IJCRR

IJCRR - 4(11), June, 2012

Pages: 151-159

Date of Publication: 18-Jun-2012

STUDY OF DEFAULTERS OF REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME IN THE THREE PRIMARY HEALTH CENTRES OF BELGAUM DISTRICT

Author: Shivappa Hatnoor, Hemagiri K, Sangolli H N, Mallapur M.D, VinodKumar C.S

Category: Healthcare

Abstract:The Revised National Tuberculosis Control Programme introduced in 1993 lays more emphasis on good quality diagnosis by direct sputum smear microscopy and quality drugs, through standardized short course chemotherapy regimens administered under direct observation along with systematic monitoring and evaluation. The goal of the Revised National Tuberculosis Control Programme is to cure at least 85% of new sputum smear positive patients detected and to detect at least 70% of all such patients after the goal for cure rate has been met. No studies have been done on evaluation of Revised National Tuberculosis Control Programme and reasons for default in these areas. Objective of this study to know the reasons for default of the patients put under Revised National Tuberculosis Control Programme. Materials and method: This study carried over for one year one month (November 1st 2004 to 31st December 2005). The data collected by using pre-designed and pretested proforma. The first visit was done when the patient was registered in the Primary Health Centre and
started on the treatment. Second visit i.e. First follow-up visit was done at the end of Intensive Phase and the data was collected regarding the scheduled intake of drugs, result of 1st follow-up sputum examination and about defaulters if any. Second follow-up visit was done in the middle of continuation phase and the data was collected regarding the scheduled intake of drugs, result of 2nd follow-up sputum examination and defaulters if any. Fourth visit i.e. third follow-up visit was done at the end of Continuation Phase and the data was collected regarding the scheduled intake of drugs, result of sputum examination at the end of the treatment, about defaulters if any and outcome of the treatment. Results: Out of 69 defaulter cases majority 63% of them were males, the main reason for treatment failure were illiteracy (42%), marital
status (79%), Class V family (58%), complaining of acidity and vomiting (63%). habit of smoking (31%) and smokeless tobacco(15%). These are the significant reasons for treatment failure.

Keywords: Keywords: RNTCP, tuberculosis, defaulters

Full Text:

INTRODUCTION
Tuberculosis continues to be one of the most important public health problems worldwide. It infects one third of the world‘s population at any point of time. There are approximately 9 million new cases of all form of tuberculosis occurring annually and 3 million people die from it each year. Out of these 95% tuberculosis cases and 98% tuberculosis deaths are contributed by developing countries1 . India accounts for nearly one third of the global burden of tuberculosis. Around 2.0 million people are diagnosed to be suffering from tuberculosis every year.1 Tuberculosis kills more adults in India than any other infectious diseases. More than 1000 people a day i.e one every minutes die of tuberculosis2 . Despite the National Tuberculosis Programme since 1992, the desired control of tuberculosis could not be achieved. Moreover, there has been an increase in the absolute number of tuberculosis patients because of the increase in population. The impending threat of Tuberculosis- HIV co- infection and the emergence of Multi Drug Resistance Tuberculosis have made the situation worse3 . In 1992, an expert committee reviewed the National Tuberculosis Programme and found that less than 30% treatment completion rate, undue emphasis on radiological diagnosis, poor quality of sputum microscopy, multiplicity of treatment regimens, emphasis on case detection rather than on treatment completion, inadequate budgets and shortages of drugs3 . The Revised National Tuberculosis Control Programme introduced in 1993 lays more emphasis on good quality diagnosis by direct sputum smear microscopy and quality drugs, through standardized short course chemotherapy regimens administered under direct observation along with systematic monitoring and evaluation3 . The goal of the Revised National Tuberculosis Control Programme is to cure at least 85% of new sputum smear positive patients detected and to detect at least 70% of all such patients after the goal for cure rate has been met2 . Belgaum district started implementing Revised National Tuberculosis Control Programme from 15th July 2003. K.L.E. Society‘s J.N. Medical College adopted three Primary Health Centres namely Kinaye, Vantmuri and Handignur on 7th April 2004 as such no studies have been done on evaluation of Revised National Tuberculosis Control Programme in these areas. So, this study was taken to evaluate the implementation of Revised National Tuberculosis Control Programme in these areas and also to know the reasons for default of the patients put under Revised National Tuberculosis Control Programme.

MATERIALS AND METHODS
Ethical clearance:
Ethical clearance was obtained from JN Medical College, Belgaum, Karnataka

Design:
This was a longitudinal study undertaken to evaluate the Revised National Tuberculosis Control Programme in three Primary Health Centres, attached to JN Medical College, Belgaum, Karnataka Source of Data: Total population of three Primary Health Centres were; Kinaye 47,159, Vantamuri 30,756 and Handiganoor 23,452 population.

