DISTRICT TUBERCULOSIS PROGRAMME - KEY ISSUES IN MANAGEMENT
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- DISTRICT TUBERCULOSIS PROGRAMME - KEY ISSUES IN MANAGEMENT
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CURRENT TOPICS
NTI NEWSLETTER(1991) 27/3 & 4, 62
DISTRICT TUBERCULOSIS PROGRAMME - KEY ISSUES Hi MANAGEMENT +
K Chaudhuri*
The District Tuberculosis Programme(DTP) is designed to diagnose
the maximum number of tuberculosis patients reporting to the health
services and treat them effectively with the ultimate objective of
bringing about a reduction in transmission of tuberculous infection,
Since the tuberculosis ceses are equally prevalent in the urban and
rural areas and 80% of the population is in the latter, 80% of our
tuberculosisi burden is also estimated to be among them.
It is,
therefore, <considered necessary to create a suitable infrastructure
in the form of DTP to diagnose the patients reporting at the health
facilities, wherever they exist, in order to reach the patients
distributed in nearly 600,000 villages in the country.
It is only
through a high coverage of patients through general health services.
that it appears feasible to achieve the above objective of the programme.
A National Monitoring Cell was created at the National Tuberculosis
Institute(UTI), Bangalore, in recent times, to monitor the efficiency
with which the DTP is operating towards achieving its objectives. The
main activity which is being monitored is, of course, the efficiency
of the programme in terms of distribution of the facilities (coverage
of services) and efficiency of diagnosis at the available centres;
and to a lesser extent treatment compliance. No doubt it is difficult
to study the issue indepth from reported data originating from the
routine
service
agencies.
It
nevertheless
appears possible to
hypothesise that the diagnostic activity under DTP takes place only
at centres where the drugs are available and further that only such
are the centres who report their activities.
Hence the efficiency
of case-finding could, in a way,
way, be seen
o be synonymous with the
total efficiency of the DTP reflecting that of treatment delivery as
well.
It is generally believed that case-finding activity is more
amenable to improvement, since it is fhe health service which happens
. to be responsible for the diagnostic activities.
On the other hand,
the efficiency of treatment services reflects more or less a fixed
kind of patient behaviour provided, of course, drugs are available
at the centres concerned. It is believed that whereas better management
actions to tone up the system could and should result in higher
efficiency of case-finding, far difficult to render and less well defined
socio-economic inputs are called for in order to organise changes in.
patient behaviour pattern.
Consequently monitoring seeks to study
the case-finding efficiency more vividly to enable identification of
corrective actions.
^Director, National
Bangalore-560C'03.
Tuberculosis
Institute,
+Based on the address delivered at the WHO
Activity, held at Bhubaneshwar in October 1991.
8,
Bellary
Road,
Group Educational
63
The monitoring data is reviewed every quarter at the NTI, Bangalore,
and the reports are transmitted to the districts concerned through
the central/state governments.
A review of the programme in different
states gives us occasion for serious thought.
Based on these, actions
to remove
the deficiencies could be initiated by the programme,
authorities at the national level as well as at the state level
concerned.
In this connection, it is noteworthy that the NTI had been
discussing the performance of different states with the state level
authorities at the seminars conducted at NTI, Bangalore, every
year
for quite sometime.
Of late, however, the NTI has been visiting some
of the states aqd discussing the findings with the state as well as
district level health & tuberculosis progranune administrators, in an
effort to inform them regarding the continual use of the data available
to them on performance of the programme.
They are sensitised on some
operational aspects of the DTP, e.g., how to organise and process the
data already being produced by the health services under them in a
routine manner and how to derive action oriented conclusions from thesQ
in an attempt to improve the programme efficiency.
It is an effort
to make it possible for them to process and use their own data-source
themselves, instead of waiting for the NTI to transmit to them the
results of the analysed reports and expect them to act on them.
Discussed below are some of the aspects of the programme implementation
and possible corrections, as available from the periodic reports, being
compiled at the.NTI in an ongoing manner.
♦
Table 1 shows the Indian population(estimated for 1990) with 438
districts and the available health facilities in them.
The average
district population is shown to be around 1.88 millions.
Of the
available districts, 378 have been covered under the DTP(85%).
At
the expectation of one Primary Health Centre(PHC), supposed to be
available for 30,000 population. there could be 27,400 Peripheral Health
Institutions(PHis)
in the country.
It is understood that only 21,230
PHIs are in position in India, with 15,270 implemented under the
DTP(567o).
Of the DTPs
DTPs functioning,
functioning, 38%
337> arf
arf <covered under the Short
Course Chemotherapy(SCC) .
In the remaining,
remaining. Standard Regimen(SR) if
available for treatment of tuberculosis.
Tabic 1 (Please see next page)
STANDARD? TO JUDGE PERFORMANCE OF DTP
Table 2 shows that a DTP is calculated to have a potential for
diagnosis of 2,500 smear positive cases in an average Indian district
having 1.8 million population, today.
These potentials are, however,
calculated on the basis of earlier NTI studies, wherein: prevalence
rate of culture positive cases was 4/1000; ^50% of the prevalent cases
were supposed to be reporting to about 50 PHIs in a district of about
1.5 million population; 30% of these self-reporting patients were smear
positive; on an average 2.5% of the new out-patient attendance had
cough of more than two weeks duration and 10% of them were expected
to be sputum positive.
These potentials were worked out on the basis
of highly motivated research workers of the Institute working under
rigorous research discipline.
However, it has been NTI*s experience
64
Table 1
POPULATION AND INFRASTRUCTURE (INDIA-1990)
1.
Mid year estimated population (1990)
822 m
No. of districts
438
No. of DTPs
378
Implemented
85%
Average district population
2.
1.88 a
Health Institutions expected:
(d 1/30,000 population
27,400
Health Institutions available
21,230
PHIs implemented
15,270
Percent
3.
56%
Short Course Chemotherapy:
DTPs functioning
378
Covered under SCC
252
Percent
67%
Percent of PHIs covered under SCC
i
38%
that no DTP in any state has ever been able to approach anywhere near
this potential. Therefore, it is considered that it could be a stiff,
nay even unreal, estimate of the potential for the District Tuberculosis
Centres(DTCs) to achieve!
It could, on the other hand, be more
practicable to consider the best performance figures achieved by ai.y
DTP anywhere in India to be the "expectation” for other performing
DTPs! The performance of the DTPs are therefore matched against this
expectation.
Those who would realise these expectations would then
be offered the challenge of achieving the "potential” as per NTI
operational studies.
In table 2, the "expectation" of an ..verage DTP
in Indra is shown to be 1,620: 1,120 for the PHI and 500 for the DTC.
It can be obseived that achievements of an average district in India
in 1990 is 52% for the DTP as a whole, n0% for the PHI and 78% for
the DTC. Table 2 also gives the treatment compliance which is about
33% for SR.
Table 2 (Please see next page)
The potential presented for the DTCs are based on observations
at the Lady Hillingdon Tuberculosis
Tuberculosis Demonstration Centre, Bangalore
(all symptoraatics eligible for sputum examination and 257O to be positive
for AFB).
The expectation of sputum positivity is taken as per the
best that could be achieved by any DTC(ie., 18%).
65
Table 2
PERFORMANCE OF AN AVERAGE DTP
1.
Case detection
Achievement
Potential
2.
Expectation
No.
%
DTC
500
500
390
73%
PHIs
2,000
1,120
445
40%
DTP
2,500
1,620
. 835
52%
Treatment
SR
Percent of patients completing
^.12 collections
33.0
see Percent of patients making 75%
or more collections
56.0
MEASUREMENT OF EFFICIENCY
i)
Spu tvim_ examinat ion
The efficiency of sputum examination,
matched against the
expectation calculated on the above manner, is presented for the DTCs
and PHIs in table 3.
It can be seen that the efficiency of the DTCs
for sputum examinations is high throughout , except in West Bengal and
Bihar. The same for PHIs is, on the other hand, very low. Of course,
some states have achieved a high efficiency of sputum examination at
PHI (Uttar Pr£de^sh-122%,I^Maharashtra~91%, Punjab-73% and Tamil Nadu-66%
of expectation).
So this singles out sputum examination at the PHIs
as one of the weeker points of the programme in most states.
Table 3 (Please see next page)
ii)
Cate detection
Table 4 presents the efficiency of the case detection in the DTCs
and
PHIs
which again shows that most DTCs, except Assam, Bihar and
Vo
Tamil
Nadu
performed near to expectation.
Some states performed very
1
close to the level of expectation (Gujarat, Haryana, Himachal Pradesh,
Jammu & Kashmir-100%, Madhya Pradesh & Maharashtra-around 90%).
With
regard to the efficiency of case detection at the PHIs, it can be seen
that while some states like Assam, Bihar, Himachal Pradesh, Kerala,
Madhya Pradesh & Rajasthan performed at the level of nearly 15% or
below, only Gujarat, Maharashtra 6c Uttar Pradesh performed beyond the
66
level of 55% of the expectation.
This really constructs a disturbing
scenario for us.
Imagine Madhya Pradesh performing at 94% of the
expectation at the DTCs, > but only at about 11% at the PHI level.
level, The
low efficiency of case-finding at DTP can thus be safely attributed
to the low performance of the PHis almost everywhere.
Table 3
EFFICIENCY OF SPUTUM EXAMINATION - 1990 (AVERAGE/DTP)
.
.
'
r -
i
’'
‘
DTC
SI.
No.
States/Union
Territories
DIP
PHI
Expec
tation
Perfor
mance
Effi
cien
cy
%
Expec
tation
Perfor
mance
Effi
cien
cy
X
Effi
cien
cy
X
India
2800
3437
123
14500
8540
59
69
1
Andhra Pradesh
4100
3508
86 i
21250
8551
40
48
2
Assam
2130
1696
80
8130
1236
15
29
3.
Bihar
3300
1671
51
6250
2958
47
48
4.
Gujarat
3200
3853
120
25000
14137
57
64
5.
Haryana
2020
5962
295
10380
5034
49
89
6.
Himachal Pradesh
520
2218
360
5630
1363
24
57
7.
Oararau & Kashmir
790
1497
189
3500
i^35
41
68
8.
Karnataka
3300
- 2567
78
29750
7989
27
32
9.
Kerala
3140
3384
108
15530
7089
45
56
10.
Madhya Pradesh
2070
2777
134
16880
4603
27
39
11.
'laharas.’.tra
3700
5097
138
25380
23208
91
97
12.
Orissa
3530
3123
88
21250
8894
42
48
13.
Punjab
2400
3036
127
10880
7910
73
82
14.
Rajasthan
2400
2226
93
10380
2169
21
3-4
15.
Tamil Nadu
5200
6555
126
33750
22461
66
75
16.
Uttar Pradesh
3530
3312
9-4
7500
9165
122
413
17.
West Bengal
6050
1650
27
14000
3674
26
27
(
67
Table 4
EFFICIENCY OF CASE DETECTION - 1990 (AVERA6E/DTP)
DTC
SI.
No.
States/Union
Territories
PHI
DTP
Expec
tation
Perfor
mance
Effi
cien
cy
%
Expec
tation
Perfor
mance
Efficien-cy
X
Effi
cien
cy
X
India
500
390
78
1120
445
40
52
1.
Andhra Pradesh
730
544
75
1700
456
27
41
2.
Assam
380
122
32
650
38
6
16
3.
Bihar
590
144
24
500
63
13
19
4.
Gujarat
570
655
115
2000
1104
55
68
5.
Haryana
360
369
103
830
206
25
•18
6.
Himachal Pradesh
110
140
127
450
51
11
34
7.
Oammu & Kashmir
140
173
280
83
30
61
8.
Karnataka
590
299
51
2380
728
31
35
9.
Kerala
560
334
60
1250
188
15
29
10.
