Tuberculosis (TB) is caused by Mycobacterium tuberculosis(MTb) which most often affects lungs. TB is treatable and curable disease with complete, consistent and appropriate drug regimen. Drug Resistant Tuberculosis (DR-TB) occurs when patients fail to complete the first line anti TB treatment or newly acquire DR-TB from another person with DR-TB. Resistance to antimicrobials in bacteria is not a new phenomenon and has been a well-established fact in Mycobacterium tuberculosis also. According to Annual TB Report 2017, there would be an estimated 1.3 lakh incident multi-drug resistant TB patients emerge annually in India which includes 79000 MDR-TB Patients estimated among notified pulmonary cases1.
After successfully establishing the DOTS (Directly Observed Short Course) services across the country in 2006, Revised National Tuberculosis Control Programme (RNTCP) of India has introduced the Programmatic Management of Drug Resistant TB (PMDT) services in 2007 to address the needs of this group of patients and is now rapidly scaling up services across the country while also expanding services towards universal access2. Under RNTCP, the patients are categorized to be DR-TB patients when the sputum or an extra pulmonary sample of the patient is confirmed microbiologically for MTb and the bacteria are resistant to the most potent first line anti TB drugs such as Rifampicin (Rif) with or without Isoniazid (INH). As part of PMDT, RNTCP in Telangana State initiated Drug Sensitivity Testing (DST) for Rifampicin and Isoniazid in December 2008 and a DR-TB Treatment Centre in Hyderabad in December 2008.
The current, RNTCP PMDT vision is to provide early and rapid diagnosis and promptinitiation of effective treatment to all DR-TB patients, integrated into RNTCP. However under PMDT, RNTCP envisages 7-10 days of in-patient treatment in the DR-TBCentrefor the DR-TB patients during which the Pre-Treatment Evaluation (PTE) of the patient for various parameters such as Liver function tests, Renal function tests, Hemogram and other important baselines physiological functions are performed so that the treatment can be tailor made / altered based on the results of physiological and biochemical tests. The PTE period is also utilized effectively in providing counselling about the duration, mode of treatment for DR-TB and the potential side effects of the drugs, follow-up visits needed, importance of adherence to the drug regimen and precautions to be taken towards reducing transmission of the disease to other members in the family. Once discharged from the DR-TBCentre the patient will be provided with ambulatory treatment in domiciliary fashion with a designated treatment regimen by RNTCP for 2 years which includes Flouro-quinolones and aminoglycosides as mainstay drugs. According to RNTCP a DR-TBCentre can be established for a geographic area covering population of minimum 10 million2. One such DR-TBCentre was established in Government General and Chest Hospital in Hyderabad city of Telangana State in 2008 December with separate female and male wards having proper airborne infection control measures in place. Telangana Region of India had a population of ~30 million in 2008 with 10 revenue districts and 1 additional TB district. Inlate 2012, an additional DR-TBCentre was initiated at Government General and Chest Hospital, Hanamkonda in Warangal district of Telangana region according to the guidelines.
On the above of all, for the patient to travel to a DR-TB centre which is far from his/her residence and stay for 7-10 days for PTE would make the initiation of DR-TB treatment even more challenging. At that point of time, there was not much experience of decentralized DR-TB treatment services in India, through there was a plan for RNTCP to progress towards decentralized care. In this situation, the State TB Cell of Telangana, India developed and implemented the innovative strategy of decentralized provision of DR-TB treatment services at the district level while ensuring maintenance of quality of care. The approach developed towards the innovative strategy is shown below:
The approach of decentralization had the following key components: