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

BOTTLENECKS OF TB CONTROL IN INDIA AND SOLUTIONS & K.A.P STUDY ON FRONTLINE HEALTH WORKERS Dr. A.K. AVASARALA MBBS, M.D. PROFESSOR & HEAD DEPT OF COMMUNITY MEDICINE & EPIDEMIOLOGY PRATHIMA INSTITUTE OF MEDICAL SCIENCES, KARIMNAGAR, A.P. INDIA: +91505417 avasarala@yahoo.com

PROMPT FOR THIS LECTURE TUBERCULOSIS IN INDIA IS STILL A MAJOR PUBLIC HEALTH PROBLEMEVEN AFTER 43 YEARS OF CONTROL PROGRAM . WHY? • I AM VERY MUCH WORRIED, SINCE A LONG TIME, DUE TO THE VERY SLOW RESPONSE IN REDUCTION OF TUBERCULOSIS IN INDIA IN SPITE OF EFFECTIVE DOTS EXPANSION.

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

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

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

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

WHO PROJECTION COMING TRUE A majority of deaths from TB occur in India (4). India faces growing mortality from TB.

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

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

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

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

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

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

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

WHICH ONE IS DEFECTIVE? • DOTS STRATEGY (DOTS FIVE COMPONENTS) • DOTS IMPLEMENTATION IN INDIA

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

KAP FINDINGS - 2 B.1) DIFFICULTIES FACING DURING DOTS • Irregular drug use -- 14 responses • Side effects of drugs -- 11 responses • Dot’s agent not serious -- 22 responses • No direct observation , just handing over medicines responses -- 24 responses • Quacks negative influence responses -- 22 responses

KAP FINDINGS-3 EXTRA REQUIREMENTS • Lab technician at local level , sub centre level - 14 responses • One lab technician at PHC is not enough - 15 responses • Lab technicians in villages with more number of cases - 31 responses • Incentives to dots agents to be given - 32 responses • X-ray facilities at Primary health centres - 14 responses. • Village Tb clubs establishment - 16 responses

PROBLEMS & SUGGESTIONS FROM K.A.P. STUDY • Outreach problems • Diagnostic problems • Side effects of drugs • Transport problems • Financial problems • Community insensitivity • Less self referral • Quacks (unqualified medical practitioners) problem • Lack of incentives • Overburdened staff

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

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

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

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

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

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

REFERENCES • WORLD TUBERCULOSIS DAY REPORT 2005 • WHO GLOBAL STAISTICS, 1996 • WHO GLOBAL TB SCENARIO-INDIA PROFILE • TB control is not a public movement in India even 18 months after the Amsterdam declaration’-- DR. DINESH KUMAR, DIRECTOR,HEALTH AND DEVELOPMENT INITIATIVE-INDIA • WHY BLAME PRIVATE PRACTIONERS? A letter to the editor published in Chest. (2001;119:1288-1289; 2001; American College of Chest Physicians) from Ashish Bhalla

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