopy centres.
Had interviews/ discussions with the DTO, Dr M.B. Leuva; the medical officer who has
stayed longest with the project, Dr A .S. Parmar, with the Supervisor, Mr V S Prajapati,
some other staff members and a number of patients during the course of the visit.
Field visits:
1. PHC, Jagtulan
2. Vill. Baliasana, Taluka, Mahesana
3. PI IC Ambaliyasana
4. Vill. Akhaj
5. CHC, I,an > a, Chanasma
6. CHC, Sander
7. PHC, Ranuj
Population A Infrastructure
The DOI’S Project was started in Oct 1993 as a pilot project for the RNTCP. Although
initially it had a feeder population of five lakh, it now has fifteen lakh population under
its coverage since Phase II launched in Aug 1995. Being the only rural area in the pilot
project, it is this project which is of importance to test the feasibility of replicating the
DOTS strategy.
16
Ihe population, except for towns is mainly that ol .. Idle class. Those in lower class are
many more in number compared to the number of the elite class. That there is no
kulcha structure in any village that J visited indicates a general prosperity in comparison
to the rural areas of BiMAROU (Bihar, Madhya Pradesh, Assam, Rajasthan, Orissa,
Uttar Pradesh) states.
The entire project has been handled by the existing government health service and
functions through the DTO, CI ICs, I’FICs, Sub centres, Anganwadis, etc. by retraining
and reorienting the staff to the DOTS and RNTCP ideology.
Since the DOTS strategy ensures alternate day avauaoility of drugs to the patients, it is
essential that wherever the ANMs/ Male health ’.."-kers aren't in accessible reach of
the TB patients, alternate DOI S workers be appointed. For this, the project has used
Anganwadi workers who are offered Rs 175/- fot every patient completing his/her
complete treatment. In one of the villages, the husband of the patient who is a Home
Guards personnel is the alternate DOI'S worker. When 1 visited him and his wife
Hansaben in village Babasan, he was meticulously maintaining the patient record card
and knew exactly how each dose had to be given. Although it cannot be called DOTS
exactly, if the proof of the pudding can be said to be in the eating, the innovation is
effective, patient-friendly, and is effective. The regular backing and support from the
ANM/male health worker and the TB supervisor ensures that it is functional and the
radiance on Hansaben's face affirms that DOTS or
DOTS, the system is suiting her.
Case Finding
Initially, the project had difficulty in identifying '■ -w cases. But over the years, the
programme has built up a formidable reputation in the rural areas and the moment
patients come to know that they may have symptoms suggestive of TB, they may even
directly report to the PHC \ Mehsana DTC for a correct evaluation before starting
treatment. Although the majority is still reaching private practitioners before snatching
over to the Govt health system, the large ratio of Cat I cases to Cat II cases itself speaks
of the accessibility/acceptability and visibility of th’’- project.
...Diagnosis ■ ■ .
, .
J
All patients reporting with symptoms of TB are sent to the nearest microscopy centre.
They are asked to give a spot sputum specimen initially and are given a sputum cup for
getting the next morning's sputum specimen. The lext day, apart from the overnight
specimen, a spot specimen is again collected and the result of the three are given the
next day morning. If sputum positive, they are reg.stered and treatment started from
the DTC/CHC/PHC, i.e., any part of the system where there is a medical officer
present. It is another matter that most patients still prefer to get the treatment
confirmed from the DTC and prefer to go to Mahesa-’a for the initial registration.
17
iI
Although, there is no doubt about the expertise of the microscopists of the tuberculosis
programme at the DTC itself,one cannot say the same about the CHC//PHC;./ ; ,'./
microscopists. The DTO, on his visit to a OHC'in my'presence/wanted, tq crosscheck//-' i/.R
some sample slides which had been declared ++ or +++ positive by the labbra'fory. '
’
assistant and treatment authorised accordingly.' After dithering' for about, fifteen
minutes, complaining about the light adjustment of the'binocular micrbscopesprqvided.u / .
in the programme, instead he was asked to show the same in natural light. Of the tvVo .;.
slides which were)marked ++andj+±+, he^could'show us fhe doubts-of oneisinglq-AEBi...,
■••■! I:
t
DTC; but what worried me was the arrogance of the' technician who continued- to blame‘ '-<■
the microscope.and continued^to be. sure that.he had.seen the AFBs quite• clearly.A—
Having seen Dr Leuva's;habit of going into minute details and'cia'eckm^'out'each'iahdc
every entry in the patient treatment cards, I am sure that this'ex'perience'musbhave, •
made him overhaul the entire lab cross checking'procedures which are laid out in the
programme but are not being followed in some programmes where'there is a shortage
of laboratory personnel.
,
•
■ Ti '
.
The insistence on the three sputum specimens before starting' treatment'1 is so
conscientiously followed that the transition from multiple x-rays to ho x-rays at all has
been easily accepted by the TB patients and by the Project staff. None of the Sputum
Positive patients are x-rayed even once — neither before nor after !
t
Ss
jI
■' ?
Registration
Once the patient is diagnosed TB, his/ her residence is checked and if found to be
within the geographical limits of the district, s/he is put on the RNTCP regimen. If not,
s/he is given the MIP regimen at the DTC or transferred with Iris/ her card to the
concerned PHC nearby. Usually, a guarantor in the form of an Anganwadi worker or
local ANM/ MPW is insisted upon.
'
1
f
I
There is no overlap of regimens in the project area. However, of tire patients taking
drugs from the DTC itself, only 50 of the approx. 500 patients are on the RNTCP
regimen. 1'hose reporting for the first time from outside the district, and those who get
transferred from some other district are kept on NTP regimens.
DOTS
Once the patient is registered, the first DOTS is given immediately. Depending on the
time expected for the drug - box to reach the DOTS/ Alternate DOTS worker, the
patient is also given one or two more doses in his or her charge. However, because an
occasional default was found in such patients in the initial stage's of the project, the
project has designed a form which is filled up in triplicate. One copy is given to the
patient while another is sent/ handed over to the nearest assigned DOTS worker, who
I
!■
»
•p
i
«
’■’
■■
.
:■
' ' £
‘ ' fi*
in turn, follows up the patient at the address given, in case the patient doesn't turn up.
This is a good system bv which f'>ey have already cut down the initial drop-out to
practically zero.
The drugs are kept in boxes in cor-'bi - packs and tire name of the patient prominently
displayed on the box. The patience drugs are,-thus marked out and allocated.'The
change of shape in combi - packs from the Intensive phase to the Continuation phase
also signals the need for a sputum specimen to be sent to the microscopist. Although
the combi - pack drugs for the programme are still imported, there has been a time
when the supply was interrupted, and the programme had to resort to unpacked loose
drugs. But, luckily the TB drug:, supply has never broken down completely. The
flexibility of having Project funds available through the District TB Society,/rave also
helped.
H; and latge, the doclots at the CHC and the pharmacist — who holds tire drugs and
the treatment cards — are well co.- ersant with the new changes in the RNTCP. They
also know about the insistence
’..irding three sputum specimens before starting
treatment. It was also good to see mat the medical officers were entirely familiar with
the case histories and addresses of those who have defaulted on the treatment. It could
be taken to be an indicator of the keen interest taken by the doctors in defaulter cases.
Usually, all the adult patients are being given the same dosage of drugs. One
discovered that patients above 60 kgs were also being given 450 mg of Rifampicin
because of oversight, and the same was corrected when pointed out. The variation in
children is being given by dividing the capsule contents where necessary.
Some of the supervisory staff ha
en provided with Bajaj-Kawasaki motor cycles and
seem to be making good use of Ju. same. There knowledge about the patients of their
respective areas is very good.
The worst area, by their own admission, is the newly added Sami block which I could
not make a visit to.
I-
Record Maintenance
rite level of recording accuracy was also very high. There: was ■ not a single entry
missing in more than fifty' forms that I went through at the various centres visited. For
treatment cards maintained by ealth workers/ alternate DOTS workers, there are .
duplicates maintained at the co
•ned.PHC/ CHC which get updated^whenjb^jiealtih^;
workers come for the monthly meeting. "
■
'' ' '
T'1';:
Most patients when questioned/ were: taking'themdrugsl.em.p,ty>stomach.(first,(thing ,m ,
the morning. However, about thirty percent had problems', taking thev Rifampicin and ... . ■
had to resort'to taking it after breakfast;«h.i& jatekh.
A tfwu i
?h.’, mir :. UTi-fuhm ; '.
'.......................... ;
IQ
i
Adverse Drug Reactions
Although doctors and the health supervisors did recall seeing quite a few drug, induced
gastritis, and even a few cases of jaundice, there is no record maintained for the same.'
However, the supervisory staff did not seem to know how to handle the reactions,
because I saw one of the supervisors advising a patient to take 'Dexona' for a skin rash
she was complaining of after starting the treatment.
Patients who are too weak to walk are admitted in the DTC till they are fit enough to
walk around. They are straightway put on the DOTS regimen and the same is
continued from their respective DOTS centres.
Drug administration directly under observation is not a problem, because all the centres
have only three to five patients staggered over a few hours of time. The patients have to
fetch a glass of water to the pharmacy counter, the drugs are shelled out from the combi
- pack by the pharmacist and the patient swallows them in front of her/ him. Those in
Category U are sent to the injection room with a Streptomycin vial and on producing
the vial an entry for the directly observed dose is made in the treatment card.
