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Q.1 a. Identify the reasons that led to the implementation of the Revised National Tuberculosis Programme?

Solution-

Tuberculosis (TB) is an infectious disease caused by a Bacterium, Mycobacterium tuberculosis. It is spread through the air by a person suffering from TB. A single patient can infect 10 or more people in a year. India has a long and distinguished tradition of research in TB. Studies from the Tuberculosis Research Centre in Chennai and the National Tuberculosis Institute in Bangalore provided key knowledge to improve treatment of TB patients all around the world. Modern anti-TB treatment can cure virtually all patients. It is, however, very important that treatment be taken for the prescribed duration, which in every case is a minimum of 6 months. Because treatment is of such a long duration and patients feel better after just 1-2 months, and because many TB patients face other problems such as poverty and unemployment, treatment is often interrupted. Therefore, just providing anti-TB medication is not sufficient to ensure that patients are cured. The DOTS strategy ensures that infectious TB patients are diagnosed and treated effectively till cure, by ensuring availability of the full course of drugs and a system for monitoring patient compliance to the treatment.

Directly Observed Treatment, Short-courseThe DOTS strategy along with the other components of the Stop TB strategy, implemented under the Revised National Tuberculosis Control Programme (RNTCP) in India, is a comprehensive package for TB control. The DOTS strategy is cost-effective and is today the international standard for TB control programmes. To date, more than 180 countries are implementing the DOTS strategy. India has adapted and tested the DOTS strategy in various parts of the country since 1993, with excellent results, and by March 2006 nationwide DOTS coverage has been achieved.

DOTS is a systematic strategy which has five components Political and administrative commitment. TB is the leading infectious cause of death

among adults. TB kills more men than women, yet more women die of TB than all causes associated with childbirth combined. Since TB can be cured and the epidemic reversed, it warrants the topmost priority, which it has been accorded by the Government of India. This priority must be continued and expanded at the state, district and local levels.

Good quality diagnosis. Good quality microscopy allows health workers to see the tubercle bacilli and is essential to identify the infectious patients who need treatment the most.

Good quality drugs. An uninterrupted supply of good quality anti-TB drugs must be available. In the RNTCP, a box of medications for the entire treatment is earmarked for every patient registered; ensuring the availability of the full course of treatment the moment the patient is initiated on treatment. Hence in DOTS, the treatment can never interrupt for lack of medicine.

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Supervised treatment to ensure the right treatment, given in the right way. The RNTCP uses the best anti-TB medications available. But unless treatment is made convenient for patients, it will fail. This is why the heart of the DOTS programme is "directly observed treatment" in which a health worker, or another trained person who is not a family member, watches as the patient swallows the anti-TB medicines in their presence.

Systematic monitoring and accountability. The programme is accountable for the outcome of every patient treated. This is done using standard recording and reporting system, and the technique of ‘cohort analyses. The cure rate and other key indicators are monitored at every level of the health system, and if any area is not meeting expectations, supervision is intensified. The RNTCP shifts the responsibility for cure from the patient to the health system.

The new Stop TB Strategy published by WHO in 2006 has DOTS in the core with additional components to address TB/HIV and MDR-TB, health system strengthening, involvement of all care providers, engaging people with TB and affected communities, and enabling/promoting research. RNTCP is already implementing/ plans to implement the activities recommended under the new Stop TB Strategy.

DOTS in India

Controlling TB in India is a tremendous challenge. The TB burden in India is still staggering. Every year, 1.8 million persons develop the disease, of which about 800,000 are infectious; and, until recently, 370,000 died of it annually —1,000 every day. The disease is a major barrier to social and economic development. An estimated 100 million workdays are lost due to illness. Society and the country also incur a huge cost due to TB—nearly US$ 3 billion in indirect costs and US$ 300 million in direct costs.

The Revised National Tuberculosis Control Programme (RNTCP), based on the DOTS strategy, began as a pilot in 1993 and was launched as a national programme in 1997. Rapid RNTCP expansion began in late 1998. By the end of 2000, 30%of the country’s population was covered, and by the end of 2002, 50%of the country’s population was covered under the RNTCP. By the end of 2003, 778 million populations were covered, and at the end of year 2004 the coverage reached to 997 million. By December 2005, around 97% (about 1080 million) of the population had been covered, and the entire country was covered under DOTS by 24th March 2006.