Madhya Pradesh
370
346
94
1350
146
11
29
11.
Maharashtra
660
587
89
2030
(5)
76
12.
Orissa
630
351
56
1700
387
23
32
13.
Punjab
430
331
77
870
381
44
55
14.
Rajasthan
430
315
73
830
116
14
34
15.
Tamil Nadu
930
414
45
2700
734
27
32
16.
Uttar Pradesh
630
400
63
600
373
62
63
17.
West Bengal
1080
159
16
1120
360
32
37
DECADAL TREND
Whereas one has to be concerned about the low efficiency, as in
the earlier paragraph, a few points need ti be taken into consideration
while according priorities in correcting some of the programme
63
activities, The number of sputum examinations has increased from 4,500
to 12,000 in uhe last decade.
But the number of cases diagnosed has
not been commensurate with this rise.
Secondly, the proportion of
smear positivity out of new sputa examined has shown a declining trend i j
both at the DTC and PHI from 14% to LI.5% and 10% to 5.27® respectively
during the decade.
POSSIBLE REASONS & SOLUTIONS
The low case-finding activity in DTP, assigned to be
deficient activity at the PHI, may possibly be attributed
following:
1. Improper
officer.
selection
of
symptoms
2. Improper smear preparation
PHI microscopist.
and
by
the
PHI
under-reading
due to
to the
medical
by
the
3. Non-availability or non-maintenance of the microscopes
(15-20% of the microscopes are estimated to be out
of order at a point of time).
/
4. Attitude of the staff at the PHI.
5. Inadequate knowledge of the
of diagnosis and treatment.
staff regarding the mode
6. Possible decline in the prevalence rate of smear
positive cases in the community and therefore the
low smear positivity among new patients attending
Pills.
Both administrative and technical activ.is arc called for to solve
these problems.
ADMINISTRATIVE
Though tuberculosis is a single major infectious disease and
recognised to be a public health problem under the 20 Point Programme,
it still lacks the requisite priority among major health programmes.
It cannot be ignored that some of the national health programmes tend
to work as powerful vertically oriented programmes, even though they
use the health infrastructure designed for an integrated Jiealth care
delivery.
The malaria programme as well as the UIP can be mentioned
in this connection, not considering the leprosy and family welfare
programmes which are vertical health programmes by design, with various
kinds of incentives being offered to all concerned!
It is little
realised that in the process, these programmes may in fact be weakening
the fibre of general health care delivery system itself, by relegating
its philosophy, objectives and activities to the background.
It is
true that, in pursuit of targets set by a few of these programmes,
the medical officers of PHIs, in some instances, do not have the liberty
IM
S
69
to accord a high priority even to out-patient care, which by all means,
should be his basic function! He may often be required to be absent
from his seat at the PHI discharging other duties outside! This could
be undermining patients’ faith in the institutions themselves to the
detriment of programmes like DTP, whose success hinges on utilisation
of the available services by the people! Moreover PHI staff seem to
take note of the incongruity, that other programmes except tuberculosis
have staff appointed specifically for the stipulated programme activities
at the PHI and are paid from out of the designated funds. Tuberculosis
programme, therefore, suffers in comparison.
fhe administrative action in this regard which should be taken
at the central and state level authorities, is to allot equal priorities
to all the national programmes, leaving out family planning, which
alone can be a special case. There should be acceptance of integration
as an operational necessity by all other national health programmes.
The district administrative medical officers(DMOs) should review the
family welfare programme as the last one in the list, sustaining interest
in programmes like tuberculosis, UIP, malaria, general health etc.,
and allowing these to occupy some of the discussion time at their monthly
review meetings.
The DMOs should familiarise themselves with the
programme dynamics in a manner enough to review the performances and
display the required keenness.
Supervision
The monitoring data reveals a serious lacuna in the activity of
supervision by the District Tuberculosis Officers(DTOs) (Table-5).
It is usually put forward, as if as an alibi, that either the vehicles
are not available or the available vehicles are put to all conceivable
uses, other than for the DTP.
Table 5 (Please see next page)
The DMOs must rectify this situation urgently. Wherever vehicles
are available with the DTOs, the administrative authority must insist
upon the DTO to make the stipulated tours. Wherever vehicles are not
available, an effort must be made to locate spare vehicles for use
in DTP.
Till that is done, several programme officers should be made
to tour jointly.
Though the concept of joint tours bv several programme officers
is a right step towards achieving optimum use of the vehicles and fuel
efficiency, yet it cannot be construed as a permanent solution.
Each
programme officer has to get the PHI doctor to devote adequate time
to him separately in order to have an effective interaction during
the supervision visit. Several programme officers, all demanding similar
attention from a given PHI at the same time may not be conducive to
a good communication situation. However, the alibi of not supervising^
the existing programme and not implementing unimplemented Pills as given
by the DTOs, should not be allowed to stand. The district administrative
level officers have to somehow see to it that the DTOs carry out the
job for which they are largely meant for, ie., implementation and
supervision.
70
Table 5
SUPERVISION OF PERIPHERAL HEALTH INSTITUTIONS - 1990
I
SI.
No.
States/Union
Territories
PHIs
Imple
mented
i
Super
vised
%
India
15270
6413
42
1.
Andhra Pradesh
1215
595
49
2.
Assam
340
129
38
3.
Bihar
597
281
47
4.
Gujarat
1190
547
46
5.
Haryana
310
127
41
6.
Himachal Pradesh
376
128
34
7.
Jaramu & Kashmir
123
81
G6
3.
Karnataka
1720
740
43
9.
Kerala
545
114
21
10.
Madhya Pradesh
1877
432
23
11.
Maharashtra
1914
1225
64
12.
Orissa
689
172
25
13.
Punjab
325
39
12
14.
Rajasthan
633
263
38
15.
Tamil Nadu
1345
52)
39
16.
Uttar Pradesh
1057
634
60
17.
West Bengal
567
74
13
I
I
DeplSpnentoftrainedgersonnel
Th. DTP requires some organised involvement of staff u-oth at the
PHI and DTC level. The DTC staff trains the PHI staff on their visit
"to the respective PHIs.
This is why in the previous para, a lot of
stress has been laid on the DTO and his team visiting the periphery
regularly.
At all times, the implemented PHIs must have in position
the staff who have been trained by the DTO and his key team.
However, it has come to light that for some strange reasons the
• DTCs themselves are not staffed by the NTI trained personnel. It will
■—be impossible for the district team to achieve the results if members
of their key staff themselves are not trained in the first place. NTI
trains the key workers specifically for the programme administration.
No level of academic qualification attained by the DTO or his team
members could replace the training given at the NTI, since academic
71
training does not train the staff to carry out the programme activities.
In some of the states the situation assumes alarming proportion, because
of non-availability of trained personnel especially at DTCs
for ex. ,
in Orissa, where most of the DTOs are not trained at the NTI. It becomes
specifically
difficult
to
the
dynamics
comprehend
of
this
non-availability of the key staff at DTCs, since NTI runs two courses
every year for all the programme personnel for years.
It is for the
states to utilise the training capability created for their benefit
and manage the trained man-power in such a way that the centres are
staffed properly.
TECHNICAL
Microscopy
The reason why case-finding at the district level is not fallen
short of the expectation, whereas the same at the PHI is very low,
probably rests heavily on the availability of a trained microscopist.
Apart from the administrative aspects of the issue for not posting
a microscopist at the PHI, it is possible that even when one is
available, he is most likely to be on the pay roll of the malaria
programme. More often, than not, he is not trained to carry out the
sputum examination: either it has got something to do with his initial
malaria service background or with the inefficiency of the DTC team
to convince or train him.
The district management should waste no time to arrange adequate
training to all microscopists working at PHIs to collect the sputum
samples and examine them properly.
The medical officers themselves
should select the right persons for the sputum examination. The required
technical training has to be imparted both to the medical officers
and laboratory technicians by the DTO and his team during his supervisory
visit.
The training aspect could also be strengthened by the DTOf
with the active involvement of the Regional Family Welfare Training
Centres.
Microscope
Tuberculosis programme relies only on a simple microscope at the
PHI for diagnosis.
It is as simple as that!
Still it requires tha
required attention from time to time. The district laboratory uachnician
should help xn servicing the equipment every now and then and train
the PHI microscopist in microscopy care. the DMO should take appropriate
action to replace or repair the same as the case may be.
Change_in_case_content
Possibility of non~achievement of the desired sputum positivity
at the PHIs could also be attributed generally to the dwindling of
smear positive case content in the community as per some reports. The
matter is being investigated by the NTI.
RECOMMENDATIONS
Only the very basic shortcomings in the performance under DTP
and the reasons for these are short-listed above. The following points
72
need to be considered for action taking on related issues on a priority
basis.
This cannot serve as a comprehensive list of actions to be
taken, but is designed only to underline the areas which can be improved
with a little effort and to create the necessary awareness on these
aspects among programme managers’
Research
Since there can be a change in the action taking pattern of patients
and the proportion of smear positive cases in the community over the
years, there is a need to study these to have a better estimate of
the potential and expectation of other activities under the programme.
Knowledge, attitude and skill of the PHI staff also require a study
to find out the reasons for their preferential performance in some
or other areas, if any.
fading
i.
Efforts are to be made to increase the coverage of available centres
by implementing the programme in them.
Action is to be taken
?by the DTO in consultation with the DMO and to be ironitored by
the
State
Health
Directorate
State
Tuberculosis
and
the
Officer(STO).
ii.
The states should strengthen the PHC by filling up all vacant
posts of microscopists and providing, if possible, an additional
microscopist for every PHC. 7*
The provision of the central programme
for imparting laboratory technician training of six month duration
for PHCs, should be taken full advantage of by the states, Action
is to be taken by the state level programme officer on minimum
needs programme(MNP) and the DMO.
The STO and DTO may play
catalystic role.
iii. All programmes except family planning should get equal priority
and to be carried out in an integrated manner. Action is to be
taken by the central government in consultation with the sua.
governments in this regard.
iv.
Health & Family Welfare Training Centres
impart training to the medical officers
are to bo held by them at least every year.
should be equipped to
and Refresher Courses
Apart from these four lead areas requiring prioritised attention,
other points which can be identified as needing due consideration of
the state/central governments are:
a.
Creation of a monitoring cell at the state level as well as at
the district level
---- for all programmes including tuberculosis,
which would continually identify the deficiency from the regular
reports.
The DTO may analyse the reports and regularly brief
his district chief utilising the statistical assistant’s services.
The Health Secretary and Director of Health Services should display
keen interest in the results of monitoring and take action on
the identified deficiencies, in consultation with the STO every
quarter (at least annually to start with).
n
b.
A liaison is to be maintained with the district hospital specialists
or medical colleges in the area, if any. Mi sunder stand ing between
participating units of the tuberculosis programme is more often,
than not, due to lack of communication, This can be bridged by
the DTO with the help of the DMO.
c.
There is a long term need to develop the concept of supervision
on an integrated basis to benefit all the health programmes.
Research on this could be taken up at health research institutions,
eg., NIHFW (Delhi) etc.
d.
Maintenance of supply line and repair services at the district
level calls for constant attention. The programme officers should
not underestimate the need for carrying out a proper planning
for procurement of drugs and materials in time and effecting as
well as maintaining the supply line of the participating units.
e.
Initial and sustained publicity should be given through media
to create awareness among the public about the health facilities
that are available in their respective areas, which can be made
use of by the beneficiaries.
CONCLUSION
Various are the problems which face the DTP today. This is expected
of a lively programme that changes with time in tune with the
requirements of the situation.
The administrative perception of the
efficiency situation of the DTPs themselves keep on varying as a result
of the exercise of matching the achievements with expectation, taking
place within the system all the time.
