Introduction:
Tuberculosis is a specific infectious disease caused by M. tuberculosis. It is an infection of the lungs, remains the second leading cause of death in the world. It can also affects intestine, meninges, bones and joints, lymph glands, skin and other tissues of the body. The disease is usually chronic with varying clinical manifestations.
Bangladesh (BD) is working to reduce the burden of TB, and halve TB deaths and prevalence by 2015. Every state health department needs the basic framework for a TB control program that includes all six components, and a designated program director. Sufficient capability in each of the following components is necessary for progress toward TB elimination:
a. Planning and developing policy
b. Finding and managing suspected and confirmed tuberculosis cases
c. Finding and managing latent tuberculosis infection
d. Providing laboratory and diagnostic services
e. Collecting and analyzing data
f. Providing consultation, training, and education
3. TB programs may perform these activities directly or programs may coordinate with other providers to ensure the implementation of these activities. Failure to meet these core standards can decrease a TB program’s effectiveness in controlling this public health risk. The National TB Program (NTP), established in 1993, created a strategic plan for 2006–2010 that includes the following activities:
a. Implement all five elements of the WHO-recommended DOTS strategy (political commitment, directly observed therapy, laboratory testing, uninterrupted supply of quality medicines, and standard monitoring and reporting)
b. Embrace the global TB control targets of 70 percent case detection and 85 percent treatment success
c. Explicitly aim to improve health and family welfare among the most vulnerable women, children, and the poor.
4. There has been significant progress toward achieving these goals. As of late 2010, the NTP reported that DOTS coverage had been extended throughout the country; the treatment success rate had reached the global target of 92 percent and the case detection rate had risen to 70.5 percent — a marked improvement on previous years.
Action plan for health educational program for intestinal worm infestation: For providing health education program for tuberculosis to the people of Bangladesh, following sequence will be followed –
1. Analysis of the present situation regarding tuberculosis
2. Establishment of objective and goal
3. Assessment of resources
4. Fixing priorities
5. Writing up formulated plan
6. Programming and implementation
7. Monitoring and evaluation
Analysis of the present situation regarding intestinal worm infestation:
1. Global situation: Tuberculosis remains a world wide public health problem despite the fact that the causative organism was discovered more than 100 years ago and highly effective drugs and vaccine are available making tuberculosis a preventable and curable disease. There were an estimated 8.8 million (range 8.5 to 9.2 million) incident cases of tuberculosis globally in 2010. Among the incident cases, there were 1.1 million deaths in HIV negative cases world wide and additional 0.35 million deaths in HIV positive cases.
Global trends in estimated rates of TB incidence, prevalence and mortality. Left: Global trends in estimated incidence rate including HIV-positive TB (green) and estimated incidence rate of HIV-positive TB (red). Centre and right: Trends in estimated TB prevalence and mortality rates 1990–2010 and forecast TB prevalence and mortality rates 2011–2015. The horizontal dashed lines represent the Stop TB Partnership targets of a 50% reduction in prevalence and mortality rates by 2015 compared with 1990. Shaded areas represent uncertainty bands. Mortality excludes TB deaths among HIV-positive people. Source: Global Tuberculosis Control: WHO Reports, 1990-2010
2. Epidemiology of Tuberculosis in South East Asia Region: The South-East Asia Region, with an estimated 4.88 million prevalent cases and an annual incidence of 3.17 million TB cases, carries one-third of the global burden of TB. Five of the 11 Member countries in the Region are among the 22 high-burden countries, with India accounting for over 20% of the world’s cases. Most cases occur in the age group of 15-54 years, with males being disproportionately affected. The male/female ratio among newly detected cases is 2:1. Though deaths due to TB have declined after introduction of DOTS.