Every day in India, under the RNTCP, more than 15,000 suspects are being examined for TB, free of charge. The diagnosis of these patients and the follow-up of patients on treatment are achieved through the examination of more than 50,000 laboratory specimens. As a result of these examinations, each day, about 3,500 patients are started on treatment, stopping the spread of TB in the community. In order to achieve this, more than 600,000 health care workers have been trained and more than 11,500 designated laboratory Microscopy Centres have been upgraded and supplied with binocular microscopes since the inception of the RNTCP. As a result of rapid expansion in diagnostic facilities, the proportion of sputum- positive cases confirmed in the laboratory are doubles that of the previous programme and is

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on par with international standards. Despite the rapid expansion, overall performance remains good and in many areas is excellent. Treatment success rates have tripled from 25%in the earlier programme to 86%in RNTCP.

 

DOTS Expansion in India

In 1992, the Government of India, together with the World Health Organization (WHO) and Swedish International Development Agency (SIDA), reviewed the National TB Programme and concluded that it suffered from managerial weakness, inadequate funding, over-reliance on x-ray, non-standard treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes. Programme review showed that only 30% of patients were diagnosed and only 30% of those treated successfully. Based on the findings and recommendations of the review in 1992, the GOI evolved a revised strategy and launched the Revised National TB Control Programme (RNTCP) in the country. Starting as pilots in October 1993, the RNTCP was implemented in a population of 2.35 million in 5 sites in different states (Delhi, Kerala, West Bengal, Maharashtra, and Gujarat). The programme was expanded to a population of 13.85 million in 1995 and 16 million in 1996. Having proved both its technical and operational feasibility, a soft loan of US $ 142 million was negotiated with the World Bank in December 1996 and the credit agreement was signed

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with IDA in May 1997. In 1997 RNTCP was launched as a national programme. It was envisaged to implement RNTCP in 102 districts of the country covering a population of 271 million in a phased manner. Another 203 SCC districts with a population of 447 million were envisaged to be strengthened as a transitional step for introduction of revised strategy at a later stage. Having started in 1997, rapid scale-up began in late 1998, when another 100 million populations was covered under RNTCP. Over the years RNTCP has expanded rapidly as shown below:

Year 1998 1999 2000 2001 2002 2003 2004 2005March 2006

Population Covered *

18 130 287 450 530 775 947 1080 1114

* cumulative, in millions

Starting in 1997, the project was implemented in a phased manner to ensure that quality of services is maintained. By March 2006, entire country has been covered under the programme.

Revised National TB Control Programme and its recent progress in DOTS expansion have been encouraging. As per Global TB Report 2003, 2/3rd of the additional sputum positive cases reported under DOTS in 2001, were found in India. In 2002, over 620,000 cases were placed on treatment of which nearly 250,000 were new smear positive cases. In the year 2003, more than 900,000 cases were placed on treatment. In the year 2004 alone more than 1100,000 cases were placed on treatment, and in the 2005, more than 1290,000 cases were placed on treatment - largest cohort of cases, more than any other country in the world. By December 2009, more than 11 million patients have been initiated on treatment, saving more than 2 million additional lives. The success of DOTS in India has contributed substantially to the success of TB control in the world.

RNTCP has consistently achieved treatment success rate of more than 85%, and case detection close to the global target. However, in 2007 RNTCP for the first time has achieved the global target of 70% case detection while maintaining the treatment success rate of more than 85%.

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Multi-drug-Resistant Tuberculosis (MDRTB)

MDRTB refers to strains of the bacterium which are proven in a laboratory to be resistant to the two most active anti-TB drugs, ionized and rifampicin. Treatment of MDRTB is extremely expensive, toxic, arduous, and often unsuccessful. DOTS have been proven to prevent the emergence of MDRTB, and also to reverse the incidence of MDRTB where it has emerged. MDRTB is a tragedy for individual patients and a symptom of poor TB management. The best way to confront this challenge is to improve TB treatment and implement DOTS. Beginning 1999, the Tuberculosis Research Centre, Chennai in collaboration with the National Tuberculosis Institute, Bangalore, initiated drug resistance surveys in different parts of the country using the WHO/IUATLD guidelines. The table below provides information about primary ionized resistance and primary multi-drug resistance based on analyses completed to date.

