"Case Finding" and "Case Holding" in Tuberculosis Control Programme
Item
- Title
- "Case Finding" and "Case Holding" in Tuberculosis Control Programme
- Creator
- U N Jajoo
- Date
- 1985
- extracted text
-
2>$
i
Medico friend circle - Annual pie^t. 1°^5
TB and Society
Ba c kground^ PaP£r_I
'•CASB mror'c- & JCASE HOLDINGi?_IN
•
CO NTROL PRO GRA MMTJ
U. N
•
J A JOO
Tbe Situation.
= 20/1000 population
(X-ray diagnosis)
= 4.1/1000 population
(bacteriologically . ->
Proved)’
= 2.5/1000 population direct smear+
Prevalence of the disease
= 1.6/1000 population smear - ve
culture +
Incidence of the = 1.3/1000 population (1/3 of
prevalance of bacillary cases)
disease
(Roughly 2C% of the prevalence or the
number whc leave the ’pool1 every
year due to death end spontaneous
cure resulting in state of near
balance in prevalence over a span of
few years)
50% die in 5 year
Natural course of the disease
20% continue to excrete
bacilli after 5 years
30% get cured spontaneously
Tuberculosis infection and disease is uniformly
distributed in urban and rural areas.
80% of the disease occurs in the age group beyond
35 years
There is a gradual but slow, natural decline of
tuberculosis in our country.
Socio economic uplift has brought down tuberculo
sis much more drastically oven before control
programmes were introduced.
Community with well functioning programme has
shown fall in the prevalence.
Under T.B. control Programme, age of T.B. has
shifted up, ■though incidonce/prevalence has not
shown any change.
B.
Case _ Detectionj-
The case detection efficiency of .BTP is esti
mated to be about 30% of the expected.
Potential risk of acquiring infection from cases
confirmed on culture only is considerably lower
then from cases with tubercular bacilli dete
cted in the smear A
Of ‘those who present with symptoms like
tuberculosis (cough more than 15 days duration)
above the age of 20 years (4.1% of total 'popu
lation), 30% show lesion like tuberculosis on
...2
I
2
MMR out of which i/4th (6.2%) are confirmed as cases by
direct smear examination.!
In the population above the age of 5 years (82% of total
population) 1.8% have x-ray shadow like tuberculosis and
0.4% (l/4th) show sputum AFB positivity.?
As much as 95% of the infections pool (bacteriologically
confirmed cases) are aware of symptoms and as good as 52% come
themselves to seek medical opinion, out of which 96% cases can
be found by meticulous sputum examination.3
Action taking for relief in the symptomatic group was 50%
however, nearly 70% of those found to have bac' ontological
evidence of active disease by x-ray took action.4
To see?. relief, symptomatic group go to 5 .
Private practitioners
58%
Public Health facilities
3 5%
5%
Do not seek any treatment
If preliminary treatment failss59% go to private practitioners
10%. to public health facility
30% can not afford and do not seek treatment.
Those who seek relief from the nearest health facility
were only 23%.
Among patients registered at DTC, only.27% have not received
treatment earlier ie., 1/3 patients come to DTC, 3/5 to private
practitioners.5
Patients were not prepared to travel more than 5 kms
' unless symptoms are very pressing.6
Repeat sputum examination increases yield of the cases
(10% of initial yield with each successive specimen). Among
symptomatics attending TB-Centre (relatively advanced cases)
two specimens examined discovered 85% of all smear positives
who could be found on examination of as many as 8 specimens
from each individual.4, 8. Peripheral health institutions
(with microscope alone) have the potential of diagnosing within
one year 60% of total direct smear +ve cases or 10% of entire
number of cases estimated to be prevalentein the district at a
point of time that could be confirmed by any bacteriological
method.9
C" Active Case Finding
For sputum positive cases, the large majority of patients,
could net be found even if services were provided close to
their villages (0.5 to 8 miles). Number of patients found
under such conditions was considerably short of the
estimated total prevalence. By none of the methods (community
development approach ie., active detection of symptomatics and
referral tc microscopy centr-./or mass campaign with x-ray
available at few miles distance) was it possible to
diagnose ever about 50% of the existing cases in the
community ie., number that was already reporting to
. . ..3
I
... 3 ...
