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1 A rap id appraisal of organisation , implementation and utilization of DOTS in Jammu district Supervisor : Dr S.Vivek Adish BY  DR Vinay Chib National Institute of Health and Family Welfare Munirka, New Delhi-110067
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    A rapid appraisal of organisation , implementation

    and utilization of DOTS in Jammu district

    Supervisor : Dr S.Vivek Adish

    BY

    DR Vinay Chib

    National Institute of Health and Family Welfare

    Munirka, New Delhi-110067

    http://www.nihfw.org/
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    Table 1Acronyms

    AIDS Acquired Immunodeficiency Syndrome

    CHC Community Health Centre

    CTD Central TB Division

    DANIDA Danish International Development Agency

    DTC District TB Centres

    DTO District Tuberculosis Centre

    DMC Designated Microscopy Centre

    GDP Gross Domestic Product

    HDI Human Development Index

    HIV Human Immunodeficiency Virus

    MO Medical Officer

    MOTC Medical Officer Tuberculosis Centre

    MDR-TB Multi-drug Resistant TB

    NTP National Treatment Program

    PHC Primary Health Care Centre

    RNTCP Revised National Tuberculosis Control Programme

    SIDA Swedish International Development Agency

    STC State TB Cells

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    STO State Tuberculosis Officer

    STLS Senior Tuberculosis Laboratory Supervisor

    STS Senior Treatment Supervisors

    TB Tuberculosis

    TBHV Tuberculosis Health Visiter

    TU Tuberculosis Unit

    USAID United States Agency for International Development

    WHO World Health Organization.

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    INTRODUCTION :-

    GLOBAL BURDEN OF TB

    Tuberculosis is the leading cause of death from a curable infectiousdisease caused by Mycobacterium Tuberculosis. TB has affected

    mankind for over 5000 years and is still continuing to be a leading

    cause of morbidity and mortality. More than 1.3 million people die of

    this disease every year. Nearly 1/3rd

    of the worlds population is

    infected with tuberculosis Bacilli and approximately 10% of them

    have a lifetime risk of developing TB disease.

    In 2008, there were estimated 9.4 million new cases equivalent to

    139 cases per 100,000 population of TB globally. TB-HIV co-infection

    and drug resistant tuberculosis has aggravated the TB situation

    globally. Of the 9.4 million incident cases in 2008, an estimated 1.4

    million (15%) were HIV positive. MDR TB (Multi Drug Resistant TB ) is

    emerging as a major challenge to the programme managers. There

    were an estimated 0.5 million cases of MDR TB in 2007.

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    TB DISEASE AND TREATMENT

    TB is caused byMycobacterium tuberculosis and is spread through airbornedroplets (Frieden et al., 2003). More than 80% of people with active TB havepulmonaryTB (World Health Organization, 2005), which can be infectious or noninfectious. There are two steps that are associated with the development of TB.The first is infection byM. tuberculosis, which usually occurs through closeexposure to persons with infectious TB. This first step leads to latent TB infection,which is asymptomatic and non-infectious (Global Alliance for TB DrugDevelopment, 2001). Nearly one-third of the worlds population has latent

    infection byM. tuberculosis and could develop active TB at anytime (World Health Organization, 2003). Within months to years after the initialinfection with the TB bacteria, approximately 10% of infected people developactive TB (Global Alliance for TB Drug Development, 2001). Untreated, a personwith active TB disease will infect 10-15 people annually (World HealthOrganization, 2005). Conditions that increase the likelihood of active infectioninclude HIV, malnutrition, vitamin D or A deficiency, underlying malignantdisease, or other medical conditions (Frieden et al., 2003).

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    TUBERCULOSIS BURDEN IN INDIA

    India is the highest TB burden country accounting for 1/5th

    of globalincidence. Every year approx. 18 Lac people develop TB and about 4

    Lakh die from it.

    In India EVERY DAY:

    More than 40,000 people become newly infected

    with tuberculosis bacilli.

    More than 5000 develop TB disease.

    More than 1000 people die of TB(i.e. 1 death every

    11/2

    minutes.)

    In 2008, out of estimated global incidence of 9.4 million cases, 1.98

    million cases were from India.

    ESTIMATED BURDEN OF TB IN INDIA

    No of million (95%CI) Rate per lac

    person(95%CI)

    Incidence( WHO

    estimate 2009)

    All cases

    AFB smear positive

    1.982

    0.885

    168

    75Period

    Prevalence(2000-GOI

    estimate)

    AFB positive

    Bacillary

    1.7

    3.8

    165

    369

    Prevalence all

    cases(2000 WHO est)

    Prevalence All cases

    4.968

    3.304

    443

    283

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    (2007 WHO

    estimate)

    Prevalence all cases

    (2009 WHOestimate)

    2.186 185

    TB-related Millennium Development GoalGoal 6 to combat HIV/AIDS, malaria and other diseasesTarget 8 to have halted by 2015 and begun to reverse the

    incidence of malaria and other major diseases, includingtuberculosis.Indicators for Target 8 to be used to evaluate the implementationand impact of TB control:Indicator 23: Between 1990 and 2015, to halve the prevalenceand death rates associated with tuberculosis; andIndicator 24: by 2005, to detect 70% of new smear positiveTB cases arising annually, and to successfully treat 85% of these cases.

    PROGRESS TOWARDS MDG INDICATOR 23

    Prevalence rate of TB

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    Mortality rate of TB

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    The revised National TB control program (RNTCP) based oninternationally recommendations Directly Observed Treatment Short

    Course (DOTS) Strategy was launched in 1997 and was expanded

    across the country in a phased manner with support from the World

    Bank and other development partners.

    The objectives of the program are to :

    a)To achieve and maintain cure rate of at least 85% among New

    Sputum positive patients.

    b)To achieve and maintain case detection at least 70% of the

    estimated NSP cases in the community.

    The only effective means by which 85% cure rate or more has been

    shown to be achieved able on a programme basis is by application of

    the DOTS strategy.

    DOTS is a systematic strategy which has 5 components:-

    1.Political and administrative commitment.

    2.Good quality diagnoses by sputum smear microscopy.

    3.Uninterrupted supply of good quality drugs.

    4.Directly observed treatment.

    5.Systematic accountability

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    GOAL of RNTCP:-

    Cure at least 85% of the registered New Sputum Positive Cases Detect at least 70% of the estimated New Sputum Positive

    cases existing in the community (67-95 cases per lac/year)

    S

    NoIndicators

    Expected

    Value/Range

    1 Chest Symptomatic among Total Adult OPD 2%-3%

    2Positive cases to be found in chest symptomaticcases examined

    8%-12%

    3 Annualized Total Case Detection Rate(ACDR) 180

    257cases/Lac/Year

    4Annualized New Sputum Positive Case DetectionRate

    6795 cases/Lac/year

    5Conversion rate of New Sputum Positive Casesat 3 months

    >90%

    6 Cure Rate Among New Sputum Positive Cases >85%

    7 Death Rate among NSP Cases

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    Tuberculosis (TB) is a serious global health threat, infecting more than 8 millionpeople with the active form of the disease and killing almost 2 million people eachyear. TB control and treatment has become a growing concern in developingcountries, particularly in India, where more than 20 percent of new TB cases

    occur annually (World Health Organization, 2005). The public health sector ofIndia is ill equipped to deal with this burden, having a shortage of functioningpublic health infrastructure (Bajpai and Goyal, 2004). This shortage leads tofurther economic and health consequences for those infected with TB as theyoften go into debt to seek treatment from the ill-regulated private sector; they usethe private sector as an alternative to seeking care from the public sector, which isoften perceived to be of poor quality (Bajpai and Goyal, 2004; Gupta,2005;Rajeswari et al., 1999).

    Previous national TB control programs in place in India since the advent of drugsto treat the disease in the 1960s were proven inefficient and ineffective at properlydetecting and treating TB.Globally, national governments and international aidorganizations have joined forces to combat this epidemic by implementingfunctioning public health care programs using the Directly Observed Treatment,Short-Course (DOTS) strategy. In India, this effort has taken the form of theRevised National Tuberculosis Control Programme (RNTCP), one of the twolargest programs of its kind in the world both in terms of population coverage andnumber of patients treated (World Health Organization, 2005). The RNTCP, firsttested at a pilot level in 1993, was implemented in almost all districts of India

    through the existing public health infrastructure by 2005 (Agarwal and Chauhan2005). Financed primarily as a centrally funded (with assistance from externalloans and grant aid) disease control program, the RNTCP also requires stateinitiative and inputs for its implementation. The program is implemented at thedistrict level, which is the lowest level of administrative division in India.

    The need for increased TB control in India is apparent, as evidenced by the factthat there are almost 2 million new cases of active TB each year in India alone(World Health Organization, 2005). The potential economic benefits of

    implementing a well functioning DOTS program in India have been estimated at$750 million (in 1993-1994 prices) annually (Dholakia and Almeida, 1996).

    The primary mechanism currently in place under WHO guidelines for the globalcontrol of TB is the worldwide implementation of functioning DOTS programs.DOTS, originally an acronym for directly observed therapy, short-course, isnow used to describe a broader WHO public health strategy for TB control(Onyebujoh et al., 2005).

