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Tuesday, November 01, 2005 11:46 PM
PHA-Exchange> [afro-nets] The Patients' Charter Tuberculosis (4)
from Erika Blair <voices@tbtv.org>
The Patients' Charter of the Tuberculosis Community (4)
In response to the posted question from George Kent
<kent@hawaii.edu > "why should there be a distinct charter for
any particular disease?":
We are a group of people who are living with, and hopefully sur
viving, tuberculosis. A highly contagious (airborne) disease
that killed some 2 million people last year. Two million the
year before, and the year before that, etc. TB has been mass
killing for hundreds if not thousands of years. Some sixty years
ago they said that the cure had been found, which in reality has
meant that those with resources live, and the poor die. Once the
rich were protected, they seem to have forgotten about the oth
ers, illustrated by the fact that no new anti-TB drugs have been
developed in fifty years. Probably some 100 million deaths ago.
As TB is a disease which affects the most vulnerable and disen
franchised populations, our rights have never been important and
our voices never heard. Today, two deadly factors are beginning
to raise the stakes: HIV/AIDS and MDR. TB is the biggest killer
of those living with HIV, and the co-infection TB-HIV is now
pandemic in Africa and large parts of Asia; multi drug resis
tance (MDR-TB) means that the old drugs do not work and the per
son dies slowly, painfully, and often in isolation. Most health
systems don't even try to treat MDR patients - they're consid
ered write-offs. There are some 700,000 to a million people with
MDR today, increasing each year, who have no hope, no voice, and
no rights. (Nor any media, rockstar or hollywood friends).
—>
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Learning from the HIV experience, we are now trying to build
'community' as a step towards organising ourselves to demand
better treatment, new drugs, diagnostics and vaccines that work.
We also demand some dignity, and some basic human rights in the
face of stigma and discrimination arising from our long margin
alisation. A good part of this stigma has historically been
passed down through the traditional medical establishment, who
has too often seen the TB patient as a burden and a problem for
public health (and not profitable to treat).
The Charter is one of our first tools to address the silence in
11/3/05
Page 2 of 2
which we suffer. Tuberculosis is the killer loose in our commu
nities, and we seek ways to stop the death toll and devastation.
By drafting a document that outlines our basic Rights and Re
sponsibilities, and that is endorsed and distributed globally
through the WHO and its partners, we are beginning to build some
of the foundations for change to occur.
In response to "Why have a separate charter for any particular
ailment?": The many people who are helping to draft the next
version write not for an "ailment", but for the human rights and
responsibilities that are specific to their needs. The Patients'
Charter of the Tuberculosis Community is the synthesis of val
ues, principles, and aspirations that are widely shared by peo
ple infected or affected by TB, TB-HIV, and MDR-TB in all re
gions of the world. It is the standard of the Rights and Respon
sibilities, for and by those living with the diseases, which
builds community amongst those most affected. People, not ail
ment, centered. Finally, I think that the Denver Principles of
1983 also serve as a response to the question.
So, we welcome your comments and input. It helps us all towards
empowerment.
Cheers,
Erika Blair
TBTV.ORG
mailto:blair@tbtv.org)
http://www.tbtv.org/texts/newsflash/patients_charter_draftl.html
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11/3/05
D r. G. Vi sweswa ra i a 11
Hon.Secielary. KSTBA..
Karnataka State Tuberculosis Association, Bangalore.
Understanding the Nature and magnitude of TB in India and Karnataka
Tuberculosis in India happened to be the major public health problem. The National
sample survey was conducted in India in 1955 - 1958, as per the report of NSS
prevalence of Tuberculosis was 20 / 1000 and incidence of Bacillary Tuberculosis Cases
was 4 / WOO. Men are more suffering than women, old age than young age. The
distribution of Tuberculosis is almost equal in urban and rural areas. However since 4
times the population lived in the villages than the urban areas.
The burden of
Tuberculosis in the rural areas could be 80% as compare to that of about 20% in urban
areas. This means that the resources for the control programme has to be reallocated
proportionately.
40% of Indian population are infected, by TB in the community . Among the infected
10% of them may get TB at any time during their life time, if their natural resistance to
the disease is reduced.
14 million Tuberculosis patients are there in India. Out of this 3.5 million are actually
coughing out TB Bacilli in their sputum for the spread of Tuberculosis in the community.
.Smillion ( 5 lakhs) deaths are caused by tuberculosis. One TB patient can spread the
disease to 10 - 15 healthy persons in a year. Thus there are 10 lakhs of new TB
patients added every year. One person in India die of TB every minute.
Tuberculosis is killer number one in the community. Of every 100 death due to all
causes in the community 10 are estimated to be due to infectious forms of pulmonary
tuberculosis. There could be many more deaths due to TB in children.
Tuberculosis
causes more deaths in women in child bearing age and even among the men in the
productive age group of 15 - 49 years
( productive age group ).
Proportion of Tuberculosis cases remains same year to year
Every year 1/3 of existing cases either die or cure . But the same number join the
existing cases maintaining the same number in the community.
National lubciculosis programme ( NTP) was started in the year 1962 in India to meet
the felt need of patients in community. It could not achieve, its objectives as there was
30% treatment completion and 70% were dropouts and with other technical,
administrative and inadequate budgetary outlety, It was reviewed by a committee of
National and International experts in 1992 as a failurte programme. The WHO declared
tuberculosis as the global emergency in the year 1993 and formulated the Revised
National TB Control Programme ( RNTCP) providing all feasible requirement to run the
RNTCP in India in a phased manner in the states, through District TB Centres, to be
delivered through the primary health care infrastructure, to achieve 85% cure rate and
to detect atleast 70% estimated smear positive Pulmonary TB Cases. <-
In Karnataka the RNTCP was launched in 10 districts including Bangalore Mahanagara
Palike in the first phase covering 218 lakhs population. The 12 districts were taken in
the second phase covering 257 lakhs population. The remaining 54 lakhs population
has been covered in the third phase having 5 districts in the state by the end of 2003
t he Role of the Prividc Scctoi in I B
('omiminily I lualth ( cl.l, .lune 'August 2000
Notes on Hie Study : Non < Jovei iiiiien(:il ()i-|>:miz:itions in Tnliei cnlosis CohIkiI: A
study iii Western Indin (by Slicehi Ruin-an, Adili Iyer, Stislnna .lliavcii)
Objective :
To investigate the role of (he Private Sector in Tuberculosis control. I bis includes
launching an organized effort aimed to understand the nature and role of the private
sector in health care in the arena of 1 ubcrculosis control. (TB control has three main
parts : case tinding, treatment, and case holding. The private sector would be defined as
including non governmental organizations (NGO’s), including voluntary organizations,
for-profit establishments, grant-in-aid funded projects and finally a range of private
physicians who practice anything from tribal Io allopathic medicine.
h n p o 11 a n c e o f IJ n d c i s t a n < I i n g I h i sy I ’ roj ec I g
Although the National Tuberculosis Program (N I P) has been in existence for
more (han 30 years, many health care providers and patients arc unaware of the benefits
and reaches of the program, thereby encouraging the notion that the programs must be re
vamped and revitalized. The focus of the revitalized programs is the detections of at least
70% of the incident cases and cnsiii ing cure of 85% of’lhc detected cases. ( I his is what is
projected Io favorably alter (he course of I B worldwide) In addition, plans arc underway
to involve the non governmental sector (NGO’s), voluntary and non-piofit scclois that all
constitute the private sector. NGO participation in the social sector ranges horn
assistance to policy making to actual field based service delivciy.
With the onset of III V, TB has renewed global interest, and a large percentage of
cases occur in India. However, despite (he urgency of prudent action, a lack of interest
has rendered N I P programs ineffective. I iirlhcrmore, although the Private Scctoi takes
care of most TB programs nationwide, (hey have not been involved in the NTP programs.
However if their input is taken, information could be provided that would improve the
performance of the NIP as well as the quality of TB care available Io patients
nationwide.
Stages in the study:
( ompile < oniplclc lists <»l the N< i( )’s working, in I B from lists of N( JO’s in the
health Held. I his was then narrowed down to include those that had a significant I B
component Io their agenda.
A survey undertaken using a mailed questionnaire to understand the number
of and nature of private sector health care providers as well as approaches Io
TB control, (obtains a directory of NGOs in the area with their profiles)
Case studies of a few selected NGO’s to document the effectiveness and
implementation of I B control programs, (from this, a detailed report can be
prepared identifying the strengths and weaknesses)
I lore, it is important to document the foilwing categories :
I'xact response rntes (’’<> replied, etc)
'I'hu Role of the Pi I vale Sector in I B
( 'on ii i inn it v I ha II h ( 'c|l, lune
Aurusl .UM 10
Location / (ieo^riiphiail I )istri/nition (Rural/! Irban ... etc)
Source of rimdinV' for N( /(> ’v (incliidinp, individual donors, stale govt, and
municipal I’ovt., inlui national lunding agencies, other N( i( )s, central govt.,
public/privalc corporation, etc)
Nature of Support Received from (he (jovernment (including supply of drill’s,
grants, supply of stationary, deputation of workers, etc)
Nature oj Tit ITork ( including only providing assistance, only ease linding ,
only follow-up, ease finding and treatment, treatment and follow-up, only
health education, ease linding, treatment and follow up )
( 'use Load and Number of New Patients registered in Ih evious year, and
Case Detection.
Diagnosis, Treatment and other I'acilitics (including X-rays or Sputum
examinations conducted by organization, referred to private laboratories, or
referred to government facilities.
Treatment Methods of Id Patients (Regimens, Medicines, etc)
( 'use Holding and Methods to Improve Regularity and Treatment Adherence
Comparative Performance of NGOs and State 77? Programs
Nature of Assistance Provided to Patients
Problems in Conducting Cohort Analysis :
Poor Record Keeping contributed to the majority of problems in the study
o
Treatment Outcome was not usually recorded . This leads to
inaccuracies in completing optimum period of treatment (COPT)
numeric values.
o
Cohort analysis was not restricted to sputum positive patients and so
o
it’s all bunched up.
No continuity in collecting sputum samples. I lard to get patients to
comply when treatment starts to work As a result, the cure rates could
not be accurately assessed in all eases.
Important as a factor in the N( i()s that deal with TB include the ease load that they
handle (usually lioni a third Io a hall Of all stale eases), lhe amount of reach that they
have lhe urban and rural areas, as well as their infrastructure and ability to handle
massive loads of eases. Many NGO’s have more of a clinical approach rather than a
public health approach : in these eases, there is not much concept of ease holding nor
treatment completion rates. The emphasis is placed on case detection.
Not many of the NGOs deal only with TB eases -- here, TB is usually only a component
of the overall health activities. Some of (he NGO approaches to tackling TB included :
Institution/I lospital/Clinic Based Programs : outreach programs from clinics,
hospitalization facilities and ambulatory treatment.
Use of Community Based Workers in well integrated programs : incentives
were given to workers for ease finding and treatment completion. Phis was
found to be fairly successful provided that there was adequate monitoring and
supervision.
I he Role of Ihu Private Sector in TB
< 'oinmiinily I Icallh (’ell, .lune Aug,nst 2()()()
I Ising Public Health Services and dependence on govcinmcn!;il services, (i.e
diagnostic and treatment facilities), hut taking care of the di tig dispersion.
I his lead to higher (realment completion rates.
Involving Private Doctors : trying to including this sector in the TB program
by setting up a proper referral system.
I here is a hesitation in relying on sputum examinations for the diagnosis of I B, and
patients prefer (he chest X-Ray.
*
1
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•4
VIS' 5".
' ' ) •
An Indian Perspect^'
■ •lop TB I igla poverty : An tndi.m Perspm live
Introduction:
Stop TB, fight poverty is the theme for World TB day 2002, TB imposes a
considerable economic toll on patients and their families. Because more than
X flTto'sn iT013'6 WiU1 aCHVe TB araN1 Ll’e eco'10mically active ageg'oup ( 5 to 5-1), the economic and social costs to them and society aim
huge. Fhey arc income providers of the family. I hey are the parents of
young children who need their economic and emotional support in order to
thiive. They have elderly parents and relatives who depend on them They
are the citizens whose productivity and talents are essential to then
countries' development. The result of TB is that access to oppm tunilies and
choices- a key principle of human development -is blocked
HI health, malnutrition and high fertility are three main reasons why
households become or remain poor. They cause poverty through diminishing
pioc activity, ieducing household income and increasing health expenditure
A more complete view of poverty includes deprivation not only from money'
income, but also human development, financial and physical security,
expanding opportunities and especially participation in key aspects of social
oor families have no buffer against loss of income-no savings and very
limited access to borrowing. The way they cope with this economic adversity
am thXchl/;
' 11101 iS cnsh-buL il1 lo'10
makes them
■md then chidien destitute. The sale of assets such as land is a common
1'
If) Liigc l||(!(||(<|| (JX|)('||!i(!S.
Income poverty leads to ill health and ill health contributes to income
poverty. A more complete view of poverty includes deprivations from not
only money income, but also human development, financial and physical
security Poverty is also seen as a lack of basic human development
indicated by poor health, malnutrition and educational development Gender
is in particular an important variable affecting both health and poverty.
TB and Poverty Links
The global experience with TB control has been able
to define certain clearcut linkages between TB and poverty:
r B is more prevalent among low-income groups than among high
o
o
income <ji oi ips.
I he cost ol IB care, if borne by families alone can be unaffordable.
113 is a chronic ill ness and requires care over a relatively long period
during which productivity is reduced, leading to interruption of
education and work.
Household income is severely reduced, family dysfunction increases,
particularly if mothers are ill and poverty increases.
Lower productivity and more poverty impede social and economic
development and increase inequalities in society.
Lower income people are higher risk-as TB spreads in crowded
places-households, school, workplace, marketplace and commuting
between them.
The real stakeholders in TB control
o
A. The people: - the low-income groups are the most vulnerable
people with limited resources to over come poverty-related TB risks
viz:
(>
Barriers in access to primary health acre ans appropriate
diagnosis and treatment for TB
o
Emerging HIV/AIDS -TB co-infection
o
Lack of knowledge about the disease
o
Overcrowded living and transport conditions
o
Urban congestion/pollution
Poor nutrition
o
o
B.Society: - as represented by politicians and policymakers, with
power to reduce risks.
Poverty in India
Statistics as provided Government of India show that about 240 million
people live below the poverty line. (The poverty line is really the line of
destitution. At this line, people just enough money to provide them with
food, converting to 2,200 calories and with nothing else. No roof, no clothes,
no secutlly, no minimal comforts, let alone schools, medicines and any fruits
ol Indusl i lai i ovolul Ion.)
Poverty iillevlatlon remains pronounced challenge before the Government.
Though there ahs been a steady decline in poverty over the last two
decades, the total number of poor people has remained more or less
constant due to growth in population. The inter-regional disparities in
poverty levels are quite alarming. According to National Sample Survey
Organization (NSSO) the poverty situation ins several states in India is
appalling: Orissa 47.15%, Bihar 42.6 %, Madhya Pardesh 37.4%, Sikkim
36.55% and Tripura 34.44%. In terms of numbers Uttar Pardesh has 53
million, Bihar 43 million, Madhya Pardesh 30 million, Maharashtra 22 million,
West Bengal 2 1 million, Orissa 17 million and Andhra Pardesh 12 million
people below the poverty line. (Economic Survey 200-2001)
Poverty alleviation programmes are still ineffective because they have not
reached the poor.
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I • / I 111 • I l< /'.I P ( I 1.111< * 11.11 ( < )l II K II < ,1 Applied | ( (> 11( > 111K p<
H ( h)
icvc.il Ih.il iilimr.l 5*)% ol all households, 4k comiliiig lor
million people,
have an annual income of less than Rs. 12500. I his means a monthly
household income of Rs. 1000 or about Rs. 200 per head. This by any
yardstick is abysmally low income.
Households with incomes between Rs. 12500 and Rs.40, 000 per year
account for 331 million people.
Only 4.1 percent, accounting for 37 million have an income of over Rs
40,000 a year.
(Life above poverty line: Rs 264 per month is all you need -Mohan
Guruswamy, Courtesy www.tehelka.com)
Tuberculosis in India: (1)
General facts
o
O
O
o
(>
o
o
o
India carries a third of global TLB burden. An eslliikiled one in I wo ol
the adult population are infected with TLB bacterium.
The estimated incidence of all cases of TB is whopping 185 cases per
1 0,000 population.
I he IB epidemic continues to giow, every year, two million people
develop active tuberculosis (more than any other country in the
world).
More people now die from tuberculosis than ever before -nearly
4,50000 every year. More than 1000 persons die of the disease each
day.
Only one in four people with tuberculosis is treated with DOTS. The
current rate of DOTS expansion is still far too slow to reach the global
targets by 2005. Failure to reach these targets will condemn millions
of people to disease and death.
Tuberculosis is inflicting enormous socio-economic costs. In India the
estimated economic cost of TB is US $ 3 billion per year.
India's DOTS programme is mainly financed through^ US$ 142
million low interest loan from World Bank with increasing costs
already being met by national and state governments.
The quantum of human cost of TB in the country is 4.56 6.28
Disability-Adjusted Life Years (DALYS). (The DALY combines a
measurement of premature mortality and morbidity and reflects-the
’burden of disease’ in a population)
The cost to the patient for successful treatment of IB averages USj.
100 to US$150, more than half of the annual income of a daily wage
labourer. The estimated cost of MDR-TB to an Indian patient is
approximately Rs 6500 a month (US$135).
Research shows that 20% of rural patients and 40% of urban
patients borrow money to pay for expenses due to TB.
