RF_DIS_5_A_SUDHA_PART_2.pdf
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RF_DIS_5_A_SUDHA_PART_2
Interview with Mr. Jayaram on 31 •'./■'
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Mr. Jayaram aged about 36 years lives in Neelsandra slum with his wife am! two
children, a son and a daughter aged 6 and 3 years. It’s a small house measuring about 28
squares has an asbestos roofing and has electricity connection for one bulb. I was told
that the house had collapsed a year ago, about 7 months ago they managed to repair the
front portion and are living in since then. It is their own house. Cooking is done in one
corner; utensils are washed outside the house on the street and use the community toilet.
Lady of the house- said that she uses the neighbor’s bathroom for bathing. Jayram is a
construction laborer, he says that he can earn about 70 - 80 rupees a day when he goes to
work. He said that the lie gets work' only for about 15 days in a month. He is a chronic
alcoholic and a chain smoker. I wonder how 4 people can sleep in such a small place.
Their son had gone to school. Jayaram and his wife participated in the interview. It took
about H'i hour for the interview and the interview was done in Telugu as Jayram’s
mother tongue is Telugu and he preferred to respond in his mother tongue. This is a ver,'
poor family and survives by financial support given by the lady’s family.
He said that he gets cough when the weather is cold and unable to eat well are his present
problems. He said that the doctor at the hospital near Sapna (Lady Wellington TB center)
Theater told him that he has TB.
His wife said tliat he had a boil in his hand and it got infected. When he went to a private
doctor it was reported that the doctor told him if he neglects treatment his hand might
have to be amputated. He was afraid and said he would rather die than going to any
doctor. She said that her brother took him to a private practioners nearby for treatment
and a surgery was done to cure his infected boil. She said “He had lost so much of blood
during the surgery and he was weak. He was also worried about his house tn
Neelasandra that had collapsed; he was not eating properly and started drinking
(alcohol) more" It was reported that this is the time he had fever and loss of appetite and
was diagnosed as affected by Tuberculosis at the place mentioned above.
He say that he doesn’t know why he got TB and said that he was doing well and was
going to work, he said suddenly one day he got cold and fever, and felt like lying down
all the time. He said that he was feeling cold, had fever and cough and it persisted for
about 2 months. His wife said that he refused to go to a doctor. He was insisted by her
people so went to Ashwin doctor (a private practioners) and told him that he had cold,
fever and cough. The doctor gave an injection and tablet for tliree days. He also gave him
a prescription and asked him to buy the medicines from a medical store. He said in two
days time his fever and cold subsided but he was unable to eat so he went back to the
doctor again. This time he said that the doctor told him that he might have TB and sent
him with a chit to the Lady Wellington TB center.
He said that his mother had TB and she took treatment from the hospital near Sapna
theatre (Lady Wellington TB center.) It was reported that she died two years ago. They
both said that they have not studied so do not know why and how we he got the disease.
His wife said, “ People say, ifpolio drops was not given when we were small, we get the
disease” they said that they are not aware of anybody suffering from TB in thier
neighborhood.
He said that as soon he went they took an X ray and did sputum test. He said that he was
informed that he has TO and told him that they would give him the tablets for 6 months
that he should take it without discontinuing. He said that he was sent with a chit to the
government hospital in Munireddy palya for collecting tablets.
He said that he approached the Munireddypalya Government hospital after a week, where
deliveries are conducted and attend also attend to the general health problems of all
people. He said again they collected the sputum for three times, once as soon as he
reached and asked him to bring after two days the sputum collected early in the morning.
He said, again they collected the sputum when he went to the center and one inspector
came and took away his sputum for investigation to be done in some other place. He said
that he was again informed that he has TB and gave him the tablets "they told me to take
the tablet without missing and I would be cured.” He said that once a week he would go
and collect the tablet by showing the tablet covers used and he took them for 5 months.
Note; during the interview he got up, went out and spat on the road, I think he does this
always.
He said that he could eat well after taking the tablet for about a month. His wife said that
the doctor told her to give him meat and soup and said that she gave and he was feeling
all right within one month. They said that after completing the treatment for about 5
months they came back to Neelasandra. They said that they knew that he had to complete
the treatment for another month and said they had to come back since they house here
was in bad shape after it was collapsed. It is seven months ever since they came back
from Munireddy palya after discounting the last month treatment.
They both said that they heard through their in laws that people form the government
hospital in Munireddy palaya came in search of him and were sent back saying that they
have gone back to Neelasandra. They said that they were told by their in laws that the
people from the hospital felt bad for Jayram taking the tablet for 5 months and
discontinuing the last month’s tablets before being cured. It was reported that they told
his mother in law to take him back there.
He said that at present he doesn’t have any problem and gets cold only when the
temperature drops. He sad that that people at the Lady Wellington hospital told him to
stop smoking and drinking and said they would not give him the tablets if he wouldn’t.
He said that he gave up smoking and drinking during his treatment for five months and
stalled again fi'om the past one month. He said that while taking the tablets, he had
burning sensation in the stomach and his appetite increased.
He said that TB affects because people don’t eat well. He said, “ Doctors told me that I
simply drink and sleep and don’t eat well” He said that al the Lady Wellington TB center
he was shown the X-Ray. “ They showed me a big x-ray and 1 could seek the picture of
my heart with holes in it and that is what called TB”. He said that “TB could affect
anybody, and it affects particularly those who are lean and weak. It doesn't affect those
who are fat and healthy and said smokers and drinkers do not eat well thus they are
affected by TB. ”
He said, it is better to many only when one is cured from because the disease can spread
to the other person. He said that TO spreads if people stay in close proximity and breathe
in their air exhaled by the person affected by TB. In his case, he said that he got after his
marriage and was told by the doctor at Munireddy palya hospital to abstain form sexual
relationship with his wife and he had abstained during his treatment. He said that he
needs to go for check up again because he gave up the treatment during the end.
His wife said one need to pay some money to the place where the treatment was given
(not sure how much) for continuing the treatment after discontinuing. She said the reason
for payment is because they failed to make use of their consideration to provide the
treatment free of cost due to their poor status. She said that outside each tablet cost 20
rupees. They said that he is planning to visit the health center where he was taking
treatment and check his sputum during dasara when he visits his in laws.
“People say that, you can get TB by stamping the urine and sputum ofthe person affected
by TB. Ifthey come to know that I have TB and ifI spit and urinate in public places they
would scold me”. He said that his people at his mother in law’s house told him to get
admitted in the hospital and told him to spit in a tin, cover it and dispose it far away.
He said that I kept the chit given by the lady Wellington for 5 days with him before he
went to the TB sanatorium. At TB sanatorium they checked his blood and sputum and
said that he I has severe TO and I needed admission. He said that he spent about 100
rupees. 40 rupees to the lab technician and 50 rupees to the x ray technician and 10
rupees to the attendant who guided him to these places. Thy said that they spent 100
rupees for auto. His wife said that her brother took him to TB sanatorium at Old Madras
road because he had seen his neighbor a teenage girl who was treated for TO there and is
cured, she is now doing teachers training.
He said “ I saw people in worse condition than me, they were awkward to look at and I
did not like to take treatment there so I came back” His wife said that they insisted that
one person should stay with him in the hospital and it was not possible for her as she had
with her the little child so she had decided against it.
The said that they went 3 times to Lady Wellington Hospital and it costs 100 rupees for
auto for each visit, they said they spent about 1000 rupees totally for transportation and
other personal expenses apart front paying money to the staff at the sanatorium.
He said that he felt the Muniredy palya hospital s better because the tablet they gave him
helped in recovering and at TO sanatorium he said that they give injection and tablet.
He said that he did not go to work during the treatment of 5 months and said he couldn’t
do the work and was feeling breathlessness. He said that all his expenses were taken care
by his in laws during those 5 months of treatment. He said that they made him become all
right and sent him back. He changed his version and said “How long I can stay in my in
laws house, they started treating me indifferently and spoke ill of me and how long can I
tolerate, they also need place for themselves. I Just decided to leave their place
discontinuing my treatment and said it did not matter even if 1 die. I brought back my
wife and children, No need for any tablets. ” The tablets given for the week he left was
still with him and he did not take them.
They knew the Neelasandra and Asustin town TB clinics and said they would get the
tablets if they get a letter from Munireddypaaly clinic. He said that he had to take
3,4,1,and 2 tablets each day. He said that he had to take and show the tablet covers to
collect the tablets for the following week. It is 7 months since he has discontinued the
treatment and has come back. His wife said that the doctor told her that both her
daughter and she had to do the test for tuberculosis. She said that she went to Neelasndra.
corporation TB clinic and asked them to do TB test for and she was told by the people
that there no necessity to do the test unless she has cough or loss of appetite. She said
about her husband she was told to take him there with a referral letter from the
MunireddypalyaTB clinic.
She said about reasons for discontinuing “ my people were always scolding him, started
telling him it is more than a. year since you come here and. you do not want to go back to
you house, he could not tolerate their words so her brought us back here"
He said that he is planning to his mother in-laws house for Dasara and said “even if I go
to my mother in-law’s house, 1 wilt not go to the clinic because they would scold, me for
discontinuing ”
"Ifpeople come to know that 1 have the disease that they would tell me to go far away
from them because it would spread to them. ” He said that he had no such experiences.
He said during those 6 months of treatment, he could not go to work and says that he can
go to work now but unable to do hard work because he feels breathlessness.
He says, “ 7 was so close to my mother I ate with, her, slept next to her and. went
wherever she went so.I got this diseases from her"
The Role of the Private Sector in TB
Community Health Cell
Questionnaire (Health Care Professional Version)
Name of Institution
Location (Address)
Phone #
Director/ In-charge
Person Surveyed
Funding Sources
Year of Establishment
# of Staff Members:
Doctors
Nurses
Lab Technicians
Other
# of Beds
# of Patients
# of TB Patients
______
# of Patients
#of TB Patients
Diagnostic Facilities Available
Case Finding/ Diagnosis
1. Approximately how many patients come in with TB Symptoms? (suspect of TB)
Of these symptoms, we include :
Severe cough for extended period of time
Severe Weight Loss
Extended Fever
Blood in Sputum
Extreme Fatigue
Patches on Chest
Other
2.
What economic background do most of your TB patients belong to?
3.
What diagnostic tools are used?
Chest X Ray
Sputum Culture
Both
Other
{PAGE} 1
The Role of the Private Sector in TB
Community Health Cell
4.
When do you repeat investigations?
5.
What do you do if a patient presents his/herself with TB symptoms yet the
investigations return with negative results?
6.
When do you ask for a sputum culture?
7.
How many of the patients do you find are co-infected with HIV?
What other co-infections are common?
8.
What information is given to patients upon diagnosis?
_
In addition to prescribing medication, what medical advice do you give patients?
9.
What audio-visual aids do you have on TB?
10.
Normally, what is the patient’s understanding of the disease?
Treatment
11.
What are the most commonly prescribed drugs?
In your experience, which ones work best?
12.
What is the duration of the treatment regiment that you advise?
To what percentage to they follow this, in your experience ?
13.
What percentage of patients responsive to treatment?
Of those who are not responsive to treatment, what do you think are the reasons?_
14.
What exactly is the prescribed regimen (i.e. SCC)
{PAGE} 2.
The Role of the Private Sector in TB
Community Health Cell
15.
What are common side effects of the treatment, and how do patients handle them?
16.
What are some major challenges in providing treatment?
17.
What form of record keeping do you practice ?
Do you have a sample to show ?
18.
What do you charge for :
a) Consultation
b) Investigation (Sputum/X-Ray)
c) Prescription
What percentage of patients finance treatment?
19.
Where do you get the medications from?
20.
How much does an average course of treatment cost the patient?
21.
Does your institution have any financing plans?
22.
Are you aware of how patients can get assistance in getting medication?
Case Holding/ Follow Up
23.
24.
What percentage of patients continue with treatment until the end?
What are the most common reasons they stop?
Fi nanci al
Social
Side Effects
Other
25.
What follow up techniques does your institution practice?
In your opinion, how effective are they?
{PAGE}3
The Role of the Private Sector in TB
Community Health Cell
26.
How often do you encounter drug resistance (or MDR TB)?
What percentage of your patients become resistant ?
What percentage of patients come with MDR TB?
27.
How do you treat these types of patients?
28.
Is there special protocol/policy that you use for treating recurring patients?
29.
When do decide to refer patients elsewhere?
30.
Are you aware of the Revised National Tuberculosis Program (RNTP)?
How often do you encounter it in practice and how often do you use its services?
31.
Any other concems/questions/comments that you would like to raise?
Thank you for your cooperation
{PAGE}4
The Role of the Private Sector in TB
Community Health Cell
Questionnaire (Health Care Professional Version)
Name of Institution
__ _____________________________
Location (Address)
____________
_____________________________________
Phone #
__________________
Director/ In-charge
____ _____________________________________
Person Surveyed
_ _______________________________________________
Funding Sources
____________________________________________________
Year of Establishment ______________________________________________________
# of Staff Members;
Doctors
_ ________________________________________
Nurses
___________________________________________
Lab Technicians
Other
# of Beds
# ofPatients
# of TB Patients
0 of'PstiS'BtB
vofTB Patients
Diagnostic Facilities Available
Case Finding/ Diagnosis
1. Approximately how many patients come in with TB Symptoms? (suspect of TB)
Of these symptoms, we include :
Severe cough for extended period of time
Severe Weight Loss
Extended Fever
Blood in Sputum
Extreme Fatigue
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Patches on Chest
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Other
_____________ _
_
_____ __________________
”2, What economic background do most of your TB patients belong to?
3, What diagnostic tools are used?
Chest X Ray
Sputum Culture
Both
Other
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In your opinion, how effective are they?
The Role of the Private Sector in TB
Community Health Cell
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What percentage of your patients become resistant ?
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How often do you encounter it in practice and how often do you use its services?
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The Role of the Private Sector in TB
Community Health Cell, June - August 2000
List of Institutions to be approached
(From the Voluntary Health Association of Karnataka)
8. Administrator
Sneha Bhavan Dispensary
Rose Garden
Vivekanagar
Bangalore - 560047
1. c/o Medical Superintendent
Sindhi Charitable Hospital
Sampangiramanagar
Bangalore - 560027
Ph: 2237117
Ph: 5110^12.
2. c/o Administrator
Chinmaya Mission Hospital
C
Indiranagar
Bangalore - 560038
Ph : 5280461
3. c/o Medical Superintendent
Church of South India Hospital
No. 2 Colonel Hill Road
Bangalore - 560051
Ph : 2861103, 2861104
4. Correspondent
Shanthinilaya Community Health
Care Center
Tambuchettypalya
K.R. Puram
Bangalore - 560056
Ph: 52^113^
5. Administrator (Father Sebastian)
St. John’s Medical College
Hospital
Sarjapur Road
Bangalore - 560034
Ph : 5530724
6. Administrator (Dr. Om Prakash)
St. Martha’s Hospital
Nrupathunga Road.
Bangalore - 560001
Ph: 2275081,2274541
7. Administrator (Dr. Michael)
Bangalore Baptist Hospital
Bellary Road, Hebbala
Bangalore - 560024
Ph : 3530321, 3530322, 3530333
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9. Administrator
St. Philomena’s Hospital
1 Nilasandra Rd.
Bangalore - 560047
Ph: 5577046
10. Administrator
St. Theresa’s Sanitorium and
Maternity Home
Rajajinagar
Bangalore - 560010
Ph: 3320432, 3320761
11. Sevakshetra Hospital
Ph: 6634080
12. Administrator
Al-Ameen Medical Trust Hospital
#2 Miller Tank Bund Rd.
Bangalore - 560052
Ph: 2200332
13. Director
Nava Jeevan Health Center
Carmelaram Post
Sarjapura Road.
Bangalore - 560034
Ph: 8^2112.1/112..’-/?!
14. Director
Jnana Jyothi
Anekal
Bangalore - 562106
Ph: OH ’itzA
Sister Elise Mary (CHAIKA)
Ph: 8440530,9844084377
Community Health Cell
367, Srinivasa Nilaya, Jakkasundra
Is' Main Is' Block, Koramangala
Bangalore - 560034
July Is1, 2000
Re: Tuberculosis Research Project
Dear Sir/Madam;
Recently, Community Health Cell (CHC), a voluntary health NGO located in
Koramangala, initiated a study entitled, “The Role of the Private Sector in
Tuberculosis Control”. Commissioned by the Karnataka State Task Force on Health,
Nutrition and Population, this research study aims to understand the nature and role of the
private sector in health care in the area of Tuberculosis (TB). In practice, TB control may
be defined as having three main aspects including case finding and diagnosis, treatment,
and case holding.
The voluntary not-for-profit sector plays an important role in the development of
TB control programs and it is an important part of the private sector. Therefore,
documentation of their approaches and effectiveness in health care is useful information
that must be collected. As a result, we are approaching all NGO’s and hospitals with
significant TB components to then' agenda, such as your institution, and requesting their
participation. This participation will be solicited in the form of information regarding
such topics as patient care, diagnostic techniques, and treatment regimens. This would
require an interview session between a member of your staff and a member of CHC. It is
important to note that all data will be collected solely for the purpose of developing the
study and all names and information will be kept strictly confidential. No names of
institutions, patients or staff members will be reproduced in any published text.
Attached is a sample survey, which includes the questions that will be asked by
the members of CHC, included for your reference. Should you have any questions,
comments or concerns, please address them to Dr. Thelma Narayan, Mr. Chander, or
Deepti Tanuku at CHC (ph: 5531518 or 5525372). We thank you in advance for your
cooperation, and we look forward to working with you.
Thanking you,
Sincerely,
Dr. Narayan
Mr. Chander
Deepti Tanuku
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In-depth interview with kavitha’s mother at S D Sanatorium on 11.10.2000
Kavitha an eight-year-old girl studying in class three comes form Tiptur is
admitted in S D sanatorium a week ago. Her father is agricultural coolie and
earns about 30 rupees a day and mother to is a coolie, studied up to class 10
and earn about 15 rupees a day.
She stopped going to school two and half months ago due to fever and cough
and said that she had fever at nights and had cough always. Her mother said
‘ she had fever and cough for five days, took her to the government hospital
and they gave an injection and tablets. Fever and cough stopped for five
days and again started. This time my mother took her to Gubbi (a village
near by) and showed her to a private doctor. They doctor gave her injection,
tablets an cough syrup. He gave her the injection for twenty days on every
alternate day. The doctor said that she has more fever and cold. May be
about 1000 rupees my parents had spent but there was little improvement.
She said her husband is a coolie and earns about 30 rupees a day and her
parents spent the cost of the treatment.
Again fever started so my parents took her to Thumkur and they asked us to
take her when she has fever again. When we took her when she had fever
they admitted her for about a month. They took four x-rays and we had to
pay for three x-rays, one was taken free. Here we may have spent about
4000 rupees. Flere they said that kavitha has TB and Limany (pneumonia)
they tested her blood, sputum and had collected fluid from side. They said
that they would cure her but referred her here. They said that a pipe needs to
be fixed to her side and they could not do it. They sent us here by saying that
there is a good doctor in this hospital.
