CDMO Review Meeting

RNTCP – Goal and Objectives Goal –The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. Objectives as per the millennium development goals –To achieve and maintain a cure rate of at least 85% of new sputum positive TB patients –To achieve and maintain a case detection of at least 70% of new sputum positive TB patients The current focus is on achieving universal access to free quality assured TB services for all the patients in the community

New Smear Positive Case Detection Rate, 2009 National Level- 72% < 60% (5 states) 60-69% (7 states) > 70% (8 states)

Where we stand (1-2 qtr) ANSP- CD R (%) TSR-NSP (%) ANSP-CDR (%) TSR-NSP (%) ANSP-CDR (%) TSR-NSP (%) ANSP-CDR (%) TSR-NSP (%) Sikkim116%88% 112%86%108%85%122%86% Delhi90%87% 86% 87%94%87% Himachal Pradesh81%89% 81%89%82%89%90%89% Andhra Pradesh74%87% 81%87%81%88%82%89% Rajasthan80%88% 81%89%81%89%82%89% Gujarat77%87% 78%87%78%87%78%87% West Bengal78%87% 77%87%76%86%77%85% Tamil Nadu68%84% 68%83%67%85%66%86% Orissa59%85% 65%86%66%87%70%86% Uttar Pradesh52%87% 56%86%66%87%71%88% Kerala43%84% 64%83%65%83%68%83%

Population projected from 2001 census Estimated no. of NSP cases - 85/100,000 population per year (based on recent ARTI report) Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, Orissa, Q*

NAYAGARH - CDR (57%) and Success (59%) High CDR and Low Success Low CDR and Low Success High CDR and High SuccessLow CDR and High Success

Baleshwar Mayurbhanj Bhadrak Kendrapara Kendujhar Jajapur Puri Cuttack Sundargarh Anugul Debagarh Sambalpur Jharsuguda Bargarh Khordha Nayagarh Ganjam Gajapati Baudh Sonapur Balangir Nuapada Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur NSP CDR RATE 3Q09 50% 50-70% >70%

TB Suspects examined per 100,000 population*, * During RNTCP expansion phase, data for districts implementing partial quarters has been excluded Quarters 158 INDIA

Baleshwar Mayurbhanj Bhadrak Kendrapara Kendujhar Jajapur Puri Cuttack Sundargarh Anugul Debagarh Sambalpur Jharsuguda Bargarh Khordha Nayagarh Ganjam Gajapati Baudh Sonapur Balangir Nuapada Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur SUSPECT EXAMINED / LAKH / QTR- 3Q09 < >150

Districts below the State Average

All PHI are expected to refer more than 2% of their new adult OPD for sputum examination

< 80% (0 states) 80-84% (3 states) > 85% (17 states) New Smear Positive Treatment success rate National Level- 87%

Baleshwar Mayurbhanj Bhadrak Kendrapara Kendujhar Jajapur Puri Cuttack Sundargarh Anugul Debagarh Sambalpur Jharsuguda Bargarh Khordha Nayagarh Ganjam Gajapati Baudh Sonapur Balangir Nuapada Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur NSP Success RATE 3Q09 <80% 80-84% >85%

Baleshwar Mayurbhanj Bhadrak Kendrapara Kendujhar Jajapur Puri Cuttack Sundargarh Anugul Debagarh Sambalpur Jharsuguda Bargarh Khordha Nayagarh Ganjam Gajapati Baudh Sonapur Balangir Nuapada Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur NSP CURE RATE 3Q09 <75% 75-85% >85%

NGO Involvement Sputum Collection: Nayagarh – 2 Sputum Transport: Nayagarh – 2, Kendrapada – 9 DMC Scheme: One each in Puri, jajpur, Kalahandi and Jharsuguda LT Scheme: Jharsuguda 1 TU Scheme: 1 in Malkangiri Nil in: Adherence Scheme, Slum Scheme and TB HIV scheme

PP Involvement Only 2 Private Organizations involved under DMC scheme: one each in Sambalpur and Ganjam.