Tuberculosis in India: (2)
I ulx'i < Hlosi', .ni<l Women's Hc.iilth
J.x l<ie bn kson Joint UK Coordinator of Institute for Indian mother and ( hild
(UK), in an article entitled Multiple disadvantages: India, women's health
arid tuberculosis, enlists the factors that make Indian women more
susceptible to TB. Poverty whom she describes as the main cause of I B,
affects 70% of women worldwide compared to 30% of men. Poverty
predisposes women to poor living conditions and nutrition and renders them
vulnerable to disease and infection. Research has shown that in their
reproductive years (15 -d9 years), women are at greater risk of developing
the disease after infection than men at the same age. They may also be
exposed more to TB than their men folk due to their particular duties and
tasks. Besides these physical consideration the shame and stigma of disease
affects women more-to the point where women commonly keep their
diseased state a secret and unmarried girls fear that it will affect their
marriage chances.
As regards the pattern of early marriage in both the major communities of
the country, young brides are encouraged to begin a family early on. H
reduces women's financial independence-which she would be able to use to
good effect were shejo develop the disease.
Clearly tackling TB in India raises many questions about the socio-economic
and political structures within society. Can TB be tackled in India without
tackling behaviors in the society, such as the low status of female, she asks?
Certainly a husband or a father with TB puts an enormous strain on I he
family whenever it threatens his wage earning powers, however she warns
that social cost to the family is much higher when the disease affects
mother. Her need to attend treatment programmes takes her away from the
children, the cost of treatment cuts into family budget and a child is at a 310 times greater risk of dying within two years if he/she loses I heir mol her
than those will) both parents alive. She suggests that TB programmes, in
future shall not use the medical model instead tackle all factors operating on
women with respect to disease side by side. The multiple disadvantages for
women in India that operate through gender and associated factors will only
he addressed by first understanding their role In both infection, disease arid
Ircalmenl slagcs and then formulating successful strategies to reduce I heir
Influence. Iherrforc solullons lhal apply to both women and men should bo
implemented.
Tuberculosis in India: (3)
TB and IIIV
The Prime Minister of India in his speech at a meeting on National Program
for prevention and Control of HIV/AIDS on December 12th 1998, said," the
health ministry puts the figure of HIV infections in the country as of now at
three million to four million. In some states, the infection rate is one percent
of the populations. Since we have these three to four million infections today
from a base of just a few infections in 1986, imagine what the scene will be
in another twelve years from the base now of three to four million. I shudder
even to contemplate the numbers."
/v. |n i 11.111< )i i. ii a||>', ( oiiliol (>i < janisal l< h i < *.1 li 11. >1 < "> Ihe total nuiiibci ol HIV
ii.il«‘< lions in llio i oiinliy <il Ihe end ol yeai ?()()() stood at EHG million.
A document on Revised National TB Control Program (RNTCP) published on
the official web site of the National TB Control Program sums up the
situation rather crudely: "while the size of the HIV epidemic in India is
presently not known, it is clear that HIV will worsen the TB epidemic". The
document makes no further reference to the problem
I In- Dial! National AIDS Control Policy has only lo say this much loi the dual
HIV-TB epidemic "with about 14 million TB cases existing in India, HIV/AIDS
also poses a twin challenge of HIV/TB co-infection. Nearly 60% of the AIDS
cases are reported to be opportunistic TB infection cases. Treatment of TB
among the HIV-infected persons is a new challenge to the National TB
Control Programme, which has now adopted DOTS strategy for control of TB
infection. At the same time looking for HIV among TB infected persons will
also cause the problem of scaring away of a large number of TB infected
cases in the country from seeking treatment under the DOTS strategy. There
is no risk of any TB patient getting infected with HIV unless he or she
practices high risk behavior or gets infected from transfusion of HIV-infected
blood." The draft policy document makes no further reference to meeting of
two programs (National AIDS Control Program and Revised National TB
Control Program) to meet the twin challenge.
There is no reliable data available to determine how the HIV prevalence has
affected the TB epidemic in India. There are only apprehensions and
estimates. Even the NACO or RNTCP have not come out with any studies to
document the linkage. The extent of collaboration (or lack of it) between the
two programmes is reflected in the documents of two programmes available
on their web sites.
On surface they appear to be two divergent lines, emanating from a
common point.but distancing from each other as they travel to states,
districts and community health centers.
Why tackle Tuberculosis ?
I’otcnli.il »•(.<HHiiniL beiiclil.s lor India
Effective TB control can help break the cycle of poverty and disease. It cures
people and returns them to active, productive life, which in turn benefits
their children and contributes to the economic and social development of
their country. As more people are cured, the cycle of transmission is broken
and fewer people are infected. Ultimately this leads to fewer cases of active
TB.
TB control is rated by the World Bank as one of the most cost-effective
health intervention because of its potential to avert a large percentage of the
global disease, its low cost for each year of healthy life saved, the low cost
per capita, and the potential impact on socially excluded and poor people.
Ravindra Dholakia, Professor of Economics from Indian Institute of
Management, Ahmedabad in an article, Potential Benefits of DOTS Strategy
’lU'iiir.l IP) in Indi.i, divides these into two broad categories:
o
Pure social welfare increasing effects of DOTS, which do not generate
direct tangible economic benefits. These include reduced suffering of
TB patients, quicker and surer cure from the disease, lives saved and
disability reduced for dependents and non-workers suffering from TB,
poverty alleviation etc.
Direct tangible economic benefits of DOTS which include: reduction in
prevalence of TB due to DOTS which improves the efficiency and
productivity of workers, IB deaths averted among cm rent and fuluie
workers and release of hospital beds currently occupied by I B
patients.
He postulates that that even if the Indian government spends about US
$0.74 billion per year to ensure the success of DOTS strategy the
investment would fetch a return of 16% p.a. in real terms.
Projected incremental costs to the government for successful DOIS
implcincnlalion throughout India are of the order of US $ 200 million per
year, compared to the tangible economic benefits of at least US $ 750 per
year, the article notes.
Conclusion
India carries a third of global 713 burden. Every year two million people
develop active 113. TB accounts for nearly d,50000 deaths every year and
more than 1000 persons die of the disease every day. TB is inflicting
enormous economic and social costs on the country. The estimated
economic cost of TB is US $ 3 billion per year.
In India 240 million people live below the poverty line. Poverty alleviation
remains a pronounced challenge before the government. Surveys reveal lh.it
almost SO'/o
households accounting for 526 million people have an annual
abysmally low income of less than Rs 12500 (US $260)
Income poveity leads to ill health and ill health contributes to income
P'lVfily. Ihc < »)•.I Irj lh<' Indi.in p.Hlonl foi •.uccessfiil trc.ilmenl ol II’
avei.iges US $ 100 to US $ I 50. Rcseaich shows that 20‘7o of mial and lO'/o
urban patients boriow money to pay for expenses due to TB.
Indian women have to pay much higher social and personal costs if suffering
from TB. Besides poverty the shame and stigma associated with the disease,
(’aily marriage’ and social pi assures to start a family early on and limited
access to treatment facilities makes them more vulnerable to disease more
so during the reproductive age group of 15-45 years.
I he nation ha-; not risen adequately to meet the twin challenge ol IB and
HIV/ATDS. The number of HIV positive persons has risen above 3.86 million.
Nearly 60% of AIDS cases are reported to be opportunistic TB infect ion. This
is going to add to the national load of 14 million TB cases..
tdfective TB. control can help break the cycle of poverty and disease. It cure-;
w
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......... I i < I i ii 11 . I I h 111 hi ai I I /<', | H i >di l.i I I /•' III <
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lilt'll 1 II lid I I 'I I .Hid < ( H 11 I II Hit <
to tilt.' I '< < H H ) I I 11 <. .111(1 !.()( lai develop I I l( *1 11 ol
l heii countiy. A < osl ellective health inlei vent ion exists (or TB control and
treatment: DOIS. Increasing public awareness about proven, effective
interventions like DOTS and providing greater access and benefit to
treatment for those with TB, will help put billions back into the economy.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US $ 200 million per
year, compared to the tangible economic benefits of at least US $ 750 per
year. The expenditure oil health has declined in last decade and stood al
1.1 1% of GDP in 1998-99. Indian government will have to increase its
expenditure on TB control.
The three aims associated with World TB Day 2002 theme viz DOTS
expansion, efforts to raise awareness among.political leaders, decision
makers and opinion leaders and mobilization of TB sufferers for demanding
greater access to treatment are more relevant to India than any other
country in the world.
Suggested further reading
I liiir.iijnal < ouh ii nci’ : lubeculosis and Sustainable Dcvdopnifin
Web Site : http://w3.whosea.org/cds/pdf/16marchOO.pdf
I’olenlial I conniiiH Benehlys of the DOIS Strategy in India
Web Site: http://www.who.int/gtb/publications/pebdots/
I libel(.ulosis and Poverty: A PPT Presentation
Web Site : http://www.wpro.who.int/themes_focuses/themel/focus3/
POWERPOINTSTB/IMPO-TB-Poverty-Aviva%20Ron.ppt
11ibei i ulu.sr. hi India : A Ciilical Analysis
Web Site :
http://apha.confex.com/apha/129am/techprogram/paper 27954.htm
I ih- ahovi- I 'n .'iiy | mr : Rupees (rill pel month is all lhal you ll•■''d
Web '.illo : hl I p://www.leheika.(.om/( hanncls/cui rent ah an s/2 00 l/o< 1/30/
( a I 0 100 I lib 1 .him
I li ill 11 Hi • di .. n I '.ml ig<1
11 id ia, Won n 'i i's I h*. ill h and I ubei < i ih i* i .
Web Site: htlp://www.fons.org/tb3.htm
Article Compiled by
Dr. Dinesh l< innar
Director Health and Development Initiative India
email: dinesh kumar(g)vsnl.com ,
dinesh ((Thea I thiniliativc.org
l)i. J<itinder Singh
Executive Editor, Health and Development Initiative India
mailto:dinesh@healthinitiative.org,
jatinder@healthinitiative.org
Article Designed by
VS Christopher
Webmaster Health and Development Initiative India
email : job340@hotmail.com ,
webmastci@healthinltlatlvc.org
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i
"I
ACTION
Advocacy
to
Control
TB
Internationally
Summary of Proceedings of the India TB Stakeholders meeting held on the
21111 of March 2005 at the India Habitat Center, New Delhi
Session 1: Introduction / RNTCP and Civil Society Partnership
Chair: Mr John Mathai, Country Director, ACTION India
Address delivered by Dr. V. S. Salhotra on behalf of Dr. L.S. Chauhan DDG-TB
Presentation by Dr. P. P. Mandal of CTD on the RNTCP and its current status
Partnering the RNTCP: Dr. Bobby John, Massive Effort Campaign
Main points from the presentations and the discussion following:
Fastest growing DOTS programme in the world - by May 2005, it will cover the entire
country
• Biggest public health success - possibly the biggest public health programme - TB is
getting into the political agenda
• Significant administrative resources: Departments and ministries - Ports, ESI, Steel,
Coal, Shipping, Railways
• Excellent data reporting systems
• Current focus on sustaining and maintaining the 85% benchmark, improving core
services, facilitate involvement of NGOs, medical colleges and enhancing PPM
• Some successful PPM model - greater role for advocacy and PPP
•
Challenges for scaling up and maintaining current success rate- 1
• Sustain quality of interventions and financial support at the state level
• Strengthening state level program for decentralized management
• Frequent transfers of trained staff / unfilled vacancies
• Inter-sectoral collaborations: Program and the civil society, the armed forces, industry
• Addressing issues for urban areas, pediatric TB cases, marginalized populations
• Quality monitoring of the microscopy: STLS cadre performance needs to be monitored.
• Mobilizing community participation: Limited success in engaging the civil society
partners to enhance case detection
1
A project by American Thoracic Society, Massive Effort Campaign, PATH, RESULTS Educational Fund, STOP TB Partnership Secretariat and WHO
Chennai: Grace Building, 4th Floor, No. 25 McNichols Road, Chetpet, Chennai 600 031, India
t: 0445 526 7284 m: 0938 234 2427 e: johnmathai@tbaction.org
Delhi: B-406, Mansara Apts., Vasundhara Enclave, Delhi 110096, India
t/f: 0112 262 3170 m: 0935 017 1914 e: pranay@tbaction.org
Hyderabad: 157/6, Staff Road, Gunrock Enclave, Secunderabad 500009, India
t. 0402 784 8457, 0402 784 1610 f: 0402 781 1982 m: 0934 662 7079 e: mateen@tbaction.org
ACTION
Advocacy
to
Control
TB
Internationally
Challenges for scaling up and maintaining current success rate- 2
Concerns
• More funds and political will needed in the government to fight TB
• Important to mainstream TB with the public health system
• No forecasts available to stakeholders on what scenarios hold in the future for the
program: Administrative and financial
• No blueprint available for integrating different stakeholders: Is it an issue for the next
phase of the World Bank funded RNTCP?
• Gaps between centre directive and state delivery
• Apprehension between DOTS and non-DOTS based treatment still persists in medical
practitioners
• What is the deployed capacity of the NGO sector working on TB issues? Are they
distributed across the country? Needs a mapping.
Session 2: HIV/TB challenge
Chair: Dr. Dora Warren, Director, CDC GAP, India
Mr. Christopher Skill, Freedom Foundation / Challenges of addressing TB in an HIV setting
Issues raised / Challenges
1. HIV epidemic will fuel the TB epidemic. There are an estimated 2 million co
infection cases in India at the present time.
2. Stigma and discrimination for seeking DOTS in community: Lack of
confidentiality / sensitivity regarding HIV status at the DOTS center
3. Poor transfer in and transfer out records for patients from one DOTS center to
another, especially those being initiated on HIV care at a place different from their
regular place of residence. This also applies to non-HIV patients.
4. Lack of clarity with regards to DOTS zone distance is a deterrent for patients
living at a distance away from the DOTS center they are attached to.
Recommendations
1. Improve understanding of DOTS providers of the linkages between TB and HIV
2. Recognition of HIV care centre diagnosis of TB for initiating patient on DOTS
3. Better understanding needed for use of DOTS with ART (especially the use of
rifampicin with nevarapine)
4. Sensitivity to patient concerns on confidentiality
5. Recognize and provide for HIV-TB co-infection within the setting of the DOTS
services
2
A project by American Thoracic Society, Massive Effort Campaign, PATH, RESULTS Educational Fund, STOP TB Partnership Secretariat and WHO
Chennai: Grace Building, 4th Floor, No. 25 McNichols Road, Chetpet, Chennai 600 031, India
t: 0445 526 7284 m: 0938 234 2427 e: johnmathai@tbaction.org
Delhi: B-406, Mansara Apts., Vasundhara Enclave, Delhi 110096, India
t/f: 0112 262 3170 m: 0935 017 1914 e: pranay@tbaction.org
Hyderabad: 157/6, Staff Road, Gunrock Enclave, Secunderabad 500009, India
t: 0402 784 8457, 0402 784 1610 f: 0402 781 1982 m: 0934 662 7079 e: mateen@tbaction.org
ACTION
Advocacy
to
Control
TB
Internationally
Session 3: Civil Society participation
Chair: Dr. Tushar Ray, Program Advisor, DANTB
Ms Sarla, Sahasee: TB is curable
Dr. Ramnik Ahuja, CII: Reponse from the Corporate Sector
Dr. Santhosh Mathew, Emmanuel Hospital Association: NGO partnerships
Dr. Sanjana Mohan, Sewa Mandir: Participation at the community level
A.
Industry / Corporate Sector
1.
2.
TB is being taken up as an issue of corporate social responsibility for Industry
Need for all corporate hospital / health care facilities to include Microscopy and
DOTS provision facilities.
B.
Challenges for NGOs
1.
Apprehension among NGOs about government programmes (attitudes in
partnering)
Resource constraints for civil society to promote DOTS/ RNTCP goals
Long delay in official recognition and clearances of NGOS for becoming DOTS
delivery partners
Lack of clear directives/ guidelines and little formal feedback for civil society
participation
2.
3.
4.
C.
1.
2.
3.
4.
Community level issues
Large awareness gaps in the community
A. That DOTS is available free in government hospitals leading to delay in
treatment (from months to a year).
B. Poor communication of the duration of treatment and follow up by DOTS
providers (therefore large numbers of defaulters)
C. Is the communications strategy an effective one?
Limited support to certain high-risk categories of patients:
Migrants, MDR TB patients
Need to understand the disease from the patient and community perspective,
improve outreach and services
Community mobilization needs to be done through NGOs to create demand for
DOTS services, but if these are not fulfilled, it leads to tremendous apprehension
and mistrust of the program itself.
3
A project by American Thoracic Society, Massive Effort Campaign, PATH, RESULTS Educational Fund, STOP TB Partnership Secretariat and WHO
Chennai: Grace Building, 4th Floor, No. 25 McNichols Road, Chetpet, Chennai 600 031, India
t: 0445 526 7284 m: 0938 234 2427 e: johnmathai@tbaction.org
Delhi: B-406, Mansara Apts., Vasundhara Enclave, Delhi 110096, India
t/f: 0112 262 3170 m: 0935 0171914 e: pranay@tbaction.org
Hyderabad: 157/6, Staff Road, Gunrock Enclave, Secunderabad 500009, India
t. 0402 784 8457, 0402 784 1610 f: 0402 781 1982 m: 0934 662 7079 e: mateen@tbaction.org
ACTION
Advocacy
to
Control
TB
Internationally
Way forward
Discussion facilitated by Dr. Bobby John
Challenge of maintaining continuity in the program needs to be addressed: It needs
dialogue within the program and its stakeholders.
Develop synergy and communications between different stakeholders: Initiate an
electronic discussion and information dissemination mechanism.
Rural Health Scheme to be introduced by the Government and will be managed under
the Panchayati Raj Institutions -tremendous opportunity to mainstream public health
issues like TB
Harnessing local innovative diagnostic tools (like Tb Research Center use of PAS for
sputum disinfection, and transport to Microscopy Centers): This needs to be pushed
aggressively, especially as this is useful for transport of sputum samples to distant
microscopy centers when patients themselves are too sick or unable to travel to the
center. This will increase the rates for case detection.