When came here they did an x-ray and collected blood. They might have
told my brother what is kavitha’s problem, the doctor has not told me
anything. Fever and cough is stopped but she cannot eat. At Thumkur
hospital they gave 10 injections and gave half medicines asked us to buy
from outside. It is a general hospital. Flere they have fixed a pipe to her side
and she is better now. Here they gave injection three time a day and give
tablets after lunch.
How do not know how she has got TB. She said neither in my family
members nor in my neighbourhood had TB. The Thumkur doctor said that
is in inc uc^huhue,
one saia mat iici uiumci wiiu is twciity-nvu
years old and he had TB when he was one year old and he took treatment till
he was three year’s. Kavitha might have got this disease from other children
in school. May be she got from the mosquito bite; the mosquito that had
bitten the affected person and bitten or she might have stamped the urine of
the affected person. TB spreads by stamping the urine and sputum of the Tb
affected person; it also spread by the mosquito bite. All these information I
learnt from some sisters used to come to our village, the anganwadi worker
and the doctors who came there.
Note: it was difficult to get more information from as Kavitha’s
grandparents accompanied her to the hospital and her mother said that she
did not know.
In-depth inteniew with Devaraju’s mother at S D sanatorium on 11.10.200
Devaraj a 10-year-old boy comes from Aroli village in kanakapura taluk, his mother
sivamma was with him, his father Siddhiah is landless lab labourer. Devaraj has two
more brothers and a sister. He came to S D sanatorium 15 days ago. He is studying in
class 3 and left school when he had come for treatment to Bangalore. She said the she had
some physical problem during the last deliver and she was advised not to do hard work.
My relatives have given a thatched house and we live in that. My husband earns about 20
to 30 rupees a day. She has studies up to class ten.
Dveraju said that he has chest pain, back pain, fever and cough in the night. He had these
problems for two months, I showed to a private doctor in the nearby village. From the
past eight days he is given tablets and injections, he is feeling much better, his fever and
chest pain is gone.
Six months ago Devaraju had fever for 15 days and I took him a private doctor and the
doctor told me that he has heart problem. My father took him to Jayadevea hospital in
Bangalore and the doctors said that he doesn’t have heart problem. He was brought back
and we were giving the tablets given by the private doctor. Jayadeva doctors had given
him 30 tablets and he took them, he was all right for four months and two months ago he
started complaining of fever, chest pain and cough. We took him to a private doctor and
he charged him 10 rupees and gave a prescription. And the medicines cost about forty
rupees and we spent about two hundred rupees for tablets. My husband borrowed the
money from some one in the village for his treatment and I do not know how much he
had borrowed.
When asked what is Deveraju’js problems she said , fever, chest pain and cough. When
asked what was she told about his problems by the S D sanatorium staff, she said they
asked if any of my family members had TB. No one in my family had TB. When we
came here they took his sputum twice for examination. We came to this place with one of
our neighbour who had undergone TB treatment from this hospital. My father knew this
man and when we told my father that my son has TB, he went and told that man and he
brought us here. The doctor at Aroli told us that he has TB. When asked if any
investigation was done, she said no. I do not know how he has got T, I don’t know if any
of my neighbours have TB. Even if they would they tell me? I only know how to take
care of children. After coming to this hospital only once I went home to have bath. Here
in this hospital they give food for Deveraju and I manage with it.
Before coming he used to go to school and complained that he could not eat, would
refuse and did not join the other children for play. The schoolmaster told us to show him
to a doctor. He said with tears “ he was healthy and fatty see how he has become- so thin
because we are poor” when asked about if any money was paid to hospital staff she said
that she doesn’t know because he father brought him and admitted.
Note: she could not answer many things, she doesn't know and said that she had never
gone to school.
INTERVIEW GUIDELINE
KNOVTEDGE ABOUT THE DISEASE
pt-
What is the name of the disease for which you are/ were
getting treatment
What do you know about this disease?
Who are more affected by this disease male/ female.; rich
/poor; children/ adult/ old people.
Any reason why they are affected more
pt-
How is the disease spread?
2. HELP SEEKING BEHAVIOR
pt-
How did you find out that you had this disease?
pt-
What were your initial complaints? What did you do?
p^ What made you seek treatment? When? Where?
Narrate your experience
pt-
If there was delay in seeking treatment what were the
reasons?
pt-
What made you come to this centre?
pt-
How long have you been taking treatment from this
centre?
How have you to take treatment?
A STUDY ON
PATIENTS PERSPECTIVES REGARDING
TB TREATMENT
LElMDEiR RMTCP IN BANGALORE MAHANAGARA PALIKE
AIM:
to understand the patient’s perspective
regarding tb treatment
Provided by the Bangalore Mahanagara Pal ike under
the RNTCP (Revised National Tuberculosis Control
Programme)
using
DOTS
(Directly
Observed
Treatment, Short course) approach.
QBJECTDVES:
Zo
cisi
uciderstGindmg
©f
the
*
psZwciG
p ?:3©pt?w ©?i TB Tirecatmesit, among the wbeiEii
n
D©©0“ ro®©po@o
SECONDARY
Zo
Understand th® treatment seeking behove©^
2»
i'jG'2CJSj'S'ij'Q]!nid uh@ ompsssu’ ©$ the disease ©trad Mhsfc
fr-ecatmein'u’ ©si these’ Saves emd the cgditsstmetat
they
u R9Q to m©k®o
miTWOOLTOY
l■■
3raZh 3Ru®rvimv
SAMPOHS W^HKWIE
Systesimotk 'mrnfem sompSmoj
826 patients registered during the
first quarter,
January - Anarch, 20© 1
SAMPLE SIZE:
fl fl 5 paSseeuSs
SAMPLE LIIMIT: male, female, children, adults
A€ate CLASS8F8CA fl 806^1:
0- 5 years
6~ fl 8 years
fl 9- 45 years
46 years arad afeow
■fliB EJfi^8flS FFtfOWS SAMPLES WEItE DRAWN
JJ^PjflE OF MiASET
•D
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u"j©saf?a2Cj
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»J S -•</£
uD c.’d -2j iTSI
_______tsL'___ _ _________________
5
6
T
^eelasaEssira
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ii © I
fl 74
96
fl 47
82
99
110
fl 08
826
SELECTED
22
15
24
fl©
14
17
fl 3
its
What symptoms have subsided? What symptoms are
persisting?
-
How do you fee! generally now?
ft-
What would happen if the disease not completed treated?
T £ A Turn V
j o a /A iiv its
cr- Does this disease affect your married life? Family life?
cr- What your family members feel about your having this
disease? What support you get from your family with
regard to treatment? What are the changes you had to
make?
cr- Do you have a child less than 2 years old? Do you
breastfeed the baby? If you stopped breastfeeding why?
cr- Does any of your family have this disease? What has he/
she has done about it?
4. COMMUNI iY
cr- Do the members of the community know that you have
this disease?
ct-
What do the community members think about this
disease?
The Role of the Private Sector in TB
Community Health Cell
Questionnaire (Health Care Professional Version)
Name of Institution
Location (Address)
Phone #
Director/ In-charge
Person Surveyed
Funding Sources
Year of Establishment
# of Staff Members:
Doctors
Nurses
Lab Technicians
Other
# of Beds
# of Patients
# of TB Patients
# of Patients
#of TB Patients
Diagnostic Facilities Available
■
_______
Case Finding/ Diagnosis
1. Approximately how many patients come in with TB Symptoms? (suspect of TB)
Of these symptoms, we include :
Severe cough for extended period of time
Severe Weight Loss
Extended Fever
Blood in Sputum
_______________________________________
Extreme Fatigue
Patches on Chest
Other
______________________ ______ _
2.
What economic background do most of your TB patients belong to?
3.
What diagnostic tools are used?
Chest X Ray
Sputum Culture
Both
Other
{PAGE}J
_
________________________
The Role of the Private Sector in TB
Community Health Cell
4 When do you repeat investigations?
y What do you do if a patient presents his/herself with TB symptoms yet the
investigations return with negative results?
6.
When do you ask for a sputum culture?
7.
How many of the patients do you find are co-infected with HIV?
What other co-infections are common?
8.
What information is given to patients upon diagnosis?
In addition to prescribing medication, what medical advice do you give patients?
9.
What audio-visual aids do you have on TB?
10.
Normally, what is the patient’s understanding of the disease?
Treatment
11.
What are the most commonly prescribed drugs?
In your experience, which ones work best?
12.
What is the duration of the treatment regiment that you advise?
To what percentage to they follow this, in your experience ?
13.
What percentage of patients responsive to treatment?
Of those who are not responsive to treatment, what do you think are the reasons?_
14.
What exactly is the prescribed regimen (i.e. SCC)
{PAGE}a
The Role of the Private Sector in TB
Community Health Cell
15.
What are common side effects of the treatment, and how do patients handle them?
16.
What are some major challenges in providing treatment?
17.
What form of record keeping do you practice ?
Do you have a sample to show ?
18.
What do you charge for :
a) Consultation
b) Investigation (Sputum/X-Ray)
c) Prescription
What percentage of patients finance treatment?
19.
Where do you get the medications from?
20.
How much does an average course of treatment cost the patient?
21.
Does your institution have any financing plans?
22.
Are you aware of how patients can get assistance in getting medication?
Case Holding/ Follow Up
23. What percentage of patients continue with treatment until the end?
24. What are the most common reasons they stop?
Financial
Social
Side Effects
Other
25.
What follow up techniques does your institution practice?
In your opinion, how effective are they?
{PAGE}5
The Role of the Private Sector in TB
Community Health Cell
26.
How often do you encounter drug resistance (or MDR TB)?
What percentage of your patients become resistant ?
What percentage of patients come with MDR TB?
27.
How do you treat these types of patients?
28.
Is there special protocol/policy that you use for treating recurring patients?
29.
When do decide to refer patients elsewhere?
30.
Are you aware of the Revised National Tuberculosis Program (RNTP)?
How often do you encounter it in practice and how often do you use its services?
31.
Any other concems/questions/comments that you would like to raise?
Thank you for your cooperation
{PAGE}4
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:
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Treatment Card
State :City/District :----------------------------------------------------------
Code district/subdistrict :
Name :--------------------------------------------------------------------------------------------------------------------- Patient TB No.:
Health Unit :----------------------------------------------------Complete Address :
Sex : M
Age :
F
Name and Address of Contact Person :
Disease Classification
Pulmonary
Extra-pulmonary
Site:
I. INITIAL INTENSIVE PHASE - Prescribed regimen and dosages :
Tick (y) the appropriate Category below.
Category III
New case
(pulmonary smear - negative,
not seriously ill; or
extra-pulmonary, not seriously ill)
Category II
Retreatment
(relapse, failure,
treatment after default)
Category 1
New case
(pulmonary smear - positive,
seriously ill smear-negative, or
seriously ill extra-pulmonary)
Type of Patient
New
Transfer in
Treatment after default
Relapse
Failure
other (specify)
Write number of tablets or dose of streptomycin in the boxes below.
3 times/week
3 times/week
Lab No.
Date
Month
3 times/week
Smear
result
Weight
0
H
R
H : Isoniazid
Z
H
E
Z
R
I : Pyrazinamide
R : Rifampicin
H
S
E
E : Ethambutol
R
2/3
Z
4/5/6
S : Streptomycin
677/8/9
Tick (/■) appropriate date when the drugs have been swallowed under direct observation.
^^oTy 1
2
3
4
5
6
7
8
9
10
11
12 13
14
15
16 17
18
19
20
21
22
23
24
25 26
27
28
29
30
31
II. CONTINUATION PHASE
(see Guidelines)
Category I
New case
(pulmonary smear - positive,
seriously ill smear - negative, or
seriously ill extra-pulmonary)
Prescribed regimen
and dosages
Category II
Retreatment
(relapse, failure,
treatment after default)
Category IIIQ
New case
(pulmonary smear - negative, not seriously ill;
or extra-pulmonary, not seriously ill)
Write number of tablets per dose in the boxes below.
3 times / week
3 times / week
R
H
H
R
3 times / week
R
H
E
Enter 'X' on date when the first dose of drugs has been swallowed under direct observation and draw a horizontal line (x) to indicate the
period during which medicines will be self-administered.
Month^-r-"
Day
Remarks :
1
2
3
4
5
6
7
8
9
10
11
12 13
14
15
16 17
18
19
20
21
22
23
24
25 26
27
28
29
30
31
pt-
Do you know of any other member of the community
having this diseas£? What has he /she done about It?
5. ECONOMIC
pt-
How much money have you spent for the foilowing;
pt-
a. Consultation
pt-
Others specify
pt-
How did you get the money for the treatment?
pt-
Family income sufficient; borrowing (from whom)
pt-
Has any of the staff of the center demanded money?
Taken money/
b. investigation
c. medicines
6. WORK AND TREATMENT
pt-
Have been away from work because of this disease?
(During treatment)
If yes, for how long?
pt-
Are you able to continue the work s before the symptoms
started?
pt-
Does the treatment affect your work? Rejection by
employer? Co-worker?
3
KNOWLEDGE ABOUT IB
hSAME OE THE DISEASE
=
Except one al! of them said TB Kaayefie or TV
KaiyeSe
=
One Eady aged 72 years ex-pul Th completed
treatment did not know that she took treatment for
Tuberculosis
WHAT THEY ABOUT THE TB
r?
fit spreads
kt-
Spreads by eating food eaten by TB patient
rcr Spreads through sexual contact
pt-
Spreads through air
kf-
TB affects people of ah age group and both the
sexes
rf-
Affects more poor because they do not eat on time
kt
Th affects people who are addicted to alcohol and
tobacco
HELP SEEKING BEHAVIOR
SJOMS AMD SYMPTOMS
= Cough, fever, tiredness, could not work, Jimp node
on the neck
° Went to doctors after month after symptoms started
° AIS of them went to private practitioner except one
more than once.
° Most of them Came to know that they are suffering
from TB from lady Wellington TIB unit, two private
practitioners informed their patients
c Taking treatment for the past 3- 6 months time
a Duration of the treatment - 6to 9 months
n One person said do not know and would take as Jong
as the doctors tells
SYMPTOM'S PERSISTED AND SMBSMMEft
o Within two weeks to two months cough and fever
stopped hut tiredness continued.
o AH of them said they are fee'ing health now
o ff treatment discontinued
Reoccur, deteriorate, death two said
MAR&IAGE AW FAMILY LIFE
© Families are generally supportive, encourage to
complete the treatment
o Few famines kept their plate and tumbler serrate
and isolated those who had small children
© One male and female Said told by doctor to
abstain from sex
COMM1MTY ATTHTOE
c
One person said that the community know and no
attitudinal changes.
c
All the others were afraid of the community
member coming to know
ECOM&MC
D
Speont 20 rupees to 6000 for consultation,
prescription, investigations and travei
n
Mo one demanded money or given one tried given
fruits to one of the staff but was refused
WOUK AbSD TREATMENT
n
Stayed back at home one month to one year
Needed break after taking tablets
°
Side effects; nansea, bamiftg sensation, very Sired
°
Onabie to work 6 days off the week
DISTANCE
°
Most off them were very dose to the treatment
center
n
One abont tow kms distance father helped m
travelling by bicycle
SATISFACTdtt
D
IMone dissatisfied
n
One said doctor not available to complain side
effects
D
One said long waiting time affects work
°
One said it is like my honse 0 walk in collect my
tablets and go
n
Another said the moment they see my they welcome
me with smile
SOGGESTOOIMS TO IMPROVE
°
Renovate the center, keejp it clean and neat
a
Be available at 9.00 am to provide the tablets.
0-5 YEAL2S
Laa«/ '\
i^essi
f^aus
T@tal
TOTAL
PL5L
Extra-PUL
SELECT®©.
5
w
■as
2
4
6
&
&
9
5
10
13
6-18 YEARS
SEX
TOTAL
pyi
E-PUL
SELECT
PUL
EE3
F®5TB
65
35
100
45
25
@2
20
n
33
0
5
13
6
9
2
2
4
BP
SEate
ToSaa
1,5?
1 9-45 years
SEX
TO’TAL
PUL
E-PUL
SELECT
Fi^L
FeWa
2?aBe
T©Saa
h'
2^8
sn
145
251
£>5)
4T
ns
27
2^U
iia
S©
33
5
65
5?
8
396
years arad ab©ve
SEX
T© ii AL
PLnL
E-PLFL
SELECT
FOL
EP
Fet??
45
LUdCJLiS
rj
k u"t» L.di
3?
139
176
S
3
11
ij)
T7
22
3
O
2©
2
©
2
*—'^.r,
r
U <jU<Yuli
OA7
U <u)./
C
■
7. DISTANCE AND TIME
psf How far is the health center from your place?
rf-
How do you go to the centre?
Does any one accompany you when you go for treatment?
Does it affect his/ her work?
8. SATISFACTION
k-
What did your like best in the centre? Why?
Rj- What did you like least in the centre? Why?
kz
Was the staff courteous? Very mucfP
kz
to some extents
rj-
Were there any side effects? Were they attended to?
rj-
Did you have to discontinue treatment at this centre?
Why?
k?-
Would your recommend your relative/ friend to attend
this centre if he/she had this disease?
rj-
Any suggestion for improvement?
not at all i—i
9. ANY OTHER MATTER
4
BANGALORE
Bellary Road, Hebbal,
Bangalore-560024. India Phone: 3 3 3 0 3 21/2/3/4
March. 22, 2001
To,
Mr.S.TChander
Community Health Cell,
No.367, Srinivasa Nilaya,
Jakkasandra, 1st Main, 1 Block,
Koramangala,
Bangalore - 560 034
Dear Sir,
With reference to your letter dated 13/3/2001 1 am sending a list of TB patients who are
under treatment from Government who are in the areas where we are working.
Hope this will be helpful for the study. Also I assure you that our full support will be
given in doing your study a success.
Thanking you sir,
Yours faithfully
DR. SHIRIN SINGH
: .. .. ■ H H .
Heapiwi
...J!;
'
b
call u. c-ca; o; ■:
' c D.
■
-Ta-‘
(&>)
lore
LIST OF TB PATIENTS
SL
NO.
NAME
FATHER’S NAME
1)
Chennai ah
S/O Nagaiah
No.238, 4th Block, Yelahanka
Upanagara, Bangalore
2)
Shiva Kumar
S/O Golappa
No.211, Manorayanapalya,
R.T.Nagar Post, Bangalore-32
3)
Ramadass
S/O Krishna
No.77, Pappanna Block,
Anandnagar, Bangalore-24
4)
Jyothi smapath
D/O Sampath
C/O Sampath, No. 181, Lalithavihar
7th Main, Mathikere, Bangalore-54
5)
Joseph
S/O Kandaswamy
63, 8th main Triveni Road,
Yeshwanthpur, Bangalore - 22
6)
Jaya
S/O Rama
Police Quarters, Vijayapura,
Bangalore 24
7)
K.P.Belliappa
S/O Poovaiah
No.9, 5th cross, Athmananda Colony
Sulthanpalya, Bangalore.
