Dr. Rajnikant K. Patel

M.O. PHC Uvarsad 21/07/2008

" Disease Burden of Tuberculosis in Gandhinagar"

Introduction :

Tuberculosis is a chronic infectious disease with varying clinical manifestation as likely affecting various system of body.

• Ø Organism was discovered 100 years ago and still availability of effective drugs and vaccine it remains a public health problem globally.
• Ø "Non - specific" determinants of TB Disease spread, it but shown improvent in the standard of living and quality of life has declined death Rate in developed countries thus causing a more impact in reducing the Burden of TB Disease in that area.
• Ø It kills more Adults than any other infectious disease especially productive age group of 15-49 years.
• Ø Globally 20,000 people infected per day 5000 develops disease in one day and 1 death occurs within 1 ½ minute.

Mortality and Morbidity :

 

• Ø In 1962, NTCP was launched but due to poor patient compliance; Diagnostic criteria was not based on sputum microscopy, sensitivity and specificity of diagnostic test was not there.
• Ø In NTCP area there were 35 case per 1,00,000 population of sputum positive during 1977 to 1991 sputum positive case was less and extra pulmonary and X ray positive case were high.
• Ø Standardize data abstraction in NTP District indicates that 8% of patients were smear positive less than half the proportion in RNTCP Districts.
• Ø In NTCP Ratio of sputum positive case to sputum negative case was 1:3.6 which Declines to 1:2.5 in 1999 after launching RNTCP in country.
• Ø Patient compliance was less in NTCP and lack of follow up and supervision made programme less effective and out come were poor.
• Ø In NTCP single Drug therapy had caused resistance to many Drugs.
• Ø The programme was not Funded by external agencies like world bank made less availability of human resources and logistics.
• Ø Drug supply was irregular, erratic and inadequate.
• Ø Sanitorium base treatment made more psycho-social effect to the patieat and community. And Not improving the status of the community.

Due to above pitfall in programme morbidity and mortality was still high. So, RNTCP was launched in 1993 in Mehsana District as a pilot project. In Gandhinagar RNTCP was started in 2000.   

• Ø Total TB patients Diagnosed in 2005 were 488, 470, 417, 434 quarter 1, 2, 3, 4 Respectively.
• Ø Total TB patients Diagnosed in 2006 were 463, 474, 500, 455 in quarter 1, 2, 3, 4 Respectively.
• Ø Total TB patients Diagnosed in 2007 were 475, 542, 500, 427 in quarter 1, 2, 3, 4 Respectively.
• Ø It shows that there is gradual Increase in number of TB patients diagnosed in comparison to past year 2005 but still there is decrease in Number of TB patient in quarter 4 in each year as compared to other quarter of year.
• Ø Annualized total case detection per one lac population ranges from 120 to 145 but it averages around 130.
• Ø Number of smear positive cases diagnosed in 2007 was 370, 411, 373, 315 in quarter 1, 2, 3, 4 respectively.
• Ø Number of smear positive cases diagnosed in 2006 was 361, 424, 366, 358 in quarter 1, 2, 3, 4 respectively.
• Ø Number of smear positive cases diagnosed in 2005 was 371, 399, 358, 331 in quarter.
• Ø Total no. of smear positive cases 1455 in 2005 increased to 1469 in 2007 showing marginal increase.
• Ø New smear positive cases Registered for treatment in 2005. Were 200, 216, 207, 191 in quarter 1, 2, 3, 4 respectively.
• Ø In 2006 were 207, 212, 212, 213 in quarter 1, 2, 3, 4 respectively.
• Ø In 2007 were 212, 212, 208, 209 in quarter 1, 2, 3, 4 respectively.

• v New Smear Negative cases initiated on treatment category III in 2005 was 101, 81, 46, 59 quarter 1, 2, 3, 4 respectively.

  

• Ø In 2006 was 61, 65, 74, 52 in quarter 1, 2, 3, 4 respectively.
• Ø In 2007 was 66, 58, 59, 49 in quarter 1, 2, 3, 4 respectively.
• Ø Total new smear Negative case was in 2005-287 in 2006-252. In 2007-232 it's Decrease year wise.
• Ø Extra pulmonary cases remains same in 2005 and 2007 and decreased in 2006.

• v Retreatment case No. of sputum smear positive patients started on category II regime.

• Ø In 2005 was 92, 81, 82, 114 in quarter 1, 2, 3, 4 respectively.
• Ø In 2006 was 104, 107, 119, 106 in quarter 1, 2, 3, 4 respectively.
• Ø In 2007 was 112, 129, 127 & 82 in quarter 1, 2, 3, 4 respectively.

It is increase from 369 in 2005 to 450 in 2007 it suggest more Failure. Relapse and defaulter cases are increased may be due to lack of supervision, not visit done by MPW. Not retrieval action was carried out etc.

• Ø Paediatric cases out of New cases were in 2005-46 in 2006-61 and in 2007-88. Due to availability of paediatric boxes the more patients are initiated or started on Treatment in 2007.
• Ø Cure rate is increased from 83% in 2005 to 89% 2006.
• Ø Failure rate is decrease from 2.6 to 2.2%.
• Ø Death rate is increased from 3.5 to 4.7 in 2006.
• Ø Defaulter rate is Increased from 6-7% to 11-13% in 2005.
• Ø Treatment completed case increased around from 80% to 85% in 2005 to 2006.

• v Seasonal Trends:

  

          No seasonal Trends is seen. But due to some reason less cases are found in quarter four of any year in comparision to other quarters of year.