Non-utilization of funds (85%) for NGOs largely on IEC and advocacy: This needs to
be utilized by getting more civil society partners to get into agreements with the Central
TB Division.
GFATM is an excellent tool to access resources for all stakeholders: Round 5
application process to be coordinated with the CCM, and with the Central TB Division
Hold regional/state level stakeholders’ consultations to be able to recognize local
achievements, issues and concerns.
4
/^project by American Thoracic Society, Massive Effort Campaign, PATH, RESULTS Educational Fund, STOP TB Partnership Secretariat and WHO
Chennai: Grace Building, 4th Floor, No. 25 McNichols Road, Chetpet, Chennai 600 031, India
t: 0445 526 7284 m: 0938 234 2427 e: johnmathai@tbaction.org
Delhi: B-406, Mansara Apts., Vasundhara Enclave, Delhi 110096, India
t/f: 0112 262 3170 m: 0935 017 1914 e: pranay@tbaction.org
Hyderabad: 157/6, Staff Road, Gunrock Enclave, Secunderabad 500009, India
t: 0402 784 8457, 0402 784 1610 f: 0402 781 1982 m: 0934 662 7079 e: mateen@tbaction.org
A C T* I• O * N
Advocacy
to
Control
TB
Internationally
Assessment of Feedback
National TB stakeholders’ meeting,
India Habitat Centre, New Delhi
March 2, 2005
The Meeting was attended by forty seven participants to discuss diverse issues concerning
programme and policy issues in the control of tuberculosis in India. Feedback forms were filled in
by participants to share their views regarding the consultation.
The following table gives the nature of feedback in writing on the meeting:
Found the meeting
Thought provoking
Point ofgood interaction and
Discussion
Got more information
3
6
Got greater awareness from
meeting
7
Suggest that
Many such meetings need to
be organized
6
Create forums for discussions
5
Improve networking among
Stakeholders
2
Session needed to structured better
1
Greater involvement ofWHO
1
Stress on advocacy
Political
Funds
4
2
Focus on medical research
1
3
1
Aproject by American Thoracic Society, Massive Effort Campaign, PATH, RESULTS Educational Fund, STOP TB Partnership Secretariat and WHO
Chennai: Grace Building, 4th Floor, No. 25 McNichols Road, Chetpet, Chennai 600 031, India
t: 0445 526 7284 m: 0938 234 2427 e: johnmathai@tbaction.org
Delhi: B-406, Mansara Apts., Vasundhara Enclave, Delhi 110096, India
t/f: 0112 262 3170 m: 0935 0171914 e: pranay@tbaction.org
Hyderabad: 157/6, Staff Road, Gunrock Enclave, Secunderabad 500009, India
t: 0402 784 8457,0402 784 1610 f: 0402 781 1982 m: 0934 662 7079 e: mateen@tbaction.org
I
Multidrug-Resistant Tuberculosis (MDR-TB)
in India: An Attempt to Link Biosocial
Determinants
SACHIN R. ATRE and NERGES F. MISTRY’
ABSTRACT
Multidrug-resisrant tuberculosis (MDR-TB) has emerged as a possible threat to
global tuberculosis control efforts in recent years. It is a challenge not only from a
public health point of view but also in the context of global economy, especially in
rhe absence of treatment for MDR-TB ar national-level programs in developing
countries. Biological accounts are insufficient ro understand rhe emergence and
dynamics of drug resistance. 1 his article focuses essentially on rhe need for a holistic
perspective, linking biosocial determinants that would probably lead ro better
insights into MDR-T B control strategies.
Journal of Public Health Policy (2005) 26, 96-1 14.
doi: 1 o. 1057/palgra vc.jphp.3 200014
Keywords: drug resistance, medical, behavioral, socio-cultural, primary,
acquired
I NIRO I) IK II ON
1 uberculosis (1 B) has long been recognized as a serious global public
health problem. It imposes a burden of nearly 8 million new cases
and i.<8 million deaths annually (i). It cost about US$5 billion to
treat new TB cases in 22 high-burden countries during the period
2001-2005 (2).
Observers have noted several trends in the occurrence of TB over
the last two centuries. While some have linked I B's decline in the
mid-twentieth century to general nutritional improvement and
economic development, as in England and Wales (3), others
emphasized specific measures that reduced overcrowded housing
patterns, as in the case of Glasgow (4). In contrast to the decline, .1
significant increase in TB prevalence has been observed in countries
Address for Correspondence: The Foundation for Research in Conununity Health, 36C4,
Iriniin B Aprs., 85, Anand Park, Aundh, Pune 411 007, Maharashtra, India. I,mail:
frchpune(«:giaspno 1 .vsnl.net.in
]<iuntal <;/ Puhlii Health 1’tilny 2005, 26, 96-114 < 2005 Palgrave Macmillan l td 0197-5X97/05 S;o.oo .Y<.
www.palgrave-journals.com/iphp <T\
ATRk
- MDR-tb |\ (M)M
like Russia in the last two decades, with a striking increase in
mortality (38%) reported between 1991 and 199/(5). F-ven in
England, notification rates among immigrants remained as high as
809 per 100,000 (6). Factors responsible for such contrasting trends
need careful identification and definition.
The Directly Observed Treatment Short-course -DOTS) strategy
of the World Health Organization (WHO, mclude> rive element's-
political commitment; case detection usmg sputum microscopy;
standard short-course chemotherapy under proper case manage
ment; direct observation of treatment; and a standard recording and
reporting system. The main contribution of this remarkable, largescale effort in TB control (7) has been in the supply of quality drugs
*
to TB patients. The niultidrug-resistant TB |.\1DR-TB) that now
threatens global TB control programs (8) is conventionally defined as
resistance to at least isoniazid and rifampicin. The phenomenon of
drug resistance was recognized as far back as rhe 1940s (9), and
many outbreaks of MDR-TB were observed in the United Stares,
Latin America and Eastern Europe during the last decade (8,10). In
Russia, between 1997 and 1999, the prevalence of MDR-TB rose
from 6% to 13% in all civilians with TB, whereas among chronic
cases the prevalence of MDR-TB was over 6o‘!o (1 1).
The G/o/m/ Pro/ect on AntPTnbercnlosi-: D,,,-’ Resist.,nee
Surve,Hance, Report no. 2, revealed that rhe median prevalence of
MDR m strains isolated from new cases (primary drug resistance)
was only 1 % (range 0-14.!%), whereas the median prevalence in
previously treated cases (acquired drug resistance) was 9.',"-.. (range
0-48.2%) (1 <). Report no. 3 indicates these levels at 1.1
(range o14.2) and 7.0% (range 0-58.3%), respectively (1 ;). The wide range
depicted in these reports suggests the need tor a separate interpret')
non of the data on MDR-TB by region, particularly data from "hoi
zoius (10). Ibis would provide a more complete picture of drug
resistance and its consequences for I B control programs and public
health. This paper attempts ro address the problem of MDR-I B in
India and compares it with observations in other countries.
Emerging anti-IB drug resistance in India deserves serious
attention as India’s rate .s highest among 22 high burden countries
(2). We fear a growing threat to public health that will draw heavily
on human and monetary resources. Surveillance data are lacking
because there is currently no provision of diagnostic and treatment
98
JOURNAL OF PUBLIC HEALTH POLICY • VOL. 26, NO. I
facilities for MDR-TB under India’s Revised National Tuberculosis
Control Program (RNTCP). Nevertheless, studies undertaken in
Tamilnadu state by the TB Research Center during rhe period
1997—1999 revealed a prevalence of MDR-TB of 3°/o (14);
surveillance of anti-TB drug resistance in two districts of South
India - North Arcot and Raichur - revealed levels of MDR-TB
among new cases of 2.8% and 2.5%. Strikingly, among previouslv
treated cases the levels were 69% and 100%, respectively (is'.
Studies carried out in a tertiary care center (16) and a hospital in
Mumbai (17) revealed high levels of MDR-TB among previously
treated and untreated cases, albeit with small sample sizes. These
sporadic studies highlight the need for further research and data
related to MDR-TB.
The fact that TB has remained a major cause of death for over 40
years despite TB control programs and chemotherapy cannot be
overlooked. According to Farmer (18), “Disease emergence models
need to be dynamic, systemic, and critical. Such models - which
strive to incorporate change and complexity, and are global yet alive
to local variation - are critical of facile claims of causality,
particularly those that scant the pathogenic roles of social inequal
ities.”
In our opinion, this failure in TB control results from another
failure: to interpret biomedical factors m the light ol social
inequalities. In order to delimit emerging infections, a holistic
understanding of underlying biosocial complexity is essential. In
subsequent paragraphs, we attempt to provide a brief overview of
the different factors involved in the emergence and sustenance of
MDR-TB.
DRUG R ESIS! ANGi:: A M U I E 11 A U E O R I A I. I’111; N O M I N O N
As a basic concept of epidemiology, any disease condition results
from a complex interplay among the pathogen, host, and environ
ment. In rhe present context of MDR-TB, the “health care system
also plays a pivotal role. We hypothesize that there are seveial
biomedical, socio-cultural, and behavioral determinants underlined
by poverty and gender and their interaction results in MDR-IB
(Figure i).
Government Policies (Health Care system)
;w
[Sr/
Private sector
•
Z
Nosocomial
Transmission
It Non-availability of
Public sector
&
MDR-TB treatment
nonqualified
providers
Negligence
towards
Program
Guidelines
Overburden
of
Work & lack
of motivation
J®
y Negligence
- -H
Lack of health
education
&j1S'
pi
Transmission
of MDR-TB
Strains
MDR-TB
laB 5
I Stigma
afeS
Illiteracy
Experienced
consequences
of treatment
Side-effects of
Financial
problems
Anti-TB drugs
■■■■ILj ::dl__________
Treatment
Interruption /
Shopping
around
-
"0
o
rt>
—4^
g No relief /
quick relief
i 2 21
rs2 §cn
s
Lack of
adequate
shelter
Indigenous
beliefs
Misuse of
anti-TB drugs
I Drug
, pressures
zC
L Migration
iwi w -------
Figure i
Bioniirdical. behavioral, and socio-cultural dcterniinanrs ol MDR-TB
3.
J
i
I
Qo
0
I
—t
II
y>
Z
'zi
1I
100
JOl’RXAL OF PUBLIC HEALTH POLICY • VOL. 16, NO. I
Molecular Epidemiology Perspective
Both primary and acquired drug resistance can be considered to be
the result of inadequate treatment, substandard drug use, use of
inappropriate drug combination preparations, or “mono therapy”.
Natural biological processes favor the survival of microbes through
rhe development of genetically transmissible resistance when
exposed to antimicrobials or by physical expulsion of these drugs
(19) . 1 \ idcncc suggests that both appropriate and inappropriate use
of antimicrobials apply selective pressure on microbial populations
(20) . Thus, empirical short-course chemotherapy and inadequate
treatment regimens amplify first-line drug resistance (10). Addition
ally, drug pressures during adequate therapy can also engender the
generation of drug resistance. Organisms have been known to shift
phenotypically from sensitive to resistant during ongoing therapy
(21) . The recording of high levels of acquired drug resistance to firstline regimens after completion of short-course chemotherapy (15)
also supports the existence of drug pressures. With the intense
application of anti-TB drugs over 40 years, sufficient drug pressures
may now be ushering in rhe post-antibiotic era.
While some strains of MDR-TB have caused large outbreaks of
tuberculosis, recent molecular epidemiological analyses suggest that
resistant strains are, on average, less infectious than drug-susceptible
organisms because they bear a physiological cost that undermines
their fitness (22,23). However, the study by Billington et al. (25)
suggests that some MDR strains are more infectious because the
relative fitness of the strain exceeds that of the wild strain. 1 he
Beijing genotype and its subtypes, associated with MDR-IB
epidemics, have spread worldwide (24) and are associated with the
active transmission of drug-resistant TB in Germany, Russia,
Estonia, South Africa, and Colombia. Elsewhere, these genotypes
have not been associated with the spread of MDR-TB (25). In
Vietnam, the Beijing genotype was associated with young patients;
preliminary studies in Mumbai, India, reported a range of 5-33% of
Beijing isolates with no evidence of an obvious epidemiological
linkage to location of residence, occupation, or health center
(25,26).
Although 111V/A1DS and MDR-TB linkage is uncommon (24,27),
it has been observed in some outbreaks of MDR-TB (2S). Strains
I
ATRE
MISTRY • MDR-TB IN INDIA
roi
associated with HIV/AIDS form larger clusters (25) and represent
actively transmitted strains. There is a likely explanation for rhe
association between HIV/AIDS and MDR-TB: if ‘
•Mycobaaenun, tuberculosis cont^es^l^‘‘
> continues replicating
non phase, it will result in exposure
exposure of
of bacilli
bacilli to rifampicin alone
because isomaz.d has a shorter half-life, as there are no other
supportmg drugs (z2). The stud.es from Mumba, (is,26) also
showed the presence of dominant clusters as well as unique strams
tnnf “TZ8 3,1 'MDR’TB eflldem,c'
the Baling
i '
1111 1 c.' 111 tB|S scenario because of an internal competition
between the resistant strains.
Patients'. Perspective
Drug resistance is often attributed to a patient’s noncompliance with
the therapeutic regimen. Noncompliance, however, has many causes
such as poverty gender discrimination, homelessness, and side effects
of the anti-TB drugs themselves, and how they affect individuals in
different settings (29).
Poverty leads to undernutrition, which itself is affected by both
scarcity of food and intrahousehold distribution. Large family size
and resulting purchasing power phis a wide variety of food habits
and certain taboos ingrained in culture also contribute to deprived
nutrition.! status. Immune system function is closely associated with
nutritional status. A poor nutritional status also affects drug
absorption, resulting in sub-therapeutic serum drug levels, winch
max lead to non-response to drug therapy (30).
(>ender issues are equally
A cr..,!,.reported>
equally sienifiranr
significant. A
study in d
Russia
"female
gender"
,
as a significant predictor of MDR-TB (u) In the
Indian context, harassment by in-laws, difficultv m getti.m married
or dismissal from the work were reported as major barr.ers for
women to get appropriate treatment (3 ,). Because someone - usually
the husband or brother - generally
" accompanies a woman when she
visits the health ccenter,
—- costs exceed those for rhe patient alone,
which already average Rs.
. 120-165 per month (^2). Arre
e/ al. (35) also found that
women have less access to information
about 11> than men. For men, being thcxhead of rhe family, loss of job
and fear of social isolation
were reported as major reasons for
discontinuation of the treatment (34).
102
JOURNAL OF PUBLIC HEALTH POLICY • VOL. 16, NO. I
Social stigma, lack of scientific awareness about rhe disease, and
social commitments are other stated reasons tor interrupting and
defaulting from the treatment (31). Morankar and Deshmukh (34)
reported similar reasons for delays of 2—8 months in diagnosis and in
seeking help among two-thirds of their patient study group.
Although in India, decentralization of DOTS has been largely
effected, problems affecting effectiveness remain in interior pockets
of the country.
Other factors contribute to problems: carb vmptomatic relief or
side effects of anti-TB drugs prompt patients to discontinue
treatment or to take drugs irregularly. Perceiving no relief also
affects the patient’s psyche and makes him/her shop around for other
treatments. Morankar and Deshmukh (34) reported that patients
make on average one to nine visits to diverse health providers, before
as well as after diagnosis. Such irregular and inadequate treatment
contributes to the development of drug resistance.
These findings underscore the importance of understanding local
needs and socio-cultural aspects of the community to implement any
disease control program, such as for 1 B, effectively.
Health Care System Perspective
Apart from the factors mentioned above, it is essential to understand
the role of health care providers and how health system function and
personnel behavior influence patient help-seeking behavior. Despite
DOTS policy, now in place in 1 19 countries, only an estimated 40%
of TB cases arc notified worldwide. I his suggests that a large
proportion of unreported TB cases arc managed by the private sector
(35). For many medical conditions, people in India prefer the private
sector despite its reputation for being highly exploitative. In all,
three-fourths of rhe patients prefer private care for treatment of
major illnesses (36,37); perhaps it is convenience and or rhe
confidentiality that offers protection against social stigmai. Unfortunatelv, studies have shown that private providers do not necessarily,
follow standard therapeutic guidelines. They offer inappropriate and
often expensive treatment (38). Consistently dismal use of public
health facilities in India, as underlined in sexcral utilization studies,
results in all likelihood from the rude behavior of the public health
staff towards patients (39,40). The socio-economic class, caste, and
ATRE &MISTRY • MDR-TB IN INDIA
103
educarion-based alienation of public health providers from their
poor, illiterate clients suggests a definite need for an overall
reorientation of public health personnel.
Re-administration of the same drugs to which the patient has not
responded probably results in further development of drug resistance
(29). We observed misuse of drugs during our field visits in rural and
urban areas of Western Maharashtra, India. Some medical officers
fail to take the history of prior anti-TB treatment; thus, rhe patient is
misclassified. Patients who fail to mention their previous treatment
bear some of the blame. More seriously, an early observational studv
by Kaul (39) and colleagues reported that one-third of rhe patients in
the study group were turned away from DOTS centers because of
homelessness or because of non-response to previous treatment. This
may explain the reluctance of some patients to provide information
about previous treatment.
Other factors affect the extent of effective TB control programs.
Our recent field experiences reveal that RNTCP does not reach
interior areas; thus, many patients are still not covered by RNTCP.
Perhaps recognizing this fact, rhe Global Fund to fight AIDS,
Malaria and TB (GFATM) has awarded funds to rhe Government of
India (GOI) to develop Urban DOTS Projects (UDP) in four
metropolitan cities in India to improve the quality and reach of
RNTCP to slumdwellers and migrants (41).
