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NATIONAL TUBERCULOSIS INSTITUTE
BANGALORE
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REPORT
,
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of
WHO - GOVERNMENT OF INDIA
WORKSHOP
I
on
!
TUBERCULOSIS AND PRIMARY HEALTH CARE
5th —8th December 1981
!
*I
,
i
I
INTRODUCTION
India is one of the signatories to the Alma Ata P
Declaration of 1978, committed
itself to provide Primary Health Care for all by 2000 A.D. Achievement of this objective
is a big challenge to any country with a huge population.
To achieve this goal, each country has to prepare its own strategy and plan of
action, depending upon the prevailing health problems, priorities and available resources.
In this gigantic endeavour, it is not possible for health services alone to undertake this
heavy responsibility, it needs sustained efforts and co-operation of'all the departments
which are involved in the overall development of the country. This plan cannot be
regarded as a separate entity, but an integral part of the over-all development of the
country where each sector contributes to the total socio-economic development.
The National Tubercuiosis Institute (NTI), Bangalore, > i:
was entrusted with the task
of organization of the Workshop on Tuberculosis and Primary Health Care, i
------ in collaboration with the WHO. It was in the fitness of things that the NTI
was asked to take up
this responsibility, since the tuberculosis p— - ------- ;
programme was formulated by this Institute.
The Workshop was held from 5th to Sth December 1981.
The inaugural session was
held at the Faculty Hall of the Indian Institute of Science, F
Bangalore, and was inaugurated by Dr. I.D. Bajaj, Director General of Health Services,
, Dr R.M. Varma, Professor
Emeritus, gave the key note address, wherein he stressed
the importance of the Alma
Ata Declaration and India's commitment to it. He emphasised that this Alma Ata
Ata
Declaration should not remain
m as a slogan, but a definite plan of action has to be formullated by this Workshop. Dr V. Narayanaswamy, Director of Health f "
.
... ----------- „. .
& Family Welfare
Services, Karnataka, presided
P^sided over
over the function
function and
and explained the
the tuberculosis
tuberculosis activity of
Karnataka and how the State Government has already taken action to introduce the con
cept of Primary Health Care in the heaith Services.
Dr A. Banerji gave a brief resume of
tuberculosis Programme in the country.
The Scientific Session was heid in the premises of the NTI with a 1 "
talk by the
Guest Speaker Dr Wallace Fox,
Director, British Medical Research Council, on the .
latest concepts in Short-Course Chemotherapy
. This was followed by a review of epi
demiological situation of tuberculosis- in
..I the country, followed by sociological dimensions of problem of tuberculosis in the
These formed
the country.
country.
a back-drop for the
exposition of the District Tuberculosis Programme (DTP).
■
This was followed by a session
on National Tuberculosis Programme and Primary
Health Care, where certain areas were
identified in the context of DTP.
Family7 wJif"31 SepSi°n reVieWed ,he Various Na,ional Health Programmes,
such as the
Fam,ly Wetfare Programme,
Nationa! Malaria Eradication Programme,
National
15
4
!
Leprosy Control Programme and these programmes were reviewed in the context of tuberculosis programme.
for the demonstration of
A field programme was arranged in Mysore District
the DTP.
The Workshop was attended by officials front the State Health Directorates,
State
Tuberculosis Officers, eminent tuberculosis specialists, social scientists, professors an
associate professors of community health from several medical colleges of the country.
The Workshop provided a unique opportunity of bringing together part.c.pants from
various disciplines to formulate proposals for organizing tuberculosis programme through
the out-reaches of the Primary Health Centre (PHC).
lac
in t
ble
ent
tun
the
eac
hervic
ihrc
iho
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ind
nor
(th.
con
'eac
hap
and
r»hy
io t
Iosif
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crpei
a opr
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tube
16
of tuber
WELCOME ADDRESS
ation of
by
;S(
Dr. A. BANERJI
State
Director-in-Charge, N. T. I.
sors and
country,
ants from
3 through
Dr Bajaj, Dr Varma, Dr Narayana Swamy, distinguished friends and colleagues.
Ladies & Gentlemen.
This workshop on tuberculosis & Primary Health Care is an important milestone
in the Governmental efforts to deal with the problem of tuberculosis. Most of us assem
bled here have had the privilege of working in the field of tuberculosis. For some the
entire career has been devoted in this field. This workshop provides us a singular oppor
tunity to share our experiences and channelise them to the future that holds the promisethe promise that diagnosis and treatment facilities for tuberculosis will be accessible to
each and every victim of the disease.
About twenty years ago, this Institute, made a giant stride in the field of public
health in formulating the tuberculosis programme within the existing ganeral health ser
vices. Today it has the expectation to see the programme unfurled to the fullest extent
through Primary Health Care - the strategy that would make.health services available to
those in reed of them, especially the economically deprived people in rural areas.
Tuberculosis through the centuries has been considered as an affliction of the
individual rather than a public health problem. Not being endemic with territorial distinc
tions and not being observable in epidemic proportions it has been a 'silent disease'
(though its main symptom—cough is by no means silent). Tuberculosis does not provoke
communities to get together to fight against it.
Nor does it provide a cause which
readily gets the attention of those who guide the destiny of the nation.
Tuberculosis
happens to be a disease, the magnitude of which is realised mostly on the basis of facts
and figures on the prevalence of the disease, the suffering in many aspects such as
physical, mental and economic and in terms of the immensity of the programme that has
to be mounted in the country to provide adequate services.
It was in 1912, full thirty years after the discovery of mycobacterium tubercu
losis that the Sanitary Commissioner to the Government of India urged that tuberculosis
be dealt with as a public health problem. The response from the Government was to
open sanatoria and institutions for treatment in different parts of the country.
This
approach emphasised individualising the patient in his treatment and isolating him from
his physical and social environment, It also gave a firm hold to the concept of treating
tuberculosis patient under specialised care.
17
The inadequacy of beds and treatment facilities for tuberculosis in institutional
v
care, perforce lead to explore alternative ways of caring for the patient. Organized Home
Care Programme taken up by the Tuberculosis Association of India, demonstrated that it
was indeed possible to care for the tuberculosis patient within his home.
r
r
ii
s
. t
th
a
. u
Education on
hygienic practices in respect of the patient, the Seal Sale Campaign etc he ped to create
an awareness in the community regarding tuberculosis.
During the crucial years of the overall development of the country immediately
after independance, it seemed possib'e to embark on effective programmes which would
have a well marked effect on the problem of tuberculos:s. Prevention of tuberculosis by
BCG vaccination had obtained world wide acceptance and in 1951, India launched a
mass national vaccination programme, the biggest in the world, in terms of population
and area covered. The fiftees were also the time, when successful treatment of tuber
o
th
tc
al
culosis by anti-tuberculosis drugs in clinical trials indicated the enormous potential of the
drugs on domiciliary basis. The Madras Tuberculosis Research Centre demonstrated that
domiciliary treatment of patients with anti-tuberculosis drugs under the prevalent socio
ra
economic conditions in India achieved the same measure of success as treatment in sana
toria. The conviction emerging at the time that control of tuberculosis were within reach
can be matched only with the conviction at the time when tubercle bacilli were dlscovered-
ev
cc
he
gn
ch
He
in
Pr<
A.
that the end of tuberculosis was in sight.
After launching the mass BCG vaccination programme - what was then believed
to be a preventive measure against tuberculosis, attention of the Government was
focussed on determining the size and extent of the problem of tuberculos s as a pielude
to its diagnosis and treatment. The National Sample Survey under the Indian Council of
Medical Research revealed the pervasiveness of the problem and other epidem ologic
features which indicated that a community oriented approach was the only way to tackle
the problem. It was given to the National Tuberculosis Institute to pool together all
dre
one
It i
me
cor
scientific information, available through studies and surveys and clinical trials, and gene
rate fresh data to formulate what is known as the National Tuberculosis Programme.