Estimated TB incidence rates 1990–2010. Regional trends in estimated TB incidence rates (green) and estimated incidence rates of HIV-positive TB (red). Shaded areas represent uncertainty bands. Source: Global Tuberculosis Control: WHO Reports, 1990-2010
Trends in estimated TB prevalence rates 1990–2010 and forecast TB prevalence rates 2011–2015, by WHO region Shaded areas represent uncertainty bands. The horizontal dashed lines represent the Stop TB Partnership target of a 50% reduction in the prevalence rate by 2015 compared with 1990. The other dashed lines show projections up to 2015. Source: Global Tuberculosis Control: WHO Reports, 1990-2010
3. Drug-resistant TB: Seven countries have reported data on drug resistance since 2002, namely, Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka, and Thailand. India reported data from three districts and one state, while Indonesia reported data from one district only. Orissa in India, Sri Lanka, and Thailand reported less than 2.0% MDR-TB among new cases. Districts surveyed in the states of Kerala, West Bengal and Gujarat in India as well as Mimika district of Papua province in Indonesia, and Nepal reported between 2.0-3.0% MDR-TB among new cases. Myanmar reported a higher level of 3.9% (2.6%-5.7%) MDR among new cases. While a few tertiary-care facilities have reported levels of multi-drug resistance as high as 60% among previously treated cases, these are not representative of the situation in the community.
4. Resistance to first-line anti-TB drugs is equally a concern for national TB control programmes in countries of the Region. The population weighted mean of MDR-TB based on all the countries that have reported in the South-East Asian Region is 2.8% (1.9%-3.6%) among new cases and 18.8% (13.3%-24.3%) among previously treated cases. However, given the large numbers of TB cases in the Region, these figures translate into nearly 150,000 cases in the Region as a whole, with over 80% of these cases residing in Bangladesh, India, Indonesia, Myanmar and Thailand. While Myanmar and Thailand report relatively lower rates of MDR-TB among new cases, the two countries report 15.5% and 35.5 % MDR-TB rates respectively, among previously treated cases, which is a serous concern.
5. Extensively drug resistant tuberculosis (XDR-TB), has been isolated in samples from India, Indonesia, Bangladesh, and Thailand. Given the widespread availability and use of second-line drugs, and as laboratory capacity to conduct second-line drugs susceptibility testing increases, additional occurrences of XDR-TB are likely to be identified.
6. The other concern is that unless well managed MDR-TB programmes are rapidly established under national programmes, MDR-TB cases will continue to be treated by the private sector through not necessarily well supervised or well designed second-line regimens, or through over-the-counter purchase of these drugs, given their widespread and easy availability, risking further increase in drug resistance.
7. Situation in Bangladesh: Tuberculosis (TB) has been a major public-health problem and one of the leading causes of adult mortality in Bangladesh. The WHO estimates on an assumed population of 162 million that every year about 83,000 (between 60,000 and 110,000) people die due to tuberculosis in Bangladesh. The World Health Organization estimated that, in 2010, there were approximately 426 TB cases per 100,000 people (between 198 and 696), of which 225 new cases per 100,000 people (between 183 and 270) were observed each year in Bangladesh. It is further estimated that about 51 per 100,000 people (between 37 and 67) die of TB every year. There are 300,000 new cases annually; 137,000 are infectious, smear-positive cases. The annual incidence of TB is 99 per 100,000 population for smear-positive cases and 221 per 100,000 for all forms. TB causes 70,000 deaths per year. The case detection rate is 41% (NTP, 2003). The cure rate of detected cases under DOTS is 84% (with 300,000 new cases annually, those cured comprise only 3.2% of all new cases). Incidence is believed to be higher in densely populated, urban areas with poor living conditions; and. The female: male is ratio 2:5 among new smear-positive cases registered for treatment.
Although the HIV prevalence is still low, HIV poses a threat to TB control. The HIV prevalence in adult TB patients was about 0.1% as revealed in three limited surveys conducted in 1999, 2001, and 2006-2007. The multi drug resistant tuberculosis (MDR-TB) rate among the new cases of TB was estimated to be 3.5%. This rate among the re-treatment cases was estimated at 20%.
Table – 1: Tuberculosis situation in Bangladesh 2011
Planning step- 1 Estimate population need & advocate for action |
Planning step-2 Formulate & adopt policy
|
Planning step-3 Identify policy implementation steps |
The step wise framework for prevention program: Before planning process starts it is to measure the overall health status of the community. Especially the prevalence of TB is sufficient to initiate a planned response to the disease program.