It is expected of the managers
of the programme to take stock of the situation and plug the loopholes
expeditiously, instead of allowing them to cumulate and acquire
frightening dimensions over time.
The DTP in 30 years has achieved considerable success in coverage
of the population with the required services.
In absolute numtex
case-finding has also gone up considerably during the last decade,
Latest treatment facilities in the form of SCO is now available in
places where even a few decades back no anti-tuberculosis services
could have been expected.
Still, we dwell here in this paper, mostly
on the deficiencies and not on success, so that we are able to remove
We endeavour to scale newer
them and achieve the required potential,
heights one after the other methodically, even while realising that
the peak could still be far away.
PRESS, THE AUTHOR
DR K.CHAUDHURI,
K.CHAUDHURb RELINQUISHES THE CHARGE
OF OFFICE AS THE DIRECTOR, NTI, BANGALORE,
HAVING ATTAINED SUPEKANUATION ON 31.1.1992.
AS
THIS
ISSUE
IS
IN
I
CURRENT TOPICS
Nil NEWSLETTER(1991) 27/3 & 4, 62
DISTRICT TUBERCULOSIS PROGRAMME - KEY ISSUES IN MANAGEMENT +
K Chaudhuri*
The District Tuberculosis Programme(DTP) is designed to diagnose
the maximum number of tuberculosis patients
reporting to the health
services and treat them effectively with the ultimate objective of ,
bringing about a reduction in transmission of tuberculous infection.
Since the tuberculosis cases are equally prevalent in the urban and
rural areas and 80% of the population is in the latter, 80% of our
tuberculosis burden is also estimated to be among them.
It is,
therefore, considered necessary to create a
suitable infrastructuie
in the form of DTP to diagnose the patients
reporting at the health
facilities, wherever they exist,
in order to reach the patients
distributed in nearly 600,000 villages in the country.
It is only
through a high coverage of patients through general health services,
that it appears feasible to achieve the above objective of the programme.
A national Monitoring Cell was created at the National Tuberculosis
Institute(HTI), Bangalore, in recent times, to monitor the efficiency
with which the DTP is operating towards achieving its objectives. The
main activity which is being monitored is, of course, the efficiency
of the programme in terms of distribution of the facilities (coverage
of services) and efficiency of diagnosis at the available centres;
and to a lesser extent treatment compliance. No doubt it is difficult
to study the issue indepth from reported data originating from the
routine
service
appears
possible
to
agencies.
It
nevertheless
hypothesise that the diagnostic activity under DTP takes place only
at centres where the drugs are available and further that only such
are the centres who report their activities.
Hence fche efficiency
of case-finding could, in a way, be seen
o 1be synonymous with the
total efficiency of the DTP reflecting that of treatment delivery as
well.
It is generally believed that case-finding activity is more
amenable to improvement, since it is the health service which happens
to be responsible for the diagnostic activities.
On the other hand,
the efficiency of treatment services reflects more or less a fixed
kind of patient behaviour provided, of course, drugs are available
at the c'ntres concerned.
It is believed that whereas better management
actions
to
tone
up
the
system
could
and
should
result
in
higher
efficiency of case-finding, far difficult to render and less well defined
socio-economic inputs are called for in order to organise changes in
patient behaviour pattern.
Consequently monitoring seeks to study
the case-finding efficiency more vividly to enable identification of
corrective actions.
^Director,
National
Bangalore-560003.
Tuberculosis
Institute,
■^Based on the address delivered at the WHO
Activity, held at Bhubaneshwar in October 1991.
3,
Bellary
Group
Road,
Educational
• 'I
X
63
The monitoring data is
reviewed every quarter at the
and the
NTI, Bangalore,
reports are transmitted to the {
the central/state
to the districts concerned through
governments.
A review of: the
states gives U6
us occasion for
programme in different
serious
thought.
to remove
Based on these,
the deficienci
could be initiated by
authorities at the nation:! S
the
level
as well as at the
concerned.
In this
it is noteworthy that the
discussing
performance
authorities' at the
! " with the
level
the senunars
seminars conducted -L states
for quite
at 1JTI, Bangalore,
Of late,
late> however, the
NTi has been
year
of the states and discussing
the NTI
beEn visiting some
discussing the findinns
district level health & tuberculosis D® s with the
' State
state as wel1 *=
effort ito inform them regarding the con!,
programme
administrators,
T' ad
“inistrators, i„ an
to them1 °n Performance of the programme."^Th/
use
off the data available
5* °
the
operational aspects of the DTP, e n
are
how r '
arG sensi-tised on some
DTP,
data ;already
'
being produced by the ’health
OrS.anise and Process the
by the health
routine
■< manner and how to derive action „
services under them in a
action oriented
in an ,attempt to improve the programme
effiCOnclusion8 from these
to make it possible
possible fc,r thera t0programme
P
fidency.
it ia an e£for|.
process
themselves, instead of waitingto for
the
ilTI
't86
t
Elr 0Wn data'aource
waiting for the
results of the
analysed
CO the" the
and expect
Discussed below are some 1 of reports
the aspects oZtho
h
° aCt on themaspects of the
and possible rcorrections, as available fr„ rb pr°Srarame implementation
ongoing
™:r.fr°m the pariodia
compiled at the
periodic reports, being
■u NTI in an
the
that
Xtu
lable 1 shows the Indian
population(estimated for 1950)
districts and the
with 438
i[n
health
--a Iacillties
facilities £n them.
district population available „„
The average
shown
to
be
around
1.88
available districts, la Sl’°Wn t0 ba
millions.
of the
J7d
have
been
covered
under
the expectation of
the
DTP(857o).
At
one Primary Health Centre(PHC),
available for 30,000
supposed to be
population, there could be 27,400
Institutions(PHis)
Peripheral Health
in
in' CT°“ntryIl: i* understood that
PHIs are in
position m India, with 15,270
only 21,230
DTP(56%).
of the r
’ implemented under the
DTPs function!
--ng, 38% are
Course Chemotherapy(SCC) .
covered under the Short
In
the remaining,
available for treatment of
Standard Regimen(SR) is
tuberculosis.
Tabic 1 (Please see next page)
STANDARDS TO JUDGE
PERFORMANCE OF DTP
Table 2 shows that a DTP is
calculated to have
diagnosis of 2,500
a potential for
having 1.8 million smear positive cases in an average Indian district
population, today.
These potentials are, however,
calculated on the
basis of earlier NTI studies,
rate of culture
studies,
cases was 4/1000; 50% of wherein: prevalence
were supposed to positive
the prevalent cases
be
reporting to about 50 PHIs in a
1*5 million
-a population; 30% o~f ’these
district of about
--- i selfreporting patients
positive; on an average 2.5% of
were smear
the new
cough of more than t
out-patient attendance had
two weeks duration and
to be »sputum
-10% of them were expected
positive.
These potentials
Of highly' motivated
were worked out on the basis
research workers of
rigorous research
the Institute
under
discipline.
However, it has been NTI working
’ s experience
I
64
Table 1
POPULATION AND INFRASTRUCTURE (INDIA-1950)
1.
Mid year estimated population (1990)
No. of districts
438
No. of DTPs
378
implemented
85%
Average district population
2.
1.88 a
Health Institutions expected:
(J 1/30,000 population
27,400
Health Institutions available
21,230
Pills implemented
15,270
Percent
3.
822 m
56%
Short Course Chemotherapy:
DTPs functioning
378
Covered under SCC
252
Percent
67%
-2*^
Percent of Pills covered under SCO
38%
4 7^ Lfi
that no DTP in any state has ever been able to approach anywhere , near
this potential.
Therefore, it is considered that it could be a stiffV
nay even unreal, estimate of the potential for the District Tuberculosis
Centres(DTCs) to achieve!
It could, on the other hand, be more
practicable to consider the best performance figures achieved by any
DTP anywhere in India to be the 'expectation” for other performing
DTPs!
The performance of the DTPs are therefore matched against this
expectation,
Those who would realise these expectations would then
be offered the challenge of achieving the "potential" as per NT I
operational studies.
In table 2, the "expectation" of an ..verage DTP
in India is shown to be 1,620: 1,120 for the PHI and 500 for the DTC.
It can be observed that achievements of an average district in Indiain 1990 is 52% for the DTP as a whole, hO’A for the PHI and 78% J°r
the DTC.
Table 2 also gives the treatment compliance which is about
33% for SR.
Table 2 (Please sec next page)
The potential presented for the DTCs are based on observations
at the Lady Hillingdon Tuberculosis Demonstration Centre, Bangalore
(all symptomatics eligible for sputum examination and 257O to be positive
for AFB).
The expectation of sputum positivity is taken as per the
best that could be achieved by any DTC(ie., 18%).
65
Table 2
PERFORMANCE OF AN AVERAGE DTP
1.
Case detection
Achievement
Potential
2.
Expectation
No.
%
DTC
500
500
390
78%
PHIs
2,0r0
1,120
445 '
40%
DTP
2,500
1,620
835
52%
Treatment
SR
Percent of patients completing
^.12 collections
33.0
SCC Percent of patients making 75%
or more collections
56.0
MEASUREMENT OF EFFICIENCY
i)
Sputum examination
sputum
examination,
matched
againsc
th.j
The
efficiency
of
manner, is presented for the DTCs
expectation calculated on the above manner,
and Pills in table 3.
It can be seen that the efficiency of the DTCs
for sputum examinations is high throughout, except in West Bengal and
Of course,
Bihar. The same for PHIs is, on the other hand, very low.
some states have achieved a high efficiency of sputum examination at
PHI (Uttar Pradesh-122%, Maharashtra-91%, Punjab-73% and Tamil Nadu-667<.
of expectation).
So this singles out sputum examination at the PHIs
as one of the weaker points of the programme in most states.
Table 3 (Please see next page)
4
ii)
Cate detection
Table 4 presents the efficiency of the case detection in the DTCs
and PHIs which again shows that most DTCs, except Assam, Bihar and
Some states performed very
Tamil Nadu performed near to expectation.
to
the
level
of
expectation
(Gujarat,
Haryana, Himachal Pradesh,
close
Jammu & Kashmir-100%, Madhya Pradesh & Maharashtra-around 90Z>).
With
regard to the efficiency of case detection at the PHIs, it can be seen
that while some states like Assam, Bihar, Himachal Pradesh, Kerala,
Madhya Pradesh & Rajasthan performed at the level of nearly 15% or
below, only Gujarat, Maharashtra 6c Uttar Pradesh performed beyond the
i
66
This really constructs a disturbing
level of 55% of the expectation.
scenario for us.
Imagine iladhya Pradesh performing at 947. of the
expectation at the DTCs, but only at about 11% at the PHI level.
The
low efficiency of case-finding at DTP can thus be safely attributed
to the low performance of the PHls almost everywhere.
Table 3
EFFICIENCY OF SPUTUM EXAMINATION - 1990 (AVERAGE/DTP)
DIP
PHI
DTC
Expec
tation
Perfor
mance
Effi
cien
cy
%
Expec
tation
Perfor
mance
Effi
cien
cy
%
Effi
cien
cy
%
India
2800
3437
123
14500
8540
59
69
1
Andhra Pradesh
4100
3508
86
21250
8551
40
48
2
Assam
2130
1696
80
8130
1236
15
29
3.
Bihar
3300
1671
51
6250
2958
47
48 ■
4.
Gujarat
3200
3853
120
25000
14137
57
64
5.
Haryana
2020
5962
295
10380
5034
49
89
6.
Himachal Pradesh
520
2218
360
5630
1363
24
57
7.
Jannu & Kashmir
790
1497.
189
3500
.‘,35
41
68
8.
Karnataka
3300
2557
78
29750
7989
27
32
9.
Kerala
3140
3384
108
15530
7089
45
56
10.
Madhya Pradesh
2070
2777
13-7
16880
4503
27
39
11.