Patient compliance
The general compliance rate was as good as has been reported. Each member of the
staff is very familiar with each case who defaults and the last ditch attempt to prevent
default is almost always made by the medical officer making a visit to the patient's
house.
■Although one got the impression that patients are usually compliant, the only field
centre where I could check out till the end of the day -- at PHC, Jagudan, two of the
three patients expected to collect their medicine dose didn't report. The health
supervisor located at the was supposed to take the drugs down to the concerned
guarantor and local health worker the next day.
Staff confidence in DO IS
The staff at the DTC and all the medical officers, supervisors and others who are part of
the TB programme directly swore by DOTS. No amount of provocation coidd disturb
their confidence. In fact, they would rather have all patients everywhere take only
DOTS. They-' are also verv confident of the futility of x-rays as a rule in the TB
programme.
I couldn't make private confidential conversations with the health workers here, but the
general feeling palpable was that of enthusiasm about DOIS. Since they were anyway
doing the rounds of the villages quite often, they didn't find it at all difficult to handle
DOTS. Also, the fact that Gujarat - at least Mahesana -- has more than ninety percent
posts of peripheral health workers filled up, and that there is little or no absenteeism,
?n
•
one can understand how tire DO " programme has so successfully been mounted on
the government health system in Gujarat.
In CHC Lanva, an attempt wa: - ade to see the Medical Officer's dependence on
Sputum for diagnosis vis a vis X- Rays. Of approximately two thousand OPD patients
seen since Januarv '98, an estimated hundred X-Ray screenings of the chest ( figure
en bv the technician after consulting his register) had been done — the steel dip tank
was rusted and leaking which prevented X-Ray plates from being developed — but the
total sputum specimens including the routine follow up for registered TB patients was
not more than thirty lour ! Even at Cl 1C Sander, 8 X- Rays Chest and 65 chest
screenings had taken place although only 12 new sputum specimens were examined
since the beginning of the year.
V ital Slalistiis
R.\. I.C.P. PH or PROJECT-MF.I IS ANA
Default- Rate
Period
'I ype of TH patients
-
PHASE I
" I th qlr 1^3
istqli ll)94
2nd qli 16'91
?rdqlr I«94 _
4lh qtr 1994
_ 1st qtr 1995 ___
2nd qtr 1995
3rd qtr 1995~
Total
11 PHASE
3rd qtr 1995
4 th qtr 1995_____
1st qtr 1996_____
2nd qtr 1996
3rd qtr 1996
Tolal
.35/325
9/68 __
~~ 8/39 ~
11/60
6/30 "
6/41
_JJ/ 60__
0/17
86/643
8/76
14/110
13/80
10/1'14
6/103
51/483
I
nos.
%
nos.
I (18
10/41
_4/16_
24.4_
25 ~
5/2i
13.4
5/15
3/1,7
5/17
8/30
1/15
41/172
23.8
33.317.7
29.4
26.7
6.7
2.4
0/2
3/17
6/11
3/5
0/5
1/6
1/9____
0/0
14/55
_0_
17.6
54.5
60
0
16.6
11.1
0
2.6
10.5
12.7
16.3
8.8
5.8
10.6
2/49
1/3
0/2
0/2
0/5
3/61
4.1
33.3
0
0
0
4.9
1/10
13/72
13/77
12/76
8/73
47/308
10.0
1818
16.9
15,8
11
15.3
20.5
18.3
20
13.6
J8.3
0
91
I
cv
/o
%
J3.2
I
Olliers
Relapse
New
Failure-Rate
Type of II! patients
New
Period
■ PHASE 1
4 th qtr 1993
1st qtr 1994
2nd qtr 1994
3rd qtr 1994
4th qtr 1994
1st qtr 1995
2nd qtr 1995
3rd qtr 1995
Total
II PHASE
3rd qtr 1995
4th qtr 1995
1st qtr 1996
2nd qtr 1996
3rd qtr 1996
Total
Others
Relapse
nos. .
%
nos.
%
nos.
1 /325
2/68
1/39
0/60
1/30
0/44
0/60
0/17
5/643
0.3
3.0
2.6
0
3.3
0
0
0
0.8
10/41' '■ '
0/16 ■
0
■ 0/2
0 ■
0/17
0/11
0/5
0/5
0/6.
0/9
0/0
0/55
1/76
1.3
1.8
2.5
3.5
2/rio
2/80
4/114
2/103
11/483
0/21
0/15
0/17
0/17
0/30
0/15
0/172
0
0
' 0
0
0
0
0
0/49
0/3
0/2
0/2
0/5
0/61
£
£
£
£
£
1.9
2.3
0
%
£
£
£
£
£
£
£
£
0
0
2.8
1.3
0
1.4
1.3
0/10
2/72
1/77
0/76
1/73
4/308
Case Fatality-Rate
Type of TB patients
Period
<v/O
nos.
tv
ZO
nos.
%
31/325
......
. . .. io/iis ’
_9.5_
14.7
0/21
”l/J6
i./’-if
0/2
0/17
2/il
0
0
7.7’
9.8
6.25
0
18 J
3/60 ~ ~
£.£_
6.8
4.5
3.3
5.9
8.4
0/15
J/17
1/17
1/30
0/15
8/172
0/5
0/5
~~0
7.9
8.2
12.5
4.4
3.9
7.0
2/49
0/3
0/2
0/2
0/5
2/61
nos.
PHASE I
____ 4lh qtr 1993
£st (Jr 199-1 "
_J_2nd_<itr 1W
3rd ijr 1994
Olliers
Relapse
New
4th qtr 1994
2/30
______ 1st qtr 1995
2/44
____ 2nd qtr 1995
2/60
_____ 3rd qtr 1995
1/17
Total/
54/643
_______ PHASE
3rd q tr 1995_____ 6/76
_____ 4th qtr 1995_____
9/110
_____ 1st qtr 1996
10/80
_____ 2nd qtr 1996_____
5/ 1 bl
3rd qtr 1996_____ 4/103
Total
34/483
77
5.8
5.9
3.3~
... H
J/6,
£_
i
0
4.7
0/9
0/0
3/55
£6.7
0
-i- 0
5.5
4.1
0
0
0
0
3.3
1/10
5/72
6/77
11/76
8/73
31/30
10.0
6.9
7.8
14.5
11.0
10.1
1 reatment Completion Rate
Type of I B patients
Period
New
Others
Relapse
nos.
%
nos.
%
17/325
5.2
4.4
2.6
3/41
%
1"’^____ !
_____ PHASE 1
4 th qtr 1993
1st qlr 1994
2nd qtr 1994
3rdqlr 1994~
4th qtr 1994
1st qtr 1995
2nd qlr~1995
2/21
__ 4/60
1/3t: '
6,7
1/15
6.7
3.3
_. ,.?ZE__
__3/4':
6.8
3/17 ■
11.7
'4/30
' o'
0.16'
0/15_____
14/172 ”
I 1.3
23/49
_ _4<' "
lYS
2.5~
0.9
6/3 '
____6
0/2
0/2
_2/76_
_l'/73_
20/308
7/60
.,T ... ......
3rd qtr 1995
1 olal
j' ‘
iTpiTAsiT-
1
3rd qh 199J
4lii qlr 1995 "
30/643^
ii.H.
j
13/iio
;
"1
"2/8O ’'
1st qtr 1996
2nd qtr 1996
___ 1/114'
3rd qtr_1996_
'Total
|
___ 0/2
7.3 _
6.25"
9.5'
3/
'
_______1/39
' 27/183
1/16
__
I
jr
1/15
5.6
24/61
39.3
_0.'5____
EH
1/6"
j
<l/55_Zl
1(1.9
16
■Uj)
’_Zji
12.5
5/77
6.5
26
Relapse
%
nos.
272/325
4S/6S
30/
46/60
26/30
_32/H_
48/60
15/17
517/6'15
83.7
70.59
76.92
76.67
86.67
72.73
80.00
80.4
88.24
10/41
78.5
13/16
17/21
81.25
60/■
78.95
72.73
67.5
84.68
88.35
93.51
87.6
90.0
83.3
7o
PHASE I
4th qtr 1993
1st qtr 1994
2nd qtr 1994
3rd qtr 1994
4 th q tr 1994
1st qtr 1995
2nd qtr 1995
3rd qtr 1995
Total
II PHASE
3rd qtr 1995
4th qtr 1995
1st qtr 1996
2nd qtr 1996
3rd qtr 1996
4th qtr 1996
1st qtr 1997
2nd qtr 1997
Total
80/1tO
54/80
94/111
91/103
72/77
78/89
90/100
619/746
10/15
14/17
14/17
80.95
66.67
82.35
82.35
'24/30
80.00
15/15
139/172
100.00
42/49
2/3
2/2
2/2
4/5
85.71
66.67
100.00
100.00
80.00
66.67
83.3
69.2
81.6
4/6
15/18
9/16
80/98
80.81
93
r- i -
20.1)’
0/9___
(NO
i
' 1 ype of IB palicuts
nos.
JZ6
9.1
0
J! 67
0
0
Sputum Conversion Rate
New
0
1
TZj7iIZ!