The Institute has since its inception done unparallelled investigations on the
in ‘
problem of tuberculosis in the country under operations research. Based on measure
ment of disease, the suffering of the patient, and the logistics of the health care delivery
system we have detailed the programme which is eminently accessible to the people and
which is well within the general health services.
nuity are its watch words.
Standardization, uniformity and conti
In order to disseminate the essence of the programme in its
pristine state, we have encapsulated the essentials of the programme in several manuals
which guide the work of the numerous health and tuberculosis personnel throughout the
country.
Training of key personnel in charge of the implementation, supervision and conso
lidation of tuberculosis programme has been the privilege of the Institute - a responsibility
which we have discharged in full meassure, so that no District Tuberculosis Centre need
be handicapped due to shortage of trained personnel. Our early satisfaction in training
18
I
ional
Home
hat it
n on
create
<
lately
vo’uld
>is by
ted a
lation
uber-
□f the
I that
ociosanareach
'ered-.
■lieved
was
elude
icil of
□ logic
I
was to draw their imagination to the great potential of the programme through which
persons with symptoms suggestive of tuberculosis could be provided diagnosis and treat
ment free of cost close to their homes and communities, on ambulatory basis
Todav
rn addition, we lay emphasis on the changing and developing field of general health
services where integration has an added dimension with other national programmes in
the nennl “c,or' dovatailln9 wlth °thcr socio-economic programmes. Reaching out to
the people through multipurpose workers & community health volunteers/village guides
are also themes that highlight our training programme. Today we have also the opport
unity to get from our trainees valuable feed back as obtained in their work situations.
Often our optimism of coming to grips with the problem is clouded
h
of any upward trend of the disease, but because of the country-s sa'g^ZmmitmPnt^n
the cause. The malaise takes various forms such as dislocation of key personnel meant
X“sno1sX^'™rUtiliSatiOn°f^
haphazard and dis~onate
nmm»HThete?hrilCa?nd operational soundness of the National Tuberculosis Prog-
=XL’S
chanoes edCe
,uberCut 0SIS Pr09ramme so that it can function within the recurring
changes and modifications of the health system. The clarion call to provide Primarv
in'th’s w
f'nd 3 reSP0nse in ,he National Tuberculosis Programme as well
wl
in this Workshop hope to give the necessary direction to the National Tuberculosis
rogramme which is worthy of the strategy expected to provide health for all by 2000
tackle
er all
are
experi-
gene3.
n the
asureHivery
mendat nn J
del,berations durin9 the various seminars and subsequent recom
mendations, will help rn establishing tuberculosis services as an intrinsic and vital
wmObePri7t:y
C3rS thr0U9h0Ut the
hiding a momentum to it
in 1 J82 will be a fitting tribute to the memory of Robert Koch.
a and
conti-
in its
anuals
Jt 'the
on'so•.ibility
need
aining
■h
SCIENTIFIC SESSION II
''National Tuberculosis Programme and
Primary Health Care"
respect to
ions.
ocial, what
1
3."'
do not have
ifffering, but
e people to
•3
Moderator
Rapporteur
:
:
Dr. D. Banerji
Mr. V.A. Menon
Miss. M.A. Seetha
Speakers
:
Mrs. Radha Narayan - Primary Health Care
Dr. G.V.J. Baily - Primary Health Care and
District Tuberculosis Programme
ruge and so
is
md commujming to the
the primary
purpose.
The outline of Primary Health Care was sketched as a backdrop to District Tuber
culosis Programme (DTP) in the context of Alma Ata Declaration, namely that "Pri
mary Health Care is essential health care made universally accessible to individuals and
families in the community by means acceptable to them through full participation and at
a cost that the community and country can afford. It forms an integral part both of the
country's health sytem of which it is the nucleus and the overall social and economic
development of the community''.
It was pointed out that the country's health system embodies the concepts enun
ciated in the declaration. In the span of more than three decades since the Health Survey
and Development Committee's recommendations, there has been consistent efforts to
improve the delivery of primary health care.
The demographic and socio-economic features of the country and the present
health system in rural areas were discussed in detail.
The following concepts embodied in the Primary Health Centre were enunciated
with illustrations:
nn
t , i
1.
2.
•i
3.
j II lu
4.
5.
6.
Regionalization.
Reaching out to people.
Spectrum of services.
Integration.
Two-way referral.
Governmental responsibility.
At the conclusion of the presentation, areas for discussion were as follows:
' I
■■
> i ,
n.j.j.xj on
1. Can health secetor give a lead to other sectrors of development?
2. Can there be equitable distribution of health services ?
3.
How much flexibilty in implementation is possible between States and within States?
37
4.
Does multi-purpose work meet the needs of the people or is it for the convenience
of the health system ?
5.
what is the recognition given to other systems of medicine ?
6.
Can voluntary agencies be complementary or are they subsidised units of Government?
7.
Are we willing to transfer responsibility for health care
what extent ?
to people ?
tla
v\
h
c»
If so, to
Dr. Baily presented the District Tuberculosis Programme performances in relation
to Primary Health Care. It was presented as follows :
1
Firstly, what is expected of the health services in relation to the National Tubercu
losis Programme (NTP)? The District Tuberculosis Centre (DTC) is expected to per
2
form 6 main functions viz., the clinical service, referral service, implementation of the
programme at the PHIs, supervision, provision and maintenance of equipment, supplies
and reporting. Peripheral Health Institutions (PHI) are expected to perform three functions
3.
viz., clinical service (diagnosis and treatment), referral of patients and reporting. It was
emphasized that all these functions are relat.veiy very simple, It has been demonstrated
that they can be performed without any difficulty.
However, from the performances of the DTPs,
4.
the following main observations
5.
can be made :
6.
1.
2.
3.
that the DTPs are functioning differentially in different States of India; whereas in
some States of India, the programme is functioning relatively satisfactorily, in others
it was not so satisfactory;
7.
that while a substantial number of trainees have been trained, a large number of
DTCs were still without trained staff;
Wi
sa
act
that implementation and maintenance of the programme had not improved over time,
but reporting had improved substantially. It was felt that improvement in the fun
ctioning of the programme would follow the improvement in the reporting.
Apparent reasons for short-comings were identified.
in
ed
co
ent
is t
per
’ra
The reasons were related
to :
1,
Health structure in the States, District and PHI level.
2.
Health activities; case-finding, treatment, referral and reporting.
3.
Interaction of resources—four resources were identified :
a) Knowledge of the health care delivery personnel.
b) Facilities, i.e., equipment, supplies, etc.
c) Man-power; professional, technical and supportive, and
d) Efficiency in use.
4.
Dis
.rev
tho
sta
sib
Reasons attributable to the community.
38
E
onvenience
At this stage, Dr. Baily briefly dealt on the primary health care and reiterated that
the NTP satisfies all the concepts of the primaty health care, since it was envisaged as
an integrated programme. However, two aspects that it did not encompass at present
was the out-reach from the Primary Health Centre (PHC) downwards, through the
Multi-Purpose Worker (MPW) and Community Health Volunteer (CHV) schemes and
community participation.
□vernment?
If so,' to
Discussion—Major points of discussion were ;
in relation
I Tubercuted to per
son of the
t, supplies
; functions
g.
It was
monstrated
servations
vhereas in
, in others
I
1.
At the present context, the District Tuberculosis Officer (DTO) and DTC have no
functions to perform and they should be scrapped.
2.
DTO cannot be functioning as manager for various reasons and that function to be
shifted to PHC doctors.
3.
Rethinking on medical education has to be done to include management as a component in it.
4.
The present health system does not allow for improvement or to provide primary
health care. Lessons from a few successful projects like Jamkhed, Mini Health
Centres, etc., have to be taken for drawing up a plan of action.
5.
The MPWs and CHVs have a great role to play in DTP and primary health care.
6.
Involving the community or community participation.
7.
Role of voluntary agencies.
The definition of Primary Health Care as given by the speaker Mrs. Radha Narayan,
number of
:>ver time,
the fun-
re related
was suggested to be changed so that more inputs could be provided. But, Prof Banerji
said, that there was no need for any new definition, as the one given was adequate and
accepted by all in the country.
