1. health and fitness

RNTCP status in UP
Dr. Jagdish Rai
State TB Officer
Uttar Pradesh
RNTCP – Objectives
• To achieve and maintain a case detection of at
least 70% of new sputum positive TB patients
• To achieve and maintain a cure rate of at least
85% in such patients
Performance under RNTCP- Uttar Pradesh
Population
covered
Year
NSP
detection
rates
Smear
conversion
rate
Cure rate of
NSP
Expected 67
(70%)
Expected 90
Expected 85
2007
1874
53
56%
90
83
2008 1st Qtr
1909
57
60%
91
84
2008 2nd Qtr
1909
71
75%
90
85
Case Detection Rate (% NSP) and Treatment Success Rate in Uttar
Pradesh, 2003-2007*
100%
90%
80%
70%
60%
Annualised
New S+ve
CDR
50%
40%
Success
rate
30%
Entire UP Covered
20%
Poly.
10%
Qtr2-08
Qtr1-08
Qtr4-07
Qtr3-07
Qtr2-07
Qtr1-07
Qtr4-06
Qtr3-06
Qtr2-06
Qtr1-06
Qtr4-05
Qtr3-05
Qtr2-05
Qtr1-05
Qtr4-04
Qtr3-04
Qtr2-04
Qtr1-04
Qtr4-03
Qtr3-03
Qtr2-03
Qtr1-03
0%
•Population projected from 2001 census
•Estimated no. of NSP cases - 95/100,000 population per year (based on recent ARTI report)
Revised National TB Control ProgrammeUttar Pradesh 2Q 08
Saharanpur
% NSP detection
> 70%
70%- 50%
< 50%
Baghpat MuzaffarnagarBijnor
M eerut
Moradabad
Jyotiba
Ghaziabad Phule Rampu r
GB Ngr
Pilibhit
Pilibhit
Nagar
Bareilly
Bulandshahar
Kheri
Kheri
Budaun
Aligarh
Shahjahanpur
Mathura
Hathras Etah
Sitapur
Sitapur
Farrukhabad
Hardoi
Mainpuri
AgraFirozabad
Jalaun
Unnao
Kanpur
Nagar Rae_Bareli
Fatehpur
Jhansi
Hamirpur
Mahoba
Shravasti
Balrampur
Gonda
Gonda
Barabanki
Lucknow
Kannauj
Etawah
Auraiya Kanpur
Dehat
Bahraich
Bahraich
Banda
Basti
Faizabad
Siddharth
nagar Maharajganj
Kushinagar
SK Nagar
Gorakhpur
Ambedkar_Nagar Deoria
Sultanpur
Azamgarh
Mau
Mau
Ballia
Pratapgarh Jaunp
Jaunpur
Ghazipur
Kaushambi Bhadoi Varanasi
Chandauli
Chitrakoot Allahabad
Mirzapur
Mirzapur
Lalitpur
Sonbhadra
Highest % NSP detection 2nd Qtr 08
Name of the
district
% NSP
detection
% of
Retreatme
nt cases
out of
total Sm
Positive
cases
Ann.
Total
cases
detection
rate
Smear
Conversio
n rate of
NSP
Cure rate
of NSP
registered
13-15
months
earlier
Cure rate
of S+ve
retreatme
nt cases
registered
13-15
months
earlier
Default
rate of
S+ve
retreatme
nt cases
registered
13-15
months
earlier
Ghaziabad
146
19
303
94
89
83
8
Rampur
144
23
211
86
85
61
19
Meerut
103
19
218
92
91
77
7
Gautam Budh
Nagar
103
25
277
92
88
72
12
Unnao
95
27
201
93
87
81
10
Lalitpur
95
31
176
87
84
85
6
Bareilly
94
25
216
90
86
47
29
Lucknow
94
34
224
85
83
50
14
Aligarh
94
20
226
94
88
70
16
Major activities conducted by state in past few months:
DTOs review meeting of selected poor performing and few good
performing districts under the chairmanship of Principal Secretary,
Medical, Health & FW, U.P. on 17th March
Review meeting of all DTOs under chairmanship of Principal
Secretary, M,H & FW(U.P.) on 16th & 17th April 08.