The misuse of antimicrobials in the form of incorrect dosages overprescribing, extravagant prescribing, underprescribing - is
commonly reported in countries such as Tanzania (91%) and India
(over 90%) (42,43). During our field visits, we found that where
monitoring of treatment is not possible, patients arc given dosages
for 1 or 2 weeks. Owing to a lack of adequate information, patients
consume tablets as per their will or sometimes doctors split the
doses of individual drugs because they fear that rhe patient cannot
tolerate them. As a result of an improper spacing of dosing
intervals, efficacious serum drug levels are probably not achieved,
leading to reduced drug efficiency and generation of resistance.
Directly observed treatment does nor work under these local
circumstances.
I’.xperiences in the developing world have revealed that traditional
healers, who have no knowledge of pharmaceuticals, drug regula
tion, or side effects of modern drugs, still incorporate these drugs in
IO4
JOURNAL OF PUBLIC HEALTH POLICY • VOL. 16, NO. I
their traditional therapy (44). Such practices may lead to adverse
drug interactions or may cause side effects, prompting rhe patient to
shop around for treatment. This also promotes drug resistance.
Ambiguity may exist in interpreting laboratory results concerning
treatment completion and cure (45). In a series of comparisons
across six countries, an average of 47% of MDR-TB patients were
reportedly cured with 6- or 8-month treatment regimens with four
drugs, always including isoniazid and rifampicin. Reported cure
rates varied from 6 to 59%, but mav ultimately have been lower
because of subsequent relapses (22). A report from Medecins Sans
Frontieres (MSF) states that sputum microscopy can at best detect
45-60% of people with active TB (46). Thus, rhe quality of rhe
sputum sample as well as sputum microscopy are major concerns
linked to decision making for categorization and treatment. In India,
because of program integration, besides sputum smears, a laboratory
technician must now also perform blood rests, urine tests, and look
for malarial parasites. Such overburdening of public health personnel
under the label of integration has resulted in a drop in quality.
In light of the above, overburdened public health facilities,
consequent lack of motivation among the staff, and rhe absence of
drug resistance surveillance facilities are major issues that need
attention while formulating MDR-TB control strategies. Recognizing
the imperative need for surveillance, the GOI has recently initiated
the Integrated Disease Surveillance Project (IDSP) with training
provided by the National Institute of Epidemiology, Chennai (47).
Role of Multincitioihils i'is-d-i'is ( JolhiliZiition
There has been a sharp increase in drug and vaccine prices in the
post-TRIPS (Trade-Related Aspects of Intellectual Property Rights)
era. Powerful multinational pharmaceutical companies control the
global drug market, and surveys have shown that they enjoy a major
share of drug sales 48.
The doctor in India is a focal point tor drug company efforts to
influence the choice of drugs. Doctors are unaware of the
pharmaceutical market and are generally ignorant about the price
variation between similar drugs manuf.ictured b\ ditiercni compa
nies and marketed under different brand names (49,50). A study by
Bhargava (51) revealed tremendous variations in branded drug prices
■i
1
ATRE &MISTRY • MDR-TB IN INDIA
^5
in rhe Indian market for rifampicin (249%) to cycloserine (1488%),
a drug widely used for treating drug-resistant TB. As patients cannot
afford expensive drugs, MDR-TB cases are left untreated and mav
continue transmitting infection. As discussed in the section above,
this provider ignorance about the pharmaceutical marker is likely to
aggravate the problem of drug resistance.
The development of a new drug spans around 20 rears and costs
US$802 million (52). So far, research and development departments of
multinational pharmaceutical companies have shown little interest in
new anri-TB drugs (53), perhaps because of rhe notion that tuberculosis
is a poor man’s disease, affecting only the developing world.
In 1998, WHO and several partners around rhe world jointh
devised a strategy, still under continuous development, called DOTSPlus and implemented through a body called the Green Light
Committee. It provides second-line anri-TB drugs in the areas with
high MDR-TB prevalence and well-implemented DOTS programs (54).
The cost of MDR-TB treatment in the open marker has been as
high as USS2o,ooo per person for 18-24 months treatment (55), a
price that constitutes a death sentence for a large proportion of
MDR-TB patients. These new efforts have reduced rhe price of
second-line regimens by 95% and for individual second-line drugs by
as much as 99% compared with prices in the open marker (7,55)^but
these reduced prices have been available only to WHO-dcsignared
procurement agents and WHO-endorsed projects (55). There S still
no implementation of DOTS-Plus strategy in many high-burden
countries, including India. One reason is that long-term treatment
(18-24 months) and severe side effects of second-line anti-TB drugs
may require hospitalization. A study bv Sterling et al. (56^ claims
that DOTS-Plus is Iless efficient and‘ more expensive than DOTS and
that DOTS-Plus, if not properly implemented, would reduce the
efficiency of DOTS.
Currently, for patients who do not respond to DOTS, the program
has no solution to offer. Such patients go to rhe private sector or
different providers. In countries like India, where medico-pluralism
is common, the situation is serious. Subsequently, the search for
alternatives has begun. I he Department of Biotechnology ((JOI) in
conjunction with Cadilla (57) has initiated trials adding immuno
therapy using the Mycobacterium W vaccine. This seven-center
tiial aims at studying the efficacy of a first-line regimen combined
106
JOURNAL OF PUBLIC HEALTH POLICY • VOL. 16, NO. I
with Mycobacterium W vaccine in fresh TB cases to improve rates of
sputum conversions and cure.
Being ranked first among 22 high-burden countries, India is a huge
market for the sale of anti-TB drugs. It has been estimated that
rifampicin sales in India (alone and in combination) account for 50%
of global sales, amounting annually to USS 139 million (58). If MDRTB spreads, then additional resources would need to be allocated for
the second-line regimens in addition to the first-line regimens, further
increasing the financial burden beyond today's nearly US$2.6 billion
per vear (59) - mostly in loans. The Commission on Macroeco
nomics of Health (CMH) recommended that the Global Fund
(GFATM) should be spent on three scourges: AIDS, malaria, and TB
but HIV/AIDS now accounts for half of the total expenditure (53).
Spending on care also leads to neglect of poverty and related issues of
drinking water, nutrition, housing, and so on - amelioration of which
had a strong influence on TB decline in developed countries (5).
RETHINKING
One can predict that with a 70% case detection rate and 85% cure
rate, prevalence of infectious cases and the number of infected
contacts would drop by 40% (60). Similarly, there would be a
decline of 6-7% in annual incidence (61). However, global trends do
nor reflect any major decrease in TB as a major cause of death
(1,18). The Revised National Tuberculosis Control Program in India
claims over 80% geographical coverage of DOFS, 69% case
detection rare, and 86% cure rate among new sputum smear-positive
cases (62). As India carries one-third of the global burden and ranks
first among 22 high-burden countries with TB (2), these rates bear
careful scrutiny. Our doubts here are solely about operational
implementation of DOIS under local conditions and nor the grand
strategy. Mere geographical coverage and reported completion of
targets will not suffice as far as public health is concerned.
Ultimately, if the program ends up with a high burden of cases and
perhaps with more drug-resistant strains (which need to be
investigated), then it would siphon huge global resources and
threaten rhe success of the program itself.
In response to the Amsterdam declaration and World Health
Assembly (WHA) Resolution, TB program managers of 22 high-
I
ATRE
MISTRY • MDR-TB IN INDIA
IO7
burden countries and WHO global TB network developed a Global
DOTS Expansion Plan (GDEP) at a meeting in Cairo in November
2000 (63). Well-conducted clinical trials in Thailand, South Africa,
and Pakistan showed little or no advantage of direct observation over
home-based self-treatment in relation to cure (64). Nevertheless,
home-based treatment was not successful in some sites (65. 66). These
observations suggest a need for careful implementation of DOTS and
possible alternatives for its expansion. In a country like India, where
one-third of the population remains illiterate, experimental strategies,
such as involvement of self-help groups and community-based DOTS
delivery, may prove more effective, and need to be worked our.
Using a mix of molecular epidemiology and other laboratory
tools, it would be useful to learn why certain strains are dominant
and actively transmitted. If social factors - for example, migration to
earn a livelihood - are associated with active transmission of drugresistant strains, then social analysis linked to molecular epidemio
logical analysis might help explain the worldwide epidemic of TB
and guide effective control measures against it.
Manabe and Bishai (67) discussed the activation of latent M.
tuberculosis. Active TB can be developed from an exogenous
infection, but latency followed by endogenous reactivation also
results in active TB. Two key questions need to be answered in the
context of MDR-TB:
• whether there is any role of human behavior predisposing to
reactivation of bacilli and subsequent development of drug
resistance in them;
• what host-related factors favor an exogenous infection with drugresistant strains.
This would help provide rhe basis for treatment of patients infected
with primary MDR-TB strains. Also, the use of anti-TB therapy in IIIVpositive patients needs to be re-examined because rifampicin is currently
contraindicated with protease inhibitors (Pls) and non-nucleoridc
reverse transcriptase inhibitors (NNRTIs) of the triple therapy regimen,
as it accelerates their metabolism and reduces their levels (68).
Treatment compliance depends upon the psychosocial behavior of
rhe patient, which is deeply influenced by indigenous practices and
beliefs ingrained in the culture in which the person is brought up.
particularly so among the illiterate and/or elderly. Stigma arising
108
JOURNAL OF PUBLIC HEALTH POLICY • VOL. 16, NO. I
from both illiteracy and traditional beliefs must be an important
consideration for health policy and clinical practice, as it contributes
to the suffering from illness in various ways such as delaving
appropriate help seeking, leading the patient to shop around for an
alternative treatment, or an abrupt termination of the treatment (69).
“Concordance”, an agreement between rhe health care provider and
rhe patient about how, when, and where to rake treatment, could be
an important step (70).
To create awareness among people, Indian health professionals,
either from rhe government or rhe private sector, have an important
role to play in conveying requisite information about the general
health as well as communicable diseases. Patients should be informed
about consequences of stopping rhe treatment prematurely. Commu
nications media can be used for this purpose. However, no
arrangement between the patient and provider is likely to succeed
in the presence of disabling factors like socio-economic disparities,
including unemployment and homelessness. Although responsible and
supportive behavior on rhe parr of rhe provider plays a signal role, we
must not fail to explore whether treatment discontinuation is linked
to social status and commitments, especially in rhe Indian context.
Vertical programs are always target oriented and restricted. They
focus on the therapeutic regimen and treatment completion, and
rarely take into account the environment in which rhe patient is
living and going to live even after treatment completion. Mere drug
therapy can never be a solution for tackling rhe problem of drug
resistance. In fact, its misuse will aggravate rhe problem. Thus, clear
articulation of governmental policies and information from multi
national companies arc required to remedy rhe provider's negligence
or lack of knowledge, especially when there is no treatment available
for MDR-TB under the RNTC.'P.
I he regulation of medical education is equally important. In India,
admission to many medical colleges is decided on rhe basis of
donations rather than merit. If the system produces such doctors,
misuse of antibiotics is inevitable, irrespective of well-designed
programs and sound strategies. Will going to fiyivare sector doctors
become “habitual” for the people because of rhe inability of the
public sector to fulfill their needs and subsequent loss of faith in it?
The private sector, although largely unregulated, could be useful
because of its close rapport with rhe community and its curative
ATRE & MISTRY • MDR-TB IN INDIA
109
function, as highlighted by Uplekar and Rangan (71). Their tendency
to be unethical and exploitative, however, argues against their
inclusion in the RNTCP. We believe that the program needs to focus
far more on the training, leadership, and motivation of grass-roots
level staff who deal directly with the patients and the drugs. The
surveillance system, when in place, should include a referral pattern
to assure use of appropriate technology from the peripheral health
posts to the referral hospitals. The gray areas tor undertaking
intervention activities are highlighted in Figure 1.
Paul Farmer and his group, through their action-oriented
philosophy, have shown a successful implementation of commu
nity-based treatment programs for MDR-TB and HIV/AIDS in the
poorest sites such as rural Haiti and Peru (72), which can guide
others. Nevertheless, these programs are dependent on external
funds such as GFATM (73). To run similar programs without such
funds would be a major challenge for many developing countries.
Through this paper, we have tried to address the multidimensional
problem of MDR-TB in the context of a developing country like
India where the highest burden of TB cases exists. Most cases are
managed by a large unregulated private sector, funds are lacking, and
one-third of the population is illiterate and strongly influenced by
local cultural beliefs. We hope that these experiences may find
suitable application in other areas and for other infectious conditions
where the problem of drug resistance is increasing.
Acknoivled^ements: We acknowledge the encouraging support from Dr. N.
11. Antia, Director, The Foundation for Research in Community I lealrh
(FRCH), Pune, and The I oundation for Medical Research (I NIR),
Mumbai, in developing rhe manuscript. We are thankful to Dr. lanaz
Birdi, Senior Scientist and Deputy Director, EMR, Ms. Desiree D' Souza,
Research Officer, FMR, Brig. Dr. Rajan, Senior Research Officer, I RCH,
and Dr. B.V. Bhanu, Department of Anthropology, Uin\crsit\ of Pune for
providing valuable comments on rhe earlier drafts of the manuscript. Some
observations from field studies are supported bv a ('RIG grant
tfGROyji jSMA from rhe Wellcome Trust, UK.
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(Reprinted from The Indian Journal of Tuberculosis, Vol. X, Nd. 3, Pp. 85-116)
• 7.-..
-t tuberculosis prevalence survey in tumkur district,
I
Raj Naraln1, A. GeserVM. V. Jambunatban3 and M. Subramanian4
BKH
iMr
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Introduction Fj L;Tumkur " District in Mys^e State was
selected for running pilot control programmes
and for evolving sUdard procedures in the
I
j .
Age and sex prevalence rates of tuberculws
.
CU1OUS infection;
2.
2- Age and
a.nd118cx prevalence rates of radto_
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tuberculous disease; }
1 J \
3. Age and sex prevalence rates of bacterio■* logically confirmed tuberculous dis
ease ;
4. Age and sex prevalence of symptoms Y
suggestive of tuberculosis and
5. A correlation between various prevalence Vz
rates.
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qn
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field as well as in the laboratory. A survey
was carried.out to provide d-jta for planning
•and assessment of the Control Programmes.
The Sample Survey of Tuberculosis in India,
9
Indian ' Council of Medical Research (1959),
Il
’■
referred to hereafter as NTSS, was the first
national effort to estimate prevalence rates
applicable to different cross sections of the
The findings in respect of objective 4 will
country. Thia report (Page 54) also states,
be dealt with later in a separate paper.
30^ E -‘while; the figures are able to give an overall
idea of the conditions prevalent in each zone,
3. Details of the survey
.they would not necessarily represent conditions
prevalent in limited areas in each zone. Specific 3.1 Study area and population
H ig
-.-control measures for such areas wouId normal ly
'Tumkur district is situated in the centre of
. call for more detailed information than can be
Mysore State, contiguous to Bangalore district.
’ provided by this survey’. The present survey
The district headquarter town, viz., Tumkur
f ., s J
contribut s its mite/towards
mite /towards that end.
contributes
is on the national highway to Bombay and is
'
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■T’his fuirvptir
utqs r
,arri*»H nut
survey 'was
carried
out dn
during, 1960-61
line . information on the 43 miles north-west of Bangalore, the capital
,to -J.QoUect -baseline
7 ..f- f?.|
prevalence
prevalence ot
of infection and radiological and of Mysore State. The district has 10 taluks,
and
being completely
v bacteriological, cases, in
L* the
uhv Iform
___ oi _age
o-----2 northernmost taluk Pavagada
_
i : . sex
specific prevalence rates. *Further
infer-separated from the rest of the district by parts
"****■ <*’1'*'V****>
USV..V.
a>a«w>Mjitjifr . mation
.necessaty
for oa wnuvi
control |/i
programme
are of Andhra Pradesh. Besides Tumkur, there
AAAALivii. .jivvuuani
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are 10 municipal towns and 2392 villages in
incidence laLvo
rates Vi
of micciivii,
infection, aitvi
and ui
of various
wamBsa *M.VKMU11VV
vauvun
‘he district. The area of the district is 4091
categories of disease among different groups
of people. These could have been collected square miles with an average density of popui R; by a longitudinal survey, but would have en>- •a on of 334 persons per square mile (1961
Census)/ The average altitude is 2,700 ft.
R
tailed a much longer time and a much biggei
above
sea-level, and the climate is salubrious
7R7
organization than was available at the time.
throughout the year.
"‘4
The
1960
population
of
the
district
was
2. Objectives
estimated on the basis of 25, per cent increase
The objectives of the survey were to in towns and 12.5 per cent increase in the rural
establish for rural and semi-urban areas of population over the corresponding 1951 census
<
Tumkur ..district (excluding. Tumkur town) figures. The 1951 census figures, the estimated
the following:
population for 1960 and the actual 1961 census
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JLnstitui till May 1962; at present, Director, National Tuber; 1 Epidemiologist, National Tuberculosis Institute,
culosis. Institute.
Iiisuiutc.
’- WHO
WHO RmEpidemiologist, National Tuberculosis Institute, till July 1961; at present, on WHO assignment to
Cyprus.
----zr-—
...
* Seninr ? - - - - —
8 Senior Statistical Officer, National Tuberculosis Institute, till July 1962; at present Professor o£
Statistics, Kamatak University, Dharwar, India.
4 Statistical Assistant, National Tuberculosis Institute, till July 1962; at present with Health Statistics
Unit, World Health Organisation, South East Asian Regional Offices, New Delhi.
