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NTI BULLETIN 1993, 29/1&2
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Case Holding in Tuberculosis Programme
Epidemiological Priorities & Operational Alternatives
«
*♦
Jagota, P. , Chakraborty, A.K.
Introduction
nphe District Tuberculosis Programme (DTP) seeks to
1 address itself to the problem of tuberculosis in the
community, through finding as many of the cases as
possible and offering them treatment near to their homes.
The services arc rendered through the existing system of
health care delivery, utilising the widespread network in a
permanent manner. The case-finding in the programme is
carried out from among the chest symptomatics reporting
on their own to the various general health institutions.
Once diagnosed, these cases arc placed on treatment,
requiring them to collect their drugs periodically for self
consumption. In the case of intermittent therapy however,
they arc required to attend convenient centres for
supervised administration of the drugs. There is provision
for motivation on diagnosis and subsequently thereafter,
for their retrieval on default.
Even as the programme is largely geared to satisfy the
peoples’ needs and demands, its effective implementation
depends on the participation of the General Health
Services in an ongoing manner. The activities, tuned as
they arc to the crucial social objectives of the programme,
the level of awareness and motivation of both the
beneficiaries as well as the health workers arc important
aspects to take into account. However, at the same time,
the programme should be able to meet the other objective
of public health importance i.e.. reduction of transmission.
Operational studies were carried out at the National
Tuberculosis Institute, Bangalore (NTI) to understand the
dynamics of the DTP as well as its possible outcome. The
potential of both the case-finding as well as treatment
activities were studied, to quantify the maximum
achievable if these were performed strictly, as provided
for in the Manuals. The results of studies were interpreted
to show that it was feasible to diagnose a number of cases
more than the annual incidence in the district . This was
indeed a breakthrough. However, the potential on
case-holding did not yield encouraging results". It was
Chief Medical Officer
Additional Director, Nil. Bangalore
♦
& Balasangameshwara, V.H.
observed “that the recommendations for management of
patients in the tuberculosis programme in India, will have
to be revised and intensified to obtain better treatment
completion’’2. Not much substantial change in the strategy
was however brought about, following the above finding,
ostensibly on grounds of availability of resources’. This
was in spile of the scientific opinion not being comfortable
with the phenomenon of diagnosed cases left inadequately
treated under a programme in the developing countries .
In due course, with the introduction of Short Course
Chemotherapy (SCC), a kind of euphoria pervaded the
scene, with the hope that cases found by the system would
be adequately neutralised in its wake.
The present report reviews the programme in its ability
to meet the potential in case-finding and treatment (CFT),
and bring about a reduction in the problem. Outcome at
the current levels of efficiency of activities as well as
following hypothetical changes in them are studied, in the
light of an earlier model on the Issue4. Further, it identifies
the areas for carrying out studies on structural changes to
be introduced in the programme, so as to obtain higher
results in terms of epidcmiologically perceptible gain.
Present Situation
The flow churl shows the dynamics of a DTP, under a
given set of hypothesis which has been used in
constructing the present model. An average Indian
district as per 1991 census is considered to have a
population of 1.9 million (a). At a prevalence rate of
bacillary cases of 4.0 per thousand in the age group five
years and over, an annual incidence of 34.0% of
prevalence, and 40% of the cases in the community smear
positive, the tuberculosis problem in a district can be
expressed as follows: 64(>0 smear and culture positive
patients (cases) in all at any time (b), 2196 newly occurring
cases every year i.e., incidence (b.2), 2584 of the
prevalence cases arc smear positive (b.l), 879 of the latter
being the annual incidence (b3).
Of the prevalence cases who present themselves for
• diagnosis (50%), 2584 can be diagnosed if all the available
1
FLOW CHART
Model on DTP efliciency as at present Vs. WHO recommendation
AVERAGE INDIAN DIS'! RIO':
Population 1.9 million — (a)
C.\SE LOAD - ALTERNATIVE
HYPOTHESIS
Prevalence of cases — (b)
6460
Cases presenting for diagnosis
(50% of b) - (c)
3230
bl = prevalence of smear pos cases
= 2584
b2 = incidence of all cases = 2196
b3 = incidence of smear pos cases =
879
Case-findingpotentail (CEP) (80% of
c) - (d)
2584
HYPOTHESES USED
2
B
C
Case-finding
DTPE@
No.
