Tuberculosis Control Project

Item

Title
Tuberculosis
Control Project
extracted text
Tuberculosis
Control Project

Tibetan Delek Hospital
Dharamsala H.P.
INDIA

March 19S4

1

Defeat TB
now and forever

All of her family members died of Tuberculosis.
NYIMA is the only survivor.

She also has TB.
same tragedy !

c-

v HF* ' ’

BACKGROUND HISTORY OF
TIBETAN DELEK HOSPITAL’S TUBERCULOSIS
CONTROL PROJECT
environment, suffer over-crow­
ding, poor sanitation, malnut­
rition and other infectious
In the twenty five years follow­ diseases which contribute to
ing the arrival of nearly 85,000 an even lower resistance. There
Tibetan refugees in India, must be only a few Tibetan
tuberculosis has been a major families who are without a
health problem resulting in member with TB or its effects.
high mortality and sickness, Moreover, there is still much
and imposing added socio­ uncertainty and
ignorance
economic burden as it is so about TB against the Tibetan
debilitating and long lasting.
population, and this adds to
the problems. Most of the
Tuberculosis still remains a
common disease among the Tibetan settlements are situated
Tibetan refugees. The number at prohibitive distances from
of new cases of infectious TB Indian government TB Centres.
in Tibetans each year is at- For those who reach a TB
least 2A times that of the In­ centre, there are language
dian National average and the difficulties, often resulting in
prevalence of -the disease is inadequate under-standing
estimated at 3.6 '/0 of the total about treatment and preven­
population. This is because tion. Consequently, there is a
Tibetans have low genetic re­ high defaulter rate (insufficient
sistance, live in an unfamiliar treatment) and thus a high

Tuberculosis Problem Amo­
ng Tibetans In India

1

95 TB patients from these
settlements under treatment
and the number is fast increa­
sing. In order to ensure proper
Health care and prevention,
Delek Hospital has trained a
number of health workers
from these settlements where
there are no nurses or health
workers, and more will under­
go training in the future. As
we now have health workers
or nurses in each of the settle­
ments in Himachal Pradesh,

we are also able to take train­
ees from other Tibetan settle­
ments in India. The whole
training programme is being
sponsored by the Tibetan refu­
gee Aid Society, Canada,
under their Brett Vocational
Training Fund.

Delek Hospital Tackles
The TB Control problem
By :
I. Health Education

As one of the basic causes of

Educating patients about the disease.

4

the high prevalence of TB
among Tibetans is the igno­
rance of the people, the hospi­
tal is attempting to educate
the community about the
disease and its treatment in the
form of lectures, slide shows,
posters and pamphlets. The
text and photos for an instru­
ctional booklet on TB are
already prepared and the
booklet is ready to go for
printing.

cases of tuberculosis in each
settlement, the Community
Health Workers initially do a
door to door community sur­
vey, asking for TB symptoms.
All those with cough and
sputum are screened by a
visiting medical team from
Delek Hospital who perform
sputum microscopy and record
the annual incidence of new
TB patients and the percentage
of children covered by B.C.G.

B. C. G. Vaccination

4. Treatment

The hospital also attempts to The treatment success rate is
vaccinate all children with greatly increased when regular
B.C.G. In areas where the drug taking is ensured. The
B C.G. vaccine is locally avai­ supervision of the treatment
lable the Community Health programme is, therefore, very
Workers arrange’for all child­ important. This responsibility
ren to be vaccinated by the lies with the trained Commu­
District Hospital. In other nity Health Workers, who are
areas where vaccines are not on the spot in each settlement,
locally available, theTB health and thus in an ideal position
team from Delek Hospital to closely supervise patients’
visits to vaccinate the children. drug taking, take prompt
action against those who de­
Case-finding
fault on their treatment, moni­
With an aim to find all active tor drug side-effect and take
5

Clinical case-finding in progress.

appropriate action according
to a written protocol. Once a
patient has been diagnosed at
Delek Hospital or by a mobile
team from Delek Hospital, or
by an Indian District Hospital,
they will be managed by the
Community Health Workers.
The patients who are ‘sick’
and not improving on the
standard treatment are then
referred to Delek Hospital for
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further investigation and are
usually initiated on the Re­
serve Regime. The cost of the
project is closely tied to the
percentage of patients requir­
ing the Reserve Regime treat­
ment and the total number of
patients uncovered in the case
finding phase.
Conclusion

