Tuberculosis (TB), an infectious disease caused by bacterium, Mycobacterium tuberculosis, is a major public health problem in India. Two deaths occur every three minutes from tuberculosis in our country. India alone accounts for an estimated one fifth (21%) of all TB cases worldwide. A single untreated patient can infect 10 or more people in an year. The mortality and morbidity can be prevented with proper care and treatment. On 24 March every year, World TB Day is observed to commemorate the birtday of scientist ROBERT KOCH who discovered TB bacilii.
Tuberculosis is curable with anti-TB drugs, if taken for appropriate duration. But the treatment is for a long duration of minimum 6 months and the patient feels better in 1-2 months. Treatment is often interrupted due to superadded factors like poverty and unemployment.Therefore, just provision of anti-TB drugs to the patient doesn’t ensure cure. DOTS strategy ensures effective treatment of TB ensuring uninterrupted supply of full course of drugs to be administered under direct observation of a DOT provider.
The WHO- recommended Directly Observed Treatment Short Course (DOTS) strategy was launched formally as Revised National Tuberculosis Control Programme in India in 1997 after pilot testing from from 1993-1996. The most effective strategy available for controlling TB has since then been widely and successfully applied. More than 180 countries of the world are implementing DOTS. In India, nationwide DOTS coverage has been achieved in march 2006 with 632 districts and 1114 million people being covered. The patient is the VIP of the programme and responsibility of ensuring regular and complete treatment of patient lies with the health systems.
DOTS provides a sure cure for tuberculosis and is available free of cost to the patient. The visual icon i.e DOTS logo presents a graphic of human anatomy divided in two parts – half red and half orange. While the orange part symbolizes the diseased state, the red represents healthy metabolism. On the other level, the icon suggests a transition from the state of tuberculosis to a healthy life, which is the very promise of DOTS. The message ‘DOTS: Sure cure for TB’ has been given a logical extension by saying; ‘DOTS: Pura course, pakka ilaaj’.
Every day in India, under the RNTCP, more than 15,000 suspects are being examined for TB, and about 3,500 patients are started on treatment, free of charge , thus stopping the spread of TB in the community. Since 2007 programme is achieving a treatment success rate of >85% and has consistently maintained the NSP case detection rate (CDR) of >70%. In 2010, RNTCP has achieved the NSP CDR of 71% and treatment success rate of 87% which is in line with the global targets for TB control.
Sputum examination is the primary test approved by RNTCP and available free of cost for diagnosis and follow up of tuberculosis. In Amritsar, 21 microscopy centres are catering to the health needs of rural and urban population of 24.91 lakhs. Since 2005, 102349 suspects have been examined for TB and 29604 patients successfully treated with DOTS strategy free of cost in the district. The global targets have been achieved by district Amritsar with a treatment success rate of 87% in 2011.
The major hurdle in DOTS implementation is drug addiction and alcohlism which is associated with high default rate. To overcome this social hurdle, collaboration has been sought with private sector and NGO’s. Indian Red Cross Society has adopted retreatment TB cases which usually have a high correlation with drug addiction and treatment default. Such high risk cases are being managed by these NGO’s with frequent councelling, affection and humanistic touch.
The programme has initiated actions to address the challenges of Multi Drug Resistant-TB (MDR-TB) and. MDRTB refers to strains of the bacterium which are proven in a laboratory to be resistant to the two most active anti-TB drugs, isoniazid and rifampicin. Treatment of MDRTB is extremely expensive, toxic, arduous, and often unsuccessful. Management of MDR-TB is being undertaken in DOTS-plus services. However, the best way to confront this challenge is to improve TB treatment and implement DOTS. The programme has established 19 accredited Culture and Drug Sensitivity Test laboratories including 4 National Reference Laboratories, 10 State level Intermediate Reference Laboratories and 5 other sector laboratories for the diagnosis and follow up of MDR-TB patients. 29 such labs are in the process of being accredited.
RNTCP DOTS-PLUS strategy has been implemented in the Amritsar since november 2011, the district being the first in punjab to start the later services for MDR suspects along with establishment of DOTS-PLUS ward which will cater to all adjoining districts of the area. Sputum samples of 74 MDR suspects have been sent to NRL Delhi for culture and DST. 15 patients have been put on treatment for MDR-TB after a weeks’ admission in DOTS-PLUS ward under appropriate clinical supervision and pre-liminary investigations in the district. The treatment costing 3 lakh per patient is being provided free of cost, under direct observation with free follow up clinical and laboratory examinations to MDR cases.
Another issue of concern is TB-HIV co-infection. As the HIV breaks down the immune system, HIV- infected people are at greatly increased risk of TB. Without HIV, the lifetime risk of developing TB in TB-infected people is 10%, compared to at least 50% in HIV co-infected. TB in turn accelerates the progression of HIV to AIDS and shortens the survival of patients with HIV infection. Thus, TB and HIV are closely interlinked. However, even among HIV-infected people, TB can be cured. Directly Observed Treatment, Short-course (DOTS) is as effective among HIV- infected TB patients as among those who are HIV negative. Amritsar district has been efficiently providing HIV tesing services to all TB patients by provision of free HIV testing at all microscopy centres of the district. Apart from this, sputum examination of all symptomatic HIV cases is being ensured.
Though RNTCP has come a long way with appreciable achievements, irrational and unsupervised use of first and second line anti-TB drugs for the treatment of TB patients is threatening the progress made by the programme and needs to be actively discouraged. Quality DOTS services should be ensured for each and every TB patient in the country. Battle against TB can be won and the vision of the Government of India for a “TB-free India” until it is no longer a major public health problem can be realized by proper implementation of DOTS.
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