Dr. B.C. Arora, started the discussion by saying that the DTO
and DTC are dead
in the present context of development and a r
new thinking has to be given in the medical
education as has been done in Australia to produce doctors u
---------; to meet the needs of the
community. This evoked a lot of discussion and each participant reviewed
enrp ■
u‘ /l---------------------------------------------------------------------- — '——the experi-
ce m his, her own State and said that both DTO and DTC have to have be retained
It
>s too premature to remove the DTO's post. All the health programmes are having their
personnel at district level and hence, DTP must have the DTO. The experience of Kar
nataka m removing the post of DTO and giving the supervision responsibilities to the
district Health Officers (DHOs) and Assistant District Health Officers (ADHOs) was
ZuoTtt ?r-.Baily'
monitors lh* DTP reports in the country mentioned that
staff of p" dec,Slon of Karnataka was in tune with the principles of integration, the
sibilTt^r ’;ure 001 haV'n9 thG necessary knowledge and skill to undertake their respon771
regard to tuberculosis, even though they are aware of the DTP.
The
The
supply system and co-ordination has been disturbed.
He pleaded that even if ADHOs
sp read
lightec
were to do the supervision of PHIs, the technical advice has to be providad by DTO
I
who is a trained man.
The two clashing functions of the DTO namely, the clinical functions at DTC and
the managerial function of managing the programme, were discussed as the basic reason
for this inadequate functioning. The Moderator made it clear that there was no dicho
tomy in the two functions. The group felt that the management aspect should become
part of medical education. It was even suggested that it should be shifted to the PHC
level.
I
t
b; sic i
this W'
jumpir
pc iitet
has s.,
anon.
During the 6 months field training of interns, all the programme officers should
participate in the field training to make it meaningful and purposeful.
I
The status of DTO was considered as another factor which hindered his efficient
functioning.
1
N<
2
S
The Punjab's experience with regard to raising the status of the Chief
Medical Officer (CMO) was reviewed.
lb
Though CMO was mini Director at district level
u
with the powers of even transferring officers upto Class II, the programme (DTP) had a
set-back with the upgrading of Block Health Officers to Class I status. While the whole
group felt that DTO's post to be made Class I, Dr. V. Benjamin, suggested that the pros
and cons of upgrading the post be reviewed in all its aspects before upgrading it.
3.
V
rc
The training of PHC doctors for undertaking tuberculosis activities were also dis
cussed. Some participants suggested that the National Tuberculosis Institute (NTI) has
to take up the training of PHC doctors.
4
It was pointed out that this aspect of training
of PHC doctors and staff was in-built in the programme in which the DTO and his team
is given the responsibility of training PHC Medical Officers and staff.
Some members
felt that the training of PHC Medical Officers was to be done at DTC instead of PHI
itself, as it would give ample time for them to learn.
At this point, Dr. K.S. Aneja high
lighted the findings of a study conducted at NTI in this regard.
Under the study, a
group of doctors of PHCs were trained at NTI and another group in their own PHCs.
This statistically designed study showed, that there was no difference in the perfor
mance of case-finding in the two groups.
During the discussions, it was mentioned that the probiem of PHCs is that, raw
graduates are posted at PHC and they are made to implement all the health programmes.
The remedy
Because they are not trained in managememt, the programmes are failing,
suggested was to post experienced doctors with training in public health.
A suggestion was made that we should start reviewing some of the projecis like
Jamkhed and Narangwal, so that lessons could be drawn from them for planning DTP
as part of Primary Health Care. In this connection,
Dr Sanjivi's recommendations of
Mini Health Centre and Health Co-operatives were mentioned.
Dr. Daniel Isaac
pointed
out that mini health centres are not viable units for implementation of the programme.
Moderator, Prof. Banerji, drew the group's attention to the fact that the small experi
ments are not applicable to a huge country like India with her 660 million population
40
L»
A
h
ir
Role
I
The n
lute c
confi
K'ode
servic
contr
avoic
Utili
comr
roje i
the rt
logy
case
drug
n if ADHOs
spread in the 5,60,000 villages, because they are not reproduceable.
dad by DTO
lighted the epidemiological limitations of mini health centres. He pointed out that the
basic issue is the optimization of the available resources to maximise the benefits and
this was not fulfilled by many of the projects. Dr. V. Benjamin, rightly pointed out that
jumping from one experiment to another without assessing it, is not a healthy move. He
pointed out that only in NTI and NIP there has been a constant evaluation on operational
bas:s, whereas in other programmes slogans are put up before having and hard evalu
; at DTC and
b^sic reason
is no dichoould become
to the PHC
ation, and the planners rush to them.
lhe bottlenecks in the success of the programme were listed as follows :
ficers shoufd
his efficient
of the Chief
district level
(DTP) had a
Non-availability of basic drugs.
2.
Sputum examination of the chest symptomatics who are knocking at the doors of
3.
p’rogramme.
>mall experin population
Learn from the experience of Jamkhed Project, in utilizing the Community Health
Workers. This stresses the need for sociological thinking and not thrust the prog
ramme on the people, and for which services are not available at PHIs.
ne also diste (NTI) has
t of training
ind his team
me members
projects like
fanning DTP
•endations of
saac pointed
How can enough motivation be provided to the doctors to
undertake this responsibility?
ing it.
is that, raw
programmes.
The remedy
The distribution mechanism is at fault.
1.
the FHIs is not done.
ile the whole
that the pros
itead of PHI
Aneja highthe study, a
own PHCs.
i the perfor-
Also, he high
4.
A proper supervisory machinery to review the treatment offered to patients in PHIs
has to be developed since many patients are on treatment for years without reviewir g his condition and thereby wasting the drugs which are scarce in the country.
Role of Voluntary Agencies
The role of voluntary agencies in DTP as part of Primary Health Care was stressed.
The role played by TB Association of India, Christian Missionaries, Rural Health Insti
I
tute of Gandh:gram were reviewed. The group felt that the Government should have
confidence in these agencies and support them for the efficient functioning.
The
Moderator at this juncture mentioned that the TB Association of India has done yeoman
service in compelling the Govt, to take up the prob'em of tuberculosis for planning a
control measure. Dr. Kul Bhushan wanted integration of all voluntary agencies for
avoiding duplication of work.
Utilisation of MPWs and CHVs
At the outset Prof. Banerji pointed out that CHV Scheme has a great potential in
community participation. The group agreed that MPWs as well as CHVs have a great
role to play in case-finding and case-holding. In this connection Dr. K.S. Aneja gave
the results of two NTI stud es in involving the MPA/s.
By active case-finding methodo
logy by MPWs the case-finding activity can be almost doubled.
In improvement of
case-holding they can motivate the patients and their families for completion of the
drugs by the patients.
Dr. Chittiseshu raised an important issue in the training of
41
MPWs. She mentioned that only one hour was made available for teaching DTP in
the entire programme and the time was very inadequate. It was stressed that the training
at State TB Centre, Central Training Institute & HFWTCs should be strengthened.
heal
I
that
moti
\ erir
Community Participation
h.e^ff
He s
The group came to the conclusion that without community participation Health
for All by 2000 A.D. could not be achieved. Primary Health Care tries to put people's
health in people's hands. Hence, Prof. Banerji mentioned that it becomes important to
learn from the people what they want and develop a technology suitable,for that purpose.
People should not become subservient to technology. He also mentioned that health
delivery system should not absolve its responsibility in the process of putting people's
health in people's hands. He pointed out four issues that emerge out of this under
standing :
1)
Are we transferring the responsibility to the people?
2)
If so, how much we back them up to support them.
3)
The health system should be with the people.
4)
Intersectoral coordination and cooperation is necessary.
The group felt that CHV scheme is a positive effort in the direction of community
participation. There is a need for the study of the social structure in the Indian villages to
find the process of election /selection of CHVs. Prof Banerji felt that the very fact CHVs
are to be trained at PHC by the PHC staff contradicted the concept of people's health in
people's hand.
