RNTCP status in UP

Dr. Jagdish Rai

State TB OfficerUttar 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

839056%5318742007

849160%5719092008 1st Qtr

859075%7119092008 2nd Qtr

Cure rate of

NSP

Smear

conversion

rate

NSP

detection

rates

Expected 85Expected 90Expected 67

(70%)

Population

coveredYear

Performance under RNTCP- Uttar Pradesh

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%Qtr1-03

Qtr2-03

Qtr3-03

Qtr4-03

Qtr1-04

Qtr2-04

Qtr3-04

Qtr4-04

Qtr1-05

Qtr2-05

Qtr3-05

Qtr4-05

Qtr1-06

Qtr2-06

Qtr3-06

Qtr4-06

Qtr1-07

Qtr2-07

Qtr3-07

Qtr4-07

Qtr1-08

Qtr2-08

AnnualisedNew S+veCDR

Successrate

Poly.

•Population projected from 2001 census

•Estimated no. of NSP cases - 95/100,000 population per year (based on recent ARTI report)

Case Detection Rate (% NSP) and Treatment Success Rate in Uttar

Pradesh, 2003-2007*

Entire UP Covered

Kheri

Etah

HardoiSitapur

Bijnor

Jhansi

Agra

Lalitpur

Unnao

Jalaun

Banda

Budaun

Sonbhadra

Bareilly

Allahabad

Pilibhit

Mau

Gonda

Mirzapur

Bahraich

Jaunp

Kheri

Etah

HardoiSitapur

Bijnor

Jhansi

Agra

Lalitpur

Unnao

Jalaun

Banda

Budaun

Sonbhadra

Bareilly

Allahabad

Pilibhit

Mau

Gonda

Mirzapur

Bahraich

Jaunpur

Mathura

Deoria

Ballia

Sultanpur

Fatehpur

Mahoba

BastiBarabanki

Rae_Bareli

M eerut

Azamgarh

Balrampur

Aligarh

KanpurDehat

Mainpuri

Ghazipur

Pratapgarh

Auraiya

Chitrakoot

Shahjahanpur

Bulandshahar

Saharanpur

Faizabad

Rampur

Muzaffarnagar

Gorakhpur

Hathras Shravasti

LucknowKannauj

Hamirpur

MaharajganjFirozabad

Etawah

Siddharthnagar

Ghaziabad

Chandauli

Moradabad

Kushinagar

Kaushambi

JyotibaPhuleNagar

Farrukhabad

Varanasi

Ambedkar_Nagar

r

Muzaffarnagar

Gorakhpur

Hathras Shravasti

LucknowKannauj

Hamirpur

MaharajganjFirozabad

Etawah

Siddharthnagar

Ghaziabad

Chandauli

Moradabad

Kushinagar

Kaushambi

JyotibaPhuleNagar

Farrukhabad

Varanasi

Ambedkar_NagarKanpurNagar

Revised National TB Control Programme-

Uttar Pradesh 2Q 08

Baghpat

GB Ngr

SK Nagar

Bhadoi

Sitapur

Kheri

% NSP detection

> 70%

70%- 50%

< 50%

167088942262094Aligarh

145083852243494Lucknow

294786902162594Bareilly

68584871763195Lalitpur

108187932012795Unnao

1272889227725103

Gautam Budh

Nagar

777919221819103Meerut

1961858621123144Rampur

883899430319146Ghaziabad

Default

rate of

S+ve

retreatme

nt cases

registered

13-15

months

earlier

Cure rate

of S+ve

retreatme

nt cases

registered

13-15

months

earlier

Cure rate

of NSP

registered

13-15

months

earlier

Smear

Conversio

n rate of

NSP

Ann.

Total

cases

detection

rate

% of

Retreatme

nt cases

out of

total Sm

Positive

cases

% NSP

detection

Name of the

district

Highest % NSP detection 2nd Qtr 08

State IEC officer & MO State TB Cell, appointed & joined in state

TB Cell

Sensitization of DTOs & consultants under revised recording &

reporting formats

World TB Day activities by partnership of NGOs, Stakeholders,

Airtel, Sahara, BSNL, Eldeco etc.

State level Paediatric conference in S.N.M.C. Agra on 26th April

2008

Regular review of programme in ADs & CMOs meetings at state

level by Principal Secretary/ DG, Med. & Health

Review meeting of all DTOs under chairmanship of Principal

Secretary, M,H & FW(U.P.) on 16th & 17th April 08.

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

Major activities conducted by state in past few months:

5 STLS have been specially trained at NTI, Bangalorefor

maintenance & minor repairs for Binocular Microscopes. They are

visiting districts for routine maintenance of BMs

8 DTOs trained at NTI Bangalore

MOTCs training of 29 MOTCs at state level.Trainings at state

level. By now only 21 MOTCs are untrained, which will be trained

shortly.

