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Cramped TB treatment unit in Kashmir's worst affected zone

Two small rooms inside a hospital serve as Treatment Unit for tuberculosis in Shopian, the most impacted district in Kashmir, leaving the staff and patients struggle for space amid cartons of medications, and jars of laboratory chemicals. Peerzada Arshad Hamid reports.

Srinagar, Jan 28, 2012:

Inside a small room at Shopian district’s main hospital, laboratory technician Mohammed Ashraf Ganai is examining some slides.

Hunched, he looks at a glass slide keenly through the eyepiece of a microscope.

After adjusting the sputum slides properly, he runs his right thumb on his fingers apparently making a count and intermittently jotting the numbers on a notepad.

Dozens of small cardboard boxes are stacked on a shelf to his right. The boxes contain strips of medicine for the TB patients registered with the centre for Directly Observed Treatment Short Course (DOTS).

DOTS is a strategy to cure TB patients under Revised national TB Control Programme (RNTCP).

Each box has a specific number and name prominently written on it.

The shelves to his left side and the ones in front are occupied with boxes and glass jars containing laboratory chemicals required in sputum microscopic examinations.

The room, rather a cubicle, can accommodate, at best four people at a time.

“My room serves as DOTS centre as well as laboratory for doing sputum examinations,” said Ganai swabbing his tired eyelids with a handkerchief. “Now I have to give medicine to the patients registered with our centre.”

Without wasting time, he ventures out and returns quickly along with two persons.

“These people have to take medicine under my supervision,” Ganai tells me after a cursory look at the patient’s card. Then he scans the shelf for the relevant box.

As he doles out strips from one of the boxes and hands the tablets to the patient, two more people show up at the door of the cubicle with prescriptions in their hands.

Ganai asks them to wait until he finishes with the ones in room.

“These people have to wait, for I remain busy doing microscopic examinations,” he said.

Next to the laboratory is Medical Officer TB Control’s (MOTC) room. The dingy and poorly lit room is the consultation room for examining patients with pulmonary infections especially TB.

Cartons containing medicinal supply for TB patients occupy a good portion of the room. In the remaining space, the MOTC examines patients and writes prescriptions.

“In our district the programme is running smoothly,” said Dr Mohammed Yosuf Naikoo. “We do have space constraints but we hope things will get better in future.”

The Treatment Unit (TU) meant to cater to the entire district’s population is running from these two rooms.

* Tuberculosis is an infectious disease that usually affects the lungs

* It spreads through air via droplets from the lungs when TB patient coughs, sneezes or talks

* If not treated, each person with active TB can infect on average 10 to 15 people a year

* Symptoms of TB include coughing for two weeks, chest pains, weakness, weight loss, fever and night sweats

* Tuberculosis is treatable with a course of antibiotics

* Tuberculosis is completely curable

* TB is not hereditary

* Improper treatment can lead to a drug resistant form of TB- MDR or XDR

* TB is a leading killer among people living with HIV, who have weakened immune systems

* Among the 15 countries with the highest estimated TB incidence rates, 13 are in Africa, while a third of all new cases are in India and China.

Fifty kilometers south of Kashmir’s main city Srinagar, the population of the Shopian district according to Census 2011 is 265,960.

Last year the district recorded highest number of TB patients in Kashmir valley.

Until November at least 293 patients were registered for the treatment.

Of them 148 have completed their treatment and have been declared cured and remaining 145 are still undergoing treatment.

Officials said because of the paucity of space, the RNTCP centre at Shopian cannot stock supplies for more than a month.

The iron racks meant to stalk medicines allotted to the centre are lying in open space unused.

“These racks were issued to us under RNTCP programme but they are lying unused ever since we received them, for we don’t have enough space,” said an official posted in the hospital.

DETECTION

Most of the detections of TB cases were made through sputum tests at the designated microscopic centres (DMC) set up across the district.

There are three DMCs in the district - Shopian’s main town, village Keller and Zainpora – where sputum tests are carried out free of cost. At times the private clinical laboratories in the district refer patients to these designated centres.

“At DMCs we have high powered microscopes, under which we can examine sputum for bacteria load,” said Shabir Ahmad Dar, senior treatment laboratory supervisor. “Under ordinary microscopes, the TB bacteria can’t be seen.”

Dar is in-charge of laboratory services in the district and constantly monitors the TB scenario in the district.

He has entire information regarding the TB relevant to the district recorded in his hand diary, which he always carries with him.

The district has set-up 14 centres, besides sought services of Aasha and Aanganwadi workers for dispensing medicine to the TB patients

“The centres have been set up keeping in view the proximity of the patients,” said Dar. “Patients visit these places at ease and take medicine under our supervision.”

Dar often visits the centres to see if patients are strictly following the regimen.

As per RNTCP data 236 suspects were identified per 100,000 in the first quarter of 2011 in Jammu and Kashmir.

DEFAULTERS

In the district five patients have been recorded as defaulters.

Defaulters according to RNTCP guidelines are those who stop taking TB treatment.

Of the defaulters one was 14-year-old girl.

She reportedly stopped taking medicine after approaching a private consultant.

Repeated efforts by the officials from RNTCP centre to convince the girl for continuation of the regimen however, bore no fruit.

“I visited the family and tried to convince them that she need to take medicine but they were reluctant,” said Dar. “After that I visited her school and talked to the school Principal believing he may be able to convince her but nothing happened. She was adamant.”

Dar substantiates his claim by showing me an entry in his diary and duly stamped and signed by the school principal saying that Dar approached him for help to convince the patient.

Two months later girl’s sister was detected positive for TB and is currently taking the medicine.

“She came here with the complaint of two weeks cough,” said Dar. “When we tested her sputum, it showed bacteria load.”

Dar says after patients are detected, he enquires their family contacts to see the vulnerable ones and advice them to ask their families members to do sputum tests.

“Sometimes, I visit the families and personally see if there are children below the age of 6 years in the patient’s family, for they too need to be put on Isoniazid for two months,” says Dar.

Experts say patients who do not finish their lengthy course of treatment present the bacterium with the perfect environment for developing further resistance.

The resistant form of TB (MDR- Multi Drug Resistant TB or XDR- Extremely Drug Resistant TB) is difficult and expensive to treat and fails to respond to standard first-line drugs.

“Once a TB patient takes medicine strictly, he begins to show signs of improvement and over a period of time he feels completely alright,” said Naikoo. “But that doesn’t mean patient should stop taking medicines instead they need to complete the course, failing which bacteria again finds the environment to grow.”

So far, no data about MDR-TB or XDR-TB is available from Kashmir.

As per 2011 annual TB report setting up of Drug Susceptibility Testing (DST) laboratory in Srinagar is under process.

A person suffering from TB can infect 10 to 15 people in a year.

India has the highest burden of TB in the world, accounting for approximately one fifth of the global incidence – an estimated 2 million cases annually.

Despite being curable and preventable, experts say yet it causes significant morbidity and mortality, which is a cause of serious concern.

Under RNTCP, TB patients after being diagnosed are prescribed treatment under two categories. Under category I, a treatment of six months is available and under category II, treatment lasts for eight months.

(Under the aegis of REACH Lilly MDR-TB Partnership)

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