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Indian Journal of Community Medicine

Evaluation of Management of TB Patients by General Practitioners of Jamnagar City

Author(s): S. Yadav, A. Patel, S. V. Unadkat, V. V. Bhanushali

Vol. 31, No. 4 (2006-10 - 2006-12)

S. Yadav, A. Patel, S. V. Unadkat, V. V. Bhanushali

Abstract

Objectives: To evaluate the management of TB patients by General Practitioners (GP’s) to fi nd out if they are following RNTCP guidelines. Research Question: Whether the GP’s follow the guidelines laid down by RNTCP for diagnosis, categorization and treatment of TB patients? To find out the type of health education given by GP’s to TB patients. Study Design: Cross sectional Setting: Jamnagar city. Participants: General Practitioners (GP’s) of Jamnagar city. Sample size: 42 Study Variables: Symptoms, investigations, treatment regimen, awareness about RNTCP, health education about TB. Statistical Analysis: Percentage. Result: Cough for more than 3 weeks as symptoms were known to all GP’s. Knowledge about other symptoms was inadequate. Sputum examination as diagnostic tool was underutilized (57.14%). Follow up with sputum examination during the course of treatment was faulty by majority of GP’s. Treatment regimen for initial intensive phase was also faulty by majority of GP’s who gave daily dose regimen instead of intermittent. Treatment during a continuation phase was also variable ranging from 4 months to 8 months and included Ethambutol. Categorization of TB patients was known to 69.05% of GP’s. Health education to TB patients was given by GP’s regarding treatment compliance, regular follow up, screening of home contacts etc. but given only by certain percentage of GP’s. Conclusion: It is concluded that GP’s have very inadequate knowledge on RNTCP and they need training for same.

Key Words: Evaluation, RNTCP, General Practitioners.

Introduction

There are approximately world wide 9 million new cases occurring and 3 million people die from TB annually. India accounts for one third of the global tuberculosis burden. Currently in India, there are about 14 million suspected and about 35 million bacteriologically proven cases of pulmonary tuberculosis with prevalence rate of 4.84/1000 population1. Tuberculosis kills more people in India than HIV, STD, malaria, leprosy and tropical diseases. The direct and indirect cost of TB to the country amounts to 12,000 crore per year. The majority of the patients who go to TB clinics have typically been under care of General Practitioners (GP’s) at one stage or other2. Thus, GP’s can be useful in providing proper diagnosis, treatment, notifi cation of cases and proper health education in the community.

Material and Methods

Present study is cross sectional, conducted in Jamnagar city in November-December 2004. There is one Tuberculosis Unit (TU) and 4 Designated Microscopy Centre (DMC) in Jamnagar urban area. Random selection of GP’s from 3 DMC areas was done. Total GP’s holding basic Medical degree (MBBS) in above 3 areas are 45 (from list of private practitioners association, Jamnagar city) of which 42 GP’s agreed voluntarily to participate and were selected for the study. Pretested semi-structured proforma was used to collect information from 42 respondents, regarding suggestive symptoms of tuberculosis, methods of diagnosis, treatment regimen, follow-up investigations, awareness regarding categorization of patients and the type of health education to TB patients.

Results

Suggestive symptoms of TB stated by GP’s were; cough more than 3 weeks by all (100%), weight loss by (97.62%), low grade fever by (95.24%), anorexia by (88.10%), haemoptysis by (76.19%) and chest pain by (19.05%). The methods of investigation employed for diagnosis of TB were only sputum examination (9.52%), sputum examination in combination with X-ray chest (47.62%), ESR (42.86%), clinical examination (52.38%) and Montoux test (26.19%). No. of sputum sample examined for diagnosis of TB was one by (11.90%), two by (23.80%), three by (21.43%) and no sputum examination by (42.86%). The follow-up investigations adopted by GP’s indicated that only 9.52% of them adopted right practice of sputum examination at end of 2 months and 6 months.

Table I – Different Regimens Used by GP’s to Treat TB Patients Multiple Response)

Regimen No.
(N=42)
%
2 (HRZE) + 6 (HR) 21 50.00
2(HRZE) + 1(HRE) + 5(HR) 19 45.23
2 (HRZE) + 6 (HRE) 04 09.52
2 (HRZE) + 4 (HRE) 06 14.28
-6 (HRZE) 04 09.52
2 (HRZE) + 3 (HRE) + 3 (HR) 02 04.76
2 (HRZE) + 4 (HR) 06 14.28
2 (HRZE)3 + 4 (HR)3 02 04.76
2 (HRZES) 3 + 1(HRZE) I + 4 (HR) 3 02 04.76
8 (HRZ) 02 04.76

Observations on various regimen used for TB treatment by GP’s indicate that as many as 11 different regimes were used by them. For intensive phase almost all of them use four drug combinations for two months. The continuous phase ranges between 4 months to 8 months with either 2 drugs or 3 drugs. (Table I) 29 GP’s, were aware about categorization of TB patients but only 2 of them were giving treatment according to RNTCP categorization. Analysis on type of health education given by GP’s indicate various responses viz. for taking nutritious diet (80.95%), regarding treatment compliance (42.86%), safe disposal of sputum (69.05%), cessation of smoking (59.52%), covering of mouth while coughing or sneezing (4.76%), regular follow up (42.86%), BCG vaccination to children (38.10%), advice for screening of family contacts for TB (64.29%) and (19.05%) gave no health education.