8)
Vijaya krishna
S/O Balakrishna
A.D. Colony, Yelahanka post & post
Bangalore District.
9)
Ravibemando
S/O Arokianathan
No.69, 4th cross, P&T Colony,
Vmkstrdhpura, Bangalore-45
10)
Viji
D/O Ramanna (late) Police quarters, Hebbal,
Bangalore - 24
H)
Vanaja
D/O Subramaniam
No.34, 5th main Venkatappa colony,
Sanjaynagar, Bangalore 94
12)
Subbamma
D/O Ajjappa
No.769, Old Canara Bank Building
Hebbal, Bangalore -24
ADDRESS
" I Seek Not Kingdom, Nor Paradise, Nor Even Salvation :
I Seek only the Deliverance From Affliction of the Afflicted "
Phone : 3443661
DEENA SEVA SANGHA
dr.b.s.ravi
MBBS.DIH.DHA,
FIELD MEDICAL OFFICER
COMMUNITY HEALTH PROJECT
Sponsored by WATER AID, LONDON
22, Risaldar Street, Seshadripuram, Bangalore - 560 020.
N.S. Srimantharajan
Dr. S.V. Rama Rao
General Secretary
M.B.B.S., D.P.H., (Cal), M.P.H. (Johns Hopkins)
F.R.I.P.H.H. (London)
Professor of Community Medicine & Director (Retd.,)
Chairman.
Ref. : T/CHP/ /| 54
/2001
Date : March 28,2001
Mr. S.J. Chander,
Community Health Cell,
526, 5th main, 1st Block,
Koramangala,Bangalore-560 034
Dear Mr. Chander:
Sub: A study on the patient's perspective regard
ing TB treatment
Ref: Your letter dated 14th March, 2001 addressed
to Dr.S.V. Rama Rao, Consultant.
With reference to your letter cited above, I would like to
inform you that Dr.SV Rama Rao was not well and he was admitted
to Bangalore Hospital. He is getting discharged to-day.
*
2«
Regarding the s ubject matter, we furnish (below a list of
'TB patients on 'treatment and their details, as desired by you:
SI.
No.
Area
1. BHUVANESWARI NAGAR
Name and address
of the patient
Ramya, D/o Pushpa
w/0 Dorai
11
BN-78
Sharadamma W/o
Nanjundaswamy
Jayamma W/o Venkataramappa
38
BN-83
48
BN-1 37
35
BK-196
2.
-do-
3.
-do-
4.
B • K.NAGAR
Nat ar aj
-do-do; C/o DSSCHP
-do-
Murthy
5.
6.
7
8.
House
No.
60
BK-53
No.238
Nasubunnisa
35
Muthulakshmi
30
28
Mariamma
Please contact the undersigned for any further details.
Delay in replying to your letter is regretted.
Yours faithfully,
Thanking you,
(N.S. RAVI.)
TUBERCULOSIS
Ari I nterdiscipliriary Perspective
Edited by
Porter & John M Grange
;
Imperial College Press
Preface
Tuberculosis presents the global health care community with a paradox
— the development of modern short course chemotherapy is one of the
greatest triumphs of ‘evidence-based’ medical science as it is not only
one of the most effective, but also one of the most cost-effective of all
known therapies. Yet, far from being conquered or even controlled,
tuberculosis is currently the most prevalent infectious cause of human
suffering and mortality and, in 1993, the World Health Organization
took the unprecedented step of declaring it a ‘Global Emergency’. For
the sake of the millions who suffer and die from this preventable and
curable affliction each year, it is essential that we look carefully at the
reason for the paradox and seek novel ways of addressing this major
public health problem, even if this means challenging the very axioms
and structures on which current health care practices are based.
The principal theme of this book is evident in its title ‘Tuberculosis
— An Interdisciplinary Perspective’. A wide range of disciplines is rep
resented, including clinical medicine, social science, epidemiology, health
policy, economics, nursing, education, ethics and history. By bringing
together different academic disciplines to address a health issue such
as tuberculosis, we are provided with an opportunity to study and un
derstand different perspectives and approaches and, thereby, through
a different vision, to approach the global issues of disease control in
perhaps more creative and effective ways.
vi
Preface
Interdisciplinary collaboration is, however, not the only theme in
this book. As we read each of the chapters, we were struck by the
other major themes that emerged: poverty, vulnerability, health care
structures, globalisation, transcultural issues and the uneasy relation
between quantitative and qualitative research methodology. It is ap
parent that perspectives on health are changing and that there is an
increasing awareness that an overarching and all-embracing concept of
health can help to link people working in different disciplines and even
in different sectors. There is, within the field of public health, the in
creasing realisation that it is not sufficient merely to prevent disease,
but that we need to be involved in the active creation of health and
‘healthy communities’.
A feature of this book is the interaction and cross-over of the dis
ciplines that occur in each of the chapters. Although a person may,
for example, be labelled as an epidemiologist, their writing indicates
that they resort to other disciplines such as history and the qualitative
methods of the social sciences to construct their arguments. Each chap
ter stands alone and there is thus an inevitable overlap. Nevertheless,
the contexts are quite different, as are the processes that are described.
They amply demonstrate the complexity of ideas expressed in the field
of public health — a complexity which, though fascinating, often makes
arguments difficult to understand. This complexity should, however, be
seen positively and as an incentive to developing novel ways of working
together. For this purpose, each of us needs to develop a clarity of vi
sion and engage in ‘healthy’ debate in order to resolve any conflict that
might ensue.
One possible area of conflict is between those who espouse the re
ductionist ‘evidence-based’ approach and those who advocate a more
‘holistic’ viewpoint. But there need be no conflict. Implicit throughout
this book is the fundamental importance of modern short course therapy,
and the vast amount of effort devoted to its development by many dis
tinguished scientists over the last half century is in no way denigrated.
Likewise, recent developments in immunology and molecular biology
are to be welcomed as the likely key to much more effective preventive,
Preface
vii
diagnostic and therapeutic approaches. We do, however, agree with
Sir Douglas Black (1998) that ‘evidence-based’ biomedicine is but one
facet of the whole complex structure of modern medicine and not with
out its limitations in addressing major public health challenges. We also
acknowledge the dangers of ‘scientism’, defined by Leggett (1997) as “an
approach to medical practice that regards the scientific understanding
of the disease as the only relevant issue, whilst ignoring any other fac
tors” . This belief system — and it is surely no more than a belief system
— is firmly entrenched in many sectors of academic medicine and may
prove to be a very powerful barrier to interdisciplinary communication
and collaboration.
One of the represented disciplines, ethics, is a focus for the develop
ment of concepts, ideas and reasoning. Interestingly, the changes and
shifts witnessed in health care and in public health are also occurring in
the discipline of ethics. Over the last decade, in the field of bioethics for
example, there has been an eclipse of‘foundationalist’ projects aimed at
the development of a moral theory capable of providing the framework
for the deduction of principles and rules that could then be applied to
particular cases. There has, in fact, been a shift away from the search
for the foundations of morality towards a greater reliance upon the co
herence of practical moral reasoning and common sense. According to
Rawls, moral reasoning is based on the linkages between “a rich tapestry
of principles, intuitions and norms” that together constitute a relatively
stable, coherent, wide reflective equilibrium (Turner, 1998). Indeed,
Murphy (1995) has remarked that “Bioethics seems to be shifting from
the image of a layer cake, with theories supporting principles that jus
tify rules which lead to particular conclusions in specific cases, towards
the image of the web, where the web consists of a rich, ‘thick’ body of
maxims, rules and norms that are a matter of shared public reason”.
The various strands of this web are mutually strengthening, with no one
aspect providing a ‘foundation’ for the other components.
This book provides us with a web of complexity — a mosaic —
around the subject of tuberculosis. All of those who have contributed
have provided us with a “rich tapestry of principles, intuitions and
viii
Preface
norms” that can facilitate the development of a structure for tuber
culosis control that is part of the overall public health goal of ‘creating
health’ and ‘healthy communities’. Rhetoric, however, is not enough.
To create this process we need to engage in debate and, possibly, con
flict, with a clear understanding of who we are and of the power vested
in our roles as health professionals and how this power can be used
to a positive or negative effect. We are living in a time of complexity
and change — the expression ‘paradigm shift’ is often heard today —
and, far from being led to despair, we are provided with an opportunity
to challenge axioms and dogmas and to create novel approaches to the
control of tuberculosis to the betterment of the health of communities
worldwide.
We hope you enjoy reading this book. We feel that it is an important
contribution to the subject of tuberculosis and we hope that it will also
be of use to people working in many different disciplines of health care.
John Porter and John Grange
August 1998
References
Black D. 1998. The limitations of evidence. J. R. Coll. Phys. Lond. 32, 23-26.
Leggett JM. 1997. Medical scientism: good practice or fatal error? J. R. Soc. Med.
90, 97-101.
Turner L. 1998. An anthropological exploration of contemporary bioethics: The va
rieties of common sense. J. Med. Ethics. 24, 127-133.
Murphy N. 1995. Postmodern non-relativism: Imre Lakatos, Theor Meyerling and
Alasdair MacIntyre. Philosoph. Forum 27, 37-53.
Contents
Preface
Part I
v
Introduction to Tuberculosis and Its Control
1
1
The Global Burden of Tuberculosis
John M. Grange
3
2
Determinants of the Tuberculosis Burden in Populations
Klaus Jochem and John Walley
33
3
A Critique of the Global Effort: Do Tuberculosis Control
Programmes Only Exist on Paper? — A Perspective
From a Developing Country
M. Angelica Salomao
4
5
49
The Politics of Tuberculosis: The Role of Process and
Power
Gill Walt
67
Public Health and Human Rights: The Ethics of
..International Public Health Interventions for Tuberculosis
Paul Pronyk and John Porter
99
Lx
Contents
X
Part II
6
7
8
9
The Current International Structure
Tuberculosis in High-Prevalence Countries — Current
Control Strategies and Their Technical and Operational
Limitations
Klaus Jochem and John Walley
121
123
Tuberculosis Treatment in the Public and Private Sectors
— Potential for Collaboration
Ruairi Brugha and Anthony B. Zwi
167
Involving the Private Medical Sector in Tuberculosis
Control: Practical Aspects
Mukund Uplekar
193
Compliance Versus Adherence: Just a Matter of
Language? The Politics and Poetics of Public Health
Jessica A. Ogden
213
Part III
Tuberculosis Treatment from the Patient’s
Perspective: Social and Economic
Dimensions of Treatment-Seeking for
Tuberculosis
235
10
The Economics of Tuberculosis Diagnosis and Treatment
Susan Foster
237
11
Socio-Cultural Dimensions in Tuberculosis Control
Sheela Rangan and Mukund Uplekar
265
12
Tuberculosis and HIV — Perspectives from Sub-Saharan
Africa
Andrew Ustianowski, Peter Mwaba and Alimuddin Zumla
283
Contents
13
14
Tuberculosis in Ethnic Minority Populations in
Industrialised Countries
Freda Festenstein and John M. Grange
313
Gender Issues in the Detection and Treatment of
Tuberculosis
Patricia Hudelson
339
Part IV
15
16
17
xi
Alternative Approaches and Future
Directions
The Way Forward: An Integrated Approach to
Tuberculosis Control
John Porter, Jessica A. Ogden and Paul Pronyk
Demystifying the Control of Tuberculosis in Rural
Bangladesh
A. M. R. Chowdhury, J. Patrick Vaughan,
Sadia Chowdhury and Fazle H. Abed
A Response by Nurses to the Challenge of Tuberculosis
in the United Kingdom and Russia
Virginia Gleissberg
357
359
379
397
18
Tuberculosis and Health Sector Reform
Elizabeth Tayler
423
19
Applying Human Rights to Tuberculosis Control
David Nyheim
449
20
The Owl and the Pussycat Went to Sea: Moving Towards
Intersectoral Policies to Prevent the Unequal Distribution
of Tuberculosis
Carolyn Stephens
467
xii
21
Contents
Educational Approaches in Tuberculosis Control:
Building on the ‘Social Paradigm’
Thelma Narayan and Ravi Narayan
489
Chapter 21
Educational Approaches in
Tuberculosis Control: Building on
the ‘Social’ Paradigm
Thelma Narayan and Ravi Narayan
Introduction
From the orthodox biomedical perspective, tuberculosis is a ‘chronic
mycobacterial infection’ requiring early diagnosis by sputum microscopy
and culture; radiological investigation; and chemotherapy, consisting
of prompt, regular and extended treatment by a combination of anti
tuberculosis drugs. This perspective generates a restricted view of the
challenges of educational approaches in tuberculosis control as it focuses
primarily on motivating patients to take regular treatment and not to
become ‘defaulters’.
There is an urgent need to broaden the understanding of the dis
ease by applying a socio-epidemiological perspective, which focuses on
the larger socio-economic-political-cultural context in which the disease
spreads and thrives in the community. This paradigm shift in under
standing would lead to a recognition of a multi-disciplinary and multi
dimensional educational response that should become a major part of
the control effort. The most significant aspect of this proposed change
would be the contextualisation of tuberculosis control efforts to the im
portant policy imperatives of equity and social justice — helping initia
tives to reach those who are not reached by our present educational or
health care efforts.
489
490
T. Narayan and R. Narayan
In this chapter this broader understanding is explored and a frame
work for a multi-pronged educational initiative that addresses these im
peratives is evolved.
Recognising and Evolving the ‘Social’ Paradigm
The Medico Friend Circle is a national network of doctors and health
workers in India concerned that health care and medical education in the
country should become more relevant to the needs of the poor and the
marginalised. In 1985, it organised an interactive dialogue on ‘Tuber
culosis and Society’ which brought together 110 doctors, social workers,
health and development activists, and many others concerned about
Patient related
Society related
Fig. 1. The Social Paradigm — Some Significant Social Factors.
Source: Sadgopal (1983) and Medico Friend Circle (1985).
Educational Approaches in Tuberculosis Control
Table 1.
491
Responding to the Social Paradigm — Some Suggestions.
*
System Development
•
•
•
•
Increasing health budget and reducing urban bias.
Increasing accountability and responsiveness in the health care delivery system.
Training paramedicals and community-based health workers to enhance
accessibility.
Reorienting medical/nursing education towards the social paradigm.
Community Involvement
•
•
•
•
Interactive, culturally sensitive health education efforts.
Tackling stigma of disease among health professionals, community and patients.
Enhancing community participation at all levels.
Tuberculosis control linked to grassroots peoples’ movements.
Seeking New Partnership
•
•
•
•
Involvement of Trade Unions and the ‘Womens movement’.
Involvement of local healers and practitioners of all systems of medicine.
Involvement/orientation of community leaders, politicians, policy makers.
Introducing ‘Tuberculosis Control’ in High School Science syllabus.
Tackling the Determinants of the Disease
•
Intersectoral action to improve nutrition, housing, sanitation, working
environment and wages.
• Minimum Wages Act and Right to Work.
• Land Reform.
‘Source: Sadgopal (1983) and Medico Friend Circle (1985).
the tuberculosis problem in India. While the discussions explored the
challenges of case-finding, case-holding and the alternative ‘regimens of
chemotherapy’ there was also an identification of a large number of sig
nificant social/societal factors and issues of concern, from the field expe
rience of the participants, that constituted a ‘social paradigm’ (Medico
Friend Circle, 1985).
Figure 1 lists some of the factors that appear to play a key part in
the patient’s experience of the disease and the response of various types
T. Narayan and R. Narayan
492
of health care providers to the disease (Sadagopal, 1993; Medico Friend
Circle, 1995). Table 1 lists a series of ideas and initiatives that were
suggested during the group discussions as ways and means of addressing
the social factors and issues of concern listed in Figure 1 (Medico Friend
Circle, 1985).
It was evident at this meeting that if the factors responsible for
the occurrence, spread and maintenance of the disease were social and
societal, then the responses needed to be social/societal as well. This
shift of emphasis would not only change the framework of tuberculosis
control but would lead to a broader framework of educational effort to
support action towards control.
Table 2.
Tuberculosis and Society — Levels of Analysis and Solution."
Levels of Analysis of
Tuberculosis
Causal Understanding
Solutions/Control
Strategies
Surface phenomenon
(medical and public
health problem)
Infectious disease/gcrm
theory
BCG, case-finding and
domiciliary chemotherapy
Immediate cause
Undernutrition/low
resistance, poor housing,
low income/poor
purchasing capacity
Development and welfare
income generation/
housing
Underlying cause
(symptom of inequitable
relations)
Poverty/deprivation,
unequal access to resources
Land reforms, social
movements towards a
more egalitarian society
Basic cause (international
problem)
Contradictions and
inequalities in socio
economic and political
systems at international,
national and local levels
More just international
relations, trade relations,
etc.
“Source: Narayan (1998).
Educational Approaches in Tuberculosis Control
493
More recently, a comprehensive review has once again stressed that
the level and depth of analysis of the problem of tuberculosis and its
causative factors influence the construction of the solution. Table 2
indicates different levels of analysis and different solutions and control
strategies, highlighting once again the shift from a ‘biomedical’ to a
‘social’ paradigm (Narayan, 1998).
Widening the Educational Framework: Reaching All
The orthodox biomedical paradigm usually results in an educational
effort that has a two-pronged focus: on the patient and on the health
team. Health education efforts are directed at the patients to make them
more informed and aware of all aspects of the disease and its treatment
and the basic rules to prevent spreading the infection to others in the
family or the community.
Instruction in all aspects of tuberculosis, including epidemiology,
clinical, laboratory, therapeutic, preventive and public health aspects,
has been an important part of medical and nursing education as well
as a component of the curriculum of paramedical workers and health
auxiliaries for many years.
The biomedical paradigm also stresses the technological component
of tuberculosis control — BCG vaccine, sputum microscopy, radiolog
ical diagnosis, and varying regimens of chemotherapy. It focuses on
individual patients, stresses only physical aspects of the illness, high
lights mainly the role of the health care provider — doctor or nurse
— and considers the role of the patient as a passive beneficiary of a
top-down providing system who must be prevented, through health ed
ucation, from becoming a ‘defaulter’. Finally, the biomedical paradigm
also stresses the challenges of research in molecular biology or pharmacotherapeutics.
The new ‘social paradigm’ discussed in the previous section and
increasingly recognised in the last decade (CHC, 1989; Qadeer, 1995;
Nikhil, 1995; Uplekar and Rangan, 1996; Narayan T, 1997; Narayan R,
494
T. Narayan and R. Narayan
1997; Chaturvedi, 1997) requires a totally different framework of educa
tion that is both multi-dimensional and multi-pronged in its orientation.