Policy implementation steps | Population wide intervention | Individual level | |
National level | Regional level | ||
| Implementation step 1. Core | Interventions with existing resources in the short term. | ||
| Implementation step 2. Expanded | Interventions with a realistically projected increase in or reallocation of resources in the medium term. | ||
| Implementation step 3. Desirable | Evidence based interventions which are beyond the reach of existing resources. | ||
Figure 7: The step wise framework for prevention program on education against tuberculosis.
Establishment of objective and goal:
Objective:
1. To prevent transmission of tuberculosis
2. To develop awareness among the population about tubercular infection and its detrimental effects
3. To provide tubercular treatment and prevent development of MDR TB
Goal:
1. Health education program for tuberculosis among the people in Bangladesh.
2. Reduction of impact of tuberculosis and MDR TB on individual, community and society.
Aim of the program:
1. To control incidence of tuberculosis and development of MDR TB themselves
2. To promote community cooperation in health matters by using control program as a means of achieving general development.
For health education the main thrust should include:
1. What is tuberculosis and other related terminology?
2. How it is transmitted?
3. Who all are the risk group people?
4. What are the complications of tuberculosis?
5. What is the treatment of tuberculosis?
6. How to prevent its transmission?
Information about tuberculosis:
1. Agent of tuberculosis: M. tuberculosis is a facultative intracellular parasite and readily ingested by the phagocytes and is resistant to intracellular killing.
2. Source of infection: There are two sources of infection – human and bovine. The most common source of infection is the human case whose sputum is positive for tubercle bacilli and who has either received no treatment or has not been treated fully.
3. Communicability: Patients are infective as long as they remain untreated. Effective anti-microbial treatment reduces infectivity by 90% within 48 hours.
4. Host factors: Tuberculosis affects all ages. It is more prevalent in males than females. Malnutrition is widely believed to predispose to tuberculosis. Man has no inherited immunity against tuberculosis. It is acquired as a result of natural infection or BCG vaccination.
5. Social factors: Tuberculosis is a social disease with medical aspects. Social factors includes poor quality of life, poor housing, over crowding, population explosion, under nutrition, lack of education, large families, early marriages, lack of awareness of causes of illness etc. all these factors are interrelated and contribute to the occurrence and spread of tuberculosis.
6. Some definitions of tuberculosis cases and treatment:
a. Definite case of TB: A patient with Mycobacterium tuberculosis complex identified from a clinical specimen, either by culture or by a newer method such as molecular line probe assay. In countries that lack laboratory capacity to routinely identify Mycobacterium tuberculosis, a pulmonary case with one or more initial sputum specimens positive for acid-fast bacilli (AFB) is also considered to be a “definite” case, provided that there is functional external quality assurance (EQA) with blind rechecking.
b. Case of TB: A definite case of TB (defined above) or one in which a health worker (clinician or other medical practitioner) has diagnosed TB and decided to treat the patient with a full course of TB treatment.
c. Case of pulmonary TB: A patient with TB disease involving the lung parenchyma.
d. Smear-positive pulmonary case of TB: A patient with one or more initial sputum smear examinations (direct smear microscopy) AFB-positive; or one sputum examination AFB+ and radiographic abnormalities consistent with active pulmonary TB as determined by a clinician. Smear-positive cases are the most infectious and thus of the highest priority from a public health perspective.
e. Smear-negative pulmonary case of TB: A patient with pulmonary TB not meeting the above criteria for smear-positive disease. Diagnostic criteria should include: at least two sputum smear examinations negative for AFB; radiographic abnormalities consistent with active pulmonary TB; no response to a course of broad-spectrum antibiotics (except in a patient for whom there is laboratory confirmation or strong clinical evidence of HIV infection); and a decision by a clinician to treat with a full course of anti-TB chemotherapy. A patient with positive culture but negative AFB sputum examinations is also a smear-negative case of pulmonary TB.
f. Extra pulmonary case of TB: A patient with TB of organs other than the lungs (e.g. pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, meninges). Diagnosis should be based on one culture-positive specimen, or histological or strong clinical evidence consistent with active extra pulmonary disease, followed by a decision by a clinician to treat with a full course of anti-TB chemotherapy. A patient in whom both pulmonary and extra pulmonary TB has been diagnosed should be classified as a pulmonary case.
g. New case of TB: A patient who has never had treatment for TB or who has taken anti-TB drugs for less than one month.
h. Retreatment case of TB: There are three types of retreatment case:
(i) A patient previously treated for TB, who is started on a retreatment regimen after previous treatment has failed (treatment after failure);
(ii) A patient previously treated for TB who returns to treatment having previously defaulted.
