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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 68  |  Issue : 1  |  Page : 24-27

Treatment outcomes of patients on non-Revised National Tuberculosis Control Programme (private) anti-tuberculosis regimen from a tertiary-care centre in Kerala, India


1 Department of Respiratory Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Viswavidyapeetham, Kochi, Kerala, India
2 Department of Community Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Viswavidyapeetham, Kochi, Kerala, India
3 RNTCP Unit, Department of Respiratory Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Viswavidyapeetham, Kochi, Kerala, India
4 Department of Pulmonary Medicine, Amrita Institute of Medical Sciences and Research Centre, Amrita Viswavidyapeetham, Kochi, Kerala, India

Date of Submission07-Jul-2018
Date of Acceptance18-Sep-2018
Date of Web Publication12-Mar-2019

Correspondence Address:
Akhilesh Kunoor
Kunoor House, Mekkad (PO), Manakkapady, Ernakulam District, Kerala 683589
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejcdt.ejcdt_95_18

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  Abstract 


Introduction Although standardised tuberculosis (TB) treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), majority of patients in the country are treated with private anti-TB drugs. The objective of the study was to assess the treatment outcome of patients initiated on non-RNTCP regimen from a private tertiary-care centre from January to June 2016.
Patients and methods A nonconcurrent cohort study was done which followed up the patients who have been initiated on private anti-TB regimen from a private tertiary-care centre in Kerala, India, during the first and second quarter of 2016. Details of further visits were sought from the hospital health management information system. A phone call interview was done with all patients, 9–12 months after treatment initiation.
Results There were 81 patients who were initiated on private anti-TB regimen. Of them, 26 were of pulmonary TB and 55 were of extrapulmonary tuberculosis (EPTB). Among pulmonary TB, 17 (65.38%) cases and in EPTB, 41 (74.54%) cases had successful treatment outcome. The overall success of the non-RNTCP regimen was 71.6%. In pulmonary TB, six (23.1%) cases and in EPTB 11 (20%) cases came under lost to follow-up category.
Conclusion The results calls for urgent actions to have a system in place for tracking patients initiated on private anti-TB drugs so as to ensure the standards of TB care. The national programme may further strengthen monitoring of treatment adherence in private sector with established ICT-based treatment support models.

Keywords: outcome, private anti-tuberculosis drugs, treatment adherence, tuberculosis


How to cite this article:
Kunoor A, Suseela RB, Raj M, Thankappan RC, James PT. Treatment outcomes of patients on non-Revised National Tuberculosis Control Programme (private) anti-tuberculosis regimen from a tertiary-care centre in Kerala, India. Egypt J Chest Dis Tuberc 2019;68:24-7

How to cite this URL:
Kunoor A, Suseela RB, Raj M, Thankappan RC, James PT. Treatment outcomes of patients on non-Revised National Tuberculosis Control Programme (private) anti-tuberculosis regimen from a tertiary-care centre in Kerala, India. Egypt J Chest Dis Tuberc [serial online] 2019 [cited 2022 Jan 23];68:24-7. Available from: http://www.ejcdt.eg.net/text.asp?2019/68/1/24/253672




  Introduction Top


India’s national tuberculosis (TB) control programme aims to provide the highest standards of care for people suffering from TB from healthcare providers of their choice.

Although standardised TB treatment in India is delivered by the public sector through the Revised National TB Control Programme (RNTCP), a vast majority of patients in the country are treated with private anti-TB drugs. Private sector accounts for more than half of the TB care delivered in India, the major challenges being quality of diagnosis and treatment [1].

There have been documented evidences that poor diagnostic practices in this sector prolong TB transmission by delaying diagnosis, whereas a general lack of counselling and support of treatment adherence hampers successful, relapse-free cure. Indiscriminate use of anti-TB drugs, especially outside the RNTCP, has alleged to have contributed significantly to the emergence of drug-resistant TB in India [2],[3]. Treating TB effectively and rationally is not only essential for good patient care, but is also a key element in the public health response to TB control. The Standards for TB Care in India (STCI) has been developed by a collaborative effort of the Government of India Central TB Division (CTD) and WHO country office for India as a way to engage with the Indian private sector for effective TB prevention and control [4]. Kerala is rated among the well-performing states as far as TB control is concerned with evidences for a lower level of TB transmission and drug resistant tuberculosis (DR TB). The annual total TB case notification for 2016 was 62 per 100 000 populations.