While neglecting neither the patient nor the health care provider, the
focus of such education goes beyond to a larger section of society and a
broader range of groups in the community so that tuberculosis control
efforts get the support, encouragement and involvement of many people.
These include:
The patients’ family. This is particularly important because tuber
culosis has psycho-social dimensions that need family support for their
amelioration. Care providers are therefore an important focus group.
The people of the community in which the patient lives. These
include community leaders -— both formal and informal, school teachers,
non-governmental organisations, women’s groups, other community
based organisations and educational institutions (Kaul, 1996).
Occupational groups. Those in which the patient works and, par
ticularly, the occupational groups in which the risk of tuberculosis is
higher.
Health care providers. This focuses beyond education of doctors
nurses and paramedical personnel to a host of other formal and infor
mal health care providers including practitioners of alternate systems
of medicine, traditional birth attendants and other types of local folk
healers, private practitioners and health teams, and technicians of the
large number of private laboratories and health institutions.
Marginalised social groups. The ‘social paradigm’ should also lead
to a special educational effort focused towards high risk groups and
marginalised groups in society, including residents of urban slums, those
who are HIV positive and those with AIDS, the homeless, destitute and
pavement dwellers, ragpickers and street children, addicts — both drug
users and alcoholics — and refugees, including those displaced by war,
ethnic conflicts and development projects.
Educational Approaches in Tuberculosis Control
495
Policy makers. Most significantly, however, the recognition of the
‘social paradigm’ leads us to focus educational/awareness building ef
forts towards those within society who make decisions, those who are
involved in policy planning and implementation, as well as those who
support the programme initiatives. These include political leaders at
all levels — particularly elected representatives at state, district and
municipal corporation levels, government bureaucrats and technocrats,
the pharmaceutical industry, and civic society. Finally, all those groups
who are contributors to the ‘watch dog’ role of civic society also need
to be addressed through educational efforts: these include the me
dia, consumer groups/organisations/associations and non-governmental
organisations.
Content of Educational Approaches: From ‘Biomedicine’
to ‘Socio-epidemiology’
The recognition of the ‘social paradigm’ will necessitate a different
framework of tuberculosis education and so the focus and content will
have to experience a paradigm shift. The focus will move from individual
tuberculosis patients, increasingly to focus on a community of potential
sufferers. It will move beyond the physical dimension and explore the
psycho-social-economic-cultural and political dimensions of tuberculosis
including relationship to poverty, the problem of stigma and marginal
isation, and the ‘social burden’ of the disease. It will move beyond
vaccine/drug distribution to include components that enhance aware
ness, motivation and empowerment of patients through counselling. The
focus will therefore be on educational and social processes and other en
abling and autonomy-building skills, and will emphasise the supportive
role of family members, other care providers, community leaders and
grassroots and community-based health workers. It will also emphasise
a change of role of the patient from a passive beneficiary of treatment to
an active participant of the control strategy whose autonomy and sense
of responsibility is to be respected and enhanced.
496
T. Narayan and R. Narayan
Clearly, such a framework of education must emphasise the key
contributions from behavioural science and a qualitative approach to
research, including both action and participatory research, and must
encourage attempts to understand attitudes, belief systems, knowledge
levels and practice options at the community level. This would also
encourage an increasing shift from the orthodox ‘clinical’ and ‘molecu
lar biology’ fixation of tuberculosis researchers to a more broad-based
sphere of interest.
Table 3.
The Paradigm Shift."
Social/Community Approach
Parameter
Biomedical Approach
Focus
Dimensions
Individual
Physical (tuberculosis
pathology)
->
—>
Technology
Type of service
Drugs/vaccines
Providing/Dependence
creating
Passive beneficiary
Molecular biology
Pharmaco-therapeutics
—>
—>
Patient
Research
—>
—>
—>
Community
Psycho-social, economic, cultural,
political and ecological (stigma,
poverty, social burden)
Education and social processes
Enabling/Empowering
Autonomy building
Active participant
Socio-epidemiology
Behavioural sciences
"Adapted from CHC (1989).
Table 3 summarises this shift so that the broadening of the frame
work and content is clearer. It is important here to emphasise that a case
is being made not for a biomedical versus a community/social model of
public health dialectic, but for the broadening of the orthodox biomedi
cal approach by the inclusion of a social/community/societal dimension
(CHC, 1989). This will make the tuberculosis control initiative more
holistic, more responsive, more relevant and definitely more effective
in the complex environment and societal reality in which tuberculosis
thrives and continues to be a major public health problem today.
An important feature of this recognition of the social paradigm in
tuberculosis is the consequent need to give socio-economic-political-
Educational Approaches in Tuberculosis Control
497
cultural determinants an important role in policy review and programme
planning.
Many determinants of tuberculosis have been known for some time
(Narayan, 1997):
Tuberculosis is related to industrialisation, which resulted in
a process of urbanisation with overcrowded, unhygienic living
conditions for the working class in the new industrial and mining
towns. These were further complicated by low wages and longer
hours of work. Research has indicated that, in the USA and
Africa, there was an increase in the prevalence of tuberculosis
at a time of industrial and urban growth.
(2) Population growth, migration, colonialism and war-initiated
epidemic waves of tuberculosis in different regions of the world.
(3) The incidence of tuberculosis often increases in times of war and
during ethnic conflicts and among refugees. In India, tubercu
losis was a big problem among post-partition refugees.
(4) Disrupted social conditions, malnutrition, poor housing and
physical and emotional stress are predisposing factors. In India,
it is not surprising that the incidence of tuberculosis is relatively
high among Tibetan refugees in the resettlement colonies.
(5) Housing is a key factor, especially small, overcrowded tenements
in shanty towns and urban slums.
(6) Poor sanitation and unregulated growth of hazardous industries
further compound the problem.
(7) Smoking, pollution and rapid industrialisation driven by an eco
nomic imperative which sacrifices safety procedures and com
promises regulatory mechanisms are all contributory factors.
(8) Finally, there is growing evidence that new economic trends
that promote ‘globalisation’, liberalisation and privatisation —
increasingly have an adverse effect on the health of the poor by
making health care more and more inaccessible (Chaulet, 1998).
In Africa and the Philippines, the documented ill effects include
a higher incidence of tuberculosis. State-run health services
(1)
498
T. Narayan and R. Narayan
experienced cut-backs in expenditure which particularly affects
services for the poor.
While these factors are all very significant, it is equally significant
that most of the literature, pamphlets and reports from the World
Health Organization (WHO), the Government of India and non- gov
ernmental organisations ignore these dimensions (National Tuberculosis
Institute, 1994; Government of India, 1995; World Health Organization,
1995a, 1995b; World Health Organization/UNAIDS, 1996; Voluntary
Health Association of India, 1994, 1996; Chakraborthy and Choudhury,
1997). Hence the narrow biomedical perspective continues.
Educational Approaches ■— What Do We Seek to
Achieve?
While all educational approaches at all levels, and for all the target
groups mentioned earlier, must emphasise these broader factors in ad
dition to the biomedical ones, the objectives of education will shift from
enhancing case-detection, case-management, and tuberculosis treatment
per se to a host of initiatives that would address the determinants and
deeper causes of the illnesses. Tuberculosis treatment and control will
become part of a wider social movement that seeks to address poverty,
illiteracy, poor environment, marginalisation, unplanned urbanisation
and industrialisation, poor housing and to increase access to, and op
tions of, health care for the poor.
In 1981, the Indian Council of Social Science Research and the In
dian Council of Medical Research in their Health for All Strategy in
India, outlined a prescription for Health for All, which included such a
broad concept of health action (ICSSR/ICMR 1981). They emphasised
the need for a mass movement to reduce poverty and inequality and to
spread education, to organise the poor and underprivileged to fight for
their basic rights, and to move away from the counterproductive con
sumerist Western model of health care and replace it by an alternative
based in the community.
Educational Approaches in Tuberculosis Control
499
More recently, echoes of this broader action are seen even in the
writings of orthodox epidemiologists who stress that medicine and pol
itics should not be kept apart. The late Professor Rose wrote, in what
was perhaps his final work after decades of extensive epidemiological
research, that “Medicine has indeed delivered effective answers to some
health problems and it has found the means to lessen the symptoms
of many others. But by and large, we remain with the necessity to
do something about the incidence of disease, and that means a new
partnership between the health services and all those whose decisions
influence the determinants of incidence. The primary determinants of
disease are mainly economic and social and therefore its remedies must
also be economic and social. Medicine and politics cannot, and should
not, be kept apart” (Rose, 1992).
The objective of a comprehensive educational initiative — compre
hensive both in target groups and in content — is to facilitate a more
comprehensive anti-tuberculosis programme that would locate program
matic action in a mosaic of multi-dimensional and multi-sectoral action
impacting on all aspects of the problem. Such a programme would
include an increase in health budgets — including funding for tubercu
losis control, poverty alleviation programmes focused on marginalised
peoples, housing and planned urbanisation programmes, occupational
safety focused on high-risk individuals and high-risk occupations, per
sonal and social support to affected people and their families — par
ticularly those from the marginalised sections and initiatives to address
social and economic inequality and injustice.
Such a broad based, social/societal-oriented model of a health pro
gramme for tuberculosis would then strike at the roots of the prob
lem and not fritter away resources in superficial biomedical reductionist
strategies that have a limited impact on the disease.
It is rather unfortunate that, in more recent times, the WHO and
other international funding agencies have failed to establish their pro
grammes for tuberculosis on a broad base and have advocated ideas
such as DOTS that are at best ‘reductionist’ and at worst totally inade
quate for the treatment of the complex social pathology of tuberculosis
500
T. Narayan and R. Narayan
in society. This continued ‘technomanagerialism’ at the cost of a com
prehensive, integrated social strategy is particularly disappointing and,
as usual, the poorest among the tuberculosis patients will bear the con
sequences of this public health reductionism (Banerji, 1996, 1997).
Educational Initiatives — Moving from Content to
Process
In the earlier sections of this chapter, the ‘who’, the ‘what’ and the
‘why’ of educational initiatives in tuberculosis control in the context of
the ‘social paradigm’ have been explored. In this section, the ‘when’ and
‘where’ of some aspects of such an educational response are explored.
Broadly, these are described under the headings of basic and continuous
health professional education and patient/community education.
Health Care — Professional Education
There is urgent need to enhance and strengthen the framework of tu
berculosis education for medical practitioners and nurses. To make an
impact on professional education, there is need to focus both on ‘basic
education’ and continuing education.
Basic Education
There a is need to make tuberculosis education comprehensive, inte
grated, multi-systemic, multi-disciplinary, problem-based and sociolog
ically and epidemiologically orientated. Doctors and nurses must be
sensitised to the wider socio-economic and cultural factors in the dis
ease causation and encouraged to see the patients as active participants
and not as passive beneficiaries of the control strategy.
Increasing patient awareness and understanding of the disease pro
cess is a challenge in doctor-patient communication and, rather than
‘victim blaming’ and considering the patient as a ‘potential defaulter’,
Educational Approaches in Tuberculosis Control
501
an attempt must be to enable and empower the patient to adhere to
treatment and other procedures.
Skills in listening, motivation and supportive counselling need to
be enhanced and humane attitudes and behaviour towards patients,
which are primarily non-stigmatising, must be emphasised. Education
in pathology and therapeutics must be balanced by instruction in ethics
and the social sciences. This is particularly important because the avail
ability of effective chemotherapy has often tended to emphasise the cu
rative aspects of the disease control strategies while disregarding the
caring aspects. Tuberculosis is a very stressful disease and, although
the clinical manifestations are irksome and often very discomforting,
the patient suffers more than just physical illness. It is very important
that the curing aspect of disease control strategies becomes more effec
tive, but it is equally important that the caring aspects of the strategies
are enhanced.
It is also important to ensure that training moves from didactics
and a focus on minutiae to a more interactive, bedside and community
based education that emphasises the practical aspects of the disease and
enhances skills in patient care and counselling. Where necessary case
studies may replace case demonstrations. But the training must always
be rooted in the human problem.
While stressing the component of tuberculosis in medical and nurs
ing education will enhance the leadership of the tuberculosis control
team, it is equally important to impart proper knowledge, skills and
attitudes in tuberculosis treatment to all grades of health care workers
— multi-purpose and community-based — who are often the peripheral
health workers. They are most in touch with those who suffer from tu
berculosis. An initiative at this level will strengthen first-line/first-level
care and will ensure that the patient, who according to most socioepidemiological surveys is already ‘knocking at the health service door’
(Narayan, 1998), will be given a supportive and relevant response by
adequately sensitive and skilled health workers.
502
T. Narayan and R. Narayan
Continuing Education
While the focus on basic professional education will ensure that health
professionals of the future will be better informed, better skilled, and
better orientated to the socio-epidemiological challenges of tuberculosis
control strategies, an urgent need today is to reach the present gener
ation of health care providers with relevant, meaningful, authentic and
practical information and updates on tuberculosis to enhance their in
volvement in, and contribution to, the fight against this disease. For it
to be effective, this must be sponsored by professional associations or
colleges and the National Health Programmes.
Much of the ongoing education on tuberculosis in many developing
countries is presently done by the pharmaceutical industry. The focus
and content of education is often orientated towards the promotion of
specific prescriptions or remedies over others that are available in the
market; to enhancing brand choice and subtly promoting the ‘me-too’
drugs that have additional, and usually unnecessary, components such
as cosmetic embellishments or they may contain irrational combinations
of drugs. In addition, they are often inadequately evaluated. Depend
ing on the skills and vigilance of drug controlling agencies and the level
and extent of legislation in each country, this ‘drug’ education is often
supported by the subtle misinformation in which indicators for treat
ment are enhanced and side effects and contraindications are played
down, thereby enhancing profits and sales, often at the cost of patient
safety. It is not at all surprising that the Report on Health for All
Strategy of ICMR/ICSSR (1981) exhorts us that “eternal vigilance is
required to ensure that the health care system does not get medicalised,
that the doctor-drug producer axis does not exploit the people, and
that the ‘abundance’ of drugs does not become a vested interest in ill
health”.
In the area of anti-tuberculosis drugs, however, sometimes other
forms of irrationality creep into the situation. If such drugs are included
in the essential drug list and the prices are controlled, then the mark
up allowed on them is often reduced, leading to a decreased incentive
Educational Approaches in Tuberculosis Control
503
for drug manufacturers to produce them. Shortages of anti-tuberculosis
drugs have not been uncommon in the past.
Another challenge in current continuing medical education (CME)
is to ensure the emphasis on the use of standardised regimes for treat
ment which have often been evolved at the national level by expert
committees who have considered clinical and epidemiological factors in
the situation analysis and have looked at other relevant factors includ
ing the availability and cost of drugs and the logistics of their supply
and distribution.
A number of very effective drug regimens for tuberculosis have been
evolved on the basis of extensive and good clinical and field trials. Un
fortunately, private practitioners and even hospital-based clinicians in
most countries tend to evolve their own very individualistic, and often ir
rational, regimes based on what they consider to be ‘clinical experience'.
Costly and therapeutically unsound regimens, supported by a host of
complementary and supplementary medications that are invariably un
necessary, ineffective and irrational are all part of regular practice. At
best, these are merely symptomatic and play on the psychology of the
patient. A good CME programme in tuberculosis should not only em
phasise rational and therapeutically sound regimens but also discourage
the use of all types of irrational and unnecessary complementary medi
cation and always stress the social context as well.
Patient/Community Education
Education of the patients, their relatives and those caring for them
within the family is an important challenge in tuberculosis control.
While making the patients aware of all aspects of the disease, its
prevention and cure, the challenge is to do so by means and orientation
that primarily enhance their autonomy, provide informed choices and
options for treatment, and enable and empower them to abandon su
perstition and stigmatising concepts and to take responsibility for their
own health. Motivation and supportive counselling must be built into
T. Narayan and R. Narayan
504
the whole educational effort so that the patients build up confidence in
‘cure’ in an environment of ‘care’. The effort must also emphasise ‘care’
after ‘cure’.
Such effective education is best achieved by'^uiturally sensitive, in
teractive, low-cost approaches including puppetry, street theatre, folk
methods, role play or even flipcharts and flashcards, and planned games
whereby the patients learn in small groups, at their own pace, supported
by other adult learners in an environment of collective trust and sharing.
Whether clinic or community-based, the process of health education is
as important as its content (Kaul, 1996).
Case Study: Health Education for Tuberculosis in Urmul
Trust (a non-governmental organisation in Rajasthan)
Health education is working on three fronts (Kaul, 1996):
Street theatre and puppet shows in the villages highlight the
symptoms of the disease and the need to identify it as early as
possible. It also gets the message across that irregular treatment
is not only detrimental to the patients but also to people around
them so that they must chip in to ensure that the patients take
the full course of treatment without a break.
(2) The importance of the regimen and its regularity and duration
and what to do in case of side effects are explained to the pa
tients and their relatives in groups. All this is done with the
help of television, puppet shows or playlets on the day of the
tuberculosis camp held on a fixed day of the month.
(3) The doctor spends at -least 15 minutes with each new patient
and at least 5 minutes with each old one.
(1)
In addition, every few months, some cured patients are assembled to
talk to the newer patients. The camp-like atmosphere on a single day
of the month encourages the patients to share experiences.
Educational Approaches in Tuberculosis Control
505
In a country such as India and in most other parts of the developing
world, the large majority of the people are illiterate or semi-literate
and ‘adult learning’ techniques need to be used, moving away from the
didactic approaches of orthodox education.
Recent studies and experiments done by a group of non-governmental
organisations in India have demonstrated that even visual aids used in
pamphlets, posters, flipcharts and flannel graphs need to be culturally
sensitive and geared to the perceptions of illiterate adults which are
rather different from those of urban literate adults. While an under
standing of ‘magnification’ and ‘depth perspective’ by those who have
had some school education including an exposure to scientific concepts
and experimentation and demonstration may be taken for granted, these
are not comprehended in the same way by adults without a basic school
education.
Health education materials must therefore be developed locally and
must relate sensitively to local socio-cultural realities. Decentralised
health education efforts are therefore a very important component of
any health programme strategy.
The centralised production of DOTS-related educational materi
als and the attempts to distribute so-called standardised, top-down
guidelines on contents and messages arc the very antithesis of current
understanding of adult education for health and are another example of
the overemphasis of the ‘global’ approach in what is essentially a local
approach or strategy.
Much health educational material including that currently available
for tuberculosis is still rather urban in orientation, context and visual
content. A concerted effort needs to be made to ensure that material
more relevant to rural and indigenous populations is evolved so that the
process of learning and motivation is greatly enhanced.
There is, nowadays, a tendency to get on the ‘electronic bandwagon’
and videos, slides, cassette sets and even computer software programmes
are being promoted. While they have their uses in situations where
there is electricity and where people are habituated to such adjuncts to
learning and recreation, they are not as widely relevant or as effective as
506
T. Narayan and R. Narayan
they are often perceived to be. To an illiterate audience, they are often
more a source of entertainment than an effective tool for learning and, of
course, the absence of continuous electricity in a large number of urban
towns and in most rural and tribal areas in many developing countries
limits their use and effectiveness. Even in this era of space and cyber
technology, traditional and time-tested folk methods and interactive
approaches still have great relevance and their importance must not be
underestimated or inadvertently played down.