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    There are five aspects that comprise the DOTS strategy: sustained political

    commitment; access to quality assured TB sputum microscopy; standardizedshort-course chemotherapy for all cases of TB under proper case managementconditions, including direct observation of treatment; uninterrupted supply of

    quality-assured drugs; [and a] recording and reporting system enabling outcomeassessment of all patients and assessment of overall programme performance(World Health Organization, 2003). The DOTS strategy requires the use ofsputum smear microscopy for the diagnosis of pulmonary TB (Global Alliance forTB Drug Development, 2001). Treatment programs are given under intermittentconditions (preferably three times per week) and must be directly observed by ahealth care provider or trained community member (World Health Organization,2003).

    The standard treatment regimen is for a duration of six months and costs as littleas $11-$17 in developing nations (World Health Organization, 2005a). DOTS hasbeen shown to be an extremely cost-effective treatment strategy; some studiesclaim that DOTS is the most cost-effective of all health interventions available.Others indicate that it costs as little as $1-$4 per discounted year of life saved(Ahlburg, 2000). In India, conservative estimates show that the potentialtangible benefits of DOTS implementation are on the order of US$750 million peryear (Dholakia and Almeida,1996).

    Strict supervision and monitoring is very important component in RNTCP. A

    study on effectiveness of DOTS on Tuberculosis patients treated underRNTCP(A.Mishra and S.Mishra NTI Bangalore 2007) showed that higher curerate and conversion rates were achieved due to concrete efforts in the form ofstrict supervision and monitoring along with motivation of cases health and non-health personnel.

    An evaluation of bacteriological diagnosis of smear positive pulmonarytuberculosis under programme condition in three districts in the context of DOTSimplementation was done by Paranasivam, CN Narang(Indian journal of TB

    2006) The study revealed an unacceptably high level of false positive in sputumsmear microscopy in Wardha district. This could be attributed to the absence ofsystematic and intensive trainings in smear examination consequent to the nonimplementation of the DOTS strategy in this district and a high standard oftrainings offered in RNTCP.

    Another study by Gopi PG and Chander sekaran (Indian journal 2006) showed that cure andconversion rates were linearly associated with initial sputum smear grading. High default anddeath rates were responsible for low cure and conversion. The proportion of patients who

    required extension of treatment and those who had an unfavourable treatment outcome weresignificantly higher among patients with 3+ initial smear grading. This reiterates the need to

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    pay more attention in motivating these patients to return to regular treatment and sustainedcommitment in the control of Tuberculosis .

    The economic burden of TB is especially high due to the number of people

    infected and the fact that more than 75 percent of TB morbidity and mortalityoccurs in the most economically active segment of the population, those between15 and 54 years of age (Ahlburg, 2000). Additionally, there is a vicious cyclebetween poverty and TB disease. The poor are more likely to contract TB due tocrowded living conditions. The probability of infection as well as the probabilityof developing active TB from this infection is correlated with malnutrition,crowding, poor sanitation, and poor air circulation; these factors are all associatedwith poverty. Those who develop active TB are then more likely to fall into orremain in poverty due to the economic costs of the illness. There is inadequatediagnosis and treatment among the poor, which leads to more ill-health and death,which ultimately increases poverty. Although TB is not exclusively a disease ofthe poor, the poor are less likely to seek and receive quality care, and are two tothree times more likely to self-medicate than higher income groups. This lack ofadequate treatment aggravates the health and economic effects of the disease(Ahlburg, 2000).The health status of the population is particularly important in India, where manypeople earn their living through physical power. Disease and poor health can pushpeople into extreme poverty, making it impossible for them to pull themselves outof this state1(Bajpai and Goyal, 2004). Some studies indicate that a third of those who had to

    borrow or sell assets to meet health care costs fell below the poverty line, andthese studies suggest that out of pocket medical costs may push as much as 2.2percent of the population below the poverty line each year (Gupta, 2005). Muchof Indias disease burden is comprised of infant and maternal morbidity andmortality, infectious diseases, and nutritional deficiencies. Many of theseproblems could be severely reduced through the use of low cost interventions andprevention undertaken by the public health structure of the government (Bajpaiand Goyal, 2004).

    In India, there is a large public health care system, which consists of the provision of carethrough a network of sub-centers, primary health care centers (PHC), community health centers(CHC), family welfare centers (FWC), and district hospitals. Coverage by government health

    services varies widely across the states of India, although almost all states were still inadequateaccording to the specific guidelines set by the Indian government. In addition to the lack ofphysical infrastructure, there is a severe lack of qualified staff in the health centers. This is aproblem particularly in rural areas, where staff recruitment is a serious problem (Bajpai and

    Goyal, 2004). This leads to health services being severely skewed towards urban areas(Seshadri, 2003). These shortages in

    the public health care system disproportionately affect the poor, who are thepredominant users of primary health care services. The absence of adequate public

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    services means that many people either entirely do without medical care or seekexpensive and unregulated care in the private sector. Spending in the private

    sector accounts for almost eighty percent of expenditure on health (Bajpai andGoyal, 2004). Many of the problems with public health services are caused by

    inadequate funding by the central and state governments, whose expenditure onhealth (combined) accounts for three percent of government spending, or less thanone percent of Indias GDP (Mahal et al., 2002).

    Governments of other developing nations spend about three percent of their GDPon 14 health, while governments of developed nations spend about five percent oftheir GDPs (Bajpai and Goyal, 2004). In India, government spending on health is

    a responsibility of the state and national governments.

    Rationale --

    The purpose of the study is to assess the extent of the objectives of DOTS being

    achieved. Since RNTCP is an integrated programme, the key challange is to

    balance the urgent need for rapid expansion of the programme with the equally

    important need to ensure quality of implementation.

    There could be situation where RNTCP guidelines may get diluted at

    some places as already observed in various studies, which may lead to problemsand negative influences on the outcome of the programme . Being such a large

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    scale programme, there is need for reliable information regarding strengths and

    weeknesses in the implementation of DOTS both at micro and macro levels, so as

    to identify areas requiring improvement. It is not enough to view the programme

    from providers perspective only ,but it is equally important to consider views and

    experiences of the patients under going treatment .taking into consideration the

    facts above, a need is felt to review the implementation of RNTCP-DOTS strategy.

    The present study is an attempt to undertake review of the programme of the

    RNTCP at the micro level, so as to identify areas requiring strengthening and

    make suitable recommendations in order to achieve the desired goals of the

    programme.

    General Objective

    To study the organisation, implementation and utilization of DOTS in Jammu

    district.

    Specific Objectives

    To describe infrastructure facilities and resources available for RNTCP-

    DOTS in Jammu District. To study providers perception regarding DOTS.

    To analyse the implementation and achievements of DOTS at various levels

    in the district

    To ascertain the extent of satisfaction with services provided and problems

    if any among patients availing treatment under RNTCP.

    To make necessary recommendations for the improvement of the

    programme.

    MATERIALS AND METHODS:

    The details of the methodology adopted for the study is given below:

    1. Study design-A descriptive study design was used in the study.

    2. Study Area-

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    The study on RNTCP-DOTS Strategy was conducted in DTC Jammu and its

    TUs, DMCs and DOT Centres.

    3. Study population-

    a. Service providers For obtaining information on operational aspects of

    the programme and problems faced in implementation , staff members

    involved in diagnosis and treatment of TB patients at DTC, TUs, DMCs

    and DOT Centres.

    Among services providers at these centres the following staff were

    included: DTO , MO , STS, STLS, TBHV, LTs.

    b. Beneficiaries- To ascertain the extent of satisfaction and problemsfaced in availing treatment for TB,beneficiaries were included in the

    study from DTC and DOT centres.

    Sampling procedure and Sampling size:-

    Jammu district has 4 Tuberculosis units and 18 DMCs. Selection of DMCs

    was done as per the RNTCP guidelines for the internal evaluation of the

    district. A total of 5 DMCs and 10 DOT Centres were selected.

    A. Service providers- with regard to service providers all staff directly

    involved in RNTCP at DTC,TU,DMC and DOT centres were included-

    1. DTO -1

    2. MO 10

    3. STS - 4

    4. STLS -3

    5. TBHV-4

    6. LTs - 8

    7. DOT Providers- 10

    8. ASHA - 10

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    B. TB patients availing treatment The DTC Jammu has four TUs from

    which proportionate samples of patients was taken. Both pulmonary

    and EP TB cases were included in the present studies. The reference

    period from which the patient were selected for the study was 9 months

    which equivalent to the longest period for which anti TB drugs can be

    prescribed under RNTCP in any category.

    C. Patients and their treatment cards- in order to ascertain treatment out

    come, treatment cards of TB patients were included.

    D.Observation- Observation was also made to see the selected activities

    under the programme. For this all TUs , 5 DMCs out of 18 DMCs and 10

    DOT centres were included. Activities like sputum examination fordiagnosis, DOTS administration , health education , waste management

    ,record maintenance etc being performed by health workers was

    observed.