Table: Primary drug resistance, India (1999-2002)

District (Zone)Intake period

Number of patients

Primary isoniazid resistance %

Primary multi-drug resistance %

 North Arcot (South)

1999 282 23.42.8

f

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 Raichur (South) 1999-2000 278 18.7 2.5

 Wardha (West) 2000-2001 197 15 0.5

 Jabalpur (West) 2001-2002 273 17 1.0

 Hoogly (East) 2000-2001 350 10.3 3.0

 Mayurbanj (East)2000-2002 343 2.5 0.7

Currently large scale representative drug resistance surveys are on-going in 2 States and 3 (Andhra Pradesh, Orissa, and Uttar Pradesh) other States are likely to conduct these surveys.

RNTCP is planning to introduce second line anti-TB treatment for MDR-TB cases, starting in early 2007. For this purpose State level Intermediate Reference Laboratories are being established to provide quality assured culture and drug susceptibility testing facilities. The guidelines for management of MDR-TB under DOTS-Plus strategy have been developed.  

Second Phase of RNTCP

In the first phase of RNTCP (1998-2005), the programme’s focus was on ensuring expansion of quality DOTS services to the entire country. There are many challenges remaining that are to be addressed in order to achieve the TB-related targets set by the Millennium Development Goals for 2015 and to achieve TB control in the longer term.

The RNTCP has now entered its second phase in which the programme aims to firstly consolidate the gains made to date, to widen services both in terms of activities and access, and to sustain the achievements for decades to come in order to achieve ultimate objective of TB control in the country.

All components of new Stop TB Strategy are incorporated in the second phase of RNTCP. These are:

1. Pursue quality DOTS expansion and enhancement, by improving the case finding are cure through an effective patient-centred approach to reach all patients, especially the poor.

2. Address TB-HIV, MDR-TB and other challenges, by scaling up TB-HIV joint activities, DOTS Plus, and other relevant approaches.

3. Contribute to health system strengthening, by collaborating with other health programmes and general services

4. Involve all health care providers, public, nongovernmental and private, by scaling up approaches based on a public-private mix (PPM), to ensure adherence to the International Standards of TB care.

5. Engage people with TB, and affected communities to demand, and contribute to effective care. This will involve scaling-up of community TB care; creating demand thorough context-specific advocacy, communication and social mobilization.

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6. Enable and promote research for the development of new drugs, diagnostic and vaccines. Operational Research will also be needed to improve programme performance.

The Revised National TB Control Programme now aims to widen the scope for providing standardized, good quality treatment and diagnostic services to all TB patients in a patient-friendly environment, in which ever health care facility they seek treatment from. Recognizing the need to reach to every TB patient in the country, the programme has made special provisions to reach marginalized sections of the society, including creating demand for services through specific advocacy, communication and social mobilization activities.

b. Explain the need for International Health Regulations?

Solution-

The International Health Regulations 2005 are legally binding regulations (forming international law) that aim to a) assist countries to work together to save lives and livelihoods endangered by the spread of diseases and other health risks, and b) avoid unnecessary interference with international trade and travel. The purpose and scope of IHR 2005 are to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.

The International Health Regulations Evolution

The International Health Regulations originated with the International Sanitary Regulations adapted at the International Sanitary Conference in Paris in 1851. The cholera epidemics that hit Europe in 1830 and 1847 made apparent the need for international cooperation in public health. In 1948, the World Health Organization Constitution came about. The Twenty-Second World Health Assembly (1969) adopted, revised and consolidated the International Sanitary Regulations, which were renamed the International Health Regulations (1969).

The Twenty-Sixth World Health Assembly in 1973 amended the IHR (1969) in relation to provisions on cholera. In view of the global eradication of smallpox, the Thirty-fourth World Health Assembly amended the IHR (1969) to exclude smallpox in the list of notifiable diseases. During the Forty-Eighth World Health Assembly in 1995, WHO and Member States agreed on the need to revise the IHR (1969). The revision of IHR (1969) came about because of its inherent limitations, most notably:

Narrow scope of Notifiable diseases (cholera, plague, yellow fever).[1] The past few decades have seen the emergence and re-emergence of infectious diseases. The emergence of “new” infectious agents Ebola Hemorrhagic Fever and the re-emergence of cholera and plague in South America and India, respectively;

Dependence on official country notification; and

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Lack of a formal internationally coordinated mechanism to prevent the international spread of disease.