Delek Hospital's Community

Health and Tuberculosis Cont­
rol Programme run concurren­
tly. OXFAM has kindly pro­
vided a two year grant for
Community Health Project
and this includes the provision
of a jeep ambulance from July
1982. With the availability of
this transport, the Delek’s
Mobile Health team is able to
get more actively involved in
the other settlements in Hima­
chal Pradesh. The Mobile
Health team consists of a
doctor, a Community Health

Nurse and
Worker.

a

TB

Health

Currently Delek Hospital has
228 TB patients on treatment
with 50 of these patients on
expensive Reserve
Regime
drugs. The total costs of Re­
serve Regime drugs per patient
is US $ 114.59, while that for
the standard Regime drugs is
US S 22.16 per patient. As
the hospital itself runs on a
shoe-string budget, help is
URGENTLY needed 1

Dclck's Mobile Health team on a settlement visit.

SUMMARY OF DELEK HOSPITAL’S
TUBERCULOSIS CONTROL PROJECT
ANNUAL REPORT- 1983
Evaluation Of The Project
Over Previous Year

The main aim of the project is
control of the tuberculosis pro­
blem. This means finding,
treating and supervising all
sputum positive cases (the only
cases which are infectious)
until they are cured. If all
sputum positive cases are
found quickly and cured then
the spread of the disease is
prevented.
a) Case-finding

The project's case-finding suc­
cess with sputum positive cases
is 56.25% for the settlements
and 90.25% for the Dharamsala area. This is much better
than the Indian success rate of
30%. The settlement rate is
expected to improve as the
project becomes more establi­
shed in these communities.
8

6) Case-holding

The project’s case-holding suc­
cess for all TB patient is
87.3% in the settlements and
80 6% in the Dharamsala
area. This reflects an amazing
success for the Delek Hospital
Community Health Workers.
Being a part of the smaller
communities where they know
all the people, they are able to
promptly follow-up any defau­
lters.

Again the project's case-hold­
ing success is much better than
the Indian National Tubercu­
losis Programme rate of 35%.
Clearly this indicates that the
tuberculosis problem amongst
Tibetans is generally much
worse than amongst the India­
ns. In fact the Tibetan popu­
lation has at least 21- times
more new sputum positive

After treatment.

Before treatment.

cases per year and perhaps
upto 4A times more. If it is
compared with other areas of
the world, this incidence in
Tibetans is amongst the high­
est in the world.

c)

Chemotherapy

The Delek Hospital policy of
treating all patients with the
cheapest regime first and only
failures with the expensive
drugs means that we have the
most effective and yet cheapest
protocol available. Chemothe­
rapy success rates are 90.5%
and 95.6% respectively for
standard regime and reserve

regime. The disturbing feature
is the number of reserve
regime failures, we are un­
covering. These cases are all
due to the prescribing ill con­
ceived reserve regimes and
wrong drug dosages by private
medical practitioners. This,
together with no supervision
and high drug costs, leads to
defaulting and non-compliance
and eventually the quick emer­
gence of multiple drug resis­
tant.

d)

BCG Vaccination

In the Dharamsala area, the
1980 coverage rate for BCG
vaccination was less then 40%
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of under 5’s children while by
June 1983 it has risen to 93%
of under 5’s children. It is
hoped that these results can be
duplicated in the settlements.
e)

Public Education

This is a very important part
of Delek Hospital’s work.
Only an aware and informed
public will be motivated enou­
gh to allow the Delek Hospi­
tal's TB Control Project to
attain an even better success
rate. A TB Educational slide
show and talk is given on
every settlement visit. TB
posters have been made and
distributed. An instructional
booklet about TB written in
simple Tibetan language with
pictures has been prepared by
Delek Health Media Services
and is awaiting funds for
printing and distribution.
CARITAS, INDIA has kindly
funded the purchase of a
movie projector and some
films on health. Besides, the
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hospital is already accepted as
a member of the film Library
of the Central Health Educa­
tion Bureau of Ministry of
Health and Family Welfare,
Government of India, New
Delhi, and this will enable us
to have use of health educa­
tion films on various health
subjects. Therefore, with the­
se facilities available, Delek is
hopeful of promoting
the
health education further.
/) The extent of the tuberculosis
problem amongst Tibetans in
Himachal Pradesh.
On the 1st June 1983, an eva­
luation of the Tibetan Delek
Hospital TB Control Project
was carried out by careful
analysis of the records for the
past three years. It was dis­
covered that the incidence of
sputum smear positive cases
(the number of new cases of
tuberculosis per year whose
sputum has demonstable tub­
ercle bacilli in it) was 0.6%.