    Data Collection techniqueThe following techniques for data collection were

    used.

    Secondary data Study of Records and Registers-

    TB register of each TU

    Lab register of each DMC

    Treatment cards

    Primary data 1. Interview of TB Patients A total of 50 patients were

    interviewed using semi structured interview schedule for collecting information

    on various aspects like accessibility to DOT centres , experiences while availingtreatment , extend of satisfaction with treatment etc.

    2. Interview of service providers All the health providers who are working

    under RNTCP i.e a total of 50 were interviewed using semi structured interview

    schedule. Information collected included duties and responsibilities under RNTCP

    , problem faced , suggestions for improvement of the programme.

    3. Observation of infrastructure and facilities - Observation check list was used

    to access the physical infrastructure , facilities and supplies at various DOT

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    centres and DMCs. This included waiting area for patients availability of

    medicines , water , electricity , lab facilities , disinfection of bio medical waste

    etc.

    Tools for data collection

    Interview schedule to elicit the information from TB patients.

    (Annexure......)

    Interview schedule for staff (Annexure.....)

    Observation check list for DMC (Annexure.....)

    Observation check list for DOT centre (Annexure.....)

    Observation check list for TU drug store (Annexure.....)

    OBSERVATIONS AND FINDINGS-

    RNTCP in Jammu District-

    Jammu District is one of the 22 districts of the state of Jammu &

    Kashmir. In the north, Jammu and Udhampur district

    bound the district; district Samba in the East, while international

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    borders are in south and west. Jammu city is situated on the banks of

    river Tawi and is the winter capital of J&K state.

    About 1/4th

    part of the district is hilly. Most part of Dansal and

    Purmandal Blocks are hilly while larger part of Akhnoor is hilly. Forest

    covers about a third of the area of District. Consequently, Jammu

    consists of difficult and inaccessible areas.

    Samba is a newly formed district of Jammu province `but from RNTCP

    point of view, it is still working as Tuberculosis Unit under DTC

    Jammu.

    RNTCP in Jammu District was implemented on 8th

    April 2004.It is a truly

    integrated programme, implemented through DTC, TUs, DMCs, DOT Centres.

    DOTS is the most cost effective way to deal with TB problem through wide

    spread network for an improved case finding activity coupled with the facility for

    the treatment of cases found as near to their homes as possible.

    The WHOs Directly Observed Treatment Short Course Strategy consists of

    measures to ensure a complete cure and to prevent development and drugresistance. Health workers are trained to directly observe TB patients ingest the

    anti TB drugs thrice in a week. DOTS also involves the establishment of case

    detection and monitoring system.

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    Breakup of Health Units in Distt Jammu

    1.District Hospital 1

    2.SDH 1

    3.Allopathic Dispensary - 14

    4.PHGs 35

    5.Urban Health Units (Under Medical College) - 1

    6.Urban Health Units (Under Heath Deptt.) 14

    7.Mobile Unit 1

    8.TB centre 1

    9.STD/VD clinic 1

    10. Railway Hospital 1

    11. Leprosy Hospital 1

    DOTS was implemented in District Jammu on 8th

    April

    District profile-

    Total Tuberculosis Unit 4

    Designated Microscopic Centres 18

    DOT centres 281

    Break up

    TU Population DMC DOT centres

    Jammu 66,844 7 85R.S Pura 4,48,235 4 69

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    Akhnoor 3,71,470 3 75

    Samba 3,19,212 4 52

    Total 18,05761 18 281

    Jyoti Gupta 5

    Map of Distt. Jammu

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    Jyoti Gupta 5

    Map of Distt. Jammu

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    STRUCTURE OF RNTCP AT DISTRICT LEVEL

    District Administrator

    District Health Services

    Nodal Point for TB Control

    District TB Centre

    z Tuberculosis Unit

    Microscopy Centre

    DOT Centre

    One / 500,000 ( 250,000 in

    Hilly / difficult area )

    One / 100,000 (50,000 in

    hilly / difficult area )

    CMO and Supporting

    Staff

    DTO, MO-DTC, LT, DEO,

    Driver, TBHVs

    MO, STS, STLS, LT, TBHV

    MO, Paramedical

    Staff, LT

    TBHV, DOT Provider (MPW,

    NGO, PP, ASHA, Community

    Volunteers)

    District Magistrate /

    District Collector

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    ORGANISATION STRUCTURE

    DISTRICT TUBERCULOSIS CENTRE JAMMU

    District Tuberculosis Centre Jammu is the Nodal point for TB Control activities in

    the district. The building of DTC is located in Chest Disease Hospital Complex,

    near Govt. Medical College Jammu. The DTO has the overall responsibility of

    physical and financial management of RNTCP at the district level. The DTO is also

    responsible for involvement of other sectors in RNTCP and is assisted by one MO.

    The post of the second MO is lying vacant in DTC.

    MO in DTC is looking after the OPD. She is sending the Chest Symptomatics to

    DMC which is a part of DTC only. DTC also has a DOT Centre where patients are

    given medicines under direct supervisions by DOT Providers ( Jr. Staff Nurse and

    FMPHW). Drug days for direct observation treatment are Monday, Wednesday

    and Friday.

    STAFF POSITION IN DTC

    S.No. Designation No. in

    Place

    Permanent /

    Contractual1. DTO 1 Permanent

    2. MO 1 Permanent

    3. TO 1 ----do----

    4. BCG Team Leader 1 ----do----

    5. Lab. Tech. 3 ----do----

    6. Pharm./ StoreKeeper

    1 ----do----

    7. X-ray Tech. 2 ----do----

    8. BCG Tech. 1 ----do----

    9. TBHV 2 1(Permanent)

    1(Contractual)

    10 Jr. Staff Nurse 1 Permanent

    11. FMPHW 1 ----do----

    12. NO 3 ----do----

    13. STS 1 Contractual

    14. STLS 1 ----do----

    15. DEO 0 ---------------16. P/T Acctt. 1 ----------------

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    17. SA 1 Permanent

    18. Accountant 1 ----do----

    DISTRICT JAMMU

    4 TUs

    DTC TU JAMMU SAMBA TU AKHNOOR TUR. S. PURA TU

    18 DMCs

    CHC SAMBA

    EH VIJAYPUR

    CHC RAMGARH

    PHC RAYA

    CHC AKHNOOR

    PHC JOURIAN

    CHC PALLANWALA

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    DTC JAMMU

    GOVT. MEDICAL COLLEGE

    ASCOMS

    PHC KOT BHALWAL

    CHC DANKSAL GANDHI NAGAR HOSPITAL

    CHC MARH

    DTC Jammu is divided into 4 TUs-

    1. TU Samba

    2. TU Jammu

    3. TU Akhnoor

    4. TU R S Pura

    A team comprising of specifically designated medical officer TB Control

    (MOTC), Senior Treatment Supervisor (STS) and Senior Tuberculosis Lab

    Supervisor is based in a CHC/ Sub district hospital.

    The TU covers a population of about 3-4 lacs and there is one DMC for every 1

    lakh population. TU is the nodal point for TB control activities at sub district.

    MOTC at TU has the over all responsibility of management of RNTCP and is

    assisted by STS and STLS.

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    OPERATIONAL ASPECTS OF RNTCP DOTS

    1. Case detection and diagnosis

    Sputum microscopy is the primary tool for diagnosing and monitoring of TBpatients. Sputum microscopy is done only in Designated Microscopy Centres

    (DMCs).

    In district Jammu there are 18 DMCs. Persons with cough for

    two weeks or more, with or without other symptoms suggested of TB are promptly

    identified as pulmonary TB suspects and are subjected to sputum smear

    microscopy for AFB By the medical officers.

    In all the DMCs there is a full time trained lab technician who

    fills up the lab forms and gives sputum containers to patients after instructing himhow to cough out the sputum. He collects on the spot specimen and gives another

    container for early morning sample. After collection of sputum staining is done and

    a report is prepared with proper grading. All the sputum positive results are

    written in red ink in the lab register. In all the DMCs all the essential consumables

    including binocular microscope is available. Facilities for running water for the

    staining purpose are also present in all the DMCs. At the end of every month a

    summary abstract is completed by every LT.

    In health centres other than DMCs there is no provision for collection of sputum.Also no sputum slides are being made in PHIs. Patients from these centres are

    referred to nearest DMC.

    2. Categorisation , Registration and initiation of treatment

    If the sputum smear examination is positive for

    AFB , the patients is referred to MO for categorisation of disease (into CAT-1,2 and 3) and

    TBHV makes home visit to confirm the address of the patient. If the patient is resident of the

    area he/she is started on anti TB treatment after assigning registration number in TB register

    of that TU, otherwise patient is referred to respective DOT centre for further case

    management.

    The anti TB treatment started after proper health education and motivation. Sputum

    negative patients are given a course of antibiotic and then sputum examination is repeated. If

    he does not improve he is referred for chest x ray and other investigations for confirmation of

    diagnosis.

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    3. Treatment regimen followed -

    CAT- I : New sputum positive , seriously ill sputum negative and seriously ill extra

    pulmonary.