Conclusion: Towards an Alternative Strategy
In these reflections on educational approaches to tuberculosis control,
an attempt has been made to highlight the following:
• Tuberculosis control initiatives need to move from the ortho
dox biomedical approach to a more social/community-oriented
approach.
• This shift of emphasis will depend upon a creative educational
initiative that helps to broaden the understanding of the prob
lem and locate it in the wider social paradigm.
• The focus of education must expand beyond patients and health
providers to a wide range of other involved persons including the
patients’ families, the people in the community where the dis
ease occurs, occupational groups, health care providers includ
ing those in the private and alternative sectors, marginalised
social groups, policy makers and society at large.
• The educational process must be primarily enabling and em
powering and must transform the role of the patients from pas
sive beneficiaries to active participants in the programme.
• Treatment and control of tuberculosis must form part of the
wider social movement that seeks to address poverty, illiteracy
and poor environment, marginalised peoples and unplanned ur
banisation and to increase access to, and options for, health care
for the poor. Such a broad-based model would then strike at
Educational Approaches in Tuberculosis Control
507
the roots of the problem and not fritter away valuable resources
in implementing superficial, biomedical, reductionist strategies.
Health care professionals must be sensitised to the wider socio
economic and cultural factors in the causation of disease and
are encouraged to see the patients as active participants in the
control strategy rather than passive beneficiaries.
Skills in listening, motivation and supportive counselling must
be enhanced and humane, primarily non-stigmatising, attitudes
and behaviour towards patients must be emphasised.
An initiative at this level will strengthen primary health care
and ensure that the tuberculosis patient will be given a sup
portive and relevant response by sensitive and skilled health
workers.
A good continuing medical education programme in tuberculo
sis should not only emphasise rational, epidemiologically sound
treatment regimens, but also de-emphasise all sorts of irrational
and unnecessary complementary medication, as well as stressing
the social context.
Culturally sensitive, interactive, low-cost educational appro
aches, such as puppetry, street theatre, folk methods, role play
or even flipcharts, flashcards and planned games, that enable
the patients to learn in small groups, at their own pace and
with the support of other adult learners in an environment of
collective trust and sharing, must be promoted.
Health education materials must be locally developed and be
both sensitive and relevant to local socio-cultural realities. De
centralised health education efforts are therefore a very impor
tant component of any health programme strategy.
All this will lead to the tuberculosis control initiative becom
ing more holistic, more responsive, more relevant and definitely
more effective in the complex environment and societal reality
in which tuberculosis thrives and continues to be a major public
health problem today.
508
T. Narayan and R. Narayan
The continuing problem of tuberculosis has been accepted all over
the world as a major public health issue of our times. Much is planned
and much is being done. The sustained success of our efforts will, how
ever, be determined by the extent to which we understand and respond
to the challenge of the ‘social paradigm’ and the creative nature of our
supportive educational response. The way forward is a paradigm shift
from ‘Directly Observed Therapy, Short Course’ (DOTS) to ‘Commu
nity Orientated Tuberculosis Service’ (COTS).
Are we ready for this paradigm shift?
References
Biuicrji. D. (199G) Serious Implications of the Proposed Revised National Tuberculosis
Control Programme for India. Voluntary Health Association of India /Nucleus
for Health Policies and Programmes. New Delhi: Voluntary Health Association
of India, pp. 1-100.
Banerji, D. (1997) Voice for the Voiceless — The Revised National Tuberculosis
Control Programme: A negligent approach. Health for the Millions 23(MarchApril), pp. 30-32. (Published by Voluntary Health Association of India, New
Delhi.)
Chakraborthy, A. K. and Choudhury, S. (1997) National Tuberculosis Programme:
Stopping the Killer. Bangalore: Action Aid.
CHC (Community Health Cell) (1989) Community health in India. Health Action 2,
5-25. (Published by Health Action For All Trust, Seconder bad).
Chaturvedi, G. (1996) Tuberculosis Programme in India: Some social issues. In:
Chaturvedi, G. et al., eds. Tuberculosis Control in India — Developing Role
of NGOs. (Theme in Development series, No. 4). Bangalore: Action Aid,
pp. 96-102.
Chaulet, P. (1998) After health sector reform, whither lung health? Int. J. Tuberc.
Lung Dis. 2, 349-359.
Government of India, (1995) Revised National Tuberculosis Control Programme with
World Bank Assistance. New Delhi: Government of India.
ICSSR/ICMR (Indian Council of Social Science Research/Indian Council of med
ical Research) (1981) Health for All: An Alternative Strategy. Pune: Indian
Institute of Education.
Kaul, S. (1996) Tuberculosis Control under an NGO in Western Rajasthan In:
Chaturvedi, G., et al. eds. Tuberculosis Control in India — Developing Role
Educational Approaches in Tuberculosis Control
509
of NGOs. (Themes in Development Series No. 4). Bangalore: Action Aid,
pp. 37-44.
Medico Friend Circle. (1985) Tuberculosis and society. Medico Friend Circle Bulletin
No. Ill (March), pp. 1-6 (Published by Medico Friend Circle, Bangalore).
Narayan, R. (1977) Editorial: Resurgence of malaria. Nat. Med. J. India 10, 157-158.
Narayan, T. (1997) Tuberculosis: Persistent Killer. Chennai, India: The Hindu Sur
vey of Environment, pp. 71-75.
Narayan, T. (1998) A Study of Policy Process and Implementation of the National
Tuberculosis Control Programme in India. Doctoral Thesis, London School of
Hygiene and Tropical Medicine.
National Tuberculosis Institute, (1994) Facts and figures on tuberculosis and the
National Tuberculosis Programme. Bangalore: National Tuberculosis Institute,
Government of India.
Nikhil, S. N. (1995) Socio-cultural dimensions of tuberculosis. Health For the Millions
21 (January-February), pp. 43-46 (Published by Voluntary Health Association
of India, New Delhi).
Qadcer, I. (1995) National Tuberculosis Control Programme — A social perspec
tive. Health For the Millions 21 (January-February), pp. 10-13 (Published by
Voluntary Health Association of India, New Delhi).
Rose, G. (1992) The Strategy of Preventive Medicine. Oxford: Oxford Medical Pub
lications, pp. 1-138.
Sadagopal, M. (1983) Health care versus the struggle for life. Medico Friend Circle
Bulletin. No. 93 (September), pp. 1-5, and No. 94 (October), pp. 2-5 (Pub
lished by Medico Friend Circle, Bangalore).
Uplekar, M. and Rangan, S. (1996) Tackling Tuberculosis: The Search for Solutions.
Bombay: The Foundation for Research in Community Health.
Voluntary Health Association of India (1994) A Report on the National Consultation
on Tuberculosis. New Delhi: Voluntary Health Association of India.
Voluntary Health Association of India (1996) Tuberculosis: A Critical Public Health
Challenge (ANUBHAV Series). New Delhi: Voluntary Health Association of
India, pp. 1-28.
World Health Organization (1995a) Stop Tuberculosis at the Source: WHO Report
on the Tuberculosis Epidemic. Geneva: World Health Organization.
World Health Organization (1995b) Tuberculosis Fact Sheet No. 93. Geneva: World
Health Organization.
World Health Organization/UNAIDS (1996) Tuberculosis in the Era of HIV. Geneva:
World Health Organization.
INDIAN ASSOCIATION OF GENERAL PRACTITIONERS
MEMBER FFPAI
BANGALORE
CME PROGRAMME
PRESIDENT
DR. SRINATH HERUR
PH : 6662914
In association with
INDIAN POPULATION PROJECT - VIII, - Bangalore., and
INDIAN MEDIACAL ASSOCIATION, - Channakeshavanagar Branch, Bangalore
VICE PRESIDENT
DR. P.G. JAYAPRAKASH
DR. H.S. MRUTHYUNJAYA
Invites you for the CME on
3304066
3490836
3rd February 2001 (Saturday) at IMA HOUSE,
Bangalore - 560 018
HON. SECRETARY
PROGRAMME
5251940
DR. D. MOHAN
1-00 pm to 2-00 pm
2-00 pm to 2-20 pm
JOINT SECRETARY
DR. Mrs. K. SOORYA
5293467
IMMEDIATE PAST PRESIDENT
3356348
DR. K.S. HANDE
2.20 pm to 2.40 pm
HON.TREASURER
DR. S. SUBRAMANYAM
6520495
JOURNAL EDITOR
DR. B.C. RAO
2.40 pm to 3.00 pm
5250882
SCIENTIFIC COMMITTEE
3.00 pm to 3.20 pm
DR. G.R. NAGABHUSHAN
3092552
DR. R.R. LAKSHMIKANTH
6765110
DR. M.S. RAJANNA
3354435
DR. SRI. LAKSHMI POORNIMA 3443337
LUNCH
RCH
Dr. G.V. Nagaraj DHS
Govt, of Karnataka
Anandrao Circle, Bangalore
Measles Clinical features
Management Prevention
Dr. Swarna Rekha Prof & HOD
Dept, of Paediatrics
St. Johns Medical College, Bangalore
Vaccine Storage Administration etc Dr. Mahendra Associate Prof.
Dept of P & SM KIMS, Bangalore
Universal Prevention in AIDS Dr. Latha Jagannathan
Managing Trustee Bangalore Medical
Services Trust
Member Task Force Govt, of Karnataka
3.20 pm to 3.50 pm
Discussion.
E.C. MEMBERS
DR. Mrs. PREETHI SHANKAR
DR.V.S. KRISHNAMURTHY
DR. A. SHANTHARAJ
DR. V.C. KULKARNI
DR. H.S. JAYAPRAKASH
DR.A.V. MANJUNATH
DR. H.M. FAREED
5543222
2265169
6568858
3320384
3483718
8394899
5540788
Note : Programme starts on time. Kindly attend in large numbers.
We are in the process hosting a WEB SITE for the Association. Hent
update your BIODATA and send the same to the Secretary.
Dr. Jayachandra Rao
Dr. S. Sheela Bhanumathi
Project Co-ordinator
IPP-VIII, Bangalore
President IMA, C. Nagar Br.
Bangalore
Dr. Srinath Herur
Dr. Mohan
President
IAGP
Hon. Secretary
IAGP
All Correspondence to Hon. Secretary :
Dr. D. Mohan, MOHAN'S CLINIC, # 613, 2nd Main, I Stage, Indiranagar,
Bangalore - 560 038 E-mail: docmohan@vsnl.com
TB-Hcalth education/d/chadncr/550
INFORMATION ON TB FOR NGO STAFF.
Tuberculosis is a specific infectious disease caused by Mycobacterium
tuberculosis. This disease primarily affects lungs and can affect other
parts of the body also.
□
One person die of TB every minute.
□
Affect more the people in the most productive age group
□
Four out of every thousand people suffer from all types of TB
□
One TB patient who is not on treatment infects 10-12 people a
year.
What are the common signs and symptoms of TB?
□
Cough with or without sputum for more than three weeks
□
Rise of Temperature in the evening for more than two weeks sweating
particularly at night
□
Coughing of blood
□
Chest pain
□
loss of appetite, Loss of weight, and increasing weakness.
For children
□
Children usually do not cough but experience loss of weight even though they eat
well.
TB-Hcalth cducation/d/chadner/550
Who does TB affect more
TB can affect any one from any soico, economic and cultural
background but it most often affects people between the age groups of
20-40. Tb affects more people who live in a overcrowded place,
malnourished and women who are married early.
TB can cause
complications for children. TB is more in men than women however
women have less access to care and some times there is greater tendency
to hide especially during marriageable age. Older people with TB are
neglected by the family, those with sputum positive TB are source of
infection to others especially to young children in the family.
Is TB a curable disease?
Yes, TB is curable if the treatment is taken regularly without
discontinuing for the duration specified by the physician. Usually the
duration is between 6-9 months. The patient would begin to feel better
after two months of treatment and some of them may discontinue the
treatment. This can lead to drug resistance, which means the signs and
symptoms would reappear and the patients would not respond to drugs
which he/she was taking earlier. The newer drugs or costlier and would
not be affordable by the poor, and not many drugs are available, which
means patient would go to a chronic state and continue to spread the
disease as they go through a gradual and painful path way to death.
Is TB an infectious disease and how
Yes TB is a communicable disease. It spreads person to person. The TB
germ is carried in air when a patient suffering from TB coughs. It does
not spread by handshake or by using the glass, plate and cloths of the
infected person.
2
TB-Hcalth cducation/d/chadner/550
How can TB be prevented from spreading to others?
□
A person suffering from TB must cover his/her mouth while coughing with a
handkerchief or a piece of cloth.
□
He/she must take the treatment immediately after diagnosis and should not
discontinue the treatment for any reason.
□
Preventive measures through Health education.
□
BCG vaccination is not useful in preventing adult pulmonary lung TB and is
not used as a public health measure to control transmission of TB. It may
however prevent complications of childhood TB and therefore used in the
universal immunization programme.
□
Nutrition, good nutritional status help developing resistance against the
disease.
Who should be approached when signs and symptoms
are noticed?
One can approach the corporation health center near to her/ his
residence. If that center is not a treatment center, after diagnosis the
person would be sent to the nearest DOTS center to his/ or her residence
for treatment. Bangalore city corporation has 130 DOTS (Directly
Observed Treatment Short course) where TB drugs are available free of
cost under the Revised National TB control programme.
3
TB-Health education/d/chadner/550
How TB is diagnosed
Usually TB is usually diagnosed by doing three sputum examinations.
One of on the spot collection and another of the early morning
collection. The third is collected again on the spot. X-ray is necessary
only when sputum is negative.
What is the cost of treatment?
It is supposed to be absolutely free, and the person suffering from TB
has the right to receive free diagnosis and treatment for whatever
duration specified by the physician. In case of money is requested by the
staff it should be reported to Dr. Narayanamurthy, Joint director TB,
Lady Wellington TB center Kempegowda road, Bangalore - 560 001,
Telephone : 2267093
Treatment
Multi drug treatment
Under RNTCP
3-4 antibiotics for 6-8 months
with an intensive phase of treatment for 2
months.
4
TB-Hcalth cducation/d/chadncr/550
INFORMATION ON TB FOR NGO STAFF.
Tuberculosis is a specific infectious disease caused by Mycobacterium
tuberculosis. This disease primarily affects lungs and can affect other
parts of the body also.
□
One person die oi’TB every minute.
□
Affect more the people in the most productive age group
□
Four out of every thousand people suffer from all types of TB
□
One TB patient who is not on treatment infects 10-12 people a
year.
What are the common signs and symptoms of TB?
□
Cough with or without sputum for more than three weeks
□
Rise of Temperature in the evening for more than two weeks sweating
particularly at night
□
Coughing of blood
□
Chest pain
□
loss of appetite, Loss of weight, and increasing weakness.
For children
□
Children usually do not cough but experience loss of weight even though they eat
well.
i
TB-Health education/d/chadncr/550
Who does TB affect more
TB can affect any one from any soico, economic and cultural
background but it most often affects people between the age groups of
20-40. Tb affects more people who live in a overcrowded place,
malnourished and women who are married early. TB can cause
complications for children. TB is more in men than women however
women have less access to care and some times there is greater tendency
to hide especially during marriageable age. Older people with TB are
neglected by the family, those with sputum positive TB are source of
infection to others especially to young children in the family.
Is TB a curable disease?
Yes, TB is curable if the treatment is taken regularly without
discontinuing for the duration specified by the physician. Usually the
duration is between 6-9 months. The patient would begin to feel better
after two months of treatment and some of them may discontinue the
treatment. This can lead to drug resistance, which means the signs and
symptoms would reappear and the patients would not respond to drugs
which he/she was taking earlier. The newer drugs or costlier and would
not be affordable by the poor, and not many drugs are available, which
means patient would go to a chronic state and continue to spread the
disease as they go through a gradual and painful path way to death.
Is TB an infectious disease and how
Yes TB is a communicable disease. It spreads person to person. The TB
germ is carried in air when a patient suffering from TB coughs. It does
not spread by handshake or by using the glass, plate and cloths of the
infected person.
2
TB-Hcalth cducation/d/chadncr/550
How can TB be prevented from spreading to others?
□
A person suffering from TB must cover his/her mouth while coughing with a
handkerchief or a piece of cloth.
□
He/she must take the treatment immediately after diagnosis and should not
discontinue the treatment for any reason.
□
Preventive measures through Health education.
□
BCG vaccination is not useful in preventing adult pulmonary lung TB and is
not used as a public health measure to control transmission of TB. It may
however prevent complications of childhood TB and therefore used in the
universal immunization programme.
□
Nutrition, good nutritional status help developing resistance against the
disease.
Who should be approached when signs and symptoms
are noticed?
One can approach the corporation health center near to her/ his
residence. If that center is not a treatment center, aft.ef diagnosis the
person would be sent to the nearest DOTS center to his/ or her residence
for treatment. Bangalore city corporation has 130 DOTS (Directly
Observed Treatment Short course) where TB drugs are available free of
cost under the Revised National TB control programme.
3
TB-Hcalth cducation/d/chadncr/550
How TB is diagnosed
Usually TB is usually diagnosed by doing three sputum examinations.
One of on the spot collection and another of the early morning
collection. The third is collected again on the spot. X-ray is necessary
only when sputum is negative.
What is the cost of treatment?
It is supposed to be absolutely free, and the person suffering from TB
has the right to receive free diagnosis and treatment for whatever
duration specified by the physician. In case of money is requested by the
staff it should be reported to Dr. Narayanamurthy, Joint director TB,
Lady Wellington TB center Kempegowda road, Bangalore - 560 001,
Telephone : 2267093
Treatment
Multi drug treatment
Under RNTCP
3-4 antibiotics for 6-8 months
with an intensive phase of treatment for 2
months.
4
HELP SEEKING BEHAVIOR
SIGNS AND SYMPTOMS
■ Cough, fever, tiredness, could not work, limp node
on the neck
■ Went to doctors after month after symptoms started
■ All of them went to private practitioner except one
more than once.
■ Most of them Came to know that they are suffering
from TB from lady Wellington TB unit, two private
practitioners informed their patients
■ Taking treatment for the past 3- 6 months time
■ Duration of the treatment - 6to 9 months
■ One person said do not know and would take as long
as the doctors tells
SYMPTOMS PERSISTED AND SUBSIDED
Within two weeks to two mo
A STUDY ON
PATIENTS PERSPECTIVES REGARDING
TB TREATMENT
UNDER RNTCP IN BANGALORE MAHANAGARA PALI KE
AIM:
to understand the patient’s perspective
regarding tb treatment
Provided by the Bangalore Mahanagara Palike under
the RNTCP (Revised National Tuberculosis Control
Programme)
using
DOTS
(Directly
Observed
Treatment, Short course) approach.