E7.6__
J3.3
_0
8.1
0
'______ 0
'__ 20.0
i
3/17
‘T"-. ■
J_.£
6.5
•• S
Period of detection
HI ASF P
PHASE 11^
TOTAL
________ T.B. Case Detection
Smear positive
Smear
negative
New
Relapse
643
172
800
(39.35%)
(10.53%)
(48.96%)
864
114
658
(50.47%)
(6.66%)
(38.43%)
1507
286
1458
(45.04%)
(8.55%)
(43.57%)
•7
Extra Pulmonary"
Total
19
1634
(1.16%) ft a. i (100%)
76
(4.44%)
95
f
Dli
(2.84%) P;;i |
1712 ’
(100%) ■
3346 •!
(100%) f
•Ay-lAi-.- ti,;-
' Period - 2nd Oct. 1993 Io 14111 August -1995
"Period- 1511: August 1995 Io 30111 Sepl -1995
A* A ■
|
-----
■■Sa
i
70.
r.
Jaipur - District TB Programme (Urban)
Population of project area
HQ
field Centres
Microscopy Centres
Tuberculosis Units
Project Officer
: 1.5 million (Municipal area Jaipur)
• Jaipur
■ 12 + l(new)
: / + 1 (new)
: DrRNSisodia
lutein iews of Dr Sisodia, Mr BL Sharma & Mr Mohammed Khan Bhati( DOI'S workers),
and Mr I lardaval Sharma ( Laboiutory incharge TB & Chest Hospital) were faken, apart
irom othm DOTS workers and patients
Manpower and Infrastructure
\lihough fh,' programme is w< kin;’ entirely through Government hospitals and
ii-a’ensa.i ii■■■. special I)(. 1IS work;. have been employed lor the project. Curiously, the
S.t’.i:- Government has de ' d to employ retired Government personnel, not
w.ui!'. Irom the health department. One would have presumed that a programme
which requires intensive monitoring, surveillance and follow-up of defaulters in field
would be recruiting young, energetic people - like those in the Gulabi Bagh project
wb'-ue !hi”> had clove; Iv taken all new entrants to the Municipal Health Department so
n to. .".’-.id those who had become worldly wise and lethargic in the erstwhile
gov ••rnment programmes -- but in its wisdom, it thought that the contractual
agreements lor long periods would lead to unionism and court cases for permanent
• absorption in a government job if awarded to younger people. Hence, this project is
saddled by old people who do not have adequate energy levels to cycle down their
areas to follow-up defaulters, w o, many of these- reemployed have little or no
background in health, and are unable to cope with the technical subject, despite an
initial training provided.
The staff for the project is not adequate too, because even the DTC staff which should
have been carrying out Tuberculin Testing at the Centre has been given field duties and
Mantoux's test discontinued.
All Government hospitals and dispensaries have been asked- to <allotia room for the
DO TS centre. Although the one at Bani Park was as good as a private doctor's chamber,
the others were rather secluded nd usually the last rooms in the back of beyond -maybe because of the TB stigm •
the step - motherly attitude of the hospitals to the
project. The-latter; was very evident at the.TB & Chest hospital where; the party linen's todebunk the "three month" regimen ( since alternate day for six months makes it threemonths ) and hence- the DOTS regimen & 'RNTCP. - In '.fact; Kanwathiya 'Hospital, •
another one of the many hospitals in Jaipur under the government which has been
I
7.5
constructed by private trusts and are still maintained by them — has refused to comply
with the request to set up a DOTS centre. The administration threatened to throw out
the furniture sent to the hospital after the government passed a written order for the
setting up a DOTS centre.
. , .
.....
There is a gross deficiency of laboratory technicians, as many of the vacancies are yet to
be filled up. This is keeping in tune with the state having a 30 % deficiency of laboratory
technicians. The main reason seems to be a disinclination to carry out so many sputum
smear examinations “for they do not want to get TB at this age ”, There has also been a
rather fast turnover because these retired people are unable to keep up with the
dynamism of the DTO, Dr Sisodia and his expectations.
Funding
Since the project started only in 1995, most problems of fund flow seem to have been
sorted out and there has been no deficiency of funds ever. All the consumables for the
project except drugs and X-Ray films comes directly to the project via the District TB
Committee now formed.
Population:
The population coming to the programme is urban. Since Jaipur has no slums as yet, the
poorest of the TB patients come from the Muslim bastis. However, most of the twelve
patients that we interviewed belonged to the middle class.
Accessibility:
All the patients whom I met told me that they had come from close-by areas, i.e., from
within a two kilometre radius. On record examination, we did find more than a few
patients coming from long distances who preferred the centre over some other ones
close to their house. This, we were told were exceptions permitted to suit the doctor
and hospital preference of patients — essentially to prevent default on account of this.
Case finding:
As vet, there is only a passive surveillance Although DTC Jaipur is one of the 12 centres
functioning from hospitals having more than a few MOs, it has provided almost 80 ’•
of ail cases registered with the project last year. Of a desirable case load in the
programme of 135 TB cases - per lakh population*, the Jaipur project has reached 65
cases last year ( 981 cases in 15 lakh population), of which the two MOs at the District
TB centres have diagnosed about 53 per lakh population.
Interestingly, the TB & Chest Hospital, which detects an average of 12 sputum positives
every day — as per the laboratory register which had no sputum positive till six months
ago when the DTO intervened - since the past six months, has given only four patients
to the DOI'S centre in its premises. The rest of the eighty present and cured patients on
its rolls were transferred to it from the Dl'C because it was closer for the patients. The
!
1 lospital according to its staff has approximately three thousand patients on its rolls at
present 1 Keeping in mind that it is a referral hospital for tire entire state and many
patients would be from outside the municipal limits of Jaipur, I am sure that the
number qualifying for IDOLS < uldn't be only two. This has to do with the lack of
confidence in DOTS amongst the doctors at large, despite, the DTO's attempts at
arranging CMEs and seminars, nr fact we learned that the second medical officer from
* - ns per programme which presumes 50% of all incidence to be going to private sector
the Dist TB Centre was about to be thrashed when he last came for a monitoring visitmid found a lot of DOTS drugs going waste and about to expire. He was personally
warned bv the Superintendent not to visit the hospital again if he valued Iris personal
safety I
I Ding. n <■><!«:
\s m-mtioned earlier, not man’.- of the microscopy centres are iregistering new sputum
positives. Il is expected that 2% of all general OPD patients are! chest symptomatics for
’ B ••••; .0 .'nt ten pen out of I lu.. • would he sputum positives. Most hospitals have not
■
n..-. : tiip; these I irgelC , t Bani I’m k though, the initiative of the young DOIS
woiLei. M K Bhali, brought a change. With the help of the hospital administration, he
h.w initiated a register which i os a record of the number of patients each doctor/
< i|'l '■ has seen during the month and it the sputum referrals are not unto the 2% mark, a
n. rilt-.-n counseling is sent to the MO concerned. It has resulted in a quick 'reaching of
tai ••.cl.--'. Although the idea is laudable, in a classical case of overenthusiasm, the targets
are enforced onto the EN 1 surgeons and Gynaecologists as well 1
I he sputum collection and exa lination is followed according to the guidelines at the
DTC. At the Jaipuriya Hospital, the MO in-charge has opposed the taking over of the
Bini-culai microscope as it does not belong to the brand that she prefers. Also, she
prefers to have her lab collect the three sputum specimens in a manner different from
the guidelines. " Take these three cups. Take out your sputum after a few hours in the
first one. Wait for about four hours and then bring out your second sputum in tire
second cup. Then, in the morning, take out tire last one and bring all of them tomorrow7.
We w ill give vou all the results tomorrow7 itself, ” explained her lab technician to a
patient in front of me.
As per the records of the DTC, the sputum positivity at tire DTC jumped from the pre
1995 level of 0.5% to 20 to 25% positive of all sputum smears examined.
Registration:
Ration Card or.proof of.residence is required for, the registration. .This is necessary
because the primary care fad es are poor in tire state of Rajas tjran, and a lot of
patients from outside Jaipur visit the city looking for treatment.
. : ;
97
7
TTT-r’.vrr-
On specific request, we received figures of initial defaulters lor two quarters .of 1997,
i.e., difference of number of sputum positives identified ami the number of patients
registered.
Total
4th qtr 3rd qtr
' , 1997 . , 1997
2687
No. of Chest symptomatics examined for sputum smear -: :1340 ;
1347
167 .
200 •• ' ■ 367.
No. of sputum positives identified
313
170 •
No. of sputum positives put on DOTS
•- • . •• ... . 14316
No. of sputum'positives put on Rx other than DOTS
8 i-u ' • 8
22
37
Smear positives not put on any treatment (initial defaulter) 15
27
16
Smear positives of initial defaulters living in project area
11
Item
/ • ■
Percentage of initial defaulters (THROW OUT Rate)
37/367 =
10%
Since patients from outside the district are not given any RNTCP sputum examination
slips and hence do not go onto the register, the throw out rate is likely to be much
higher just as in the case of CCGB.
DOTS
As most of the sputum positives get identified at the DTC, s/he is sent to the local
DOTS centre closest to the patient's home. When the local DOTS worker comes to the
Dist TB Centre, or the supervisor goes to the DOTS worker, the patient's details arc
handed over. Although the procedure explained to me was that the address is checked
by a home visit before starting the treatment., the only patient starting treatment in
front of me was given the first dose without checking the residential address for proof
of living and a appointment taken for the DOTS worker's home visit.
