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Original Article

Proportion of Hospitalization at a Respiratory Centre Under RNTCP

Ruchi Sachdeva, Dept. of TB and Respiratory Medicine, Pt. B.D Sharma, PGIMS, Rohtak, Haryana. Rohit Sarin, LRS Institute of TB & Respiratory Diseases, New Delhi. Sandeep Sachdeva, Dept. of Community Medicine, PGIMER, Dr RML Hospital, New Delhi. Vikram Vohra, LRS Institute of TB & Respiratory Diseases, New Delhi.

Abstract Objective: To determine proportion of patients requiring hospitalization under RNCTP. Methodology: All area-patients registered for treatment under RNTCP at LRS Institute, New Delhi through 16 DOTS centre during the reference period (1st April 2006 to 31st Dec 2006) were listed and those patients requiring hospitalization (upto 31st Dec 2007) at LRS Institute were identified and interviewed by a single investigator using semi-structured proforma with certain inclusion and exclusion criterias. The data was entered into master sheet and analysis carried out using software statistical package by computing proportion (%) and chi-square test. Results: It was observed that there were 2,345 patients registered for treatment under RNTCP during the reference period, out of which, 4.22% (99) required hospitalization. The males outnumbered females in absolute numbers, however, gender related hospitalization was similar, 4.08% for males to 4.47% for females (p=0.647). Maximum case load (75.75%) was seen in economically productive age group (15-49 years). The proportion of hospitalization amongst 114, 15-49, 50-60 and 61 years & above age group was 2.36%, 4.10%, 5.11% and 8.60% respectively (p=0.08); category II (7.61%) patient admissions was twice than category I (3.65%) patients (p<0.001). The proportion of hospitalization was 2.37% and 5.4% amongst patients with negative and positive sputum status respectively. Conclusion: The study

was undertaken at a respiratory tertiary care centre in a metro city and within the study constraints it highlights disease severity, late presentation and minimum need for TB beds under prevailing socio-economic circumstances in the country. Keywords TB; program; proportion; hospitalization; gender; category, RNTCP, sputum, operational research, city Introduction Global scenario of TB In 2008, nearly 9.4 million new cases (139 cases per 1,00,000 population with women accounting for 38% of new cases) and 1.8 million deaths were reported due to TB, and over 90% of these occurred in the low and middleincome countries1. In these regions, TB is one of the leading cause of adult mortality, ranking third after HIV/AIDS and ischemic heart disease as a cause of death among those aged 15-59 years (and 7th globally among all age groups)2, 3. The South-East Asia region, with 25% of the worlds population accounts for 34% of the TB burden. India is the highest TB burden country globally, accounting for one fifth of the global incidence and 2/3rd of the cases in south East Asia. Nearly 40% of the Indian population is

Address for correspondence: Dr Ruchi Sachdeva, D-1/1395, Vasant Kunj, New Delhi-110070. E-mail: drsachdeva@hotmail.com.

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infected with the TB bacillus. Each year, 1.9 million new cases of TB occur in the country, of which about 0.8 million are infectious new smear positive pulmonary TB cases. On a positive note, TB Control Programme in India has successfully completed the largest and most rapid expansion of DOTS in history to cover the entire country in 20064. Background The issue of earmarking hospital beds exclusively for TB-patients has been an area of concern & intense deliberation not only in India but also globally. Sanitorium treatment was a mainstay Anti-Tubercular therapy before 1950s. However, Madras Trial of 1956 concluded that sanatorium treatment was not superior to home treatment, in terms of clinical, radiological and bacteriological response and transmission of disease. Revised National Tuberculosis Control Programme (RNTCP) in India advocates Directly Observed Treatment Short course (DOTS) therapy for all categories of patients through domicillary mode. Even though cure rate with this strategy is expected to be over 85% but some proportion of TB patients would still require hospitalization for varied reasons. This prospective cohort study was carried out to ascertain proportion of TB patients requiring hospitalization and reasons thereof. Material and Method Setting The study was conducted at a tertiary care respiratory centre, LRS institute of TB and Respiratory diseases, New Delhi that caters largely to population of Delhi but significantly from adjoining states also. For effective and efficient implementation of RNTCP activities, operational work areas at LRS Institute have been classified based upon patients residential status in three categories as Area patients, Non-Area patients (non-area but within Delhi) and Outside patients (outside Delhi). On the first contact of patient with LRS Institute, depending upon his residential status, patient is categorized in any of the above three categories and appropriately recorded on the OPD card. The population covered by LRS Institute in the geographical jurisdiction of Area patients through 16 DOTS centre is approx. 16 lakhs that include sizeable section residing in slums/low socio-economic environment. This prospective study captured data related to area patients registered for treatment under RNTCP during the reference period and admitted to LRS Institute any time till their completion of DOTS treatment.

