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

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
[email protected]
PROMPT FOR THIS LECTURE
TUBERCULOSIS IN
INDIA IS STILL A MAJOR
PUBLIC HEALTH
PROBLEM EVEN AFTER
43 YEARS OF CONTROL
PROGRAM . WHY?
• I AM VERY MUCH WORRIED, SINCE A LONG
TIME, DUE TO THE VERY SLOW RESPONSE
IN REDUCTION OF TUBERCULOSIS IN INDIA
IN SPITE OF EFFECTIVE DOTS EXPANSION.
LEARNING OBJECTIVES
1. PRESENTING MAGNITUDE OF THE
TUBERCULOSIS PROBLEM IN INDIA,
(SLIDES 5-11)
2. 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
1. 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.
1. Non adherence to the regimens by the
doctors while prescribing drugs, is very
common
2. 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
1. THE PROVISION OF QUALITY TB
SERVICES TO A POPULATION OF OVER 1
BILLION IS A DIFFICULT TASK.
2. THIS MEANS PERFORMING ALMOST
100,000 SMEAR EXAMINATIONS EVERY
DAY
3. PROVIDING AN UNINTERRUPTED
SUPPLY OF ANTI-TB DRUGS TO MORE
THAN 1.3 MILLION CASES EACH YEAR.
4. THIS REQUIRES THAT A LARGE AMOUNT
OF RESOURCES TO BE MOBILIZED
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 No immediate lab facilityStaff deficiency Negligence on the part of
chest symptomatics to report • Superstitions decreasing case finding • Illiteracy being the problem • Lack of involvement of
the community leaders
13 responses
14 responses
11 responses
12 responses
09 responses
10 responses
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
1.
2.
3.
4.
5.
6.
Outreach problems
Diagnostic problems
Side effects of drugs
Transport problems
Financial problems
Community insensitivity
7. Less self referral
8. Quacks (unqualified medical practitioners)
problem
9. Lack of incentives
10. 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;119:12881289; 2001; American College of Chest
Physicians) from Ashish Bhalla