The drugs as at other places, are kept in boxes marked out for the patients. The drugs
are partially from imported stock and partly from a Pimpri (Pune) company marketed
by Ciba - Geigy. All the case records (about sixty at three different centres) which we
want thrwigh happened to
of adults and none less than 30 kg or more th m
kg.
making us wonder if the paediatric patients are being missed or if the tali and burly
Rajasthani men are presenting too late to have a weight more than 60 kgs. I lowever,
there was no shortage of drugs ever.
Only one DOTS worker was really diligent enough to ensure swallowing of the doses
in front of him. This man also had the best method of explaining the complete
procedure of taking medicines and all that was to be told to a new patient. All the other
four we observed, either asked the patient to go to the next tap or handed over the
complete weekly pack in the hand of the patient.
?R
Those in Cat II have to purchase syringes on their own as there were none available
with the DOI'S workers.
We observed two supervisor visits and both visits appeared extremely cursory. 'There
was no attempt to check the mods or the lab quality. At tire TB and Chest Diseases
hospital, the lab incharge coir ■' >ined that there had been no sputum cups for the last
six months and the DOTS worker confirmed that he had passed the demand to the
SI l.S but had not got them.
l or patients coming from outside the municipal area of Jaipur, Dr Sisodia has managed
to gel loll over drugs from arious districts in his capacity as the President of the
Rajasthan 1 B Association. As tiic Government doesn't supply any non DOTS drugs to
districts under the RNTCP, this is the only recourse for people like Dr Sisodia who have
the sensitivity not to send away patients from other districts.
V. •. In.u ni that a there had bcm in instance where a DOI'S worker had been caught
■■■
I i.A..' a bribe ol R<
•><' as to allow tin' patients to take drug*; at home
.saplnim.-. haw been ••• d about the Delhi projects also. The system allows
money to be made by DOIS workers and since it makes life less tedious for the worker,
and saves a lot ol effort and money on part of the patient, the scope of this practice
increasing esp. in the B1MAROU stales is enormous.
Reco.d .Maintenance
Although the record keeping hoe too is much better than is expected of government
departments, it is not as good as 1 found in the other projects. It was partly due to the
high turnover of the newly recruited re-employed personnel rvho take time to come to
terms with the extensive recor ,;ng systems required for a well functioning RNTCP/
I k'Tl'S.
i
In the TB A Chest Diseases hospital, the records in the lab register seemed to be in the
same handwriting and pen always for each of the entries recorded against specimen I,
i! and Ill. raising suspicions of manipulated records in my mind. As soon as it came to
my mind, the lab incharge confirmed it and told me that he did only one sputum smear
examination and filled the rest of the entries according to that one result.(see statement
of Mr 1 lardayal Sharma in inset)
Adverse Drug Reactions
Although there are no formal rec rds of Adverse Drug Reactions, Dr Sisodia recalled
seeing a couple of jaundice case, i" the last two years. Gastritis to Rifampicin was quite
common, but none has been so severe so to discontinue the drug.
?Q
Patient Compliance
We didn't get any formal records of compliance and defaulter rates, except of the initial
defaulter ones. However, they seem to be quite high given the statements of all the
interviewees.
During the period of observation on one whole day at the DTC, only one patient out of
eighteen who were to have come for drug ingestion that day hadn't arrived and was to
have been followed up the next day in case he didn't turn up even the next day.
Staff confidence in DOTS:
The confidence of the staff handling DOTS varied from place to place. As usual it was
the highest at the DTC. The worst was at the T13 and Chest Diseases Hospital, where the
medical staff as well as the lab staff we interviewed had no faith at all in the DOTS
regimen for more reasons than one.
One DOTS worker who used to be a TB health visitor before his retirement, was
nostalgic about the good old times when there were no follow-ups to be made. He used
to administer Streptomycin, INTI and PAS and used to find them very effective. “Now
there are much more chances that the patient would have started some treatment
earlier and defaulted already. Some of them do not even respond to Rifampicin.” He
was also relieved to see Thiacetazone out as it used to give a lot of skin rashes.
Rifampicin causes a lot of Gastritis, he feels.
As we were informed, eighteen patients sent from the DTC to the TB and Chest
Diseases Hospital as it was the nearest DOTS centre were hijacked by touts standing in
the corridors of this hospital. The.medical officers and specialists changed them to other
regimens after having warned them of dire consequences of taking the DOTS regimen. I
also saw a complaint filed by one such patient giving details of his hijacking and asking
for compensation for not permitting him to get free treatment. [See inset]
■\s uieiiliui.ed earlier, then1 le,: been .1 very poo- response to the programme from all
the other hospitals where the DOIS centre are running although one must appreciate
that persistent efforts of Dr Sisodia and his team have started making a dent in the
attitudes of these people.
Vital Statistics
Year
New
Smear
Positi
vc
Smear
Negat
ives
Relap
sc &
Other
Ext: ■
Puh.;
Sp + :
Sp -ve
J__
qlr
3rd
-1
‘1
I?.
9 4th
5_
1_ 1st
9 2nd
9 3rd
6 ' 4Uj_
J
1st
26
7
21
I 4
25
44
42
66
87
10
22
23
23
2<>
77 _
_5
_48
5f
15
13
1
total
Sp.
conver
sion
Cure
Rate
CA TEGORY - WISH
«/,
%
Cal 1
-1
: 21
1:3
100
100
i 58
1:1.2
84.6
91.4 ' 26
1:3
E4.8
1:5.2
1:1
1-0.47
i Lo’W
88
72.7
76.2
8E8_
86.2
81.5'
84.82
73.9
85.7
76.7
71.2
Cal ] Cat-] Total
i i2 j
II
4 " i 13 "'| 21
0
2
I
V'j'Znd i'll?'
V'd
9’ ''| 3rd
7 | 4th
I 58
| 36
H2
89
"2-ls_
2i9
69”~
4 i”
[??
| 68
nzz
121
i 38
i .329
~| 335
i 173
T!]67
’ '. j i
| 1:0.61
| 1:0,86
; 263
! 240
-
It) •
_..tl
;'5b
/
25___
10
| 31 " '117 _
2?." "jJ63’_ 329
44__
23 ’I 186
42__ 84
335
2’l _i 23
I 70 __ | 173__
66
17 |'2<>
‘37 ]'_]67_
87
i
‘ 9.!' “rTn
i‘r>
311
wL
10 :
• 8-.
| 240..... !
j96
| 89
I '19 j 3o
2L,
J(,L
Results of Sputum positive Cat 1 patients
Year
QU
Regd
Patients
Cured
Treatment
completed
Died
fad
Default
Tfr
1995
1995
1996
1996
1996
1996
3rd
4 th
1st
2nd
3rd
4th
4
26
25
44
42
66
207
4
17
17
28
29
47
142
2
2
2
2
2
2
0
2
1
2
3
3
11
2
2
2
2
2
0
6
6
3
6
8
29
0
0
1
7
3
4
15
Total
4
3
6
Cure Rate of
patients
completed
treatment
100%
94.4%
100%
87.5%
96.6%
92.1%
93.4%
Results of Cat II patients
Year
Qlr
1995
1995
1996
1996
1996
1996
__ 3rd
__ 4 tli
__ 1st
2nd
3rd
4111
Total
Regd
1 Patients
4
7
.10
22
24
23
90
Cured
2
5
_6
10
n •
13
54
Treatment
completed
0
0
0
1
0
0
1
Died
Fail
Default
Tfr
£
2
£
2
2
2
2
0
1
0
. 0
0
3
0
1
3
6
3
7
20
2
2
2
2
2
2
9
3
Cure Rale ( as
above)
50%
100%
85.7%
90.9%
100%
100%
93.1%
21
. .-.iiu.i...
H
Sm 3ii
Results of CAT III patients
Year
Qlr
Regd
Patients
13
25
82
263*
225
84
692
I
1995
1995
1996
1996
1996
1996
3rd
4th
1st
:2nd
3rd
I "TtiT
total
Cured
Treatment
completed
13
' 17
49
' 199
158
61
497
Died
Fail
Default
Tfr
0
0
1
4
6
0
0
0
3
3__
0__
6
O’
’ 7- ‘
25
■ 46 ■
49
19
146
0
1
7 ■
10
9
1
28
14
* one case found non TB
ri.J ■
i
i
Sputum conversion of Sputum positive Cat II patients
Qlr
At the end of three months
At the end of four months
i at II •
i
1995:
IT?.
pi'-o ■
3rd
Jlh
I si
2nd
Jnl’
‘9% "
■
4 th
i-l
’
! JSSu_ !_
r n
I
10
10
17
it
o’
23
if
o'
11
21
2nd
0
4
L u
l nt.il
:
r
NA
0
0
0
5
12
1_
20
Conversion rate
~ 100%
Neg
4
5
10
17
21
11
21
' 89
71.4%
100%
77.2%
91.3%
47.8%
80.76?;
77.4%____ '
Pos
0
2
0
0
0
0
4
6
NA
0
0
0
5
2
~12~
Conversion rale
1
20*
too?;
71.4?;
100%
77.2%
91.3?;
47.8?;
80.76?;
77.4%
Not compiled yet
Not compiled yet
-----
Suutum examination -enort
Finial sputum
,
Number of
spuluin
positives
431
436
870
111
98
209
I
•I
:
examined
semi-1997
3rd
_4tly_
Total
.3?
