Innovative Experiment done at West Godavari District of Andhra Pradesh

ICT to help fight TB

Every year, approximately 2 million persons in India develop tuberculosis (TB), accounting for one fourth of the world's new TB cases

Tuberculosis (TB) is an infectious disease caused by a bacterium, Mycobacterium Tuberculosis. It spreads through air by a person suffering from TB. A single infectious patient can infect 10 or more people in a year.

It primarily affects people in their most productive years of life and is commonly associated with poverty, overcrowding, and malnutrition.

National TB Control Programme (NTCP) was launched in 1962 in India on a 50:50 sharing basis between Centre and State in regard to supply of anti-TB drugs. The objective of the Programme was to detect as many cases as possible and effectively treat them so as to render infectious cases as non-infectious. Since its inception, the programme is integrated with the primary health care infrastructure in the States.

Though the NTCP has been in operation since 1962, it had not made any significant epidemiological impact in controlling this scourge. The Programme was reviewed by an Expert Committee in 1992. Based on the findings and recommendations of the Review, the Government of India evolved the Revised National TB Control Programme (RNTCP) based on Directly Observed Treatment Short Course (DOTS) strategy with the objective of curing at least 85% of new sputum positive patients and detecting at least 70% of such patients.

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, supervisions are intensified. The RNTCP shifts the responsibility for cure from the patient to the health system.

 

Diagnosis of TB cases is made through quality sputum microscopy, by examining three sputum samples of the chest symptomatics over a 2-day period. Facilities for sputum microscopy are available free of cost at RNTCP microscopy centers.

 

If all three acid-fast bacilli (AFB) smears are negative, 1--2 weeks of broad-spectrum antibiotics are prescribed. If a patient with negative smears continued to have symptoms after 1--2 weeks of broad-spectrum antibiotics, a chest radiograph was taken, and if that is indicative of disease, the patient is treated for TB.

 

The entire TB treatment is given three times weekly on alternate days; the diagnostic evaluation and the entire course of treatment is free of charge. During the first 2 months of treatment (intensive phase), patients are treated with isoniazid, rifampin, pyrazinamide, and ethambutol (streptomycin is added for retreatment patients, and ethambutol was omitted for smear-negative, non seriously ill patients); every dose is observed directly by either a health-care provider or a non family community member. For the remaining 4--6 months of treatment (continuation phase), either Isoniazid and Rifampin or Isonizaid, Rifampin, and Ethambutol are prepared into weekly packs, and at least the first dose each week is observed directly

Under the DOTS strategy, patients swallow the drugs under direct observations of the health worker viz. the DOT provider. The selection of the DOT provider is not restricted to medical personnel. Any responsible person of the locality /community except a family member can function as DOTS provider. The patient is required to visit the designated DOTS center and consume the medicine in the presence of the DOT provider. In case the patient drops out/fails to attend the health facility on the scheduled day, then it is the responsibility of the DOT provider to retrieve the patient to the system and ensure completion of the treatment regimen.

One of the unique features of this programme is the fact that patient wise treatment boxes are available with the DOT provider with the full regimen of drugs needed to complete the treatment. This facility ensures availability of anti-TB drugs for a patient for his/her full course of treatment on the very first day he/she is registered.

The RNTCP is implemented through TB Societies at the State and District levels. There is a State TB Officer and District TB Officer who are responsible for the effective implementation of the programme in the States and Districts respectively. The District TB Societies are headed by the District Collectors while the state level society is headed by the State Health Secretary.

This revised strategy was initially pilot tested in 1993 in a population of 2.35 million and it showed remarkable success. The RNTCP was then extended to a population of 13.85 million to assess its operational feasibility.

RNTCP has been expanding rapidly. As on date, the coverage is more than 744 million in 414 district in 26 states and union territories. It is envisaged to cover 800 million population by the year 2004 and the entire country by 2005.