PHC for examination because of their chest symptoms.'.'C
Out of every 15-25 sputum smears examined one
is expected to be smear +ve. If all the smear nega
tive patients were to bo X-rayed, two or three
-suspects could then be found (including those
•cases who could be culture +ve). Even if every one
is referred only 20% may actually report to a distant
centre for X-ray examination2.
The Cost in ys $ of diagnosing one case by
different methods
Approximate
cost of one
examination
Examination
Direct microscopy
Culture ex?ina tion
70mm X-ray film
(static unit)
70mm X-ray film
(mobile unit)
A ppro ximat e cost
of diagnosing
one case
0.21
0.49
0.26
3.4
12.1
3.5
0.50
73.0
Method of case finding at BTC if supplemented with
sputum
from symptomatics on house visit
by multipurpose workers has shown encouraging results
in the preliminary trials (doubled)*'
No matter what we do or say, some patients will
always first consult a private practitioner of one or
other systems of medicine. Therefore if we want to
diagnose and suspect early, all practitioners of all
systems must be involved in the health care’plan1-' .
D. Snr v e il 1 ar.ce: Epidemiological groups of population and their
contribution towards new ccses in a year*2
Category
Size of
population
X-ray normals
Probably active
TB shadow
Inactive X-ray
shadow
Contribution
to new cases
X. 5%
48.2%
26.6%
9.8%
25.2%
88.7%
Remarks
Most
rewarding
Survielence of abnormal shadows (11 ...3% population)) can at the bast
b^st prevent only 1/2 the inci
inci-
dence of cases that are expected to arise in the
community in a year.
E. Ca s_e_Ho 1 d in g^,It is a process of ensuring that a case.of •
Tuberculosis completes the vrescribed duration of
chemotherapy which is atleas'.t 12 months. The
efficiencv of this component has been estimated
to be about 30-35% in NTP.
Proportion of patients making 9 out of 12
monthly collections in one year was 52% from the
...4
treatment centre near at hand, compared to 7% when
patient had to travel a long distance to collect
medicines^.
Drug collection was the same(30%) whether the
patient was asked to collect drugs from the nearest
primary health centre or from a local village panchayat
member1-5. Organising periodic reminder services enhances
regularity in drug collection.
P-hking just :ne attempt at niotivation at the
start of treatment was found to be rather inadequate 13
Motivation of patients with household members a
every month for a period of 3 months was more rewar
ding (doubles drug collection)1z*
Sizeable proportion of patients drop out imme
diately after starting the treatment15.
Collection at which first default takes place
Centre
1
I
I Obligatory
PHI I
3
4
„5+
19.1
8.5
17.0
DIC
55.6
Tieatment failures were as often due to lapses
on the part of the patients. Inadequate diagnostic
equipment.y drugs and trained manpower could not
meet the felt need of patients. In the small group
in which the lapse was on the part of the patients,
it was found that acute social and economic factors
were often responsible for the default, if it was
not caused by human forgetfulness'0.
In punctual drug collectors- only 5 to 10% did ?
not properly consume drx<gs, rest did take regilarly^91'
Regimen'
Cost in
rupees
12 TH
12 PH
12 S2H2
2 SHT/10 TH
2 SHP/10 PH
2 RSHZ/5S9H2Z2
1 RSHZ/7 TH
2 SHZ/5S9
2'H19
2Z
/J92
5'1.10
446.83
136.24
120.64
516.34
746.8C
265.32
516.40
Efficacy in
experimen
tal situa-
Efficacy in *
field situa
tion %
“• - tien-%- -
82
89
94
96
60
64
68
76
100
100
'100
INH 100 mg(.O8 Rs.),1 r„
Pyre 7, inamide
500 mg (0.93 Rs.) Rifampicin 150 mg(1.28 Rs.) 9
no.), PAS 500 mg
Thiacetazone 1>G
150 LU£)
mg (G.vG
(0.06 Rs.)