I
I
Number of
sputum
positive by 1st
spot sample
50
34
84
Number of
sputum
positive by
llnd OS’
sample
61
64
125
Number of
•; putum
positive by
Hird spot
sample
i
..I
STATEMENT Ol; MR HARDa AL SHARMA, LABORATORY INCHARGE, TB &
CHEST ""'EASES HOSPITAL, JAIPUR
"Since vou are from Delhi, you must take my statement down. Please give it to
i the TB department. Please note my name first. I am Hardayal Sharma, Lab in charge at
’this hospital Even if you aren’t from the government, you may be able to pass it down
■ to tin' Dilliwalas there."
I In-re is no incentive L ’ as in (his project. Why should I send patients to this
she had promised us with an
-ject larlier a ladv had also come from Delhi
inci'nox e. but nothing has come. . tiis year, we have given two patients to the project —
onlv because these poor chaps , . were crying for patients."
i ww much incentive ■ Should be at least Rs 3000/- or so. If given on a piece
i.ite basi- . it should b.' al least Rs,10/- per sputum positive. At fifteen sputum positive
which halt would be horn Jaipur municipal area, we would be
-,iat
least
lilteen
in. died patients a year. We in the lab ee.-’d dfv’dc the
ark
im -.mtix e amongst us then. "
lex on want to listen to the truth or only to good things ? Truth, okay. See (his
laboralorv register. Yes, vou arc smart to catch the fact that the same handwriting an
■pen has been used lor all three entries of sputum records. We test only one sputum and
entei positive or negative into all three columns based on this result. See, I am a
niibin ■ k (leai less) person. Since you are interested in the patients, 1 am telling you."
i lie: ' is tola! /hr/n(w//i(fraud) here. You think these aged DO IS workers who
anvwav . de six to eight kilometres a day to reach this centre, will have the energy to
go and iollow up those who do not come to take medicines. Ask this man, this DOTS
worker, lie is standing in Iroi of you, if I am speaking the truth or not."
No, you don’t have to thank me to be frank. I am nirbhcck. What can you do to
;me. Even if you were to be fw •. the Government, what could you do? I get my salary
brom i lie Medical College. Ai ' do whatever they tell me to do.. What is there for me
■in this project, tell me. The Delhi people, I am told even go abroad to tour-; what about
us ? ”
\ou are my guest today so 1 must look after you — he served us some samosas and
kachoris and tea - and since you are here for TB patients welfare, see the slides that we
keep. We know our job (never in my life since my medical college days had I seen such
clear AFB staining, slide after,slide !) and you can check our work. Come, see this
register, it has records since the past August.( we learnt later from Dr Sisodia that there
was not even a single sputum positive recorded before August for many years).
,1
See, we have at least fourteen to seventeen sputa turning, out positive every day. This is |
also because doctors here do not bother to explain to the patient. The patients just give'
out their saliva half the times. And must are spot samples. Otherwise we can find a lot |
more positives."
•••■.:
" There are incineration facilities here, but 1 wonder why the crows find the TB
patients sputum so tasty. A number of people on the staff staying within the campus
tell me that they find the crows picking out the viscid sputum from the containers
sitting on their roofs. See, I think the containers mustn't be burning up well; you know
how this fourth grade staff is. What better can you expect."
" See, I told you I am nirbheek . Why should the doctors go in for the DOTS
regimen. The present way, the patient hands him a fifty rupees note every visit for a
check up. Your DOIS will dry that up. And then, what about the physician samples? I
sell their samples, so I should know. I remove the capsules and tablets from the foils
and give the patient the foils to go and check the market price. They learn that the
monthly treatment is for five hundred rupees, and easily buy the same for three
hundred. And sir, if I give the doctors one hundred, isn't it only fair for me to get
twenty five ? In your system what do we get — nothing. If this the system here, how do
you think the doctors will give patients to the project? No way."
"How to get the system to work? Maybe you will have to give some incentive to
the doctors as well. Or, tighten the screws on them. We are only pawns in the whole
game; if the top complies, dare we resist?
i
General discussion:
At the end of the observations, let us examine the RNTCP as it is seen to be on ground
vis a vis the revisions lor winch it was.launched. To begin with, what are the answers to
tie.'<;■.! -di;-!■
.1
o
i
! otf'.-.•itb?
1. Is DOTS really directly observed?
No. At most centres, the programme could be called KNOTS — Knowing but Not
Observing 'Treatment — Short course. From the DOTS envisaged, the RNTCP guidelines
had anyway diluted the scheme to POTS - Partially Observed Treatment Short course.
The ground realities have taken it to KNOTS. Even if the majority of the patients are
having, the drugs after coming to the DO IS Centre but not exactly swallowing, the drug
in front of the DO IS worl ■•rs , it means that the patient is being believed and trusted —
something which could have been done by simply handing over the drug tor
domiciliary treatment.
■Ad
What is the point of troubling the patient so much and making, her/ him travel a
distance and waste her/ his precious time and money when the swallowing, is no1
observed. The non - compliance of the DO IS workers to follow the guidelines were on
account of lack of belief in the DOIS methodology, empathy with the patient, lack ol
watei (or space) in front of the DO IS worker to observe, or because ol corruption.
Wh.il is probably expected of the DOTS worker is to see the glottis make the
swallowing movement and to examine the emjily mouth at the end of the intake,
something which I saw in the film 'Till'. WHITE PLAGUE’ by WHO on the TB
epidemic in post communist Russia It is what the Army resorts Io While giving the
weekly antimalarials. It is simply demeaning and humiliating for any self respecting
patient in a democratic society and presumes that only patients need l.o be directly
• 'b -- somethin;; which •ninny incidences in Delhi and Jaipur of I 'OTS workers
'
o, ,i- .
1 . il ., ;n,, p.jji; j.-p>
. • r. • -
nt i r.'c-. ■ d i-.pi' ivi'B
Su< h a methodology may be initiated il it is known that there is a sudden epidemic ol a
highly infectious disease and a public health emergency has been declared. What is the
evidence for such a thing. And in those cases, even if the President of India were to get
the disease, lie needs to be subjected to treatment under direct supervision. 1 don't
think there is any evidence of such a thing happening in Indian TB.
2. What is the universe of patients against which all the cure and compliance rates are
being calculated ?
Although the area lias been demarcated quite clearly for the three projects, since the
patients are unaware of such demarcations, they report nevertheless to centres such as
these because they know that these centres have drugs available regularly. However,
because the project does not have sufficient coverage — only 16 districts have been
covered as of December 1997 against the target of 102 districts — many patients get
THROWN OUT of the system.
Since the last three years , all patients reporting to the CCGB have been put on tire
DOTS regimen alone. Patients not staying in the geographical area or not agreeing to
taking the drug every alternate day from the DOTS centres are requested to take drugs
from elsewhere — or prescribed a daily regimen for the patient to purchase from the
market. (In other words, there is no option for the quintessential urban TB patient —
daily wage labour living in dank overcrowded areas who can't have the luxury of going
for his thrice a week drug between nine and twelve in the morning since his contractor
is not going to allow him/her this luxury W
To get an idea of how many patients diagnosed TB were not gelling registered lor
reasons of false address, temporary stay or inability to come every alternate day for
'As
I
«
treatment to the centre, we tried to collate the data from the CCGB records. The data
tor Sputum positive cases detected in CCGB in 1997 which have not been registered
under the RNTCP is as follows.[In all cases which are likely to become defaulters (not
people hailing from other districts or states, because if the staff is convinced that the
patient is likely to stay at tlv ddress and is likely to take the ATI’, s/he is registered
irrespective of the permanent residence)].
Mouth
I an. 97 _
Feb 97”
VV
I I olal
Sputum
; examined
’ 549
'”.521
5oi
1 638
Jul 97
i 613
’
108
i 91
|~96
TS5
■I 5b
"■
■ 16 I
78
______________
'
,
"63
~ 68
51
i l.’2
' Me
I 53
tS"
I lol.il
47
JsV_________ ~ 47
' T7? _____________ II I
in_____________ ~ 96
i 575
Apr 97
Slav 97
Registered in DOTS
New
Sputum
pe tives detected
76
I
! 5'115
.
30
645
! 1102
"THROW
RAlli"
38.16 %
13.37 %
21.88 %
33.33 %
27.78 % _
30.77V
29.17 %
!W1"
35.35 '.<•
3375 V"
30. 19
'
33.33 V
OUT
41. 47 %
\ -11 irow ou r rate of (1I.47%) is something we should be ashamed of. If we are
concerned with DO I S alone amTnot with TH,, we can live ■with it. But if we are trying to
scream out that 1’B is a problem and we are concerned about it, we need to search our
souls if we cannot provide A’ V — the conventional NTP treatment is also not given to
those patients — free treatment.
The THROW OUT rale of Manesana was not available, but Jaipur is no good cither.
Despite the fact that they do net give a RNTCP laboratory form to those who do not
belong to the demarcated area, the initial defaulter rate is recorded as 10%.
What needs to be seen also are the inconsistencies in the figures handed out. For
example, the Jaipur records show a registration of 295 new sputum positive cases in the
3rd and 4th quarters of 1997. But, their Laboratory records in the last table show that
onlv 209 new patients were diagnosed sputum positive. Where did the other cases come
from ? A backlog of l/3rd of patients diagnosed in the last few days of the previous
month ? It is an unbelievably large a figure.