’lahara s’.tra
3700
5097
138
25380
23208
91
97
12.
Orissa
3530
3123
88
21250
8894
42
48
13.
Punjab
2400
3036
127
10880
7910
73
82
14.
Rajasthan
2400
2226
93
10380
2169
21
3-4
15.
Tamil Hadu
5200
6555
126
33750
22461
66
75
16.
Uttar Pradesh
3530
3312
94
7500
9155
122
413
17.
Nest Bengal
6050
1650
27
14000
3674
26
27
SI.
No.
States/Unlon
Territories
67
Table 4
EFFICIENCY OF CASE DETECTION - 1990 (AVERAGE/DTP)
DTC
SI.
No.
States/Union
Territories
Expec
tation
Perfor
mance
PHI
Effi
cien
cy
%
Expec
tation
Perfor
mance
DTP
Effi
cien
cy
X
Effi
cien
cy
i
India
500
390
78
1120
445
40
52
1.
Andhra Pradesh
730
544
75
1700
455
27
41
2.
Assam
330
122
32
650
33
6
16
3.
Bihar
590
144
24
500
63
13
19
4.
Gujarat
570
655
115
2000
1104
55
68
5.
Haryana
360
369
103
830
205
25
48
6.
Himachal Pradesh
110
140
127
450
51
11
34
7.
Oarmu & Kashmir
140
173
121
280
83
30
61
8.
Karnataka
590
299
51
2380
728
31
35
9.
Kerala
560
334
60
1250
188
15
29
10.
Madhya Pradesh
370
346
94
1350
146
11
29
11.
Maharashtra
660
587
89
2030
1450
71
76
12.
Orissa
630
351
56
1700
387
23
32
13.
Punjab
430
331
77
870
381
<14
55
14.
lajasthan
430
315
73
830
116
14
34
15.
Tamil Nadu
930
414
45
2700
734
27
32
16.
Uttar Pradesh
630
400
63
600
373
62
63
17.
West Bengal
1080
159
16
1120
360
32
37
DECADAL TREND
Whereas one has to be concerned abort the low efficiency, as in
the earlier paragraph, a few points need ti be taken into consideration
while
according
priorities
in
correcting some
of the
programme
63
The number of sputum examinations has increased from 4,500
activities.
But the number of cases diagnosed has
to 12,000 in the last decade.
been commensurate with this rise. Secondly, the proportion of
not
smear positivity out of new sputa examined has shown a declining trend
'both at the DTC and Pill from 147o to 11.5% and 107o to 5.27o respectively
during the decade.
>•
POSSIBLE REASONS & SOLUTIONS
The low case-finding activity in DTP, assigned to be
deficient activity at the PHI, may possibly be attributed
following:
1. Improper
officer.
selection
of
symptoms
2. Improper smear preparation
PHI microscopist.
and
by
the
PHI
under-reading
due to
to the
medical
by
the
3. Non-availability or non-maintcnance of the microscopes
(15-207o of the microscopes are- estimated to be out
of order at a point of time).
4. Attitude of the staff at the Piil.
5. Inadequate knowledge of the
of diagnosis and treatment.
staff
regarding the mode
in the prevalence rate of smear
6. Possible decline
positive cases in the community and therefore the
low smear positivity among new patients attending
Pills.
Both administrative and technical actii.is are called for to solve
these problems.
ADMINISTRATIVE
Administrative priority
Though -uberculosis is a single major infectious disease and
health problem under the 20 Point Programme,
recognised to be a public
[
it still lacks the requisite priority among major health programmes.
It cannot be ignored that some of the national health programmes tend
to work as powerful
powerful vertically oriented programmes, even though they
use the health infrastructure
infrastructure designed
designed for an integrated healtu care
delivery.
The
The malaria
malaria programme
programme as
as well as the UIP can be mentione
in this connection,
connection.; not
not considering
considering the leprosy and family welfare
programmes which are vertical health programmes by design, with various
It is little
kinds of incentives being offered to all concerned!
realised that in the process, these programmes may in fact be weakening
the fibre of general health care delivery system itself, by relegating
its philosophy, objectives
It is
objectives and activities to the background.
true that, in
in pursuit
pursuit of targets set by a few of these programmes,
the medical officers of PHIs, in some instances, do not have the liberty
69
to accord a high priority even
r*
. . . .by all means,
to out-patient care,
which
should be his basic function!
He may often be required to be absent
from his seat at the PHII discharging
*•
other duties> outside!
This could
outside!
he undermining patients’ faith in the
ln the institutions themselves to the
detriment of programmes like
like DTP,
DTP, whose
whose success hinges on utilisation
of the available services by the oeoDle’
Moreover PHI staff seem to
at the PUT and a
"or t^ie stlpulated programme activities
- -- ---- — -rculosi:
The administrative action in this j
regard which should be taken
at the central and state level authorities,
is to allot equal priorities
-o a
the national programmes, leaving out
family planning, which
alone can be a special case.
There should r
as an operational necessity by all other
lhe district administrative medical officers(DMOs) should programmes.
review the
family welfare y
---programme
as the last one in the list, sustaining interest
in programmes like tuberculosis, DIP, malaria,
general health etc.,
and allowing these to
occupy some of the discussion time at their monthly
review meetings.
The DMOs should familiarise
programme dynamics in a manner enough to review themselves with the
the performances and
display the required keenness.
Sypervision
serious
activity of
(Table-5),
It -s usually put forward, as if as an alibi,
that either the vehicles
are not available or the available vehicles
are put to all conceivable
uses, other than for the DTP.
Table 5 (Please sec next page)
The DMO s must rectify this situation urgently.
Wherever vehicles
are available with
the DTOs, the administrative authority must insist
upon the DTO to make the stipulated tours.
Wherever vehicles are not
available, an effort must be made to locate spare vehicles for use
in DTP.
Till that is done, several programme officers should be made
to tour jointly.
rhough the concept of
of joint
bv several programme officers
joint tours bv
is a
igtit step towards achieving optimum use
use of the vehicles and fuel
efficiency, ccyet it• cann°t be construed as
Each
a permanent solution.
programme officer has to get the PHI doctor to devote adequate time
o him separately in order to have an effective interaction during
re supervision visit. Several programme officers, all demanding similar
attention from a given PHI at the same time may not be conducive to
a good communication situation.
However, the alibi of not supervising
G^1GX1S^.ln8 Pro8rai[unG and not implementing unimplcmented PHIs as given
y he ulus, should not be allowed to stand. The district administrative
level oi^cers have to somehow see to it that the DTOs carry out the
supervision
Cne^ are largely meant for, ie., implementation and
70
I
Table 5
SUPERVISION OF PERIPHERAL HEALTH INSTITUTIONS
1990
Pills
SI.
No.
States/Union
Territories
Imple
mented
-
Super
vised
7o
India
15270
6413
42
1.
Andhra Pradesh
1215
595
49
2.
Assam
340
129
38
3.
Bihar
597
281
47
4.
Gujarat
1190
547
46
5.
Haryana
310
127
41
6.
Himachal Pradesh
376
128
34
7.
Jammu A Kashmir
123
81
66
8.
Karnataka
1720
740
43
9.
Kerala
545
114
21
10.
Madhya Pradesh
1877
432
23
11.
Maharashtra
1914
1225
64
12.
Orissa
689
172
25
13.
Punjab
325
39
12
14.
Rajasthan
633
263
38
15.
Tamil Nadu
1345
52?
39
16.
Uttar Pradesh
1057
634
60
17.
West Bengal
567
74
13
!
Deployment of_trained_gersonne1
Th. DTP requires some organised involvement of staff u-oth at the
The DTC staff trains the PHI staff on their visit
PHI and DTC level.
This is why in the previous para, a lot of
to the respective PHIs.
stress has been laid on the DTO and his team visiting the periphery
regularly.
At all times, the Implemented PHIs must have in position
the staff who have been trained by the DTO and his key team.
However, it has come to light that for some strange reasons the
" . It will
DTCs themselves are not staffed by the NTI trained personnel.
the
results
if members
team
to
achieve
I
------be impossible for the district
trained
in
the
first
place.
NTI
are
not
of their key staff themselves
for
the
programme
administration,
trains the key workers specifically
No level of academic qualification attained by the DTO or his team
NT I, since academic
members could replace the training given at the NTI,
71
training does not train the staff to carry out the programme activities.
In some of the states the situation assumes alarming proportion, because
of non-availability of trained personnel especially at DTCs, for ex. ,
It becomes
in Orissa, where most of the DTOs are not trained at the NTI.
of
this
the
dynamics
specifically
difficult
to
comprehend
non-availability of the key staff at DI'Cs, since NTI runs two courses
It is for the
every year for all the programme personnel for years.
states to utilise the training capability created for their benefit
and manage the trained man-power in such a way that the centres are
staffed properly.
TECHNICAL
Microscopy
The reason why case-finding at the district level is not fallen
short of the expectation, whereas the same at the PHI is very low,
probably rests heavily on the availability of a trained microscopist.
Apart from the administrative aspects of the issue for not posting
a microscopist at the PHI, it is possible that even when one is
available, he is most likely to be on the pay roll of the malaria
programme. More often, than not, he is not trained to carry out the
sputum examination: either it has got something to do with his initial
malaria service background or with the inefficiency of the DTC team
to convince or train him.
The district management should waste no time to arrange adequate
training to all microscopists working at PHIs to (Collect the sputum
samples and examine them properly.
The medical officers themselves
should select the right persons for the sputum examination. The required
technical training has to be imparted both to the medical officers
and laboratory technicians by the DTO and his team during his supervisory
visit.
The training aspect could also be strengthened by the DTOf
with the active involvement of the Regional Family Welfare Training
Centres.
Microscope
Tuberculosis programme relies only on a simple microscope at the
PHI for diagnosis.
It is as simple as that!
Still it requires the
that ?
required attention from time to time. The district laboratory Mechnician
should help xn servicing the equipment every now and then and train
the PHI microscopist in microscopy care.
the DMO should take appropriate
action to replace or repair the same as the case may be.
Change in casecontent
Possibility of non-achievement
non-achicvement of the desired sputum positivity
at the PHIs could also be attributed generally to the dwindling of
smear positive case content in the community as per some reports. The
matter is being investigated by the NTI.
RECOMMENDATIONS
Only the very basic shortcomings in the performance under DTP
The following points
and the reasons for these are short-listed -above.
72
need to be considered for action taking on related issues on a priority
basis.
This cannot . serve as a comprehensive list of actions , to be
taken, but is designed only to underline the areas which can‘ be improved
with a little effort and to create the necessary awareness ;on these
aspects among programme managers!
Research
Since there can be a change in the action taking pattern -of patients
in tne
the community over the
and the proportion of smear positive cases m
need
to
study
these
to
have
a better estimate of
years, there is a
expectation
of
other
activities
under the programme.
the potential and <
skill
of
the
PHI
staff
also
require a ? study
Knowledge, attitude and
for
their
preferential
performance
in some
to find out the reasons
or other areas, if any.
Case-finding
i.
Efforts are to be made to increase the coverage of available centres
Action is to be taken
by implementing the programme in them.
consultation with the DM0
DMO and to be monitored by
by the DTO in
:
Health
Directorate
and
the
State
Tuberculosis
the
State
Officer(STO).
ii.
The states should strengthen the Pl-iC by filling up all vacant
posts of microscopists and providing, if possible, an additional
microscopist for every PHC. The provision of the central programme
laboratory technician training of six month, duration
for. imparting
:
*"*■
for PHCs, should be taken full advantage of by the states. Action
is to be taken by the state level programme officer on minimum
The STO and DTO may play
needs programme(MNP) andI the DM0.
catalystic role.
iii. All programmes except family planning should get equal priority
Action is to be
and to be carried out in an integrated manner.
consultation
with the sua;
taken by the central government in
governments in this regard.
iv.