%
@@
Level
No.
Treatment
Efficiency
(TE)#
Ai current case
finding level
(CFE S:36%)
936
LcvcpTE 1
465
18.00
El
936
Level TE 2
735
28.44
E2
1809
Level TE 3
1537
5950
E3
At case finding
level
recommended
by WHO
(WRCF*-70%)
Case-finding
treatment
(a) Population of an average Indian District
= 1.9 million
(b) Prevalence of all cases 5 + age
= 4/1000 population
bl) Prevalence of smear positive cases
= 40%ofb
b2) Incidence of all cases
= 34%ofb
b3) Incidence of smear positive cases
= 34% of bl
(c) Cases presenting at health institutions for
diagnosis = 50% of b
(d) Sensitivity of diagnostic tool at health
institutions = 80%
INTERVENTION OUTCOME
A
LEGENDS
Case:
CFP:
Bactcriologically positive patient of tuberculosis.
Case-finding Potential-proportion of cases
diagnosed among those presenting themselves at
health institutions (80% of c or 40% of b) = (d)
CFE $:
Case-Finding Efficiency =
* WRCF:
performance
x 100
CFP
WHO recommended case-finding lcvel:70%
of bl (2584)
#TE:
Treatment Efficiency-sputum negativity
achieved in cases found
TE.l:
Cases on SR-compliance 45% at level 4;
TE-50%
TE.2:
Cases on SCC-compliancc 56% at level 4;
TE-79%
TE3:
TE = 85% as recommended by WHO
(Compliance level &. Regimens not stated)
@ DTPE: DTP Efficiency.Sputum negativity achieved
out of cases presenting themselves for
diagnosis ie.,CFP (d)
CFP (d)
@@ E1-E3: DTP Efficiency under various options of case
holding including WRCF
health institutions participate in the programme as per the
Manual(d). This is called the case-finding potential
(CFP). The ease-finding efficiency (CFE) is expressed as
a proportion of the eases being diagnosed by a DTP
(current average for DTP as per information available
from the periodic monitoring report prepared by the NTI
being 936, the CFE is calculated at 36% of CFP: see under
Column ‘A’ of the (low char t). The results of treatment al
the current treatment efficiency (TE) is shown in Column
‘B’: TE.l for the eases on standard regimen (SR; and TE.2
for those on SCC. Column ‘C’ gives the proportion of
cases which could be cured with the respective TE,
calculated out of the CFP (DTP efficiency - DTPE)4.
DTPE under SR is shown as 18.0 (E.l) and on SCC 28.4
(E.2).
Table 1 calculates the epidemiological impact of CFT
while taking_ into consideration the natural dynamics of
tuberculosis'’. Part A’ of the Table shows the natural
dynamics without intervention6. For calculation of
dynamics of intervention in Part'B' 1. the natural dynamics
has been applied to the proportion of prevalence eases
which is not being diagnosed in the programme. In Part ‘B’
II (a) the dynamics of the programme where the cases arc
diagnosed and treated with SR under the current
efficiency is applied2. In Part ‘B’ II (b), the same under
treatment of cases with SCC regimen is imputed7. The
cure (CT) and death (DT) among treated eases (‘B’ II a
and ‘B’ II b) is added to the natural cure (CN) and deaths
(DN), among those uncovered by the CFT activities of the
DTP (Part ‘B’ I). These add up to constitute the number of
cases excluded from the initial prevalence (EX.T1 = CT
+ DT + CN + DN). The remaining number is shown in
column 5 (Tl - EX.T1), to be 4264 under no-intervention
situation, 3964 under intervention with SR and 3842 with
SCC. The annual incidence eases (Column 6) arc added
to these numbers to give the prevalence at the end of the
year (T.2).
