Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 1  |  Page : 46-50  

Performance and treatment outcome of tuberculosis among patients on Revised National Tuberculosis Control Programme in Urban and Tribal areas of a district in Maharashtra


1 District Tuberculosis Centre, Nanded, Maharashtra, India
2 District Tuberculosis Centre, Sindhudurg, Maharashtra, India
3 Department of Community Medicine, Government Medical College, Dhule, Maharashtra, India
4 Department of Community Medicine, Government Medical College, Miraj, Maharashtra, India

Date of Web Publication9-Jan-2017

Correspondence Address:
Dr. Shivshakti Dattatray Pawar
District Tuberculosis Centre, Old Civil Hospital Campus, Vazirabad, Nanded - 431 601, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.197916

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  Abstract 

Background: Revised National Tuberculosis Control Programme (RNTCP) was introduced in the country as a pilot project since 1993 in a phased manner and expanded throughout the country by the year 2005. Although studies have shown the success of RNTCP, data pertaining to the indicators of programme performance in urban and tribal set up are rare. Objectives: The objective of this study was to assess and compare the RNTCP in urban and tribal areas of Maharashtra through the indicators of performance and outcome of the patients. Patients and Methods: A retrospective comparative record-based study was conducted in selected urban and tribal areas' tuberculosis (TB) units. Records of patients enrolled newly for TB treatment and those already undergoing treatment under RNTCP from April 2015 to September 2015 (6 months) were considered for analysis. Chi-square test and Z-test (test of significance) are applied where required by using Epi Info 7 and Microsoft Excel 2010.Results: Sputum smear collection was significantly higher in urban areas (P = 0.001). In urban areas, new TB case detection was 35%, while in tribal areas, it was 42% as per the RNTCP norms. Sputum positivity was marginally more in tribal (5.87%) than urban (3.28%) areas. Cure rate was more in urban areas than tribal (P = 0.001) areas. There were statistically significantly high default cases in tribal areas. Conclusions: Sputum collection and sputum positivity rate were low in urban and tribal areas, but TB screening, especially in tribal areas, was significantly low. Sputum positivity was significantly higher in tribal areas. Significantly low cure rate and high default rate in tribal area warrant the need for strengthening of RNTCP activities in tribal areas.

Keywords: Defaulters, Revised National Tuberculosis Programme, tribal health, tuberculosis


How to cite this article:
Pawar SD, Jadhav HR, Pagar VS, Radhe B K, Behere V. Performance and treatment outcome of tuberculosis among patients on Revised National Tuberculosis Control Programme in Urban and Tribal areas of a district in Maharashtra. Med J DY Patil Univ 2017;10:46-50

How to cite this URL:
Pawar SD, Jadhav HR, Pagar VS, Radhe B K, Behere V. Performance and treatment outcome of tuberculosis among patients on Revised National Tuberculosis Control Programme in Urban and Tribal areas of a district in Maharashtra. Med J DY Patil Univ [serial online] 2017 [cited 2019 Dec 7];10:46-50. Available from: http://www.mjdrdypu.org/text.asp?2017/10/1/46/197916


  Introduction Top


The United Nation's Sustainable Development Goals (SDGs) along with the World Health Organization's end TB strategy has made global targets for “To End the Global Epidemic of Tuberculosis (TB).” The targets are set within the context of SDGs and that the overall incidence rate of TB should be halved by 2025 compared with their level in 2015, and there should be a reduction of 75% of TB deaths by 2025 compared with 2015.[1]

There are numerous challenges to measure prevalence, incidence, and deaths due to TB. The WHO task force on TB impact measurement has developed a framework for analysis and tools for this purpose.[2] The major recommendation of it is that all countries should strengthen their routine surveillance system, which includes recording and reporting and improving diagnostic capacity to achieve case detection.[2] The vulnerable population (e.g., tribal population) experience disproportionate barriers in accessing TB services. Enhancing access to TB diagnosis and treatment to these population is utmost important.[2],[3],[4] To maintain the success of primary objectives of the Revised National Tuberculosis Control Programme (RNTCP) of achieving 85% cure rate and 70% case detection rate in these vulnerable populations, the programme needs continuous critical reviews to find out where things are going wrong.[5],[6]

The technical manuals of the RNTCP provide the specific indicators, against which the programme is to be monitored.[5] Hence, these indicators need to be compared in various geographical, sociocultural heterogeneities to find out the key result areas for better programme implementation. Intensive programme monitoring is required in especially vulnerable populations such as tribal areas to implement effectively the programme as of urban areas.