Health A
& Family Welfare Training Centres
impart training to the medical officers
are to b- held by them at least every year.
should, be,,equipped to
and Refresher Courses
Apart from these four lead areas requiring prioritised attention,
as needing due consideration ■ of
other points which can be identified
are
:
o
the state/central governments
a.
Creation of a monitoring cell at the state level as well as at
the district level for all programmes; including tuberculosis,
which would continually identify the <deficiency from the regular
e
reports.
The DTO may analyse the reports ;and regularly briet
his district chief utilising the, statistical. assistant ’ s services.
The Health Secretary and Director of Health Services should display
keen interest in the results of monitoring and take # action on
the identified deficiencies, in consultation with the STO every
quarter (at least annually to start with).
.1
'>
7'T
b.
A liaison is to be maintained with the district hospital specialists
oi medical colleges in the area, if any. Misunderstanding .between
participating units of the tuberculosis programme is more often,
than not, due to lack of communication.
This can be bridged by
the DTO with the help of the DMO.
c.
There is a long term need to develop the concept of supervision
on an integrated basis to benefit all the health programmes.
Research on this could be taken up at health research institutions.
eg., NIHF57 (Delhi) etc.
d.
Maintenance of supply line and repair services at the district
level calls for constant attention.
The programme officers should
not underestimate the need for carrying out a proper planning
for procurement of drugs and materials in time and effecting as
well as maintaining the supply line of the participating units.
e.
Initial and sustained publicity should be given through media
to create awareness among the public about the health facilities
that are available in their respective areas, which can be made
use of by the beneficiaries.
J
CONCLUSION
Various are the problems which face the DTP today. This is expected
of a lively programme that changes with time in tune with the
requirements of the situation.
The administrative perception of the
efficiency situation of the DTPs themselves keep on varying as a result
of the <exercise of matching the achievements with expectation, taking
place within the system all the
-- time,
----.
It is expected of the managers
of the programme to take stock of the situation and plug the loopholes
expeditiously,
instead of allowing
them to cumulate and acquire
frightening dimensions over time.
The DTP in 30 years has achieved considerable success in coverage
of the population with the required services.
In
In absolute
absolute numcex*
case-finding has also gone up considerably during the last decade.
Latest treatment facilities in the form of SCC is now available in
places where even a few decades back no anti-tuberculosis services
could have been expected.
Still, we dwell here 'in this paper, mostly
on the deficiencies and not on success, so that we are able to remove
them and achieve the required potential.
We endeavour to scale newer
heights one after the other methodically, even while realising that
the peak could still be far away.
AS
THIS
ISSUE
IS
IN
PRESS,
THE
AUrilOH
K.CHAUDHURI, I (ELINQUI SHE S THE CHARGE
OF OFFICE AS THE DIRECTOR, HTI, LJAHGALOHE,
HAVING ATTAINED SUPERANUATION ON 31.1.1992,
DR
L
t
,
■
J. Com. Dis., I? (2) : 146-150, 1985
UBHAEx
UEIW.Y }r.
‘
!
Naticna1 TB Programme, Its Development, Concepts, Monitoring •
• '
’
and Evaluation Aspects
■/
•
S. P. Gupta*
I
{Receivedfor publication : 15th February, 1985)
■
Tuberculosis in India began to engage attention as a public health problem
from the early part of this centmy. Most of the early attempts to provide treat-'
went for TB patients which meant at that time isolating the patients, in far otT
sanatoriums located in the hills etc. were made by various philanthropic Societies
and individuals on compassionate grounds. The first open air sanatorium for isola
tion of TB patients was founded in 1906_in Tilaunia near Ajmer in Rajasthan,
followed by establishment of similar institutions at Almorah (U. P.), Pandara Road
(M. P.), Madnapalle etc. In 1910, Sir Pardly Lukis, the then Directer General of
Indian Medical Services highlighted for the first time the problem of tuberculosis in
the country and similar observations were made in the All India Sanitary workers’
Conference in 1912. During the same decade Dr. Lankaster also confirmed that
tuberculosis was a widely prevalent disease in the country and subsequently Dr.
Leonard Rogers on the basis of analysis of postmortem reports concluded that
about 17 per cent of total deaths in Calcutta were due to tuberculosis. In I93O’s
limited tuberculin surveys were carried out in some parts of South India and West
Bengal which showed a high rate of infection in the urban and semi urban areas.
As a result of public opinion gathering strength demanding action to deal with the ,j I
increasing menance of tuberculosis, the first concerted effort was made through the '
organisation of the King George Fifth Thanks Giving Fund in 1929. With the funds
raised by this organisation, the Tuberculosis Association of India, a premier
Voluntary body organisation, was established in 1939. In 1944, the first-Health
Survey and Development Committee popularly known as the Bhore Committee after
assessing the overall situation recommended provision of comprehensive tuberculosis
services throughout the country. As a consequent to this recommendation and as a
first step, the office of the Tuberculosis Adviser was created in the Directorate
General of Health Services in the year 1948, to plan effective anti TB measures
throughout the country, and BCG vaccination was introduced for the first time in
the country as a pilot project, in South India, in 1948, which was later extended as
a school vaccination programme launched in 1949-51. The mass BCG Vaccination
Campaign launched in 1951 gave the first indication that the problem of tuberculosis
in the rural areas could be as big as that in the urban areas.
1
J
I
♦ADG, TB, DGHS, Nirman Bhavan, New Delhi 110 C01.
146
s
II
i
•
f:
■'I
t
c II
If
Ilri •
Evaluation ofTB Control Programme
147
Epidemiological scene of Tuberculosis in India
India is one of the few developing countries of the world, where epidemiology
■of pulmonary tuberculosis has been studied fairly extensively and for a long time.
In most of the epidemiological studies conducted by different experts or by different
organisations and Institutions one or more of the 3 main epidemiological tools viz.
tuberculin test, Chest X-ray examination and bacteriological examination of sputum
have been employed to study the prevalence and incidence of tuberculosis infection
and prevalence and incidence of abacillary and bacillary pulmonary tuberculosis
The information regarding the mortality rates due to tuberculosis, has been unreli
able because of the well known difficulties in notification of deaths and ascertaining
the exact cause of death in an individual under the existing situation in our country.
The first National Sample TB Survey was conducted by the ICMR in six .Zones of
the country in the years 1955-58. Limited studies on the morbidity pattern have
been conducted in localised groups of population in different parts of the country
thereafter in Delhi, Madanapalle, Thumkur area of Karnataka by National TB Insti
tute Bangalore, Chingelput district of Tamil Nadu and the last one in Kashmir
X alley by ICMR in 1980-81. The findings of all these morbidity surveys have almost
firmly indicated that the prevalence of tuberculosis remains almost the same through
all these years, though there are some indications that the problem may be showing
I-'1 slow_downward trend, especially in these areas where the services arc well
|
cd. In any case, it can be submised with a fair degree of certainty, that
there is no increase in the prevalence rate due to tuberculosis during all these three
decades. The available data indicates the following main epidemiological dimensions
•of the problem of tuberculosis in the country viz.,
!
r
■•r
t
t
I
(I) The prevcalcncc of infection as evinced by tuberculin test is of the order
■of about 40 per cent in all age groups rising from about 2 per cent in the youngest
age group to about 70 per cent at the age of 35 years. Further, the incidence of
infection is highest in the individuals between the ages of 5 and 20 years, and the
risk of the infection is about 2 per cent per annum.
(2) The prevalence of radiologically active TB disease of the lungs is of the
■order of about 1.8 per cent amongst the population aged 10 years or more, and of
these, about l/4th i.e. 0.4 per cent arc sputum positive or infectious. The annual
incidence of the new cases is estimated to be about 1 /3rd of the prevalence rate.
(3) The prevalence as well as the incidence of the disease is higher in the
■elderly age group and is comparatively more in the males as compared to females.
(4) The prevalence rate.of TB disease is almost the same in the rural and
urban areas. As nearly 76 per cent of our total population lives in about 5, 75, 000
r
148
5. P. Gupta
villages, the bulk of the TB patients would be found in the rural populace and thus
there would be atjeast about 2-3 sputum positive cases in each of our villages with
an average population of about 700 each and about 8-12 persons would be sufferin<from radiologically active TB disease of the lungs, at any point of time.
I
(5) The prevalence rate of tuberculosis is higher in those groups of populalation whose socio-economic condition is not staisfactory and who are living in
‘kutcha houses’ or in slums in congested localities under unhygenic conditions.
(6) The non specific sensitivity is highly prevalent throughout the country
though it is definitely lower in areas located at higher altitudes.
(7) The mortality rate due to Tuberculosis arc estimated to be about 80-100
per One lac population. In these areas where intensive anti-tuberculosis measures
have been introduced the rates have however significantly come down.
Thus, tuberculosis continues to be a major public health problem in the
country and it is estimated that at present there may be about 10 million persons )
suffering from radiologically active TB disease of the lungs of which about 2.2 to
2.5 million would be sputum positive or infectious.
J
Formulation of National TB Control Programme-]ts performance over the years
I
Way back in 1966, the controlled clinical trials conducted by TB chemotherapy
centre Madras, now known as TB Research Centre, firmly indicated that domiciliary
treatment of TB patients is as effective as sanatorium treatment and the role of
extra nutritious diet, absolute bed rest etc. in the management of TB patients is '
ardly of any significance. With the morbidity pattern of Tuberculosis revealed
y National Sample TB Survey, conducted in the same years, when it was proved
that the problem of tuberculosis in the country is essentially a rural one, the Govern
ment of India in 1959, established the National TB Institute at Bangalore to evolve
nationally applicable TB Control Programme which can possibly suit our require
ments. After extensive field research, the institute evolved the concept of District
TB Programme for application throughout the country which was recamm^d to
tne State Governments for implementation in 1962. Basically, the District TB
Programme engages a permanent country wide programme based on relevant
epdcnnological, technical, administrative and financial considerations and is integrat
ed into the general health and medical services at both the rural and the urban
7nS\ T°?y 360 maj°r diStrictS °f the counlry havc been covered under the ambit
ot District TB Programme and nearly 12,000 peripheral health and medical institu10ns are involved in case finding and treatment activities, though not to the extent
to which we would have liked. More
the implementations
More recently,
recently, with
with the
implementations of
c." health
orkers scheme in the rural areas, the
health
workers
of
the
primarv
health
the health workers of the primary health eentrec
centres
■J
1
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i
-x
1
I
)
1
Evaluation of TB Control Programme
149
have also been entrusted the task of ease finding; ease holding and BCG Vaccination
activities. IIn addition, the recently formed cadre of village health guides, have also
been involved in the basic aspect of healtlieducation of the con^^S^Ty and other
essential activities under TB Programme. Simultaneously, the Primary Health Care
itself, is being strengthened by establishment of more number of Primary Health
Centres, Sub-Centres, Community Health Centres and Subsidiary Health Centres. .
Monitoring and Evaluation of the National Programme
The National TB Programme has the twin objectives, namely,
(a) Long term objective—which is to reduce tuberculosis in the community
to that level when it ceases to be a public health problem i.c.—
(i) One case infects less than one new person annually; •'
(ii) the prevelancc of infection in age group' 14 years is brought down to
less than 1 per cent against about 30 per cent as at' present.
(b) Operational or short term objectives—
.’ •
(i) to detect maximum number of TB patients among the outpatients
attending any health institution with symptoms suggestive of tuber
culosis and to treat them effectively;
(ii) to vaccinate new borns and infants with BCG vaccination; and
(iii) to undertake the above objective in an integrated manner through
all the existing health institutions of the country.
I
.H
!
. f
, J,
J
I
■
w
1_ I.