Table 1 shows that without a programme, the
tuberculosis situation in terms of ease prevalence would
have remained unchanged (Part A, Column 8). With all
the treated cases on SR, the programme appears to show
a reduction of 4.6% annually (Part ‘B’ total I + II a) and
Table 1
Estimated load of sputum positive cases in a district at the end of a year:
Natural dynamics vs intervention through district tuberculosis programme
p
Intervention
Situation
Fate of eases in a year
T1 Pre
Difference
prevalence
Excluded from Prevalence
Incidence of
valence
(Number
of
T1-T2
(Ex.Tl)
x 10(1
(Number of
eases in a
Remaining as
eases at the
T1
year (I)
eases
cases (Tl-ExTl)
end of a year
(%)
Death
Cure
initially)
(Col 5 + 6)
R
7
1
4
5
6
7
8
2196
6460
0
2196
2196
6160
6039
4.6
6.5
64(>0
904*
12'J2‘*
4264
I
5524
773*
1105‘*
3646
H(a)
H(b)
936t
936t
15011
OHU
468 +
739+ +
318
197
Total:I +11(a)
1+11(b)
6460
6460
923
773
1573
1844
3964
3<842
A
B
Given : Population of a district = 1.9 million.. Total cases = (Tl prevalence = 6460;
Incidence of eases in a yea r = 34% of prevalence
A - Natural dynamics
* Case fatality rate = 14%
♦*
Cure rale = 20%
B - Dynamics of intervention (DTP): I - Not diagnosed under DTP
Il - Diagnosed under DTP:
(a) treatment with SR
(b) treatment with SCC
t - Current case-finding efficiency (CFE) - 36.22% of CFP
CFP - Case-finding potential - 2584
Case fatality rate : U - all eases on SR = 16%; UH all eases on SCC = 0%
Cure rale : + - all eases on SR = 50%; + + - all eases on SCC = 79%.
3
.......................................... ■
Table 2
Prevalence of cases after a year under some intervention alternatives with varying compliance levels in a district
tuberculosis programme
Intervention
alternatives
Case finding
Efficncy
(CFE)t
1
2
I
n
m
IV
v
VI
vn
Cure on
treatment
(CT)#
Excluded
from Tl*
(Ex.Tl)##
Prevalence at
the end of a
ycarT2**
Problem
reduction
(%)
Additional
decline
compared to
alternative I
%)
Relative
benefit ft
(%)
■>
4
5
6
7
8
468
599
655
739
2496
2627
2683
2618
2655
2674
3083
6160
6029
5973
6038
4.6
0.0
2.1
3.0
2.0
2.6
2.9
9.5
0.0
45.7
65..2
43.5
56.5
63.0
206.5
936
936
936
936
936
936
1809
Til
796
501
6001
5982
5573
6.7
7.5
6.5
7.1
7.4
13.7
Abbreviations used : t CFE = Case-finding Efficiency (Proportion diagnosed out of potential 2584): (for
I to VI al 36.22% = 936; for intervention VII at 70% 1809)
# CT = Cure with treatment = CFE xTreatnient Efficiency (TE))
TE calculated as follows by respective complicancc at level IV;
Intervention
alternatives
CFE
(%)
Regimen
compliance
(%)
TE
(%)
I
36
36
36
36
36
36
70
SR 45
SR 70
SR 90
SCC 56
SCC 70
SCC 90
SCC 70
50
64
70
79
83
85
83
n
in
IV
v
vi
VII
* Tl = Initial prevalence (6460);
##
Calculated from the formula : Excluded = Ex.Tl = CT + DT + CN + DN
DT = Dead on treatment in a year: (CFE x Case fatality rate); case fatality rate on SR = 16%
(on intervention I-III = 150); on SCC Nil (0 on intervention VII)
CN = Natural cure (Tl - CFE) x 20%.