These challenges were placed against the backdrop of the increased travel and trade characteristic of the 20th century. The IHR (2005) entered into force, generally, on 15 June 2007, and are currently binding on 194 countries (States Parties) across the globe, including all 193 Member States of WHO.

The Principles Embodying the IHR (2005)

The implementation of IHR (2005) shall be:

1. With full respect for the dignity, human rights and fundamental freedom of persons;2. Guided by the Charter of the United Nations and the Constitution of the World Health

Organization;

3. Guided by the goal of their universal application for the protection of all people of the world from the international spread of disease;

4. States have, in accordance with the Charter of the United Nations and the principles of international law, the sovereign right to legislate and to implement legislation in pursuance of their health policies. In doing so, they should uphold the purpose of these Regulations. (Art 3. IHR (2005))

Q.2 a. Write short notes on the Executive Board of WHO and UNICEF?

Solution-

Executive Board of WHO

The Executive Board is composed of 34 individuals technically qualified in the field of health, each one designated by a Member State elected to do so by the World Health Assembly. Member States are elected for three-year terms.

The Board meets at least twice a year; the main meeting is normally in January, with a second shorter meeting in May, immediately after the Health Assembly. The main functions of the Executive Board are to give effect to the decisions and policies of the Health Assembly, to advise it and generally to facilitate its work.

a. Chairman of the Executive Board .b. Executive Board members . c. Composition of the Executive Board .d. Documentation of Executive Board sessions and Health Assemblies .e. Executive Board Committees .

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f. Ad-hoc open-ended Intergovernmental Working Group to Review the Working Methods of the Executive Board.

Executive Board of UNICEF

The Executive Board is the governing body of UNICEF, providing intergovernmental support and oversight to the organization, in accordance with the overall policy guidance of the United Nations General Assembly and the Economic and Social Council.

Comprising 36 members, representing the five regional groups of Member States at the United Nations, the Executive Board reviews UNICEF activities and approves its policies, country programmes and budgets. Its work is coordinated by the Bureau, comprising the President and four Vice-Presidents, each officer representing one of the five regional groups.

The Office of the Secretary of the Executive Board supports and services the Executive Board. It is responsible for maintaining an effective relationship between the Executive Board and the UNICEF secretariat.

The Executive Board’s annual term is identical to a calendar year, running from 1 January to 31 December. The Executive Board meets three times each year, in a first regular session (January/February), annual session (May/June) and second regular session (September). Executive Board sessions are held at the United Nations headquarters in New York.

b. How useful is digital imaging in the field of medicine?

Solution-

Digital Imaging and Communications in Medicine (DICOM) is a standard for handling, storing, printing, and transmitting information in medical imaging. It includes a file format definition and a network communications protocol. The communication protocol is an application protocol that uses TCP/IP to communicate between systems. DICOM files can be exchanged between two entities that are capable of receiving image and patient data in DICOM format. The National Electrical Manufacturers Association (NEMA) holds the copyright to this standard.[1] It was developed by the DICOM Standards Committee, whose members [2] are also partly members of NEMA.[3]

DICOM enables the integration of scanners, servers, workstations, printers, and network hardware from multiple manufacturers into a picture archiving and communication system (PACS). The different devices come with DICOM conformance statements which clearly state the DICOM classes they support. DICOM has been widely adopted by hospitals and is making inroads in smaller applications like dentists' and doctors' offices.

DICOM is known as NEMA Standard PS3, and as ISO Standard 12052.

DICOM Data Format

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DICOM differs from some, but not some other, data formats in that it groups information into data sets. That means that a file of a chest X-Ray image, for example, actually contains the patient ID within the file, so that the image can never be separated from this information by mistake. This is similar to the way that image formats such as JPEG can also have embedded tags to identify and otherwise describe the image.