Hence, this study was envisaged with the objective of comparative assessment of RNTCP performance and outcome indicators in urban and tribal TB units (TUs) of Nanded district to find out the differences, if any.


  Patients and Methods Top


Study setting

The present study was conducted between November 2015 and January 2016 of the TUs at two TUs in Nanded urban and two TUs of Kinwat and Mahur tribal areas.

Study design

TB registers and laboratory registers were availed from the respective senior treatment supervisors and senior TB laboratory supervisors for retrospective analysis. Data of 6 months from April 2015 to September 2015 were availed for the study.

Sampling and participants

Records of all newly detected patients who were yet to complete their treatment and already detected patients who were in treatment completion phase during the aforesaid 6 months duration under the selected TUs were included for the analysis.

Data processing

Data were analyzed by standard statistical procedures using Epi Info version 7 (CDC, Atlanta, USA) and Excel 2010 manufacturer Microsoft. RNTCP performance indicators were comparatively analyzed between these urban and tribal TUs.

As secondary data were collected and the study did not include direct patient involvement, ethical clearance was not obtained.

Principal variables were used in this study with operational definitions.

New sputum smear-positive (NSP) case

A patient who has never had treatment for TB or has taken anti-TB drugs for <1 month and is at least one initial sputum smear-positive out of two sputum (one spot sample, second morning sample).

New sputum smear-negative case (NSN) case

A patient who has never had treatment for TB or has taken anti-TB drugs for <1 month and presenting with symptoms suggestive of TB with at least two initial sputum smear-negative for acid-fast Bacilli (AFB).

Extrapulmonary tuberculosis case

TB of any organ other than lungs, such as pleura, lymph nodes, intestines, genitourinary tract, skin, joints and bones, and meninges of the brain.

Cured

The cured patients were initially, sputum smear-positive patient had completed treatment and had negative sputum smears, on two occasions, one of which was at the end of the treatment.

Treatment completed

The patients in whom treatment was completed were sputum smear-positive patient who has completed treatment, with negative smears at the end of the intensive phase (IP) but none at the end of treatment or sputum smear-negative TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment or extrapulmonary TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment.

Defaulted

A patient who has not taken anti-TB drugs for 2 months or more consecutively after starting the treatment.

Died

A patient who died during the course of the treatment, regardless of the cause.

Sputum conversion rate

Sputum conversion rate was calculated as percentage of the number of sputum smear-positive cases converted to sputum smear-negative at the end of IP divided by total number of sputum smear-positive patients initiated on the treatment.

Cure rate

Cure rate was calculated as percentage of total number of patients cured divided by the total number of NSP cases registered for the treatment.


  Results Top


Sputum collection and population covered

Each TU should be for approximately 5 lakh population, but these criteria are relaxed for tribal and hilly areas where for 2.5 lakh population, there is one TU.[5],[6]

[Table 1] shows that two TUs in urban areas are for approximately 380,107 population while two TUs in tribal areas cover approximately 413,588. As compared with urban population coverage by two TUs, two tribal TUs cover more population. Total patient attendance in government dispensaries and hospitals in 6 months was 80,158 in studied urban areas, while in tribal areas, the attendance was more at 89,350. All these patients were screened for chest symptoms related to TB. Out of these, outpatient department (OPD) patients in urban areas, 1915 patients were suspected for pulmonary TB and these all were subjected to sputum examination, and of these (on sputum examination), 63 patients detected as new sputum smear positive (NSP) and put on treatment. Similarly, in tribal areas, 1362 patient's sputum samples were collected over 6 months, of the OPD attendees who were chest symptomatic suggestive of TB, and similarly, all were subjected to sputum examination; out of these, 80 patients were detected as NSP cases and were all put on treatment.
Table 1: Sputum collection activity in urban versus tribal tuberculosis unit and population covered

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[Table 1] also shows that total patients subjected to sputum examination in urban areas were 1915, which was much less than the expected number of 3206. Similarly, in tribal areas, total patients subjected to sputum samples during the study period were 1362, which was very less than the expected number of 3574. According to the RNTCP norms, in both the areas, patients subjected to sputum-smear examination should be 4% of the total OPD attendees.[5],[6] When both areas' TUs sputum-smear collection activity was compared, there was a statistically significant difference (P = 0.001).