The private sector is well established in healthcare of the state accounting for more than 70% of all facilities and 60% of all beds. TB management in the private sector of Kerala seems to follow reasonable standards of care. A published study reports that in two major cities of Kerala, 94% of the 124 participated TB practitioners prescribed a complete four-drug regime (HREZ) for a minimum of 6 months to treat drug-sensitive TB. However, provider-initiated follow-up is in its rudimentary stage, though 83% participated in the study believed that more than 80% of their clients adheres to treatment for the entire course [5]. It is important to know whether the care offered to these patients meets the standards, to reengineer the current public–private partnership strategy if required.

Our institute where study has been done is a tertiary-care hospital in Kerala, strengthened TB notification system from 2016 onwards. How we ensured 100% TB notification has been discussed elsewhere [6]. Following that, we were curious to know what happened to the TB patients diagnosed in our hospital and to take any appropriate actions including provider-initiated follow–up, if necessary.


  Objective Top


To assess the treatment outcome of patients started on the non-RNTCP regimen from the institution from January to June 2016.


  Patients and methods Top


We conducted the study in a tertiary-care teaching hospital located in Central Kerala which has an annual patient turnover of 800 000 outpatients and 50 000 inpatients. The hospital receives patients from all over the state and even from neighbouring states. DOTS centre and Designated Microscopy Centre (DMC) are being functional in this hospital and a TB Health Visitor and a Medical Officer have been provided by the National Programme.

We planned a nonconcurrent cohort study and followed up the patients who have been diagnosed with TB during the first and second quarter of 2016 (January–June, 2016). The list of patients who were diagnosed with TB from the institution from 1 January to 30 June 2016 was obtained from NIKSHAY and from our TB Notification Register. Details of their further visits were sought from the hospital health management information system using the Medical Records Number recorded in our TB Notification Register. A phone call interview was done with all patients listed after obtaining prior appointment. All interviews were conducted by a Medical Officer, RNTCP Unit 9–12 months after treatment initiation. Each interview lasted for around 10 min. Details of the patients registered under RNTCP were excluded from the current analysis.

Treatment outcomes were categorised according to the WHO and RNTCP definition into the following [7]:

Successful outcome: if the TB patients were cured (negative smear microscopy at the end of treatment) or completed treatment with resolution of symptoms. New TB patients who completed their treatment for at least 6 months without lost to follow-up and with resolution of symptoms were considered as successful treatment.
  1. Unsuccessful outcome: if treatment resulted in treatment failure (remaining smear positive after 5 months of treatment), lost to follow-up (patients who interrupted their treatment for one consecutive month or more after initiation of treatment), or died.
  2. Those patients whose outcome details could not be obtained due to various reasons was considered as ‘lost to follow-up’.


Data were entered, cleared and analysed using Microsoft Excel. To ensure the quality of data entered into the computer, two people independently cross-checked each entry.

Institutional Ethics committee approval was taken for the study dated 23 June 2017.


  Results Top


We followed up 129 new cases of TB diagnosed during January to June 2016. Out of the 129 cases, 48 cases were treated under RNTCP and 81 cases were treated under non-RNTCP private individualised regimen.

Out of the 81 cases, 49 were men and 32 were women. Of them, 26 were pulmonary TB and 55 were extrapulmonary tuberculosis (EPTB) ([Table 1]). Among pulmonary TB, 17 (65.38%) cases and in EPTB 41 (74.54%) cases had successful treatment outcome. The overall success of the non-RNTCP regimen was 71.6% ([Table 2]).
Table 1 Demographic characteristics

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Table 2 Treatment outcome of non-Revised National TB Control Programme tuberculosis cases notified during the study period

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In pulmonary TB, six (23.1%) cases and in EPTB 11 (20%) cases came under lost to follow up (LTFU). It included 15 who could not be followed up (nine changed their addresses, four phone switched off, two went abroad) and two patients refused to reveal their status. There were three deaths in pulmonary TB and two deaths in EPTB. Overall, 6.17% cases died.


  Discussion Top


The major challenge in India’s TB control is due to the vast disorganised private healthcare system. The major challenge in private sector is misuse of anti-TB drugs, lost to follow-up due to various reasons and lack of monitoring. Ensuring universal access for quality diagnosis and treatment for all TB patients is made as a policy by RNTCP for its vision for TB-free India. Extension of its services to private sector is also a strategy of RNTCP.