For the success of any National Programme, monitoring and evaluation has
to be taken up concurrently. It is particularly important for the National TB Pro
gramme because of the long pfiriod of time required to achieve control of this
disease in the country. The main purpose of monitoring is to keep a close watch
on the performance of various activities of the Tuberculosis Programme as highlighted
above, so that wherever shortfalls are observed, necessary corrective action is
taken. There is a provision for two tier reporting system under the National TB
Programme, one from the peripheral health institutions to the district TB centres
and other from the District TB Centres to the State Directorate, National TB insti
tute Bangalore and the Directorate General of Health Services. The reports are
prepared by the District TB Centres on a special design standard forms and are
submitted on .a periodical, regular and continuous basis. The reports provide
information on—
(i) the number of reporting centres vis-a-vis number of implementing centres.
(ii) position of the trained staff.
•f.
I
150
5. P. Gupta
(iii) condition of various equipments available.
(iv) Diagnostic hnd treatment activities undertaken at various levels, etc.
The performance of each Centre is matched with expectations and the reasonsfor shortfalls are identified and the programme performance is far below the expecta
tions, then the reasons for such shortfalls has to be gone into and necessary
corrective actions has to be taken.
There is no machinery at present to study tuberculosis situation systematically
on a community wide and permanent basis excepting three isolated surveys done:
in different parts of the country from which inferences are drawn on the tuberculosissituation in the country. The National TB Institute is working on a methodology
in which the measurement of a. suitable index-is'done at pre-determined intervalsin order to study the trend of the disease in the community. It is proposed to
organise repeated estimates of prevalence of tuberculosis infection in 0-9 years age .
group in the community on a country wide basis at intervals of 5 years to find out .
any possible decline in the trend of the disease in the area.
i
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The Rationale of T.B. Control Programme
Sang ‘lo‘
’ ladia
^60034
-560034 -'
cal_Per sgec t i ue
- Prepared by ‘"ARCH"
’ARCH" fflangrol
for 1985 GVHA Convention.
Like all other infectious diseases, T.B. has its own
peculiarities and characteristics. Unless this is firmly grasped,
the adequate understanding of T.B. Control programme is impossible.
One of the ways these peculiarities manifest themselves is to
be seen in the fact that only in T.B. and Leprosy (which in many
respects is like T.B.) the control of the infection in the
community is very closely linked with treatment of individual
cases.
In all other infections, treatment of individual cases
either has no place in control programme or has marginal role
in the over-all strategy of the control programme.
In T.B.,
treatment of individual cases dominate the strategy almost
completely.
This may creajte a misunderstanding in our minds
that T.B. control programme is, after all, curative medicine
with no preventive component.
For a group that is committed to primacy of prevention
this state of affair may not be intuitively satisfactory.
This note is also an attempt to dispel such misgivings, if they
are there.
over cure,
i
(I)
T. B.
infection and disease:
T.B. is unique amongst all the infectious diseases in
that its germs, having entered the human body multiply in
the lungs and various organs, producing what is called
infection, but not overt disease in all the victims in
whom they have managed to enter.
The Tuberculous germs,
thereafter, may be overcome by the body's defence system
and eliminated completely or may be forced to go into a
dormant state.
In a small proportion of cases where the
body's defences are overwhelmed, Tuberculous disease is
manifested, which is the only portion of the total cases
of T.B. infection that is apparent to our day-to-day common
perception.1
The things get a bit more complicated, because the portion
T.B. infection in a community, tuhich is dormant can get
reactivated any time during life, producing the overt
disease T.B..
This gives T.B. infection an extraordinarily
large variability of incubation period. A person once
infected, and in whose body the germs lie dormant, can
become diseased anytime during life.
The spread of T.B._infeetion?
* The spread of the T.B. infection occurs by
transmission of bacteria mostly from person
to person and in some cases from cattle to
human being, (bovine T.B.).
The spread from
person to person occurs almost exclusively
through air.
1 In a situation like ours there are 300 per 1000 who are infected
but only 4 to 6 per 1000 who are diseased
2
* All the infected persons cannot excrete
the germs in the air.
Only those
infected and who have T.B.
. . disease of
the lung and who are actively coughing
out the T.B. germs in the sputum are
the ones who spread infection.
The
T.B. disease of organs ether than the
lungs (extrapulmonary T.B.) occurs
through blood following primary infec
tion.
The proportion of extra pulmonary
T.B. disease is quite small compared tc
lung.T.B- disease. Extra pulmonary
diseases are, therefore, of little
consequence in so far as spread of T.B.
infection is concerned.
Two important points, from the point of
T.B. control may be made here.
(a)
Only lung cases who are coughing
out T.B. germs in their sputum
(Sputum positive- open cases of
T.B.) are responsible for spread
of infection in a community.
(b)
These open cases of T.B. arise at
different intervals and at different
rates from those who are infected
wi th T.B. germs.
■
* T.B. infection is a very
i
slow infection,
i.e. it spreads very slowly.
\
A prolonged
contact with a case of T.B. is necessary,
which explains concentration of cases in
families.
(ID
Ah
/IB- -
Factors responsible for the spread of infection in families
(a)
Infection in family contact is closely related to
the extent of disease and sputum positivity of the
source case.
(b)
Next in line is overcrowding- measured as cubic
feet per person and subjective assessment of intimacy
of contact
(c)
Surprisingly enough,the household income purse is
not of much importance, while what household
furnishings the families purchase with their income
seems to be a factor of considerable significance.
(d)
Contrary to our expectations, nutrition is not a
factor of any importance in the spread of infection.
(a)
Infectiousness of T.B. patients decline rapidly
by adequate treatment.
Thus a patient who is on
chemo-therapy stops infecting others althcugh he
may still be sputum positive.
This is so because
germs in ths sputum do not remain viable once t.he
chemotherapy starts.
This is, what is caJLled,
'Chemical isolation' - an important point from the
point of view of prevention of transmission in
practical terms.
n
I
I
3
(HI)
Factors responsible for manifestation of T.B. disease:
Contrary to T.B. infections where the risk factors are
extrinsic, the risk factors in the development of the
disease are largely intrinsic.
(IV)
(a)
Different infected populations develop T.B.
disease at very different rates. e.g., risk of
developing T.B. disease in Eskimos is 20 times
more than that in the infected, non-urban
Danish population.
(b)
Young, adult, infected women are at higher risk
of developing T.B. disease than young, adult,
infected males.
(c)
Housing, including overcrowding and ventilation,
is of no importance.
(d)
Importance of nutrition is also of a peculiar
character.
Only those who weigh 10% or more of
their average expected weight are at lower risk
of developing T.B. disease.
Those with lower
weights have proportionately increased rate of
T.B. disease.
Strategy of T.B. Control in the light of Epidemiological
Insights:
Theoretically to control the infectious disease in a
community the strategy should be directed at :
1)
source and reservoir of the infectious
germs ;
ii)
the routes of transmission of the germs to
the susceptible human beings via media like
water, food, air, insects;
(iii)
strengthening the defence mechanisms of
susceptible individuals against the invading
germs, e.g. - Vaccination
The most important components of T.B. control programme
are:
i)
Case detection,
ii)
Case holding for the whole length of time
during which chemotherapy is instituted.
How does this strategy help control T.B. in
a community ?
(a)
and
Ue know that the germs of T.B. theoretically
are to be found in all the open cases of
pulmonary T.B., in all the cases of extrapulmonary T.B. and in all who are infected and
have T.B. germs lying dormant in their bodies,
which can become active any time during the
life in a most unpredictable manner and
produce the disease.
However the open cases
transmit the infection most and also T.B. germs
4 -
can be detected much more easily in the open
cases.
It is also true that the suffering and
death is to be found only in T.B. disease,
pulmonary or extra-pulmonary, and not in the
third category in which the germs are lying
dormant.
In the T.B. disease category, also,
overwhelmingly large proportion of the disease
is pulmonary T.B.
In practice, therefore, an attack against the
source of infection has to be confined to the
open cases of T.B. And as long as the detected
open cases are treated adequately, they are
effectively removed from the most active part
of the part of infection in a community.
And
this matters most.
This explains the emphasis
given in T.B. control programmes to case
detection and case holding.
This also explains
why case detection is most reliable by micro
scopic examination of sputum to detect T.B. germs
directly and unumportance of X-ray as a method
of diagnosis.
(Screening of the chest is not
even worth mentioning.)
This also explains the
apparent curative orientation of control
programme which, in fact, is the best available
means to check the transmission- the best
possible way to prevent T.B.
(b)
The reason why T.B. control programme ignores
the classical, preventive measures like improving
sanitation housing etc. has also to do with the
peculiarities of its epidemiology.
Improvement
in housing, specifically reducing the over-crowding
has an influencing effect on T.B. infecti.o.n.
But, it cannot influence sufferings and deaths.
It also cannot have any iniluence on the clearing
of a huge backlog of existing infection in the
community which will continue to generate hundreds
of thousands of new cases of T.B disease for many
decades to come,
It is also of secondary importance
in checking the transmission of the infectioni of
T.B. germs, when compared with the chemical
isolation of active cases of T.B. disease in a
family.
This, however, should not lead to an
interpretation that improvement in housing should
be outside the limits of the strategy of T.B.
control, as is the case to-day.
In fact, improve
ment in housing dees not only affect transmission
of T.B., but also cuts down transmission of many
other infections. No community health movement of
some worth can drop the demand for the improvement
of housing for poor.
(c)
This brings us to the thrid component of strategy
of controlling infectious diseases in the community:
protection of all individuals against the infection
by vaccination. UJhat is the role of B.C.G. vaccine
in T.B. control programme ?
= 02 X 2 0 =
6th November 1985
COMMUNITY H-ALTH CTU
I
47/1,(First FlooDSt. Marks noad
lagDICU F&IJSjxD CluCmg - ANNLaL h.^aT ^^GALOB£ - 5vu 001
„
BACKGitU Ui\ju x"Ax~ Ah,
AS in most other countries of the world, the first antiJ^erculosi®me?s ^es taken in India were of an unplanned adhoc
jgture, confined mainly to the establishm ent of hospitals Fnd—
sanatoria. Partly due to lack of resources and parity to
^reoccupation with epidemics such as plague, saallpo* cholera
poncyCtrin£'aoat it^ ?£id t0 thC <^velopEent of a tuberculosis
were a
even rudimentary diagnostic facilities
liUl C
C- MO CliL •
<-i^c4.iae
ul CJLtrjl
tuberculosis in the country was
*2 1 mooted m 192C aid efforts for control were througl/the
organization of the King George V Thanks Giving Fund. The Funds
pri^iil^
rr"^6 U“liSed
the
CT^s Safety
rrpreventive aim ecucatioual activities, establish-
of hA^+h1 ’iCSl tr,:-1L1Vt “f aecltii visitors and preparation
' ti n of
“ y-*eri£1- In 1939« «« Tuberculosis Associati^n oi ineia was established with the object of providin'
■ .expert aavice, evolving standcxd methods to deal w ith the^
misease, setting up of model institutions for training of tuber
culosis workers, education of public regarding preventive
cad organist meetings and conferences for scientific
nere io^al’k
We
at its inception
? ohclk out programmes, encourage establishment of clinics
cispere. cries ata sanatoria, undertake research ir, con unity wide ’ '
nanageaent jf t&oerculosis and to serve as an advisory buXau.
+ , ^Ofe^ising the eraoruity and complexity of the disease and
mnh et toe needs of large nuaber of tuberculosis patients the
Tuberculosis Association conceived the idea of doniciliarv’treat*.
kSAeEriy S8 iC i94&‘ Jt estobiiehed the New Delhi TB Clinic
(now known as New Delhi TB Centre) to try out the efficiency of
DrtieJf1^5, tto£t^alt '°y 3ftaring collapse therapy froc outt ^ertLeut anc to guide patients aid their contacts
'nd^DD^ie^r
6 ’V^L0E-SUreB' 3516 '-ethOfi wtE f und acceptable
applicable £.e.g the experiment smticfyirg.
c.ljg
The Association established
Lady
,
- Linlithgow
~
Sanatorium in
kasx.uli,. Simla Hills, to
'aemonstrate
•
I'.oc’el sr.na tori urn services.