Health education in progress

This ment that the annual risk
of infection from tuberculosis
was approximately 10%. It
confirmed the suggestion by
the Central Relief Committee’s
TB team who did tuberculin
surveys a number of years ago
that the infection rate was
much higher than the Indian
average. From the same
Delek Hospital records the
prevalence of pulmonary

tuberculosis (the number of
people suffering from lung
tuberculosis at any point in
time) has been estimated at
2.95% (3.5% if all forms of
TB are counted). A number
of studies on the Indian popu­
lation have shown the follow­
ing statistics. Annual risk of
infection is between 2% and
4%. The incidence of sputum
positive tuberculosis ranges
ii

between 0.1% and 0.25% with
an average of 0.13%. The
prevalence of pulmonary tub­
erculosis is 3%.
Project Implementation Po­
licies

Project implementation meth­
ods and policies have been
revised every year since the
project started in 1980. This
has resulted in a strong and
sound project which is impro­
ving all the time and which
has also been kept up-to-date
with the latest scientific find­
ings in tuberculosis research.
In July 1983, a detailed revi­
sion was again undertaken.
A number of new features will
be summarized here.
In line with the World Health
Organization Expert Commi­
ttee on Tuberculosis policies,
the standard regime has been
reduced from 18 months to
12 months where appropriate
and short course chemotherapy

12

has been adopted for the rese­
rve regime (a reduction in
duration from 12 months to
6 months). A biweekly stan­
dard regime has also been
introduced in an attempt to
use streptomycin injections as
a complying force in non­
compliers.

Actions against defaulters have
been standardized into a set
protocol with added features
such as defaulters declaration
forms and penalties for defau­
lters.
Culture/Sensitivity sputum
testing has been arranged for
double failure patients at re­
putable laboratories to give
these patients some hope of
cure as well as to provide
appropriate treatment regime.

The protocol for contact
follow-up has been completely
revised. For the patients’ own
benefit, a patient treatment
card will be introduced with

the patient himself being res­
ponsible for keeping it up-todate.

Diagnosis protocols and pati­
ent supervision methods have
been standardized for doctors
so as to avoid confusion.
In line with Delek Hospital
policy'of cooperation with the
Indian Government National
Tuberculosis Programme, close
liaison has been kept with the
Kangra District Tuberculosis
Centre. Also over the past
years discussions have been
made with the District Tuber­
culosis Centre Medical officers
in Chamba (near Dalhousie)
and Nahan (near Poanta
Sahib, Puruwala, Sataun and
Kamrao).
Current Project
and Facilities

Funding

At present we receive TB drugs
and funds from a variety of
sponsors. These have been

gratefully received and have
been enough to allow the
major work to continue un­
interrupted. To date, they
have usually been funds ear­
marked for a single purpose
or a single lot of drugs or
funds with no promise of
continuity.

A major sponsor for a longer
period of time would relieve
the anxiety related to maintain­
ing Delek Hospital’s Commit­
ment to this project.
Unfortunately some areas of
last years budget had to be
curtailed due to insufficient
funds and this perhaps preven­
ted the project from reaching
its potential. The most out­
standing of these were staff
salaries. Only one TB Health
Worker could be employed
while there is definite need to
train and employ another one.
This has resulted in patient
supervision being less than
optimal at times (particularly
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when the TB Health Worker
is doing settlement visits).
With more settlements to
supervise this problem will
become worse. The community
health workers continue to
survive and support families
on amazingly meagre salaries,
even by the standards of their
own communities. A monthly
stipend for TB patient super­
vision and treatment will
definitely go long way to
maintaining a high level of
morale and add an incentive
for continuing to do a good
job. It should be added here
that most of the Delek Hospi­
tal trained Community Health
Workers have taken on the
job out of concern for their
fellow Tibetans and in the
process of doing so have
missed opportunities for bett­
ering themselves financially.
The extra field microscope has
not been purchased as yet.
Over the last six months the
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hospital X-ray unit has broken
down several times. It is anti­
quated and of foreign make
and has become expensive to
repair and main'ain. It is
feared that further breakdowns
are imminent and the machine
may finally become irrepairable. Owing to this situation,
the hospital is trying to purch­
ase a new Indian made machi­
ne which would solve the
problem of spare parts and
maintainance. the UMCOR,
New York has kindly agreed
to contribute 4030 dollars to­
wards this and the hospital is
looking for the remaining
funds required. The total
costs of the machine is 15,000
dollars.