Regular review of programme in ADs & CMOs meetings at state
level by Principal Secretary/ DG, Med. & Health
State level Paediatric conference in S.N.M.C. Agra on 26th April
2008
World TB Day activities by partnership of NGOs, Stakeholders,
Airtel, Sahara, BSNL, Eldeco etc.
Sensitization of DTOs & consultants under revised recording &
reporting formats
State IEC officer & MO State TB Cell, appointed & joined in state
TB Cell
Major activities conducted by state in past few months- 2:
Intensive monitoring of 18 (May 08) + 4 (June08) low performing
eastern districts of state by state level teams under technical
assistance of WHO consultants
State level supervision of 15 districts by both Medical officers &
other regular staff of State TB cell
Release of funds to districts under NRHM
8 DTOs trained at NTI Bangalore
5 STLS have been specially trained at NTI, Bangalorefor
maintenance & minor repairs for Binocular Microscopes. They are
visiting districts for routine maintenance of BMs
MOTCs training of 29 MOTCs at state level.Trainings at state
level. By now only 21 MOTCs are untrained, which will be trained
shortly.
Districts with low referrals
Name of the district
TB suspects
examined/Lac Pop
Gorakhpur
74
Ambedkar nagar
83
Balia
84
Khushinagar
84
Siddharthanagar
89
Ghazipur
Lowest 10 Districts w.r.t.
% NSP detection- 2nd Qtr 08
Name of the district
% NSP detection
Gorakhpur
35
92
Pratapgarh
36
Azamgarh
93
Balia
40
Deoria
99
Mau
42
Maharajganj
99
Maharajganj
46
Gonda
103
Azamgarh
47
Basti
105
Ambedkar nagar
50
Jaunpur
105
Siddharthanagar
50
Pratapgarh
109
Agra
50
Sonebhadra
112
Mau
113
Sant Kabir Ngr
52
Initiatives taken by the state for achieving
desired objectives under programme:
1. Intensive monitoring strategy: The intensive monitoring of48
districts in past 6 months, has been done by state level teams of
WHO Consultants & DTOs, as per the protocol developed by
state
2. Awareness generation in the community by special drive “TB
awareness week” under supervision of State IEC officer & WHO
consultants
3. Sensitization & trainings of ASHA under DOTS, has improved
referral of TB suspects to DMCs
4. Regular review of program at all levels
Few directions from the Principal Secretary,
has facilitated the programme to sky heights:
• Directions to CMO & CMS for improving
referral of TB suspects
• Release of Binocular Microscopes from
Leprosy programme to RNTCP
• Deployment/transfer of LTs/LAs to vacant
places in DMCs
• Posting of DTOs at vacant places
• Circular for NOT to transfer trained MOTC
or if required, transfer vacant place as MOTC
only.
Future strategy to sustain & further improve the
programme
• Bishop of Methodists has issued letter to Pratapsagar
TB Hospital (Buxer) Bihar & other institutions under
Methodists
• Meeting with Catholic (CBCI) has just finished in Delhi
Today. Action Plan has been prepared. Very soon all the
Catholic Hospitals will follow RNTCP guidelines.
• IMA: Sensitization & training done in majority of
districts.
•
IMA members yet to follow RNTCP guidelines
Future strategy to sustain & further improve the
programme performace
• Planning of meeting with association of Industries under the
Chairmanship of Principal Secretary, Med. & Health in August.
• After the meeting, Action Plan will be drawn up & action will be
initiated.
• Very soon planning meeting of Ulemas (Shia & Sunnis). These
religious groups will release a call to all followers for free treatment of
TB patients under DOTS this has to be announced on every Friday in
all the districts
• Sputum Collection to be done at the mosque with the consent of the
Moullavi on every Friday
• The information has to be given in the following table:
S.no.
Date
Name of the Mosque
Name of Moullavis Phone no.
• Very soon a meeting with Sikh Sevadars is planned & directions will
be initiated from Gurdwaras.