Reference Period All area-patients registered for treatment under RNTCP at LRS Institute during the reference period of threequarters (1st April 2006 to 31st Dec 2006) were listed and those patients requiring hospitalization at LRS Institute were identified and enumerated. The reference time-frame was selected keeping in mind the maximum duration of TB treatment under RNTCP and resource constraint for conduct of study. Study Population The study population comprised of two distinct subtypes based on RNTCP registration/hospitalization i.e. 1. All Area patients registered for treatment under RNTCP during reference period and admitted in LRS Institute any time till completion of DOTS (upto 31st Dec 2007). Area-Patients admitted directly to LRS Institute during the reference period following which they were diagnosed and registered for treatment under RNTCP.

2.

Data Collection A single investigator collected the data using semistructured interview schedule after obtaining clearance from ethical committee of the institute and informed consent of patient. The study variables included socio-demographic details, TB/treatment history, sputum status, RNTCP category, reason of hospital admission, date of admission & discharge and outcome of hospitalization. All operational definitions prescribed under RNTCP were used for the purpose of this study. Data was then entered into MS excel sheet and analysis carried out using software statistical package (SPSS ver. 16.5) by computing proportion (%) and applying chi-square test. Exclusion Criteria 1. 2. 3. Non-area patients and outsider patient under RNTCP. Area patients receiving anti-tubercular therapy not registered under RNTCP. Patients diagnosed and registered for treatment under RNTCP earlier to reference period and admitted during study period.

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Limitations of Study Information pertaining to following categories of patients though important could not be captured in the present study: 1. Patients registered under RNTCP for treatment at LRS Institute but admitted in some other hospital due to any cause. Patient with extra-pulmonary tuberculosis. Patient who defaulted under RNTCP who may or may not require hospital admission.

4.

Pulse oxymetry assessment, sputum culture sensitivity and HIV status was not ascertained. Results

2. 3.

It was observed that there were 2,345 patients registered for treatment under RNTCP during the reference period, out of which, 4.22% (99) required hospitalization at LRS Institute (Table 1). It was also observed that majority of patients i.e. 84 (84.85%) were diagnosed and registered under RNTCP after admission to LRS Institute suggestive of severity of disease condition and/or late presentation. Rest of the patients i.e. 6 (6.06%) were admitted within

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one month & 9 (9.09%) were admitted after more than a month of RNTCP registration & initiation of therapy. Thus, once the patient is put on DOTS the requirement for hospitalization is markedly reduced. Socio-demographic profile of admitted patients: Out of 99 admitted patients there were 81 (81.81%) Hindu, 13 (13.13%) Muslims and 5 (5.05%) belonging to other religion (Sikh/Christian). There were 42 (42.42%) literate & 57 (57.58%) illiterate patients and 70% had family composition of 5 or more members. There were 18 (18.19%) and 81 (81.81%) patients belonging to lower and upper-lower social class respectively according to Kuppuswamy classification. Out of 99 patients, 49 (49.49%) gave history of receiving ATT in the past and 43 (43.43%) gave history of current smoking. Gender profile: The present study showed that ratio of male registration was 1.83 times higher than female under RNTCP. The picture was similar with regard to admitted patients as well (1.67: 1). The males outnumbered females in absolute numbers however, gender related hospitalization was similar (4.08% for males to 4.47% for females). This observation was not found to be statistically significant (p=0.647). Age profile: The highest caseload (>75%) registered for treatment under RNTCP and those requiring admission was found to be in the economically productive age group of 15-49 years. The proportion of hospitalization amongst 1-14 years, 15-49 years, 50-60 years and 61 years & above age groups were 2.36%, 4.10%, 5.11% and 8.60% respectively. Even though there appears to be increasing trend of hospitalization with higher age groups but this observation was not statistically significant (c2= 6.69, p=0.08). RNCTP category wise patient profile: Even though category I and II admitted patients were similar i.e. 50 (50.5%) and 49 (49.49%) but on comparing proportion of hospitalization amongst respective categories it was noticed that category II (7.61%) admission far exceeded category I (3.65%). This observation was found to be statistically significant (p<0.001). Category II patients are those who have either taken treatment (partial/complete) in the past or whose treatment has failed whereas Category I are new sputum positive or seriously ill sputum negative. This observation throws light on probability of hospital admission

