Knowledge attitude and practice of paediatricians regarding tuberculosis case management in five major districts of Punjab state, India

INTRODUCTION

India accounts for one fourth of the global TB cases with highest burden of both TB and MDR TB based on estimates reported in Global TB Report 2016.¹ Proportion of TB cases in children have reported from 6% to more than 10% in few states like Delhi, Chandigarh, Madhya Pradesh.¹ This segment of the population turns to Pediatricians for their TB treatment. This operational research was done to assess the Knowledge, Attitude and Practice of Pediatricians regarding TB case management in five major cities of Punjab, India.

METHODS

It is an observational cross- sectional study. Target population were pediatricians of five major cities of Punjab. The present study was conducted over period of one year from January 2017 to January 2018. The study was carried out in five major cities of Punjab i.e. Ludhiana, Jalandhar, Amritsar, Patiala and Bathinda, which inhabit nearly half of the urban population of Punjab. Pediatricians registered with Indian Academy of Pediatrics (IAP) in the listed five districts of Punjab was obtained from IAP office bearers. Pediatricians were randomly selected by computer generated randomization method to include at least 50% of members from each of the five districts.

Data collection

The Pediatricians were told the nature and purpose of the study and a written consent was taken. The data collection was done using a structured questionnaire containing information about age, sex, professional qualification, experience of Pediatricians and their knowledge of TB Disease, Case suspicion, Diagnosis and Treatment. The second part included their information of DOTS centre, DOTS treatment, Case Notification and Barriers in notification, and reasons for Non-referral.

Adequate Knowledge was considered when at least 50% of responses were correct regarding TB Case Suspicion and TB Treatment (i.e. 2 out of 4 responses) and TB Diagnosis (i.e. 3 out of 6 responses). DOTS centre was considered to be accessible if travel distance by road was less than 2.5 Km. For the study, Pediatricians were also divided into two groups, Referral group and Non-referral group. Referral group involved Pediatricians who had referred at least one TB patient during last two quarters to the nearest DOTS centre for treatment. Non-Referral group included Pediatricians who did not refer any patient during the study period.

The Operational Research (OR) Project was approval by Institutional Ethics Committee and Operational Research committee of the State Task Force-RNTCP (Punjab). The study was registered with Clinical Trials Registry - India (CTRI).

Sample size

With confidence level of 95%, power of 80%, difference of proportion of adequate knowledge of TB between referral and non-referral to be 20% (from pilot study), sample size was calculated to be 95. To compensate for non-response and incomplete data, minimum sample size calculated was 105. Representation from each district was ensured by including at least 50% Pediatricians from each district.

Data analysis

The data so generated were entered by data entry operator and further analyzed using Statistical Package for Social Sciences (SPSS package), version 21 (IBM SPSS statistics 20.0.0, 2011). Chi-square test and p value was estimated for each variable and value <0.05 was considered to be significant.

RESULTS

A total of 139 pediatricians from 5 major cities of Punjab participated in the study (Ludhiana: 45, Jalandhar: 32, Amritsar: 28, Patiala: 22, Bathinda: 12). Of the Paediatricians,69% were male. A quarter doctors (24%) had diploma qualification and rest had MD/DNB degree. Mean age of pediatricians was 44±7.4 years (range: 27-63) and mean experience was 11.5±5.6 years (range: 1- 28).

Pediatrician age, gender, qualification and years for experience had no influence on referral of TB cases to DOTS centre (Table 1).

* p value <0.05 is significant

* p value <0.05 is significant

TB disease and case suspicion knowledge

Of the doctors, 99% had adequate knowledge of TB disease and case suspicion. Majority of doctors had knowledge of when to suspect pediatric TB. Commonest form of extrapulmonary TB as lymph node TB was known to 74% doctors. Different modes of transmission to Neonates (not through breast feeding) was known to 67% pediatricians.

TB diagnosis knowledge

Adequate knowledge of TB diagnosis was seen in 87% pediatricians. The use of CBNAAT from different samples was known to 82% doctors. Utility of gastric lavage and different methods of diagnosis of TB was known to 90% pediatricians. Sputum induction to get sputum sample was known to 53% doctors. Correct strength of Tuberculin units (2U) was known only to 17% doctors. The correct algorithm approach of Lymph node TB (giving course of antibiotics, before FNAC) was known to 40% doctors.