Expectations from Principal Secretary for further
improvement in the Programme
•To fill up the vacant posts of DTOs at following
place:
Mau, sant Kabir Nagar, Allahabad, Kannauj,
Firozabad, MuzzaffarNagar, Mathura (Retiring 31st
July), Bahraich (Retiring 31st July), Sitapur (Retired
30th June)
•To track the referred or transfer out patients and
reduce default; Many states have provided mobile to
STS, making core group with minimum expenditure
IMA Activities
Units
No of
CMEs
Unit I
No of
districts
Doctors
trained
22
No.of
doctors
Sensit.
1133
9
180
Unit II
23
1156
9
209
Unit-III
24
1289
11
270
BRANCH CME BARABANKI
DISTT. TRAINING PROGRAMME
SHAHJEHANPUR
NEWS COVERAGE
Awareness about DOTS
during Intensive Monitoring of Jaunpur
At
ATALA MASZID
on Friday Namaz
Community Meeting in Ghazipur during I.M.
Community Meeting in Ghazipur during I.M.
Self Motivated Cured patientDoing Miking in villages without any incentive
Village level miking by Cycle
Model of Cycle,
Fabricated & designed
in Ghazipur
Innovation by Ghazipur- Specially designed Cycle for Miking
in villages
IEC In Azamgarh
IEC In Azamgarh
Meeting STS and STLS- Azamgarh
Patient Provider meeting- Azamgarh
Patient Provieder Meeting at TU
Meeting of ASHA- Ballia
Projection of T.B. Spot in Village (Ballia)
Projection of Spot in Basti(Ballia)
Projection of Spot (Ballia)
Projection of Spot in Fefna Mela(Ballia)
Rickshaw
concept
(Ballia)
Meeting of Asha at Bidnu(kanpur)
ASHA training in Kanpur Nagar
MEETING AT GRAM PRADHAN’S HOUSE
PROJECTION OF T.B. spot in different villages
PROJECTION OF T.B. spot in different villages
Gathering at Community meeting in Kanpur Dehat
Gathering at Community meeting in Kanpur Dehat
IEC - different ideas
Awaring People Via cart- Azamgarh
TB awareness in Kisan Mela- Ghazipur
IEC With Rickshaw
IEC by cured Patient
DOTS at Workplace
Success stories
Ravi Sadhana Hospital
Barrielly
How I learnt About RNTCP
• The person who
introduced & inspired
me about RNTCP is—
Dr. J. K. Bhatia – Was
running a DMC cum
DOT center
successfully with
satisfactory results.
Motivators from RNTCP
• Dr. S.V Garde (ex - D.T.O.
Bareilly)
• IMA leader- ship of Unit-II
• Dr. Rajesh Raju (WHO
Consultant-Barielly
How I got convinced
Dr. J. K. Bhatia assured me that ….
• Program is good and technically sound
• TB patients will be benefited.
• Mutually beneficial program to each
other
• Results are excellent
What were my initial queries/
doubts?
• Will it affect my consultation fee ?
• How will pt who is seeking free treatment
will come to private clinic ?
• Why only three days in a week treatment ?
• Is it scientific ?
• How will my pt. from remote area will get
treatment ?
How I started
• First six months - DOT center only.
• My patients & pts referred by other microscopy centers
after diagnosis – were initiated on DOTS at my DOT
center
• 10-12 cases put on treatment per month.
• In MAY 06 microscopy center started.
Infrastructure
•
•
•
•
A room of 10*10 ft.with sink and shelves.
Binocular Microscope.
Lab technician-trained by RNTCP
DOT provider- Rs 250/- per
cure/completion
• Returns – Rs. 15/ slide examined
Cooperation extended by DTCS
• Sensitization &Training in RNTCP
• Consistent technical and logistic support by
DTCS
• Lack of action by DTCS toward the
recommendations /suggestions given
through SUPERVISORY REGISTER
• Reagents supply - buffer stock not available
though functioning never stopped except
few days
How is it going in my institution
• 25 chest symptomatic examined per week.
• Increasing day by day.
• Any patient who comes for x-ray,I always
advise sputum examination (package)
• Encouraging results
• Increasing flow of cases to my hospital.