OBJECTIVES:
Primary
1.
Gain an understanding of the patient
perception on TB Treatment, among the urban
poor people.
SECONDARY
1.
Understand the treatment seeking behavior
2.
Understand the impact of the disease and their
treatment on their lives and the adjustment
they nee to make.
METHODOLOGY
In-depth interview
SAMPLING TECHNIQUE
Systematic random sampling
UNIVERSE:
826 patients registered during the
first quarter,
January - March, 2001
SAMPLE SIZE:
115 patients
SAMPLE UNIT: male, female, children, adults
AGE CLASSIFICATION:
0- 5 years
6-18 years
19- 45 years
46 years and above
TB UNITS FROM SAMPLES WERE DRAWN
1
2
3
4
5
6
7
NAME OF UNIT
Yeshwanthpura
Hosahalli
Hanumanthnagara
Jayanagara
Neelasandra
Broadway
Lady Wellington
TOTAL
174
96
147
82
99
110
108
826
SELECTED
22
15
24
10
14
17
13
115
0-5 YEARS
SEX
TOTAL
PUL
Extra-PUL
SELECTED
Fem
Male
Total
5
10
15
2
4
6
3
6
9
5
10
13
6-18 YEARS
SEX
TOTAL
PUL
E-PUL
SELECT
PUL
EP
Fem
Male
Total
65
35
100
45
25
82
20
11
33
8
5
13
6
3
9
2
2
4
19-45 years
SEX
TOTAL
PUL
E-PUL
SELECT
PUL
EP
Fem
Male
Total
213
298
511
145
251
396
68
47
115
27
38
65
24
33
57
3
5
8
46 years and above
SEX
TOTAL
PUL
E-PUL
SELECT
PUL
EP
Fem
Male
Total
45
142
187
37
139
176
8
3
11
5
17
23
3
17
20
2
0
2
SL.NO
NAME
AGE
SEX
TYPE
CENTRE
POSITION
DATE OF
INTERVIEW
1
2
3
4
5
6
7
8
9
10
11
12
13
14
I5
16
17
18
19
20
21
22
23
24
25
26
27
Jacob
■Shashikala
•Ramesh
'prashanth
Palani
/ 'Sharmila
Shivanna
Lakshmi
/ MM swamy
Pallavi
Raju
Durgasingh
Armugham
Y amuna
/ Selvakumar
LJsha
X^ajrappa
Sridevi
Neela
/ Srinivas
Hanu m an thrayapp a
/Venkattappa
Male
Female
Male
Male
Male
Female
Male
Female
Male
Female
Male
Male
Male
Female
Male
Female
Male
Female
Female
Male
Male
Male
Broadway TB Unit
Jayanagar TB unit
Hanumanthnagar Tb unit
Hanumanthnagar Tb unit
Jayanagar TB unit
Jayanagar TB unit
Neelasandra Tb unit
Lady Wellington Tb unit
Hanumanthnagar Tb unit
Hosshalli Tb unit
Hosahalli Tb unit
Ladywellington Tb unit
Ladywellington Tb unit
Broadway Tb unit
Neenasandra TB unit
Yeshwanthpura TB unit
Yeshwanthpura TB unit
Hanumanthnagar TB unit
Ladywellington TB unit
Broadway Tb unit
Yeshwanthpura Tb unit
Yeshwantpura Tb unit
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Typed
Aiyesha Fatima
•Vijayalakshmi
/ Krupavalli
■'Pramila
•Mani
Female
Female
Female
Female
Male
Yeshwanthpura TB unit
Ladywellington Tb unit
Broadway Tb unit
Neelasandra Tb unit
Yeshwanthpura Tb unit
Typed
Typed
Typed
Typed
Typed
28
29
30
31
31
33
34^
35
36/
37/
38
40
41
Krishnappa
Male
Yeshwanthpura Tb unit
Typed
Indramma
Muniraju
Female
Male
Yeshwanthpura TB unit
Jayanagara Tb unit
Typed
Typed
Bharathi
Venkataramanna
Narayanarao
Kamakshi <
Anand
Yeshodha 4.
Mohan r
Mohan 4
Shekar
Venkataramanna
Sr. Cecili
Female
Male
Male
Female
Male
Female
Male
Male
Male
Male
Female
Broadway TB Unit
Hanumanthnagar Tb unit
Hosahalli Tb unit
Yeshwanthpura Tb unit
Neelasandra
Yeshwanthpura Tb unit
Yeshwanthpura Tb unit
Yeshwanthpura Tb Unit
Hosahalli Tb unit
Yeshwanthpura TB unit
Neelasandra Tb unit
Typed
Typed
Typed
Written
Written
Written
Written
Written
Written
Recorded
Interviewed
FW: TB and Anti-Retroviral Treatment
'»
«
Subject: FVV: TB and Anti-Retroviral Treatment
Date: Tue. 9 Jul 2002 20:03:23 +0100
From: "Roger Drew" <rogerdrevv@rogerdrew.iree-onliue.co.uk>
To: <drew.r'ahcalthlmk.org.uk>
Is this of interest?
From: Paul Sommarfeld [mailto:paulBsomhealy.demon.co.uk]
Sent: 09 July 2002 11:33
To: Ian Smith; morganl@who.cn ; Roger Drew; Ryder Cheshire Foundation;
Owain Tucker; Angela Mynors; Brian Watt; Caris Grimes; Edward Sadler;
Geraldine Mynors; Gini Williams; Jenny Conway; John Crofton; Julie
Lethaby; Ken Citron; Kenny Roger; Madeline Webster; Margaret Knight;
Melanie Matthews; Nick Banatvala; Nils E. Billo; Noel Snell; Peter
Davies (Attachments); Tilak S Chauhan; 'Vanessa Graham'; Tim Baker; sa
-ov navies; Rifat Atun; Richard Coker; Jack Barker; Ian Campbell; Fred
Festenstein; John Grange; Tim Healing; Peter Ormerod; Michael Felly;
John Porter; Richard de Soldenhort; Alistair Story; Veronica White;
Karen Bissell; Peter Davies
Subject: TB and Anti-Retroviral Treatment
fl) bf
Roger
Door Friends
Please rind attached details of a conference on 2nd October organised b
the
Royal Society ot Medicine ana co-sponsored by TB Alert.
Please consider attending; and also please pass this notice on to other
circuits or individuals you think may be interested.
Paul
Paul Sommerfeld
22 Tiverton Road
London NW10 3HL
United Kingdom
Tel: 020 0969 4030
Fax: 020 8960 0069
Mobile: 07979 860266
Email: paulQsomhealy.demon.co.uk
TB Alert Website: www.tbalert.orq
---- Original Message ---From: ’’Francis Ann-Marie" <Ann-Marie.Francis@ccl-tr.nwest.nhs.uk>
To: "Paul Sommerfeld (E—mail) ” kpaulQsdmhealy.demon.co.uk>; "Sharon
(E—mail)" <AdminQlmi.org.uk>; "Bertie Squire (E—mail)"
<sbsquire@liverpool.ac.uk>
Sent: Tuesday, July 09, 2002 10:21 AM
Subject: Pregamma
> Please find attached programme for RSM/LMI/TB Alert meeting on 2nd
> «RSM Piogramine. doc»
> Thanks
> Ann-Marie Francis
1 of 2
FvV: TB
‘
> Mr. C.A.C. ChiL'criz Const;.; tar. t Cardiac Surccon
> <5 Dr. r.D.O. Davies, Consulxtsnt Respiratory Physician
> Cardiothoracic Centre. Cho.ras Drive, Liverpool, LI 4 3 PE
> Tel: Olbl-293-2392
Pax: 10:1-293-2254
> E-mail: Ann-Marie.Francisgccl- tr.nwes t. nhs. uk
> <ma11 to:Ann-Marie.Prencis^ccl-tr.nwest.nhs.uk>
> CAUTION
> The information contained in this e-mail is confidential and is
> intended for use only of the addressee. Any unauthorised
dissemination or
> copying of this e-mail, and any use or disclosure of information
con 13 ins ci
_% i j} i i
> is strictly crohiisitcd and msy .bs ill&cfsl.
PI&cisg l&t us know k>y
telephone
> on
> +44(0)151 229 1616 if this e-mail has been sent to you in error and
delete
> it together
> with any backups on your system immediately.
i ■ >] RSM Programme.doc •
of 2
Name: RSM Programme.doc
Type: Microsoft Word Document (application/msword)
Encoding: base64
7/10/02 9:46 AN
*
Meeting of tine Respiratory Medicine
Section,
TB Alert and the Liverpool Medical
Institution
Anti-viral treatment
Royal
Society ?f
Medicine
FOR TB PATIENTS IN
AfricaCAN WE AFFORD NOT TO
GIVE IT?
Wednesday 2 October 2002
Barnes Hall, The Royal Society of Medicine
I Wimpole Street, London, WIG OAE
TITV is the greatest risk factor for tuberculosis (TB) known. The combination of
TB and HTV/AIDS is devastating many parts of the developing world, especially
sub-Saharan Africa. The diseases are commonest in children and young adults,
the economic future of the countries affected. While TB drugs are now largely
affordable, anti-viral medication is not.
Doctors treating TB/HTV patients can cure the TB but are frustrated that patients
either get reinfected with TB or go on to die of other AIDS related diseases.
Only giving specific anti-HIV treatment can reverse the impact of these deadly
diseases on the populations and economies of the developing world. Can we
afford not to treat both diseases?
RSM contact:
Fleur Raggatt
Academic Department, Royal Society of Medicine,
1 Wimpole Street, London WIG OAE
Tel: (+44) (0) 20 7290 2984 Fax: (+44) (0) 20 7290 2989
Email: respiratory@rsm.ac.uk
10.00 am
Coffee and registration
10.30 am
The layman looks at the problem
.Jeremy Lawrence, The Independent, London
11.00 am
The length and breadth of the problem
Chris Dye, World Health Organisation, Geneva.
11.30 am
HIV7TB prophylaxis
Peter Godfrey-Faussett, London School ofHygiene and Tropical
Mdeicine, London
12.00 pm
Treating HIV/TB together
Anton Pozniac, Chelsea and Westminster Hospital, London
12.30 X nm
Lunch
1.30 pm
Can we treat both ?
Alison Elliott, London School of Hygiene and Tropical Mdeicine,
London
2.00 pm
Drug access for HJV7T.B in the developing world
Alison Grant, London School of Hygiene and Tropical Mdeicine,
London
2.30 pm
Frustrations of the clinician treating fflV/IB
Nicky Hargreaves, Malawi Project, Liverpool School of Topical
Medicine, Liverpool
3.00 pm
BCG and HIV
Paul Fine, London School ofHygiene and Tropical Mdeicine,
London
3.30 pm
Would clean water provide better health for the money ?
Frank Greaves, TEAR Fund.
4.00 pm
Tea
4.30 pm
The ethics of resourcing the developing world
David Cook, Green College, Oxford
5.00 pm
Close of meeting
5 CME/CPD points
REGISTRATION INFORMATION
Respiratory Medicine Section
Anti-viral treatment for TB patients in Africa - can we
afford not to give it?
Wednesday 2 October 2002
Venue : Barnes Hall
Office use only
Received:
Delegate:
/1666
Finance: 40-0-43-042-01
Publicity:
Please fill in your name and present appointment and institute as you would
like them to appear on the delegate list, your name badge and the attendance
register.
Please use one form per person, feel free to photocopy.
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□
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PLEASE COMPLETE BOTH SIDES OF THIS FORM
I enclose payment of £by cheque made payable to The Royal
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Please return your form by Monday 23 September 2002 to:
Fleur Raggatt, Academic Department. Royal Society of Medicine. 1 Wimpole
Street, London, WIG 0AE
Tel: (+44) (0) 20 7290 2984, Fax: (+44) (0) 20 7290 2989
email: respiratory@rsm. ac .uk
Book on-line at: www.rsm.ac.uk/respiratory
If you are a Non-Fellow/Non-Member of the RSM please tick here if you
do not wish to receive future mailings from the Royal Society of Medicine:
Registrations will not he accepted over the telephone. Places are only
guaranteed upon written confirmation. Acceptance onto this meeting is at the
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accepted up to four working days before the meeting. Refunds on fees over
£10.00 only. An administration fee of 15% will be charged on refunds.
ih I’At'L’
L’ l’L' dmtu uinL’V
tuk' iv'ion-i
In India today,
like any other day this year,
more than 1,000 people
will die from tuberculosis (TB)
But these deaths can be prevented
With proper care and treatment,
TB patients can be cured
and the battle against TB
can be won
A
Central TB Division
Directorate General of Health Services
Ministry of Health and Family Welfare
Nirman Bhavan, New Delhi-110 011
■WHi uberculosis (TB) is an infectious disease caused by a
| bacterium, Mycobacterium tuberculosis. It is spread through
tJ the air by a person suffering from TB. A single patient can
infect 10 or more people in a year.
India has a long and distinguished tradition of research in TB.
Studies from the Tuberculosis Research Centre in Chennai and
the National Tuberculosis Institute in Bangalore provided key
knowledge to improve treatment of TB patients all around the world.
Modern anti-TB treatment can cure virtually all patients. It is,
however, very important that treatment be taken for the prescribed
duration, which in every case is a minimum of 6 months. Because
treatment is of such a long duration and patients feel better after
just 1 -2 months, and because many TB patients face other problems
such as poverty and unemployment, treatment is often interrupted.
Therefore, just providing anti-TB medication is not sufficient to
ensure that patients are cured.
Today, for the first time since the discovery of the first anti-TB
medicines in 1944, there is hope of stopping TB.This breakthrough
is a strategy known as DOTS, an acronym for Directly Observed
Treatment, Short-course.
The Director-General of the World Health Organization has
declared that, ‘The DOTS strategy represents the most important
public health breakthrough of the decade, in terms of lives which
will be saved."
Directly Observed Treatment, Short-course (DOTS)
DOTS, known as the Revised National Tuberculosis Control
Programme (RNTCP) in India, is a comprehensive strategy for TB
control.
DOTS is the only strategy which has proven effective in
controlling TB on a mass basis. The DOTS strategy is in practice in
more than 100 countries. India has adapted and tested DOTS in
various parts of the country since 1993, with excellent results, and
the RNTCP now covers more than 120 million population.
DOTS is a systematic strategy which has five components:
■ Political and administrative commitment. TB is the leading
infectious cause of death among adults. It kills more women
than all causes associated with childbirth combined and leaves
more orphans than any other infectious disease. And, since TB
can be cured and the epidemic reversed, it warrants the topmost
priority, which it has been accorded by the Government of India.
This priority must be continued and expanded at the state, district
and local levels.
■ Good quality diagnosis. Top quality microscopy allows health
workers to see the tubercle bacilli and is essential to identify
the patients who need treatment the most.
■ Good quality drugs. An uninterrupted supply of good quality
anti-TB drugs must be available. In the RNTCP, a box of
medications for the entire treatment is earmarked for every
patient registered, ensuring the availability of the full course of
treatment to the patient the moment he is registered for
treatment. Hence in DOTS, the treatment will never fail for lack
of medicine.
□ The right treatment, given in the right way. The RNTCP uses
the best anti-TB medications available. But unless treatment is
made convenient for patients, it will fail. This is why the heart of
the DOTS programme is “directly observed treatment” in which
a health worker, or another trained person who is not a family
member, watches as the patient swallows the anti-TB medicines
in their presence.
■ Systematic monitoring and accountability. The programme
is accountable for the outcome of every patient treated. The
cure rate and other key indicators are monitored at every level
of the health system, and if any area is not meeting expectations,
supervision is intensified.
The RNTCP shifts the responsibility for cure from the patient
to the health system.
DOTS in India
In the 1950s, Indian TB researchers documented the
tremendous burden of suffering caused by TB. In the 1950s and
1960s, the modern principles of the diagnosis and the treatment of
TB were established by research done in India.
The National Tuberculosis Programme (NTP), established in
1962, created an infrastructure forTB control throughout the country.
A comprehensive review in 1992 determined that the programme
had not achieved the desired results. To intensify the efforts to
control TB, the Government of India adopted the RNTCP.
The RNTCP has been remarkably successful. In a population
of more than 200 lakh in 13 states throughout the country, the quality
of diagnosis is dramatically better than that of the previous
programme or of private practitioners.
Nearly 8 out of 10 patients diagnosed in the programme since
1993 were cured; this cure rate is more than double that of the
previous programme.
Quality of Diagnosis: Laboratory Confirmation
Quality of Treatment: Cure/Completion
* Cure not assessed h NIP; 30% of patients collect meoicine tor the presenbed duration
HIV
While the size of the HIV epidemic in India is presently not
known, it is clear that HIV will worsen the TB epidemic. The Human
Immunodeficiency Virus breaks down the immune system and
makes patients highly susceptible to TB; these patients can then
spread TB to other people. In some countries, the HIV epidemic
has doubled or tripled TB cases.
Fortunately, DOTS is as effective among HIV-infected TB
patients as among those who are HIV negative. Even among HIVinfected TB patients, DOTS cures patients and results in longer,
healthier lives.
Multidrug-Resistant Tuberculosis (MDRTB)
MDRTB refers to strains of the bacterium which are proven in
a laboratory to be resistant to the two most active anti-TB drugs,
isoniazid and rifampicin. Treatment of MDRTB is extremely
expensive, toxic, arduous, and often unsuccessful. DOTS has been
proven to prevent the emergence of MDRTB, and also to reverse
MDRTB where it has emerged. MDRTB is a tragedy for individual
patients and a symptom of poor programme performance. The only
way to confront this challenge is to improve the treatment
programme and implement DOTS as rapidly as possible. A poorly
performing programme will create drug-resistant cases at a faster
rate than these cases can be cured, even if unlimited resources are
available.
The Future of DOTS in India
The Government of India has significantly increased the national
budget for TB control. The RNTCP will be implemented in a phased
manner in a population of nearly 300 million in the next two years.
At the same time, the rest of the country will be prepared for RNTCP
implementation by receiving updated technical material, diagnostic
equipment, uninterrupted supply of drugs, and by implementing
the RNTCP registration system. It is hoped that the RNTCP will be
implemented nationally as soon as operationally feasible.
Experts caution that DOTS must not be implemented too rapidly.
The experience in the past 4 years in India, which matches that of
many countries, is that phased expansion is critical. Trying to expand
too fast can result in a poor programme which can actually worsen
the prospects for TB control by increasing drug resistance.
Effective implementation of DOTS will save hundreds of
thousands of lives in India. DOTS has been deemed one of the
most cost-effective health interventions. Each life saved represents
a child, mother, or father who will go on to live a productive, TBfree, longer life. Every patient who is cured stops spreading TB.
Working together to implement DOTS, we can win the age-old battle
against TB.