Due to generous construction
and equipment funding from
West Germany a new multi­
purpose wing has been built
at the hospital. Part of this
wing provides separate TB
wards. This was urgently

One of our new TB wards

needed and is operational
now. For the first time we are
able to separate infectious,
non-infectious and resistances
cases from each other.

structure. Therefore, the suc­
cess of the Delek Hospital TB
Control Project is dependent
on the success of the Delek
Hospital Community Health
Project. Delek has been orga­
nizing a regular (twice yearly)
Community Health Project
3 month Community Health
It should be recognized that Workers Training Programme.
the running of a good TB The training give particularly
Control Project is only possible emphasis to Tuberculosis case­
through having a strong infra­ finding, patient supervision
15

and treatment. Once a comm­ them. Therefore the hospital
unity has a Delek trained charges Rs. 8/- per month per
Community Health Worker patient for the Standard Regi­
then regular visits by the me and Rs. 32/- for the Re­
Delek’s Mobile Health Team serve Regime. However, there
is arranged and that commun­ are many patients who are
ity is brought under the Delek unable to pay even this nomi­
Hospital Tuberculosis Control nal amount and the hospital
Project. It is therefore, fortu­ will continue to give free treat­
nate for the TB Control Pro­ ment to these cases. Contri­
butions from the beneficiaries
ject that the Community Hea­
will
be a very small fraction of
lth Project has also been such
the
total
budget.
a success. It is also fortunate
that funds have been made Conclusion
available from Tibetan Refu­
The current 1st June, 1983
gee Aid Society, Canada, to
evaluation should not be con­
train the Community Health
strued as a rigid scientific
Workers and OXFAM has
study. It is recognized that
funded the hospital ambulance
many points need to be evalu­
jeep, petrol costs and expenses
ated
and validated. It is how­
incurred on the Community
ever based on facts gleaned
Health Project.
through the records of Delek
Contribution
from
the Hospital and the experience of
Delek hospital staff. Light
Beneficiaries.
should now be shed on many
It has been found that patients areas which were subjected in
are more compliant with treat­ the past to educated guess
ment when that treatment re­ work and individual observa­
presents something of value to tion.
16

Because of the high annual
risk of infection, many Tibet­
ans have already been infected
with tuberculosis (non-clinical
tuberculosis infection) and
therefore for many years yet
clinical tuberculosis cases will
regularly appear amongst the
Tibetan population. There is
also the problem of spread
from a surrounding Indian
population in whom tubercu­
losis still goes largely uncheck­
ed. Intensive case-finding will
have to be maintained for
many years so that infectious
cases are controlled quickly.
Despite the daunting prospect
of many years of hard work
there is the satisfaction of
seeing the immediate effects of
a good tuberculosis control
project amongst T i b e t a n s.
Already the hospital project
has meant a large decrease in

mortality and morbidity from
this terrible disease amongst
the Tibetan population of
Dharamsala. Many families
now will not have the tragedy
of the mother or father dying
of tuberculosis and leaving the
family without support. With
high BCG Vaccination rates
mothers and fathers’ will not
have the anguish of watching
their children die in the throes
of tuberculosis meningitis
(brain TB) or miliary tubercu­
losis (desemminated blood TB).

To past and current sponsors
of the Tibetan Delek Hospital
Tuberculosis Control Project,
no matter how large or small
the donation, the Delek
Hospital staff sincerely thanks
you for helping us control this
devastating disease amongst
Tibetans.

Printed at Imperial Printing Press, Dharamshala, H.P. (Tel. 390)

17

How you can help
YOU CAN:

—Sponsor a TB patient bed at US $ 27 per month.
—Sponsor a food supplement for a TB patient at US 8 10
per month.
—Sponsor a standard treatment for a TB patient at US S
22.16 for 12 months.
—Sponsor a reserve regime treatment for a TB patient at
US S 114.59 for six months.
—Sponsor a stipend for a TB Health Worker at US S 38.46
per month.
—Sponsor a stipend for a Community Health Worker at US S
28.84 per month.
—Send contributions towards :
a) TB drug Fund.
b) Health Education & Teaching Aids Fund.
c) X-ray Fund.
d) Unspecified (to be used where we feel the need is
greatest).
—Send TB drugs, food supplements and used clothing, (the
hospital has DUTY EXEMPTION CERTIFICATE on gift
supplies coming from abroad).
Financial contributions may kindly be sent by cheque, I.M.O.
or Draft in favour of TIBETAN DELEK HOSPITAL and
addressed, under registered cover, to the
Administrator
Tibetan Delek Hospital
Gangchen Kyishong
DHARAMSALA-176 215
H. P., INDIA
NB : All contributions are exempted from Income Tax under
section 80-Gof the Income Tax Act 1961 of Government
of India.
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