(0.05 Rs.), JEthambutol 200 mg (0.21 Rs.)
19: SM.75 5-41(1.14)
* less due to inefficient case holding
.. .5
X
0 0
0 >: pW *3 rt
o o or
co 0
•
r* CD
O O
Cb
cQ
H 0
0 O
< cQ
0 H
I—• 0
0 ‘d
3 or
g p0 0
0
O I-1
Hi
0
d g
H* 0
3
» 0
o
H <
CO 0
H
0 0
0 c£
0 0
0
0 O
. Hi
or
nj ro
o
o 0
O 3
3
> 3
U 0
s:
P- n
I-1 0
H* Cb
d
tr o
.0 (+
CD O
o£
O H"
C F-'
ft
o or
ft 0
0
H NJ
nj
H K
0 P0
3 cQ
H
0 O
3 0
£b c+
II
3
’
cQ
fb
PHi
Hi
□
3
3
rtP0
H"
O
d
h
Q
0
0 rtcQ
M
O
0
0
0
cQ
3
O
0
O
Cb
•
£b a rr<
u
P- O- G
0
r*cQ <Q
3 3
O r
0
0
H*
0
10
3
Cb
tu
3
o
cb
rt
no
CT
0
0
o
rt
d
0
rt
0
0
Cb
O
3
Cb
0
cQ
0
O
0
0
Cb
s:
P-
Cb
0
I
II
I
II
I
11
I
II
>
I
I
Q
CD
3
CD
cQ
3
O
0
0
Ob
O
rt
0
0
d-
CD
5
O
cQ
H
0
I
0
£
rt
7? ■
O
d
rt
’0
3
O
cO
3
0
3
I
I
<D >>
O NJ
o NJ
o 4^-
CD >>
O NJ
o NJ
CD
o
II
l
II
;
II
I
I!
0 CD O
OXOO
rt
CD
0 0
3 0 0 ^"
ft ft- Hi NJ
P- 0
CD
0 Cb ft I
CD
O
O
O
CD
o
o
o
o
cO
0
o
o
o
o
t-1 rt 0 S
0 O 0 0
3
0 0
O U 0
0 3 0 0
Hi
0
< 0
0 rt
l
CD
O
O
4N
O
rr
CD CD
cO CO
O
NJ
CD
cd CO
O
4^
4^
cO
O
O
4^
NJ
O
CD
CO
o
o
o
4^
4^
.p
—U
I
I
I
I
I
I
I
I
I
J
0
i
0 0
*3 0
d Cb
rl-
§
i
<
II
rt I
I
I
or II
0
in
0
3
0
Pft
P-
<
i
II
I
II
I
II
I
II
I
i
I
to co
o 4^
NJ CD
CD
CD
NJ co
o 4^
NJ CD
NJ
O
II
I
II
0 I
3 II
Cb I
Q
1-5
0
0)
P0
ft
0
3
ft
0
CD
0
0
0
0
0
0
P0
rt
c
u
I
I
n
H hj
0 PCb 0
0 J-*
0
d
k:
Cb s
p- o
Cb
II
II
5
II
3 I
0 II
ft I
0 II
0 I
II
Hi I
O II
3 I
• 0
NJ 0
0
t§
I
Hi I
rt ||
“
I
0
3 II
I
CD II
*3 I
II
X
P- NJ
3 4^
Hi •
Q <!
0 CD
rt "
0 3
CD P0 3
> •:
or
P> G
O
O 0
O Hi
oai o'
II
I
to
H> >Z
CO CD
NJ < CO
II
I
li
p3
Hi
P0
H*
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
l
II
I
II
I
11
I
H
&!l
0
pft
C
0
ft
pC
3
0
I
II
I
II
I
II
I
II
I
II
I
II
cd
CD
CD
NJ
O
4^
CD
I
o
o
o
o
!