    2 months-RHZE , 4 months RH (thrice in a week).

    CAT-II : Retreatment cases

    2 months SRHZE , 1 month RHZE , 5 months RHE (thrice in a week)

    CAT- III : Non seriously ill sputum negative and EP

    2 months RHZ , 4 months RH (thrice in a week)

    R- Rifampicin

    H- Isoniazide

    E-Ethambutol

    S-Streptomycin

    Z- Pyrazinamide

    ( GOI 1997 )

    All drugs are administered trice weekly for a period of 2/3 months. Patient is asked to

    swallow the medicines in front of the health worker in Intensive phase. After this repeat

    sputum examination is done, if found negative continuation phases started. In this phase

    drugs are provided on weekly basis, the first dose of which is directly supervised. All the

    entries are made and patients record is maintained by TBHV/DOT provider at DOT centre

    which is under supervision of STS. MOTC is responsible for managing the treatment unit.

    Drug Administration

    During intensive phase thrice in a week patient is given medicine under direct

    supervision Monday, Wednesday and Friday. If the patient misses taking drugs on a

    specific day, he can take them next day. The patient must be contacted within one day

    of missing dose in intensive phase. During continuation phase the first dose of weekly

    blister should be directly observed. The patient must be contacted within a week of

    missing weekly collection of drugs.

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    Follow up-

    The follow up of each patient is to be done at 2-3 months and second at 4-5 months and last at

    the end of the treatment. Two sputum smears are examined each time during follow up. For

    the patients who need to be transferred from one TU to another, the transfer form is filled and

    patient is referred to respective areas.

    4. DRUGS FOR TB TREATMENT

    An uninterrupted supply of good quality Anti-TB drugs is one of the five components of DOTS

    strategy. A strong procurement & logistics management with respect to drugs is essential to

    strengthen every link in the drug supply chain from manufacturer to patients. There is a unique

    system of providing drugs in patient wise boxes ( PWB ) which contain drugs for entire

    duration of Treatment for each category of Patient. Once a patient is started on anti- TB

    treatment, a box is assigned to that patient, thus ensuring that entire course is available

    uninterrupted.

    DRUG MANAGEMENT :

    a. Selection : The essential drugs used in RNTCP are Rifampicin , Isonized , Ethambutol ,

    Pyrazinamide & Streptomycin.

    b. Procurement of Drugs : Procurement of anti TB drugs is done both for PWBs as well as

    loose drugs. In exceptional circumstances few patients may have to be put on Non-

    DOTS regimen. For such patients loose drugs need to be procured. Loose drugs are also

    required for pediatric patients , adult patients with low body weight & over weight

    patients. Procurement of anti TB drugs is made through independent agency appointed

    by the Ministry of Health & Family Welfare, Govt. of India .

    c. Distribution : Govt. Medical Stores Depot ( GMSDs )

    ( at karnal , Mumbai , Kolkata , Chennai, Gawhati & Hyderabad )

    State Drug Stores

    District TB Centre

    Treatment Unit

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    d. Storage of Drugs : Establish storage procedure to ensure that drugs & other supplies are

    o protected from Unauthorized access.

    o Protected from heat, light, moisture, dust ,pests & fire.

    o Easy to locate & identify : Drugs stored according to their expiry date with

    clearly marked & differentiate. Use the FEFO ( First expiry first out)

    o Maintain of Records : To know that sufficient stock is available at all levels &

    there is no expiry of drugs.

    o Maintaining adequate supplies : It is very important to make sure that every

    health facility in the district has an adequate supply of anti TB drugs. Pts. Must

    take all their drugs regularly to be cured of TB. Timely initiation if Treatment is

    not possible if the supply of drugs is inadequate.

    o Quantity of reserve stocks at each level at the start of quarter

    Level Reserve Stocks

    PHI 1-Month

    TU Drug Store 2-Months

    DTC Drug Store 3-Months

    State Drug Store 3-Months

    Recording and reporting

    Maintenance of accurate records and registers of patients of

    programme activities and reporting data to the State / Central Unit each quarter is

    essential for proper monitoring and management of RNTCP. The reporting is done

    through various periodic reports from different levels of Health System.

    In Jammu Distt. , DTO is the overall incharge of Tuberculosis Control

    Activities and answerable to State TB Officer at State Health Directorate. He / She reviews the

    monthly activity reports of all MOTCs, STLS and STS with in the Distt. during the monthly Distt.

    level meeting of the said staff. The monthly PHIs reports are also available at these meetings.

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    The date of the review is fixed in advance. It is held on 1st

    of every month. Minutes of these

    meetings are also kept by DTO.

    At TU level reporting and recording is done by MOTC, STS and STLS.

    Tuberculosis register is kept at Sub-Distt. (TU) level in the Distt. TB treatment cards of the

    patients are kept in all peripheral health units. A duplicate card is given to the peripheral

    health functionaries who administer DOT. Patients keep identity card only. Monthly report is

    prepared every month and submitted to DTC. Quarterly report on case finding, sputum

    conversion rate of patients who are on treatment and all possible outcomes of smear positive

    cases of pulmonary TB (Cured, Treatment completed, Failure, Defaulted, Died and Transferred

    out) is prepared by STS. The STLS is primarily responsible for supervising all the lab. activities

    including checking 100% of sputum positive slides and at least 10% of sputum negative slides.

    It is the responsibility of TU to compile the DMC wise reports of sputum examination done,

    sputum found positive, NSP, sputum negative, patients put on treatment, extra pulmonarycases and submit the report to DTO.

    At DMC, the responsible staff are MO and LT. Tools at this level will be

    referral for treatment register, patients treatment card, RNTCP lab. register and supervisor

    register. MO should meet weekly all the staff involved in RNTCP. He is responsible for

    compilation of monthly PHI reports and its submission to TU.DTO who compiles the report (4

    copies) in respect to all TB units and sends three of them to the STO, The National Tuberculosis

    Institute Bangalore and to Central TB Division, DGHS Nirman Bhawan New Delhi.

    5. Supervision and monitoring

    Supervision is a systematic process for increasing the efficiency of health workers by

    developing their knowledge, perfecting their skills, improving their attitude towards work

    and increasing their motivationRNTCP has inherent ability to conduct regular supervision

    and monitoring at all the levels- national, state, district and sub- district.

    In Jammu District , District Tuberculosis Officer is the overall incharge of Tuberculosis

    Control Activities and answerable to State Tuberculosis Officer at the State Health

    Directorate. D.T.O. with the support of M.O. of DTC is responsible for ensuring the quality

    diagnosis , treatment, logistics and reporting. She is undertaking supervisory visits to all

    T.Us and Medical Colleges in the Distt. every month and all CHCs and PHCs in the Distt.

    every quarter. D.T.O. is provided with a govt. vehicle for purpose of supervision. She is

    maintaining the Tour Diary for keeping the record of supervisory visits.

    At T.U. Level , MOTC, STS, and STLS are responsible for undertaking supervisory visits to all

    the PHIs, NGOs and PPs. The MOTC is responsible for supervising the work of TU, STS and

    STLS in addition to his / her other responsibilities. He has to submit Tour Programme at the

    begining of the month to D.T.O. and maintains Tour Diary for keeping the record of his

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    supervisory visits. He can hire the vehicle for this activity and can claim charges as per

    RNTCP guidelines from DTC.

    STLS is responsible for the quality of sputum smear microscopy services provided by

    DMCs under TU. He is visiting all the DMCs under the TU at least once in a month.

    STS visits all the PHIs at least once every month he checks whether all the sputum smear

    positive patients recorded in the TB Lab. register are placed on treatment and register in

    TB register. He also compares the date in the TB Lab. register with that in the TB register.

    STS & STLS are provided with a motor bike under RNTCP guidelines for supervisory visits.

    They also prepare Tour Programme and maintain Tour Diary every month. They also carry

    supervisory checklist for this activity at DMCs and DOT Centres.

    Methodology of Supervision & Frequency of Visits

    Category of

    Supervisor

    Methodology of Supervision No. of Supervisory Visits

    DTO Interviews MOTC, M.O I/C of PHC / CHC,

    STLS, LT and DOT Provider, Health

    personnel of other sectors (NGO, Private)

    and the person incharge of anti-TB Drugsand consumable storage.

    Interacts with community and local

    opinion leaders.

    Randomly Interviews the patients and

    community leaders.

    Inspects records of TU, PHC and CHC and

    stock of anti- TB Drugs and Lab.

    consumable.

    Randomly Checks the microscopy centres

    and treatment observation centres.

    Visits all TUs every month

    and all DMCs every quarter.

    Visits all CHC / PHCs in the

    Distt. every quarter, onesub-centre from each block

    PHC area and proportion of

    DOT Centres every quarter.

    MOTC Interviews M.O I/C, PHC / CHC

    Randomly Interviews patients and

    community leaders.

    Interacts with community and local opinion

    leaders.

    Randomly checks the microscopy centres

    and DOT Centres. Stock of anti-TB Drugs

    and Lab. consumables.