DN = Dead with Natural Dynamics : (Tl-CFE) x 14%);
under Intervention I-VI = 773; under intervention VII = 651
** T2 = Prevalence at the end of one year (Tl-Col 4 + 1)
I = Incidence in a year = (34% x 6460 = 2196)
ft Relative benefit (columun B)
4
Additional Decline from alternative in question
X 100
Decline on Intervention alternative at I
i
i
I
i
i
-
on SCC 6.5% (Part ‘B’ total I + II b). The latter shows a
benefit of 41% over the former, besides causing
prevention of deaths at the end of treatment (none on
SCC and 150 with SR).
Intervention Alternatives with Fixed CEE
It could be observed from the flow chart that at the
current efficiency, 936 cases arc found: of these, only 465
on SR and 735 on SCC could be cured. It could be taken
as a failure of case-holding, calling for corrective actions
in order to improve the epidemiological impact of the
programme.
In Table 2, various intervention alternatives stand
presented along with the extent of likely reduction of the
problem under current CFT efficiency and all cases on SR
(alternative I), taken as the baseline. With the CFE
pegged al the current level (36%), effects of raising the
treatment compliance for level 4 on SR from 45% to two
higher levels of 70% and 90% arc studied. They give a
problem reduction of 6.7% and 7.5% respectively i.e., an
additional decline of 2.1% and 3.0% compared to
alternative I taken as baseline (rows II and III at Column
7). On SCC regimen with current compliance of 56%
(alternative IV), a problem reduction similar to that on SR
with improved treatment compliance to 70% (alternative
II) is observed: around 2% additional decline with both. Il
could be concluded that in a situation where SCC is not
available, gain equivalent to SCC in epidemiological terms
could accrue by raising the compliance on SR lor level 4
from the current 45% to 70%. On the other hand, raising
the compliance for level 4 of patients on SCC from current
56% to 70%, the additional decline is only marginally
different (2.0% Vs 2.6%). However, raising the level 4
compliance, whether on SR or SCC to 90%, would not
result in much difference (3.0 on intervention III Vs 2.9 on
intervention VI). Further, the question of raising the
compliance for level 4 on either regimens may pose to be
too ambitious a task operationally, besides not yielding
commensurate epidemiological gain.
Intervention Alternatives Recommended by WHO
From the above, it appears reasonable to expect almost
similar possible benefit by raising the compliance for level
4 to about 70%, SCC having a marginal advantage over SR
in its ability to prevent deaths. For higher epidemiological
gains, it is obvious that CFE also needs to be raised.
The WHO, in several of its reports, recommends a
global target of 70% case detection (WRCF), an 85% cure
rale (TE) of all sputum positive cases8’'’’1 ’ll. However,
the target on case-finding, as expressed, is amenable to be
variously interpreted. In two documents, it mentions the
target to be “70% case detection” interpreted to be out of
the total prevalence8,9. In respect of this target, the result
of treatment at 85% TE, expressed as DTPE will be
148.76%(scc Appendix Table). Since no methodology
exists to diagnose all prevalent cases in the community,
this intervention alternative is not feasible.
In a third document issued by the WHO10, the target is
given differently as “70% of the detection of all new eases”
TE being the same. Since there is no method of detection
of culture positive new cases in the DTP, the target can be
interpreted as all newly occurring smear positive cases. Al
70%, the WRCF works out to be 615 with DTPE being
19.8% (Appendix Table). At the current CFE (36%), it
appears that the performance in ease-finding (936 average
per DTP), is ahead of the WRCF of 615. However,
because of a low TE, the impact of curing a number of
eases more than the incidence of smear positive cases (b.3
= 879), is not obtained.
In the fourth document of the WHO11, the target of
CFE is mentioned as 70% out of all smear positive eases
(WRCF:1809), TE being 85%. When the efficiency of this
WRCF is compared with the current CFE of 936 eases,
the latter is nearly half of the former. The DTPE for this
alternative at 59.5% is very high indeed (See flow chart).