Poor ACSM a)In spite of intervention by other partner agency like Lepra and The Union (apart from State Govt. initiative) TB awareness has not penetrated into the rural pockets. b)Slum dwellers constitute a large percentage of urban population and the prevalence of TB is high amongst them. Awareness is still low in the slum population.

DOTS Plus

Progress of DOTS-Plus Programme (as on 30 th September 2009) Intermediate Reference laboratory (IRL) at Anti TB Demonstration & Training Centre, Cuttack accredited on 10 th Aug’ 09.

The Way Ahead…. Expansion of DOTS Plus activities to the rest of the State in a phased manner – the next two DOTS Plus sites planned at MKCG and VSS Medical Colleges. DOTS Plus wards in these two medical colleges may be constructed through NRHM funds. Meeting conducted in VSS – they have agreed to give space for the ward. NRHM to take up. Preparatory activities to be initiated for installation of LPA and Liquid Culture systems in the IRL at Cuttack. Four rooms identified in the ground floor of existing IRL – these have to be vacated and necessary civil works initiated.

Launch of DOTS Plus 1.Four RNTCP districts of Cuttack, Ganjam, Khurda and Bhubaneswar taken up for DOTS-Plus activity in in 1st phase. 2.Three MDR-TB cases identified so far (two from Cuttack and one from Khurda). 3.CAT-IV treatment started for MDR-TB patients from 11 th November Secretary Health inaugurated the event.

FINANCE

> 70% 50% - 69% 25-49% Total Expenditure April’09 – Sept’09 Baleshwar Mayurbhanj Bhadrak Kendrapara Kendujhar Jajapur Puri Cuttack Sundargarh Anugul Debagarh Sambalpur Jharsuguda Bargarh Khordha Nayagarh Ganjam Gajapati Baudh Sonapur Balangir Nuapa da Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC <25% SOE for Dec’09 not submitted

Civil Works April Sept 2009 Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC Nuapada > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

Payment of honorarium to DP April’09 – Sept’09 Dhenkanal Jagatsingpur g Kalahandi Kandhamal Koraput Malkanagirii Nowarangpur Rayagada > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

IEC April’09 – Sept’09 da Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

Training April Sept 2009 da Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

NGO / PP Support April’08- Sept’08 d a Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC > 70% 50% - 69% No Budget <25% SOE for Dec’09 not submitted

Misc. April’09 – Sept’09 da Kandhamal Kalahandi Rayagada Nabarangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

Contractual Services April’09 – Sept’09 da Kandhamal Kalahandi Rayagada Na b arangapur Koraput Malkangiri Dhenkanal Jagatsinghapur BMC > 70% 50% - 69% 25-49% <25% SOE for Dec’09 not submitted

Thank You

Low cure rate (82%) CauseSteps taken to improve Poor counseling to patients/DPs Counseling made mandatory for MO, DMC/LT at the time of card initiation. leaflet / booklet on DOTS supplied to DPs Improper address verificationHW/ASHA/AWW/NGO/any other DP to verify the address before putting under treatment. Last sputum not done (in sputum +ve cases) Last sputum examination made mandatory & DP’s honorarium granted only after last sputum examination. Lack of feedback on transfer out casesDTOs’ monitoring electronically/ telephonically each month. Inter district coordination meetings held quarterly Improper DOTSDTO, MO-TU, MO-PHI, STS to ensure DOTS High Default Timely supervision Timely card updation Redressing ADR NGO involvement

Matter of Concern… Death Rates in all districts are above the expected norm of <4% except: –Anugul, Baleswar, Dhenkanal, Jagatsinghpur, Khurda and Puri

Why are so many new sputum negative cases dying?

Why are so many new sputum negative cases defaulting treatment?

Prescription Audit of Anti TB Drugs SECY. HEALTH HAS DIRECTED THE DC OF ODISHA TO SEE THAT NO ANTI TB DRUG BE SOLD WITH OUT PRESCRIPTION BY A REGISTERED MEDICAL PRACTIONER.