The process of obtaining people's participation was discussed at length.
Dr.
Ramachandran explained their experiences in Gandhigram and mentioned that there is no
common solution for this. Each community has to be studied and dealt with in its
own way. Sitting with the people and discussing with them to define their needs &
priorities can help in involving the community. Prof. Banerji also stressed that commu
nity participation can become part of the system only when we learn from the people.
Prof. Banerji while summing up the session highlighted the importance of involving
CHVs and DTPs in case-finding. He mentioned that resources may have to be increased
if necessary. He also drew the attention of the group to the fact that the concept of
Primary Health Care was anticipated two decades back under DTP in the form of treat
ment organization, referral system and reporting.
42
prov
i-
I
»
Dr. G.V.J. Baily mentioned that if DTP has to become part and parcel of the -
shing DTP in
at the training
lened.
health care, there should be improvement in all aspects of health system.
system. He mentioned
that MPW scheme can be efficiently used for improvement of case-finding and CHVs in
I
motivation of patients.
But he gave a word of caution to resist the temptation
vering the anti-TB drugs at the homes of the patients either by MPW or CHV,
he felt that there would be a tremendous wastage of drugs if such
)ation Health
put people's
important to
that purpose,
i that health
ting people's
this under-
community
in villages to
ry fact CHVs
e's health in
length.
Dr.
there is no
with in its
>eir needs &
:hat commute people.
of involving
be-increased
concept of
01 of treat-
of delibecause
a procedure is adopted,
He suggested that unless in very special circumstances, it would not be adviseable
to
provide drugs below the sub-centres level.
sputum posi-
persons with
-al services if
RECOMMENDATIONS OF THE WORKSHOP
;
1.
t there should
»dical Officers
y be properly
wherein the Centre and State shared 50 : 50 of the programme expenditure. This
has adversely affected the domiciliary treatment programme, as large number of
TB Centres are unab'e to get the requisite amount of anti-TB drugs. It is, there
was also the
>r supervision
) the necessary
e and unitary ,
I into 4 zones
h programmes
fore, recommended that tuberculosis programme be reclassified as 100% Centrally
sponsored scheme.
2.
At present, in the Health Care Delivery System, referral procedures from the peri
phery to the District and specialised leve's and vice-versa, are casual and not
systematized except for tubercu'osis. Because of this, tuberculosis referral is also
not properly functioning.
systematized.
uld be further
Guides could
jr.
3
nion that the j
ious supply of
The Tuberculosis Programme which originated as a 100'u Centrally sponsored
scheme in 1962,|was subsequently converted to a Centrally aided scheme in 1978
It is recommended that the two-way referral system be
Since the time of laying down of the treatment policy in the National Tuberculosis
Programme (NTP), as enunciated in the Manuals for the District Tuberculosis
Programme (DTP), several technical developments have occurred in the field of
chemotherapy
In view of this, the treatment policy in the NTP requires to be
reformulated and fresh guide lines laid down. The following recommendations
were made :
..
form of Health
Id guide the
of people for j
or operational
is mentioned
n tuberculosis
md reports so
4.
5.
a)
Priority to be given to sputuni positive cases, but "suspects " diagnosed at
the District Tuberculosis Centre (DTC), should not be neglected.
b)
PAS should be replaced by Ethambuto!, in view of its better acceptability,
and
c)
The possibility of using Short-Course Chemotherapy in the programme, be
examined.
Several National Programmes are 1target-oriented. ..
It was felt that this is not
..
; j per_
appropriate for NTP', since there already exist indices for evaluation
of. the
formances of the programme.
The greatest possible use should be made of the Multi-Purpose Workers (MPWs)
and Community Health Guides in the activities of the DTP through the provision of
appropriate facilities and training. It was stressed that the MPWs should be
trained at the Primary Health Centre (PHC), where DTC personnel along with the
Medical Officer of the PHC who has been trained at the Health & Family Welfare
Training Centres and- other personnel of PHC should be involved.
51
In this connec-
tion, the following have already been circulated by the Ministry of Health & Family
We.fare, vide their letter No. Z. 22015'13 78-RHD, dated 14th April 1978 :
Z/
<
a)
A lesson plan for training of MPWs in NTP,
b)
Guidelines of NTP, lesson plan for Block Level Medical Officers, and
c)
Role of PHC in NTP.
0
1 1.
It was stressed that this document may now be circulated to the PHCs by the
State authorities.
6.
It was stiongly emphasized that for the efficient functioning of the Health Care
Delivery System, appropriate supervision is essential. For this, the channels of
superv sion of workers were identified
The MPWs would be supervised by Health
Supervisors, while the Medical Officer of the PHCs would be responsible for
over-all supervision of all hea'th activities including tuberculosis at the PHC level.
The District Tuberculosis Officer would cont nue to give technical guidance, super
vision and provide supplies to the Medical Officers of the PHCs.
7.
The existing recording and reporting system of the MPW Scheme was reviewed
and its was recommended that they should further be simplified. It was noted
that tuberculosis has been included in the integrated report at the MPW level.
8.
In view of the experience gathered from the other National Programmes, it was
recommended that operational studies be conducted by the NTI, on the feasibility
of involving the MPWs to perform tuberculosis work along with all the activities
assigned to them.
9.
To ensure better community participation in the Health Care Delivery at the PHC
level, it was recommended that Health Advisory Committee be formed both at the
PHC and at village level.
The function of the Health Advisory Committee
would be :
a)
To raise resources from the community to augment the funds of the health
services,
b)
To enlist the co-operation of the community to participate in the health
services offered at the PHC, and
c)
To help the Medical Officer of the PHCs to sort-out some of the problems
of the PHC.
The exact mechanism of the formation and functions of the Committee will have
to be worked-out. It was pointed out that this Committee would form a component
of the Development Committee at the Community Development Block level. It
was further suggested that a Health Committee at the village level be formed which
can assist in defaulter retrieval and motivation of the patients.
52
I
I
t
1th & Family
78 :
I
10.
The role of Voluntary Organizations to involve the community was discussed and
it was noted that the contribution by the various Voluntary Organizations, except
the Tuberculosis Association, was meagre and the activities tend to overlap each
other. In view of this, it was recommended that the role of Voluntary Organiza
tions should be comp ementary to the governmental efforts’ and should be directed
towards mobilizing community participation without overlapping.
11.
It was recommended that studies In the mechanism to obtain the community
participatian in health programmes should also be conducted.
a.nd
HEs by the
Health Care
channels of
ad by Health
ponsible for
j PHC level,
ance, super-
.<as reviewed
t was noted
level.
imes, it was
ie feasibility
the activities
- at the PHC
1 both at the
■ Committee
of the health
n the health
the problems
ee will have
a component
>ck level. It
:ormed which
■M-;
,
i
Directorate General of Health Services
Mirman Bhavan, New Delhi-110 011
> Ji
:<
No. T. 18020/6/80-TB
■i',,;
26th Aug, 1980
i
i
I
From :
The Director General of
Health Services
To
All Directors of Health Services
:
T
district I
the use
prevent
the triaf
of States/Union Territories
h
Sir,
Sub :
«’]
The new policy of BCG vaccination in the National TB Control
Programme
incidenc
like milk
lymphad
evidence
clinical r
As you are aware, the VCG vaccination programme has been in operation in
our
country for the last 30 years. The vaccination was initialiy offered to all
persons negative to tuberculin tests and later to all pe.sons in the 0-19 years age group without any
tuberculin te^t. The strategy of BCG vaccinat on programme was to cover the entire
susceptible population initially by a mass campa gn and thereafter to maintain the pro
tective effect of BCG vaccination in the (community by covering the young population
added by new births regularly through the general health services.
s
Ji
To make BCG vaccination routinely available in the general health service, therefore
the BCG vaccination policy of the country was revised about three years back fend it was
decided that :
clinical ti
Oi
paramedi<
under the
in the tc
circulatec
During t
higher age
This has
for intrade
in the pro<
0-19 year
1)
the mass BCG vaccination teams should be disbanded and the technicians
of these teams should be posted in Primary Health Centres and sub centres
for training of all the paramedicais workers in the rural areas in the technique
of BCG vaccination.