    Visits all DMCs every month

    and PHCs / CHCs and DOT

    Centres once every quarter.

    Conducts supervisory visits

    7-days a month.

    STS Interviews Health workers at sub-centres.

    Inspects Records TB treatment cards and

    TB registers.

    Visits all PHIs at least once

    every month and all DOT

    Centres every quarter.

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    Randomly Interviews the patients.

    STLS Inspects all microscopy centres and Lab.

    records.

    Visits all DMCs once in a

    month.

    6. TRAININGS

    The RNTCP involves many activities, such as Case finding by sputum smear microscopy,

    Directly Observed Treatment with standardized short course Chemotherapy, Use of

    Recording & Reporting System, etc.. High quality training is critical to the successful

    implementation of RNTCP. It is imperative to conduct quality training of all levels of

    personnel who have TB related responsibilities.

    In Jammu district, most of the staff looking after Tuberculosis programme in trained

    but motivation level can still be improved by time to time refresher trainings.

    10. Information, Education & Communication (IEC)

    The stigma associated with TB precludes many from seeking medical help. The patients tend to

    discontinue treatment after sensing a feeling of well being. There is over reliance on X-ray for

    diagnosis especially in private sector & unsupervised treatment is offered with non

    standardized regimens.

    In order to control TB, there is need for dissemination of information about

    tuberculosis ( signs & Symptoms ), its cause, detection & treatment there by empowering

    individuals, families & communities to be responsible for behavioral change to achieve cure of

    people suffering from tuberculosis.

    7. Role of Medical Colleges in RNTCP in Jammu

    Involvement of Medical Colleges in RNTCP is a high priority in Jammu Distt.

    Medical College Professors have an important role in TB Control as opinion

    leaders and trend setters in sustaining the programme by teaching and practicing

    DOTS & most important of all as role models for practicing Physicians. In Jammu

    District following Medical Colleges are involved in RNTCP:-

    1. Govt. Medical College, Jammu.

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    2.Acharya Sri Chander College of Medical Sciences.

    Govt. Medical College, Jammu

    GMC, Jammu is playing a very important role in RNTCP. It is functioning as DMCas well as Dot centre. Since it is a tertiary level Hospital, people have lot of faith

    in the medical facilities available here. It caters to both rural & urban population

    in Jammu District. There is a separate Chest Diseases Hospital in Jammu city,

    where all chest symptomatics prefer to come for diagnosis & treatment. Also

    there are special wards for indoor patients. Patients in emergencies are referred

    to CD hospital. They are admitted here & treated with prolongation pouches.

    There is a well established Microscopy Centre which is performing very

    well as far as sputum microscopy is concerned. A well trained team of Medical

    Officer, Lab. tech., TBHV ( DOT provider ) is looking after RNTCP in CD Hospital.

    Also the Chest Physician posted in CD Hospital are contributing a lot in this

    programme. Above all Principal medical College who is a Chest physician. He is

    running a evening chest clinic in the hospital premises to help the chest

    symptomatics.

    Acharya Sri Chander College Of Medical Sciences. ( ASCOMS )

    ASCOMS is a private Medical college. It also has a DMC & a Treatment centre.

    RNTCP team comprising of Medical Officer, Lab. Tech., Dot provider ( TBHV ) is

    working there. Since the medical college is situated away from the city, the

    patients generally avoid going there. Most of the Doctors in the hospital are

    trained in RNTCP. Chest physicians working there are also trying their best to

    improve the outputs / results.

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    DTO ( District Tuberculosis officer ) Jammu is overall incharge of the DMC,

    ASCOMS. She is regularly supervising the DMC work & coordinating with the

    Doctors of ASCOMS for better results.

    No. of NGO's and Private Practioners in Jammu Distt.

    Initial attempts were made to involve many NGOs and private practioners.

    1. St. Josephs Missionary Hospital at Barjani Smailpur28 pts.

    2. Mother Teresa Charitable Trust at New Plots2 pts.

    3. Shivgotra Medicos (Retd. Army Personal) Bahu fort7 pts.

    4. Shivam Medicos Talab Tillo2 pts.

    5. Catholic Social Service Society, Kunjwani8 pts. (Sh.Nayamat Ali) (Coordinator)

    6. (7-8) ASHA Workers.25-pts.have completed their treatment.Only 1 (one) ASHA Worker

    is presently engaged-3 pts.

    7. NGOs and PVT. Practioners in other parts of TU Jammu.

    8. Approx. 45-50 ASHA Workers in TU R.S. Pura.

    9. ESI Hospital (DOT Centre).

    10. Railway Hospital (DOT Centre).

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    PERFORMANCE OF THE JAMMU DISTRICT FOR THE LAST FIVE YEARS

    The RNTCP has set certain expected levels of performance against whichthe calculated performance indicators are compared.Case detection rate indicates the extent to which patients with pulmonary

    smear positive tuberculosis are being treated by the public health system.The expected annualised case detection rate used in the programme

    planning is 95 NSP per lakh of population of Jammu and kashmir state, ofwhom at least 70% are expected to be detected in the Government healthfacilities. From Fig 2, it can be observed that with respect to case detectionrate, jammu district is not doing very well. The case detection rate isslowly increasing in the district.

    A.CASE FINDING REPORTNEWSPUTUM POSITIVE CASE DETECTION RATE

    YEAR Population

    [in lacs]

    No of NSP Per lac per

    year

    Percentage

    2005 17.41 618 36 38

    2006 18.11 594 33 35

    2007 18.69 883 47 492008 19.30 957 50 52

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    2009 19.95 1019 53 53

    NSP case detection

    618 594

    883

    9571019

    38 35 49 52 53

    0

    200

    400

    600

    800

    1000

    1200

    2005 2006 2007 2008 2009

    years

    NoofNSP

    No of NSP

    Percentage

    RE-TREATMENT CASES -

    All the defaulters, failures and chronic cases, in which the

    treatment is started again come under Re-Treatment cases. The

    expected value for is about 30%.

    Year No of Re-

    Treatmentcases

    percentage of

    RT cases out oftotal sputum

    positive cases

    2005 136 18

    2006 293 33

    2007 446 34

    2008 473 33

    2009 553 35

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    Retreatment cases

    136

    293

    446473

    553

    1833 34 33 35

    0

    100

    200

    300

    400

    500

    600

    2005 2006 2007 2008 2009

    years

    Noofretreatmentcases

    No of Re-Treatment cases

    percentage of RT cases

    out of total sputum

    positive cases

    From the graph ,it can be observed that re-treatment cases are

    with in the expected value.

    SMEAR NEGATIVE PULMONARY CASES-

    (out of total new pulmonary cases)

    The detection of smear ve cases also needs improvement for effectingcontrol of TB in the community. There should ideally, be a one to one

    relationship between the number of new smear positive case sand newsmear negative cases. Thisratio should however be never higher than1:1.2

    Year No of NSN percentage

    2005 614 50

    2006 748 56

    2007 629 42

    2008 493 34

    2009 578 36

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    Smear negative EP

    614

    748

    629

    493

    50 56 42 34

    0

    100

    200

    300

    400

    500

    600

    700

    800

    2005 2006 2007 2008

    Years

    NoofNSN

    No of NSN

    Percentage

    EXTRA PULMONARY CASES-

    Year Extra

    pulmonarycases

    All New

    cases(NSP+NSN+NEP)

    percentage of

    New EP out ofall New cases

    2005 349 1581 22

    2006 380 1722 22

    2007 620 2132 29

    2008 564 2014 28

    2009 632 2229 28

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    new sputum conversion rate

    87

    79

    87

    89

    92

    70

    75

    80

    85

    90

    95

    2005 2006 2007 2008 2009

    Years

    convers

    ionp

    ercentage

    conversion rate

    It can be seen that for each cohort of NSPs detected in the years 2005 -

    009, the smear conversion rate has been excellent and is around90%.

    NSP CURE RATE-

    Outcome indicators such as cure , completion, default, failure, death andtransfer rates are crucial for assessing the performance of the programme.The cure/success rate achieved for new pulmonary smear-positive casestreated under DOTS is the most important indicator of effectiveness ofchemotherapy in treating TB cases and hence success of the programme.Jammu district has achieved excellent success rates of about 86% formost of the cohorts of NSPs detected during 2005-2009.