(iii) A patient who was previously declared cured or treatment completed and is diagnosed with bacteriologically-positive (sputum smear or culture) TB (relapse).
j. Case of multidrug-resistant TB (MDR-TB): TB that is resistant to two fi rst-line drugs: isoniazid and rifampicin. For patients diagnosed with MDR-TB, WHO recommends treatment of at least 20 months with a regimen that includes second-line anti-TB drugs.
Writing up formulated plan: The health education program should include the following components –
1. Justification of the program: The control of tuberculosis (TB) is a high priority of social and health care policies in many countries, especially less developed countries (LDCs). Indeed, the disease is responsible for 26% of all the avoidable deaths in LDCs, and the cause of 3 million deaths annually, worldwide. Although the nature of the distal causes of TB is socioeconomic, medical health care can substantially reduce its burden in both developed countries and LDCs. The most effective medical strategy for TB control, so far, is to find suspect cases, diagnose with direct smears those transmitting the bacteria (case finding) and then treat them by short-course chemotherapy under supervision of health care workers (HCWs). This is the basis of the so-called direct observed therapy short-course (DOTS) promoted by the World Health Organization. Two fundamental elements are needed for this strategy to succeed: first, efficient health care services, making it feasible for people with tuberculosis (PWT) to have an early diagnosis and to adhere to treatment; and secondly, individuals and communities who are well informed about TB and its means of control. Community health education on the process of this strategy for TB control is extremely relevant, and may be particularly useful in those settings where high cure rates are already achieved. Community education in the basics of TB epidemiology may help to increase case finding, reduce diagnosis delay and promote adherence to treatment.
Resources/Inputs:
1. TB program staff
2. Training and continuing education staff
3. Funding
4. Physical or structural components (space, testing facilities)
5. Infrastructure resources that are part of the health department
6. Partner organizations
Activities
1. Hiring and training new staff
2. Policy development or revision
3. Providing targeted TB testing to specific high-risk populations
4. Identifying persons with latent TB infection or active TB disease
5. Administering DOT
6. Educating patients or community members
7. Providing laboratory and diagnostic services
8. Surveillance
9. Managing clinic operation
10. Providing technical assistance
Outputs
1. A strategic plan for your program
2. TB Tests conducted
3. Providers educated about TB
4. Education sessions presented to community groups
Outcomes
1. Patients’ knowledge is increased
2. Patients accept treatment for TB and LTBI
3. Patients identify contacts
4. Patients on appropriate treatment
5. Patients adhere to treatment
6. Timely completion of treatment
7. Reduced hospital admissions for TB
8. Reduced transmission of TB
9. Trust built within the community
10. Patients identify all of their close contacts
11. Stigma about TB reduced
12. Improved patient quality of life
13. Patients are healthier overall
Activities to be achieved: The over all activities to be achieved through the awareness program are as follows –
Detailed Planning: The plan will be formulated in different ways for different tiers. The basic principles of this plan are: community centeredness, empowerment, sustainability, accountability, commitment and team work.
1. Intermediate results (IR): The measurable, lower-level results that must be achieved in order to reach the goal. Each IR may be supported by several strategies or kinds of activities. Achieving all of these lower-level results will ensure the achievement of the related objectives and contribute towards the achievement of the Goal.
a. IR One – Availability. The first intermediate result addresses problems of the availability of community-based health, hygiene, and nutrition services. Strategies and activities for IR1 include:
(1) Routine mass treatment of TB cases.
(2) Treatment of common health problems.
