|Year : 2011 | Volume
| Issue : 1 | Page : 46-48
Structural and qualitative evaluation of microscopy and directly observed treatment centers under revised national tuberculosis control programme in Nanded city of Maharashtra
Vijay Manohar Bhagat1, Prakash Laxminarayan Gattani2
1 Assistant Professor, Department of Community Medicine, Raichur Institute of Medical Sciences, Raichur, Karnataka, India
2 Associate Professor, Department of P. S. M., Government Medical College, Aurangabad, Maharashtra, India
|Date of Web Publication||30-Jun-2011|
Vijay Manohar Bhagat
Assistant Professor, Department of Community Medicine, Raichur Institute of Medical Sciences, Raichur, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Structural and qualitative evaluation of Revised National Tuberculosis Control Programme (RNTCP) is important to determine actual status of the programme in the field settings and to uncover the concealed gaps. The present cross-sectional study assessed the infrastructural facilities and quality of services provided through microscopy and directly observed treatment (DOT) centers at Nanded city of Maharashtra. The investigator made on spot observation on the activities at microscopy and DOT centers and assessed the infrastructural facilities using an observational checklist. Expert microbiologist cross checked the microscopy report done by the laboratory technicians. It revealed that retrieval mechanism was not functioning in more than half of the DOT centers. Only 5 DOT providers were trained in RNTCP. Stock of sputum containers, methylene blue, and carbol fuchsin was found to be inadequate at some microscopy centers. Half of the laboratory technicians reported high false positive result in spite of being trained. Improvement of infrastructural and logistic support along with the refreshing training for the workers are needed for effective implementation of RNTCP.
Keywords: Evaluation, Qualitative, RNTCP, Structural
|How to cite this article:|
Bhagat VM, Gattani PL. Structural and qualitative evaluation of microscopy and directly observed treatment centers under revised national tuberculosis control programme in Nanded city of Maharashtra. Indian J Public Health 2011;55:46-8
|How to cite this URL:|
Bhagat VM, Gattani PL. Structural and qualitative evaluation of microscopy and directly observed treatment centers under revised national tuberculosis control programme in Nanded city of Maharashtra. Indian J Public Health [serial online] 2011 [cited 2020 Jan 25];55:46-8. Available from: http://www.ijph.in/text.asp?2011/55/1/46/82553
Revised National Tuberculosis Control Programme (RNTCP) has successfully completed the largest and most rapid expansion of directly observed treatments (DOTs) in the history to cover the entire country. Maintaining diagnostic and treatment quality is crucial throughout this expansion. It is observed that although all patients recorded as having received DOT, more than 60% did not actually receive it. Non-receiver of DOT accounted for 86% of treatment failure and relapse.  Structural and qualitative evaluation of RNTCP is important to determine actual status of the programme in the field settings and to uncover the concealed gaps. The present study was undertaken to assess the infrastructural facilities and quality of services provided by microscopy and DOT centers under RNTCP.
A cross-sectional, evaluative study was carried out in Nanded city area of Maharashtra in the year 2005 with the stated objective. Visits were made to all DOT centers (30 numbers) and microscopy centers under Tuberculosis Unit of Nanded city during the study period and collected relevant data in the pre-designed and pre-tested questionnaires and checklists.
Each DOT provider was observed while providing treatment to these patients. During the visit to the microscopy center, the practices of laboratory technicians were observed during collection of sputum sample, preparation and staining of smear, time given for each step, and observation of smear under microscopy adequately. Infrastructural facilities and logistics were assessed in all the centers. Standard laboratory guidelines  utilized for evaluation of practices of lab technician. Slides stained and reported by lab technicians were collected from each microscopy center and Senior Tuberculosis Laboratory Supervisor (STLS) cross checked these slides. Standard reporting guidelines followed for this purpose. , In addition, expert microbiologist also cross checked the smear microscopy done by laboratory technicians. For evaluation of defaulter retrieval mechanism, the patients' treatment cards observed for steps taken toward retrieval of patients failed to take treatment as per norms which were also confirmed by cross questioning patients about these actions taken by the DOT provider.
Definitions used in the study: Accessibility: meant if a patient reached the facility within 30 minutes by commonly used route throughout the year. Identifiable: The facility was said to be identifiable if it followed at least two of three criteria i) Located within the community ii) Information, Education and Communication (IEC) material displayed outside the premises iii) Located in the crowded public place e.g., market places, within multi-specialty private or government hospitals railway stations or bus transit points and should not be located in isolated areas.
The present cross-sectional study carried out in 30 DOT centers and 4 microscopy centers (GMC, Itwara, Shivaji Nagar, and Jungamwadi) of Tuberculosis Unit in Nanded city. Out of 30 DOT centers, 13 (43.33%) centers were run by corporation health facilities and remaining 17 (56.77%) by private practitioners. All the DOT centers run by private practitioners were accessible and identifiable, while the DOT centers at corporation health facilities though accessible, they were not identifiable to the public. Non-accessibility of center may result in suboptimal uses of services under RNTCP.