The epidemiological impact as given in the Table 2 for this
alternative is 13.7% annually, with additional decline of
9.5% over alternative 1, representing a benefit of 206.5%
over the current CFT efficiency. Since CFP is similar to
the prevalence of smear positive eases (b.l = d), this
alternative appears feasible on the face of it. However, it
must be understood that the coverage of implementation
of general health institutions as well as high treatment
compliance arc to be ensured for such achievements.
From the above, it appears that raising CFE to a level
of WRCF 70% and TE to 85% remains an attractive DTP
objective to attain in the long run, however unrealistic it
may presently seem. We may work for this. At the same
lime, we have to consider other alternatives which may not
appear as imposing.
Examining the alternatives given in Table 2, it has
already been observed that between 2% and 2.6%
additional decline is possible to achieve by keeping the
CFE at the present level, but raising the compliance to
70%, whether on SR or SCC. The system could be geared
to achieve this, as it would rekult in a TE of 83%
(alternative V). Besides ensuring uninterrupted drug
supplies, improvement in treatment compliance to this
level would call for a revised action plan on ease-holding.
It is possible that corrective measures at higher
case-holding may have an indirect consequence of a
higher CFE as well. The possible inputs to raise the
5
T7....
achievements in respect of case-holding requires to be
examined.
Operational Alternatives on Improving
Treatment Compliance
Some of the areas of concern in an anti tuberculosis
treatment programme arc to see that patients arc treated
free and (hey get supply of drugs regularly as near to their
homes as possible. Further, it may even be desirable to
give supervised treatment, especially in the initial intensive
phase. The question is how to achieve these under the
available health services. Fortunately, the development of
infrastructural facilities in health in India makes it possible
today to consider alternatives to ensure the supply of
drugs close to patients’ residence and monitor treatment
compliance more effectively than hitherto possible.
Availability of treatment facility till recently was restricted
upto the level of Primary Health Centres and dispensaries
(Peripheral Health Institutions — PHI), catering to nearly
100,000 population in the villages on the average. Today
there is likely to be one PHC for ever,' 30,000 population.
Besides there arc sub centres one for 3000 to 5000
persons. Beyond the level of sub centres, even though
there may not be institutional facilities from the
Government, alternatives exist in the Non-Governmental
sector. Thus, there is the provision for one community
health volunteer (Health Guide — CHV) for even'village.
CHV is selected by the community leaders to render
elementary and general health care at the village level.
Over and above this facility, workers oriented to special
health problems arc also available in the villages today viz.,
traditional birth atlendcrs or ‘Dais’ (TBA) and Angan
wadi workers (under the integrated child development
scheme - ICDS workers). There could also be private
medical practitioners of various systems working in the
villages.
Table 3 depicts the health functionaries below the level
of PHI and the possibility of involving them in some or
other manner in tuberculosis treatment activity under a
programme.
Governmental Agencies
There are two categories of health personnel available
with the agencies under direct Govt, control viz., health
worker (male & female) and the Anganwadi worker
(ICDS).
Health Workers:
The health workers are stationed at sub centres to
visit villages on previously appointed days (as per beat
schedule). From the nature of their schedules they
6
cannot visit a village out of turn cither to make a drug
supply or for defaulter retrieval action. Moreover,
they may not be present on the day a patient chooses
to visit the sub centre for drug collection. Therefore,
they may not be utilised for drug distribution
routinely at the centre also. Secondly, the State
Governments have not been able to provide, as yet,
residential accommodation to all the health workers
al the villages not even to the female health workers.
In some places the clinic accommodation of the sub
centre itself may not be there. The health workers
however, can be utilised to motivate the patients in
the respective villages, while visiting them as part of
their fixed programme. Patients’ general welfare can
be one of the major concerns of the health workers.
They can render valuable service by advising/
referring the patients. They may also collect data
concerning patients and forward the same to the PHI
(e.g. death, hospitalisation, serious set back in
condition, etc). More importantly, these workers can
supervise, al the village level, the activities of the
Anganwadi workers/CHV/Dai working in the
respective villages as peripheral drug distributor for
tuberculosis. Since a Health Worker as a rule visits a
PHC once a month, he can collect the monthly quota
of drugs required for the drug distributors in his area
and maintain the routine peripheral supply on a
regular manner.