A DICOM data object consists of a number of attributes, including items such as name, ID, etc., and also one special attribute containing the image pixel data (i.e. logically, the main object has no "header" as such - merely a list of attributes, including the pixel data). A single DICOM object can only contain one attribute containing pixel data. For many modalities, this corresponds to a single image. But note that the attribute may contain multiple "frames", allowing storage of cine loops or other multi-frame data. Another example is NM data, where an NM image by definition is a multi-dimensional multi-frame image. In these cases three- or four-dimensional data can be encapsulated in a single DICOM object. Pixel data can be compressed using a variety of standards, including JPEG, JPEG Lossless, JPEG 2000, and Run-length encoding (RLE). LZW (zip) compression can be used for the whole data set (not just the pixel data) but this is rarely implemented.

DICOM uses three different Data Element encoding schemes. With Explicit Value Representation (VR) Data Elements, for VRs that are not OB, OW, OF, SQ, UT, or UN, the format for each Data Element is: GROUP (2 bytes) ELEMENT (2 bytes) VR (2 bytes) LengthInByte (2 bytes) Data (variable length). For the other Explicit Data Elements or Implicit Data Elements, see section 7.1 of Part 5 of the DICOM Standard.

The same basic format is used for all applications, including network and file usage, but when written to a file, usually a true "header" (containing copies of a few key attributes and details of the application which wrote it) is added.

Q.3. Outline the impact of:

a. Impact on Health-

Research focusing on individuals has found a very robust relationship between an adult Individual’s income and that individual’s health, using a range of measures for both. Regardless of how measures of health status and measures of SES are combined, there is little doubt that poverty leads to ill health. For example, in a recent review of the literature, Benzeval and Judge provide evidence from 16 studies using eight different data sets from four different countries. Health status outcome measures include: subjective self-reports, mortality, emotional stability, chronic conditions, general life satisfaction and physical functioning. Socio-economic status measures include: current income level, recent income change, poverty flags, current earnings, multi-period averaged incomes, relative position in the income distribution and number of spells of poverty. In summing up their review, the authors conclude: .All of the studies that include measures of income level find that it is significantly related to health outcomes.

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Similarly, Mullah and colleagues conclude: Voluminous empirical studies and reviews demonstrate a robust association between income and morbidity and mortality, using various measures of both income and health, across samples, and at various time points. An important research issue in the study of poverty and health is the possibility for ill health to limit an individual’s ability to engage in paid work and hence reduce his or her income, even if he or she comes from an affluent background.

Further important conclusions from this body of work include the following:• The relationship between individual income and health is non-linear (i.e. low-income individuals suffer larger negative health consequences than high-income individuals reap health benefits, though high-income individuals do reap benefits).• Longer-term measures of average income have larger associations with health than measures of current income, which can be highly volatile.

b. Health on economic growth

Although the health of individuals in a country can only be roughly approximated in national averages, the models showed significant effects of adult survival rate (ASR) on economic growth for low income countries. Thus, for example, for the poorest countries, a 1% change in ASR was associated with an approximate 0.05% increase in growth rate. While the magnitude of this coefficient was small, a similar increase of 1% in investment/GDP ratio was associated with a 0.014% increase in growth rate. A novel aspect of the analysis was that we were able to estimate the threshold point beyond which ASR had a negligible effect on growth rates; confidence intervals for the net impact of ASR on economic growth highlighted the asymmetries for poor and rich countries. The specification tests based on instrumental variables estimates showed that the explanatory variables lagged ASR, investment/GDP ratio, GDP, and the interaction between ASR and GDP, should be treated as simultaneously determined with growth rates.

From the viewpoint of the conceptual issues addressed in the paper, it is important that future research compile more elaborate data on health indicators. Thus, for example, ASR in poor countries reflects the levels of nutrition, smoking prevalence rates, infectious diseases, health infrastructure, and factors such as accidents leading to premature deaths. By contrast, differences in ASR in middle and high income countries may be strongly influenced by genetic factors and by the timeliness and costs of preventive health care. Because investments in skill acquisition in poor countries depend on the ASR, the years for which skilled labour remains productive is likely to be important for explaining economic productivity.

It would be useful to augment statistics such as percentages of skilled and unskilled labour in countries by measures of physical and mental health. For example, work days lost due to ill health can be estimated from household surveys or using other methodologies (e.g. Murray and Lopez, 1996). Measures of cognitive function in different age cohorts may also be useful

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for explaining economic performance of countries. Analyses based on elaborate data sets would afford sharper insights into the likely impact of health on economic growth.

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