• Ø Socio- environmental and economical factors leads to more occurrence and spread of diseases.

In Dehgam Taluka of Gandhinagar District due to more presence of lower socio-economic group cases are more seen in that area as compared to other Taluka of District.

• Ø Though Gandhinagar urban area have more population despite the occurrence of cases are less in urban area.
• Ø It is mostly seen in poor people, less income lower hygienic and sanitation practices and over crowding area.

Intervention

Initial home visit by health worker along with supervisor which make verification of address. Social determinant and surrounding environment which provides sustainable supported environment to TB case giving more emphasis on health education. Decreases spread of disease in community it makes patient more self reliant and self determined. Family members are motivated for patient's support and compliance. Regular intake of Drugs can make patients free from TB. We realizes the community members that what importance the role of IP phase. Initial 12 week treatment give symptomatic relief and decrease infectivity that leads to less numbers of cases in the community. If patient is migrant then by giving address to another TU. The treatment should be started at patient's residential place.

• Ø If Dot's centre is far away accessibility is making easier for drugs near by center for patient's accommodation and needs.
• Ø Suspected cases among family members who have cough within 1 week are examined for sputum leads to early detection of cases in family and surrounding area.

How many children they have are surveyed and confirmed during home visit and by doing weight of that children and assured Isoniazid prophylaxis to children below 6 years regularly by preventing tuberculosis incidence in children.

Regular visit by STS and STLS of poor working PHC. Regular visit by medical officer and supervisor and checking of box with treatment card. Field visit of TB patient and evaluating dots by asking indirect question to them.

Diagnostic algorithm displayed in medical officer room and laboratory diagnostic algorithm displayed in lab technician room. During routine surveillance activities m.p.w. keep sputum cup with them and give to symptomatic patients for further dignosis by sputum microscopy.

Laboratory technician and pharmacist prepared a follow up list and give to all MPW and FHW of PHC with referral slip and tell them for regular sputum follow up of patients and asked to start continuation phase within seven days of follow up result. They are drawing the attention of medical officer who are not coming up for follow up examination.

Regular meeting of pharmacist and lab technician block level by DTO and BHO and giving them all logistic supply including drugs for one month and review the progrmme at grass root level.

• Ø Those patients whose sputum are negative are tracked down and re diagnosis is done. The patients who are negative during re diagnosis of sputum examination but having symptomatic complain continue are gathered at PHC and send to district TB centre for X-ray examination along with worker in PHC vehicle thus by finding the extrapumonary cases and started to them on RNTCP cat III regime.
• Ø Monitoring of weight - The patients whose weight was not increased are specially focused and care to be taken for DOT compromised or not. The poor patients are benefited by social welfare department by collaborating through them.
• Ø Regular attending of M.O. meeting at District level by DTO and encouraged who had done good work and strict action are taken against who have worked poorly.
• Ø World TB day are celebrated at District and Taluka level. Reward are given who has done best work in RNTCP. The reward are given to all caders, workers, lab. Tech., Pharmacist, STS/STLS , M.O. and BHO in presence of political leaders and District administrators.
• Ø The best DOTs worker and best cured patient who had taken treatment regularly are also rewarded at Taluka level.
• Ø Exhibition of TB Disease related information in forms of posters, pamphlet IEC activities by various media during "GRAM SABHA" at village level.
• Ø The patients provider meeting are held at PHC every 3 months attended by District level staff.
• Ø N.G.O. are involved in the RNTC programme which are increased from 2 in 2005 to 6 in 2007. public private partnership along with private doctors and private lab technician are increased from 2 in 2004 to 12 in 2007.
• Ø Rootine immunization of B.C.G. coverage around 65-70% had done impact on TB meningitis and Millary TB cases in children.
• Ø Social mobilization is done by involving the local leaders and competition in school children for TB awareness in particular area and community by various types of IEC programme and try to change the mind set of community and individual that TB is not a social stigma now and responsibility of every citizen to fight against tuberculosis.
• Ø ICTC centre works for TB - HIV con-infection.

Above all programme had made success of this programme in best way in Gandhinagar District by performing more then 70% detection rate more than 90% sputum conversion rate and more then 85% cure rate.    

Limitation of Date Bases

• ü Data are not showing that how many suspected were examined and from them how many are not come for treatment.
• ü Date does not shows how many patients are not put earlier on Dot's regime and what was the prognosis in that type of cases.
• ü Data does not shows that how many cases are treated as sputum negative are re sputum examination was done.
• ü Data does not show that why retreatment cases are increased it is due to Dot's compromised or lesser effective drugs or other reason etc.
• ü Data does not show how many patients are restarted by retrieval action within 2 month period.
• ü Data does not show actual prevalence of disease in the community.

Though the last survey was carried out in 1958 by Chennai for actual prevalence of Infection and incidence of disease which is followed in RNTCP programme for giving goals, targets and Norms to achieve.

• ü Data does not show actual annual risk of Infection according to that the occurrence of cases pulmonary, extra pulmonary and retreatment. Cases yet. Some cases are missing.
• ü Data does not shown that how many patients whose one sputum was only given and they are positive but they are not come again to the health care system.
• ü Data does not shows that how many patients have not given their last follow up and they are declared as cured or treatment completed.

Data does not show Multi-Drug resistance cases.

Source -          Central TB Division

                        Health and F.W.

                        New Delhi.

                        www.ntc India.org

                        (WHO SEARO)

Thanks,