Anganwadi Workers:
Each village with more than 1000 population may
have an Anganwadi worker under the integrated
child development scheme. She functions from the
ICDS centres called Balwadis, attended by pre
school children. These workers can be utilised for the
motivation of TB patients or to render daily
supervised administration of treatment to the patients
in the villages. They can in any case carry out periodic
drug distribution. Being educated, they can maintain
proper records and make adequate reports to the
supervisors. Motivation rendered by them could be
very effective. They may not take part in defaulter
retrieval action or make drug collections from the
PHIs for the patients under their-charge. This is
because of their unipurposc nature of work related to
the ICDS scheme. They arc also not expected to treat
side effects to chemotherapy.
Non-Governmental Agency
Under the voluntary/Non-govcrnmcntal agencies
working in the villages, the CHVs, private practitioners
and ‘Dais’ arc likely to be found in every village. Their
is
Table 3
Availability of health personnel in field and suitability of involvement in a tuberculosis programme
Additional Activities Under DTPs
Category of Worker
Not Suitable
Suitable
Governmental Agency
I. Health Worker
(Male,’'Female)
*
*
*
♦
II Anganwadi Worker
(ICDS)
Motivation
Collection of information about
patient’s general welfare
Collection of drugs from PHI and
supply to the drug distributor
Supervision of peripheral drug
distributor
- Routine drug distribution
Defaulter retrieval action
Treat side effects
Motivation
Drug distribution
Recording and reporting
- Defaulter retrieval
- Collection of drugs from the PHI
- Treat side effects
Motivation
Drug distribution
Supervised administration of
treatment
Defaulter retrieval
Minimal recording and reporting
- Collection of drugs from the PHI
- Elaborate recording and reporting
- Treat side effects
- Elaborate recording and reporting
- Treat side effects
*
'
Motivation
Collection and distribution of drugs
Supervised administration of
treatment
Defaulter retrieval
Minimal recording and reporting
*
*
*
Motivation
Distribution of drugs
Treat side effects
*
*
*
Voluntary
Non-Governmental
Agency
I
Dai
(Traditional Birth
Attcnder)
*
♦
*
*
II Community Health
Volunteer(Schemc not
uniformly acceptable &
may be on the wane)
III Private Parctilioncr
*
*
*
likely role in tuberculosis treatment programme is
discussed as under:
CHV
I
The CHVs are capable of making periodic drug
distribution, supervise treatment administration,
carry out motivation, defaulter retrieval, recording &
reporting. On the face of it, they look ideal for all the
activities under the tuberculosis treatment
Defaulter retrieval action
Collection of drugs from the PHI
programme. Even though they are not able to collect
drugs from the PHI, treat the side effects or make
elaborate recording and reporting, they could be
otherwise very helpful. Since the collection of drugs
as well as reports can be carried out by the health
supervisors or health workers of the PHIs, the latter
category may serve as a vital link between the system
(PHI) and the village level drug distributors. Patients
with side effects can be referred by the CHVs to the
PHIs.
7
________ ... ._______
■
Private Practitioners:
Private practitioners, by the nature of their profess
ional involvement in patient care in the villages, arc
capable of treating patients of tuberculosis including
side effects. They arc also capable of maintaining the
elaborate records and carry out reporting. Though
they may not be making home xisits for retrieval of
defaulting patients they may still be successful in
ensuring this through local influence. However, it may
be realised that the interest of the private
practitioners may not necessarily converge with the
programme policies. Their economic interest in the
patients may often be so overriding as to prevent
them in conflicting situation vis-a-vis the programme.
€
1.
At the sub centre level drugs may be collected by the
patient from the health workers (male or female) on
appointed days. This will obviate the need of patients
to travel a longer distance in order to make drug
collections. Moreover their visits should be so
adjusted, as to fall on days of the week, when the
health worker is supposed to be available at the sub
centre.
2.