Vacancy status of key contractual posts (as per PM report of 3 rd and 2 nd Qtr 09) To be appointed by the respective district: Senior Treatment Supervisor- 2 (Mayurbhanj – 1, Kalahandi – 1) Senior TB Laboratory Supervisor- 10 (One each in Sundergarh, Rayagada, Khurda, Cuttack, Bargarh, Baleswar, Balangir and Angul and Two in Mayurbhanj) To be appointed by NRHM at the State level: Laboratory Technician (RNTCP)-29 –Total LT sanctioned (DMC)-546 NRHM moved on to initiate process of recruitment of contractual Laboratory Technician (LT) LTSanctionedIn positionVacancy Govt440*41921 Contractual106988

Vacancy status – State Level (to be appointed by NRHM at the State level) One Microbiologist for ATD&TC, Cuttack One Contractual MO – VSS Medical College, Burla Contractual MO – one each at DTC Koraput and Nuapada One Accountant Post at State TB Cell Communication facilitator: One each at Koraput and Baripada

Drug Management 1.DTOs to stick to the timetable for quarterly indent of Anti TB Drugs. 2.Return the short expiry drugs at least 6 months before the date of expiry. 3.Any surplus drug not likely to be utilized should be returned back to the SDMU. 4.The practice of sending drug boxes to the PHI through the STS in motorcycle should be stopped. 5.Necessary steps to be taken to ensure that the MO-TCs send the drug boxes to the concerned PHI as per schedule. 6.The person handling the TB drugs at the District level should be well versed with Pro-MIS. All receipts and expenditure should be made online through Pro-MIS.

The Programme Indicators (1) a) Suspects Examined / Lakh / Quarter Norm>150 State Achievement = 137 Major Causes of low suspects examination: 1.Block wise referrals not monitored at CDMO review meetings 2.Referrals from PHC (N) very low / not monitored 3.Sub Center wise referrals not monitored at Block level 4.Referrals from other Care providers / NGOs / PPs negligible

b) Annualized new sputum +ve case detection / lakh Norm: NSP Case Detection Rate > 60 / lakh / year NSP Case Detection Rate (%) >70% State Achievement – 57 / Lakh / year (67%) The Programme Indicators (2)

c) Annualized total case detection rate Norm – 230 / Lakh / year State Achievement – 131 / lakh Major Causes: 1.Low detection of NSN and EP Cases Diagnostic algorithm not followed Defective X Ray machines / shortage of X-Ray technicians Suboptimal involvement of Medical Colleges / Private Practitioners 2.Very Low Detection of Retreatment Cases Improper history taking The Programme Indicators (3)

Poor Access to Health Facility 1.Difficult demographic profile of the State. 2.Lack of manpower (mostly LTs) to manage microscopy centers as per need.

Initial Defaulters 1.Defined as diagnosed as sputum positive TB in the Lab but failed to get registered for treatment. 2.During last Quarter 482 diagnosed TB cases did not turn up for treatment, which constitute 7% of the total cases detected. 3.Although some of these would have started treatment and will get registered in the subsequent quarter, there are many cases which are missed out completely after diagnosis. 4.Had these been initiated on treatment, the case detection in the State could have been substantially higher.

e) Cure rate Norm - >85% State Achievement – 82% Major Causes: 1.Mostly high Deaths and Default Rates in many districts 2.DOT not being followed 3.Inadequate counseling at all levels (especially by the treating physician) 4.Very low feedback of Transferred out cases The Programme Indicators (5)

Contd… The IRL was formally inaugurated and dedicated to the people of Odisha on for diagnosis of MDR- TB cases.

Secretary Health Inaugurating the DOTS Plus Ward at SCB Medical College, Cuttack

Secretary Health giving the first dose of DOTS Plus medication to MDR TB patient (Y. Sita) in the DOTS Plus ward

Secretary Health giving the first dose of DOTS Plus medication to MDR TB patient in the DOTS Plus ward