These institutions were also entrusted with the responsibility of
training medical aid para medical workers.
i*' C u ixilfit v i ■
F
X/X b
jri
^»t the instance o'
’ h__ Central Cover rite nt , the Health
zf^the
Survey anc Development Committee headed by Sir Joseph Shore (1),
ior fee first time, outlined a conventional phased scheme for
management of tuberculosis in 1946 ,
For reasons of scarcity of resources aj d impracticability
ox.e scheme c^uld not be implemajted. The administrator, however
2
suffering uf patients and the public demand’
for definite action, even though the facilities for diagnosis
anm treatment were lacking. After independere e, in 1948 thp
Tuberculosis Sub-Committee of the Kee.lth Panel of the National
Planmrjg Commission, crew up a pr ogratme f^r dealing with
tuberculosis £nc suggested application of BCG vaccination, which
WC.S considerec to be the only measure for prevention and control
01 tae mioease and was expected to yield good results within the
resources cvEilable in the foreseeable future. FolloJng tte
o
2
ang towns. Tnerecfter, the BCG teams were sMft^ + 1 ciJles
areas, is per conventional procedure t*e “euht- „ rUrel
vuoerculin tested prior to vaccination t-J
non-reactor eligibles for BCG veccirati
™ 1 fy t“borc«lin
^vealed
prevalent ^tui^K"6
infection both in rural (2)
ci.*d urban areas which was contrary
to the earlier iapressiui.s
tnat
tuberculosiswas mainly a problem
of crowded urban arecs .
A country-wide tuberculosis sample
survey (3) to get inf >r ..ati on c - *
ov prevalence
verijus strata
str etc. of the country was
versus
’ therefore of disease in
--------.* c jus leered necessary.
vF i1^ TdBx&CUmublb rkCBmNM'
i larg^ scale sample survey was conducted in six zeros of
tie country coverir^
-< lurban a.c rural populations under the
euspices of the Inclicn
------1 Council of fcedical liesearch (3) in
1955-58 to get c£ f__
precise an information as passible about the
eegnitude of the tuoerculosio
_ -- -------- i pruolem in the country. The
survey covered
c. t ot cl po
?uleti
.
* *■—-v^JL jf about 3 . CC . GOG onrr’-irR
residitg r
'
■ncUnfira=deri-U^eC
ru'£-1 cre^s ^f the co unt ry.
'fhe survey r
’ o
? impression of high prevalence of
t uoerciilosis
revealed
toe tX
°“lier beeB
that of w e?bt i il i ?
K WM estimted
about 80% werT'in kf r^aPXL/”**^"1* fr'Jn tuberculjsis
TpyAQ Arm
v
The discovery of specific, potent. '
cvE;.ilabt c.htituberculLPc-;;;;,^7
------------by
Gru&s arc
the effic ien cv
trectuent -proved
proved
/^
liay
domiciliary
by the
the New
New nZlh^m^r
Delhi
- f C1
^Cy
cy °f eotlici
Chemotherapy Centre, jv?rrr^
CfJtr e J4 £ nc' Tuberculosis
ix TB patients. The probability of forZuklinn
ruberculosis pr.^ rr.-. - +-.
rmuja tmg
nnfj« i % 1
J
—
disease
on a cogmunity-wide
basis seemed possible.
The c o n tr o 1 mec s ur es
from those commonly known f£ c^rtrni1^16 0°U^ nOt be flifferent
xor control of ary other infectious
^he£;Semi■e•’ Preventive vaccination,
case-find ir^ £ng treatment . The cvailable to^ls ----for
the
control
c ons is t eci o f BCG vc cc in pti ir ^P'
u • ~ of tuberculosis
w ,cx v M JL ■JL
aid sputun microscopy i^r chef indiX^-r ^0D\°ie^ radiography
chenotherapy for trecthnt
The
^ulatoiy domiciliary
/V
urgently needed
^-t ‘•’f'ouir’*-I^oleL. of tuberculosis was
in terJ o? tr^ne?persor el be .the
“ “gaiafllio^sofl resources
equipment,
___ '
the tools werG to be
^i^C'r ’ erU£E etc
earner
techniques
to be
be ^-Pl^ed
ol.ployed were
some of the ques tions tri'at "r = vnC. ~°
C?“i.?UeS to
The National
iiiberculosis institute (hTljregained to be answered.
rc^
t
e
,
st
^
lishe
<2
in
1959
in
Bangalore
by the Government of ?ibCie toeyolYe
prjtrc..x.c v.-hi * would
answer these questions
be feasible t.K€ suitdote for both
rural and urban er ec.G
/fhe Institute was given
the responsibility
training tuberculosis workersand continuing research for eocificc.tijti clcI
evolut i on of th e pr ogr erxie
in tiie light of newer 111 v>wl edge.
3
m„r,
JT“e.evJ1^ti-^ -f the Nttiutcl Tuberculosis ProgroEte (MP?)
u£.S£< jh £. I)ULaer
factors reletec to e.id"i!loXl
eJidemiolz ic' 1 r
ctete suitAle Z.-th^
f
i ^^ccition, the WX conducted
t £nC J^rcti3K-i studies to ecur,WCre nade BSe
P^Lint the
j**'-^-Xza^Iiilk/jLlvL. XkzXXj j/, up xb
fro.
1C£1 e£t£1 thet I7ere c.nsidered were obtrired
.ir
.uucrcuxxiv surveys coL.ductec by xCU. (1955-58') (■?)
-Dolhi^C), iX^pffiVcij ace
3
jr v (o;.
^c^try
Kiese £tucles r evealed hiat infect i
it- 7
f0Ut 1 ihC t3tEl P^^fioJ of tte
find about.
j Mio annual iic icenco
f d sc —
sv: 2."- «•
Z..
hi^h er age groups.
«•*.«
^Ste.piee?i01% ica ii«irIcs deeded thst tuberculosis
services be s o -organized
--u lc
cover the entire country, on a
peruanert baai. s sire ce cases
zz___ would continue to arise all tie
9 all over the countiy,
Priority had to be civen to finding
sputuu positive patience to
prevent tee spread of infection.
SpgIOIaIwxGaL Uuhtb.i.Liixu.i'x vi\S
Socio-economic core, it io ns in <■— cny -w country
have_ .v?iee
innli1A <%
_ —-r.
.
x
ccti tc for pro^rtiiLe planners,
me
importer
ce
of
the
tuber
—
culosis problem fror. the social angle h£s
J
to
be
considered
m relation to other heel th and social needs of the courtly,
&£oources are the u.iin coLstraints
-J f ^r forr.uk ti on jf the
t.roeraa1...e.
lu.|10A tJxt 95%3Ch°s-ut»rh!hUf?
X
Cun3ucte<3 at the Nil bed shown
various
health
c-itutionsm search .;f relief fjr their ch est
r—
- J syr.pt ors . On
ofe?coo
14 w-s estinted. tbh
---- j abort half
or
e l Jtd 5C00 infectious cases in rn ■------average district with
Of ;^UJ 1,5 l illlon ^tended tee
'-J gene rd. ie alth
IE ti tut io ns. vut of these about 2CG0
c^xld
be er.sily discovered
.yt/- sputum microscopy, £-tJ~e
; ' '
first
point
of
contact in a. net
wrk of general health"services .
Kxi';:hLs‘ xsrdsn? >
-•
shortest
was not cons klered likely,
it
V7£S
satis fact r y
treati sr-t e« sp.tuc coiyersian could be expected
to res ult
4
in reduct io
However,
to the
2J. the tUjorculosis oroblen pithir • *
c fop ys £_rs.
^‘e effective,
- _ J Fie ar
pEtillX5S? Q“CCtiVG>
h &e'3ffer^
Ox'i!hualfxvAL>^
Gas e-ii bdi, to
cty iL.pt.
iL-pcct
rjcuoe eny
ct oc the problem of
i_ ex; to „
of c es es c"
in rural accl urban c.reas
,. x cs c. one-tiL-e
efiortjer-uhh
V£th-a£ t;'En
onc-1 iz;e ef
f or t.
teth
or
htii
otf*
’
tth
1HT cese-f itg inr
CP S’ *1* to.r^WSiSTTe
Hobile te gLs 7
of -ess uiHetiro i-LCiS, r-yhv
-tub^c ullIL * es tTTEFlis e
iu b ercu 1 os is
LhfJtjr cenSes etTg at the c iotri ct^hh 0Ut i" vilif’£es> ^imry
cp^icltion of Mbiie x_ray unit- for 1r® •“J0?itels •
thi'.uth s..vciaiso?-.e-p'^php6;? r g^yculosis case-fire’ilE
wes iounc o.eratihdlv r Xht -^rCU10S1£ teci E in viH a£es
of cases XOu^wt^S^tt^thT^i^t^fnUnbe'r
.lealfir centres f ta St. or ' rur^i
1
c ct the Pritxiy
Moutst those Who re ort bv
ht
chleS
, £r^
eilL.ert (12). O-oratilblt^ ^eS 10r 1 elief of
eir
to villate6, InaCeqLcy or hseLeeo“3fCcifiH°Or 5p-rocb r0EC’s
aa. repairs, shorta e of Y-r-v film i“11xti es for laint enatc.e
JC-rny united esorMtantVu^in o^st^tr St£W *2 °perete tfce
ciniaturo i-ray uni.s hr case-fin <1^ the “
is V
e ef1 IOblle CCGS
In the NTP th e acthoCol . v r e
1'>Une feasible .
I WariiMJij^oi-s^^ of at'i^’tBM
/ at tile institutions of , -ier <f Vo - th
V“V: CiiCSt syapton^
thouhh siuple, eeonoJ^ffrZ1 £ 2 liSb’ T^s pro
™,
™ Sowa prgttoata^e techulcd
^unk '
the G^^1
Ifu^Jb.^i^C/Jo^-xfvxuLxiG )
<
The t-ain £iia of <case-iird
—
..........irg is t o t_
treat patients, ajjeviat;
teeir sulferitg C.nc toJ p
•
p^ut-Cown
tae transnission of itf ectio[i*
Uie priority in -fc , i.i’P EZd ^o Oe
-o c ivento fi®’. irg
d treat iij
s puU
iiiv e
11 ant s, since they constituted, theaa i£_aed.7
te
_publ ic ho alth ^r able a.
s e eki nc roll ef u nt er '■ - xx.e sputuii negative patients, however
curecn^J
the benefit .f cia^nosis
—» c nc cure Give services «
were found ^^TIT^r^sup a^of
treataertser.
hones as possible
l^iec ma reguler treltT^rt S
" *here wlth regard to prosiacleffects aW free uvcilabilit^
reL1L-eES few iron
crucirl factors for orc ur i r ' *-rX - ~'f^crugs were soeb otter
L<e care
tahen f or ceetiL
tre£ tL;ent
itsconpie t ior.
uee-cxr^ tnese requ r er.ai ts.
by thcr'M-l!rCaeLfat“study
itU?c (13) on
cofwtefi
The ^at ia.. ts res iclirg
foir groups, 0£
& *7group
_r_ou 3 ‘ co
t n f-fth 1G v 11
es were divided into
consistiw.
v-TnatesT-The
Theeato
drits
for
one
/X?
of
ort^^
°f E<3Jacetlt
drut s '■
Aarea
Citqc. health
nr.uith centres. To *tart rd'i ** x1 S were star^ et th:
h
^lth
—*s xi_e. 1 th ceif
cent r
ree ^ere
where t^'0^ VrtO
Officer, given det' 4 lor i <
+• 1LbrocLceC; ts ^el/iedical
Mnt for’ Me yeb^Tiven
f™“ V?,?
treatIn another
^ej^L^^/^h^
"th were^dHsed
_
------ i^oor-s f. ru 1°. O.oIiVtier' ' the Patients
------
to collect oru.s
the tfc ~y v■ ’ -
— - tx^e Panchayat i-eabers fortnigitlv.