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2
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RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M.
figures (obtained subsequent to the survey)
are as follows:
’
-
SUBRAMANIAN
3.2 Methods
Co-operation of local officers of the district
Estimate of I
1951
was secured by addressing one of their routine
1961
Population of
population
Census
meetings under the presidentship of the
in 1960 I Census
Deputy Commissioner. The District Medical
District
1,151,694
1,366,722
Officer and the staff of the National Tuber
•'
*
culosis Institute, explained in detail the neces
Rural areas
(2392
sity for and the requirements of the survey.
villages) ... 1,045,797
1,175.000 1,227,392
Before the actual commencement of the
sun^ey
of any village, a preparatory visit was
The 10 towns
69,812
88,000
91,893
'•
made by the Planner-Organiser, and/or the
Tumkur town
36,085
Medical Officer—Field Teams, accompanied
47,437
by either of the two team leaders (see Appendix
A sample of 30,000 persons was considered 1 • u
inhabitants was convened
operationally convenient and within the facili with the help of the village headman (Shanties then available and was believed to be bhogue or Patel). The objectives and the
*
.
able to give sufficient accuracy for the purpose procedure of the survey and the part to be
* of planning control programmes and their played by the villagers were explained. The
assessment. *
date and time of starting was settled in con
The 10 municipal towns and the 2392 sultation with them.
villages were treated separately and approxi
In each of the 62 villages, every house was
mately 3 per cent population in each was numbered. A map of the village showing
included m the sample. The district head the number and location of each house was
quarter Tumkur was excluded.
prepared A census of the total population
r
The sample for the towns was selected in a of the village was taken by a house-to-house
three-stage sampling as four groups of 525 visit by the census takers of the field team. A
people each. Four towns were selected at similar procedure was adopted in each of the
random from amongst the 10 municipal towns four town blocks. For each individual in
without excluding the possibility of selecting the 66 groups a card was prepared giving
the same town more than once. One of the information regarding group number, indivi
administrative sections of the selected town was dual number, name, age, sex, father’s name
chosen at random giving weights to the or husband s name, household number and
different sections according to the size of the relation to the head of the household. All the
population. Using the household schedules persons normally resident in the village (per
of a recently conducted municipal census one manent residents), whether present at the time
household in the selected section was randomly of registratmn or temporarily absent as well
chosen. With this household as
_
starting
as visitors temporarily present in the village
point, the census was carried out following the were included in the census and registered.
numerical order of the households until 525
Definitions of terms are given in Appendix II.
people were registered.
All the available individuals in the registered
From the inhabited villages as given in the population
A )vere S’ven a Mantoux test with
1951 census handbook, 63 villages were selected n i*
0-1 C»h’ °f TU.RT 23 with 0 °57,o tween 80
as a simple random sample. Together with
on the mid-volar surface of left forearm
the four town blocks, there were 67 units in
Before giving the test, both deltoid regions
all, and these constitute the study population.
were
exammed for the presence of a previous
Each one of these units was called a group
BCG scar, definite or doubtful, and the findings
One village with a 1951 population of 9 was
recorded on the individual cards. Three to four
found depopulated and was excluded. Figure 1
days after the test, the longitudinal diameter
!S a map of the district showing the taluks
of induration of the tuberculin test was measurand the location of various groups surveyed.
ed and recorded in millimetres.* At the
*L
■
bv th * L°^Itud,"aI diameter of induration was measured because of th,
e considerably greater support provided
by the length of the volar aspect of the forearm to the
transparent scale which, when held by one hand
shakes much less than when similarly held along
the breadth of the forearm.
TUBERCULOSIS PREVAIJJNCE SURVEY IN TUMKUR DISTRICT
3
•!
Rgl TUMKUR DISTRICT
%
I
p R
ade
H
S
o
SHOWING
y
O
HOSKOTE
LOCATION OF GROUPS EXAMINED
i
AND
TALUKS
P A V A G
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Ar
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ci
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TUMKUR
Ar
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4i
O
• VILLAGES
' .
e
O TOWNS FROM WHICH
SAMPLE BLOCKS HAVE
BEEN SURVEYED.
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RAJ NARAIN, A. OESER, M. V. JAMBUNATHAN AND M. StlBRAMANlAN
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time of measurement, the reader had no know at work during the day, -examinations were
ledge of the presence or absence of previous carried out mostly late in the .evenings,: but
BCG scar in the examinee (vide infra).
sometimes also early in the mornipgs. LThis
At the time of the tuberculin test, all indi naturally meant hard work at odd hours for
viduals 10 years of age or above were offered the survey teams.
a single 70 mm. photo-fluorogram by a mobile 3.3 Staff and time taken ;
’ AOf.’J;1
X-ray unit temporarily stationed at a conve
nient place in the village.
The survey was carried out by two teams,
' No village included in the
1* random
'
, I, each with its own complement of census takers,
sample
was given up because it was inaccessible. testers, readers, laboratory and X-ray techni
I his was possible not only because of more cians, mobile X-ray unit, transport and other
mobile and lighter X-ray units than were\ staff and working in different areas (Appendix I j.
available for the NTSS but also due to a daring
The survey was started on 23rd August 1960,
use of vehicles for reaching the village some with testing and X-ray examination, while
times through knee-deep water and sometimes tuberculin test reading and collection of sputa
on non-existent tracts. S<|me villages com in the last village was completed on 6th
pletely inaccessible during the monsoons February 1961.
were surveyed after die rains, the teams being
3.4 Population surveyed
I
kept busy in other villages in the meantime.
■ The X-ray Aims were developed in the NTI
In the 66 groups, a total of 34,746 person^
and read by two X-ray readers independently. were registered, 17,652 males and 17,094 femaids
Any^ X-ray picture found abnormal was (Table 1). This includes 2779 temporarily
categorised according to a classification based absent and 1589 temporarily present. The
mainly
on '*
the
NTSS v
(Appendix
population,
i.e.,
the---------------------permanent residents
J
s one
- used in------ri.------ defacto xx
------ r—
^lIpe For each picture read as abnormal, . ancL those temporarily present total 31,967.
including non-tubercular pathology and for The tesults presented in this paper refer only
each technically inadequate picture, for which *to the defacto population
,
in the sample groups.
another X-ray picture could not be repeated, a y I Age distribution ‘by/ sex of the defacto popiild-l
^spot’ specimen of sputum of the individual 1 Jon is given in Table 2 and Fig. 2. J The; ,
concerned was collected at the time of tuber- distribution of the 1951 population of the
.culin test reading. Persons who could not district (by age and sex) was drawn from the
;be X-rayed due to physical disability or other*
reasons were also eligible for sputum examina
Table 1
/
If
tion. To avoid any possible bias, care was
Sex distribution of the registered population
taken to see that the tuberculin test reader did
by various
variout categories
{
•Dot know before the actual reading of the test,
_________________________
j
whether a particular individual had been mark
ed for sputum collection or not. In fact, all
Males Females Total
‘cards were handled, not by the tuberculin test
treader, but by the laboratory technician acting
Permanent residents
j3S the secretary. It was only after recording
(present)
15,684
14,694
30,378 |
of the tuberculin reading of all the tested
Temporarily present
persons present in the house that sputum of any
(T.P.)
990 '
599
1,589
eligible individuals of the house was collected.
.All sputum samples were brought to the NTI,
Total Defacto
Ijcooled by ice in the containers (no cooling in
population
16,283
15,684
31,967
winter months), and were stored in a refrigerator
before being sent to the Union Mission Tuber
Temporarily
absent (T.A.)
culosis Sanatorium, Arogyavaram (UMTS)
1,369
1,410
2,779 j
I
for a direct smear and a culture examination
as the NTI laboratory did not start functioning
till some time after the survey.
Total Registered
17,652
17,094
34,746
population
To suit the convenience of the examinees,
most of whom would be away in the fields or
t
1.1 f \
U* ZV «•
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TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
Table 2 ,
Age-sex distribution of the defacto^ population
Coverages for various examinations
-- ------ L.
Distribution
per 1,000 persons
Defacto population
•■..r su-
Age
I
0- 9
10-19
20-29
30—39
40-49
50-59
60+
Total
Male | Female
Male j Female
4584
3562
2512
2071
1463
1123
959
16274
143
111
79
4643
3140
2924
1831
1348
1039
756
15681
145
98
92
57
42
65
46
35
30
33
24
t Excludes 12 persons whose ages had not been
mentioned. These persons could not be contacted;
nor was any examination carried out for them.
re.2.ACC PYRAMID OF DEFACTO POPULATION
SURVEYED
TUMKUR DISTRICT
PGEIN YEARS
/■
I
50-59
35
46
40-49
«5
■ I
33
42
30-39
79
57
20-29
92
—p
111
10-19
0-9
I
w
120
•
/
20
0
0
20
20
40
40
60
60
80
wo GO »4O w
FEMALES
figures in District Census Handbook (1951)
and on comparison, no appreciable difference
between these two distributions was noticeable.
3.5 Coverage
The coverages of the defacto population
obtained in respect of the various stages of the
survey are given in Table 3. Coverages vary
from 92 per cent to 95 per cent of the eligibles.
3.6 Comparison with NTSS
The general procedures adopted in the pre
sent survey were more or less the same as in
the NTSS except for the following differences:
■
5
I I
Table 3
as §
D
m 43
6
g-Sa
Defacto population
31967
100.0
Tested
30431
95.2
95.2
Read
28994
90.7
95.3
Eligible for X-ray
22740
71.7
X-rayed
21021
65.8
Eligible for sputum examination
2441
7.6
Persons sputum examined
2333
7.3
o V
92.4
95.5
1. A tuberculin test was offered to all in
the sample.
Sampling technique was different.
Villages and towns were selected at
random from the entire district with
out any stratification according to size.
The sampling ratio was 2.8 per cent
as compared to about 0.2 per cent
of the eligible population in the
NTSS.
3. No village included in the random
sample was given up because it was
‘inaccessible’.
4. Towns or villages of the size 5,000-10,000
were excluded in the NTSS but not
from the present survey. However,
the headquarter town, Tumkur, was
excluded.
5. As the present survey was for mainly
control purposes, only persons 10
years of age and above were eligible
for the X-ray examination. In the
NTSS all persons 5 years of age and
above were eligible for such an
examination.
6. In the present survey a spot sample of
sputum was examined by one direct
smear for microscopy and a culture
after homogenisation and centrifug
ing, while in the NTSS from each
eligible person, two laryngeal swab
cultures and if sputum was available
2.
■'
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6
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
two direct smears for microscopy and
two sputum swab cultures were
obtained.
4.
i
i
Results of tuberculin tests
y/
4.1
Tuberculin reactions
Distributions
of tuberculin reactions by
|
, millimetre size in eleven age groups, separately
for males and females, among those without
any previous BCG scars are given in Tables
4, 5. The frequency of bigger reactions as
also of intermediate reactions increases in
each succeeding age groupji Histograms for
tuberculin reactions in different age groups for
the two sexes among those with no evidence
of previous vaccination are shown in Fig. 3.
The five year age groups in this figure do not
show a clear line of demarcation between what
may be called positive and negative reactors.
In Fig. 4 distributions of reactions for each of
the age groups 0-9 and 0-14 are shown.’ / The '
distributions are what is usually called ‘bimodal’
with one mode near 0 mm. and the other
between 22-24 mm. In age group 0-9 the
‘line’ of separation into unimodal distributions
Table 4
Distribution of persons without previous BCG scars by each millimetre of
tuberculin induration in various age groups
Males
0-4 ! 5-9
Age Group
g
!«
■
-o
.a
a
□
***
V
0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
1,394
313
235
90
30
4
12
5
4
2
3
2
2
1
2
1
3
6
5
5
6
5
5
5
4
2
1
1
1
30fTotal
10-14 15-19-20-24 | 25-29 | 30-34 | 35-39 40-44 | 45-49
504-
Total
2
4
267
2
24
31
26
32
41
57
50
49
47
67
88
64
82
72
99
91
78
47
59
80
63
39
39
25
46
16
15
12
17
3,307
578
865
571
423
255
355
370
296
247
241
286
363
301
340
380
450
414
426
304
319
361
293
212
224
138
141
87
64 •
43
58
639
1,725
12,712
I
2,149
I
718
158
278
151
90
38
42
27
14
3
5
3
11
8
9
7
11
7
12
13
21
11
29
15
22
13
17
8
7
3
3
324
63
166
114
92
43
54
48
35
18
14
18
15
16
17
15
24
13
29
18
19
34
34
30
31
18
17
18
15
5
14
1,754
1,371
124
14
55
60
42
39
41
43
35
30
27
25
23
19
24
16
19
22
25
29
26
27
20
18
10
16
9
13
5
7
108
8
32
36
51
29
41
38
34
38
33
30
40
28
33
43
37
39
46
35
34
37
22
23
14
8
9
7
1
3
2
99
5
27
29
32
29
52
48
41
33
31
36
47
40
47
63
70
53
46
37
36
36
23
17
23
11
9
2
5
5
5
72
4
20
21
27
11
24
44
23
27
27
34
44
42
42
55
57
57
43
35
39
41
28
14
24
12
7
5
5
1
5
939
1,037
890
69
2
8
19
11
7
23
23
25
19
28
32
41
39
35
35
57
56
49
32
31
34
24
25
23
12
11
8
3
2
5
| 788
58
3
13
11
9
11
13
16
19
4
^20
22
17
22
31
34
35
45
26
23
23
23
8
20
11
9
6
7
2
3
557
74
6
7
9
13
12
12
21
16
24
15
19
30
27
27
40
39
35
•18
27
25
33
22
18
14
12
5
3
• 16 persons for whom the presence or absence of a BCG scar was not stated have been excluded from
Tables 4, 5, 10 and 11.
fVA o il
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TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
7
Table 5
Distribution of persons without previous BCG scars by each millimetre of tuberculin induration
in various age groups
Females
Age Group
0-4
5-9
g
10
S ii12I
.9 13
•E 14
2
15
16
17
18
oOJ 20
12
CO
21
22
23
24
25
26
27
28
29
30^
Total ...
1,413
284
244
83
29,
6
5
6
1
2.
4
”1
”4
*6
8
5
4
3
5
3
4
2
2
2
2
2128 f
799
190
304
161
79
35
31
28
11
5
9
5
9
4
12
8
17
13
19
15
19
14
21
21
17
13
14
11
7
7
12
191?
2
T "
50^
---------Total
354
184
221
210 155
114
92
113
64
35
33
13
14
7
4
8
179
87
113
78
41
28
20
27
135
83
95
82
41
40
31
22
94
68
76
75
39
32
28
16
56
53
52
52
25
16
19
15
60
41
66
52
30
29
24
20
45
33
46
39
34
34
18
12
26
22
40
33
24
21
16
14
24
9
32
35
20
21
11
13
8
11
21
25
18
14
12
15
8
11
22
23
13
20
15
15
11
20
29
21
30
12
17
16
16
13
19
25
15
14
18
12
11
4
17
22
23
14
14
18
9
14
25
27
16
25
15
12
11
14
41
49
31
21
29
18
14
19
26
39
28
22
20
24
15
16
29
36
32
27
18
26
15
17
26
28
27
25
10
18
21
16
35
23
19
26
10
22
36
21
40
34
34
33
35
18
36
29
42
30
42
22
26
14
30
21
32
29
32
24
27
32
37
18
35
38
31
23
21
24
28
12
30
32
25
16
16
10
23
22
27
21
14
22
16
14
22
8
12
17
13
11
3
9
11
8
11
10
7
14
12
9
11
6
4
10
8
2
5
6
21
6
10
22
17
14 ' 14
10
?434
918
1307 1245 883~ 743
624
594
377
13
52
42
40
29.
45
56
37
31
31
40
43
35
44
45
46
54
51
45
34
56
54
58
40
35
35
15
26
13
42
4032
665
1173
815
576
358
403
351
245
203
168
172
209
171
183
196
283
267
274
230
228
326
319
310
286
219
210
121
115
74
168
10-14
15-19'20-24 25-29 30-34 35-39! 40-44145-49
i
0
1
2
3
4
5
6
7
x
A
in-
I !i '!
11«i
II
pi
1564 13350
____
w• 16
10 persons for who
whom the presence or absence of a BCG scar was not stated have been excluded
from Tables 4, 5, 10 and 11.
could be anywhere between 8 and 16 mm. Ir
aSe group 0-14, this line of separation could
, be between 10-16 mm. Thus these histograms
.do not give a clear or definite line of separation
|between positive and negative reactors. This
.dif !ty of defining any clear line of demarca
tion between a negative and a positive reaction
;in some communities is well recognised.
Perhaps no sharp line of demarcation exists
sfor- these communities. ’
4,2 Definition of a positive reaction '
In an attempt to define a positive reaction,
the following hypothesis was propounded. If
a sharp line of demarcation between ‘positive’
and ‘negative’' reactors exists, the positive re‘
actors at this level would jwssibly show the
host correlation with the prevalence of radio
logical and bacillary disease in the several age
groups. To examine this hypothesis correla
tion co-efficients between infection rates at
various levels with the radiological and bacterio
logical case rates in village groups were cal
culated. Further, so that non-specific allergy,
waning of allergy or some similar factor(s)
may not reduce the magnitude of these cor
relations, especially if infection rates in the older
age groups were included, co-efficients of
correlation were calculated separately between
infection rates in each of the four age groups
0-4, 0-9, 0-14 and all ages at various levels of
tuberculin reactions and X-ray and bacillary
I
I
Ii
■
<4
n k' .L
2
J
8
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
FIG. 3. HISTOGRAMS SHOWING THE DISTRIBUTION
(
OF TUBERCULIN REACTIONS Bi’ AGE AND
SEX AMONG PERSONS WITHOUT
PREVIOUS BCG SCAR
I
0 4 YEARS
eoT-i
B
MALES
70
;!
40
N = 2I4O
K-ALES
25-29YEARS
501
40
N-2128
N »1037
30
1
N = I245
30
20
0
50
20
1
-T
10
—-
< JlfariTTh-rrh =»
5-9YLARS
30-34 YEARS
50
40
I '1754
40
N’>9iO
30-
N«890
o
“ 20
2 ,oj
Zj..}
w o
i
30
1
r rTTTn
< 50l
2 10
i1 500
H»I37|
N« 788
h.,.
0
'[
■■■■
u,V>-
O >0
<A 0
e 50
i,ojl
N«292i
a 30
N«I3O7
30
NH27I2
N-13350
30
' ..ji •
20
20
"‘Lhuxi i! 11—1--h
u
4
8
12
16 2U
20 24
24 20
»2
4
8
INDURATION (m-.3
12
□uXTb-im
IB
•6
20 24 29 32
(CO
t ■
a
■■
'0
0
IzhTrnrr^T, . -t&.w rrrn-h~r.