4^
CD
NJ
o
I
4^
O
O
cO
NJ
NJ
O
X
1
l
1
CD NJ
GJ
o
NJ
cd
00
CO
co
o
CD CO
CO
NJ
NJ
NJ
CO
CD
O
NJ
CO
o
CO
O
O
CD
GJ
O
O
— O
0 G
I
I
I
I
n i
c 0 i
rt Cb I
d
I
3
I
l
I
5
<
0
l
l
I
I
70 !
10
’ T5
■ d
I rt
d
3
0
3
0
p3
P3
1
I
i
i
!
I
I
+ cO I
<
I
I
I
I
I
I
I
0 Q I
Cb 0 l
Cb 0 I
0 0 1
Cb 0 I
I
I
Q
i
,
f
o
o
O
O
O
O
o
o
4^
>£■
CD
O
CD
O
CD
4^
CD
00
O
4N
4N
NJ
O
03
F—*
CO
O
o
o
S
F-1
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
1
II
I
II
I
II
I
II
I
II
I
II
I
II
I
II
o
R
;0
h
P
’0
0
:0
jet
|0
P- W
rt r+
7? PO 2
d 0
c+ r+
0
0 fb
Ob co
p-*0
0 d
rt- r+
h d
p- 3
0
rt-^
O
rt- 0
d pCT ri0 PH <
0 0
d
O
O 0
0 0
P- 0
0 0
II
I
II
I
II
I
II
I
II
I
II "3 PI H 3
II O
I uQ 0
"33
II
I 0
II 3 0
I 3 <
II 0 0
I 3
I!
0
I 0 Q
II ft 0
I
II rr H
I 3J 3
II 0 Cb
I
11 0 0
I 3 3
II
I
U
II C PI Hi 0
II
rt
I O tf
II 3 PI 0 0
rt
II
I
hoc
I 0 PII 3 rr
I
3*
II
I
CD
II
3
Cb
I
II
I
II
I
0 2 II
3 0 O I
.. in
. °
II
Q
< 0
I
0 0 O II
Hi I
II
Q 0
3 ft
I
II
O
I
Q
II
i
3 TJ ft CD II
CD
3 0 0!
fb 0 Cb ft II
P- •I
d er
3 II
0 0
0 I
rt er
I II
o o
3
t
QUESTIONS ;
aej*
— «a
v.
1. Which component of TB control i.e.case detection,
case holding and drug management has the potential
of increasing its efficiency in field situations
and to what extend?
2. Which component of TB control i.e. case detection 9
case holding and drug treatment is likely to he
more rewarding if their efficiency is increased
in the field situation?
Estimate of overall success in the treatment
programme for various levels of efficiency
of case finding, case holding and chemotherapy 22
Levels of^efficiency
Component Present With expected W ith
With With
best hotter all
estimate improvement
of PTP
che
case
inefficiency
of finding
mo the hoirapy 50%
Case finding
70%
50%
45
50%
50%
50
Case holding
55%
55%
55%
Chemo therapy75%
95
95%‘'
75%
75%
Overall success
8%
19%
11%
10%
21%
5. What can be the role of (1) MMR (Static & Mobile
units) in augmenting case detection?
(ii) Village health worker in augmenting case
detection?
4. How can private practitioners of all the systems
of medicine be actively involved in case detection
and management?
5. If the distribution of antitubercular drugs is
centralized through the peripheral network of
government services only (.Drug is not allowed)
to be sold in the open market so that registration of a case of tuberculosis is mandatory
before receiving treatment-what will be its
impact?
I
• >'•
REFER
CES i
1.
1 case finding by micros ouys D.R.Nagpaul., D.1‘4. Sa vic
K.P.Rao 3; G.V.J.Baily, W
1 .H.0./T.B./Techn. In formation/68.63-
2.
District T.B.Control Programme in concept & outline
D.R.Nagpaul, Ind J Tub.XIV. 196-198.