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    NSP CURE RATE-(2005-2009)

    YEAR No cured Percentage

    2005 449/618 73

    2006 479/594 812007 785/883 89

    2008 850/957 89

    2009 917/1019 90

    NSP Cure Rate

    73

    81

    89 89 90

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    2005 2006 2007 2008 2009

    Years

    Nspcure%

    Cure Rate

    PROGRAMME MANAGEMENT REPORT-

    TB SUSPECTS EXAMINED-

    YEAR POPULATION Q1 Q2 Q3 Q4 TOTAL Per

    lac/qtr

    2005 17.41 1433 1680 1617 1464 6194 89

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    2006 18.11 1256 2632 2981 2981 9841 135

    2007 18.69 3057 3623 2732 2732 12554 167

    2008 19.30 3428 3468 3202 3202 12573 162

    2009 19.95 3546 3946 3425 3425 14830 186Total TB suspects cases

    6194

    9841

    12554 12573

    14830

    0

    2000

    4000

    6000

    8000

    10000

    12000

    14000

    16000

    2005 2006 2007 2008 2009

    years

    TBSuspectcases

    TB suspects

    SPUTUM POSITIVE DIAGNOSED-

    YEAR Q1 Q2 Q3 Q4 TOTAL

    2005 168 234 266 180 848

    2006 157 409 384 392 1342

    2007 407 455 488 365 1715

    2008 450 513 379 484 1826

    2009 534 529 543 427 2033

    PATIENTS PUT ON DOTS-

    YEAR Patients put on DOTS Percentage

    2005 763/848 90

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    Patient put on DOT

    90

    63

    8993 91

    0

    10

    20

    30

    40

    50

    60

    70

    80

    90

    100

    2005 2006 2007 2008 2009

    Years

    Patientputo

    nDOT

    Patient put on DOT

    .

    2006 852/1342 63

    2007 1543/1715 89

    2008 1704/1826 93

    2009 1864/2033 91

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    Practices followed by programme personnel under RNTCP-To review the actual practices followed under RNTCP in terms of detailed

    operational aspects , the various categories of staff were interviewed

    using semi structured interview schedule.

    1. Distribution of staff according to sex and status of appointment.

    Category

    of staff

    Male Female Permanent Contractual total

    DTO - 1 1 - 1

    MO 8 2 8 2 10

    STS 4 - - 4 4

    STLS 3 - - 3 3

    TBHV 4 - 2 2 4

    LT 8 - 8 - 8

    DOT

    Providers

    5 5 7 3 10

    ASHA - 10 - - 10

    Total 32 18 26 14 50

    2. Training- All the staff members involved in RNTCP were trained except

    one MO , who has recently joined. 3 MOs looking after the work of

    TUs are not trained for MOTC. STS and STLS had training for 15 days

    and LTs 10 days.TBHV/DOT Providers had undergone training for the

    period of 10 days. ASHAs working in the field are not at all trained in

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    RNTCP. Most of the staff is working for TB programme for more than 5

    years.

    3. Duties and responsibilities of the staff- It was started by all staff

    members interviewed that none of them were provided with written

    job responsibilities by the higher activities. They had come to know

    about these from their training as well as day to day experience on job.

    4. Address verification-All MOs were asked as how to verify the address

    of the patient, all of them answered that the address is verified,

    through home visits by TBHV. As mentioned by TBHVs after obtaining

    report of the sputum examination of the patient, if found positive for

    AFB , address is confirmed by home visits. The contact person of the

    patient, who is any responsible person who knows the patient and can

    take his responsibility is approached if address can not be verified.

    5. Initiation of treatment when asked how the treatment of the TB

    patient started before confirmation of address, where as fourmentioned that treatment can be started if someone responsible

    guaranties and address is verified later.

    6. Drug administration - when asked how do they ensure that patient

    really consume medicines , all of them said by direct observation.

    Regarding help from the community volunteers or NGOs , six out of

    ten DOT Providers said they take the help of NGOs and ASHAs in

    administering DOTS. For the purpose of home visits they stated for

    address verification and for tracing the patients in case they default.

    For the mode of transport, 8 of them replied by their own transport

    and 2 said by bus.

    7. Action taken for seriously ill patients TBHV/DOT Providers were

    asked as to what they do in case of seriously ill patients who fail to

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    report for drug collection on scheduled date. 2 TBHV;s and 6 DOT

    Providers told that it is the familys responsibility to take care of

    seriously ill and medicines are given to family members for

    unsupervised therapy.2 of them said that home visits are made and

    sometimes of ASHA is taken.

    8. Material management Drugs and Supply - As per information

    available from 9 out of 10 MOs all ATT drugs are received as central

    supply from central TB division. The drugs are available in adequate

    quantity and in regular supply. Supply of the lab chemicals , reagents

    and consumables were also reported to be regular and adequate. Only

    1 MO reported that he faces problem of irregular supply of drugs and

    lab consumables as he working in tertiary level health centre and

    patient load is very high there. All STS , STLS and LTs also reported

    adequate and regular supply of drugs and lab chemicals but they

    themselves have to go to the DTC and collect these consumables asthere is no provision from district to supply these medicines to their

    centres.

    9. Supervisory visits MOs , STS and STLS were asked about frequency

    and the nature of supervisory activities perform by them. Only 1 MO

    reported that he is making 3- 4 visits in his DOT centres per month. All

    the 4 STS and 3 STLS reported to make 4-8 visits to their centres per

    month. They are using motor bikes provided to them under RNTCP for

    this purpose. They are making tour programme and maintaining tour

    diary which they submit to DTO at the end of the month. They are

    provided with supervisory checklist. STS said that they check all the

    treatment cards and records of the patients and also supply of the

    drugs. They make defaulter visits along with TBHV in case the patient is

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    not retrieved by TBHV alone. All STLS said that they cross check all the

    positive slides and 10-20% of the negative slides, they also check

    regularity of supply of lab consumables. They visits all the DMCs at

    least once in a month. MOs visit DMCs occasionally as reported by all

    STLS. DTO Jammu is also playing important role in the supervision. She

    is visiting all the DOT centres in the district regularly and putting

    forward the reports of her findings to STO. She also mentioned that

    she is provided with a vehicle for supervision.

    Medical officers perception regarding satisfaction level in staff & patients.

    Medical officers were asked about their perception regarding satisfaction

    among the staff & patients with the implementation of the programme. All of

    them replied that staff was only partially satisfied with the implementation of the

    programme.

    Regarding patients satisfaction, 6 out of four said that patients were

    partially satisfied. All M.Os mentioned that they were fully aware of the

    problems faced by patients. They all said that there is no difference in working of

    regular & contractual staff.

    Information, Education & Communication

    All 10 LTs were asked as to what Instructions they give to patients for

    sputum sample. All said cough deeply.

    All the MOs, TBHVs & DOT providers mentioned that motivation & health

    education is provided individually. The detailed health education is provided at

    the beginning of treatment & is supported by all health workers.

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    When asked regarding IEC in there DOT centres, said that posters are used

    for conveying messages, whereas MO mentioned about community meetings

    and health talks.

    Waste Management: All medical officers & LTs stated that sputum cups & slides

    are kept in 5% phenol & then disposed off in the hospital bins.

    Recording & Reporting: This information was collected during interview of

    service provides as well as during observation of various DOT centres. The TB lab

    register at all DOT centres in maintained by LT as well as lab forms for sputum

    are entered by LT. The patients treatment cards & drug records are maintained

    by DOT provides. All patients maintain their Identity cards but all entries are

    made by DOT provider/TBHV. The indent register for lab chemicals, reagent &

    consumables is maintained by all STLS & for drugs , disposal syringes & needles in

    maintained by all STS. The TB register for each treatment units is maintained by

    respective STS as well as all entries in it are made by him.

    All LTs stated that performance reports are sent monthly to STS &

    quarterly reports are also being submitted at the end of each quarter.

    All the STS & STLS stated that monthly reports are submitted to DTO,

    which are compiled into quarterly reports by Data Entry operator.All medical

    officers also confirmed that reporting on performance of cases in done monthly

    by LTS & TBHVs. 4 MOs stated that reports are sent to central TB Division

    MOHFW & state TB officer.

    Monitoring of the programme:

    All MOs mentioned that regular monthly meetings are held between DOTS

    implementing staff i.e. LTs, TBHVs, STS, STLS & DTO. Regular monthly meetings

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    are also held between DTO & STO. As told by DTO teams from MOHFW & other

    agencies also visit to review the programme.

    Problems faced & suggestions given by staff:

    Health workers were asked to enumerate the problem faced by them &

    suggestion for improving the patient care services.

    Out of 10 LTs, 5LTs said that they did not face any problem. 2 LTs remained

    silent & rest 3 mentioned few problem:-

    Lab was too small & working space was inadequate.

    Patients do not give proper sputum samples so smear examination has to be

    repeated.

    They also mentioned about heavy work load be cause they also have to do all

    the routine has lab in the health centres TBHVs told that they face problemduring have visits. It was difficult & hectic job to find a house in many

    localities especially in case of slums.

    One TBHV mentioned that area covered by him was to big. They also stated

    that they had to walk a lot to trace a house. Some patients give wrong

    address because of which patient can not be traced.

    DOT providers stated that patients prefer taking medicines home rather

    swallowing them in their presence. In DOT centres, patients bring some local

    leaders/influential peoples of that area to take medicines at home.

    Two DOT providers also stated that space provided for the centre is not

    adequate for administration of DOTS.

    STS, & STLS also stated problem because of absence of MOTC, in their TUS.

    They also stated that few health worker do not co-operate with them during field

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    visits. AT few DOT centres there is no permanent DOT provider because of

    scarcity of man power. They suggested that community volunteers/ASHAS should

    be involved in activity.

    Not much suggestion were given by them. MOs stated that refresher training

    of staff should be done time to time. They also reported scarcity of man power in

    the fields should be sorted out.