•
Similar discrepancies.can be seen elsewhere too. The Mahesana tables repeat the entry
of 3rd quarter 1995 for both Phase I land'for'Phase II’results. But’the'figures for Phase I
and for Phase II vaiy so much in each, table, that one wonders how much rigour goes
"36 ’
..
■■
>
... ...„S
into the tabulation of records. Or the fact that no one has pointed it out to them since
1995 which means that no one is monitoring, the records at all.
■
'
, > |l.
•
. it
■ -■ ,
<
1/1
■'.! i
'
T
As pointed out earlier, there is no believable uniformity for seeing the denominator for
the treatment results. If one project is registering, the patients immediately after
diagnosing them as TB irrespective of the fact that they reside within their demarcated
area or not, the other is keeping separate records ab initio for patients from within and
without the area of jurisdiction.
' " ■
-
Similarly, if the Jaipur experience is an indicator, we are not sure if records are being •
fudged by corrupt staff to suit the numerator requirements being stressed on in the
programme.
3. What is the detection of TB patients vis a vis the expected incidence of TB ?
Considering the fact that there is roughly a 0.2% annual incidence expected in India —
agreed that it may not hold out for each individual district — the expected registration
vis a vis the actual number of patients registered in each of the projects areas in 1996 is
as follows:
Population of the project area
Expected incidence at 0.2% annually
z\clual Registrations in 1996
CCGB
1,000,000
2000
1177
Mahesana
1,500,000
3000
717*
Jaipur
1,500,000
3000
910
figures for Oct 1995 to Sep 1996
Although the case registration according to the programme indicators is 135 per lakh
population accepting'that not more than 60% patients are to be expected to join the
i towrimii el IB programnw ( even il tie’ drugs arc ii> foils ami the latest short '.oursc
1
>' ' : ; .I'.im i;asl
1 .. h•_ h ■ . . J. ■. .'•>n i : D th .• prwji..d.• i; >•;' -I,
expectations, esp. the Mahesana and the Jaipur projects.
/*
It is clear that Jaipur would meet the annual incidence figures if the Medical College
brethren were not to act truant, but Mahesana ? I did a small, rapid survey around the
District TB Centre. There are about forty chemist shops within two hundred yards of
the District TB Centre. The minimum sale of Rifampicin capsules every month in four
shops 1 went to was 200 which would imply aboiit seven patients at least for each shop.
This area, which is far away from the District I lospital and from mapy of the doctors'
clinics must be thus feeding 280 TB patients besides the 550 odd ■ 50 with RNTCT and
500 of N I P - patients. Since there is an over - diagnosis of TB in the priyafe sector, one
can easily see that there are many cases yet to be tapped by the RNTCP programme in
^7
n-'A'pe;' <■
Mahesana which by my reckonmust be the best of the programmes if following the
programme guidelines is the criteria.
4. Is a strict vigil being maintained on the case holding ?
By and large, one felt happy v ’ '• the amount of pains being taken to motivate patients
u < mnplelc the tiealment once started. The information with the staff about reasons for
the patient not taking treatment and about her/ his address was quite good in the
i\?< 1C1’ areas except lor the Jaipur area. Last ditch efforts made by the medical officers
ami senior doctors too needs to 1 ' appreciated.
I lie (, ase holding rates for the project areas is as follows:
CCGB
005 / 9b2
Mahesana
1480/1722
or
Jaipur
163 / 209
or
88.8%
\ith.oim.h these are good ligurc tor the fact that it is belter not to give treatment than
to give hall a treatment, since tiie patients are registered only after a careful screening
lor aeeeptabililv <if DOTS, one needs to push these rates up:
'■ V. li.it .ire I he patients reactions ?
Most patients whom 1 met were not unnecessarily bothered about the fact that they had
to travel a distance of one or ’wo kilometres to get their drugs thrice a week. But the
exceptions — like the girl described in the CCGB section — were the ones which:
deservediv required an alternative system.
1 iowever, this is because they k”ow the rules of the game and see no alternative. One
would probably need a questionnaire survey to find out if they preferred the DOTS
methodology to the unsupervised treatment.
Barring a couple of people, no one had experienced any side effects and were quite
comfortable with.the drugs.
6. How strictly are the guidelines for case detection and treatment being followed?
I he case detection is good wlr -ever the sputum is checked centrally, like the CCGB.
Even in Jaipur, the District TD Centre seems to be doing ,the major case finding.
Wherever the job is delegated to people outside the programme, the case finding seems
io drop.. It probably indicates either a lack of seriousness with which instructions
RR
regarding laboratory procedures are taken by non TB staff from the TB staff, or the lack
of expertise in checking symptomatics for their sputum specimens. If it is the latter,
much more training, and supervision needs to be reinforced.
As far as the treatment is concerned, the conversion of DOI'S to KNOTS has already
been discussed. Besides, there are other parts of the treatment which need to be
strengthened.
a) explaining to patients why ingestion of A IT drugs on an empty
stomach is considered desirable and insisting on it as far as
possible.
b) explaining the side effects of various drugs.
c) recording the incidence and type of side effects.
d) awareness amongst the staff about the changes in dosages according to
patients weights and or ages.
e) the evaluation of sputum positive slides and sputum negative patients
rejected for treatment: there may be an overdrive for sputum positives in
the CCGB area and an easy tendency to diagnose TB without sputum as
before in the Jaipur project area. That is why the ratios of Sputum Positive
to Sputum Negatives which needs to be as close to 1:1 in a well
functioning TB programme, is currently quite skewed. The ratio at present
for the three project areas is:
Mahesa-ta
3686: 3'06
or
1:0.87
CCGB
3302: 1599
or
1: 0.46
J a i p i.i r
896: 11'18
or
1:1.25
I
f) the overall cure rates need to be kept under surveillance. The rates are
still not satisfactory. For a short course therapy as strong as RHEZ, the
comparative rates of cure/ treatment completed are very poor:
Phase 1 - 65' /870
or
698 / 989
or
89.32%
75.74%
70.57%
860 /962
or
Phase II-6( >/852
or
78.52 %
g) children below 6 years at least ir Jaipur are being, give n INI I
prophylaxis irrespective of having syt ploms of TB. I bis is against not
just the I B guidelines, but against all k -own principles of TB treatment.
This seems to have the sanction if the Indian Association of
39
Paediatricians - who seem to be advocating Rifampicin prophylaxis
lately - but it needs to be urgently addressed.
Other issues which come to light in view of the reality that is RNTCP. — -which are
responsible for so many doubts amongst TB specialists, public health specialists esp.
those working in the field of TB since so long, and NGOs also need to be discussed.
Some ot these are doubts about the basics of the rhetoric which go by the name of
advocacy, while others are v it many concerned individuals are asking. However, this
discussion is not complete because there is a necessity' to take this debate further, and
resolve the issue at the earlit '. That there has been a good amount of publicity' and a
reawakening, of interest in TB - exemplified bv the new Prime Minister making a
mention I the RNTCP in his maiden speech in parliament - which heeds to be
>11 ll.osv who arc nterested in the disease of the poor. But the strategy has
in be based on sound public health principles and indigenous research, of which
fortunatelv there has been no dearth in TB.
i. i [ ide nii< of i B ?
Vol in India at least I here may have been an upsurge of the disease in the US, the CIS
slates, and all the countries hit by the HIV epidemic, but there has been no evidence
whatsoever oi this epidemic >n India. Although there may be many like me who have
loved the media attention to this poor man's disease caused by the announcement of
the global epidemic by WHO in 1993, it docs not automatically follow that one should
accept the rhetoric to be true.
it is necessary to know this because epidemics cause panic and chaos; strategies
adopted by understanding the ground realities are far belter for countries like India
which can ill afford to have revisions after revisions of programmes which require
loans to be taken lor strategy not suiting its crumbling health infrastructures.
I a India, there is no evidence to prove that the incidence or prevalence of TB has
increased over the past decade or so. Not even from the states of Manipur and
Maharashtra, which report 14% and 10% HIV seropositivity' these days. However, what
may be of future concern is that the epidemic has come into many of the nations where
the SAP reforms have failed, and developing nations like India need to be alert for a rise
.in this disease which has shown a stable trend of morbidity and mortality in India until
tuWSTtef.’-7
■;
i ■
B. Was a revision necessary in the TB programme ?
1 would say yes. Even without a formal TB study as was organised with the support of
S1DA, any TB watcher would have enumerated the ailments of £he TB programme.
40
I here was definitely a need of a revision in 1993, and the reasons for.them continue to
exist in 90% of the areas of India even today.
Unless the revisions are carried out in the primary health care services and the
administration itself, no cosmetic surgery is going to help the majority of TB patients.
Al best, only 27 % population is to benefit from the revision, and that 27% may not be
the one really in need for the revision. People in the far reaches of Arunachal Pradesh or s
of Barmer or Ladakh are the ones who need primary health care - and TB care and they
may be the last ones to access any interest at all. As Dr. D. Banerji, an erstwhile Director
of the prestigious National Tuberculosis Institute, and currently with the Nucleus for
Health Policies often repeats, 'the TB Control ship needs to sink or sail with the
primary health care system' or else the remedy may be worse than the disease itself.