Districts Scheduled for Full
RNTCP Implementation
-------- 1998 ---------Ahmedabad. Gujarat
Imphal, Manipur
Mumbai, Maharashtra
Ahmedabad Corp., Gujarat
Jaipur, Rajasthan
Murshidabad, West Bengal
Amreli, Gujarat
Jamnagar, Gujarat
Nadia, West Bengal
Bangalore UrbanTZKarnatak
angra, Himachal Pradesh Patna, Bihar
Bangalore, Karnataka
Kaphoor, Kerala
Barabanki. Uttar
ades
Bhopal,
onjhar, Orissa
Pathanamthitta. Kerala
Pune, Maharashtra
ottayam. Kerala
Raigad, Maharashtra
leutta, West Bi
Lutkpow, Uttar Pradesh
South Arcot, Tamil Nadu
Oaussa, Rajasthan
Madras City, Tamil Nadu
Sundargarh, Orlss
Delhi
Malaflbmm, Kerala
ihiruvananth:
Di
Maida, WesCBest^^
£hur. Keryl
andi. Himachaf^radesh"
Hami
ayurbfibHj.
alsad, Gujatfa
Medak, Andhra
Vf^isha, f
Mehsana, Guja
Ajmer,
mad, Keral
Rajkot, Gujarat
Than
Banaskanttya, Gujarat
Ranchi, Bihar
Bankura, Wqst Berj(jat
Sabarkanta, Gujarat
Kollamy-Kerala
ka
Kozhikode, Kerala
Samastipur, Bihar
Mednipur. West Bengal
Sambalpur, Orissi
Bijapur, Karnataka^
Muzaffarpur, Bihar
Shimla, Himachajffrtldesh
Birbhup^'West Bengal,
North 24 Parganas,
Slrmaur, Himachal Pradesh
Chitradurgd, Karnat^k
-West Bengal
Solan, Himachal Pradesh
Dharmapuri, Tamil N
•“Pallakad, Kerala
South 24 Parganas;^,
Deogarh, Orissa
Pallamav, Bihar
West Bengal
Ernakulam, Kerala
Panchmahal, Gujarat
Surat, Gujarat
Hazaribagh, Bihar
Rai Barelli, Uttar Pradesh
Thanjavur, Tamil Nadu
Jalpaiguri, West Bengal
Raichur, Karnataka
Unnao, Uttar Pradesh
Jharsugda, Orissa
Rajgarh, Madhya Pradesh
Bellary, Karn
•
Salem, Tamil Nadu
t Bengal)
Bardhaman.-
IBhavnagar. Gujarat
bi
Tuberculosis—Key facts
■ More adults die from TB than from
any other infectious disease—1
every minute, more than 1,000 every
day in India.
■ The
National
Tuberculosis
Programme was begun in 1962 and
created an infrastructure for TB
control throughout the country.
However it has not achieved the
desired results.
■ The Director-General of the World
Health Organization has declared
that ,rThe DOTS strategy represents
the most important public health
breakthrough of the decade."
■ The strategy of Directly Observed
Treatment, Short-course (DOTS) is
based largely on research done in
India in the field of TB over the past
35 years.
■ Since 1993, DOTS has been pilot
tested in 20 sites of India as the
Revised National Tuberculosis
Control Programme (RNTCP). In the
RNTCP, the proportion of TB cases
which are confirmed in the
laboratory is double that of the
previous programme, and the cure
rate is nearly triple that of the
previous programme.
■ The operational feasibility of DOTS
in the Indian context has been
demonstrated, with 8 out of 10
patients treated in the programme
being cured, as compared with
approximately 3 out of 10 in the
previous programme.
■ Multidrug-resistant tuberculosis
(MDRTB) is a result and symptom
of poor programme performance.
Reliable and representative data on
the rate of MDRTB in India is not
available. DOTS has been shown to
prevent the emergence of MDRTB
and to reverse the trend of MDRTB
in communities in which it has
emerged.
■ The Human Immunodeficiency
Virus (HIV) is the strongest known
risk factor for development of TB.
In some countries, HIV has tripled
TB caseloads. However, DOTS earn
cure TB even in HIV-positive^
people.
■ Success of the RNTCP depends on
communication, collaboration, and
coordination between the Govern
ment and private practitioners, non
governmental organizations, and
other institutions of prominence
such as medical colleges.
■ In the next two years, the RNTCP
is to be implemented in a phased
manner in a population of more than
300 million throughout India, and at
the same time the rest of the
country will be prepared for
RNTCP implementation. Phased
implementation is essential to
success.
■ By the year 2000, the number oU
infectious patients cured per year,
will increase from the current level
of at most 1,50,000 to more than
5,00,000 per year. By the year
2000, 1,00,000 fewer patients will
die every year from TB as a result
of the RNTCP. Every patient who is
cured stops spreading TB, and
every life saved is a child, mother,
or father who will go on to live a
longer, TB-free life.
For more information, contact the District TB Centre
RAICHUR / KOPPAL
'T
g
►!<
►H
H
Central TB Division
Directorate General of Health Services
Ministry of Health and Family Welfare
Nirman Bhavan, New Delhi-110 011
CONTENTS
Definitions: The Revised National Tuberculosis Control Programme
1
.
Diagnosis
2
Staining method
Key steps in the preparation and staining of smears
Ziehl-Neeisen staining
3
4
Treatmen
5
Expected breakup of 135 cases under RNTCP
5
Treatment categories and sputum examination schedule
6
Phases and duration of treatment
7
Duration of treatment it sputum smear is positive at 2/3 months
7
Management of patients who interrupt treatment
Management of patients who were smear-negative at diagnosis and who
8
interrupt treatment
Management of New smear-positive cases who interrupt treatment (Category I)
9
Management of retreatment smear-positive cases who interrupt
10
treatment (Category II)
Treatment of children
11
Dosages for children
11
How to proceed with preventive chemotherapy in children under 6 years of age
11
who were in contact with a smear-positive case
Possible side-effects of anti-tuberculosis drugs
12
Supervisory visits
1^
Summary of key indicators and possible actions
Reporting
14-17
18
DEFINITIONSjTHE REVISED NATIONAL TUBERCULOSIS CONTROL ^^GRAMME
CASE DEFINITIONS
Pulmonary tuberculosis, Smear-positive
TREATMENT OUTCOMES
TYPES OF CASES
Cured
New
TB in a patient with at least 2 initial sputum smear
A patient who has never had treatment for
examinations (direct smear microscopy) positive for
tuberculosis or has taken anti-tuberculosis
AFB,
drugs for less than one month.
smears, on at least two occasions, one of which
Relapse
was at completion of treatment.__________________
Or. TB in a patient with one sputum examination
positive for AFB and radiographic abnormalities
A patient declared cured of TB by a
Initially smear-positive patient who has
completed treatment andhad negative sputum
Treatment completed
Sputum smear-positive case who has completed
consistent with active pulmonary TB as determined by
physician, but who reports back to the health
the treating MO,
service and is found to be bacteriologically
treatment, with negative smears at the end of the
positive.
initial phase but none at the end of treatment.
Or TB in a patient with one sputum specimen
positive for AFB and culture positive for M. tb
Pulmonary tuberculosis, Smear-negative
TB in a patient with symptoms suggestive of TB
Transferred in
Or: Sputum smear-negative TB patient who has
A patient who has been received into a
received a full course of treatment and has not
Tuberculosis Unit/District, after starting
become smear-positive during or at the end of
treatment in another unit where he has been
treatment.
and radiographic abnormalities consistent with active
recorded._________
pulmonary TB as determined by an MO, followed by a
Treatment After Default
Or: Extra-pulmonary TB patient who has
received a full course of treatment and has not
with at least 3 sputum examinations negative for AFB,
decision to treat the patient with a full course of anti
tuberculosis therapy,
Or. Diagnosis based on positive culture but
negative AFB sputum examinations.
"Extra-pulmonary tuberculosis
TB of organs other than the lungs, such as the
___
________________
A patient who received anti-tuberculosis
become smear-positive during or at the end of
treatment for one month or more from any
treatment.
source and who returns to treatment after
Died
having defaulted, i.e. not taken anti-TB drugs
Patient who died during treatment, regardless of
consecutively for two months or more._______
cause.___________________________________________
Failure
Failure
pleura (TB pleurisy), lymph nodes, abdomen, genito
urinary tract, skin, joints and bones, tubercular
A smear-positive patient who is smear
Smear-positive case who is smear-positive at 5
positive at 5 months or more after starting
months or more after starting treatment. Also, a
meningitis, tuberculoma of the brain, etc
treatment Failure also includes a patient
patient who was initially smear-negative but who
Diagnosis should be based on one culture-positive
specimen from the extra-pulmonary site, or
who was initially smear-negative but who
became smear-positive during treatment.___________
becomes smear-positive during treatment.
Defaulted
histological evidence, or strong clinical evidence
Chronic
consistent with active extra-pulmonary TB followed by
A patient who remains smear-positive after
an MO’s decision to treat with a full course of anti-TB
completing a retreatment regimen.___________
therapy.
“Other”
Pleurisy is classified as extra-pulmonary TB
Patients who do not fit into the above-
A patient who, at any time after registration, has
not taken anti-TB drugs for 2 months or more
consecutively.____________________________________
Transferredout
A patient diagnosed with both pulmonary and extra-
mentioned categories. Reasons for putting a
A patient who has been transferred to another
Tuberculosis Unit/District and his/her treatment
pulmonary TB should be classified as pulmonary TB.
patient in this category must be specified.
results are not known.
DIAGNOSIS
( COUGH FOR 3 WEEKS OR MORE )
3 Sputum smears ]
(
[ 3 or 2 Positives ]
1 Positive
■ray
[
Positive
]
)
)
[ Negative for TB ]
[Negative forTB ]
[ Positive )
Smear-positive TB
[ Non-TB
Anti-TB Treatment
]
[ Smear-negative TB]
__ 1__
Antl-TB Treatment |
Key steps in the preparation and staining of smears
Step
1
Step 3
Break a
broomstick
into two
Step 7
Place the
slides In serial
order on the
staining rack
Step 8
Spread evenly
onto 2/3 of
central
portion of the
numbered
slide
Step 5
Air-dry the
slide for 1530 minutes
Let the slides
stand for 5
minutes
Stain the
slides with 1%
carbol fuchsin
Heat the slides
from
underneath
until vapours
rise
Step 9
Decolourize
with 25%
sulphuric acid
and let it
stand for 2-4
minutes
(repeat, letting
stand for 1-3
minutes, if
necessary)
Rinse away
excess stain
with tap water
Counterstain
with 0.1%
methylene
blue and let
stand for 30
seconds
Gently rinse
^the slides
-with tap
“water, drain
“the water off,
and allow the
slide to dry
Examine the
slides under
the
microscope
STAINING METHOD
Pick up the
large, yellow
purulent
portion of
sputum
Step 6
Fix the dry
slide by
heating briefly
3-5 times for
3-4 seconds
each time
STAINING METHOD,
Zlehl-Neelsen staining
1.
Select a new unscratched slide and label the slide with the Laboratory Serial Number.
2
Spread sputum on the slide using a broomstick.
3.
Allow the slide to air dry for 15-30 minutes.
4.
Fix the slide by passing it over a flame 3-5 times for 3-4 seconds each time.
5.
Pour filtered carbol fuchsin to cover the entire slide.
6.
Gently heat the slide with carbol fuchsin on it until vapours rise. Do not boil.
7.
Leave carbol fuchsin on the slide for 5 minutes.
8.
Gently rinse the slide with tap water until all free carbol fuchsin stain is washed away.
9.
Pour 25% sulphuric acid onto the slide.
10.
Let the slide stand for 2-4 minutes.
11.
Rinse gently with tap water. Tilt the slide to drain off the water.
12.
If the slide is still red. reapply sulphuric acid for 1-3 minutes and rinse gently with tap water.
13.
Pour 0.1% methylene blue onto the slide.
14.
Leave methylene blue on the slide for 30 seconds.
15.
Rinse gently with tap water.
16.
17.
Allow the slide to dry
Examine the slide under the microscope using x40 lens to select the suitable area and then
examine under x100 lens using a drop of immersion oil.
18.
Record the results in the Laboratory Form and the Laboratory Register appropriately as per
the table given below:
No. of
fields to be
examined
Result
Grading
More than 10 AFB per oil immersion field
Pos
3 +
1 -10 AFB per oil immersion field
Pos
2 +
50
1 +
100
Record exact
200
Examination
10-99 AFB per 100 oil immersion fields
1-9 AFB per 100 oil immersion fields
Pos
Scanty
20
number seen
No AFB in 100 oil immersion fields
Neg
0
19.
Store all positive and negative slides until instructed by the supervisor.
20.
Disinfect all contaminated material before discarding.
100
TREATMENT
•
**
Patients with extra-pulmonary T8 should receive Category III treatment unless they are seriously ill, in which case they
should recieve Category I treatment
Examples of seriously ill patients are those suffering from meningitis, disseminated TB. tuberculous pericarditis.
pentonitis. bilateral or extensive pleurisy, spinal TB with neurological complications, smear-negative pulmonary TB with
extensive parenchymal involvement, intestinal and genito-urinary TB.
Expected breakup of 135 cases under RNTCP
New smear-positive : New smear-negative
50 : 50
New smear-positive (CAT I) : Retreatment smear-positive (CAT II)
50:25 (initially)
New smear-positive : Extra-pulmonary
50 : 10
Non-seriously ill smear-negative : Seriously ill smear-negative
40 : 10
Non-seriously ill extra-pulmonary : Seriously ill extra-pulmonary
8 : 2
Treatment
Smear-positive
Smear-negative
Extra-pulmonary
Category I
50
10 (seriously ill)
2 (seriously ill)
62
Category II
25
Nil
Nil
25
Category III
0
40
8
48
Total
75
50
10
135
Total
SPUTUM EXAMINATIONS FOR PULMONARY TB
Category of
treatment
Type of patient
Regimen
New sputum smear-positive
* ■ i----------------------------------------- THEN
IF
*
Pre
Test
result
treatment
at
is
sputum month
+
2
2(HRZE)j
Category I
Seriously ill sputum smear-negative
4(HR)3
-
Category III
Continue Intensive phase for one more month
-
Start continuation phase, tost sputum again at 6 months
Continue Intensive phase for one more month, test sputum again
+
Sputum smear-positive Relapse
2(HRZES)3
Sputum smear-positive Failure
1(HRZE),
Sputum smear-positive Treatment
After Default
5(HRE)3
Sputum smear-negative, not
seriously ill
2(HRZ)j
Extra-pulmonary not seriously ill
Start continuation phase, test sputum again at 4 and 6 months
*
+
2
Seriously ill extra-pulmonary”
Category II
-
4(HR)3
+
at 3, 4 and 7 months
Start continuation phase, test sputum again at 5 and 6 months
3
Continue intensive phase for one more month, test sputum again
+
-
at 4, 6 and 9 months
-
Start continuation phase, test sputum again at 6 months
+
Re-reglster the patient and begin Category II treatment
2
The number before the fetters refers to the number of months of treatment. The subscript after the letters refers to the number of doses per week H. Isoniazid
(600 mg). R Rifampicin (450 mg) Z; Pyrazinamido (1500 mg). E: Ethambutol (1200 mg). S. Streptomycin (750 mg) Patients who weigh more than 60 kg receive
additional rifampicin 150 mg Patients more than 50 years old.receive streptomycin 500 mg Patients in categories I and II who have a positive sputum smear at
the end of the initial intensive phase receive an additional month of intensive phase treatment
Examples of seriously ill extra-pulmonary TB cases are meningitis, disseminated TB. tuberculous pericarditis, peritonitis, bilateral or extensive pleurisy spinal TB
with neurological complications and intestinal and genito-urmary TB.
tn rare and exceptional cases, patients who are sputum smear-negative or who have extra-pulmonary disease can have Relapse or Failure. This diagnosis in all
such cases should always be made by an MO and should be supported by culture or histological evidence of current, active tuberculosis. In these cases, the
patient should be categorized as ’Other’ and given Category II treatment
Any patient treated with Category I or Category III who has a positive smear at 5. 6 or 7 months of treatment should be considered a Failure and started on
Category I) treatment afresh
TREATMENT CATEGORIES AND SPUTUM EXAMINATION SCHEDULF
TREATMENT REGIMEN
MEDICATION
Medication
Dose
(thrice a week)
Number of
pills in comblpack
Isoniazid
600 mg
2
Rifampicin
450 mg
*
1
Dyrazinamide
1500 mg
3
Ethambutol
1200 mg
3
Streptomycin
0.75 g"
—
Patients who weigh 60 kg
or more are given an extra
150 mg dose of rifampicin
Patients over 50 years of
age and those who weigh
less than 30 kg are given
0.5 g of streptomycin
Phases and duration of treatment
Category
Duration (number of doses)
Intensive phase
Total
Continuation phase
CAT I
8 weeks (24 doses)
18 weeks (54 doses)
26 weeks (78 doses)
CAT II
12 weeks (36 doses)
22 weeks (66 doses)
34 weeks (102 doses)
CAT III
8 weeks (24 doses)
18 weeks (54 doses)
26 weeks (78 doses)
Duration of treatment if sputum smear is positive at 2/31 months
Category
Duration (number of doses)
Total
Intensive phase
Continuation phase
CAT I
12 weeks (36 doses)
18 weeks (54 doses)
30 weeks (90 doses)
CAT II
16 weeks (48 doses)
22 weeks (66 doses)
38 weeks (114 doses)
’ CAT I—positive at 2 months
CAT II—positive at 3 months
MANAGEMENT OF PATIENTS WHO INTERRUPT TREATMENT
Management of patients who were | smear-negat/ve| at diagnosis
and who interrupt treatment
Length of
Treatment
interruption
received
before
interruption
Less than
1 month
Less than
2 months
Do a
sputum
smear
examination
Outcome
Result
of sputum
smear
examination
No
—
—
Re
registration
Treatment
—
Resume
treatment
and
complete
all doses
2 months
or more
More than
1 month
Yes
Resume
treatment
Negative
—
—
Positive
Default
New
Begin CAT I
afresh .
Less than
2 months
No
—
—
—
Resume
treatment
and
complete
all doses
More than
2 months
Yes
Negative
—
—
Resume
treatment
and
complete
all doses
Positive
Default
Treatment
After
Default
Begin CAT II
treatment
afresh
;
A
MANAGEMENT QF PATIENTS WHO INTERRUPT TREATMENT
Management of | New smear-posltlve~\ cases who Interrupt treatment (Category I)
Treatment
Length of
received
Interruption
before
interruption
Do a
sputum
smear
examination?