According to the programme guidelines,  it is mandatory that patient should swallow drugs under the supervision of the DOT provider. Therefore, it is necessary that each DOT center should have drinking water facility, failing to which patient might not be observed by DOT provider while swallowing the drugs. This may lead to failure of direct observation of treatment. Drinking water facility was available only at 8 (61.54%) of the corporation DOT centers and 11 (64.71%) DOT centers run by private practitioners
An almirah is essential for safety and security of drug storage. In our study, we observed that more than 40% of DOT centers were lacking an appropriate sized almirah for the storage of drugs. Only 7 (53.85%) corporation DOT centers and 11 (64.71%) of DOT centers run by private practitioners were found to have an appropriate sized almirah for the storage of drugs.
Direct observation of treatment, the basic principle of DOTS  was followed only at 13 (43.33%) DOT centers. We observed that more than half of the patients were not directly observed while swallowing the drugs. Balambal  observed a relatively high proportion (82.47%) of DOT providers follow the principle of DOT, while Balasubramaniam  noticed that though all patients recorded as having received DOT, only 26.45% actually received it. He also noted that risk of failure or relapse among patient not receiving DOT was 16.6 times higher. It is a well-known fact that failure to follow DOT is associated with an adverse outcome. Patient-wise-boxes contain patients' complete treatment. Lack of correlation between empty strips in patient-wise-boxes and entries in treatment cards indicate non-existence of DOT. In the present study, we noted that the correlation of drugs in boxes and entries on treatment cards were in 66.76% of centers only, however, Patel and Sanghvi  observed that in 20% cases, there were inconsistencies between entries in treatment cards and number of strips in patient-wise-boxes.
Regarding the training status, it was observed that only 5 (16.67%) DOT providers were trained in RNTCP. Untrained workers will ultimately undermine the objectives and performance of the programme. There is an urgent need of re-orientation training of workers.
Insufficient stock  of essential stains and reagents will lead to failure of diagnostic efficiency and indicates lack of supervision. Inadequate stock of methylene blue and carbol fuchsin were observed in 25 and 50% microscopy centers, respectively. All the microscopy centers had binocular microscope in working condition. Kaul  observed various aspects of the RNTCP, such as infrastructure facilities, adequacy of supplies, and waste management procedure in microscopy centers at Gulab Bagh (Delhi), Jaipur (Rajasthan), and Mahesana (Gujarat); and these were found to be according to the norm. Inappropriate disinfection and disposal of infected lab materials is subsequently dangerous not only to the staff, but also to the community too. Defaulter retrieval mechanism functioning was only at 14 (46.67%) DOT centers.
High false positive reporting will impose greater burden of non-TB patient in the programme. It will also hurt patient's faith in the health system. Two of the trained laboratory technicians were found to be reporting high false positive reports [Table 1] in spite of having been trained in RNTCP. Ang et al.,  observed that slides positivity among smears reported by lab technicians was 16.6%, while same slides when read at medical research laboratory (lab), only 10% were found to be positive for acid fast bacilli (AFB). Only 50% lab technicians found to follow appropriate procedure  for disinfection of slides and sputum containers [Table 2].
|Table 1: External quality assurance of sputum microscopy in different microscopy centers|
Click here to view
|Table 2: Assessment of directly observed treatment centers and Microscopy Center for essential practices|
Click here to view
It is evident from the study that there is lack of logistics and infrastructure in the designated microscopy and DOT centers which might hamper the effective implementation of the programme. Therefore, there is an urgent need for refresher training for the workers involved in the programme.
| References|| |
|1.||Balasubramanian VN, Oommen K, Samuel R. Dot or not? Direct observation of anti-tuberculosis treatment and patient outcomes, Kerala State, India. Int J Tuberc Lung Dis 2000;4:409-13. |
|2.||Central TB Division, Director General of Health Services; Ministry of Health and Family Welfare, New Delhi, Manual for laboratory technicians, May-1999. |
|3.||Central TB Division, Director General of Health Services; Ministry of Health and Family Welfare, New Delhi. Managing the Revised National Tuberculosis Control Programme in your area. Module 1-10, April 2005. |
|4.||Balambal R. Profile of DOT providers in private sector. Indian J Tuberc 2001;48:73. |
|5.||Patel BK, Sanghvi AS. Revised National Tuberculosis Control Programme internal evaluation of Kheda district, Gujarat. 31 st March and 3rd April 2004. Available from: http://www.tbcindia.org/pdfs/RNTCP%20Internal%20Evaluation%20of%20Kheda%20District%20of%20Gujarat.pdf. [last accessed on 2006 Oct 14]. |
|6.||Kaul S. An observational study of RNTCP-DOTS strategy in three districts. Voluntary Health Association of India, New Delhi: Sept. 1998:31-46. |
|7.||Ang CF, Mendoza MT, Tan TT. Accuracy of AFB smear techniques at the health center level. Phila J Microbiol Infect Dis 1997;26:153-5. |
[Table 1], [Table 2]