5
roTul^r
enrirg thecoxse
> f the ir
* <tiUur irtiat try visits to the villa es
To
the
fourth
tne ^rugs were distributee’ tiir .nrt> M
heal^ visitor, in the Patients homes f^tn^specially
tK"
agpointed
re^rity of drug intake through en the f± . ‘ • Th e
ftoimr: hardly 30% to 40% uf “■
tne four channels was
This
th- d’ bJ0-11?
CE’Se wkgre.Jhegills r-■
ct
by
the
spacial
stilt;
TO^yrath'cetoe
being si nil
ar” to
cul us is ^erci^ ---ices
c^eieie^, it was concluded that the jricarv
h
ceutr es are
as well eccp •J+^’iio
r
4.
.
xn.exy real h
Ir
thZ
i
’
j
v
-w
?
centres
for
tuberculosis
s er vic es .
‘ “ drn «bZierefOr 6’ tice gene
generEl
ral institutions
ins t itKtions
were activated,
centralisedto be giver/*jtA ■ ?u
£ r^
— the
—j treati.ent
treati.ent was
was de(^e—
-ostly for self-adi-iDistration “wen* su^ii
7 brsis > ’ Drugs,
Drugs,
,. 1/^
-—
near tie ^tients hone.
’
sailed free of charge
IidTbiGuaTii) h
Specialised services wei’e found ii.grccticabfe
would cousu^siUs.tatiaL^^.^^an 0I recou.ceS) £S these
cwelo^ Bbt ol essentia hklt* *rogr^s e6
depriving
^FurV^r nhEMr
66
&OCial ’’^viSeB
rura.er, taking ir.tiaccjurt tae seech r tretfi
he tod^ry’ fce WKP/has t3 continue I or
vne ciagnustic services (sputum microscopy)
^r£tive itservice star,tod
to ed
- — — '*'-t iJr til pit’ ppflv
applicability all
over tlie c untry. 'these besides beitg sirole
V7er e with in fcie t echnical
The pr QP,rai_;_e , in orGer''toCreet ^Ce °f eeiErd practitioners. ’
orcer to meet tie above r efAu irere nt was
conceived as an in
i tetral art of overall cevelopreit of general
services instead □I
of functioning
:
in isolation ash s.;.eciai!sed
vertical progrtGi.e for control
--------- Ox tuberculosis alone.
--------- ----------------
1 •!
SCfr- Vh^CAK1 ATI o hi (PiuniVaieoixj)
^i°r ?o .lormulation of M'i> riCG vaccination in India was
s ter ted in 1951
--- as a Lass campaign with fee help of so ci J
BCG tears .
set up teuporazy
! a centr£1 Place in every locality
Those who attended
e '7ere Offered tuberculin t est
at first attendetK)“ e . HOG1'1vaccination
vo.ee
mation r
were given to tuberculin
non-reactors at second
after 72 hours,
attended the centres for
of the test at
could he given BCG. BCG
coverage by thisprocedi.
was_ inadequate. ; ‘ _
vaccination prograue
was integrated wit—
a the
—j curative servicesJ of
-- the
■•
district
tuberculosis prograat.e as s part jf the c~
cocgr ehens ive tuberculosis control progrcuue. house to house
- o vaccinat ion (14)
waa rec or., ended at first, Later, d..
nat i on wi th out ■'tuberculin testing (15)i9G4, direct BCG vacci —
c~i9 yetrs only was advised. restricted to the age
These liodif icat io®
well as < •
the
.-r ogr ai.A
e,
vaccination tutoculiL •tect^
tother^^if
3f pre~
test.
in BCG
smallpox
at
ti?e.sc“°01
Children in schools?it the cities and
All these aired
Site e 1977,
k3&rt of the expanded
. _ -.j s taff of
o
fr0G ^eatj aEea *°
-r.;: -T;. .“xtpP”
„ lo
„ b.eSftXsViK
6
6 oner al health
services
first‘v® UJW
y> eil-iL,
c- ul‘tr
try
.iir.,t year of faeir
life.
L-ultipurposg health
workers all
v^ccirati on of all
new-borns in the
.LIV)
Permanent K"iljr
•
^e£e fe-*ur
^verace of
—e
es- and
--(li)
£L
d
(is)
country-Wide
coLveivec al. a evolved
) was txie a unit
, was
rn 1962 1■•
oy the
hl7’i,
u/i o e r a^. 21. e w c.s s
-ys
t
ei_a
tier
educ
1
1
o
11
of
xxie
objective
of th e
-iiu^ing uajriaur.
-- tuberculosis through
nueber
of
sputun:
Luore than t.e
incidence), positive patients (probably
ireatient, as yearly
Prevent ion of‘‘ia^ge^rSortio1"°T e“ect*ve
well as yr
susceptibles throng BCG
- vaccination.
portion of the
Briefly
tealttT1®
’M-tSSJ? *> «* ’»• w
^'SioW/^^ D*® ' res See
in^i
Of gelTal
Patients to he fol?o “Ptre£tie
ect s^J"fSsi^ of
patients, (c )
, i
jy culture end abaciiin ■'U*u‘" positive
ooi^onantsp/th
resource itu^ ^^oulosis
(C) operational, 0^r±-aLf^put £n d progr
in
adui-
the Ll’r i-,hich is
a unit of the
ceric re nd Ui) the
(i) LjjjfftACi) ■pa3|ii.,Ci. .. c t
—------- —>S
jjwa. y
Tne
were recoiaC
s id es r ~
^r.d curative r
resjoLi;ihility
, j, 1,0, or121
addition 1
t uberculogjfi u?dic al of ft
er
Specialise) 4,
~
9
xhe senior
technician,
x»Cg teaa ; _
-1 the Kfi so t.atl^';^^--erv^e“5h^ed
trainiig at
in taeir
responsibiiitt
additional faciL
Provided
tfanse“'teit;e:
s; neceBB&ry iteCs t
record
ihe
Peripheral
heath
fiiaenostic, cur
£
tivp
Sta
"
curative ar.d Brevfrh1 feGrertl health rs
er
v
ices
in th e
Kley have to1 superviSe the
Preventive
itBtitutiowV'!1£ti'_E to
'
’ t ule rculos is,
servic es' *®4sL'1£-rly to ensure satisf-ot" t:>^ tiie Cer--eral
he elth
findirg , axaenosis, treatL®t° recoP ir7 tochctqueB of
c istrict centre provides uecess^v
fe and reportig . cas cstains, record for^s etc. l-Ce“s^ xt ens of supply like The
drugs ,
(ii)
;FirBrle-w ji&rt±t^lzh®ctGU^visi of
of a dlst^
hy the
Ler.eral hs £ it h pservic
*
es
£f'C ar© designated
-J
as
.. _
."X-JP
z-VM- -4
I
,'V <
7
the ones done only sputucssGear microscopy is possible h-?
°f S?utuc Xination
aesignated as 'microscopy centres'. Ofc ers were n-eiti er J'-ravglcl"°JC0?.es “e available, are entrusted with the r esponsl-'sr n^y 01 0011 acting sputa from symptomatic patients of oj-eoaritE
f‘tld o'-lxlIfe 4he;- to the neerby institutions hrviig ‘micro-*
deXnXt
^“ttion: such institutions have bo^en
jr "x.*-».»•
-fsi"
^C,il^orrl centres treat the patients on am'irlrijiv
^cilxary b^is
The
Tlie drugs
dru£s for
fjr their
taeir treatment
trectusnt are sup-fi^
oy the District Tuberculosis
**
co.
-- ------ ; Centre.
The District Tuberculos -s Officer and his tear. lave fe on
‘•aae responsible for trainin
c? cJrEtion of work, arrangirg
cu^^iy, oupervisior, ixc- compilation of the reports
in respect
of
the working of tc tuberculosis programme ir. the entire
district.
» g"“' ■««
v
Th e r
t.l cr r c-por ts on the. performance of LTP, <
quarterly by the Birec ter General of health Services,compiled
at the
natiDncl level reveal that the achievement regarding , caserrti case-holding aspects are about
36% of laie e^t>^^tations .
h review of the i<T<.was undertaken by
by the
the( 1CW
IChfe ' Exper<
Expert
(
Co^ittee in 1976. The Committee highlighted.
?
' some inadequacies'’ ,
recarcirg operational aspects, the almost com lete absme^ of
supervision by the staff of BTC,
Ll^vxxw luL
oX
District and State health >
administrction, the inadequacy Lf tiie
posting*of^staff
and sappliesy
mac_-. ^i interest in the programme at all levels was also reported,
correct ive actions were alsj suggested, the results of whi<h
.still reaairi to be seen.
»
'i1
Wviui'^tb
01.-0-Ui-^TY
■.
L-blLEb h-JB TIJE kLLTI-PUkPOSE
.a.
t0 Jridce the gap between expectations a rd a& ieveu-ut c.ttempts are naw been made to avail of the services of the
con unitv hPfi^a-structu- e of Lulti-pur?ose health workers and
of th” c^ant ri
"PriL£ry Hetlth c°™" prograute
Tuberculosis case-finding which was of a somewhat passive
sputa -oec^er" -T
G ekr-tioc- ^ey can collect
ihe Pri "-rv '
1+X
1
^s^ns, make smears atd send these to
trne Pri^ar^ mec.lth Centre 1 jr microscopy. This strata... ■ "1
augment tuberculosis ccsg detection c jnsiderably. A recent Iv
^r^UC^SC stu<3y (2C
shown that multi-purpose heath
S? ,C£f Perf^ th’i£
clong with taeir
er dut ies
cintt taeir routine visits to the households, zlti oug.h in the
8
«rs i:“SSr
woulc
substantial,
two rounds of
subsequent visits
average, 2-3 sue.ers
* By this nethac! th e
ns id er ably.
& upervise ard uidp tbn»-+
•
t^eir areas they ■can
retrieve the defaalters‘'mJ® Jttvttc0‘etMt‘u,'t reguhrity,
regularly. It is expected tfat -ViVi® , c^tinue treatment
definitely i^ove the 7^ ^’^^n
i-.^auh1:^8:^™ under the
°*
•f
entrustee
with the
res
nation alont are
Jther
v:;lti:
11 xi ot
he r vacch^
v acc i izft
t iIfnZ
or- □. 60BCGv^cilr‘ a yTar/ tee WiU
tte^in^
will &e
be vaccinated b^
by fcat in
in'the^vill^
hc.ve shown that the'oj’i
c ,£kjC
stuflies (21)
capable discovering iL
y "d
th ins tit u tiers is
i-LS cases in tne cistnet, c^..ut
?°j1 of inf GCt“
annual incidence i.e. C5% f -? «
Cr<: c i2G^f tines the
regards the case-holcin
utent^itive cases.
uecoae sputua native, 2« co^tilu^tn infections patients, 63%
^f one year of treat^t afd IM
Vf
J ^sitive
the end
fell considerably short of tfae fotertl..?1 “tu&l Performance
case-firdiig .
1 er*tial, specially in reject
the
’ ^i^i^es potential c r£ peri or r. a no es of
Governae^r ler “ e*l “ft ■*
'
/J.thoi£h primarily a
,,->1 ^^e-raut-e it neecs active
co-operctioL
assistance
riht
^‘t£ry Realisations,
heflth imitations and
ih ? L-eGlc^i Pfectitioners.
“ h°pe t0 aCliicve
it- objectives speedily and effectively®11
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