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Year : 2013 | Volume : 1 | Issue : 2 | Page : 64 - 65  


Brief Report
Exploring the role of drug resistant tuberculosis center in the programmatic management: An Indian perspective

Assistant Professor, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Kancheepuram, TamilNadu.

Summary:

Global tuberculosis control report – 2012 has revealed that 3.7% of new cases and 20% of retreated cases are estimated to have multi-drug resistant (MDR) TB worldwide. Specific strategies have been implemented under the Programmatic Management of Drug Resistant TB in India (PMDT) to address the MDR-TB problem. Considering the long duration of treatment, PMDT recommends that treatment of drug resistant forms of TB should be decentralized. However, to supervise and guide the health care providers in the complex medical needs, an expert resource center called as Drug-resistant TB (DR-TB) center has been proposed. A DR-TB center plays a crucial role at different levels in the management of drug resistant forms of TB such as pre-treatment evaluation; initiation of treatment; maintenance of hospital wards & airborne infection control measures; management of severe adverse drug reactions; modification in the choice of drugs based on the drug sensitivity test results; and as a clinical expert resource for guidance to the program managers and the health care providers. To conclude, DR-TB center plays a defining role in the overall integrated model of care in RNTCP-PMDT services.

Keywords: Tuberculosis, Revised National Tuberculosis Control Program, Medical College, India

Corresponding Author: Dr. Saurabh RamBihariLal Shrivastava. 3rd floor, Department of Community Medicine, Shri Sathya Sai Medical College & Research Institute, Ammapettai village, Thiruporur - Guduvancherry Main Road, Sembakkam Post, Kancheepuram - 603108, Tamil Nadu, India                E-mail- drshrishri2008@gmail.com

 

 

A multidrug-resistant tuberculosis (MDR-TB) case is one whose sputum culture is positive for Mycobacterium tuberculosis and is resistant to isoniazid and rifampicin with or without other anti-tubercular drugs, provided the drug sensitivity test (DST) results have been obtained from a Revised National TB Control Program (RNTCP) certified culture & DST laboratory.[1] Global TB control report – 2012 has revealed that 3.7% of new cases and 20% of retreated cases are estimated to have MDR-TB worldwide.[2] However, the exact burden of MDR-TB is still not clear as most of the high burden countries have not completely expanded the coverage of surveillance of drug resistance to obtain accurate estimates of the burden of MDR-TB.[2,3] RNTCP has recognized that implementation of a good quality Directly Observed Treatment program is the first priority for TB control in the country.[4] However, specific strategies have been implemented under the Programmatic Management of Drug Resistant TB (PMDT) to address the MDR-TB problem through appropriate management of patients and measures to prevent the propagation and dissemination of MDR-TB.[1]

Studies done across different parts of the world have identified multiple determinants which affect the outcome of drug resistant forms of TB in.[5,6] Considering the long duration of treatment (MDR-TB = 24-27 months; extensively drug resistant [XDR] TB = 24-30 months), PMDT recommends that treatment of drug resistant forms of TB should be decentralized. However, to supervise this decentralized treatment and to guide the health care providers regarding the complex medical needs of the patients, an expert resource center called as Drug-resistant TB (DR-TB) center has been proposed. One DR-TB center is expected to extend therapeutic services to 10 million population. As a part of the vision to achieve universal access of TB care, the plan is to establish 120 DR-TB center across the country. All the proposed DR-TB center sites are to be preferably established in a government medical college hospital under the auspices of the department of chest medicine or internal medicine. These centers are entitled to one-time monetary assistance from RNTCP of up to Rs.10 lacs for up-gradation of the ward and to incorporate airborne infection control measures. In exceptional cases, private hospitals / hospitals run by non-governmental organization (NGO) can serve as DR-TB Center, provided no government medical college is available in the near vicinity.[1,2]

The DR-TB center executes its assigned roles and responsibilities with the assistance of a DR-TB center committee, consisting of a Chairperson - Medical Superintendent / Director of the institute; Vice-chairperson – Head of respiratory medicine / general medicine department; Nodal officer; Member secretary - senior medical officer of the DR-TB center; Clinicians – Heads of Psychiatry / Gynecology / ENT / Microbiology; one pulmonologist from NGO / private sector; and local program managers - District Tuberculosis Officers of the districts catered by the DR-TB center.[1]

A DR-TB center plays a crucial role at different levels in the management of drug resistant forms of TB such as pre-treatment evaluation - a thorough clinical evaluation by a physician &/or psychiatrist, chest radiograph, and relevant hematological and bio-chemical tests to identify patients who are at increased risk of developing adverse effects because of consumption of second line anti-TB drugs; initiation of MDR / XDR treatment by provision of free drugs; maintenance of hospital wards & airborne infection control measures; management of severe adverse drug reactions; rendering free laboratory investigations; modification in the choice of drugs based on the drug sensitivity test results during the course of treatment; decision to shift patient from intensive phase to continuation phase; transfer-in and transfer-out of patients (in exceptional cases); accurate management of records; declaration of the outcome of a patient started on treatment; and as a clinical expert resource for guidance to the program managers and the health care providers.[1,4]

To conclude, DR-TB center plays a defining role in the overall integrated model of care in RNTCP-PMDT services. In addition, records maintained by DR-TB center can act as significant evidence in shaping of future policies and recommendations.

References

  1. TBC India. Guidelines for PMDT in India. [Internet] 2012 [cited 2013 Sep 22]. Available from: http://tbcindia.nic.in/documents.html
  2. World Health Organization. Global Tuberculosis Control Report. 2012. Geneva:WHO press;2012.
  3. Moradi G, Naieni KH, Rashidian A, Vazirian P, Mirzazadeh A, Vaziri MR et al. Evaluation of tuberculosis situratio in economic cooperation countries in 2009: Achievements and gaps towards millenium development goals. Int J Prev Med 2012;3:77-83.
  4. TBC India. Managing the RNTCP in your area - A training course (Modules 1-4). [Internet] 2011 [cited 2013 Sep 22]. Available from: http://tbcindia.nic.in/documents.html
  5. Hirpa S, Medhin G, Girma B, Melese M, Mekonen A, Suarez P, et al. Determinants of multidrug-resistant tuberculosis in patients who underwent first-line treatment in Addis Ababa: a case control study. BMC Public Health 2013;13:782.
  6. Sagar T, Singh NP, Kashyap B, Kaur IR. Current status of multidrug resistant tuberculosis in a tertiary care hospital of East Delhi. J Postgrad Med 2013;59:173-6.

 

Source of Support: Nil. Conflict of Interest: None





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