2)
In future, BCG vaccination will be performed by the multi purpose health
workers like basic health workers, ANMs etc., in their respective areas of
responsibility under the expanded programme of immunization.
the target
3-9 mon
3)
The multipurpose workers will cover the infants within 3-9 months of their
birth rather than immediate y after birth,>s tuberculin conversion after
In u
practised f<
■■I
4
that eno
58
Wh
vaccination immediately after birth has been found to be unsatisfactory and
"or the X" W'thin 3 ,0 9 m°n,hS a,'er birth is oP-ationahy convenient
mu tipurpose
workers
in thp ppi
oo tut-the
of giving
any of the
C ^of
DP^v'c^"
4)
980
In urban areas where BCG vaccination of T
the newborns immediately after
birth has been in operation for a number of
-f years because the newborns
are available in the maternity institutions
immediately after the mother's
confinement, and once the mother leaves
> the hospital, it is difficult to
contact the child newborn vaccination i ,iewuorn vaccmat.on immediately after birth may continue.
districJhaVcrZated so'm^oub^
°f
'CM3 in the Chingleput
The results have sho^n
Pr°feSSiOn about
prevent emergence of infectious Dulmnn.rw t
the triah However, the direct benX^BC^^^
vacc,nat,or> failed to
the use of BCG vaccination.
incidence of clinical forms of tuberculosis d’
cc'natlon >s m the reduction of the
like miliary tuberculosis meningial tubercul .'Se^SeS ollow!n9 upon primary infection,
.rol
on.
. . . ,rx.“r
,h,
„s>ramg
:r "Tr
R”",d
”»
»">■
elm,cal diseases after primary infection, whereas other scientific BCG stT""9
•
•
d'eS SU9gest
"
our
jamy
that enough protection is indeed conferred bv BGC v
~ tuberculosis manifestations that are moLiy
tire
ro-
PatamX;XX:^a “iOn
ion
under the Expanded Programme of immunXnX ‘sho^d'": ^^d^9056
o te
t/as
ms
res
ue
th
m the technique of BCG vaccination
THa t • ■ '
'd b exp3ditiously trained
circulated vide Government of India Letter No'"TsOnTXpu''
bSSn
During training, the trainees are to perform the va •
24-5-1977higher age groups first and gradually an rK
u ccmation m the thicker skins of
This has been done with the purpose X
thin skin °f
newborns.
,or intradermal vaccination in the very thin skinsof the ^h'"9
in the process of such training, to cover the' back o nf
paramedical workers
and als°
0-19 years age group that is still available in the Lal areasVaCC'na,ed POP'jlation in the
... ..x “ “
of
3 ■9“ ■“
);r
In urban
Practised for a
er
the
implemented i
••
*««.
«.• ..—.d.” ..I.
being
59
¥
The aqe groups to be covered under BCG vaccination in urban and rural areas have
in fact been clearly explained in this Directorate Circular No. 12-16/75-TB dated 21.2.78,
I
iV
that has been circulated to all AMOs, TB Officers and Directors of Training and Demon
stration centres, in all the States and U.Ts.
One BCG vaccination performed properly within the first year of life is considered
to be adequate, as the protection afforded lasts for several years, Revaccination at
subsequent years of life is therefore not being considered at present.
I wou'd request you to kindly bring the above instructions to the notice of all
nprsons engaged in BCG vaccination and others responsible for implementation of the
rni fn youXe including paediatricians, District and State TB and EPI Officers, PHO
To
1
c
Medical Officers, etc.
Sub:ec
Yours faithfu'ly,
sd/(Dr. B. Sankaran)
C hector General of Health Services
I
Sir,
I
Mu Iti du
Bloc/ L
I
CL' I os is
Il
under IV
of each
'•■J
■'F-
ft
i
c
.••sSW,
1.
2.
3.
4.
1'1
1
I
!
60
'
have
1.78,
non-
No. Z. 22015/13/78-RHD
MINISTRY OF HEALTH St FAMILY WELFARE
(RURAL HEALTH DIVISION) .
ercd
n at
NIRMAN BHAVAN
NEW DELHI-110011
.f all
the
Dated 14 th April 1978
PHC
To
The Directors of Health Services
of all the States Union Territoris.
I
Subject
National T.B. Programme-Role of Multipurpose Workers
Sir,
’ am di?A?teld t0 encl0S9 herewith (i) the Lesson Plan for Training of
Multipurpose Workers in N.T.P. (ii) Guidelines of N.T.P. Lesson Plan fo
culosis PiYgr™"1
and (iii) Role of
on National Tuber-
under MPwr^qh8Sted ‘hat.,h3se m3y bs included in training Programme
/
.MPY S3hen2e- , c°P'es of this paper may please be sent to the C.M 0
of each aiotrict and all the PHC in your State for their use.
Yours faithfully,
Sd/(Dr. MRS. K. KATHPALIA)
Deputy Assistant Commissioner (TRG).
Copy for information and necessary action:-
1.
2.
3.
4.
All Central Training Institutes
All H.F.P.T.Cs.
All Regional Directors.
Advisor (TB).
*
(Dr. Mrs. K. KATHPALIA)
Deputy Assistant Commissioner (TRG).
61
I
I
T
m
-to
Directorate Genera! of Health Services
A L
TB SECTION
Subject:-
1.
Gc
of
cai
2.
Tr
3.
Rc
a bl
various aspects of launching and revitalising
I
National TB Programme.
In continuation of this Directorate U.O.
No.
20-11 75-TB, dt. 20-4-77
a copy each of the 'Lesson Plan for Training M.P.Ws for N.T.P.', 'Role of
P.H.Cs in NTP and Guidelines of the NTP Lesson Plan' for the Block Level
Medical officers is forwarded herewith. It is requested that these documents
I -5
i)
may plaese be passed on to the Department of Family Welfare for i ncorporation
ii)
in the manuals for training and job specifications and in the meantime for
immediate multiplication and circulation to all the States UTs.
• § is ■!
and Health
and Family Planning Training Centres and to other Institutions training
iii)
multipurpose workers etc. so that the services expected specially from these
field workers in respect of TB Control Programme is highlighted.
iv)
v)
Sd -
vi)
(Dr. B.N.M. BARUA)
Adviser-in-Tuberculosis
for Director General of Health Services
4.
The
A,
FIR
Cont*
Deptt. of Health, US (PH)
DGHS U.O. No. 20-11.75-TB, dt. 26-4-77
I
a)
I
becau
most
why i
b)
Case-
of TB
pain 4
•I
li
I ntro
infect
nor fc
62
of b'o
Diagnosis sputum examination done at
PHIs and following an X-ray of chest
at DTC.
Show
bacilli
under the
In
it
I
De
|h(-
micro
scope
C)
Discussion :
How advice to persons
EC
^nc
(including pregnant females/mothers)
with chest symptoms will help in case
finding, show how the advice is to be
given the people
II
B.
15
b)
SECOND LESSON :
c)
a)
Content
Time
Preparation of sputum smear in
villages : Recording name and
1 5 mt.
30 mts.
Method of
presentation
Media
Lecture and
Class
Demonstration
room
Practicals twice
including disposal
of sputum cup
PHC
Rec
Ro I
address of the symptomatic, number
ing of slide, collection of spot
'r'l
sputum specimens, preparation of
sputum smear from suitable sample.
Fixing smear by passing over flame,
sending smear to PHC.
||
if i
Requirement : Sputum Cups-Record
forms, slides, spirit lamp and spirit,
glass marking pencil, match box.
b)
Disposal of sputum cup
Discussion
C.
I
NT
ho\
EC
PH-
a)
1 0 mts.
THIRD LESSON
Treatment : What drugs are avail
able, what Regimens are prescribed
importance of regularity, dosage,
duration and uninterrupted treatment
what to do when toxic side effects
Lecture
30 mts.