    MOs also suggested that supervisory staff should act more activity for better

    performance of the programme.

    Problems faced & satisfaction with treatment among TB patients.

    In order to obtain information regarding various problems faced by patients &

    their satisfaction with services provided, a sample of 60 patients was selected

    from various DOT centres of Distt.

    General profile of patients interviewed

    Category Male Female Total

    No. No. No.

    Cat. I 20 15 35

    Cat II 12 3 15

    Cat III 6 4 10

    38 22 60

    Category wise distribution = pie chart

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    Category & Age

    Age CAT I CAT II CAT III CAT IV

    < 19 1 0 1 2

    20-29 5 2 3 10

    30-39 7 4 2 13

    40-49 16 6 3 25

    50 & above 6 3 1 10

    Total 35 15 10 60

    Out of 60 patients interviewed 38 (63.3%) were male & 22 females (36.7%)

    As for as age is concerned, max patients lie between 40-49 yrs of age (25 out of

    60 patients i.e 42.6% )

    Only 2 patients were less than 17 yrs of age.

    Source of Referral of patients:

    All respondents were asked from where they were referred to DOTS

    centre. Out of 60 patients interviewed, 38 patients were referred from various

    government hospitals & dispensaries in the areas. 6 patients reported to DOT

    centres on their own and 6 after getting information from neighbours & friends.

    About 10 patients were referred by private practitioners.

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    Source of Referral No of patients

    1. Private Particulars 10

    2. Govt. Dispensaries 38

    3.Divelty reported 6

    4. Neighbours &

    friends

    6

    Total 60

    LAB INVESTIGATIONS:- All patients were enquired about the number & types of

    investigations done for the at DMCs. All 60 patients reported to have got 2

    samples of sputum exam done before initiation of treatment. Majority of patient

    had to make 2-3 visits to get reports of sputum samples & in 3 patients.

    In about 8 patients X-ray chest FNAC was done in the hospital for the

    diagnosis.

    Accessibility to DOT centres

    Patients were asked about distance travelled by them from their residence

    & travel time to reach the centre. About 20 patients had to travel 1 km or less to

    reach DOT centres. 26 patients had to travel to 2-3 km to reach centre & 14

    patients had reported to have travelled beyond 5 km to reach the centre for the

    treatment. Majority of patients reported to reach DOT centres by mini bus.

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    Waiting time at DOTS centre

    The average waiting time in getting treatment was reported to be 15 to 25 .

    Patients at DOT centres at secondary & tertiary level hospitals reported thatthey have to wait for about half an hour.

    Availability of Medicines

    All patients were asked if they could obtain all medicines prescribed to the

    to them. According to all, the anti TB medicines were available for every patient

    put on DOTS treatment from the centre & were available free of cost in blister

    packs.

    Improvement in symptoms from in of Treatment

    When patients were asked regarding of doses of treatment taken after

    which there was improvement in their symptoms, majority of then (45 ie 75%)

    reported improvement in symptoms with 10-12 doses of anti-tuberculosis drugs

    ie 3-4 weeks of regular treatment.

    Missed doses during treatment whenasked about number of doses of

    treatment they have missed till date, only 4 patients said that they have missed

    one dose. 2 patient reported too sick as the reason for missed doses, whereas 2

    other reported gone out.

    Attitude of health staff

    As regards the attitude of DOTS centres health staff patients, 54 (90%)

    stated it to be fully sympathetic & only 6 had different views of which 3 stated to

    be rude/unsympathetic.

    As regards the availability of staff of DOTS centre 59 respondents stated

    that the staff was present.

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    Health Education:

    54 patients said that they were provided. Information about TB and

    related issues whereas 6 said no information was provided to them. They toldthat they were advised to cover their face while coughing & not to food &

    utensils so that other dont get disease from them.

    Satisfaction in the services available.

    56 patients (96.6%) said that they were satisfied with services. However, 3

    patients responded by saying as some what satisfied & one even said that he is

    not satisfied because he has to come from from far off place.

    When asked about reason for satisfied they said lack of financial burden as

    these medicine are available free of cost. Also sympathetic attitude of the

    providers was enumerated as reason for their satisfaction.

    Problems faced by patient

    Out 60 patients interviewed, 18 patients (30%) reported to have faced one

    or more problems. Some of the problems they maintained were:-

    Difficult to come on alternate day

    Symptoms not improving

    Wastage of time

    Owners dont allow to go to centre

    Long distance to be travelled to reach DOT centre

    Too week to go to centre

    Long distance to be travelled to reach DOT centre

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    Findings Based on observation of DOT centre

    A check list was used in order to obtain information on operational

    procedure & practices adopted under RNTCP at DOT centres.

    A total of 10 DOT centres were selected for this purpose and following

    observations were made:

    All the patient wise boxes were being marked & maintained for each

    patient. There was facilties for clean water in all DOT centres. A total of 50

    patients were observed for direct observation of treatment & the findings were:

    Patients physically reported to collect drugs 48/60 = 80%

    Drugs carried by relatives 12/60 = 20%

    Medicines swallowed under direct observation 40/48 = 83.5%

    Medicines carried have by patients = 8/48 = 16.5%

    All entries were correctly entered & treatment cards were complete:

    Home address verification was done in 45 patients.

    Adequate stock of anti TB drugs was available for Cat I, Cat II & Cat III patients,

    but not as per RNTCP guidelines. Boxes were stored in safe dry places not

    exposed to sunlight. Adequate number of disposable syringes, needles & distilled

    water ampoules for CAT II patients were available only in 2 centers. In Rest 8 DOT

    centres patients were getting then own disposable syringes.

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    IEC material in from of banners& posters were displayed in all the DOT centres.

    Health workers were also motivating & giving health education to TB patient so

    that they adhere to treatment.

    Observations at Designated Microscopic Centres-

    A total of 5 DMCs were selected as per RNTCP guidelines for the internal

    evaluation of the District. A Check list was made and following observations were

    made

    All the chest symptomatic from OPD were referred to DMCs where RNTCP

    trained LT was present who was filling up the lab forms and was giving

    sputum containers to patients after instructing him how to cough out the

    sputum. He was collecting on the spot specimen and was giving another

    container for early morning sample. After collection of sputum staining

    was done and a report was prepared with proper grading. All the sputumpositive results were written in red ink in the lab register. In all the DMCs

    all the essential consumables including binocular microscope was

    available. Facilities for running water for the staining purpose were also

    present in all the DMCs. At the end of every month a summary abstract is

    completed by every LT.

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    Discussion-

    Appraisal of any programme is important both at macro land micro levels, the

    present study has been conducted with the aim of a micro level performance

    appraisal of the RNTCP in a District the important aspects of the programme like

    organizational` and operational features, availability of resources, treatment

    outcome among patients registered as well as experiences and problems among

    service providers and beneficiaries of services.

    Since initiation of RNTCP in this district about 6 years have passed and it is

    assumed that the programme has overcome the likely problems in the initial

    phase of implementation. For successful implementation of the programme it is

    essential to have an effective organization with committed staff who are well

    conversant with the programme objectives and their own role towards its

    implementation. From the study of the organizational set up, it was evident that

    the human resource available and their distribution in the different functional

    units i.e. the Treatment Units and their attached DOTS centres had been quite

    satisfactory as per the programme guidelines, trained in RNTCP and well

    experienced in TB control activities. Another strength of the programme in terms

    of human resource in this District was that on the whole the staffs were aware

    about their job responsibilities towards the RNTCP even though they were not

    provided with any written job chart.

    One of the essential features of RNTCP is the commitment under the programme

    to ensure a regular, adequate and uninterrupted supply of all anti TB drugs and

    other supplies including equipment and consumable items for running the

    programme.

    One of the parameters for assessment of performance of the TB control

    programme is its ability to detect maximum number of cases and to put them on

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    regular treatment and thereby achieve best cure rate of over 85% as per the

    objective of the RNTCP.

    In this study the different indicators of treatment outcome for the District werecalculated for five years i.e. from 2005 to 2009 and it was observed that case

    detection had been very low in the past but slowly improving. The cure rate

    achieved for new sputum positive cases treated under DOTS is the most

    important indicater of effectiveness of chemotherapy in treating TB cases and

    hence success of the programme. Jammu district has achieved excellent cure

    rates of about 89%-90% in last 3 years. The Sputum conversion rates at the end

    of 2/3 months were nearing 90% in last 2 years which is well in comparision with

    expected levels.

    With regard to the various qualitative aspects of treatment of patients, the

    practice in this Distt. was reported to be to initiate treatment only after

    verification of address of the diagnosed case as already described. Those who are

    residing outside the area of jurisdiction of the TUs are referred after investigation

    and diagnosis, to their respective TUs/DOTs centres near to their residential

    areas. This practice will be useful for all patients registered for treatment at the

    centre since it will ensure proper follow up of patient as well as default action

    when required, provided the timely home visit and address verification is done

    and treatment initiated by the staff. Problems like too large population and areato be covered by staff, inadequate work space for staff particularly for

    laboratory, patients giving wrong addresses should be taken care of.