Though there are not many studies regarding the outcome of TB treatment in private sector from India, similar studies were done in other countries. The present study has shown nearly 70% success in treatment outcome, whereas the study from Nigeria showed 83.7% treatment success from the private sector [8]. Another study from Mumbai showed a success rate of 81% from the private sector [9].The present study showed an LTFU of 20.98% whereas Gidado and Ejembi [8] showed an LTFU of only 5.8%. LTFU from a study in North India showed 11.5% when involving the private sector [10]. This figure in our study could be inflated, as we could not get information from nearly 20% of cases due to various reasons and we included all of them in the lost to follow-up category. They might have completed or continued treatment from some other hospitals or even countries!

To the private sector, it calls for urgent actions to have a system in place for tracking TB patients, with or without government system support, so as to ensure the standards of TB care to all patients. Adherence to regular and complete treatment is one of the important factors for cure from TB and for preventing emergence of drug resistance and relapse. Currently the national programme promotes patient-centric management strategies by allowing him to choose even private sector as per his/her convenience in TB care. It may prompt to build models for private sector engagement based on the social responsibility of private sector in ending TB blended with profitable customer-care services, without much direct involvement of the government field staff.

The results of the study could not be generalised due to a high selection bias involved as most cases diagnosed in a tertiary-care centre like AIMS would be comparatively serious. There could also be bias by doctor, patient, or disease severity to be included in the private regimen. Though the numbers of patients are not too big, the findings of this study have got great public health implications.


  Conclusion Top


Adherence to regular and complete treatment is one of the important factors for cure from TB and for preventing the emergence of drug resistance and relapse. The study shows that there is an urgent need to have a system in place for tracking TB patients initiated on private anti-TB regimens so as to ensure standards of TB care to all patients.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Arinaminpathy N, Batra D, Khaparde S, Vualnam T, Maheshwari N, Sharma L, Nair SA, Dewan P. The number of privately treated tuberculosis cases in India: estimation from drug sales data. Lancet Infect Dis 2016; 16:1255–1260.  Back to cited text no. 1
    
2.
Satyanarayana S, Subbaraman R, Shete P, Gore G, Das J, Cattamanchi A et al. Quality of tuberculosis care in India: a systematic review. Int J Tuberc Lung Dis 2015; 19:751–763.  Back to cited text no. 2
    
3.
Institute of Medicine (US). Facing the reality of drug-resistant tuberculosis in india: challenges and potential solutions: summary of a joint workshop by the Institute of Medicine, the Indian National Science Academy, and the Indian Council of Medical Research. Washington, DC: National Academies Press 2012.  Back to cited text no. 3
    
4.
World Health Organization. Standards of TB Care in India. WHO SEA Regional Office and Central TB Division, MOHFW, Goverment of India; 2014. Available at: www.searo.who. int/india/mediacentre/events/2014/stci_book.pdf  Back to cited text no. 4
    
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Rakesh PS, Balakrishnan S, Jayasankar S, Asokan RV. TB management by private practitioners. Is it bad everywhere? Indian J Tuberc 2016; 63:251–254.  Back to cited text no. 5
    
6.
Nair P, James PT, Kunoor A, Rakesh PS. How we ensured 100% TB notification: experiences from a private tertiary care hospital in India. Public Health Action 2017; 7:179–180.  Back to cited text no. 6
    
7.
Central TB Division, Ministry of Health and Family Welfare. Technical and operational guidelines for tuberculosis control in India, 2016. Chapter 4. Treatment of Tuberculsis. Delhi, India: Ministry of Health and Family Welfare, Government of India. 2016. Available at: http://tbcindia.nic.in/showfile.php?lid=3216. [Accessed August 2016].  Back to cited text no. 7
    
8.
Gidado M, Ejembi C. Tuberculosis case management and treatment outcome: assessment of the effectiveness of Public-Private Mix of tuberculosis programme in Kaduna State, Nigeria. Ann Afr Med 2009; 8:25–31.  Back to cited text no. 8
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9.
Ambe G, Lönnroth K, Dholakia Y, Copreaux J, Zignol M, Borremans N, Uplekar M. Every provider counts: effect of a comprehensive public- private mix approach for TB control in a large metropolitan area in India. Int J Tuberc Lungs Dis 2005; 9:562–568.  Back to cited text no. 9
    
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Krishnan A, Kapoor SK. Involvement of private practitioners in TB control in Ballabgarh. Northern India. Int J Tuberc Lung Dis 2006; 10:601–606.  Back to cited text no. 10
    



 
 
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Abstract
Introduction
Objective
Patients and methods
Results
Discussion
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