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The RNTCP and Medical Colleges

I

S.P. Agarwal, J. Tonsing, L.S. Chauhan.

Background
Medical colleges play a central role in training and shaping the attitudes of the future generations of medical practitioners who will manage TB patients, in their individual capacity or as future health managers. As opinion leaders and role models for practicing physicians, medical college professors influence the practice in the private sector. As care providers, medical colleges treat a significant number of TB cases in the country. They also provide specialised services for seriously ill TB patients or complicated cases like those TB patients co-infected with HIV and multi-drug resistant TB. Thus there is a pressing need for all medical schools to advocate the RNTCP and through this strategy, provide the best opportunity for the cure of patients. The programme recognises the importance of introducing DOTS principles into training and clinical care practices of medical colleges. DOTS needs to be a part of both undergraduate and postgraduate training so that future and present medical practitioners have a solid grounding in TB control activities and the RNTCP. It also should be integrated into the clinical care provided by the medical colleges so that all patients in India have access to the quality services provided by the programme.

Initiatives Undertaken by the RNTCP

The programme has made great progress in collaborating with health care providers to extend the reach of RNTCP services, reduce diagnostic delay, improve case detection and patient adherence. Since 1997, when the first national consensus conference on TB was held in Delhi1, concerted efforts have been made to involve medical colleges and their hospitals in the programme. However, at this time reservations were expressed by the medical college community, which arose due to inadequate communication about the programme rather than the programmes policies. Subsequent wider interaction with the concerned staff of medical colleges has led to a clearing up of previous apprehensions, and renewed efforts have been made to bring medical colleges further into the purview of the RNTCP. Over the last two or three years, the programme has organised a series of sensitisation seminars, training for medical college faculty staff at the Central TB Institutes, and national and zonal level workshops. In 2002, seven premier medical colleges in different zones of the country were identified as nodal centres for the RNTCP to take this initiative forward
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RG Kar Medical College, Kolkata Lokmanya Tilak Municipal Medical College and Hospital, Mumbai SMS Medical College, Jaipur All India Institute of Medical Sciences, New Delhi Post Graduate College of Medical Education and Research, Chandigarh Christian Medical College, Vellore Guwahati Medical College, Guwahati

Figure 1 Medical colleges functioning as RNTCP nodal centres

(Figure 1). The seven colleges are: All India Institute of Medical Sciences (AIIMS), New Delhi; Christian Medical College (CMC), Vellore; Guwahati Medical College, Guwahati; Lokmanya Tilak Municipal Medical College, Sion, Mumbai; Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh; RG Kar Medical College, Calcutta; and SMS Medical College, Jaipur. In October 2002, RNTCP and AIIMS, Delhi, organised a national-level workshop of medical colleges to develop the structure and processes required for the effective nationwide participation of medical colleges in the programme. It was recommended that different levels of task forces with defined roles and responsibilities be formed2. Subsequently, a national and five zonal task forces were formed. In addition, state task forces have been formed in all states which have medical colleges and an increasing number of colleges are forming core committees in their respective institutes. The structure of the different task forces, along with the composition of members, is shown in Figure 2.

Roles and Responsibilities

A National Task Force (NTF) comprising representatives from zonal nodal centres, central TB institutes, WHO and the Central TB Division, Ministry of Health and Family
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Figure 2 Structure and composition of the RNTCP-Medical College task forces