TB treatment knowledge

Only 20% doctors had adequate knowledge regarding treatment of TB cases. Three drugs in the continuation phase of Category I therapy was known to only 21% doctors. Correct pediatric weight-band wise boxes were known to 19% pediatricians. The concept of lag period as basis of alternate day therapy was known to only 26%.

Knowledge about TB notification

Majority of the Pediatricians knew the need to notify TB cases to the authorities (91%), only few knew which year it started. The common concerns were lack of self-motivation (31%) and unclear method of notification (30%). There was significant difference between referral and non-referral group regarding knowledge of TB notification (67% vs 34%) (p value=0.044).

* p value <0.05 is significant

Concerns of pediatricians

Some Pediatricians had apprehension of losing the patient (13%) and had doubt regarding quality of medicines available in DOTS centre (30%). Some had a previous bad experience regarding DOTS centre (23%). Sensitization from the RNTCP about TB control programme for pediatricians was lacking (35%). In spite of the concerns, 69% doctors had faith in the government sector for treatment of TB cases.

DOTS centre referral

Overall 64% of Pediatricians referred TB cases to DOTS centre for treatment. Although 92% of doctors knew location of DOTS centre and it was accessible for 93% doctors, one third doctors did not refer TB cases to DOTS centre.

There was no significant difference between referral and non-referral group regarding knowledge of TB disease and case suspicion (65% vs 36%) (p value=0.181) and also of knowledge of TB diagnosis (62% vs 38%) (p value=0.193). There was significant difference between referral and non-referral group regarding knowledge of TB treatment (82% vs 18%) (p value=0.025) (Table 2).

Comparing the two groups, fear of losing patient was significantly more in non-referral group (71%) compared to referral group (30%) (p value=0.002). Also, apprehension about quality of drugs was much more in non-referral group (66%) compared to referral group (34%) (p value <0.001). Faith in government sector was very strong in referral group (77%) compared to non-referral group (23%) (p value<0.001) (Table 3).

DISCUSSION

In the study, although knowledge of TB Disease and TB Diagnosis was more than 90%, only 20% doctors had adequate knowledge regarding TB Treatment. Fear of losing patients and apprehension about quality of drugs available in the DOTS centre were significantly factors hindering referral of cases. This knowledge gap was significantly more in Pediatricians non-referring cases to DOTS centre (p value=0.025).

All over India, treatment practices of TB cases are quite varied.^2,3 A recent study done in the slums of Mumbai showed, only 6 of the 106 private doctors respondents wrote a correct drug regimen. Further, 106 doctors prescribed 63 different drug regimens.⁴ A study in low- and middle-income areas of Delhi showed only 21% patients were correctly managed by the private providers.⁵ General Practitioners in Kolkata regarding RNTCP and DOTS showed good knowledge and proper practice only in 24 and 19.7% of the practitioners, respectively. About 68% of the practitioners sent TB patients to private laboratories for diagnosis, while only 31% sent to the government ones.⁶

In the study, there was significant difference between referral and non-referral group regarding knowledge of TB treatment. This knowledge gap can be effectively improved by sensitizing pediatricians through workshops and by attending CMEs conducted by RNTCP. It was noted only 38% doctors were sensitization from the RNTCP program (in any form). An Interventional study conducted in Rahata Taluka of District Ahmednagar, showed significant improvement in diagnosis and treatment by giving personal visits by RNTCP programme to Private Medical Practitioners.⁷

Although in the study, majority of the pediatricians from 5 districts knew the need to notify patients, annual national report on TB 2016 shows none of the states throughout the country having proportion of notification > 30%, with notification from private sector in Punjab to be <10%.^1,3 The paradox here referred as “perception-practice gap” highlights that due to under-reporting by the private sector, many cases of TB might be missing by the notification system.^8,9 Thus, there remains a lot to be worked on to improve notifications from private providers, which is being done in recent times.

In 2014, global reporting system created by WHO measured a marked increase in global TB notifications. The annual total of new TB cases increased globally to 6%, mostly due to a 29% increase in TB notifications in India.^10,11 To promote TB case notification, incentives are provided upon notification in the TB reporting software i.e. Nikshay through a smooth and programme integrated direct beneficiary transfer.

