role of medical coll in rntcp

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RNTCP AND MEDICAL COLLEGES14

CHAPTER

14

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 thebest 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 RNTCPThe 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

The RNTCP and Medical Colleges

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


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I TUBERCULOSIS CONTROL IN INDIA I

(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 nation-

wide 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

Figure 1 Medical colleges functioning as RNTCP nodal centres

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


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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 inthe 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:

G Faculty members;

G Undergraduates and postgraduates ;

G Residents and Interns; and

G Paramedical staff (laboratory technicians and nursing staff).

2. Engagement with the RNTCP:

Figure 2 Structure and composition of the RNTCP-Medical College task forces


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G Establish microscopy and DOT centres in all medical collegesa ;

G Strengthen infrastructure of the laboratory where required;

G

Involvement in the quality assurance of the smear microscopy network; andG Consultation and management of difficult cases.

3. Advocacy of the RNTCP:

G Sensitisation and training through the Indian Medical Association and other professional

bodies;

G 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.

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

aIn 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

Figure 3 Management of TB cases presenting to a hospitals. Outdoor patient from a RNTCP district for

referral for treatment within the respective district

Outdoor patients (1)


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Paediatrics consensus statement on Management of Paediatric TB under RNTCP5.

Future ChallengesSeveral 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

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

referral for treatment to other districts

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

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 theDOTSCentre in

theMedicalCollege

Attending physician prescribes

thrice weekly RNTCP regimen*

Patient is from RNTCP District

Indoor patients

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

Outdoor patient (2)


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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

2. 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

3. Medical Colleges involvement in the RNTCP: Current Status.J Indian Med Assoc 2003;

103:164-166.

4. 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

5. Consensus statement: Management of Paediatric TB under the Revised National Tuberculosis

Control Programme (RNTCP). Indian J Paed 2004; 71:341-343.

role of medical coll in rntcp

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