Welfare (MoH&FW) has been formed. The main role of the NTF is to provide leadership and advocacy for the RNTCP, develop policies regarding medical colleges involvement in the programme, coordinate between the Central TB Division, MoH&FW, and monitor the activities of Zonal Task Forces. Zonal Task Forces (ZTF) facilitate the establishment of State Task Forces (STF), coordinate between the national and state-level task forces, as well as between medical colleges and the State/District TB Centres, and monitor the activities of the STF. As indicated in Figure 1, zonal division of states for this activity comprises five states in the East, eight in the North-East, eight in the North, seven in the South and seven states in the West zone. However, the real implementing unit is the STF, which undertakes the necessary activities to facilitate the establishment of DOTS centres, as well as other activities, in all medical colleges in the respective state. Each medical college is expected to form a core committee with representatives from all relevant departments to oversee RNTCP activities undertaken by the college. All task forces have well defined roles and representation from different levels of the programme, as well as from medical college faculty members. The major activities to be undertaken by the medical colleges themselves include3: 1. Training/teaching of RNTCP amongst: Faculty members; G Undergraduates and postgraduates ; G Residents and Interns; and G Paramedical staff (laboratory technicians and nursing staff).
G

2. Engagement with the RNTCP:

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G G G

Establish microscopy and DOT centres in all medical collegesa ; Strengthen infrastructure of the laboratory where required;

Involvement in the quality assurance of the smear microscopy network; and G Consultation and management of difficult cases. 3. Advocacy of the RNTCP: G Sensitisation and training through the Indian Medical Association and other professional bodies; Workshops and CMEs for medical colleges/and the private sector; G Use of newsletters, the press and other media to spread the RNTCP message to a wider audience; and G Involvement of the Medical Council of India to enhance the place of TB and RNTCP in the medical curriculum. 4. Conduct Operational Research on relevant topics to RNTCP, such as: G How to increase case detection of smear-positive cases; G How to improve DOT services; G Appropriate studies to inform the further development of consensus guidelines for diagnosis and management of childhood TB and extrapulmonary forms of TB; G Management of multidrug-resistant TB; G Profile and treatment outcomes of hospitalised patients; and G Diagnosis and management of HIV-infected TB patients.
G

Provisions made by the RNTCP

The programme provides the necessary human resource and logistics support to implement and coordinate the activities of RNTCP in medical college hospitals. One Medical Officer, one Senior Tuberculosis Laboratory Supervisor, one Laboratory Technician and one TB Health Visitor can be provided on contractual basis through the District TB Control Society. In addition, laboratory consumables and supplies, drugs and funds for civil works for upgradation of the laboratory facilities, are made available to the medical college by the programme. Medical colleges are expected to provide space for the DMC/DOT Centre in the hospital, designate faculty members to supervise the functioning of the centre and arrange training or sensitisation of their staff through the respective District Tuberculosis Officer. Activities of the task forces and core committees are funded through the State or District TB Control Societies. In addition, a computer with Internet facility and a data entry operator has been provided to all seven medical colleges that act as RNTCP nodal centres.

Status and Achievements

An increasing professional consensus regarding the efficacy of the DOTS strategy has now been reached. A sound strategy for effective involvement and collaboration between
a In districts that are preparing for implementation of the programme, efforts are made at the planning stage itself to establish a Microscopy Centre or even a Tuberculosis Unit in the respective medical colleges.

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the RNTCP and medical colleges is now in place nodal centres have been established, task forces and core committees have been formed. Regular meetings are held at the national, zonal and state level to review progress and performance, and to draw up action plans for the future. By the end of 2004, 206 medical colleges situated in RNTCP implementing districts established DOTS centres. Thus most colleges located in RNTCP implementing areas now have first-hand experience in managing TB patients under DOTS and have data on case diagnosis as well as treatment outcomes of TB patients under their care. Medical colleges have played an important role, especially in the past two years, in the national effort to control TB. In Gujarat, medical colleges contributed to over 11 percent of the chest symptomatics examined for sputum microscopy. Most colleges referred over 2 percent of their new adult OPD patients for sputum microscopy, and a significant number of their patients were started on treatment in medical college DOT centres. Data from the 12 Intensified Public-Private Mix (PPM) scaling-up project sites have shown that after the general health facilities of the public health sector, it is the medical colleges that detect and treat the second largest number of TB cases. Thus, medical colleges seem to be the most important source for TB case detection outside the public sector. A focus on medical colleges has resulted in greater yield in case detection in the third quarter of 2004. In consultation with the medical colleges, guidelines have been developed on the management of TB cases presenting to a medical college hospital, with a focus on diagnosis, referral, and treatment under the RNTCP. This applies to outdoor as well as indoor patients, from within or outside the district (Figures 3, 4 and 5)4. A notable achievement of the engagement of the RNTCP with the medical academia of the country was the publishing, in December 2003, of a joint RNTCP-Indian Academy of Outdoor patients (1)

