Global Burden of Tb

8/4/2019 Global Burden of Tb

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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 1 Acronyms

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 world’s 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 by Mycobacterium 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 by M. 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 world‟s population has latent

infection by M. 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

67–95 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 <4%

8 Default rate <5%

8 Failure Rate among NSP Cases <4%

REVIEW OF LITERATURE



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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 of India 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,” is

now 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 of sputum 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 potential

tangible 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 of strict 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 of systematic and intensive trainings in smear examination consequent to the nonimplementation of the DOTS strategy in this district and a high standard of trainings 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 of the 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 of adequate 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 India‟s 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 of physical 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 seek expensive 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 India‟s 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 of their 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 technique – The 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 WHO’s 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, TBHV’s

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 TU R. 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 patient’s 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 MOTC’s, STLS and STS with in the Distt. during the monthly Distt.

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



34

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.U’s and Medical Colleges in the Distt. every month and all CHC’s and PHC’s 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 PHI’s, NGO’s and PP’s. 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



35

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

DMC’s under TU. He is visiting all the DMC’s under the TU at least once in a month.

STS visits all the PHI’s 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 DMC’s and DOT Centres.

Methodology of Supervision & Frequency of Visits

Category of

Supervisor

Methodology of Supervision No. of Supervisory Visits

DTO Interview’s 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 TU’s every month

and all DMC’s every quarter.

Visits all CHC / PHC’s in the

Distt. every quarter, onesub-centre from each block

PHC area and proportion of

DOT Centres every quarter.

MOTC Interview’s M.O I/C, PHC / CHC

Randomly Interview’s 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 DMC’s every month

and PHC’s / CHC’s and DOT

Centres once every quarter.

Conducts supervisory visits

7-days a month.

STS Interview’s Health workers at sub-centres.

Inspects Records TB treatment cards and

TB registers.

Visits all PHI’s at least once

every month and all DOT

Centres every quarter.



36

Randomly Interview’s the patients.

STLS Inspects all microscopy centres and Lab.

records.

Visits all DMC’s 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.



37

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.



38

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 NGO’s and private practioners.

1. St. Joseph’s Missionary Hospital at Barjani Smailpur–28 pts.

2. Mother Teresa Charitable Trust at New Plots–2 pts.

3. Shivgotra Medicos (Retd. Army Personal) Bahu fort–7 pts.

4. Shivam Medicos Talab Tillo–2 pts.

5. Catholic Social Service Society, Kunjwani–8 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. NGO’s 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).



39

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 REPORTNEW SPUTUM 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



40

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

N o o f N S P

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 of total sputum

positive cases

2005 136 18

2006 293 33

2007 446 34

2008 473 33

2009 553 35



41

Retreatment cases

136

293

446473

553

1833 34 33 35

0

100

200

300

400

500

600

2005 2006 2007 2008 2009

years

N o o f r e t r e a t m e n t c a s e s

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



42

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

N o o f N S N

No of NSN

Percentage

EXTRA PULMONARY CASES-

Year Extra

pulmonarycases

All New

cases(NSP+NSN+NEP)

percentage of

New EP out of all New cases

2005 349 1581 22

2006 380 1722 22

2007 620 2132 29

2008 564 2014 28

2009 632 2229 28





44

new sputum conversion rate

87

79

87

89

92

70

75

80

85

90

95

2005 2006 2007 2008 2009

Years

c o n v e r s

i o n p

e r c e n t a g e

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.



45

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

N s p c u r e %

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



46

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

T B S u s p e c t c a s e s

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



47

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

P a t i e n t p u t o

n D O T

Patient put on DOT

.

2006 852/1342 63

2007 1543/1715 89

2008 1704/1826 93

2009 1864/2033 91



48

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 MO’s looking after the work of

TU’s are not trained for MOTC. STS and STLS had training for 15 days

and LT’s 10 days.TBHV/DOT Providers had undergone training for the

period of 10 days. ASHA’s working in the field are not at all trained in



49

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 MO’s 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 TBHV’s 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 NGO’s , six out of

ten DOT Providers said they take the help of NGO’s and ASHA’s 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



50

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

Providers told that it is the family’s 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 MO’s 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 LT’s 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 – MO’s , 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



51

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 DMC’s at

least once in a month. MO’s visit DMC’s 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 officer’s 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.



52

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 patient’s 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



53

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



54

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



55



56

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.



57

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.



58

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.



59

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 don’t 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 don’t allow to go to centre

Long distance to be travelled to reach DOT centre

Too week to go to centre




60

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.



61

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.



62

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



63

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





65

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.



66

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.



67

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



68

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.



69

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 patient’s 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 MOTC’s, 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 –



70

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 PHI’s, NGO’s and PP’s STLS is responsible for the quality of sputum smear microscopy

services provided by DMC’s under TU. STS visits all the PHI’s 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,



71

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.

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.

Problems faced & suggestions given by staff :

Lab was too small & working space was inadequate heavy work load because

they also have to do all the routine has lab in the health centres.

TBHVs told that they face problem during have visits. It was difficult & hectic

job to find a house in many localities especially in case of slums, area covered

by him was to big.