(3) Psychosocial counseling for TB cases and their family members.
b. IR Two – Quality: The second intermediate result addresses the quality of the community environment, with a particular focus on access to water and sanitation facilities.
c. IR Three – Knowledge, Attitudes, and Interest. The third intermediate result addresses problems of people’s knowledge of attitude towards and interest in health services and health-protective behavior. Strategies to address this IR consist of behavior-centered health and nutrition education and communications. Strategies for IR3 include:
(1) Skills-based health education to enable people to stay healthy and avoid risky behaviors
(2) Teacher training on skills-based health and nutrition education
(3) Training of health workers and community participants on the different elements
d. IR Four – Community Support & Policy: The fourth intermediate result addresses problems of support systems and policy. Strategies for IR4 include:
(1) Educating caregivers and patients on improving health and nutrition.
(2) Training the community leaders to support and maintain on going activities.
(3) Working with key stakeholders from the community up to the national level to ensure effective program implementation, increase sustainability and create an environment favorable to meeting the health and nutrition needs of the vulnerable groups.
(4) Advocacy to scale-up to national-level health programming.
2. Community level planning: It includes –
a. Orientations with local infrastructures, local partners, local leaders and personnel and the community people as well.
b. Deliberation of mission.
c. Discussions to promote the plan.
d. Working partnership- local leaders, imams, teachers and community health workers.
e. Confidence building activities.
3. Community Mobilization: It is a capacity building process, where all will participate for improving the health education on TB. These include-
a. Ongoing dialogue.
b. Strengthening the community organizations.
c. Promoting and assisting the participation of all the peoples.
Implementation: DIP is a detailed implementation plan for a program, which is target-oriented, responsibility-specific and time-bound. It helps program managers and field staff to implement the program as planned and keep the program on track. Program Managers at Country Office level are responsible for program design, annual planning, monitoring of field implementation, national networking and budgets. Program Officer/Program Office at Impact Area Office level are responsible for the implementation of plans, networking with local government and reporting. Field Officers at Impact Area Office level are responsible for field level implementation concerning quality and planning and networking with lower level stakeholders.
1. Standard Procedures:
a. The DIP will be an annual plan prepared by the program team following a recommended process, outline and framework.
b. It should be developed in September/October for the following year January to December.
c. It is a tracking tool to monitor progress in implementing planned activities on a monthly or quarterly basis.
d. The DIP should list all major activities, supporting sub-activities, planned targets, and resources required, persons responsible for carrying out each activity, timeline, partners involved, level of community contribution, estimated budgets and process indicators.
e. The DIP may be reviewed and revised after six months of implementation as needed following the same process and outline.
Consider Ongoing Programs: Nation wide in all secondary level health care services and TB clinics has the facility to test sputum, x-ray, montuax-test facilities. Anti tubercular drugs are supplied free of cost. But there is no exclusive program for education on awareness for prevention of tuberculosis. I will take in confidence all the on going programs conducted by GOB as well as other agencies.
Implementing Interventions: This is the planning execution part of the project which includes –
1. The field officer is responsible for preparing the SIP (Summary Implementation Plan) with support from all field staff.
2. All major planned activities for that year are listed for each IR and program strategy. The time of each activity, by quarter, and funding needed is also noted.
3. At the end of each fiscal year, the Program Manager should prepare an annual report on the basis of the SIP.
4. The SIP cannot be prepared without completing a detailed DIP beforehand.
Training and capacity building: Most of the interventions described below are delivered using the same training system, which is summarized in the training tree below. It indicates how information is shared at all levels and who is responsible for each level of training and orientation. A list of materials used for each intervention is as follows –
a. Training manual
b. Health education materials and
c. Monitoring and supervision forms.
Special emphasis will be given on the following heads –
Motivation:
1. Pills to Prevent TB: That’s why the doctor has prescribed them for you to protect you from TB. The pills must be taken regularly as often and as long as the doctor says.
2. Why do you need pills?
a. Your test shows that you got the germs quite recently.
b. You had TB once and maybe were not treated completely with the medicines we have today.
c. Something on your chest X-ray.