Discussion

GP’s had reasonably adequate knowledge about suggestive symptoms of tuberculosis while (100%) of them knew about cough for more than 3 weeks, chest pain was known only to (19.05%) and haemoptysis to (76.19%). Only 57.14% GP’s were using sputum examination as a tool for diagnosis of TB and only (21.43%) were using three sputum check-ups for such diagnosis. Remaining 11.9% used only one sputum sample and 23.80% were using two sputum samples. As many as (42.86%) were not using sputum examination as a tool for diagnosis of TB which is very much in contravention of RNTCP guidelines. There was over emphasis on X-ray chest for diagnosis of TB and as many as (85.71%) of GP’s were subjecting their patients for X-ray chest for this purpose. Similar of results were seen by Singla et al3 who found that only 12% of GP’s were advising sputum examination while 89.5% of them recommended chest X-ray. Marsh et al4 found that only (14%) of GP’s performed any sputum test and overreliance on other unhelpful test. Rizvi N, Hussain M5 their study found that only 38% GP’s used sputum analysis for diagnosis of tuberculosis.

Observations on various regimen used by GP’s indicate that majority of them were giving treatment for 2 months during initial intensive phase using 4 drug combination. The continuation phase was seen to be ranging between 4 months to 8 months with either 2 drugs or 3 drugs. This treatment was given in daily dose, unsupervised instead of thrice a week supervised drug administration. Majority of the GP’s were over-treating the patients keeping the duration between 6 to 8 months. About 7 GP’s were also using Ethambutol in the continuation phase. Only one GP was using correct regimen according to category of patient. These observations suggest need for training of GP’s including subsequent training at periodic intervals for RNTCP.

Singla et al3 in their study also noted tha 29.4% were using the regimen recommended by RNTCP, rest were using some other regimen. 102 such regimen were suggested by 187 practitioners. It was found that 51.3% practitioners were over-treating their patients in their study. Study carried out by Prasad et al6 also showed 33 different drug combinations regimen being used by GP’s. 64.5% of them were treating the patient for longer time. It was also noted in their study that there were error in the drug dosage by 30% of GP’s. 80 type of different regimen for treating TB patients by 100 GP’s was noted by Uplekar and Shepard (1991)7.

The sputum examination during the follow up visit was adopted correctly by only (9.52%) GP’s. Rest were using either X-ray alone or X-ray and sputum at wrong intervals. Singla et al 19983 observed that only (23.5%) GP’s requested sputum examination before the end of treatment while (35.5%) dependent on X-ray examination with clinical improvement.

Out of 42 GP’s, 29 (69.05%) had the knowledge regarding the categorization of TB patients as per RNTCP programme but only two of them were actually categorizing the patients and than treating them correctly. The observations on health education given by GP’s indicate that not all of them are advising on various components of health education and there is further scope of improvement. Treatment compliance was advised by (42.86%) in present study while only (19.05%) of the GP’s did so in the study carried out by Singla et al (1998)3. In the present study 38.10% GP’s advised BCG vaccination for children while 71.00% did so in the study carried out by Rizvi N and Hussain M. (2001)5. It is concluded that, there are so many lapses on the part of GP’s in the management of TB patients as per guidelines of RNTCP viz. methods of diagnosis, underutilization of sputum examination as a tool, over emphasis on X-ray chest, no categorization of patients, faulty drug regimen etc. It is recommended that GP’s should be properly trained and sensitized to use RNTCP guidelines and there should be periodical CMEs for the same on regular basis.

References

  1. Lalit K. On estimation of Burden of tuberculosis in India. Indian J TB 2000; 47: 1298-1299.
  2. Tandon RN. The role of general practitioner in the control of tuberculosis in India. Souvenir Silver Jubilee TB Assoc India, New Delhi 1964; 114-117.
  3. Singla N, Sharma PP, Singla R, Jain RC. Survey of knowledge, attitudes, and practices for tuberculosis among general practitioners in Delhi, India. INT J TB AND LUNG DIS 1998 May; 2(5): 384-389.
  4. Marsh D, Hashim R, Hassany F, Hussain N, Iqbal Z, Irfanullah A. et al. Front-line management of pulmonary tuberculosis: an analysis of tuberculosis and treatment practices in urban Sindh, Pakistan. TUBERCLE AND LUNG DIS 1996 Feb; 77(1): 86-92.
  5. Rizvi N, Hussain M. Survey of knowledge about tuberculosis amongst family physicians. J Pakistan Medical Association 2001 Sept; 51(9): 333-337.
  6. Prasad R, Nautiyal RG, Mukherji PK, Jain A, Singh K, Ahuja RC. Treatment of new pulmonary tuberculosis patients: what do allopathic doctors do in India? INT J TB AND LUNG DIS 2002 Oct; 6(10): 895-902.
  7. Uplekar MW, Shepard DS: Treatment of tuberculosis by private general practitioners in India. Tuberculosis 1991 December; 72(4): 284-290.

Department of Community Medicine
Sh. M.P. Shah Medical College, Jamnanagar, Gujrat
E-mail: [email protected]
Received: 1.03.05

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