Y.S. Rana,Chandigarh :It has all the trappings of a paradox but not the one that defies an answer. Even as the Government of Himachal Pradesh—a state known for its salubrious and blaming environment conducive to all kinds of cure–is marshalling every resource at its command to take head-on the age-old enemy of tuberculosis (TB), fresh cases keep cropping up at a more-or-less matching pace, making even the noticeably commendable efforts made by the state government, look pale.Ironically, the detection and cure rate of TB and the rate at which fresh TB cases spring up, seem to be engaged in a race of sorts. And this too in a state where, elders recall, soldiers suffering from TB during the days of the British Raj, were sent, especially to the Shimla belt, for treatment. The other parallel destination, they add, was Karachi (now in Pakistan).
It’s official. Equipped with the latest tools provided by various national health programmes, the Himachal Pradesh Government has taken well-heeled measures to beef up its healthcare system to address the gamut of growing public health problems. The tiny hill state has done it for the fifth year in a row. Official data confirms that Himachal Pradesh has been adjudged among the top best performing states/UTs in the country with 87 per cent cure rate of new smear positive (NSP) patients, and has 89 per cent success rate. In controlling TB, Himachal is now rubbing shoulders with Delhi, Rajasthan, Gujarat and Arunachal Pradesh, leaving its big cousin-states, straddling way behind.
In fact, the hill state has been achieving this distinction since 2005. Hamirpur was the first district where revised national TB control programme was implemented in 1995 followed by the districts of Kangra and Mandi. Up to January, 2002, the entire state was covered under the programme. Since then, Himachal has never looked back, and has been achieving this distinction year after year, and the credit goes to its dedicated staff and untiring efforts made by the State Health Department. “It is a matter of pride for the state that both detection and cure rates of TB have been consistently achieved as per national targets,” said a senior official of the Health Department. The state has 244 suspects examined per lakh of population per quarter, as compared to the national average of 160.
Decentralization constitutes the cornerstone of the programme
which aims at optimum rural intervention to eradicate the menace of
TB. The country has been facing 1/5 of global TB burden. The RNTCP isan application of the globally recommended Direct Observation of
Treatment (DOT) strategy to control TB.
The total number of cases treated in the state soared from 6,097
in 2000 to 14,179 in 2010. But not wanting to be left behind, fresh
smear positive cases swelled from 2,259 in 2000 to 5,133 in 2010. The
biggest increase was registered in 2010. While Kangra District topped
with 910 cases Lahaul and Spiti was at the bottom of the ladder with
only ten fresh cases. (See Table Below)
New smear positive patients Total cases treated
2000 2259 2000 6097
2001 3614 2001 9763
2002 4559 2002 12456
2003 4830 2003 13310
2004 4954 2004 13458
2005 4832 2005 13697
2006 4965 2006 13303
2007 4978 2007 13611
2008 5091 2008 13618
2009 5057 2009 13743
2010 5133 2010 14179
Giving details, the official said that in 2010, 69,133
suspects were examined all over the state; 8,285 patients were
diagnosed smear positive; and 14,179 patients were registered for TB
treatment. Out of them, 5,133 (80 per cent) were found new smear (NSP)
positive, and they were put on treatment. The new sputum positive
detection rate is 76 per lakh of population in the state. Up to
December, 2010, 14,179 patients were put on treatment. There were 187
deaths (four per cent) and three per cent was failure rate with four
per cent defaulter rate, quite low in the country, reveal official
”Our target is to reduce the death rate and the prevalence of TB
patients to half by 2015 as a Millennium Development Goal (MDG)”, he
added. The Health Department has launched a pilot project to involve
IMA doctors in the programme under which 55 IMA doctors have been
trained so far.
The improvement in the indices of health and development in the
state has been incredible. However, the benefits of these programmes
elude a number of people, especially in the remote rural areas as they
do not seem to be aware of them.
Application of the WHO recommended Directly Observed Treatment
Course ( DOTs) has led to decline in the TB prevalence rate. Up to
December, 2010, 1,44,057 TB cases were treated in the state. It may
sound incredible but it is true that Kangra District topped the list
of TB patients. The death rate of TB patients which was 26 per cent
about six years ago has now been reduced to four per cent, lower than
the national average of six per cent.
The treatment success rate has tripled from 25 per cent in
pre-RNTCP era to 82 per cent. The TB death rate too has been cut down
to three per cent from 29 per cent in pre-RNTCP.
Lending healthcare the orchestra of infrastructure, the state
government has built and operationalised 12 district tuberculosis
centres; 41 tuberculosis units; 164 microscopy centres all over the
state. Funds for necessary additions and alterations for upgradation
of IRLs at TBS Dharampur and Dr Rajendra Prasad Government Medical
College, Tanda, have been provided and work is in process.
The state ranks second in providing healthcare services through
networking of over 3,800 health institutions. Health indicators of the
state are far better than the national average. Regular monitoring is
being done and the default rate which was 30 per cent, has been
reduced to mere four per cent, thanks to the revised national TB
control programme and setting up of five trauma centres in the state.
Dr K.C. Kaushal, Medical Consultant WHO-RNTCP, Shimla, while talking to this reporter, stated that increase in number of TB cases in almost all the states and throughout country. But in the State to achieve at least 70% case detection among the existing cases in the community and at least 85% of cure/success rate among the registered cases initiated on treatment and for the past few years this achievement has been consistent along with other programme indicators.
Technically speaking this was not the increase in number of cases but increase in case detection among the existing cases in the community. The number of existing cases was being estimated on the basis of epidemiological studies and Dr.Stabylo Hypothesis which is relevant till date in India. Surveys are being conducted from time to time to know the extent of Annualized Risk of Tuberculosis Infection in the community.
REASONS FOR INCREASE: Change in the definition of TB suspects. Duration of cough was reduced from three weeks to two weeks with the result that number of suspect identification & referral have been on the rise.
Earlier three sputum samples were collected for sputum smear examination and patients who were having two positive samples out of three were diagnosed as TB patients.
.Efforts have been intensified to minimize Initial Defualters i.e the diagnosed cases who were not initiated on treatment due to various reasons. Now more emphasis is being given to counsel the patients so that they are motivated for early initiation of treatment and thus minimze the IDs and thus stigma part is also taken care of.
Contact Tracings: All the fimily members of sputum positive patients are counseled and among adult family member if any one is having any symptom suggestive of disease is referred for investigation and children below six years of age are subjected for investigations for any evidence of disease and if there is no evidence of any disease then these children are given Chemoprophylaxis to protect them from development of disease.
Concept of Universal Access: Efforts are being put on to involve all the stack holders i.e Private Practitioners, NGOs, community and civil society involvment. Maximum numbers of IMA Members in the state have sensitized regarding the programme and availability of various revised new schemes.
Sputum negative patients. Diagnostic algorithm as per guidelines from WHO/ CTD are being followed for diagnosis of patients who sputum smear negative so they are also not missed.
Dr Kaushal further disclosed that since 2006, Stop TB partnership of WHO has come out with Millennium Development Goals and Stop TB Strategy has been developed with some components for development of new diagnostic tools for early case detection which may confirm the diagnosis of TB/MDR TB much faster than the available laboratory tools, early treatment initiation of diagnosed case and prevention of the disease by developing the vaccine. “So all the efforts are towards these steps to ensure the transformation of these to eliminate TB from world by 2050,” added Dr Kaushal.