3. Things to watch: In fact, tell them about any illness you feel while pill-taking, report to doctor.
4. Are You a Parent? Children taking TB pills should not be kept apart. Let them play with others. Let them go to school if they are school age. Because your child feels fine, it may be hard to remember the medicine every day perhaps for a whole year. But it must be every day, or it may not work. That applies to you too!
Improvement of sanitation:
1. Use sanitary latrine.
2. Regular hand washing.
3. Improvement of Existing Living Condition
4. Inform About Side Effect
5. Don’t listen to propaganda and false believe.
School Based Health Services: School based health and nutrition services are simple and easy to administer by the teachers. Health Education is the process of sharing health-specific content in such a way as to increase knowledge, attitudes, and practices and thereby change individual behavior.
Classroom-based health education sessions are designed to incorporate health information and messages for children by subject and in a way that forms part of their existing grade-specific curricula.
They help school children to learn more about personal hygiene, safe water and sanitation, food and nutrition and first aid treatment. Health education sessions should help children to change their behavior regarding personal hygiene and food habits and also in protecting themselves from water-borne diseases and worm infestations.
1. Standard Procedures:
a. Health education sessions should be a part of class routines for all classes once per week.
b. Teachers shall conduct health education sessions for every class as per the schedule adopted.
c. Textbooks with health education content and accompanying teacher’s training manual shall be used as teaching aids for these sessions. PHASE (Personal Hygiene and Sanitation Education) materials and any other health and nutrition materials, endorsed by the Government may be used as supplementary materials for these sessions.
d. Program staff, with government support, shall train teachers prior to them conducting health education sessions.
e. Head Teachers of each school shall ensure regular health education sessions by the use of a tracking chart.
Cost calculation: It will cost 5000 taka per primary level package program.
Community Supports:
1. Mothers Gatherings: Mothers Gatherings are one of the most effective ways to communicate school issues including health education with parents.
2. Annual Sports.
Monitoring and Supervision: It explains the difference between results and progress indicators and lists the recommended indicators by Intermediate Result (IR).
1. Standard Procedures:
a. Visited every month or alternate months using a checklist.
b. Checklist findings may be shared with community leaders and teachers.
c. At least five home visits per month by health workers.
d. Regularly by result and process indicator report.
Evaluations: To identify whether any change has occurred in program sites by –
1. Random sputum examination.
2. Clinical examination.
Measures and Report the Progress: Repeated measurement of the disease burden among community population.
Lesson Learned: Results and report returns should be extracted and documented for future guidance.
Conclusion:
1. World TB Day on March 24 is an opportunity to recognize the global fight against tuberculosis. It is an opportunity to mobilize communities and raise awareness; to engage with governments and encourage donors to invest in TB control. HIV does not appear to have fundamentally altered the epidemiology of TB in our country to the extent observed in sub-Saharan Africa. Available data suggest that the incidence of TB has been minimally affected by the HIV epidemic. The impact on TB mortality however, has been much more substantial. In India, Myanmar and Thailand, high TB case-fatality rates have been reported in areas with high HIV rates in the general population.
2. The nation-wide TB prevalence survey was implemented during 2007-2009 and included 52, 098 people aged 15 years or older and 33 new smear-positive cases were detected. The survey results revealed that the overall adjusted prevalence of smear positive TB was 79.4 per 100,000 population aged 15 years and above. It was higher among males, among rural population and people with low socio-economic conditions. (4) Only NTP can not combat TB successfully as dropped out cases are increasing day by day. Much more emphasis should be given on awareness buildup programs. As I have discussed above, integrated approach on education about awareness on tuberculosis can successfully face the forth coming challenges.
Bibliography:
- World Health Organization (2009). “Epidemiology”. Global tuberculosis control: epidemiology, strategy, financing.
- www.medicinenet.com
- · www.who.int/topics/tuberculosis/en/
- Kumar V, Abbas AK, Fausto N, Mitchell RN (2007). Robbins Basic Pathology (8th ed.).
- asmer RM, Nahid P, Hopewell PC (2002). “Clinical practice. Latent tuberculosis infection”
- K. Park, Preventive and Social Medicinr, 19th Ed.