Tuberculosis case detection performance

When sputum positivity (sputum smear-positive for AFB) activity was compared in TUs of both areas, the difference was statistically significantly (P = 0.001), though both the areas were performing very less according to the expected RNTCP norms. Hence, sputum sample collection activity was good in urban TUs, but tribal TUs were better in terms of sputum positivity than urban TUs.

[Table 2] shows that in both urban and tribal areas, the new sputum-positive (NSP) and the new sputum smear negative (NSN) cases detection. In urban TUs, only 45% of the NSP case detection rate was achieved than expected; while in tribal TUs, it was 53%. Total case detection (NSP + NSN) of urban TUs was 35% than expected, and in tribal TUs, comparatively more, i.e., 42%. Expected values are calculated according to the annual risk of TB infection (ARTI). Currently, the average ARTI in country as a whole is 1.40%.[5],[6] It has been estimated that for every one percent annual risk, there are about fifty new pulmonary sputum smear-positive cases per lakh population, and equal number of new smear-negative cases.[5],[6] On comparing this activity in both the areas, there was no statistically significant difference between the performances (P values of 0.45 and 0.73).
Table 2: Comparison of new tuberculosis case detection performance in both tuberculosis units

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Outcome indicators of the Revised National Tuberculosis Programme

[Table 3] shows the cure rate was good in urban TUs than tribal TUs (though both were performing less than RNTCP norms), and there was a statistically significant difference (P = 0.02). “Sputum conversion at the end of IP” activity was statistically not significant (P = 0.89) after applying Chi-square test. On comparison of “number of defaulted patients,” these were more in tribal areas than in urban areas, and this difference was statistically significant (P = 0.04). Death rate was more than expected in urban TUs, but difference between tribal and urban TUs was not statistically significant (P = 0.15). “Number of treatment completed cases” activity in both the areas on comparison was found to be statistically significantly different (P = 0.04), urban areas were performing better in these terms.
Table 3: Comparison of outcome indicators of the Revised National Tuberculosis Programme in both tuberculosis units

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  Discussion Top


The present study revealed that total pulmonary TB suspects which were sent to sputum microscopy in both urban TUs (2.38% of total OPD) and tribal TUs (1.52% of total OPD) were very less as per the existed RNTCP norm (should be 4% of total OPD).[5],[6] This finding might reflect the lack of correct knowledge and practice about RNTCP diagnostic criteria of TB “case” and “suspects” based on a study done by Roy et al. to find out the knowledge about the national disease control programme, which showed that only 17.6% of the physicians had correct knowledge about TB diagnosis and only 41.1% had correct knowledge about the suspect criteria of TB under the RNTCP.[7]

Our study shows that the ratio of NSP: NSN was 1:0.55 in urban TUs, and in tribal TUs, it was 1:0.58, which should be 1:1–1:1.2 according to the RNTCP norm. These findings suggest under-diagnosis of extrapulmonary cases in both TUs. On the contrary, a study conducted by Bisoi et al. had found a ratio of NSP: NSN is 1:1.06, which is very close to the RNTCP norm.[8]

In contrary to the finding of more NSP case detection in tribal areas in our study, a study conducted by Mukhopadhyay et al. showed that NSP case detection in urban areas was more than anticipated by RNTCP.[9] NSN case detection was low when compared with the given RNTCP norms, similar to this study, Mukhopadhay et al. in their study found that NSN case detection was less than the RNTCP norm.[9] In our study, there was no significant difference in NSP as well as NSN cases in urban and tribal TUs, but Mukhopadhyay et al. got a significant difference between the performance of detection of NSP cases in urban and rural TUs and no difference in NSN cases in both groups.[9]

Higher sputum positivity in tribal areas means better application of RNTCP's TB suspect criteria and collection of quality sputum with good laboratory supervision activity, but the overall low sputum collection activity in tribal TUs points out that if programme activity is robustly implemented in these areas, hidden cases may come out, as positivity is good in tribal.