Recently RNTCP has deployed the CB NAAT (Cartridges Based Nucleic Acid Amplification Test) machines across the country for diagnosis of TB cases. CB NAAT is a rapid molecular assay that detects M. tuberculosis and Rifampicin resistance and provides results within two hours.¹² Currently, CBNAAT is used for diagnosis of Pediatric TB, extra-pulmonary TB, smear negative pulmonary TB, HIV-TB patients as well as diagnosis of drug resistant. In the study, 80% of Pediatricians were aware of use of CB NAAT for diagnosis of TB from different body fluids and also from gastric aspirate sample. These strategies have improved TB case detection in children.

To authors knowledge this is the first study to assess the knowledge, attitude, treatment practices and referral pattern of Pediatricians in an Indian state. Improving the knowledge of pediatricians by regular sensitizing them will go a long way in improving the coverage of TB treatment.

CONCLUSION

Although 90% doctors had adequate knowledge of TB Disease and Diagnosis, only 20% doctors had adequate knowledge regarding TB treatment. Overall 64% of Practicing Paediatricians referred TB cases to DOTS centre for treatment. This knowledge-gap was significant more in non-referral doctors. Improving the knowledge of TB treatment of paediatricians by regular sensitizing them regarding TB management will go a long way in improving management of TB treatment.

Funding: This Operational Research was funded by State TB society, Punjab State on approval of State Task Force for Medical Colleges, RNTCP, Punjab

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Tuberculosis India 2017. Annual Report of the Revised National Tuberculosis Control Programme. New Delhi: Central Tuberculosis Division Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India; 2017.
2. 2. Hazarika I. Role of private sector in providing tuberculosis care: evidence from a population-based survey in India. J Global Infec Dis. 2011 Jan;3(1):19.
3. 3. Central Tuberculosis Division. National Strategic Plan 2017-2025 for TB Elimination in India. Available at: https://tbcindia.gov.in/WriteReadData/NSP%20Draft%2020.02.2017%201.pdf Accessed 12 February 2020.
4. 4. Udwadia ZF, Pinto LM, Uplekar MW. Tuberculosis management by private practitioners in Mumbai, India: has anything changed in two decades?. PloS One. 2010;5(8):e12023.
5. 5. Das J, Kwan A, Daniels B, Satyanarayana S, Subbaraman R, Bergkvist S, et al. Use of standardised patients to assess quality of tuberculosis care: a pilot, cross-sectional study. Lancet Infec Dis. 2015 Nov 1;15(11):1305-13.
6. 6. Dasgupta A, Chattopadhyay A. A study on the perception of general practitioners of a locality in Kolkata regarding RNTCP and DOTS. Ind J Commu Med: Offici Publ Ind Assoc Preven Soci Med. 2010 Apr;35(2):344.
7. 7. Palve SB, Parkhad SB, Phalke VD, Phalke DB. Strategy to increase awareness and involvement of private medical practitioners in RNTCP in taluka Rahata of district Ahmednagar. J Clin Diag Res: JCDR. 2015 Feb;9(2):LC10.
8. 8. Philip S, Isaakidis P, Sagili KD, Meharunnisa A, Mrithyunjayan S, Kumar AM. “They know, they agree, but they don’t do”-the paradox of tuberculosis case notification by private practitioners in Alappuzha District, Kerala, India. PLoS One. 2015;10(4):e0123286.
9. 9. Central TB Division. Notification of TB cases 2012. Available at: https://tbcindia.gov.in/showfile.php?lid=3136. Accessed 12 February 2020.
10. 10. World Health Organization. (2015). Global tuberculosis report 2015, 20^th ed. World Health Organization. Available at: https://apps.who.int/iris/handle/10665/191102. Accessed 12 February 2020.
11. 11. Satpati M, Burugina Nagaraja S, Shewade HD, Aslesh PO, Samuel B, Khanna A, et al. TB notification from private health sector in Delhi, India: challenges encountered by programme personnel and private health care providers. Tuber Res Treat. 2017;2017.
12. 12. Sharma SK, Kohli M, Yadav RN, Chaubey J, Bhasin D, Sreenivas V, et al. Evaluating the diagnostic accuracy of Xpert MTB/RIF assay in pulmonary tuberculosis. PloS One. 2015;10(10):e0141011.