    For the success of the DOTS strategy adopted under the RNTCP, one of the most

    essential requirements is to ensure direct observation of treatment taken by the

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    and sustained efforts on the part of the staff during subsequent contacts with

    the patients during the later part of treatment. Other media of communication

    like hoardings and posters were seen to be displayed in most of the DOTS centres

    but there is need for more emphasis on IEC through interpersonal

    communication to ensure continued motivation of patients to complete the

    treatment.

    Being a highly infectious disease, infectious sputum samples are to be handled by

    the laboratory staff, one of the essential requirements under the programme is

    proper and hygienic disposal of all such infectious material for the safety of the

    community and of the personnel handling such materials.

    On the whole the infrastructural facilities under the programme at the Distt

    centres were quite satisfactory. Accessibility and approachability of the

    diagnostic and treatment facilities at convenient locations in easily identifiable

    manner are the strong features that could be noticed in this study.

    Few DMCs are working as DOTs centres due to shortage of space & also at few

    centres LTs administrating the treatment to patient. Though there were few

    problems related to the lay out and availability of space in some of the DOTS

    centres, in general there was adequate space for staff as well as waiting space

    for patients, availability of water and electricity, maintenance of general

    cleanliness etc. Binocular microscopes were available in all the microscopy

    centres. It was satisfying to note that generally patients did not have any

    problem in getting the tests done or in getting the reports as seen from the

    interview data from patients. There was no shortage of items like drugs or other

    laboratory reagents reported by any staff, which is to be recognized as a very

    strong feature of the programme.

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    Though DTO, STS and STLS are looking after supervision & monitoring of the

    RNTCP. Medical officers at the TUs should be made responsible and accountable

    for the activities so that case detection can be improved in the peripheral areas.

    Patients were also by and large satisfied with the services from the centres.

    However few patients had stated to have faced some kind of problem like

    difficulty in coming on alternate days for treatment and long distance to travel,

    financial loss etc. Patients who have to attend centres from their place of work

    had express difficulty in getting permission could have contributed to the

    increase default rate only a very small number among the interviewed patients

    reported to have missed any dose during the treatment. However, those few

    who missed gave reason like urgent work or gone out etc which gives an

    impression that they have not clearly realized the significance of uninterrupted

    treatment which needs to be stressed while motivating the patients.

    Maintenance of records and submission of monthly and quarterly reported were

    found to be reasonably good in the DTC, TUs and DOTS centre as per the

    programme guidelines.

    Some of the shortcomings observed at the implementation level in DOTS centre

    could easily be overcome if proper and adequate supervision is being carried out

    by the concerned staff, it seems that no regular schedule of visits are prepared or

    followed. Need for special emphasis on more regular and effective supervision is

    amply evident.

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    Conclusions and recommendations-

    Conclusions-

    A rapid appraisal of organisation , implementation and utilization of DOTS in

    Jammu district of Jammu and Kashmir.

    General Objective

    To study the organisation, implementation and utilization of DOTS in Jammu

    district.

    Specific Objectives

    To describe infrastructure facilities and resources available for RNTCP-

    DOTS in Jammu District.

    To study providers perception regarding DOTS.

    To analyse the implementation and achievements of DOTS at various levels

    in the district

    To ascertain the extent of satisfaction with services provided and problemsif any among patients availing treatment under RNTCP.

    To make necessary recommendations for the improvement of the

    programme

    Methodology-

    The study was descriptive in nature and was conducted in DTC and DOT Centres

    of Jammu.

    The study population comprised of(1) service providers i.e DTO, MOs, STS, STLS,

    TBHVs, LTs, DOT Providers and ASHAs.

    (2) Beneficiaries included 60 patients.

    Observation of selected activities and infrastructure facilities and resources was

    done using an observation check list in 6 DMCs and 10 DOT Centres. All 50

    service providers were interviewed using semi structured interview schedule for

    collecting information on various aspects like accessibility to DOTS Centres

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    experiences while availing treatment ,extent of satisfaction with treatment etc.

    The records studied were TB registers, TB Lab registers and treatment cards of

    the patients. Thorough information was obtained on space available, availability

    of water, electricity, medicines, lab facilities etc.

    Study findings-

    The present study focuses on some of the important aspects of RNTCP-DOTS in

    Jammu District. RNTCP has been operational since 2004.

    Profile of the district -

    Total Tuberculosis Unit 4

    Designated Microscopic Centres 18

    DOT centres 281

    District Tuberculosis Centre Jammu is the Nodal point for TB Control activities in

    the district.

    DTC Jammu is divided into 4 TUs-

    5. TU Samba

    6. TU Jammu

    7. TU Akhnoor

    8. TU R S Pura

    A team comprising of specifically designated medical officer TB Control

    (MOTC), Senior Treatment Supervisor (STS) and Senior Tuberculosis LabSupervisor is based in a CHC/ Sub district hospital.

    OPERATIONAL ASPECTS OF RNTCP DOTS

    8. Diagnosis and Treatment - Sputum microscopy is the primary tool for diagnosing

    and monitoring of TB patients. Sputum microscopy is done only in Designated

    Microscopy Centres (DMCs). In all the DMCs there is a full time trained lab

    technician who is looking after collection, staining and grading of the smears.

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    If the sputum smear examination is positive

    for AFB , the patients is referred to MO for categorisation of disease (into CAT-1,2 and 3)

    and TBHV makes home visit to confirm the address of the patient. The anti TB treatment

    started after proper health education and motivation. During intensive phase thrice in a

    week patient is given medicine under direct supervision Monday, Wednesday and Friday.During continuation phase the first dose of weekly blister should be directly observed. All

    the entries are made and patients record is maintained by TBHV/DOT provider at DOT

    centre which is under supervision of STS. MOTC is responsible for managing the treatment

    unit.

    There is a unique system of providing drugs in patient wise boxes ( PWB ) which contain drugs

    for entire duration of Treatment for each category of Patient.

    Follow up-

    The follow up of each patient is to be done at 2-3 months and second at 4-5 months and last at

    the end of the treatment. Two sputum smears are examined each time during follow up

    Waste Management: All medical officers & LTs stated that sputum cups & slides

    are kept in 5% phenol & then disposed off in the hospital bins.

    Recording and reporting

    In Jammu Distt. , DTO is the overall incharge of Tuberculosis Control

    Activities and answerable to State TB Officer at State Health Directorate. He / She reviews the

    monthly activity reports of all MOTCs, STLS and STS with in the Distt. during the monthly Distt.

    level meeting of the said staff.

    At TU level reporting and recording is done by MOTC, STS and STLS.

    Tuberculosis register is kept at Sub-Distt. (TU) level in the Distt only. Monthly report is

    prepared every month and submitted to DTC. Quarterly report on case finding, sputum

    conversion rate of patients who are on treatment and all possible outcomes of smear positive

    cases of pulmonary TB (Cured, Treatment completed, Failure, Defaulted, Died and Transferred

    out) is prepared by STS. The STLS is primarily responsible for supervising all the lab activities. It

    is the responsibility of TU to compile the DMC wise reports and submit it to DTO.

    DTO compiles the report (4 copies) in respect to all TB units and sends three of them to the

    STO, The National Tuberculosis Institute Bangalore and to Central TB Division, DGHS Nirman

    Bhawan New Delhi.

    9. Supervision and monitoring

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    In Jammu District D.T.O. with the support of M.O. of DTC is responsible for ensuring the

    quality diagnosis , treatment, logistics and reporting.

    At T.U. Level , MOTC, STS, and STLS are responsible for undertaking supervisory visits to all

    the PHIs, NGOs and PPsSTLS is responsible for the quality of sputum smear microscopy

    services provided by DMCs under TU. STS visits all the PHIs at least once every month he

    checks whether all the sputum smear positive patients recorded in the TB Lab. register are

    placed on treatment and register in TB register.

    10.TRAININGS

    In Jammu district, most of the staff looking after Tuberculosis programme in trained but

    motivation level can still be improved by time to time refresher training.

    IEC-

    In order to control TB, there is need for dissemination of information about tuberculosis ( signs

    & Symptoms ), its cause, detection & treatment there by empowering individuals, families &

    communities to be responsible for behavioral change to achieve cure of people suffering from

    tuberculosis.

    As per health providers, motivation & health education is provided individually,

    at the beginning of treatment. In DOT centres, posters are used for conveying

    messages, whereas MO mentioned about community meetings and health talks.

    11.Role of Medical Colleges in RNTCP in Jammu

    In Jammu District following Medical Colleges are involved in RNTCP:-

    1. Govt. Medical College, Jammu.2.Acharya Sri Chander College of Medical Sciences.

    Govt. Medical College, Jammu

    GMC, Jammu is playing a very important role in RNTCP. It is functioning as DMC

    as well as DOT centre. Since it is a tertiary level Hospital, people have lot of faith

    in the medical facilities available here. It caters to both rural & urban population

    in Jammu District. There is a separate Chest Diseases Hospital in Jammu city,

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    where all chest symptomatics prefer to come for diagnosis & treatment. Also

    there are special wards fo