C. Will the focus on Sputum positives help in drastically altering the dynamics of
transmission ? Will it help in cutting down transmission and hence the spread of the
epidemic ?
The question needs to be addressed well, because the rhetoric of TB being a highly
infectious disease needs to be challenged. It does not mean that one takes away tire
importance of this disease, but a scientific discussion must validate or negate the fear of
TB being a highly infectious disease. L.et us examine the transmission mathematically :
livery 100 untreated sputum positives will lead to 1000 new infections in one year of
which:
a ) 950 enter the latent phase of ■which:
i) 900 remain latent -throughout life and never develop TB disease.
ii) 30 develop TB between a few months after infection to a few years after
infection. j
iiil 20 develop TB sometime later in life but after two years of the infection.
b; 51) progress to IB immediately.
/‘
Of these hundred patients in (a) and (b) above, forty patients get well or die inspile of
treatment. Of the other sixty patients:
,
all sixty require treatment.
;e> fifteen (25%) are sputum positive which by the same mathematical
extrapolation can cause nine patients requiring treatment of which ,3
shall be sputum positive. These can further cause a total oi two patients
requiring, treatment of which at worst, one shall be sputum positive.
In other words, 100 sputum positives in our locus can cause:
♦. 60 plus 9 plus 2, i.e., 71 patients requiring treatment.
di
♦ 15 plus 3 ' 'us 1, i.e., 19 sputum positives who can transmit TB.
Assuming that each TB r alien! requiring treatment but not given the same can
averagely last two and a
years, we get the TOTAL TRANSMISSION figure of:
180 TB patients requiring ' eatment and 48 sputum positives if 100 sputum positives
are left untreated.
Ihe difference in cutting down transmission between the NTP regimens and the
RNTCP regimens maiy further disenchant those who have been afraid of TB in the same
fashion as people are af'aid of snakes. Because the end result may; be fatal, we are
prepared to believe the v. -st epithets about a disease agent.
I he aim of this exercise i: *'■> put into perspective the bogey of "faster cure rates leading
to quick cutting down o'
TB epidemic. "Cures, and fast cures are equally welcome
«•>.<; '■!<
'■ . t. Io; co IV
‘I
. 11-. ••••m IB, <?sp. !?•.•< .lUSi
oi :
■
p.J icul-.
aie poor and need to get on their leet last enough to not just earn iheii livelihood but
also to pay for their treaonent if necessary. This is where the RNTCP needs to learn
from the sociological approach of the N I P which stressed upon the need of early and
prompt treatment for e’ y patient who presented with the symptoms of TB - which
meant tackling the suffering and not the transmission - irrespective of her /his sputum
status. The stress also was on a rational, affordable and hence, free treatment. The
endeavour of all revisions must be to minimise the chances of patients with symptoms
being returned with cough mixtures. TB detection has to be strengthened at Pl Ils and at
private practitioner level
D. Is DOTS necessary k •
ing in mind the ailments of the NTP ?
The principle behind DOIS is necessary, not DOIS. With frontline drugs being
available universally, there is no reserve worth its name to delve into. Hence it is
imperative that patients take anti - TB drugs correctly, regularly and for the complete
duration.
Patients have no vested interest in cheating. Whatever Mr Bumgarner of the Global TB
Programme may have to say of the cheating in TB by 'doctors, paramedics and
patients,' the fact is that oatients usually adhere to their duty as a patient much better
than doctors or paramedics ever have. Tire staff of TB programmes may have an
interest in selling drugs, saving on labour , or to take bribes for sabotaging the DOTS
programme. DOTS aims at policing the wrong people in the crime of "non compliance". Tire overwhelming reasons of patients not completing their treatment are
a lack of regular drug supply, lack of faith in the treating physician/institution/
diagnosis, or due to intolerance but never because of cheating.
a?
X < ”<t
The r egular supply of anti - TB drugs in all the project areas of RNTCP may be the sole
cause of the higher case holding rates seen compared to the erstwhile NTP areas. One
wonders though if the phenomenon will last for long because the recent tender notice
appearing in the Delhi papers on 20"' March — asking for supply of sixty lakh rupees
worth of anti - TB drugs by the 31s1 of March — raises questions about good inventory
control.
E. What has been the basis of selection of the districts for RNTCP?
Of the 102 districts which were to be covered by the 31sl of December 1997, only 16
districts have so far been revised. Till 1995, DTP had been launched only in 70% of the
Pl Ils of 391 - out of 496 - districts. Short Course Chemotherapy had been accorded
sanction only for 47% PHIs of the 252 districts.
Now that the RNTCP has been launched in 16 districts, the confusion has been
confounded; not just for the patients but also for the doctors. Even in Delhi, some
districts are under NTP and others under RNTCP. Patients knowing that regular supply
of drugs in silver foils are available at certain centres, often give fake addresses to avail
of RNTCP facilities, something which the staff cannot permit because the resources
have to last their allocated areas. It is thus, that patients get 'THROWN OUT of
government TB
programmes which are supposedly made with their concerns
uppermost in their minds.
It inav not be entirely wrong to presume that the hyped up media advocacy is the
reason of the bias for urban and educated areas in the selection of the RNTCP areas.
People who were affected tlie most by the media advocacy were the English speaking
upper middle class and even though they may be epidemiological!)’ the least risk
group, thev are the ones who cornered the fast curing RNTCP.
1 here are very tew trials on thrice weekly reg.imviis lasting tor t> months or 0 mouth;:
as approved in the RNTCP. Of these, the trials carried out in India are even fewer.
Worse still is the fact that there is verv little knowledge about this in the medical
fraternity and hence there are valid doubts. If only the GOI had spent time and etfort in
having a wider debate on the DOI'S and the thrice weekly regimen, ami if they had
disseminated the results of the successful studies, it may have avoided the resistance
faced by it from the doctors themselves and it would have prevented this avoidable
delav in expanding the RNTCP programme area.
Il this has not been done, an honest and transparent evaluation of the project areas
carried out by independent researchers can remove doubts about the efficacy of such
regimens because the period of four years can be treated as action research itself.
,
G. Are lhe RNTCP regimens unaffordable for a country like India?
No. If the alternate day regimens are effective as in the RNTCP, an entire Category I
regimen costs Rs. 714.00 (LYK.l drug rates) and the entire Category II regimen costs Rs.
1250/-(excluding syringe and-administration costs). At two million cases a year, at an
average cost of Rs. 1000/- per patient, an annual budget of Rs. 200 crores is required for
the ilnir-- annually. Il is a cos. • Inch India can allord il then' is a political will.
In fiscal year 1997, the World Bank (IDA) had approved an interest free loan ol $142.4
million or Rs. 570 crores, at a -.ime when we did not even expand our RNTCP to the
required area of 102 districts. But that is not the way to see the economic feasibility and
affordability of strategies. T1 e costs to be worked on should be such which successive
governments will not fail t>. ommit, because failures ot drug supply are the worst
enemy of TB programmes worldwide. Operational models which study cheap and
■'(lun’h ■
live 1 p; V- >■/•>«•!
, I Io 1
|
|, , ,,,[
■■ • .•:< .
,r,<
sic ,,wds ■
•• ' I'• I; .C > •Is.
Money can be raised innovatively from within the country as well. Instead of going lor
loans, postage stamps like the ones used lor refugee relief if innovatively designed will
have a threefold benefit:
oc raise money from indigenous sources without repayment liability.
oc raise consciousness amongst masses and help in TB awareness.
oc can be used for health education if a proper range of messages is used for the stamps,
OC this may create a public pressure on the health department to perform - 'lick to kick'.
This much having been said,
me reiterate that unless our health care house is put
into order, one needs to be w '.;y of committing out; last frontier of anti - TB drugs at .
such a scale.
H . Is there a real threat of MDRTB which necessitates five drugs including
injeclables like Streptomycin for retreatment/relapses patients ?
If the multi - centric study done by WHO last year in Delhi is an indication of the
MDRTB, one must acknowledge its presence amongst us at the earliest. This study done
on 3000 Sputum positive pat' nts reporting to 10 Delhi clinics in 1995 - 1996 has shown
a 13 % incidence of MDRTB, all of which are resistant to at least Rifampicin AND
INH. Of this 13%, 11% is initial resistance, and the rest 2% is acquired. Single Drug
resistance also is of a signify
level - 24% to INH alone, 10% to Streptomycin alone
and 7% to Ethambutol alone[ACi|.’
In view of this, there is a necessity to :
0 closely monitor the treatment in RNTCP programmes.
■ Personal ( 'ommunication from a researcher involved in lhe study.
44
“1
0 closely monitor the level of MDRTB and the types of drugs the bacteria has
become resistant to.
0 foresee changes in drug, combinations used.
Since Rifampicin and INI I art! the backbone of the short course regimens, and the fact
that they make the continuation phase drugs, there is a danger of reconversion of
■sputum after the initial conversion to negative if the patient has MDRTB. Also, a high
level of MDRTB may mean a lot of patients taking only two effective drugs during the
intensive phase as well and thus lead to further creation of more MDRTB.
I .How can the private sector be involved?
Presuming that 50 % of all TB patients remain with the private sector till the end of
treatment, it is essential that the Indian Medical Association be involved in the task
ahead.