Release of funds to districts under NRHM

State level supervision of 15 districts by both Medical officers &

other regular staff of State TB cell

Intensive monitoring of 18 (May 08) + 4 (June08) low performing

eastern districts of state by state level teams under technical

assistance of WHO consultants

Major activities conducted by state in past few months- 2:

113Mau

112Sonebhadra

109Pratapgarh

105Jaunpur

105Basti

103Gonda

99Maharajganj

99Deoria

93Azamgarh

92Ghazipur

89Siddharthanagar

84Khushinagar

84Balia

83Ambedkar nagar

74Gorakhpur

TB suspects

examined/Lac PopName of the district

52Sant Kabir Ngr

50Agra

50Siddharthanagar

50Ambedkar nagar

47Azamgarh

46Maharajganj

42Mau

40Balia

36Pratapgarh

35Gorakhpur

% NSP detectionName of the district

Lowest 10 Districts w.r.t.

% NSP detection- 2nd Qtr 08

Districts with low referrals

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 beinitiated.

• 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

1809113322Unit I

27011128924Unit-III

2099115623Unit II

Doctors

trained

No of

districts

No.of

doctors

Sensit.

No of

CMEs

Units

BRANCH CME BARABANKI

DISTT. TRAINING PROGRAMME

SHAHJEHANPUR

NEWS COVERAGE

Awareness about DOTS

during Intensive Monitoring of Jaunpur

At

ATALA MASZIDon Friday Namaz

Community Meeting in Ghazipur during I.M.

Community Meeting in Ghazipur during I.M.

Self Motivated Cured patient-Doing 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 Provieder Meeting at TU

Patient Provider meeting- Azamgarh

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

PATIENTS

Referral

Diagnostic

Services

DOT Centres

•Public Sector (H)

•Govt.health facility (G)

•Medical College (M)

•Corporate Sector (C)

•Private providers (P)

•NGO sector (N)

Name of Referring

Centre/person

Observations/

Clinician’s Diagnosis

TB

Treatment

Card

Opened?

(record

date)

Results of

Sputum

Examinatio

ns

1 2 3

Date

Results

Receiv

ed

Date

Sputu

m

Sent

to Lab

Complete AddressAge

M FName of TB Suspect

TB

Suspe

ct

Numb

er

Date

Year………… Register of Suspects Facility/Private…………….

Appendix 10

TUBERCULOSIS LABORATORY REGISTER

Year

Reason for examination Results of specimen Signature Remarks Lab

serial

No.

Date Name Sex

M/F

Age Name Treatment Unit / Address -

new patientsdiagnosis* follow up* 1 2 3

*These are diagnosed New or Relapsed cases ** These are patients on chemotherapy

LT enter name of referring

provider based on:

A. Lab request/referral form

B.Oral info about who sent patient

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

Ad provider code

DISTRICT TUBERCULOSIS REGISTER

Type of patient**Date of

Registration

District TB

No.

Name

(in full)

Sex

M/F

Age Address

(in full)

Name Treatment Unit / Date Start treatment and

regimen*

Disease

classification

P/PE New

(N)

Relapse

(R)

Treatment

after failure

(F)

Treatment

after default

(D)

Transfer in

(T)

Other

(O)

Code and name of DOT

provider

Year

Sputum examination: (M. Indicate months of treatment) Upper space: Result Lower space: laboratory number Date treatment stopped***

Pre treatment End of 2nd

m. / 3rd m. End of 6

th m. / 8

th m.

Ref Lab Ref Lab Ref LabLocal

SmearSmear Cult

Local

SmearSmear

5th m.

SmearLocal

SmearSmear Cult

1 Cure 2 Treatment

completed

3 Treatment

failure

4 Died 5 Default 6 Transfer

out

Remarks

Code of referring

provider type

S+ case

detection, by

provider type

New S+

conversion, by

provider type

DOT delivery,

by TB type and

provider type

Treatment

results, by

provider type

Providers

involved, by

provider type

Supervisions, by

supervisor and

provider type

IndicatorReportingRegister

Quarterly Report

new and

retreatment Cases

Quarterly Report

of Sputum

Conversion

Quarterly Report

on the Results of

Treatment

Quarterly report

on provider

involvement and

supervision

Consultant’s and

STS’ logbook

TB register

Lab register

Treatment card

No change

Minor adaptation

New

Lab request

70%

30%

WHERE PATIENT OF

TUBERCULOSIS GO FOR

TREATMENT ?

Government

Setup

Private

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

(G), 597

(H), 8434

(M), 1433

(C), 0

(P), 41

(N), 1130

Health Department facility (H) Government facility outside health department (G)

Medical College (M) Corporate sector (C)Private provider (P) NGOs (N)

Contribution to NSP case detection Luck now 2Q 08

Contribution to NSP Cases

Health Department facility (H), 785

Government facility outside health

department (G), 67

M edical College (M ), 205

Corporate sector (C), 0

Private provider (P), 24

NGOs (N), 45

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

Heal t h Depar tment f aci l i t y ( H) , 787

Gover nment f aci l i t y out si de heal t h

depar tment (G) , 27

Medi cal Col l ege (M ) , 55

Cor por at e sect or ( C) , 0

P r i vat e pr ovi der ( P ) , 14NGOs (N) , 58

Health Department facility (H) Government facility outside health department (G)

Medical College (M) Corporate sector (C)Private provider (P) NGOs (N)

Contribution to NSP cure outcome 2Q-07

648

27

62

019

41

535

2145

017

39

cases registered 648 27 62 0 19 41

cases cured 535 21 45 0 17 39

Health

Departm

ent

Governm

ent

facility

Medical

College

(M)

Corporat

e sector

(C)

Private

provider

(P)

NGOs

(N)

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