Till date more than 1 million patients have been put on treatment under RNTCP averting nearly 200,000 deaths & preventing more than 2 million infections.

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."

The implementation of RNTCP has resulted in a net savings of more than $400 million in economic costs; effective nationwide implementation by 2005 would save more than $27 billion through 2020. Sustaining and expanding this program will require continued high-level commitment from the central and state governments of India, supplemented by continued and coordinated assistance from international and bilateral organizations.

Progress toward TB control in India is critical to global TB control and has direct implications for TB elimination efforts in the world.

However the picture is not yet complete.  Unless every patient who is identified and screened is tracked till his final treatment, the possibilities of the patients dropping out before their final cure always present a lurking danger.  The false sense of satisfaction due to temporary relief coupled with economic factors and bureaucratic apathy is the identified cause.

The statistics coming out currently is based on the aggregate data and does not provide the possibility of knowing what is happening to various individual cases.  In order to address this, a Patient based Monitoring System has been designed and implemented in West Godavari district of Andhra Pradesh.  The system uses the information and communications technology for achieving this objective.

All the Primary Health Centres that act as the basic delivery point for this programme have been computerized.  Every PHC has a data entry operator who has been trained on this web based system. The PHC, microscopic centre and the treatment unit have their own logins and passwords enabling them to access and feed data.  Although the PHCs currently access the website through a dial up network, plans are afoot to establish a district wide area network for better connections. 

The suspected cases that come to the PHCs are first recorded in the web based system and allow the possibility to be tracked till their microscopic examination is done at the MC unit.  This would allow strengthening of the referral system from the PHCs to the microscopic unit and reduce the chances of the suspected cases and the investigation drop outs.  This would help in establishing a two way feedback system.

  

 

The data pertaining to all the suspected cases is thus available on the website and the microscopic unit can then access them in its inbox and make required entries after the test is done.

 

 

 

SPUTUM EXAMINATION FORM

 

InBox

Back

 

 

 

PHC Name:

Veravasaram (MS)

Ms Name:

Veeravasam

Op.No

2003-536-878

Lab No:

Name of the Patient:

ADALA NARAYANAMMA

Lab Visit No :

1

Address:

BANDAMVARIST. GAVARAPALEM

 

Age:

31

Sex:

Female

Group:

Adult

Weight

 

Disease Classification:

Pulmonary

Extra-pulmonary

 

Both

Reason for Examination:

Diagnosis

Follow-Up of Chemotherapy

Type of the Patients :

Select Category :

Select Phase:

Site :

Date :

// (DD/MM/YYYY) 

(a) Various Specimen Of Sputum:

 

Mucopurulent

Blood-Stained

Saliva

Specimen 1:

Specimen 2:

Specimen 3:

 

 

(b) Microscopy:

Specimen 1:

Results:

Specimen 2:

Results:

Specimen 3:

Results:

Xray

 

Examined By Doctor:

Remarks:

 

Once the investigation details are entered on the site, the treatment unit can access the same and based on the results generate an auto treatment card, which then becomes the basic document at the PHC level for the subsequent follow up of the patient.  The treatment card for individual patients can be periodically updated at the PHC level and would therefore eliminate the possibilities of false reporting.

PATIENT TREATMENT CARD

Name of the MS Center: lingapalem (TU)

Back   

Patient TB No:

463 

Health Unit:

lingapalem (TU) 

 

Name of the Patient :

Buddarapu Santhamma

Address:

Peda malapalli Kothapalli Lingapalem Md

 

Sex:

Female 

Age:

45 

Category:

1 

Type of Patient:

NEW  

 

Disease Classification:

Pulmonary
Extra-Pulmonary
 Site:  

Month

Date

Lab No

Smear Result

Weight

0 

11/11/2003 

331 

3+ 

42 

2 

13/1/2004 

037 

-Ve 

44 

Patient Out Come :Treatment Going on

 

 

M/D

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