Black
board
a
A demonstration of
BCG vaccination*
are observed/reported
* Th is could be arranged according to the vaccination manual to be issued separately
for MPWs.
i
Importance of motivation and how
it is to be done.
Show
>aci I li
?r the
Defaulter actions - why and how
they are taken.
licroscope
4
BCG vaccination efficacy, safety,
indications and method.
b)
NTP :
Four principles of NTP,
how diagnosis, treatment and
BCG vaccinations are done from
PHC ?
c)
5 mts.
Recapitulation and discussion :
Role of PHCs and MPWs.
vledia
1 0 mts.
Class
room
1
1
PHC
I
■Black
aoard
4
ately •
65
Lecture/discussion
Flip
charts
f'
f
J
i
i
GUIDELINES ON THE NTP LESSON PLAN FOR THE
BLOCK LEVEL MEDICAL OFFICERS
priority
tuberci
I
the mo
i
The lesson plan is based upon four factors, (i) that tuberculosis (being a com
municable disease) control is an accepted activity of PHCs, (ii) that National Tuber
COUNTS
ca’e-fi
PHC.
culosis Programme (NTP) being integrated with general health services is a routine and
not specialised activity, (iii)
MPWs will be involved in work-loads hardly worth
mentioning and (iv) that medical officers of Primary Health Centres are the trainers and
I
It c0uIc
for X ra
supervisors of multipurpose workers.
c
Duties of MPWs under NTP
hdr e,
a)
■
"Symptomatics" i.e., persons with cough of 2 weeks or more,
chest pain
and fever of 4 weeks or more or haemoptysis encountered during routine field visits are
to be referred to the PHC for sputum examination for diagnosis of pulmonary tuberculosis.
1
(^AS),
This would be specially relevant of MCH/FP work and would fit in with their responsi
bility of giving treatment for minor ailments.
are take
at the ti
is for a
the MO.
doses re
b) The treatment of tuberculosis has to be for 1-2 years.
Therefore, tubercu
losis patients under treatment of the PHC are to be encouraged to take their drugs
regularly for that period. During routine home visits, those patients and the.'r family
!
Motiva-
members are to be reminded of the bad consequences of irregular and inadequate treat
ment. This fits in with the advisory relationship that MPTVs are expected to develop with
families.
s
treatmer
to be de
c) The Newborns and other unprotected children are to be given BCG vaccination
along witn other immunization.
I
3
I
fl
d)
The basic facts about tubercu'osis diagnosis, treatment and prevention facili-
lities available free at the PHC are to be told during health education of the com
munity.
The above duties do not interfere with other routine duties of MPWs since not
more than 2-3 TB patients may be in an average village.
Content of Teaching :
a) Under introduction : TB is not hereditary, it is caused by a microscopic
germ, it spreads from one TB patient to another through sputum droplets sprayed
during coughing or sneezing, therefore sputum positive patients are given priority as they
are most dangerous. It causes great physical, psychological, social and economic suffering
not only to patients but their families and the community.
Therefore, TB is a major
public health prob'em and its control is essential.
motivati
the MO
I
D
regular f
a letter i
come, tl
a routine
Mduring tf
their trea
Pr
tuberculc
It Is give
■
i
Infectious patients of pulmonary tuberculosis if diagnosed and properly treated on
priority basis in large numbers would cut the transmission of infection and control
tuberculosis. All the tuberculosis services are offered free.
I
b) Case finding : Among the suggestive symptoms of tuberculosis cough is
the most important and common symptoms. Its duration (2-weeks) is crucial because
f • coughs of shorter duration are likely to be non-tubercular. It is imperative for proper
£
case-finding to examine all chronic cough patients by sputum examination at the
PHC.
9
Diagnosis : TB is diagnosed by examination of sputum under a microscope.
It could be repeated if once negative and those who are sputum negative could be sent
for X-ray examination at District TB Centre.
r
li
c) Treatment: Anti-tuberculosis drugs cure tuberculosis even when taken at
home, there is no need for hospitalisation, isolation, special diet or absolute bed rest.
The common drugs for tuberculosis are isoniazid (INH), Para-amino Salyclic acid
(PAS), Thioacetazone (TZN) and Streptomycin (SM). Excepting SM, the other drugs
are taken by mouth. There are five standard drug regimens; one of them is prescribed
at the time diagnosis is made by the PHC Medical Officer. The duration of treatment
is for a minimum period of 12 months but could be Prolonged to 18 months or more by
the MO. Treatment should be uninterrupted, and drugs have to be taken in proper
doses regularly without fail otherwise there is danger of emergence of drug resistance.
I
Motivation :
Since the treatment period is a long one, the importance of regular and continuous
treatment is emphasised upon the patient through motivation.
Primary motivation has
to be done by the Medical Officer, as patients have confidence in him.
Subsequent
motivation by the Drug Distributor at the PHC is permissible as the patient does not see
the MO at every drug collection, which is generally once a month.
■s
J
«
I
l-N
Defaulter actions : are important since it is difficult for patients to remain
regular for full one year. If a patient does not come to collect drugs on the due date,
a letter is written to patient first reminding him to collect drugs.
If he still does not
come, the area MPW will be informed so that the MPW can motivate the patient during
a routine visit to that village to collect drugs.
MPWs should keep a list of all TB patients on treatment
1
'in their'
/*area so that
during their periodic visits to those families the patients could be encouraged to complete
their treatment properly.
Prevention of tuberculosis :
BCG vaccination protects persons from getting
tuberculosis. It is a safe and effective vaccination, simple to give after proper training.
■' It is given to all newborns and those under 20 years age who are unprotected.
The
In
67
'•
I
adverse effect after vaccination.
Medical Officer of PHC.
i he
have to be brought to the attention of
if noticed,
At present BCG is given intradermalley by syringe and needle. Primary vaccination
should be given as early in life as possible.
Re-vaccination is not essential,
as protec
tion lasts for many years.
d)
*
National Tuberculosis Programme :
The anti-tuberculosis services are
offered free and near to people's homes. The organisation consists of a DTC at district
head-quartersand a large number of PHIs (see background document). The services
are supervised and maintained by a managerial team operating from DTC.
I
I
Health education of the community :
Pul
App’-nxim
of active
sputum ar
urban and
time .s es
MPWs have to educate the people on
tuberculosis-its causes, spread and the free services available for its diagnosis and
treatment whenever they give their routine health talks.
psycholoc
The
allevi e tl
merKs f.oi
Govern me.
covers a n
District
I
A dlosis Progr
Tuberculos
comprisinc
The
district Fo
personnel e
Tuberculos
an X-ray Tt
The
attending th
rendering si
C*ase
to every on
haemop*ysi
officer to s^
netion. He
be carefully
68
I
n of
The Role of PHCs in National Tuberculosis
Programme
ation
otec-
; are
strict
/ices
e on
and
I
Pulmonary tuberculosis is a major public health problem, next onlv tn rnrrir.,^
Approximately 16 persons per thousand of population have X rav shadn
of active pulmonary tuberculosis. And four Pper thousand^:ng tub^eZT;8
sputum are spreading the disease to others.
Tuberculosis is equally prey lent
n th"
infec,irs p“at—
is^imX^:.
psychological, social and economic suffering inflicted by
The National Tuberculosis P
PrO9ramme (NTP) a'mS to contro1 tuberculosis
and
alleviate the human suffering. The control services
-------- 3 are offered by the State Governments from all health institutions (integrated
programme), urban rural. and the Central
Government renders assistance to the programme in many ways
At present, the NTP
covers a majority of the districts in the country.
District Tuberculosis Programme:
A district is the basic administrative unit of the
country.
The District Tuberculosis Programme (DTP) is the basic unit of NTP
A DTP consists of one District
Tuberculosis Centre (DTC) and on an average,
50 Peripheral Health Institutions (PHI)
comprising PHCs, general hospitals, rural dispensaries etc
..orc
Tuberculosis Officer (DTO), ” ';’boratorv Technician (LT), a Treatment Organiser (TO)
an X-ray Technician (XT), a BCG Team Leader (NMTL) and a Statist.cal Assistant (SA).
