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Awareness of Tuberculosis and RNTCP among Interns at a Tertiary Care Hospital in Goa

1Post Graduate Student and Junior Resident, Department of Preventive and Social Medicine, Goa Medical College, Goa, India. 2MD, Senior Resident, Department of Pulmonary Medicine, Goa Medical College, Goa, India. 3MD, Professor and Head, Department of Preventive and Social Medicine, Goa Medical College, Goa, India. DOI: https://doi.org/10.24321/2455.7048.202019 Introduction: India is the highest burdened country with Tuberculosis (TB) bearing over one fourth of the global TB burden. HIV and drug resistance have further complicated the scenario. Thorough knowledge about TB, its diagnosis and treatment as well as about HIV-TB and drug resistance is needed to make RNTCP and TB control a success. Materials & Methods: A cross sectional study was conducted among 90 medical interns who answered a self-administered semi structured questionnaire consisting of 30 questions, answered over 30 minutes, conducted over a 3-month period from July to September 2019. Data was entered in MS Excel and analysed using SPSS 14.0 software. Results were expressed in percentages and proportions. P value <0.05 was considered as statistically significant. Result: The response rate was 100%. Mean age of interns was 23 to 25 years with 56.6% of them being females. 98.8% of the interns correctly identified the chief symptom of TB. 90% of them knew the role of DOTS centre in TB control. However, the overall knowledge regarding HIV-TB and Drug resistant TB was poor. None of them had received prior RNTCP training. Conclusion: Our study has identified several gaps in the knowledge among medical interns in Goa regarding various aspects of TB diagnosis, RNTCP, HIV-TB and Drug resistant TB. RNTCP training and sensitization must be a mandatory part of the interns training to improve the control of TB in India.


Introduction
As per the Global TB report 2019, 1 there are nearly 10 million new cases of TB worldwide in 2018, with more than one fourth of the burden (27%) being contributed by 78% had MDR TB), with 27% being contributed by India. 1 RNTCP after being formally launched in 1992, has attained nationwide coverage in a phased manner by 2005 with the help of WHO recommended DOTS strategy. 6 Information, Education and Communication (IEC) are an important strategy of the program to create awareness among public, health care providers and policy makers. Despite all this, India continues to be the highest TB burdened country in the world.
Inappropriate and incomplete prescription and treatment leads to the development and spread of TB and drug resistance. 8 Lack of knowledge and awareness of TB among medical students, interns, doctors in the private sector and other health care personnel further contributes to the poor disease control in the country. Internship is one of the most crucial periods in the training curriculum of a doctor, when a student acquires new skills and applies theoretical knowledge into clinical practice. 3

Objective
To assess the level of awareness among medical interns at a tertiary care hospital, of the various aspects of DOTS & RNTCP towards the diagnosis and treatment of TB, including drug resistant TB.

Materials and Methods
A cross sectional study was conducted among 90 medical interns of Goa Medical College, the only tertiary care hospital in Goa during July -September 2019. Census method of sampling was followed. A semi-structured predesigned questionnaire was self-administered to the study participants. This questionnaire had thirty questions in English language pertaining to the diagnosis and treatment of TB, basic knowledge about RNTCP, TB-HIV and drug resistant TB. The interns were given a period of 30 minutes to complete the questionnaire under the investigators supervision after obtaining their informed written consent to participate in the study. All MBBS interns (2019-2020 Batch) who consented to participate in the study were included, whereas those interns who either declined consent or who were unavailable despite multiple attempts made by the study investigators to contact them twice, were excluded from the study. The data was collected after ensuring confidentiality. Prior approval was obtained from the Institutional Ethics Committee.

Statistical Analysis
The data was entered in MS Excel and analysed using SPSS 14.0 software. The results were expressed in simple percentages and proportions.

Result
A total of 90 interns participated in the study, of which 43.3% (n=39) were males and over half i.e. 56.6% (n=51) were females. Their ages varied from 23 to 25 years. Surprisingly, none of the interns interviewed received RNTCP training during or at commencement of their internship. The responses by the study participants are provided in the tables below.
More than half of the interns (55.5%) correctly identified the objectives of RNTCP pertaining to case detection and cure. Nearly 94.4% of them were aware that TB is a notifiable disease. Also, 98.8% of the interns identified cough as the predominant symptom of TB.
Nearly 91.1% of the interns correctly knew the definition of sputum smear positive pulmonary TB, but the overall knowledge of the interns about RNTCP and DOTS was poor.
Nearly 90% of the interns were aware of the six months duration of TB treatment for new cases and also that culture was the gold standard test for TB diagnosis. 92% of them correctly identified the bactericidal anti TB drugs from the options provided.

Awareness regarding TB Diagnosis and Treatment
Most interns in our study (90%) could correctly identify the treatment regimen for new TB patients, unlike study finding by Balamurugan SS et al. 8

Knowledge regarding TB in Pregnancy and HIV Patients
Only 16.6% of the interns were aware of streptomycin being contraindicated in pregnancy. This was in contrast to studies by Sangma BK et al. 5 (72%) and Chennaveerappa K et al. 3 (72.7%). Majority of them were aware (88.8%) that breastfeeding is not contraindicated in pregnant TB patients, which was higher than that reported by Chennaveerappa K et al. 3 (68.8%). Majority of the interns (94.5%) were unaware of use of co-trimoxazole as a part of TB-HIV mortality reduction. So also, the knowledge regarding the 99-DOTS for TB-HIV co-infected patients and the lifetime risk of TB in HIV patients with PPD positivity was very poor.

Awareness of Recent Advances in TB and MDR TB
83.3% of the interns in the study correctly identified the definition of MDR-TB. Our finding was similar to some studies by K Chennaveerappa et al. 3 (77.6%), Sangma et al. 5 (84.2% )and Basu M, Das P 6 (91%). It was disheartening to note that only one fourth of the interns (25.5%) were aware of Bedaquiline as a new drug for MDR-TB. Also, only over half of the interns knew the acronym of CB NAAT correctly, and could identify that CB NAAT cannot be used as a TB follow up assessment tool.

Conclusion
This study reveals that the knowledge of the medical interns was good about TB being a notifiable disease, the chief symptom of TB, the sputum criteria for pulmonary TB diagnosis and the new duration of treatment recommended by RNTCP for previously treated patients. So also, the definition of MDR TB was correctly known by most of the interns. Majority of interns knew that breastfeeding is not contraindicated, but we're unaware that streptomycin is contraindicated in pregnancy. However, the interns had poor knowledge regarding LTBI, adverse effects of anti TB drugs, the latest approved drug bedaquiline for drug resistant TB, TB HIV and CB NAAT. Our study highlights the need for RNTCP training of medical interns to make TB control and RNTCP a success, as they are going to be the future resident doctors, specialists or medical practitioners.