Figure 3

Management of TB cases presenting to a hospitals. Outdoor patient from a RNTCP district for referral for treatment within the respective district

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Outdoor patient (2)

Figure 4 Management of TB cases presenting to a hospitals. Outdoor patient from a RNTCP district for referral for treatment to other districts

Indoor patients
Patient is from RNTCP District Attending physician prescribes thrice weekly RNTCP regimen*
All indoor patients who reside in an RNTCP implementing district, will be treated with RNTCP regimens and will utilise prolongation pouches. The DOTS Centre of the Medical College must be informed of the patients admission as soon as possible. The patient will be registered under the local TU. The drug requirements to operationalise this system need to be assessed by the respective DTOs and STOs, and CTD.
*

Via the DOTS Centre in the Medical College

If attending physician judges that the RNTCP regimen is not appropriate for the individual patient, a non-RNTCP regimen will be prescribed

Figure 5 Management of TB cases presenting to a hospital. Indoor patient from a RNTCP district

Paediatrics consensus statement on Management of Paediatric TB under RNTCP5.

Future Challenges
Several issues need to be streamlined and improved upon in the coming years to make this partnership between the RNTCP and medical colleges a truly effective collaboration. One key area is the need to ensure that all clinical departments of these colleges, in addition
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to those departments that run the DOTS centres, are involved and manage their TB patients according to RNTCP guidelines. There is a need to improve on the referral of patients between the various departments of the college itself, as well as outside the hospital. This assumes importance as medical colleges often cater to an enormous catchment area. The Central TB Division is piloting a referral for treatment mechanism in 12 districts which have large medical colleges situated in the respective districts. This pilot aims to develop a seamless RNTCP service between the medical colleges and the general health services so that all TB patients diagnosed at the medical college, receive RNTCP treatment services at the most convenient location to the patient. An urgent requirement is to establish a reporting system, which will not over-burden the existing system, but will provide information to the centre on activities undertaken by the medical colleges and the various task forces. In the coming years, as the programme widens the scope of services that it provides, medical colleges will have an increasingly important role to play in areas such as TB/HIV coordination, external quality assurance of the sputum microscopy network, drug resistance surveillance and management of multidrug-resistant TB patients. Appropriate operational research in these areas to guide the development of the programmes future policies is required and is an area where the programme looks to medical colleges for their active support. To conclude, the key challenge is to ensure strengthened co-ordination between the RNTCP and medical colleges so that the RNTCPs vision to make DOTS the standard of care in all health care settings is realised. This will ensure that all TB patients, irrespective of where they seek help, receive the best available care, free of cost.

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References
1. Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Government of India. National Consensus Conference on Tuberculosis Control. 1997, Delhi. Also available at www.tbcindia.org Recommendations of national workshop for establishment of nodal centres in medical colleges. October 29-31, 2002. Can also be accessed at http://www.tbcindia.org/documents.asp Medical Colleges involvement in the RNTCP: Current Status. J Indian Med Assoc 2003; 103:164-166. Recommendations: Second meeting of the national task force for involvement of medical colleges in the RNTCP: November 22, 2003, New Delhi. Can also be accessed at http:// www.tbcindia.org/documents.asp Consensus statement: Management of Paediatric TB under the Revised National Tuberculosis Control Programme (RNTCP). Indian J Paed 2004; 71:341-343.

2. 3. 4.

5.

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