..nd..™ ...»
Th.
...
»...xx
ixx.z:'
“ r-
netion. However, if sputum test
nonof
/
P
ordering sputum examibe carefully examined to decide whether to^r hiXX-ray'examination TthV DTC.
AQ
i :
For so few sputum examinations in a PHC, either the PHC microscopist or one Of
the PHC staff, who does not have to leava the PHC for routine duty, is trained by the
R2
DTC/LT, besides providing supplies such as sputum cups, stains, etc. Although the
PHC Medical Officer should exercise day-to-day supervision on microscopy at his centre
I
the LT from the DTC would visit once a month for technical supervision.
*
Treatment
R3
>1
F
R4
I
R5
T
Every sputum positive patient diagnosed at the PHC (and those referred patients
diagnosed at the DTC on the bas!s of X-ray) should be put on treatment by the MO on
the day of the visit. It is important to avoid losses from treatment, not only at the time
of diagnosis but till the treatment is successfully completed,
controlled successfully.
if tuberculosis is to be
It has now been established that domiciliary treatment of TB patients gives as
good results as sanatorium treatment and generally preferred by patients because their
home life is not disrupted. Moreover, bed rest, nutritious diet, multivitamins, nursing
care etc. p.ay a minor role in treatment if at all, because the chemotherapeutic drugs are
highly effective. Therefore, the PHC medical officer should educate such of hrs patients
who are not aware of these modern advances to enlist their willing co-operation in their
treatment.
The following standard drug regimens are available for prescribing,
They are
almost equally good and their use really depends on the availability of drugs or distance
which may prevent a patient to come to PHC for injections twice a week or side effects
etc. Drugs are provided to PHIs by the DTO. Treatment is to be entirely free.
I
It would be useful to bear in mind that more important than a regimen are the
treatment criteria i.e., (i) the patient must understand and take the drugs in the proper
dosage, (ii) regularly i e., daily or twice a week, according to the regtmen, (iii) unin
terruptedly and"in the event of side effects, he should not stop taking drugs but report to
the MO and (iv) for at least one year longer, as advised by the MO. Good results expected from a regimen cannot be ensured without the mentioned criteria.
Regimen
I
R1
Drugs and doses
INH - 300 mg and Thio
acetazone 150 mgm.
Mode of adminis
Other instructions
To be taken in a single
To be self administered
or to divided doses orally
at home; daily after
(INH preferably to be
mea s; co'lected mon
given in a single dose)
thly from DTC/PHIs.
70
V
s
V
re
Note :
Pati
sput
exte
Acer
poin
othe
or re
drug
work
back
nega.
from
BCG Vaccin
BCG va
atioTi u
better,
trailed
vaccine
has to |
be avai
r
I
R2
of
the
the
’.re,
INH - 600 to 700 mg
and SM-1 g. or 0.75 g.
Pyridoxine 10 mg. if
prescribed
INH to be taken in a
single dose orally &
SM by intramuscular
injection; both drugs
given at the same time
under direct supervision
of DTC/PHI Staff
Administered under full
supervision biweekly
i.e. at intervals of 3 and
4 days alternately.
Pyridoxine may be
given with every dose
of INH
t
R3
INH - 300 mg and
PAS - 10 g.
ntt
on
ime
To be taken in two
divided doses orally (INH
may be given in a single
dose of 300 mg)
be
as
heir
;ing
are
snts ,
heir
-do-
INH - 300 mg.
R5
Two-phase chemotherapy
Whenever practical DTO may prescribe an initial intensive chemotherapy for
seriously ill TB patients with daily SM, INH and PAS or TZN for the first 8
weeks followed by less intensive chemotherapy with any one of the two-drug
regimens described above for the rest treatment period.
Patients with X-ray evidence of pulmonary tuberculosis who are negative on
sputum examination should also be prescribed drug regimen R1 in the case of
extensive and/or cavitary disease; for others, drug regimem R4 should be sufficient.
Accordingly, it becomes the duty of the MO to 'motivate' each patient on those
points at the time of starting his treatmant. Subsequently, the pharmacist or any
other person entrusted with the duty of drug distribution should remind
or remotivate the patient on those points.
And, in the event of a default in
drug collection, take defaulter action, either through a post card or home visit by
worker, multipurpose worker (basic health worker A.N.M etc.) to bring the patient
back to treatment. This is important, if failure to convert the patient to the sputum
negative status and emergence of drug resistance are to be avoided. The TO
from DTC would visit once a month for technical supervision.
the
oper
nin-
t to
ex-
i
ions
ertd
after
nq»n•His.
tered at home; daily
after meals, collec
ted once a month
from DTC/PHIs
R4
Note :
are
mce
ects
To be taken in a single
dose orally
To be self-adminis
I
■
BCG Vaccination
BCG vaccination will be given by multipurpose workers, to the susceptible popul
ation under their care. BCG vaccination can be given soon after birth, the earlier the
better, and direct i.e. without the tuberculin test. Multipurpose workers have to be
trained how to reconstitute freeze-dried vaccine in the field, give intradermal
vaccination correctly and ensure good coverage of the population. The MO of PHC
has to play an important role in this, even though services of BCG technicians will
be available at the supervisory level.
71
5® $ . vi
Role of the PHC Medical Officer under DTP
1.
Select symptomatics amongst the PHC outpatient for sputum examination.
2.
Prescribe treatment and motivate patients diagnosed to be suffering from tuberculos
3.
Train and guide the multipurpose workers under him in how to (i) reorganise "
"symptomatics" for sputumi smear making and referring to the PHC (ii) ensure proper $
treatment completion of patients registered at the PHC and (iii)
of the susceptibles, amongst their respective populations.
4.
is.,
BCG vaccination
Supervise the day-to-day work of the microscopist, the drug distributor and the
multipurpose workers of the PHC.
i!
Role of supervisors of multipurpose workers under DTP
1.
That multipurpose workers understand the nature of tubarculosis
as a disease ai'id
details of the TB Control services offered from the PHC
2.
That they enquire about symptomatics during their "beats" of the villages under
them, prepare sputum smears and refer them to PHC for exam-nation
3.
Hand over names of defaulting patients (obtained from the PHC) to them for home
visits, remotivation and bringing those patients back to treatment
4.
Ensure that the newborns and other non vaccinated i
persons below the age of 20
years are given BCG vaccination bv the multipuroosej workers in their respective
population.
Role of Multipurpose Workers under DTP
1.
bout S1'., of the population are likely to be symptomatics. Casual questioning
during home visits only is sufficient to find out who they are, and, if they have not
already been to the PHC, they could be asked to do so now
2.
In a village not more than 2 or 3 patients could likely to be
on treatment for
tuberculosis.
Close rapport with them will c
------- -------ensure
proper *treatment completion (what is proper
treatment will be told to them by the PHC medical officer), In some cases a special
home visit may be needed to retrieve the defaulters.
3.
Only half of the population is below 20 years in age.
Many of them would already
have been BCG vaccinated. The annnal birth rate is about 4f’... Therefore, a limited
number i.e., new births and the non-vaccinated susceptibles, would have to be
vaccinated in a systematic manner.
Y
I I
O-b<o-H S CA5u'Cn'v<cJLQ_> (
C<EivCl\.c.P (-Co C’Uv
t
•'-i 1
t'c>t Ip
‘T d vj <
! Tc^pr- —
o-O-ia-
/ r^O .
7 *+ /c?
(k \
,
-^^^.-’6-.
Let
________ _______ i,,
;t iUTIOh^L TUBERCULOSIS^ L’SIIITTE' lt
i’! '
RESEARCH
J
’
RSSBURCH ^CIIVTTES
^CilVlIS S
. -,^ .,
J
l
t
t
I
The Institute has formed an Oo^ration .Research Forum(0r.)
consisting of the Senior Technical Officers of the
Institute, to study and analyse the problems un.dtr D>?F;
and to plan and undertake research projects in a
sequential manner. The forum met numb.:? of times to
c-iscuss the performance of the programme during the
ycarthrough the reports received from DTPs in the
country ana to identify areas where research has to be
taken up.
is an
iiose-rchZimpo t nt function of th'.-, na.i-?nal Tuberculosis
institute j B aim-al ore.