4
8
12
1$ 20 24
29 32 O
4
6
12
16
16
20 24 2B
32
INDURATION (mm)
could be expected to be a better index of the
present or recent pool of infection in the com
7C
munity. But infection rates in lower age
0-9 YEARS
0-14 V(AA$
groups did not give a higher co-cflicient of
N • 7‘Ml
N - 10744
Jcorrelation with X-ray and bacillary case rates.
The co-eflicicnts of correlation were highest
for infection rates in all age groups. These
co-efficients of correlation in respect of infec
O40
tion rates for all ages for the 62 villages are
° 30
shown in Fig. 5. The co-efficients of correla
tion are not significantly different at any level,
and therefore do not seem to be very helpful
5 20
V
in defining a line of demarcation between
w
•• 10
positive . and negative reactions. However,
for falculat.in8 infection rates in the community
0
i s i2 i6 zo j* zb 32 an induration of 10 mm. has been chosen as
8 12 16 20 2 4 28 32
0
I NOURATION(tnm)
the reasonable minimum for a positive reaction
on the basis of the histograms, the co-efficients
case rates as found in age groups 10 years and of correlation and, it must be admitted, some
above. Infection in the younger age groups what arbitrarily.
rlG 4 DISTRIBUTIONi nr
TO TH( S
■ ize
i
ft
AU. AGES
« 50
*.0
N- 939
11
N«27B2
- riTh-nTmTrrn
20 24 YEARS
40
b'
irnTHTn-i.,
40 YEARS AND ABOVE
°20
[
-
winfhiru
u. . 0
“■ 501
i
540
N'9>A
< ZOi
11
N» 743
2 20
15 r? naos
1
■
33-39YEARS
< 30
5 10
§
Irn^rnrrTh^
MirfTTbn-r
x
*" 4Q
N«I434
o 30
20
rrp^ohs with ho e:c y*R actorping
Of
TUfllRCUUN
1
!
20
lO M YEARS
' ? 40
N-883
I.
REACTIONS
9
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
nc 3 COCFFK It NTS or CORRClaTiOn MTw((n patvaiCNCt or iHrtct^N af
UACrO ANO a-Rat and •ACu.uaAy ?MvaU*C< among viiiagcS
town groups. Tiie number of persons test
read in the four town blocks is only 1603 and
may not be adequate for drawing a definite
conclusion. For this reason the four town
groups have been excluded from some of the
tables.
Distribution of 62 villages by prevalence of
infection is given in Table 8. In one of the
rural groups, the defacto population was 5.
u*n.s 0<
ion
1
5o-S.
o
>0
>2
>4
>6
»a
>10
>12
UVUS Of *t«CTiON(ma)
>20
>14
Table 6
With this definition of a positive reaction
for the infected, 38.3 per cent of the population
examined were found infected, the figures
’ for the two sexes separately being 42.8 per cent
| males and 33.9 per cent females (Tabic 6).
For persons 10 years and above (not shown in
the table) infection rate for males is 58.5 per
:ent and for females 45.2 per cent. Table 6
also shows the number and percentage of
persons infected in other specified age groups
for each sex. The percentage of infected
persons rises with age reaching a maximum at
about 40 years. Thereafter this percentage is
rather steady. For age group 10-19 years
and above, infection rates arc consistently
| higher among males than among females, the
difference being most marked between 20 and
60 years of age, the peak being at 30-39 years.
Difference in the infection rates in the two
sexes has also been reported by Benjamin
(1951).
No. Test Read
Age
group
No. infected
(Reactors>10 mm.)
Male Femalej Total Male Female Total
0-4
2,149
2,128
5-9
1,754
1,910
10-19 2,234
2,352
20-29 1 976 2,552
30-39 1,678
1,626
40-49 1,196
1,218
50-59
945
905
60+ t
780
659
4,277
60
(2.8)
3,664 235
(13.4)
4,586 794
(35.5)
4,528 1,166
(59.0)
3,304 1,199
(715)
2,414 845
(70.7)
1,850 671
(71.0)
1,439 475
(60.9)
I
)
55
(2.6)
267
(14.0)
700
(29.8)
1,109
(43.5)
861
(53.0)
695
(57.1)
493
(54.5)
349
(53.0)
I
S'-n *
£79'
I!
Over- 12,712 13,350 26,062 5,445 4,529 9,974
(42.8) (33.9) (38.3)
all
i
■i)' I
w
Total
Female
Male
Tested and Reactors Tested and Reactors Tested and ! Reactors I Preval
Read
' >10 mm | ence
>10 mm
Read
Read
> 10 mm
11,942
5,074
12,521
4,196
24,463
9,270
37.9
Semi-Urban
773
371
830
333
1,603
704
43.9
Total
12,715
5,445
13.351
4,529
26,066
9,974
38.3
Rural
,
ir |
115
(2.7)
502
(13.7)
1.494
(32.6)
2,275
(50.2)
2,060
(62.3)
1,540
(63.8)
1,164
(62.9)
824
(57.3)
4.4 Infection in village and town groups
Table 7 givea^the number and percentage of
(Figures in brackets represent per cent infected)
infected persons in the 62 villages and the four
J t*
Table 7
Sex specific prevalence of infection in rural and semi-urban groups
i’.bl
>•7/.
Sex and age specific prevalence of infection
i 4.3 Infection rates
;
I
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il £ I
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11
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
FIG B DISTRIBUTION OF RADI ©LOGICALLY ACTIVE AND BACILLARY
at. The
h 4 age
Table 9.
lot high,
eactions,
rs to be
is except
in any
CASES BY SIZE OF
NG«. CRAFH
showinc thj
TO TH(
.0
J»»,o
Ptna».T*ct o«
TO’*!
tXAMINtO IM (ACM AM
j ?9,_)
. 20
CAOV*
CASES
RADIOLOGICALLY ACTIVE
|-o
13
TUBERCULIN INDURATION
------ MAK
' . t — ftMAU.
N—379
>6 —
| TO
O’r''
‘ ■
• •■j •
< io —
’> j
o
2-50
o
tfh
I 40
‘large
0
o
& 30
•-20
z
b
, 12,14,
£ as the
ns were
icn that
at all
t; males
cactors
among
I, This
specific
qual to
the two
reactors
iqual in
iquency
lale has
ied out
of this
tion of
o have
*
< 10
BACILLARY
s
I
o
N-85
<0
»o
»5
W
IN VMM
40
»0
tk; l muz-h
i
10 l»l HilAi <
Thd ,i - I I I I I I H I
to
------ M«l|
------ •(MAU
r°
0
tic
k
SI 10
I
I
.■ i
10
T
K
*<( liIN
w
Vf*M
«O
11.0
6.6
5.8
5.4
r
t
30 32
.5j2_vtARS
50
WITHOUT BCG SCAR
SCAR
M'«0l
N»3664
10'
0
10-14 YEARS
o 30
X
Ni 1207
20
N.2805
10
-J
£
*■
--Th-mTHTh-n
0
15-19 YEARS
O 20
N« 385
N» 1781
="11
= .UJ^LU
lllhwTnr^
5-19 YEARS
a 40
N.2393
N.825O
50
20.
•o
■-IhirrnTIrt^
o
8
12
16
20 24 28
32
0
4
INDURATION (mm)
L
22 24 26 28
?o
50
4.7 Tuberculin reactions among patients
Figure 8 shows the tuberculin reactions
among X-ray and bacillary cases. There were
in all 392 X-ray cases of whom tuberculin
reactions were available in 379. There were
86 bacillary cases in all, among whom tuber
culin reactions were available in 85. Of the
X-ray cases 291 or 77 per cent were positive
tuberculin reactors. Of the bacillary cases
73 or 86 per cent were tuberculin reactors.
Similar findings with 1.0 mgm. of standard
old tuberculin were reported by Gass and his
co-workers (McDougall, 1949) ‘Among sub
jects regarding whom on the basis of an X-ray
picture 4 independent specialists agreed that
there were definite tuberculosis lesions, 24.7
?-4
ecc
30
been noticed before, is not clear. But this
observation appears to be in line with the earlier
observation of higher incidence of complications
of tuberculin reaction in the female although
the total number of reactors among them
is lower.
r—
20
18
16
9 omTnijitnioH o»
fUBfnruilN RfACTIONS AMONG PERSONt
With
ANO WITHOUT BCG SCAR IN OIMERINT AGE GROUPS
with
I
J per
,000
M
INDURATION ( mm )
e30
trail
P
K 10
*T
I
—
CASES
-------- >?0-»
8
<2
'
16
--- 30
20 24
32
V
<■
12
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
per cent showed completely negative tuberculin
reactions . Limitations of an index for in
fection rates have to be kept in mind.
Retests of persons with BCG scars
scars
Of the total 28,994 tested and read, 2,916
or 10 per cent showed BCG scars, definite or
doubtful. Distributions of tuberculin reactions
tor these by millimetres size in 11 age groups
separately for males and females arc given
in Table 10 and 11. A Mass BCG Vaccination
Campaign had been carried out during 1952
t,1C ta,,lks (Kunigal) and during
1954-55 m rest of the district. 30 per cent
4.8
1
i
■s*
of the children in the age group 10-14 years
and 18 per cent in each of the two age groups
5-9 and 15-19 years showed such scars. In
hardly^any
(0.75 per cent)
V
*
---- J----- -J
yv.r
showed such scars. In Fig. 9, distributions
of tuberculin reactions in the 3 age groups
5-9, 10-14 and 15-19 arc compared for those
with no evidence of previous vaccination and
those with evidence of previous vaccination.
1 he 3 age groups do not show an adequate
level of post-vaccination allergy. From tables
10 and 11 it can be calculated that for both
sexes among the vaccinated 61.4 per cent of
the persons in age group 5-19 years show in-
Table 10
Diunbuiion aJ pe„nn, ,„ith pr„,inM llcG ,cart by tarh miliimrtre nf lub„culin
induration among various age groups
Males
Age
group
.•
i
0
1
2
3
4
5
6
7
8
a
o
9
10
11
-U
.s 1312
c 14
15
3 16
17
18
19
20
N
w 21
22
23
24
25
26
27
28
29
30f-
Total
0-4 I
|
11
5-9
140
34
61
49
31
11
18
12
10
4
6
3
7
6
1
3
4
5
6
4
3
2
2
5
3
1
2
1
1
3
438
j 10-14 j 15-19
175
34
82
67
53
28
57
35
28
21
12
16
18
15
13
12
11
17
15
6
4
7
9
7
6
3
2
5
2
4
3
767
35
7
20
14
11
10
14
17
14
16
13
10
13
6
5
9
6
4
7
3
3
2
1
2
1
1
I 20-24 125-291 30-34 I 35-39|40-44 45-49| 504
8
1
4
9
2
1
4
3
3
4
2
2
3
2
3
5
3
1
4
3
2
1
2
2
1
12
3
5
1
6
1
2
2
5
1
2
1
3
2
3
5
1
1
1
3
2
1
1
2
1
1
1
3
1
2
1
1
1
1
1
1
2
1
1
1
1
1
2
1
1
1
1
1
1
1
1
1
1
76
1
1
2
1
3
2
4
1
1
1
1
3
250
1
1
1
2
4
3
4
3
1
2
2
1
1
1
1
2
2
1
2
3
2
1
1
59
35
28 I
I
13
10
14
Total
392
76
175
149
101
55
101
81
60
49
41
38
49
37
30
33
31
31
35
17
20
18
17
17
14
7
6
9
2
9
7
1,707
• 16 persons for whom the presence or absence of a BCG
scar was not stated have been excluded
from Tables 4, 5, 10 and 11.
TUBERCULOSIS PREVALENCE
S’ramm°f 51mm.
1...... ■"*
or luvvcr
lower ana
and 23.9y P" cent
SURVEY IN TUMKUR DISTRICT
]j
basis of certain assumptions, the annual inci
dence of infection (see Appendix IV). For
the scxeral age groups upto 35 years the
incidence of infection is shown in Table 12
I he
vaW|
. Jlergy as elicited by 1 TU RT 23 with
weak or
,hc vaccine was
perhaps 1had wanedfr
-a.is not a good dose for
/* 15X11C
nai incidence
eliciting post-vaccination allergy or bcin?
r,Se9 ----upto
yearttIU|
« of
age. After
“nxewhat softer, __
post-vaccinatio.^eactions
"re
e^nT d,frerenccs ,n incidence rates among the
aomewhat
_
•«
-- — -j
VMVVlAlilLH
Powibily more difficult to read.
possibily
remaimng age groups are not marked, 'nicre
...................
.‘L3 dcc ln,i
,h? incidence rates in later years
4.9 Incidence of infection
/
1 he right half of figure 10 shows the incidence
ha'e bec" adS
tho^with’n age.9pecific infection rates among for,theCtBCGhen
In attemm h
0^Previous vaccination
ior tne BCG vaccinated people amonrr
an attempt has been made to estimate, on the population (Appendix TV). After this adjust
ment the mcidence of infection seems to rise
^4 V™,SSi-KS-. *r hr “d I'5,;, ? £1 “>■. > —I
I
Table 11
Ofp„,on*, with previmi BCG
t a i by ta h
.
1 ‘
of tuberculin induration
among variout age group!
Females
Age
I
dE? I
group
6
2
3
4
5
7U
6
7
8
9
10
11
12
13
•S 14
I
•g/ 15
S 1716
1
I
18
*0
19
20
21
22
23
24
/ 25
26
27
28
29
30^
Total ...
1
1
2
1
1
1
1
7
1
5-9
116
25
47
40
15
14
9
15
10
7
3
4
3
7
3
4
4
3
4
6
4
2
5
3
4
2
1
1
1
4
”I
366
| 10-14
>5-19
.89
30
57
51
37
27
22
19
10
10
11
9
8
5
4
9
4
5
5
4
3
3
7
4
1
2
2
1
2
3
4
448
I
| 20-24 125-29 J 30-34 | 35-39
25
1
12
14
5
9
6
10
6
6
3
5
1
1
14
5
8
7
4
2
5
6
2
2
3
3
3
1
3
1
8
1
3
1
3
■I
9
1
7
4
5
3
6
1
1
2
1
1
1
2
*3
1
6
4
1
1
1
1
3
3
4
3
1
1
2
2
3
:::
vp
3
4
i
1
2
2
2
1
:::
2
2
‘h
2
2
2
1
6
2
1
1
4
1
2
i
Y
1
1
i
1
1
1’
2
1
1
1
1
2
1
1
1
1
1
1
1
i
i
1
3
7
1
1
1
. 1
1
2
136
po-«ps-4<>| 50f
i
1
1
i
84
55
« I 24
i
17
(I
Total
283
65
134
122
72
57
58
57
32
30
24
25
22
20
11
18
21
13
16
18
13
14 i
14
15
15
r ’
4 |
4 I
I #
, »•
a
I
2 I
7 I
12 I
I-------- ,
112
11
1,209
; : j
16 persons for whom the
presence or absence of a BCG
Fables 4, 5, 10 and 11.
scar was not stated have been excluded from
■
3 !' 1
l-
Si
M f
i
14
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
Table 12
Estimates of incidence of infection (> 10 mm) in the unvaccinated and general population
•n (See Appendix J17)
:T i
Pre\ alence
among
unvaccinatcd
Age group
!■
i-1
Approx.
Least
squares
Log
Approx.
Least
squares
2
3
4
5
6
7
8
0-4
2.7
1.09
1.08
2.1»
1.09
1.08
2.11
5-9
13.7
2.38
2.26
2.78
2.29
2.16
2.69
10-14
28.9
3.81
3.52
2.81
2.69
2.49
2.72
15-19
38.3
2.80
2.64
2.79
2.65
2.58
2.70
20-24
47.1
3.04
2.85
2.69
4.39
4.02
2.61
25-29
53.4
2.51
2.38
2.48
2.51
2.38
2.43
60.7
3.35
3.13
2.12
3.35
3.13
2.11
62.4
0.89
0.87
1.60
0.89
0.87
2.65
30-34
35 +
■’
Incidence of infection among
general population by the
method of
Log
1
i
Incidence rate of infection
among Unvaccinated population
by the method of
I
I
upto age group 20-24. Thereafter there is 3 FiGJO ESTIMATED ANNUAL INCIDENCE
OF INFECTION BY VARIOUS AGE
INCDCNCt OF INFECTION BY VARIOUS AGE
FOR THE UNVACCINATED AND GENERAL POPULATION ADJUSTED FOR
decline in the incidence of infection. The
E LOGORiTHMIC. APPROXIMATION AND LEAST
reason (s) for this decline in incidence rates PREVIOSLY VACCINATED BY ThSQUARE
METHODGENERAL POPULATION / .
is (are) not understood. It is not due to the
UNVACCINAT EO
lOGORlTHMlC
POPULATION
(ADJUSTED FOR PREVIOSLY
number of uninfected persons who are still 5
'
VACCINATED)
at risk being insufficient after 20-24 years. A
Could it be due to waning of allergy perhaps 3
due to desensitization by repeated small 2
infections with specific or non-specific agents
or perhaps due to some other factor which may O
be specific to these higher age groups? Further
investigations may be necessary to explain
APPROXIMATION
this decline.
5.