Result of
Outcome
sputum
smear
examination
Less than
1 month
Less than
2 weeks
No
—
2-7 weeks
No
—
8 weeks
or more
Yes
Positive
Default
New
Start again on
CAT I**
Negative
—
—
Continue CAT I*
—
Re
registration
Treatment
—
Continue CAT I*
Start again on
CAT I**
>
1-2
months
More than
2 months
Less than
2 weeks
No
—
—
—
Continue CAT I*
2-7 weeks
Yes
Positive
—
—
1 extra month
of intensive
phase of CAT I
Negative
—
—
Continue CAT I*
8 weeks
or more
Yes
Positive
Default
Treatment
After
Default
Start on
CAT II"
Negative
—
—
Continue CAT I*
Less than
2 weeks
No
—
—
—
Continue CAT I*
2-7 weeks
Yes
Positive
Other
***
Default
Start on
CAT II"
Negative
—
—
Continue CAT I*
8 weeks
or more
Yes
Positive
Default
Treatment
After
Default
Start on
CAT II"
Negative
—
—
Continue CAT I*
• A patient must complete all 24 doses of the initial intensive phase. For example, if a patient has to continue his
previous treatment and he took 1 month of treatment (12 doses) before interrupting, he will have to take 1 more
month (12 doses) of the intensive phase treatment He will then start the continuation phase of treatment.
” A patient who must 'start again' will restart treatment from the beginning.
” Although this patient does not strictly fit the definition of default, default most closely describes the outcome of this
patient, although at re-registration they should be categorized as 'Other'
MANAGEMENT OF PATIENTS WHO INTERRUPT TREATMENT
Management of \retreatment smear-positive] cases who Interrupt treatment (Category II)
Do a
Length of
Treatment
Interruption sputum
received
smear
before
examination?
interruption
Less than
1 month
1-2
months
More than
2 months
Outcome
Result of
sputum
smear
examination
Treatment
Re
registration
Less than
2 weeks
No
—
—
—
Continue CAT II
*
2-7 weeks
No
—
—
—
Start again on .
CAT II"
II
8 weeks
or more
Yes
Positive
Default
Treatment
After
Default
Start again on
CAT II
**
Negative
—
—
Continue CAT II
*
Less than
2 weeks
No
—
—
—
Continue CAT II*
2-7 weeks
Yes
Positive
—
—
1 extra month
of intensive
phase of CAT II
Negative
—
—
Continue CAT II
*
8 weeks
or more
Yes
Positive
Default
Treatment
After
Default
Start again on
CAT II”
Negative
—
—
Continue CAT II’
Less than
2 weeks
No
—
—
—
Continue CAT II
*
2-7 weeks
Yes
Positive
Default”
Other
Start again on
CAT II
Negative
—
—
Continue CAT II
*
8 weeks
or more
Yes
Positive
Default
Treatment
After
Default
CAT II
—
Continue CAT II
*
Negative
—
Start again on
A patient must complete all 36 doses of the initial intensive phase.
Although this patient does not strictly fit the definition of default, default most closely describes the outcome of this
patient, although at re-registration they should be categorized as ‘Other'.
1
TREATMENT OF CHILDREN
Dosages for children
Drugs
Therapy per dose
(thrice a week)
Isoniazid
10-15 mg/kg
Rifampicin
10 mg/kg
Pyrazinamide
35 mg/kg
Streptomycin
15 mg/kg
Ethambutol’
30 mg/kg
Should not be given to children below 6
years of age
How to proceed with preventive chemotherapy In children under 6 years of age
who were in contact with a smear-positive case
I
IF:
AND:
THEN:
The child has symptoms
of tuberculosis
an MO determines
(preferably in
consultation with a
paediatrician) that the
child has tuberculosis
a full course of anti-tuberculosis
treatment (CAT III) should be given.
The child does not
have symptoms of
tuberculosis
a tuberculin test is
not available
the child should receive preventive
chemotherapy for 6 months
(isoniazid daily—5 mg per kg body
weight).
a tuberculin test is
available
the child should receive 3 months
of INH preventive chemotherapy and
a tuberculin test should then be done
IF:
THEN:
The child's
induration to the
tuberculin test
is less than
6 millimetres
in diameter
stop the preventive
chemotherapy and
give BCG
vaccination (if
not previously
vaccinated).
The child's
induration
to the tuberculin
test is 6
millimetres or
more in diameter
continue isoniazid
preventive chemo
therapy for another
3 months.
POSSIBLE SIDE-EFFECTS OF ANTI-TUBERCULOSIS DRUGS
Action to be taken
Symptom
Drug (abbreviation)
Drowsiness
Isoniazid (H)
Reassure patient
Red-orange urine/tears
Rifampicin (R)
Reassure patient
Gastrointestinal upset
Any oral medication
Reassure patient
Give drugs with less water
Give drugs over a longer
period of time (e g. 20 minutes)
Do not give drugs on empty
stomach
If the above fails, give anti
emetic if appropriate
Burning in the hands
and feet
Isoniazid (H)
Give pyridoxine 100 mg/day
until symptoms subside
Joint pains
Pyrazinamide (Z)
If severe, refer patient for
evaluation
Impaired vision
Ethambutol (E)
STOP ethambutol, refer patient
for evaluation
Ringing in the ears
Streptomycin (S)
STOP streptomycin, refer
patient for evaluation
Loss of hearing
Streptomycin (S)
STOP streptomycin, refer
patient for evaluation
Dizziness and loss of
balance
Streptomycin (S)
STOP streptomycin, refer
patient for evaluation
Jaundice
Isoniazid (H)
Rifampicin (R)
Pyrazinamide (Z)
STOP treatment, refer patient
for evaluation
In all cases of jaundice, anti-tuberculosis
drugs should be stopped immediately
and the patient referred for evaluation.
'
SUPERVISORY VISITS
Category of
supervisor
Methodology of supervision
Number of supervisory visits
DTO/MO (DTC)
Interview the MO-TC, MO 1/C of
PHC-CHC, STS, STLS and the
person incharge of anti-TB drug
storage.
Random Interview of patients
and community leaders.
Inspection of records of the TU,
PHC and CHC. and stock of
anti-TB drugs and laboratory
consumables.
Random checking of the
microscopy centre and sub-centre.
To visit all TUs every month, all
CHCs and Block PHCs in the district
every quarter, one sub-centre from
each Block PHC area and a proportion
of tribal sub-centres every quarter.
MO-TC
(Tuberculosis
Unit)
Interview the MO 1/C BPHC/CHC/
PHC. Random interview of
patients and community leaders.
Random checking of the
microscopy centre and sub
centre stock of anti-tuberculosis
drugs and laboratory consumables
To visit at least once every
quarter all CHCs/BPHCs/
PHCs, microscopy centres, and a
proportion of sub-centres.
STS
Interview MPHS and MPWs at
the PHC sub-centre. Inspect
records, Tuberculosis Treatment
Cards and Tuberculosis Laboratory
Register.
Random Interview of patients.
To visit all PHCs and CHCs every
month and all sub-centres every
quarter.
STLS
Inspect all microscopy centres
and laboratory records.
To visit all microscopy centres in the
jurisdiction of the TU at least
once a month.
11
H
Indicator
Quarterly Report
Possible Actions
Now and retreatmont cases
Expocted:
Now smear-positive
cases: 40-85/100 000
Ensure that sputum smear microscopy is being done correctly (5%-15% positivity among patients
examined (or diagnosis). Intensify review of slides read as smear-negative, particularly those of
patients placed on treatment.
Ensure that all smear-positives in the Laboratory Register aro recorded in the Tuberculosis Register.
Ensure that sputum smear microscopy is accessible to patients throughout the assigned area, with
trained laboratory technicians in place.
Calculated annualized
Ensure that active case-finding is not being done in any area
incidence of New
smear-positive cases is Ensure that sputum smear microscopy is accurate. Ensure review of slides of smear-positive patients.
more than 85/100 000
Ensure that only patients who reside in the area are being treated.
Expocted:
Retreatment smear
positive cases are 50%
of New smear-positive
cases in initial years of
RNTCP implementation
Retreatment cases
are less than 40%
of New smear-positive
cases
Ensure that accurate history-taking is being done at all levels Patients must be questioned carefully
about prior treatment for tuberculosis from any source. It should be explained to patients that only if
they provide accurate information can the most effective treatment be given.
Make sure that definitions are being applied correctly. Any smear-positive patient treated in the past for
more than one month and has defaulted for more than two months, should receive the retreatment
(CAT II) regimen
Retreatment cases are Ensure that active case-finding is not occurring. With active case-finding, many ‘old’ TB cases are reported.
more than 70% of Nev.
smear-positive cases
Ensure that history-taking is accurate and definitions are being correctly applied.
Ensure that new symptomatic patients undergo three sputum smear examinations for acid-fast bacilli (AFB).
Expected:
At least 50% of all New
pulmonary cases will bo
smear-positivo
Among Now pulmonary Ensure that over-diagnosis of sputum smear-negative patients is not occurring on account of over
cases proportion whict reliance on radiography. No patient should begin treatment without having three sputum smear
are smear-positive is
examinations dono
loss than 40%
Ensure that three sputum smoar examinations are being done on all chest symptomatics.
Ensure that sputum smear microscopy is being done correctly. Consider review of slides of smearnogative palients placed on treatment
SUMMARY OF KEY INDICATORS AND POSSIBLE ACTIONS
Calculated annualized
Ensure that chost symptomatics in all facilities undergo sputum smear examination (at loast 2% adult
incidence of Now
outpatients).
smear-positive cases is
less than 40/100 000
Ensure that three sputum smear examinations aro being done on all chest symptomatics.
Indicator
Possible Actions
New and retr&atment cases (continued)
Expected:
No more than 20% of
smear-negative/
extra-pulmonary
patients are considered
seriously ill and placed
under CAT 1
The proportion of
smear-negative or
extra-pulmonary
seriously ill patients
included in CAT 1 is
greater than 25%
Ensure that only senously ill patients are given CAT 1 treatment Non-seriously ill smear-negative
New patients should receive CAT III treatment
Less than 85% of
smear-positive CAT 1
patients are
documented
to become sputum
smear-negative at 3
months
Ensure that Medical Officers, treatment supervisors, and all staff in the programme and at peripheral
centres understand the importance of follow-up sputum examinations. Follow-up sputum examinations
are the best measure of patient response Io treatment Results of sputum examinations change patient
treatment and are critical to programme evaluation
Ensure that sputum microscopy is being done correctly Consider review of slides ol smear-negative
patients placed on treatment.
Conversion
Expected:
Conversion rate is 90%
Visit all centres with low rates of sputum conversion and resolve any problems with the help of the
staff
Make sure defaulter rates in the lirst two months are <5%. and that there is not an excess of patients
who die or who are transferred out.
Visit centres with a low sputum smear conversion rato to discuss with patients and staff about potential
reasons. Make sure each centre is aware of their result so that they may take steps to improve
performance.
Ensure that accurate history-taking is being done at all levels. Patients must be questioned carefully
about prior treatment for tuberculosis from any source It should bo explained to patients that only if
they provide accurate information can the most effective treatment be given. If previously treated
patients are not given the retreatment regimen, they may not respond well to treatment.
Make sure that definitions are being applied correctly Any smear-positive patient treated for more than
one month in the past, and with default of more than two months, should receive the retroatment (CAT
II) regimen If previously treated patients are not given the retreatment regimen, they may not respond
well to treatment.
Ensure that sputum microscopy is accurate. Ensure review of slides of patients who remained smear
positive at the end of the intensive phase
Ensure that every dose of medication is observed during the intensive phase of treatment Observation
sites should be convenient to the patient The possibility that DOTS is not being strictly followed should
be checked by observation, including checking and comparing Treatment Cards with the drugs available
in patientwise boxes
SUMMARY OF KEY INDICA T ORS AND POSSIBLE ACTIONS
Quarterly Report
Quarterly Report
Indicator
Possible Actions
Treatment outcome
Visit centres with low cure rates to discuss with patients and staff the reasons and possible
solutions. Make sure that each centre is aware of its cure rate so that it can take steps to
improve performance.
Ensure that accurate history-taking is being done at all levels. Patients must be questioned carefully
about prior treatment for tuberculosis from any source. It should be explained to patients that only if they
provide accurate information can the most effective treatment be given If previously treated patients are
not given the retreatment regimen, they may not respond well to treatment
Make sure that definitions are being applied correctly. Any smear-positive patient treated for more than one
month in lhe past, with default of more than two months, should receive the retreatment (CAT II) regimen
Ensure that every dose of medication is observed during the intensive phase of treatment, and at least
one dose per week in the continuation phase. Ensure return of empty blister packs during weekly
collection of drugs. Observation sites should be convenient for the patient.
Ensure that health workers are dispensing medication properly as per technical guidelines.
Ensure that follow-up sputum smear examinations are being done according to guidelines.
Cure rate of smearpositive CAT I patients
is more than 95%
Expected:
No more than 3% of
smear-positive
patients are given the
treatment outcome
'complete'
Check Io make sure the report is correct If it is, consider checking to make sure that reporting and
classification of treatment outcomes is being done correctly and that all detected smear-positive patients
are registered.
Per cent of New smear Ensure that follow-up sputum examinations are being done as per policy. Carefully track this at all New
positive patients who
treatment units
are classified as having
'completed' treatment is Explain to Medical Officers and others the crucial importance of the follow-up sputum examinations
more than 5%
Locate patients who have recently completed treatment and obtain sputum samples for examination.
Carefully review all data on patients to ensure accuracy of information and to ensure that treatment is
being given under direct observation as per policy.
Expected:
No more than 4% New
smear-positive patents
die during treatment
Per cent of New smear Ensure that every dose of medication is observed during the intensive phase of treatment, and at least
positive pattens who
one dose per week in the continuation phase. Observation sites should be convenient to the patient.
die during treatment is
more than 5%
Review information on patients who died to determine the reasons.
If patients are presenting for treatment when already moribund, consider ways and means to encourange
more prompt referral and diagnosis so that patients can be treated earlier in the course of their TB
illness.
If all of the above has been done and death rate is still more than 5%. consider evaluation of the
prevalence of HIV infection among TB patients, to be done strictly as per policy with safeguards of
confidentiality.
■
SUMMARY OF KEY INDICATORS AND POSSIBLE ACTIONS
Expected:
Cure rate is 85% or more Cure rate of
smear-positive patients
is less than 80%
Quarterly Report_______ |
Indlcavfc^
|_____________________________________ PoBalblo Actions
Treatment outcome
Ensure that accurate history-taking is being done at all levels. Patients must be questioned carefully
about prior treatment for tuberculosis from any source. It should be explained to patients that only If
they provide accurate information can the most effective treatment be given. If previously treated
patients are not given the retreatment regimen, they may not respond well Io treatment.
Make sure that definitions are being applied correctly Any smear-positive patient treated for more than
one month in the past, with default of more than two months, should receive lhe retreatment (CAT II)
regimen.
Ensure that every dose of medication is observed during the intensive phase of treatment, and at least
one dose per wook in the continuation phase. Ensure return of empty blister packs during weekly
collection of drugs. Observation sites should be convenient for the patient
Ensure that health workers are dispensing medication property as per technical guidelines.
Ensure that drugs are of acceptable quality, that drugs are stored in appropriate conditions, and that
they are being used before their expiry ponod
If all of the above has been done and failure rate remains higher (han 5%. consider evaluation of the
level of primary drug resistance in (he community.
Expected:
Default rate is less than
5%
Default rate of smear
positive CAT 1
patients is more
than 10%
Visit centres which have the highest default rates and interview staff and patients to determine the
efforts made to retrieve patients, the reasons for default and possible solutions. Make sure that centres
are aware of their default rate so they can take steps to reduce it.
Ensure that patient history is bemg carefully ascertained, including the address A visit to patients'
homes should be made to verify addresses, and landmarks near the house should be recorded in the
Treatment Card. To the greatest extent possible, services should be convenient to the patient in terms
of distance, time and staff attitudes.
During lhe visit to the house for verification of address, note lhe name and address of a person who
can be contacted in the event lhe patient defaults
Ensure that directly observed treatment is being givon to patients in the Intensive phase and at toast
one dose per week is being directly observed during the continuation phase.
Ensure that oach centre is aware of iis own default rale so that It can take steps Io improve
performance.
Expected:
Transferred out is
less than 3%
Percentage of patients
who fall under outcome
category 'Transferred
out' Is more than 5%
‘Transfer out' can be a way of disguising default. Patients should only be categorized as 'Transferred
out' if they have been givon a Transfer Form to bring to the jurisdiction to which they are being
transferred. Ensure that counterfoils have boon received.
SU MMARY Q FKEYJNDIGATQbs and possible ACTIONS
Expected:
Failure: No more than 4% Per cent of New
of New smear-positive
smear-positive patients
patients are smear-positive who fall treatment is
more than 5%
5 or more months after
the start of treatment
REPORTING
Due dates for reports from Tuberculosis Units to DTC
Due On
Quarterly Report
Period Covered
7 April 1997
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 January-31 March 1997
1 January-31 March 1997
1 October-31 December 1996
1 January-31 March 1996
7 July 1997
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 April-30 June 1997
1 April-30 June 1997
1 January-31 March 1997
1 April-30 June 1996
7 October 1997
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 July-30 September 1997
1 July-30 September 1997
1 Apnl-30 June 1997
1 July-30 September 1996
7 January 1998
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 October-31 December 1997
1 October-31 December 1997
1 July-30 September 1997
1 October-31 December 1996
7 April 1998 ’
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Oulcome cohort
1 January-31 March 1998
1 January-31 March 1998
1 October-31 December 1997
1 January-31 March 1997
7 July 1998
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 April-30 June 1998
1 April-30 Juno 1998
1 January-31 March 1998
1 April-30 Juno 1997
7 October 1998
Case-finding
Programme Management
Sputum Conversion cohort
Treaimcnt Outcome cohort
1 July-30 September 1998
1 July-30 September 1998
1 April-30 Juno 1998
1 July-30 September 1997
7 January 1999
Case-linding
Programme Management
Sputum Conversion cohort
Treatment Oulcome cohort
1 October-31 December 1998
: October-31 December 1998
1 July-30 September 1998
1 Octobor-31 December 1997
7 April 1999
Case-finding
Programme Management
Sputum Conversion cohort
Trealment Outcome cohort
1 January-31 March 1999
1 January-31 March 1999
1 October-31 December 1998
1 January-31 March 1998
7 July 1999
Case-finding
Programme Management
Sputum Conversion cohort
Trealment Outcome cohort
1 April-30 June 1999
1 April-30 June 1999
1 January-31 March 1999
1 April-30 June 1998
7 October 1999
Case-finding
Programme Management
Sputum Conversion cohort
Treatment Outcome cohort
1 July-30 September 1999
1 July-30 Seplomber 1999
1 April-30 June 1999
1 July-30 September 1998
Reports should be received from the OTO to the STO, the Central TB Division of the Directorate
General of Health Services, Ministry of Health and Family Welfare, Nirman Bhavan, New Delhi
110011, and National Tuberculosis Institute, 8 Bollary Road. Bangalore 560003 no later than 14
days after the dates listed above.
DISTRICT T.B. CONTROL SOCIETY
RAICHUR/KOPPAL
B
"
T
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