Inclusion Criteria:
All cases diagnosed for tuberculosis by the Medical Officers of three Primary Health Centers from November 1st 2004 to April 30th 2005.

Study Period:
From November 1st 2004 to 31st December 2005 (One year One month)

Methods of Data Collection:
Using pre-designed and pre-tested proforma the data is collected. The first visit was done when the patient was registered in the Primary Health Centre and started on the treatment. The following data was collected in the first visit Name, Age, Sex, Religion, Occupation, Address, Educational Status, Marital Status, Type of Family, Socio-economic status, DOT provider, Category of Treatment, Disease Classification, Type of patient, result of 1st sputum (at the start of the treatment) examination and if there are any reasons for initial default.

Second visit i.e. First follow-up visit was done at the end of Intensive Phase and the following data was collected regarding the scheduled intake of drugs, result of 1st follow-up sputum examination and about defaulters if any. Third visit i.e. second follow-up visit was done in the middle of Continuation Phase and the following data was collected regarding the scheduled intake of drugs, result of 2nd follow-up sputum examination and defaulters if any. Fourth visit i.e. third follow-up visit was done at the end of Continuation Phase and the data was collected regarding the scheduled intake of drugs, result of sputum examination at the end of the treatment, about defaulters if any and outcome of the treatment.

The present study was a longitudinal study undertaken to evaluate the Revised National Tuberculosis Control Programme in three Primary Health Centers of Belgaum which are adopted by K.L.E. Society‘s J.N. Medical College under Public Private Partnership. The total study population covered was Kinaye47,159, Vantmuri-30,756 and Handignur23,452 out of this 69 patients were put on antitubercular treatment under Revised National Tuberculosis Programme, by Medical Officers of respective Primary Health Centers from November 1st 2004 to April 30th 2005 were included in the study. All the three Primary Health Centers are located within the radius of 25 kilometers from J.N. Medical College. Our study showed that among defaulters 63% of patients had acidity and vomiting, 16% patients were alcoholics, 10.5% left the place, 5.3% had taken treatment previously and 5.3% not willing to disclose the identity. A study done in Bangalore city showed that alcoholics were more among the defaulted i.e. in category I 56.7% and in category II 68.7%.4 In another study done at Tiruvallur, District in Tamil Nadu showed that 17.1% of defaulters were alcoholics5 . In a similar study conducted in West Bengal, Jharkand and Arunachal Pradesh showed that intolerance to drugs among defaulters ranged from 5.6 % to 20%.6 In our study maximum defaulted cased were in Primary Health Center Handignur i.e. 36.4%, followed by 32% in Primary Health Center Vantamuri and 21% in Primary Health Center Kinaye. Overall in all Primary Health Centers defaulted cases were 27.5%. In a similar study conducted in West Bengal, Jharkand and Arunachal Pradesh showed that defaulted patients ranged from 10.78% to 38.13% in four centers where the study was conducted.6 In our study majority of defaulted patients were males i.e. 63% and 37% were females. In a study done in Bangalore city among category I 89.6% of defaulter were males and 90.9% males in category II.4 In our study maximum number of defaulters were seen among housewives i.e. 31.6%, followed by 26.3% each among farmers and labours, 5.3% each among business persons, drivers and children under seven years of age. In our study maximum number of defaulted patients were illiterates i.e 42%, followed by 37% Primary level education, 16% Secondary level education and 5.3% children under seven years of age. In a study conducted in Tiruvallur District in Tamil Nadu revealed that among all defaults 12.7% were illiterates6 . In a similar study conducted in the states of West Bengal, Jharkand and Arunachal Pradesh showed that 48% to 64.9% of defaulters were illiterates, Primary school level raged from 19.1% to 40%, High school level ranged from 15.9% to 40% and college level ranged from 5.6 % to 20%.7 In our study maximum numbers of defaulted patients were married i.e 79% and 21% were unmarried. In a similar study conducted in Bangalore city revealed that 73% in category I and 69.7% in category II were married.5 In our study majority of defaulted patients were from Joint family i.e 47.3%, followed by 37% three generation family, 10.5% nuclear family and 5.3% problem family. In our study maximum percentage of defaulted cases were in class V i.e 58%, 26.3% were in class IV, 10.5% were in class III and 5.3% were in class II. In a similar study conducted in states of West Bengal, Jharkand and Arunachal Pradesh revealed that in class V and IV the defaulted patient ranged from 24.5% to 63%, in class III and II it ranged from 24.5% to 45.5% and in class I it ranged from 12.5% to 30%.7 In our study maximum number of defaulted cases were having the habit of smoking and alcohol i.e. 31.6%, 15.9% were having the habit of using smokeless tobacco, 15.9% were having the habit of smoking, alcohol and use of smokeless tobacco, 5.3% were having the habit of smoking and 5.3% were having the habit of smoking and use of smokeless tobacco. 26.3% of the defaulted cases were not having any habits. In another study conducted at Tiruvallur district in Tamil Nadu showed that in overall defaulted cases 14.6% were smokers and 17.1% were alcoholics.6 In our study majority of the defaulted cases were in category I i.e. 55%, 35% were in category II and 10% were in category III. In a study conducted in Bangalore city showed that the defaulted cases in category I were 25.4% and in category II were 45.2%. 4 In our study maximum percentage of defaulted cases i.e. 68% had Anganwadi workers as DOTS providers and 32% had Health workers as DOTS providers. In our study the defaulters among males were 36% and non defaulters were 64%. Among Females 19% were defaulters and 81% were non defaulters. Which did not show any statistical significance where P = 0.116. In the study the defaulters among illiterates were 40% and non defaulters were 60%. Among literates 21% were defaulters and 79% were non defaulters. We found that their is no statistical significance between illiterate and literate defaulters. Where P=0.114. In a similar study conducted in the states of West Bengal, Jharkand and Arunachal Pradesh showed that 48% to 64.9% of defaulters were illiterates. 7 In our study defaulters among class II and III were 23% and non-defaulters were 77%. Defaulters among class IV were 20% and nondefaulters were 80%. Defaulters among class V were 35% and non-defaulters were 65%. It did not show any statistical significance where P=0.402. In a study done in West Bengal, Jharkand and Arunachal Pradesh the defaulted patients among class II and III ranged from 24.5% to 45.5% and in class IV and V it ranged from 24.5% to 63%. 7 In our study among category I 37% were defaulters and 63% were non-defaulters, among category II 21% were defaulters and 79% were non-defaulters and in category III 27% were defaulters and 73% were non-defaulters. It showed a statistical significance where P= 0.013. In a study done at Bangalore revealed that defaulters among category I were 25.4% and in category II were 45.2%. 4 In our study among Anganwadi workers 31% were defaulters and 69% were non-defaulters. Among Health workers and others 22.2% were defaulters and 77.8% were non- defaulters. It showed no statistical significance where P= 0.428. Reasons for default during the course of treatment being 12(63% ) due to toxicity of drugs (Acidity and Vomiting), 31(16%) due to addiction to Alcohol and 2(10.5%) left the place. Numbers of defaulters in category I were 11(37%), Category II were 6(46%) and category III were 2(8%). Which was statistically significant.