The drugs can be supplied to Anganwadi workers on
diagnosis of a patient at the PHI. Supply could be
carried out by the supervisor, under whose
jurisdiction the village falls. Patients could collect the
drugs on due date from the Balwadis. The working
time of the Balwadis should be kept in mind and the
patients to be advised to attend them accordingly.
Balwadi being available in every village, the working
hour may not pose much problem to the patients. The
Anganwadi workers can also render supervised
treatment daily or twice a week. However, daily
attendance of sputum positive patients to Balwadis,
devoted to child welfare activities, may not be
welcome to some. This may pose a problem in the
supervised administration of treatment.
Dais:
Ever}' village in India from the times of yore has been
served by the Traditional Birth Atlcndcrs or Dais.
They render assistance in carrying out home
deliveries. In recent limes, the Govt, of India has
implemented a plan to impart elementary training
and orientation to them, so that the services rendered
by them arc carried out in a scientific manner with
maximum safety to the mother and the child. They
may thus be in a position today to appreciate the
importance of the procedures in the scientific
context, by being linked to the health care delivery
system. There is a provision to train one Dai for a
village of 500 persons on the average. Presently, this
scheme appears to be accepted widely throughout the
country and functioning. Il is possible to visualise the
Dais as capable of participating in the tuberculosis
treatment programme. However, the activity they are
supposed to perform in the programme should, in the1
first place, be acceptable to them. Further, the
modalities should be worked out to impart to them
the minimum training in drug distribution, defaulter
retrieval, as well as identification and referral of
patients with side effects. It should however be
understood that they may not be expected to keep
elaborate records and carry out sophisticated
reporting. However, the fact remains that they arc
experienced enough in rendering responsible service
in the health sector at the door steps of the people. It
will be good sense to employ them usefully in the
tuberculosis treatment programme supported by
adequate training, supervision and guidance.
3.
Both Dais and the CH V may be utilised as peripheral
drug distribution agencies as well as for supervised
administration of treatment. In this case also, drugs
need to be supplied to the distributors by health
supervisor as and when the patient is diagnosed al the
PHI. Since the Dais or CHV may find it difficult to
advise on individual dosages of drugs, it may be
worthwhile to supply a day’s dosage of all the drugs in
a blister pack or pouch, thereby simplifying the
process of identification of individual drugs and their
dosages. As these workers arc available in the villages
al all limes, the prospect of success of the supervised
treatment through the involvement of these workers
appears reasonable. There is a problem of
acceptability of ‘dais’ to the community as well as the
services rendered by them for tuberculosis treatment.
Even sometimes the ‘Dais’ themselves may not accept
the responsibility in this regard.
Thus, the action plans given above need to be studied
from the angle of acceptance of the proposed services by
the community, by patients in particular as well as by
workers themselves. The feasibility and linkage to the
health system needs to be worked out in detail. The
question of involving the peripheral health workers in the
tuberculosis treatment programme is indeed a priority
area of research today!
Conclusions
Acknowledgements
The following alternative action plans utilising the
peripheral level functionaries could be investigated:
The authors arc thankful to Miss. Pramccla, KR and
Miss. Alamclu.TJ for their secretarial assistance in the
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preparation of this manuscript. The authors arc also
thankful to Sri Srccnivas TR, Statistician and the Director,
NTI for their suggestions and encouragement.
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Appendix Table
DTP efficiency with various WHO recommended case-finding targets
Results of intervention*
Target poo! in an Indian district
*
WRCF
TE
DTPE**
Prevalence of all cases
= 6460
4522
3844
148.76
Incidence of all cases
= 2196
1537
1307
5058
Incidence of smear positive cases
=
879
615
523
20.24
Prevalence of smear positive cases
= 2584
1809
1537
59.48
At WHO recommended case-finding efficiency (WRCF) — 70%
and treatment efficiency (TE) — 85%
* * Proportion cured out of smear positive cases presenting for diagnosis at all the health facilities (i.c., case-finding
potential — 2584)
TE
DTPE = CFPX10°
I
#
The alternative used in the flow chart.
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