Results of X-ray examination
K 3
5.1 General considerations
<->
The aim of X-ray examination in surveys
is to find out
an estimate of the prevalence of “■ 0
««£an
disease. Difficulties in X-ray interpretation are well known. To reduce the extent of <
under-reading it is considered necessary to or 5
have two independent readers. Many of the A
cases missed by one reader are picked up by
the other under this procedure, but at the
same time the number of over-readings in
creases. A correlation of the readings of the O
a
LEAST SQUARE
5
IO
15
20 2 5 30 35
O 5
AGE IN YEARS
10
15
20 25
30 35
>
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
15
Table 13 (3
Correlation between the radiological findings of the two readers
Males
Reader II
| Normal
i-h
Normal
Unsatisfactory films
Calcification only
« A
JB
« c
D
Total
Unsatis- j Calcifica
| fuctojy films I tion only
8,835
45
203
41
119
16
15
148
9,259
163
BI
A
C
195
I 77
259
3
11
1
2
6
38
24
13
1
44
24
65
38
32
1
3
18
26
86
11
469
161
472
177
Table 14
(jfJ .
301
D
Total
6
1
28
69
9,455
196
515
130
246
182
81
104
10,805
Correlation between the radiological findings by the two readers
Females
Reader II
Normal
Normal
Unsatisfactory films
Jj Calcification only
hh
1<u A
B
c
D
Total
Unsatis
factory films
8,504
49
101
92
66
11
21
140.
8,823
161
Calcifica- i
tion only i
194
2
^275
8
5
484
A
B
C
D
Total
• 170
|
1
! 14
‘80
23
15
214
2
25
20
'35
14
1
30
1
3
11
19
\?6
4
1
11
-44
9,134
195
418
215
148
87
19
311
104
30
10,216
303
4
I
two readers in the present material according
to classification shown in (Appendix TH is
prcJACntcd iii)Tnhlq 13 nnd ’ruble I I .<»t ninlcM
and females separately. Percentage agreement
between the two readers for each category of
X-ray reading has been calculated by taking
the total read by at least one of the two readers
as the denominator and the total read by both
readers as the numerator. Thus in Table 13
(for males) and category of reading D we find
that Reader I read 81 films’as D and Reader II
read 104 as D while both of them read only
69 as D, thus showing an agreement in 59 per
cent amongst the total 116 cases read as D
in males by either reader. The percentages of
agreement for some categories of X-ray cases
are as follows:
In general, there is greater agreement
. I
■
Males
n/
Females For both
/u
%
' I)1
59
•10
55
‘ C * or ‘ D ‘
55
37
49
‘C’
32
23
29
between the readers in respect of the films of
males. The greatest agreement is seen in
the category of reading D, viz., 59 per cent for
males and 40 per cent for females. The
agreement for the category C or D is only
slightly lower, but the coverage of bacillary
cases is considerably higher as shown by the
following results.
i, j .3
■ )§
1 ;i
I
I
•
I
3
i
t l
I
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
I6
(There were in all 84 bacillary caret among
those x-rayed).
Category of
X-ray reading
No. of
cases
Bacillary
cases
Bacillary
D by both
83
42
50.6
D by either
151
54
35.8
C or D by both
259
60
23.2
C or D by either
525
71
13.5
i
%
One may use bacillary findings for choosing
a suitable index of radiologically active disease.
D by either or both does not give a satisfactory
coverage of the bacillary cases. C or D by
‘either’ reader gives the greatest coverage of
bacillary disease while C or D by ‘both’ reader
yields a larger percentage of bacillary cases.
These two latter indices could be used as a
lower and an upper limit for the true prevalence
of disease. If agreement between the two
readers become closer, the difference between
the lower and upper limits would be smaller.
In the present study the agreement between
the two readers for C or D cases was 49 per cent.
■
I
5.2 Umpire reading
Following Yerushalmy (1956) the 266 dis
agreed films i.e., read as C or Dby only one of
the two readers, were submitted to umpire
reading. A list of the 266 films was prepared.
The readings of the two readers were arranged.
In two columns with the more ‘serious’ of the
two readings in the right hand column. The
umpire thus knew the readings of the two readers
but not the identity of the reader for any
reading. He recorded his readings in a separate
column on the list. Tables 15 and 16 show
correlation between the readings of the umpire
and I and II readers respectively. Out of
die 110 disagreed cases read by reader I only
31 (or 30 per cent) was confirmed. Out of
156 cases by reader II, 102 (or 65 per cent)
were confirmed. It is seen that 133 (i.e.,
one half of the disagreed cases) were confirmed
in the umpire reading. These included 10
out of the 11 bacillary cases among 266 dis
agreed films. Thus die coverage of bacillary
cases was better when the method of umpire
reading was used.
5.3
Choice of an index for prevalence of
radiological disease
v
One may use any of the above indices or
readings by any one reader as a means to
denote disease in the community. In search
for the ‘best’ index, correlations of the various
indices with prevalence of infection and bacil
lary case rates were calculated. These along
with bacillary findings and prevalence rate of
X-ray cases according to each index are shown
Table 15
Correlation between the readings of reader I and those of umpire reader
Reader I
’■
X.
Norrnai
Normal
UnsatisCalcififactory films cation only
A
B
10
Unsatisfactory films
11I
I ‘
s
■ }’
w
Calcification only
&
A
6
5
B
13
C
33
1
D
1
1
Total
63
2
D
C
Total
13
23
1
1
1
1
4
1
27
38
1
2
16
38
70
4
26
28
28
1
121
7
1
1
1
12
39
46
108
6
|
2 | 266 J
(
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
17
Table 16
Correlation between the readings of reader II and those of umpire reader
Reader II
Normal
UnsatisCalcififactory films cation only
____
§
o
Normal
13
Unsatisfactory films
1
B
C
Total
23
1
Calcification only
1
A
5
B
5
C
2
18
9
2
38
26
30
2
70
22
92
L"'
29 I «
2
8
12
144
12
266
1
26
2
1
2
1
4
2
I
Total
D
10
D
v.
A
I
■
121
table 17
Comparison of various indices of prevalence of X-ray eases
Category of X-ray Cases
No. of
cases in
given
X-ray
category
Bacillary cases
in given
X-ray
category
%
<n
tn 6
Sa
o
No.
|
2?
■
U
73
2^
•Correlation
co-efficient
with
prevalence of
2
o
5
oa s
£
o'*
reac
tors
Bacil
lary
cases
£
‘oh
U-
o'
Q «
C or D by I Reader
369
63
17.1
73.2
25.0
0.59
0.41
1.76
C or D by II Reader ...
415
68
16.4
78.4
19.0
0.61
0.38
1.97
C or D agreed by both reaflers ...
259
60
28.6
0.63
0.49
1.23
C or D by either reader
525
71
l 13.5
73.6
15.5
0.58
0.32
2.50
C or D agreed by both readers
+ C or D by umpire ...
392
70
17.8
77.0
16.7
0.58
I 0.41
1.86
23.2 I 80.6
■5
I
;
I
!
I
* Sputum positive cases among the X-rayed - 84 (excluding two bacillary
cases not X-rayed).
Correlation co-efficient calculated on the basis of 62 villages only,
r* correlation
in Table 17. C or D cases by ‘both’ readers
gives the highest co-efficient of correlation
(though not significantly different) with bacillary
?fases (0*49) and with tuberculin reactors
(0.63). But this index as shown earlier
misses 24 r.e., 29 per cent out of the total 84
bacillary cases and may not thus be the best
representative of X-ray disease in the survey
area. ,
J
Auwug the 62 villages, as shown later in
Table 24, as many as 30 did not have a single
bacillary case. Co-efficients of corrHnti™
correlation
,»l
'I
l(
■
!\
■
;
>
'I
'■
I
fc
HI
18
RAJ NARAIN, A. GESER, M. V. JAMBUNATUAN AND M. SUBRAMANIAN
Table 18
Co-ejficients of correlation (c.c.) of disease prevalence, t
according to different categories of diagnosis, toith
prevalence of (7) bacillary cases and (2) infected,I, among different types of villages
Type of village
Category of diagnosis
I
I
I
!
!
<
C or D by Reader I
C or D by Reader II
C or D agreed by both readers
C or D by cither reader
C or D agreed by both readers
+ C or D by umpire
Bacillary cases
J
S' .1
Hi
case
Villages without
Bacillary case
c.c. with
Bac. cases
c.c. with
infected
c.c. with I
Bac. cases
c.c. with
infected
c.c. with
infected
0.41
0.38
0.49
0.32
0.59
0.61
0.63
0.58
0.61
0.54
0.67
0.51
0.70
0.67
0.66
0.71
0.46
0.56
0.53
0.50
0.41
0.58
0.51
0.65
0.65
0.42
0.52
calculated separately for the villages with and
without bacillary cases arc shown in Tabic
Table 18.
Co-cfficicnts of correlation for both infection
Co-cfiicicnts
and bacillary disease with various categories of.
X-ray
X
’r<?y cas
cases
Js a™
are ^variably
invariably higher (though not
cScs Can y d‘fferent) f°r VlllageS with bacillary
considerations it may not be desirable to prefer
the
The
f 11 f* readings
rn'l/lmn-n of
«»C a single reader
1
«because'
*
results would not be easily comparable It was
therefore, decided to prefer a ‘method’ r-uher
than an individual reading and C or D bv l oth
Plus those confirmed by the umpire was selected
A consideration of all the data presented
radiologicallyactiv^d^sXemtfeare^survcye^
represent amount of
above docs not make the choice of a suitable This had also given a better coverage ^or
1 his. had also given a better coverage for
index (of the best index) for X-ray disease bacillary cases, i e 70
+
> or 83 per cent out of the
in the community easier or definite. There total 84 bacillarv e;
total
bacillary cases discovered among
may not be much to choose between different
those X-rayed. Unless otherwise stated this
indices, but keeping in view the bacillary cases
index only has been used as indicative of Radiocovered, agreement with the umpire and varous logically Active Disease in this paper.
co-efficients of correlation, two indices appeared
suitable, namely, C or D by both plus those 5.4 Prevalence rates for radiologically
confirmed by the umpire from the disagreed
active disease
films between the two readers and C or D
According to this index prevalence of radioby reader If only. Co-efficients of correlation logically
activc tuberculosis for all persons
for these two indices with infection rates in the
'i* k! i r
aU^ Scx groups is shown in
total population at four different levels for a
1 able 19. 1 he overall prevalence rate is 1.9
positive tuberculin test were as follows:
per cent, respective figures for males and females
being 2.5 per cent and 1.2 per cent. About
at I
nt
’
at
!
at
66 per cent of the total X-ray disease was in
I 8 mm | 10 mm | 12 mm | 14 mm
the age group 40 years and above. Prevalence
rates are higher among males than
-i among
C or D by both I
females for all age groups except 10-19 years"
plus those con- ,
finned by the
lIiis greater prevalence among males is espe
umpire
cially well marked after the age of 30 years and
0.56 j 0.58
0.59
0.61
increases with rise in age. The higher pre
C or D by II
0.61 !
valence of disease in the female in the age group
~
reader only ... > 0.56
0.63
0.63
10-19 years was also seen in the NTSS*
Table 20 shows the distribution of villages
The differences are i._
not significant and choice by X-ray disease
rate and size of village,
between mdices remains indefinite.
On general Eight villages with
a population of over 900
1
I.
Villages with Bacillary
All villages
I
I
I
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
Table 19
Sex and age prevalence of radiologically active disease
■
No. X-rayed
Male
Male
Female
%
| No.
%
Total
No. |
%
3,402
2,991
6,393
9
0.3
17
0.6
26
0.4
2,304
2,708
5,012
18
0.8
17
0.6
35
0.7
30-39
1,892
1,716
3,608
53
2.8
18
1.0
71
2.0
40-49
1,347
1,261
2,608
46
3.4
26
2.1
72
2.8
50-59
1,019
948
1,967
67
6.6
26
2.7
93
4.7
60+
841
592
1,433
78
9.3
17
2.9
95
6.6 '
Overall
10,805
10,216
21,021
271
2.5
121
1.2
392
1.9
0
0(excl. ‘ 0 ’)
Number of villages according
to defacto population size
Total
I
I
<250 I 250-499 500-749 750+
7
1
2
4
2
2
5
5
2
6
8
2
7
2
2
4
3
2
3
12
20
12
6
3
6-
1
Total
No.
Female
20-29
X-ray rate
per 100
X-rayed
5- '
Total
10-19
Table 20
Distribution of villages by radiologically
active disease
23-
Radiologically active disease
I
Age group
■
19
I 21
19
i” I
::
-i
11
62
did not show a single X-ray active case. Half
of the villages showed a prevalence rate from
1 to 3 per cent. One village with a population
of 152 X-rayed had 7 X-ray cases, 4 of which
were bacteriologically positive.
Appendix III were also recorded, and are
presented in Table 21 by each reader and by
the umpire for the C or D cases read by each
of them.
Bacillary cases have been shown
in brackets. Reader I read in all 74 cavitary
cases, definite or doubtful, among the 369 active
cases read by him. Reader II read 56 cavitary
cases among the 415 active cases read by him.
Of the 74 cavitary cases read by reader I,
32 were bacillary. Of the 56 cavitary cases read
by reader II, also 32 were positive bactcriologically. Reader I read in the total, 3 active
cases due to pleurisy with effusion and 1 due
to hilar adenitis. Reader II read 13 cases in
each of the two categories. None of the cases
in either of these two categories by either
reader was positive on sputum examination.
Readings of the umpire for the 133 C or D
cases from among the disagreed cases by the
two readers are also shown.
!
I 1,
I
1
»
..I +
|
;
■
■■
■
1
6.
Results of bacteriological examination
6.1
Bacillary cases
Table 22 shows the number and percentage
of bacillary cases in the several age and sex
groups as found by examination of a single
.8P?!. 8amP^e
sputum. The percentage of
% bacillary
f
cases
especially
among the males rises
5.5 Other radiological findings
with age as has been seen for radiologically
In addition to reading X-ray pathology as active cases and infected persons. The per
active, other findings on the X-ray films as in centage of bacillary cases also is higher among
s
I, [•
1
I
i
I ;
u
20
HAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
iff
Table 21
V
Pathology and aetiology of C and D cases of each reader separately
(See Appendix III)
Reader
■fi
Pathology
Aetiology
I•
c
d
C
1
4
260 (19)
3
D
45 (24)
24 (8)
30 (12)
1
259 (16)
10
12
281
22 (10)
74 (20)
3
1
134
6
109 (7)
3
3
121
2
3 (1)
2
1
12
c
I
Second
I
Umpire
I
b
First
I
Total
a
D
34 (22)
e
1
269
100
I
C
D
4 (2)
_____________ _ ______ ________________
Figures in brackets show bacillary cases
I
Table 22
Age ami ,ex specific prevalences of bacillary cases in the defacto population examined
I
No. of sputa positive by
either method
No. X-rayed
Age group
Male
Female
I
I
Total
Male
Female
Total
2
(0.06)
9
(0.39)
15
(0.79)
4
(0.13)
6
(0.22)
7
(0.41)
3
(0.24)
2
(0.21)
6
(0.09)
15
(0.30)
22
(0.61)
15
(0.58)
14
(0.71)
14
(0.98)
86
(0.41)
I
10-19
3,402
2,991
20-29
2,304
2,708
5,012
30-39
1,892
1,716
81
3,608
40-49
1,347
1,261
2,608
1
50-59
1,019
948
60 +
841
592
1,433
(1.18)
10
O zerall
10,805
10,216
21,021
(1.19)
60
■7
1 r Ji
s- <4
g
‘Ik
h
!
$
6,393
1,967
12
(0.89)
12
(0.56)
4
(0.68)
26
(0.25)
Figures in brackets represent percentages
males in all age groups except 10-19 years.
The bacillary cases found in the different age
groups are however small. 0.41 per cent of the
total X-rayed population (0.56 per cent males
and 0.25 per cent females) have been found
to excrete tubercle bacilli. It can be calculated
from the table that 50 per cent of the bacillary
cases were found in age group 40 years and
above. JThe X-ray findings of the two readers
for the bacillary cases have been correlated in
I able 23. One bacillary case, was read normal
by both readers. Sputum examination had
(
tuberculosis prevalence survey in tumkur district
21
Table 23
x/
Correlation between tbe radio^iemfi„dings o} the
riad„s <mong
Reader II
j Noimalj
£
Normal
Unsatisfactory films
Calcification only
3
«
B
c
1
Unsatisfactory films
r
i A | B | C
Calcification only
1
1
D
1
?.*.
Not X-rayed
Total
...
2
1
1
1
1
i
2
1
9
2
2
2
1
42
togiSlly8 9 baClUary cases as “ormal radio-
round positive by different techniques was:
<250 | 250-499 | 500-7491
0
1
16
9
4
••
5
2
2
1
1
2
3
4
5
fouT
Tb^n"01Single baciUary case was
round. These 30 villages represent about 25
14
15
1
i
6
7
12
13
„ „„,d „„ duc c.hcr
|
2
L
86
ij
Number villages of according
to defacto population size
Bact.
preva
lence rate
It may be seen that 27 or 46 per cent bacillary
cases were added by culture to thorn positive
by direct smear /.
pvsiuve
Distributionvillages by bacii ary case
rates is given in fable 24. It will be seen
nerL’n “y"13117 ,as 30 v,llage-<’. comprising 5,367
This greater frequency of abacillary lesions
52
2
Table 24
Distribution of villages by the bacillary case
rata according to the size of population
Positive by direct smear
59
Positive by culture
66
Positive by culture and direct smear
39
smear
Positive by direct smear, culture
—-J contammated
per cent of the population X-rayed. On the
other hand one village with an X-raycd
population of 152 showed as many as 4 bacillary
cases,
Number and percentage of bacillary cases
among the X-ray cases in different age groups is
femX4 F Tab'e 25 KSeparatC'y
’-les mid
emales. Except in the age group 10-19 the
1517I,6I
1
5
5
19
44
2
's
8
2
s -1
< Distrihminn of the 86 bacillary cases as
wh
4
2
ng it apex. 4 further cases had been read
as normal or non-tubercular pathology by both
the readers
One reader had read in all as
•</
2
Not | Total
X-rayed
D
1
8
9
1
1
10'
11
16
17
18
19
1
Tl
3
1
1
7
4
2
2
3
2
1
1
1
2
1
1
1
1
1
2
...