RECOMMENDATION

• Training newly recruited staff of Primary Health Centers.
• Regular re-orientation of all the staff and also DOTs providers.
• Sputum examination should be made mandatory for all the patients (Pulmonary as well as extra pulmonary).
• IEC activities for the public regarding Tuberculosis and its treatment and also to increase the cure rate, decrease the default and failure rate amongst the patients.

ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed

References:

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2. Sengupta S, Pungrassami P, Balthip Q, Strauss R, Kasetjaroen Y. Social impact of tuberculosis in southern Thailand: views from patients, care providers and the community .Int. J. Tuberc. Lung. Dis. 2006; 10(9):1008-12.

3. Srivastava S.K., Ratan R.K. Srivastava P, and Prasad R: report on Revised National Tuberculosis Control Programme: urban pilot project in Lucknow, Ind J. Tub, 2000;47:159-162.

4. Sophia Vijay, Balasangameshwara .V.H, Jagannatha. P.S, Saroja V.N and Kumar P; Defaults among tuberculosis patients treated under DOTs in Bangalore city: A search for solution: Ind. J.Tub, 2003,50,185-195

5. Chandrasekaran V, Gopi P.G, Subramani R, Thomas A, Jaggarajamma K, and Narayanan. P.R; Default during the Intensive phase of Treatment under DOTs Programme. Ind. J. Tub, 2005, 52,197-202.

6. Chatterjee P, Brutoti Banerjee, Debashis Dutt,Rama Ranjan Pati and Ashok kumar Mullick. A comparative evaluation of factors and Reasons for defaulting in tuberculosis treatment in Ind. J. Tub, 2003, 50,17-22.

7. Revised National Tuberculosis Control Programme at Glance, central Tuberculosis division Directorate General of Health Services Ministry of Health and Family welfare Nirman Bhavan, New Delhi.