A larger consensus on a cafeteria of two or three rational and equally effective regimens
which allow some choice according to the needs of the patient and the doctor. Once
decided, the regimens have to be monitored and implemented with conviction. This
may require:
♦ Notification of TB becoming an important pre - requisite to treatment and
procurement of anti - TB drugs.
4 Prescription audit by District level committees comprising of the
Pharmacologist, the 'I B & Chest specialist, and CMIIO etc. Preferably an
individual /NGO with good track record may also be involved for this audit
which is a must in organisations like the Army and Railways and is common
feature in many countries.
J. Is there a requirement of three sputum specimens ?
t
Informal communication with the staff at CCGB and at Mahesana revealed that there
are no patients whose spot samples were positive even though the overnight sputum
was negative. This could reduce one ti ip as patients could be told by the DO IS centre
■■la.| to go v. ilh theii overnight sputum where anodier spot sample could be tai'- n to,
increase the chances of finding the Ab')’.
K. Are DOTS regimens more toxic ? L .What are the relapse rates of patients who
have been declared cured or had completed their duration of treatment under the
RNTCP? ■’
The answer to both is not known although the staff says that the rates of intolerance to
anti - TB drugs is very low. Also, since no records are maintained of relapses amongst
patients treater! under the RNTCP, ami the lact th.it there is no follow - up alter the
treatment is completed or a cut', announced, the rates of such relapses ( and hence the
effectivity of the regimens) is not known.
as
Conclusion:
After the small observational study, one thing which comes out clearly is the need for
that a wider debate and clearing, of intellectual cobwebs is required on either side of the
debate. It is necessary because I B as disease and the patients suffering from it are more
important than our viewpoints. There is a need to utilise the attention which has been
generated in a proper, rational and cost effective manner for the sake ol IB. And the
faster this gets done, the belter it would it be.
Also, there is a need to present experiences of successful models, involve/ motivate
medical college professors, teachers, IMA and others from the programme planning
stage or else the consequences can be disastrous in the long, run
Suggested Readings:
J. RNTCP Operational Guidelines for Tuberculosis Control, Central TB Division, DGHS, May
1997.
2. RNTCP Technical Guidelines for Tuberculosis Control, Central TP Division, DGHS May
1997.
3. Review of the RN ICR, Nucleus for Health Policies and Programmes and VHAI, 1997.
4. The Potential Economic Benefits of the DOTS Strategy against TP in India, Global TB
Programme, WHO, 1997.
5. TB Patients and Private Tor - Profit Health Care Providers in India, Global TB Programme,
WHO, 1997.
6. WHO Report on the Tuberculosis Epidemic 1995 to 1997.
•
7. World Bank Annual Report 1997.
S. MIMS, February 1998
Af.
fasaran
KN I t I’S< I II’DUI.I-
I’.ilienl with TH '.vinplonr.
One Overnight Sputum smenr(OS)
Tu'<> Spi'l Sputum Smcnrs(Spul)
—~4
Nrydlivc snirm
Tu'o Siiirur i’osiliw
Iz,4
()ue Smear Positive
I
-i oc<..-- X-Ray
< One month
of ATI' taken
I - 2 weeks of I
- ve
\l-.l
... ..
____ i-
[CMI'Il I B ]
?. mlhs R i H • I> /
|
Serious? .
<(Meningitis,
I’oric.irdilis,(>lc)
I
OS sim’iw + •to/
!•
.
Both -ve
Any +?■<•
Any
continue
RIH’7 one
more mnth
continue
RHEZ one
more ninth
Both -ve
Yes
OS +spol
I
J— 7kBoth
Any
+ve
-ve
1!
7
I Observalio
!
J'
Any
+ve
Extra 1’ulin
TB svmplains’
Not serious
•T
OS + si'ol
( or Rx for
other disease.
2 months R+ll+Z
--------R+H+E for five months
j
mlhs R+H <----- 1
” I
4
/</»!/ -i'C
2 mlhs S ’- R + l ’4 I -i /
i
()S smear + spot
Both -ve
--- 3
... J ■
One mth
;
.
X Hay +ve
■~i7~
.c.i
J
lowered-
X- Ray Chest
|CA1 I IB
tail
spectrum A;: -
=—= -y
> One nionlh
of \’rl taken
OS + spot
______ T
Any + ve
OS every,
two mlhs
OS +spot
after
Hath - ne
Imo mlhs
4 months R+H
Both negative
-
.+pc al
any lime
Any smear +ve
till end of
S/9 mlhs
c
'
Both smear -ve
fill end of
S/9 mills
Culture &
2 inths R+ H
I
I
OS +spot
+/><■
J - ve
Ar.ST
OS +spot
J.
Both -ve
-A ,4111/ +<'!•
_______
CHRONIC
TB
|cure|
H+E continuous
‘ ICUR|;I
■>s ■:'
■
■
AB_. AN'H&iot ic
21
ATI-ANTI-T>3 TRGAIMCNT
enc/ix B>
11OUSE CONTACTS SCHEDULE
Adult & Child
more than 5 years
Child
1 to five years
. . . r---- ------
Infant
less than one year
i
■
)
vr.>c< WiUt-'. •
•
• r
Symptoms? :
Symptoms?
1
1
No
Yes
Mother/ house contact
sputum positive ?
Yes
v
Yes
i
No
No
I.
sputum exam
NoTB^
INH for
3 months
v____
Give
. BCG only.
Mantoux Test
<-
4/
less than
10 mm
Mantoux test
more than
10 mm
more than
10 mm
(jive BCG
only
a!
net improved
.
TB |
1/
J
INH for
three more
months
Observe-twee
after
■.
to:
IT
less than
10 mm
Ap_.
_
ANTI &IOTICS.
- TRC A-rmCN'T
i:
25
■
l
•;
>5t«i ■:
G A' ! ’
i-Vu-*'- ’ i
Appendix C
GENERAL MODEL
CHEST SYMPTOMATIC
Primary Hea-'h
Centre
‘
i i ‘run.n v I lealth i
Centre
........ ...\1Z______ ___ _
Microscopy Centre
Community Health ;
Centre
District TB
Centre
1 )iagnosis and i realment
e omimmilv I lealth
Centre
District I B
Centre
j 1 iircclly Observed Treatment]
iSub Centre : MPW
'Village lex-el: Angan wadi Workers, Dai, Village Health Guide, Community Volunteers
■J - i
'•.?
■
Appendix I?
SPECIALISED MODEL
CHEST SYMPTOMATIC
_______ Microscopy Centre
DISPENSARY
CHEST CLINIC
Diagnosis & Treatment Card
Microscopy Centre
Directly Observed Treatment
Microscopy Centre : TB Health Visitor
Treatment Centre : Health Worker
Community Volunteer
Appendix E
DIAC ■■ OSIS AND MANAGEMENT
COUGH FOR 3 WEEKS OR MORE
thsee i
■■ OR 2 POSITIVES]
' iurp grreoRS
|j positive]
3 NEGATIVES
ANTIBIOTICS
(1-2 WEEKS)
[SYMPTOMS I’ERSi'J
[x-ray]
| positive]
| negative]
_____y/______
X - RAY
I
I
I___I
v
NEGATIVE
| POSITIVE |
I
sputum positive
TB FOR TREATMENT
NON TB
SPUTUM NEGATIVE TB
FOR TREATMENT
A. '
Appendix G
TREATMENT AND FOLLQV’-UP OF SMEAR POSITIVE CASES
PERIOD
SPUTUM POSITIVE CASE
4
r
NEW
0
I
RETREATMENT
CATEGORY I
l.P.
CATEGORY 11
l.P.
spu tum
to \ I i\ l
PC AVE
I l.P. ONE MON I I1 MORE)
i
•I
SPU 1 UM
(NEGATIVE/ POSITIVE)
SPUTUM
■V
I
F
NEGATIVE
POSITIVE
C.P.
(l.P. ONE MONTH
MORE)
SPU I UM
( NEGATIVE)
< '.P.
3
. SPUTUM
(NEGATIVE/POSITIVE)
i
!/
SPU 11 ’M
SPUTUM
(NEGATIVE)
C.P.
I
POSITIVE
'1/ NEGATIVE
6 SPUTUM
C.P.
CATEGORY 11
NEGATIVE
AFRESH
.CURED
7
S
Q
SPUTUM
(NEG/POSITIVE)
C.P.
SPUTUM
NEGATIVE
CURED
spyruM
• POSITIVE
NEGATIVE
CURED
CHRONIC
(|
SPUTUM
■P
J
NEGATIVE POSITIVE .
CURED
CHRONIC.
i
Appendix I I
TREATMENT AND FOLLOW-UP OF SMEA R NEGAT1V E CAS. ES
PERIOD
(IN MON THS)
SPUTUM NEGATIVE CASE
(PULMONARY/ EXTRA-PULMONARY)
.
r
SERIOUSLY ILL
CATEGORY I
l.P.
NOT SERIOUSLY ILL
CATEGORY III
l.P.
Y
r__ _
2
SPUTUM
I
---------- I
POSITIVE
CATEGORY II
AFRESH
NEGA’llVE
X.P.
6
SPU1UMNEGA11VE
TRI ■' ATMENT COMP! .ETED
/
l.P.
lNTeNSW£
c-P
CON Tl NUAlTIOry
phasc
PHp-Sg .
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