Payment to PP under signed
scheme
PPM Sentinel Survillence
Lucknow
List of Indicators
Outcome Indicators :
1. Contribution to case referral
2. Contribution to case diagnosis
3. Contribution to DOT Provision
4. Case management quality – Sp. Conversion rate
5. Treatment Outcome
Process Indicators :
6. Provider Involvement
7. Provider Supervision
1. Contribution to case referral
• Quarterly number of New S+ cases
registered in the TB register in respective
TU
– by type of referring provider
(Health Department facility, Govt. facility outside health department,
Medical college, Corporate sector, Private provider or NGO)
2. Contribution to case diagnosis
• Number of smear + cases diagnosed in lab
according to monthly MC report
– by place of diagnosis
(Health Department facility, Govt. facility outside health department,
Medical college, Corporate sector, Private provider or NGO)
3. Contribution to DOT delivery
• Number of TB cases on DOT as per
registration in TB register in a TU;
– by type of case (all types);
– and by type of DOT provider (Health Department
facility, Govt. facility outside health department, Medical college,
Corporate sector, Private provider or NGO)
4. Case management quality
• Three months sputum conversion rate for
new s+ cases, by DOT provider type (Health
Department facility, Govt. facility outside health
department, Medical college, Corporate sector, Private
provider or NGO)
5. Treatment outcome
• Treatment results by:
– TB types (all types);
– DOT provider type (Health Department facility, Govt.
facility outside health department, Medical college, Corporate
sector, Private provider or NGO)
6. Provider involvement
• Number of providers (by type);
–
–
–
–
Contacted,
Sensitised,
Trained,
Involved in various tasks (case detection,
treatment, both, others)
7. Provider supervision
• Number of supervision visits;
– by type of superviser (DTO, MOTC, STS.
STLS, PPM Consultant, PFS)
– by provider type (as above)
(To be recorded at monthly meeting & report
quarterly)
Health Department facility (Govt.)
• All facilities under health department of
State or local self government as well as
community volunteers supervised by health
department facilities.
Government facility – outside
health department
• Government facilities not under health
department, including; for eg:
–
–
–
–
–
–
Central Government facilities
ESI facilities
Railways
Military health
Prison health
Ports
Medical college
• Public as well as private medical colleges
(all streams – Allopathy, Ayurvedic,
Homeopathy, Unani etc.)
Corporate sector
• Health facilities under private as well as
public corporate sector, e.g:
– NTPC, ONGC, SAILCoal India
– Tea Estates, Telco, TATA, Sahara, etc.
Private providers
• Private hospitals, clinics, nursing homes,
and individual practitioners from all
medical systems, including unauthorised
medical practitioners, community
volunteers supervised by private provider
NGOs
• Registered NGOs with non profit motive as
well as community volunteers supervised by
NGOs.
Coordination
All sectors, Referral, Diagnostic facilities & DOT centre
•Public Sector
(H)
Referral
•Govt.health facility (G)
•Medical College
PATIENTS
(M)
•Corporate Sector (C)
•Private providers
(P)
•NGO sector
(N)
Diagnostic
Services
DOT Centres
Name of Referring
Centre/person
Register of Suspects
Year…………
Date
TB
Suspe
ct
Numb
er
Name of TB Suspect
Age
M F
Complete Address
Date
Sputu
m
Sent
to Lab
Date
Results
Receiv
ed
Facility/Private…………….
Results of
Sputum
Examinatio
ns
1 2
3
TB
Treatment
Card
Opened?
(record
date)
Observations/
Clinician’s Diagnosis
LT enter name of referring
provider based on:
Appendix 10
A. Lab request/referral form
B.Oral info about who sent patient
TUBERCULOSIS LABORATORY REGISTER
Year
Lab
serial
No.
Date
Name
Sex
M/F
Age
Name Treatment Unit /
Address new patients
Reason for examination
diagnosis*
follow up*
Results of specimen
1
STS codes type of referring provider for S+ cases :
H=RNTCP/Health Department facility
G=Non-health department facility
M=Medical college
C=Corporate sector
P=Private provider
N=NGO
*These are diagnosed New or Relapsed cases
** These are patients on chemotherapy
2
Signature
3
Remarks
Ad provider code
DISTRICT TUBERCULOSIS REGISTER
Date of
District TB
Registration
No.