3. 1 S' iological Survey of awareness of symptoms
Suggestive of Pulm. Tuberculosis-: Bull.Wld.Hlth.
Org.'29, 665-683, 1963.
4
\ Sociological study of awareness of symptoms and
action taking of persons with pulm,T.B. Rad ha
Narayan S., S.Prabhakar, Susy Thomas, S.Pramila
Kumari, T.Suresh and N. Sriknntaremu. Ind J. of
Tub. XXVI, 136, 1979.
5. Socio-cultural context of T.B.treatment?
Ind J Tub. 1982.
6. Prevalence of symptoms in’ a South Indian rural
community and utilisation of area health centre.
Ind J.Med.Res. 1977,66,635.
7. •Symptom awareness and action taking of persons
with pulm.T.B. in rural community surveyed repea
tedly to determine the epidemiology of disease.
Rad ha Narayan & H. Shrikantaram. Ind J Tub.28,
1?61, 1981.
8. Some aspects of sputum examination in T.B.case
finding: Dr. Nagpaul, N. Nngnnathan & M. Prakash.
Ind J Tub. XXVI, 11, 1979.
9. Potential yield of pulmonary tuberculosis cases by
direct microscopy of sputum in a district, of
South India. G.V.J.Baily, D.Savic, G.D. Gothi,
V.B.Naidu & S.S.Nair, Bull ..Wld. Hl th Org. 1967,
37, 875/892.
10. An operational study of alternative methods of
case finding for tuberculosis control, NT I
Bangalore. Ind J. Tub.XXVI, 26, 1979.
11. Active case finding in tuberculosis as a compo
nent of primary health care. K.3.ineja,R.Chandra
sekhar ,M.A.Seethe, V.C.Sunmuganandan & GF
Rupert Samuel. Ind J Tub. 1984, 37, 65.
12. Incidence of sputum +ve T.B. in different epide- '
miological groups 5 yr.follow-up of a rural
population in South India? GB Gothi, A.K. Ch-ikraborty & M.J.Jayalakshmi. Ind J.Tub.XXV.No.2,
83, 1978.
13.A.
\ study of some aspects of treatment cards in
a DTP: Seethe et al. Ind J. mub.23, 90, 1976.
13B.
Feasibility of involving multipurpose workers
in xase finding in district tuberculosis
programme- Aneja et al: Ind J.Tub. XXVII,
4, 158, I960.
14.
Drug collection by patients through motivavetion of the families: Seethe M.A.Srikantaramu M., Aneja K.S. and Harden Singh. Ind
J.Tub.XXVIII 4, 1981.
15. Chemotherapy in national tuberculosis programme.
K.S. \neja. NT I Nows letter 19, 58, 1982.
16. Effect of treatment default in India" D,Boner,ji.
rroceedings of the XXtb. Ini T,B.Conference, Paris’,9
International Union against T.B. 1970.
17.
study to determine the reliability of assess
ing the regularity of self administration of
drugs at home by patient's attendance at the
clinic. S. Gehani, V.K. Perumal & D.G. Mathur.
Ind.J.Tub. 1984. 31,74.
18. Cost consideration in short course chemotherapyo
7.Siv^rar^n. Ind.J.Tub.Vol.XXX,9, 1983.
19. Tuberculosis in India - A perspective 2 Do R-.Nagpaul :
J. of the Ind.Xed.Ass. 719 44-1-8, 1978.
20. Tuberculosis in India - The prospect’; S.Shrinivasan Ind J.Tub.XXIX 71, 1981.
21. Recommendations made by tuberculosis Association
of India - A Scheme for primary health care in
tuberculosis’ Ind J. Tub. 1981, 28, 218.
22. National Tuberculosis programme - relative
merits of enhancing the operational efficiency
of different components of the treatment
programme. Ind.J.Tub.S.Radhikrishan Vol.XX 5,1983.
/ '] -?< r
-x- " -x- ~ -x- • > ~ : J -x-
77
Position: 405 (11 views)