amongst various categories of treatment under RNCTP. The proportion of hospitalization is less for category-I patients and could be possibly due to lesser severity, absence of co-morbid illness, early diagnosis, and/or high level of awareness/motivation among the patients Sputum status of patients: The proportion of hospitalization when compared with RNTCP registration was 2.37% amongst patients with negative sputum status and 5.4% for positive sputum patients. This was suggestive that risk of hospitalization was more for sputum positive patients. However, it did not vary significantly with degree of sputum positivity. Overall, this observation was found to be statistically significant (p=0.007). Reasons of hospital admissions: There were varied reasons for hospital admission and some of the patients were having multiple presentations. Primary reasons of hospital admission were cachexia (77.78%), respiratory distress (49.49%), heamoptysis (26.26%), social causes (14.14%), gastric intolerance (8.08%), cor-pulmonale (4.04%), surgical emergency (4.04%), elective surgery (3.03%), disseminated Kochs (3.03%) and ATT induced hepatitis (2.02%). It was noticed that 17 (17.17%) admitted patients had additional co-morbid/other conditions. These included 7.07% patients with Diabetes Mellitus, 6.06% COPD, 2.02% hypertension, and amongst others, one each for deep vein thrombosis and another case of physiological condition like pregnancy. Length of Stay (LOS) and outcome: Out of 99 patients, 41 (41.41%) were admitted in the hospital for less than a month and 58 (58.58%) stayed in the hospital for more than 1 months (mean: 46.94 [ 30.7] days; range: 1-132 days). The outcome of 99 admissions was 87 (87.87%) discharge alive, 6 (6.06%) expiry and 6 (6.06%) either absconded or Left Against Medical Advice (LAMA). Discussion RNCTP advocates scientifically proved successful domiciliary treatment but some proportion may require hospitalization due to various reasons. In the present prospective study it was observed that nearly 4.22% (99) out of 2345 registered TB patients required hospitalization. Within the available resources, feasibility and some of the highlighted limitations of present study, this observation reflects the need for TB beds in conjunction with

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availability & accessibility of quality health services including infrastructure, trained personal, diagnostic technology & socio-economic circumstances prevailing in the country. One of the limitations of present study was that it did not capture data related to registered patients under RNTCP at LRS Institute reporting to other hospitals and extrapulmonary tuberculosis cases. If this were also considered then requirement for in-patient beds for TB would be invariably more than the calculated figure of 4.22%. To the best of our ability, we could not retrieve studies with similar objectives for purpose of comparison. There was no admission noticed under the treatment category III at LRS Institute during the study period. The Cat III patients included extra-pulmonary TB and sputum negative not seriously ill pulmonary-TB patients. Extra pulmonary cases usually report to respective specialties like surgery, orthopedics, gynea etc in different hospitals and such types of patients had already been excluded from the preview of the present study. In the current scenario, the chances of multi drug resistance (MDR) is substantial globally including India due to easy availability of anti-tubercular drugs in private sector not in controlled manner compounded by unsatisfactory treatment services, compliance issue & poor socioeconomic conditions. Further, reports also indicate the existence of Extreme Drug Resistance (XDR) TB in the country. The management of such cases require intense monitoring, individual drug-titeration & close supervision that can happen more effectively & efficiently in hospital setting. During transition from National Tuberculosis Programme (NTP) to RNTCP, an extensive infrastructure with a network of 446 District TB centres, 330 TB clinics and approximately 47,600 beds had been created for TB control 5. Country wide cross-sectional survey of TB hospitals during the year 2003-04 indicated that there were 15,773 TB beds in India that was almost 1/3rd of total beds in the country6. However, the need of hospitalization arises due to severity of disease condition, treatment titration, presence of other co-morbid condition, social reasons or delay in seeking appropriate health care at the right time. Data from specific surveys, suggest that case fatality rates prior to RNTCP were generally greater than 25%. In RNTCP era, case fatality has remained less than 5% for new cases registered under the program in the country7. Overall, our study documented case fatality as 6.0%.

The study results are of concerns especially in a metro like Delhi with relatively good transport, medical & communication services and supposedly high information education communication (IEC) activities. Though the findings emerging from this study cannot be generalized as majority of residents were from slum-area, the estimates may be worse if results are applied to other areas like smaller cities or rural areas of country. There is also a possibility that such patients die before reaching any hospital and as a result mortality statistics does not get registered/reported anywhere. Poor health management information system (HMIS) including civil registration system and lack of medical certification of cause of death (MCCD) further compound the phenomenon of under-reporting of morbidity and mortality in the country due to tuberculosis. To conclude, present prospective study was undertaken in a tertiary care respiratory institute reflecting requirement of TB beds under RNTCP with varied reasons for hospital admission however further studies in other areas are required to have a more comprehensive view on this important national topic. Reference 1. Global Tuberculosis Control: Epidemiology, Strategy, Financing. Geneva: WHO; 2009. WHO/HTM/TB/ 2009.411. The World Health Report 2003: Shaping the Future. Geneva: WHO. World Health Statistics 2008. Geneva: WHO. TB India: RNTCP Status Report-2009. Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhawan, New Delhi. Khatri G.R., Frieden T.R. The status and prospects of Tuberculosis control in India. Int J Tuberc Lung Dis. 4 (3): 193, 2000. A survey of tuberculosis hospitals in India. Stop TB department, WHO, Nirman Bhawan, New Delhi; 2004. TB India: RNTCP Status Report-2010. Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhawan, New Delhi.

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