Name
(in full)
Sex
M/F
Age
Address
(in full)
Name Treatment Unit /
Date Start treatment and
Disease
regimen*
classification
P/PE
Type of patient**
New
(N)
Relapse Treatment Treatment Transfer in
(R)
after failure after default
(T)
(F)
(D)
Code and name of DOT
provider
Other
(O)
Year
Sputumexamination: (M. Indicatemonthsof treatment) Upper space: Result Lower space: laboratorynumber
nd
Pretreatment
Local
Smear
Endof 2 m. / 3 m.
Ref Lab
Smear
rd
Cult
Local
Smear
Ref Lab
Smear
th
5 m.
Smear
th
Datetreatment stopped***
th
Endof 6 m. / 8 m.
Local
Smear
1Cure
Ref Lab
Smear
2Treatment
completed
3Treatment
failure
4Died
Cult
Code of referring
provider type
5Default
Remarks
6Transfer
out
Register
Reporting
Indicator
Lab request
Quarterly Report
new and
retreatment Cases
S+ case
detection, by
provider type
Lab register
Quarterly Report
of Sputum
New S+
conversion, by
provider type
Treatment card
TB register
Conversion
Quarterly Report
on the Results of
Treatment
Consultant’s and
STS’ logbook
No change
Minor adaptation
New
Quarterly report
on provider
involvement and
supervision
DOT delivery,
by TB type and
provider type
Treatment
results, by
provider type
Providers
involved, by
provider type
Supervisions, by
supervisor and
provider type
WHERE PATIENT OF
TUBERCULOSIS GO FOR
TREATMENT ?
Private
Setup
30%
70%
Government
Setup
Partnerships with
professional organizations
Process of IMA
•
•
•
•
•
•
•
•
Orientation of Programme staff- public sector
Listing of Service care providers
Sensitizing opinion leaders – Branch leaders
Prioritization of Service providers (PPs) by patient load
Orientation of providers (PPs)
Training of providers (PPs)-with pre & post evaluation
Training of Programme staff on modified surveillance system
Involvement of health providers(PPs) under Programme
guidelines and schemes, using existing Programme funds
• Member can start DMC/ DOT Center
• IMA consultants follow up visits after sensitization & training
Contribution to case referral Luck now 2q-08
Contribution to case referral
(C), 0
(N), 1130
(P), 41
(M), 1433
(G), 597
(H), 8434
Health Department facility (H)
Medical College (M)
Private provider (P)
Government facility outside health department (G)
Corporate sector (C)
NGOs (N)
Contribution to NSP case detection Luck now 2Q 08
Contribution to NSP Cases
NGOs (N), 45
Private provider (P), 24
Corporate sector (C), 0
M edical College (M ), 205
Government f acility out side healt h
department (G), 67
Healt h Depart ment facilit y (H), 785
Health Department facility (H)
Government facility outside health department (G)
Medical College (M)
Corporate sector (C)
Private provider (P)
NGOs (N)
Contribution to NSP DOT provision 2q-08
P r i v a t e pr ov i der ( P ) , 1 4
N GOs ( N ) , 5 8
C or por a t e s e c t or ( C ) , 0
M e di c a l C ol l e ge ( M ) , 5 5
Gov e r nme nt f a c i l i t y out s i de he a l t h
de pa r t me nt ( G) , 27
H e a l t h D e pa r t ment f a c i l i t y ( H ) , 7 87
Health Department facility (H)
Medical College (M)
Private provider (P)
Government facility outside health department (G)
Corporate sector (C)
NGOs (N)
Contribution to NSP cure outcome 2Q-07
648
535
62
27 21
Health Governm
Departm
ent
ent
facility
cases registered
cases cured
648
535
27
21
45
0 0
19 17
41 39
Medical
College
(M)
Corporat
e sector
(C)
Private
provider
(P)
NGOs
(N)
62
45
0
0
19
17
41
39
Conclusions
• Intensification of IMA activity can helps the program
– Increasing case detection .
– Decentralization of the DOTS by utilizing the available resources of
Private providers.
– More Convenient & Economical to the patients
– Flexibility in Dots-- Flexidots
– RNTCP Coverage increases in real sense
• Coverage in Dark areas – where public health facilities unavailable
• From patients of Government/Public health services to patients of
other PPs health facilities
Thank you
Thanks