DOT providers stated that patients prefer taking medicines home rather

swallowing them in their presence..

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

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.

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



72

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

60 patients i.e 42.6% )

Source of Referral of patients: Maximum were referred from variousgovernment hospitals & dispensaries in the areas. Few patients reported to DOT

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

LAB INVESTIGATIONS:-. All 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.

Accessibility to DOT centres Maximum patients had to travel to 2-3 km to reach

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

centre for the treatment.

Waiting time at DOTS centre-15 to 25 minutes.

Medicines

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

There was improvement in their symptoms, after 10-12 doses of anti-

tuberculosis drugs i.e 3-4 weeks of regular treatment.

Missed doses during treatment only 4 out of 60 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- sympathetic and available during working hours.



73

Health Education:

Patients said that they were provided information about TB and related

issues. They told that they were advised to cover their face while coughing & notto food & utensils so that other don’t get disease from them.

Satisfaction in the services available.

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

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 don’t allow to go to centre


Too week to go to centre


The high quality of care and strict adherence to the RNTCP guidelines should becontinued and maintained to sustain the smear conversion and success rates alreadyachieved by the State under the programme.



74

RECOMMENDATIONS-

Based on observations and findings made during the study on organisation,

implementation and utilisation of RNTCP-DOTS Strategy, it was foundthat overall performance of the district was satisfactory. But still there is

scope for improvement in various components of the programme.

PROBLEM RECOMMENDATIONS

1.Low case detection- The case

detection had been low in the district

since the implementation of RNTCP.

To improve the case detection,

supervision at DMCs and DOT Centres

should be intensified. MOs at the TUlevels should be trained for MOTC

training and should be held

accountable for supervision. All BMOs

and MOs at PHCs should stress upon

case detection in their monthly

meetings. Community volunteers,

NGOs, ASHAs and AWWs should also

be involved more for this purpose.

2. Trainings- Very few trainings were

conducted in the district in last two

years.

Training of the staff has to be

according to the guidelines. The health

professionals across all strata , have to

be sensitized to proper diagnosis and

treatment of all sputum positive cases.

Skill based training programme are part

of RNTCP strategy. Because of transfers

, promotions and retirements ,

trainings need to be a constant affair.

-3. Inadequate Space and Staff -

Problem of inadequate space was

observed in few centres. Medicines

The DOT centre for administering

treatment should be separate from the

lab so that patients are observed better



75

were kept in the lab and LTs were

administering the DOTs because of

absence of DOT provider.

while taking medicines. There should

be a separate person acting as a DOT

provider so that lab technician can

concentrate on sputum microscopy.

4.Absence of separate counter for

sputum collection

There should be a separate window

available for handling over sputum

sample by patients for lab tests, for the

convenience and protection of staff as

well as parents.

5.IEC:- Very few activities were

observed in the district to educatepeople regarding sign& symptoms of

TB and facilities available under RNTCP

IEC activities should be intensified so

that people are educated abouttuberculosis diseases and about the

facilities available under RNTCP. This

can increase case detection and

adherence to the treatment. The load

on the tertiary level hospitals can be

decreased if people utilise the services

available to them in the peripheral

health institution.

6.problems of the staff - like too large

population and area to be covered by

the staff, non-cooperation by

peripheral staff. In absence of MOTC

the STS and STLS in 3 TU’s are facing

few problems. The heath providers in

the field show negative attitude and

don’t pay much attention to them.

Even the LT’s who are permanent , at

times don’t cooperate thinking that STS

and STLS are on contractual basis and

junior to them, so they don’t have any

right to supervise their activities. The

MO’s who are made in charge to look

As we know , a good supervisor is a

friend , philosopher and guide for his

colleagues and subordinates.

Supervision helps to motivate people

to perform their best in achieving the

goals. Most of the problems have local

solution and can be easily resolved by

interacting with the workers of health

facility. Out of 4 TU’s only one TU

has MOTC trained in RNTCP and doing

supervision. So, training of the MOTCs

is essentially required so that they look

after the work of RNTCP and help in

solving the problems of the staff.



76

after work of RNTCP are so busy in

their routine and emergency duties

that they hardly find any time for

supervisory activities.

7.Role of NGOs and Private

Practitioners- very few NGOs and PP

are participating in RNTCP

The NGO’s and private provider are

consider closer to and more trusted by

patients and perform an acute role in

health promoter in the community. The

GOI has developed guideline for NGO’s

and private sector involvement in TBcontrol Private providers are very

accessible to patients and can play a

key role in TB control.

The first contact of a large proportion

of TB Patients is a private practitioner.

It has been acknowledged that

involving private providers helps toimprove both case detection and

access to standard services under

RNTCP in Jammu.

8.MDR TB-Findings of the district

show quite a number of re-

treatment cases. Not all patients can

afford sputum culture and

sensitivity test.

A lab for sputum culture and

sensitivity should be made

operational at the earliest so that

MDR-TB patients are diagnosed

and treated according to their

culture and sensitivity reports.



77

9.TB/HIV Collaboration

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