Cure rate was less than RNTCP norm in our study. Mukhopadhay et al. found that cure rate was more in urban areas than expected.[9] In our study, tribal TUs showed cure rate very less than RNTCP norm, and it was significantly lower than urban TUs' cure rate, in contrary to Mukhopadhyay et al. study, where there was no significant difference in cure rate in urban and rural areas. Zaman et al. showed an overall cure rate of 91.84% in Dhubri, Assam, which was pretty high when compared to findings of this study.[10] For the findings, we got less cure rate in tribal areas in our study, which was probably because of poor strengthening of RNTCP activity in these regions, probably because population is sparsely located and difficult terrain areas for TB supervisors to travel. Less cure rate in tribal area also might be because of comparatively high defaulter rate in tribal areas. Out of these defaulted patients in tribal areas, one was detected recently as a case of multi-drug resistant TB. A study conducted by Roy et al. in Bankura, West Bengal, had revealed the reasons for high default rate which were illiteracy, low socioeconomic status, and long distance for traveling from patients residence to DOT provider; these might be the reasons in our study and also high default rate in tribal areas.[11]

In our study, there was no significant difference in defaulter rate and death; though defaulter rate was more in both areas' TUs than the RNTCP norm, similar to Mukhopadhay et al.'s findings.[8]

Limitations

Sociodemographic details of patients were not taken in the present study, which might have influenced the output indicators of program.


  Conclusions Top


In this study, suspect patients' ratio with total OPD was low in both tribal and urban TUs that indicates poor quantitative performance of TB screening activity which will be improved by information, education, communication and behavior change communication activity, especially more in tribal areas and training and retraining of medical officers working in these areas. Sputum positivity rate in new case detection was low in urban areas as compared with the RNTCP norms, which signifies that the quality of sputum microscopy in urban TUs was not satisfactory as of tribal TUs.

Performance indicators were low in tribal areas when compared with urban areas. Peripheral health institutes were not screening patients up to the mark for pulmonary TB (according to the RNTCP norms) and are to be trained and monitored for this activity. Poor cure rate and high defaulter rate in tribal areas reflect poor monitoring, which should be strengthened. Hence, periodic re-orientation training of medical officers, treatment supervisors, DOT providers, ensuring of proper supervision at each level, review of performance, and timely feedback (especially of tribal areas) can be undertaken to improve the performance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
World Health Organization. Geneva: WHO's Stop TB Strategy; 2015. Available from: http://www.who.int/tb/strategy/en. [Last accessed on 2015 Jan 30].  Back to cited text no. 1
    
2.
World Health Organisation. TB Impact Measurement, Policy and Recommendations for How to Assess the Epidemiological Burden of TB and the Impact of TB Control, Stop TB Paper No. 2. Geneva; 2009.  Back to cited text no. 2
    
3.
Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Soc Sci Med 2009;68:2240-6.  Back to cited text no. 3
    
4.
Kemp JR, Mann G, Simwaka BN, Salaniponi FM, Squire SB. Can Malawi's poor afford free tuberculosis services? Patient and household costs associated with a tuberculosis diagnosis in Lilongwe. Bull World Health Organ 2007;85:580-5.  Back to cited text no. 4
    
5.
Central TB Division, DGHS, Ministry of Health and Family Welfare, India. A Guide for Practicing Physician – Revised National Tuberculosis Control Programme. Nirman Bhavan, New Delhi; 2010.  Back to cited text no. 5
    
6.
Central TB Division, DGHS, Ministry of Health and Family Welfare, India. Managing the Revised National Tuberculosis Control Programme in Your Area, a Training Module from 1-9. Nirman Bhavan, New Delhi; 2010.  Back to cited text no. 6
    
7.
Roy SK, Roy SK, Bagchi S, Bajpayee A, Pal R, Biswas R. Study of KAP of the private medical practitioners about national disease control programmes. Indian J Public Health 2005;49:256-7.  Back to cited text no. 7
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8.
Bisoi S, Sarkar A, Mallik S, Haldar A, Haldar D. A study on performance, response and outcome of treatment under RNTCP in a tuberculosis unit of Howrah district, West Bengal. Indian J Community Med 2007;32:245-8.  Back to cited text no. 8
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Mukhopadhyay S, Sarkar AP. Comparative Analysis of RNTCP Indicators in a Rural and an urban tuberculosis unit of Burdwan district in West Bengal. Indian J Community Med 2011;36:146-9.  Back to cited text no. 9
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Zaman FA, Sheikh S, Das KC, Zaman GS, Pal R. An epidemiological study of newly diagnosed sputum positive tuberculosis patients in Dhubri district, Assam, India and the factors influencing their compliance to treatment. J Nat Sci Biol Med 2014;5:415-20.  Back to cited text no. 10
    
11.
Roy TK, Sarker G, Gupta A, Ghosh S, Sarbapalli D, Pal R. Bridging the gaps in Revised National Tuberculosis Control Programme in Bankura, West Bengal, India. Am J Public Health Res 2015;3:130-4.  Back to cited text no. 11
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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