The research h- rc- is based on
?
Research” vhich was applied for the first ".inie in
I
in th
t:Opcr? t^cnul.
cou
fielc of public tuslth.
Th< results of a-.pliecl research ccncuctud by th
InstiTv
led to the formulation of integrut-.u District i uberculocis
uo ’
(DIP).
impor tant ilos earch S tuhi --s
Some iinporrar.it contributions of 1?TI in rhr fi. 1c of i/nidemioj o:
Socicl gy, Bacteriology,
;c
9
a r e r.
Sputum Ixaminotion
Sputum imam
rion by Siroct microscopy - Ziehl
is able to diagnose 85 per c-. nt of the cu.lcur:- pot
-.at attend c
iron mi’c’. c_v-- casec
out-pati-nt d-. part.-, .nt of th. I- uriph- r;l H. al"
Institutions( Hs).
Direct Microscopy is o. rt-liablo, car y an. "radical tool of
□iagnosis applic:-; lu at the grass-root
of available
ra-motical personnel at t'v:
supervision from
■m'ch :.
rum trai
His end - prep.r
train-U technician from the district lev- 1.
Epicemiological Survoy
The repeat epidemiological survey among rural population vas
conducted by hTI through tuberculin tests, mass
!
-7-
miniattire radiography and sputum examina tion(culture and
microscopy), to establish the prevalence and incidence of
inf ect ion , and the disease.
After thq initial round, three more
rounds of survey w^re conducted at an interval of 1^- years,
two
1-2- years and /years. The period of field v’ork v/as spread
0
•I
over seven years. A fifth round was taken up in 1977 after
I
about nine years interval and complet-d in two years.
The
study showed that atout a third of the population was infected
and also that the nre cases occuring during A year, almost
equalled the number of cures and deaths during the same
.3
period, thoracy maintaining the prevalence at the same- level.
: tonal
Th'.,se findings have given an insigi.t into the almost unknown
I
/
problem ane changed the concept of a control programme.
Another epidemiological survey wes carried out among
12,535 children in the age group of 0-9 years in 90 villages
in a taluk of Bangalore District.
The children were tested
with 1_TU Ri 23 anc the tests were read after 72 ,tb 96 hour s.
The •tuberculin rc-actions in the previously BCG vaccinated
ane non vaccinated groups showed no evidence of influence of
BCG over the tuberculin reactions.
H-.nce,
H-..nce a methodology
of tubcrcul. sis surveillance using simple method of noriodic
i
tuberculin testing of the population in younger age group,
i
■
has been suggested by 17TI as the cheapest, pa^icable and
technically appropriate method of studying overall tuberculosis
situation.
:.i?<
Sociological Studies;
Results of sociological studios on the awareness of
symptoms suggestive of tuberculosis and action-taking among
the cases of tuberculosis revolutionized the case-finding
programme and gave a revised thinking on the concept of
’’early case-finding through mobile mass miniature X-rays”,
D.G.H.S, Chroiiicle/S■ pt~Oc t. 198r"
-8implementation of which would have been an expensive effort;,
yielding very little results»
The awareness'study showed that almost all (95%) of
the cases of tuberculosis were aware of symptoms suggestive
of pulmonary tuberculosis and more than half of them (52 %).
were seeking.relief from doctors of modern medicine, This
important finding was one of the. few factors which led to the
formulation of integrated DTP, integrating the case-finding .
activity with PHIs where patients are already coming for
relief of suffering.
This methodology reduces the cost
as well as helps the patients to get their services through
institutions in which they have confidence.
■
I
Case finding;
The possibility of improving th
case-finding activity
of PHI by ’active Ccsc-finding’ through the participation
of i-.ulti-Purpose Workers (I'iPW) who can collect sputum from
patients suffering from cough for cv.r two weeks, prepare
a smear and send it for examination at PHCs, would help
in improving the programme of tuberculosis control.
A pilot study conducted by MI in selected PHCs m
Chittoor District, Andhra Pradesh, has shown that Lhc- case
finding can be improved 3-4 times with the participation
of
MPWs without adding much to their existing work-load. This
study has also shown
the need for strengthening the laboratory
i
services of PHCs for effective diagnosis of all diseases
including tuberculosis.
Dav Light X-ray Dcvcloucr
Research in X-ray picture developing, led to the
development of a day-light X-ray developer box which has
development of X—ray pictures.
helped a lot in the process of
=»• T-
y
-9-
■ NTI has also evolved a monitoring system for the use
of X-ray Technician for miner repairs of the X-ray
units
of DTCs. For a systematic reporting of the
br-ak-dovzn of
5
X-ray machines, a breals-down report form v/as evolved.
This
has helped in saving of X-ray Engineer's time for minor repairs
which involves huge expenditure to the state exchequer.
Duiang 1980, some of the rosearch projects started
f.c
during earlier years wore completed. Some wore continu.n and
few now projects w.ro started.
1[cw_-Rqsearch Studios undertaken
I
Zrcblcm cf Dr^ Def,-nit Under Short-Courso
Chemo the rep y
- -----------Clinical trials to study the efficacy of. Short-Ccurso
Cnenothcrapy involves a v< ry strong organization with all the
resources t
compel the patients to consume- the drugs.
It
It
is
essential to know th? drug default under the 1 idcnlT conditi ns
trial and
ano tho troncndous organizati'-nal need tr
of a clinical tri^l
t
help them complete their treatment,
The study envisages tc
get the- infermation.
.Stud.Y_of_Int_;rnitter.t Short-Course Chcsothc-rMv
-is sequential to the study of Short-Course Chemotherapy,
anotte r study of Intermittent Short-Course Chemotherapy was
started in collabcrution with the Tuberculosis Research Centre,
Madras.
The study is continuing along with tte Short-Course
LS
Chemotherapy study at tte Lady Willingdon Tuberculosis Demons
>ry
tration and Training Centro, Bangalore.
Social iksp.cts of Patients jn Inter nit tent Sho rtc ?ursc Chemotherapy
“
------ ------
Compliance with a clinical trial poses a challenge to
tho patients who arc compelled to complete the treatment as
desired by the dGsige of the study. Since completion of trGuti'nt
of
by the pationt^tuberculosis involves various social aspects me
Did.
C'hronicle/ Sept. - Oct7~1981
net
-10-
L
r
social problens, the study ^luis to identify ssne of the
r-..
socio-econonic proolens of the patients on Internittent
c?.]:
Snort-Course Cnanotherapy.
^LLiL'Lotlic al Studio^
Utilization of urban treatment
facilities by patients
wj
on short—course Chemotherapy and taeir households.
xv.
Utilization of treatment "facilities by TB patients
in iticLed on treatment ’ by LWTMTC and th-ir famili.-.s.
i
I
These two sociological studies ar? planned to undc.rtstand
'th?- household mor bid i ty d ur ing a re f ercrc
- period and - ac tion
taken, oesid.GS the history cf ch'-st symptoms and action taken.-
-—yi :
* t
BOOKS
I
I I
1 1
re
XI
Ro
c ci
/
I.
to
C^^rLnORBIDITY
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Oenigh £'0RKE-'^
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ati
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ncn-nalignnnt diseases.
disrises.
national Agency
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carric-d out studies nf th? h-'olth hazards associated with alcohol.
m-,1
This publication reports cn the risk of canc-r and of d-aths
The
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This is followed by seven chapters in which the
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rovi-w is given of the literature. r.n the
and. an up-t j-d
csscciati^n b.~tw£-n
ale :h~l and cancer.
■his s^udy -.f the putt rr. of concur and causes of cc th
among hr- ivy drinkers
with a section
f beer wh ■ v --
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edirr. wita the effects -f dcoh 1 e.nd ale-h 1:
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