121 i
19
?
f,-
30
2
1
I -i
204Total
Total
7504-
1
1
I
I
T]
2
11
I " |“
r due to new ,es«ons in older
o
i
• I
K
I
22
RAJ NARA1N, A. GESER,
. V. JAMBUNATHAN AND M. SUBRAMANIAN
Table 25
Number andpercentage of bacillary caset among X-ray
cases in different sex and age groups
1
11
li
1
I
^4)
£
10-19
9
20-29
g<u
C3
£
*5
Um
5
i
17
2
3
22.2 | 17.6
18
17
8
4
44.4 I 23.5
I
IS
14
5
26.4
27.8
40-49
46
26
11
2
23,9
7.7
1
50-59
67
26
11
1
16.4
3.8
f
W'-
Percentage
53
I
I
Age
group
30-39
I
Ip
Bacillary
cases
r
i
11
X-ray cases
None of these factors could be held res
ponsible for the high contamination rate.
6.3 Absentees for examination
Sputum could not be collected from 108
persons out of 2,441 persons eligible (Table 3).
These included 13 X-ray cases read as C or D
by both the readers.
The number of bacillary cases found in this
study should be taken as a minimum, because
the collection of a single ‘spot’ sample of
sputum and the presumption that all the
absentees at sputum examination had negative
sputa and the high contamination rate, all-tend
to reduce the number of bacillary cases detected.
7.
Other results
7.1 Standardised rates
60+
78
17
8
1
10.3
5.9
In order to make figures comparable, it is
Overall I 271
54
121
16 . 19.9
usual to compute standardised rates which take
13.2
I
I
I
into account differences in the sex and age
composition of the population examined and
probably less reliable from a single picture the actual population. The age and sex
in older people.
distribution of the population in the district
as in 1960 being not known, this standardisation
6.2 Contamination rates
is not feasible.
Since the absentee rates
The maximum distance from the field to the have been found to vary in the different age
NTI was over a hundred miles and from and sex groups, it was considered desirable
the NTI to the UMTS Laboratory, 75 miles. to make due allowance for this and calculate
It took one to thirteen days for the sputum standardised rates assuming that the prevalence
samples to be delivered at UMTS. Among rate among the absentees was the same as
the 2333 samples of sputa cultured, both tubes among those examined in each age and sex
were contaminated in 395 (i.e., 17 per cent of group. These standardised rates worked out
the samples) and one tube was contaminated to be 38.3 per cent for infection, 1.86 for X-ray
in another 536 samples (23 per cent). Among cases and 0.41 per cent for bacillary cases, the
.the contaminated, 616 cultures were repeated latter two for ages 10 years and above only.
from the material left over from the first cul These standardised rates are not different from
tures and preserved in a refrigerator. A total the prevalence rates for the population examin
of 2 from both tube contaminations and 12 ed due to high coverages obtained during the
from one tube contaminations were found survey.
positive in these repeat cultures.
The unusually high contamination rate of 7.2 Estimates for the district
40 per cent was considered to merit further
1 he population of Tumkur district excluding
study. The influence of the following
the headquarter town of Tumkur was estimat
characteristics on contamination was analysed.
ed to be 12.2 lakhs during November, 1960,
(i) X-ray category of the examinee
the middle point of the Baseline Survey period.
(n) Age of the examinee
Appendix V gives details of findings for each
(m) The interval between collection of the group in the survey.
sputum sample and its inoculation in
Standard error and co-eflicient of variation
the culture medium
for three prevalence rates are given in Table 26
(tv) Seasonal variation as shown by a study (Appendix
. ..
’
’VI). It may be seen that a co
of weekly fluctuations in contami- efficient of variation of 5 per cent for infection
nations
rate, 8 per cent for radiologically active disease
23
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
Table 26
3
‘
Estimates of prevalence for various epidemiological
characteristics in Tumkur District
,
i 95% confi°o-5 I C 'nce limits
c c I of prevalence
u
a
v
s
• v. Category
u
1)
"u
£.2 I J;
6 g i o',-?
o
u
I -1
ai o
u.
Oh
tn
I
i
I
Infection
> 10 mm
38.3
1.8
4.8
34.6
41.9
X-ray (by both
plus umpire)
1.86
0.15
8.10
1.56
2.16
Bacillary
0.41
0.05
11.5
.31
.51
Note: Prevalence of infection relates to persons
test read, and for the other two categories to persons
X-rayed.
rate and 12 per cent for the bacillary case rate
has been achieved. In the NTSS (Page 92)
the co-efficient of variation for X-ray disease
rate in villages varied from 5.7 per cent to 10.2
per cent in various zones.
With a confidence of 19 in 20 it can be
asserted that the number of radiological cases
aged 10 years and above in the said population
lies between 11.8 thousand and 18.8 thousand,
and is likely to be round about 16.2 thousand.
Similarly with a confidence of 19 in 20 it
may be asserted that the number of bacterio
logical cases aged 10 years and ov er iuthe above
population may lie anywhere between 28
hundred and 44 hundred and is likely to be
about 36 hundred.
7.3 Variation within the district
The villages surveyed were a random sample
from the entire district.
Therefore, estimates
for smaller units like the taluks are not valid.
But the differences between the southern
half consisting of 6 taluks (Tumkur, Chiknayakanahalli, Tiptur, Gubbi, Kunigal and Turuvekcre) and the northern-half consisting of 4
taluks (Pavagada, Sira, Madhugiri and Koratagcre) have been strikingly large. The findings
in the two halves are presented in Table 27.
It will be seen that although the population in
the two halves is nearly the same, the prevalence
of infection in the northern-half is 46 per cent
compared with 30 per cent in the southern-half
while the prevalence of active disease is 2.3
per cent in the north and 1.4 per cent in the
south. The bacillary rates are 0.58 per cent
and 0.24 per cent respectively. T’hc reason or
reasons for these differences arc not known, but
these have not been found due to any differences
in the coverages by age and sex or due to size
of village in the two zones.
A further difference observed may also be
recorded. Although only 25 out of 86 bacillary
cases are in the southern-half, the sex ratio of
these cases in this half is different from that in
the nortlicrn-half. In the southern-half there
arc 11 male and 14 female bacillary cases,
while in the nori hern-half there are 49 male
and 12 female cases. Among X-ray cases in
the northern-half this prepondercnce in the
number of males is not seen. The prevalence
rates in the 10 taluks range from 1.6 per cent
to 3.7 per cent. Results of significance tests
for the differences mentioned above have not
been presented in this paper, because even
though such tests showed significant differences
these arc not necessarily valid as the sample has
not been stratified by taluks.
i
i|
I
h
I
I I
(I*
■I T
Table 27
Prevalence of infection and diseased in the Southern and Northern Zones
No. of
groups Defacto
(incl.
popln.
towns)
Southern Zone
Northern Zone
40
26
15,911
16,056
2O) O«
Infected
No.
X-rayed
<D u-
|
No. |
%
12,895 3,907
30.3
da
113,171
60,67
46.1
Radiologically
act. cases
No.
10,514
10,507
150
242
Bacillary
cases
%
1.43
|
2.30
|
No.
%
25
0.24
61
0.58
4
> J
r
fl
24
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND
M. SUBRAMANIAN
^^ABLE 28
Prevalence of infection. X-ray and bacillary casesf by size of village
I
Size of village (defacto
population)
No. of
Infected
villages ! Test-read ' > 10 mm
< 250
21
250-499
19
r
2,300
775
(33.70)
2,045
(33.63)
1,752
(32.46)
4,698
(43.97)
6,081
500-749
11
5,398
> 750
11
10,684
-F
Overall
F
ft
[ ij I 1
IIn
IJ
lr
62
|
X-rayed
1,792
4,722
4,329
8,892
RadiplogicalJy
Bac. cases
active cases
34
(1.90)
76
(1.61)
8
(0.45)
62
(1.43)
185
(2.08)
15
(0.32)
14
(0.32)
40
(0.45)
357
(1.81)
77
(0.39)
24,463
9,270
(37.89)
19,735
Figures in brackets represent percentages
7.4 Variations with size of village
cases arc not statistically significant but the
In 'fable 28 the prevalence rates for infection
sample was not stratified for this characteristic.
and radiological and bacillary disease have been
given for villages of different size. The total
8. Some remarks
X-rayed was only 1792 in the ‘smallest’ villages
rn??
0
Ba
?
cline
in Tumkur district
and the high radiological and bacillary disease
confirms,
in
general,
the
findings of NTSS
rates may not necessarily be reliable for such
villages. Ihus all the three prevalence rates that there is a considerable amount of tuberculosis m the villages. There is an appreciable
appear to be highest for ‘large’ villages with
population of 750 or more. For reasons given variation in the prevalence rates of infection
m the preceding paragraph the results of difre°r '>g|"'t I Td bacterio,°gical cases among
liferent taluks, among villages of different
significance tests for the differences observed
are not given.
of tl a"r
IC ",,rllle111 aud soulhern halves
< f the district. As the sample surveyed was
7.5 Accessible and inaccessible villages drawn from the entire district, these differences
The difference in the prevalence rate in the ifsLh°dffeCeSSarily be Valid- AU the sa">e
t such differences are there these can seriously
accessible and m the inaccessible villages is
interfere
with the assessment of different conof considerable importance. NTSS was con
ro programmes applied to different parts of the
fined to accessible villages only and all surveys
in developing countries will of nece< ’ ‘
NTO/p"^ 1<”dy tO acc“aible’^11^7
ind SSf Plge
3
StateS’ ‘Preliniinary results ro uble “Th01”111 ?TOUld haVe been mor=
indicate that there is no significant difference stmtifiomconclusion may be drawn that
regarding the tuberculosis prevalence in the should be aCCO.rdlnJ to the factors mentioned
accessible and ‘inaccessible’ rural areas now shoulil be considered necessary in drawing a
ample for a survey, especially so, if the results
surveyed . 46 out of the 62 villages of the
present survey were considered accessible. are to be used for assessment of different
control programmes in different areas of the
h''ni!Z'29 Tl" SetS °f Vi"a8CS arC PreSented
1 able 29. 1 he percentage of tuberculin ndT10? A- any ra^c thcre can be no serious dis
reactors and radiologically active cases is higher advantage in stratification.
percentage of' a ^o’cf]lclents of correlation between infection
in the inaccessible villages while percentage
percentage
of :and various categories of disease on the one
bacillary cases is higher in the accessible
villages
However, the differences for X-ray and bacillary
<Jnnthen„dthbetTn 3E"ray and bacil,ary disease
the Other, have been shown earlier. The
r' "i
ii
wr—
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
25
Table 29
Prevalence of Infection, radiological and bacillary cases in accessible, inaccessible and urban
areas covered by the Survey
c
.2
Areas
d
•8 o
Qa
1
No. of reactors
> 10 mm
No.
|
i
Radiologically
act. cases
%
OX
No.
%
5
6
7
8
Sputum 4- ve by
either method
I
No.
%
9
10
2
3
4
22,671
18,731
6,961
37.2
15,125
266
1.76
63
0.42
Inaccessible
(16 villages)
7,142
5,732
2,309
40.3
4,606
91
1.98
14
0.30
Urban (4 blocks) ...
2,149
1,603
704
43.9
1,290
35
2.71
9
0.70
Total (66 groups) ...
31,962
26,066
9,974
38.3
21,021
392
1.86
86
0.41
Accessible
(46 villages)
■■
No.
tested
end
read
I
■h
I
j
j
■
.
J
value of some of these co-efficients is not as better and
may make their application more
high as to be useful in utilising the comparative precise.
ly simple tuberculin test forjudging the amount
of radiological and bacillary disease in a group
Summary
or a community. It is possible that some of
these values have not been high enough due
A Tuberculosis Prevalence Survey was
to the relative crudeness of the methods that carried out in Tumkur District, Mysore State,
are available for surveys. Limitations due to India, to provide basic information regarding
reader error in tuberculin tests and X-ray age-sex specific prevalence rates for infection
readings are well known. Limitations of radiologically active disease and bacillary cases’
a single spot sample of sputum for juding the
1 he survey was confined to 66 groups—62
number of bacillary cases have
reported rural and 4 semi-urban selected ....
at random.
earlier Raj Narain (1962). There ?.re many Coverages
« were _____________
about 92 to 95 per cent.. The
other limitations of the methods available for rcsults
the survey showed (and <confirmed)
surveys which may account for the low values t,lc imitations of these examinations: in providof the many co-efficients of corrclaCon in this ’n£ dear indices for prevalence,
Attempt
report. The value of these co-efficients of J138 been niade to find the best possibe indices
correlation will be judged better, U is hoped,
prevalence of infection, radiologically active
by further surveys.
disease and bacillary cases by correlating the
Some methods for defining more accurately findings of one with the other two and making
a positive reaction and an index for X-ray use of 0,1
all types of data available.
■’ ”
A
‘ clear
‘
disease have been used. The results may not cut choice of the best possible indices was still
appear commensurate with the labour put in. not available, but a basis for further work has
However, a basis for further work has been, been defined. Some interesting variations in
it is hoped, defined. Another survey with a prevalence, which have been observed in this
sampling ratio of 20 per cent with more inten survey, indicated the desirability of stratified
sive sputum examination is nearing completion. samples for such surveys.
Correlation of the findings by the different
The main findings of the survey, in the
may^help in judging their value
techniques used may-help
defacto population examined are:
■
>
'
I
)
1
I 3
II
26
1.
1
K
I1
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
2.
3.
4.
•*
*
5.
6.
7.
8.
9.
10.
38.3 per cent were infected; 42.8 per
cent among males and 33.9 per cent
among females.
The percentage of infected persons
rises with age, reaching a maximum
at about 40 years.
For age group 10-19 years and above,
infection rates are consistently higher
among males than among females.
Complications to tuberculin test were
observed in about 5 per cent of the
tests read and consisted mostly of
oedema; incidence of complications
was significantly more among females.
Large reactions of 20 mm. or more
were observed among a larger pro
portion of females than males.
Incidence of infection rises with age at
first, but drops in later years.
1.9 per cent had radiologtcally active
disease; 2.5 per cent among males and
1.2 per cent among females.
66.3 per cent of the radiologically active
cases were persons aged 40 years or
more.
Prevalence rate for radiologically active
disease increases steadily with age;
the increase being particularly marked
among males.
0.41 per cent were bacillary cases
among persons of age 10 or more;
11.
12.
0.56 per cent among males and 0.25
per cent among females.
Prevalence of bacillary cases steadily
increases with age among males.
50 per cent of the bacillary cases were
persons aged 40 years or more.
Acknowledgements
The .authors are grateful to the field teams
for their hard and painstaking work.
To Miss J. McLary for training the techni
cians and for conduct of the survey in general.
To Dr P. Chandrasekhar who from September
1960 onwards was Medical Officer-in-charge of
field teams. To the teams and team leaders Shri
G. Dwarakanath and Shri N. Suryanarayana
Rao. To the statistical unit and secretarial
staff for their help and co-operation. ’Po Dr J.
O’Rourke WHO Medical Olficcr for ncling as
the umpire reader for the disagreed films.
To the Union Mission Tuberculosis Sana
torium, Arogyavaram, South India, for carrying
out all bacteriological examinations.
The authors are also grateful to members of
the Technical Co-ordinating Committee of the
National Tuberculosis Institute for their help
ful suggestions and criticism, especially to
Dr N. L. Bordia, Dr M. Pint, Mr S. Andersen
and Mr S. S. Nair who joined the NTI as
Senior Statistical Officer in August 1962.
REFERENCES
14-i
I
I
I
I
1.
Benjamin, P. V. {X^SX)',Proceedings of the Eighth
Tuberculosis Workers Conference, 1951, Tuber
culosis Association of India, New Delhi—P. 43.
2.
Indian Council of Medical Research, New
Delhi (1959): Tuberculosis in India, a sample
survey (1955-58).
3.
McDougal, J. B. (1949): Tuberculosis (A Global
Study in Special Pathology)t Baltimore, The
Williams and Wilkins Company—P. 261.
4.
Raj Narain and Subramanian, M. (1962);
Proceedings of Eighteenth Tuberculosis Workers
Conference, Bangalore.
5.
Yerushalmy, J. (1956): International Tuber
culosis Year Book, 26, No. 1-2.
APPENDIX I
Composition of a field team
1.
2.
3.
4.
5.
6.
Team Leader
Two census takers
One tuberculin tester
One card controller
One X-ray technician
One tuberculin test reader
7.
8.
9.
10.
One laboratory technician
Two scouts
Two drivers for X-ray units
Two drivers for staff cars of testing and read
ing teams.
Drivers help in positioning persons for X-ray
examination, for scouting and in various other ways-
■ f
TUBERCULOSIS PREVALENCE SURVEY IN TUMKUR DISTRICT
27
APPENDIX II
Definitions of some terms used
persons who live in the village. In the case of
(а) Household
homeless persons, the answers given by them as to
whether they belong to the village or not, may be
A household is defined as a group, whose members
taken as the basis of the classification.
live together and have their main meals prepared in
the same kitchen.
(d) Temporarily present (T.P.)
If the group consists of persons who live and sleep
A person is classified as temporarily present if he
under the same roof but take meals in different
does not belong to the village but has slept in the
places, they are still to be regarded as forming a
village the previous night.
household.
A person who has stayed in the village for more
Ex. (i) Students or others occupying a house or
than one year shall be regarded not as a TP but as
a room in common and messing else
permanent resident of the village.
where should be registered at their
Similarly, a person who has been staying in the
common residence.
village for a period of less than one year and does
(m) Servant who sleeps in h;s own household
not intend to leave the village within a year from now,
in the village but takes his meals in
shall be regarded not as a TP but as a permanent
the master’s house will be registered
resident.
in his own household.
(e) Temporarily absent (T.A.)
(б) Homeless persons
A person is clfissifted ns trinpoinrily nhsent if he
Persons who have slept in the
ihe village the previous
belongs to the village, but wits nbsent from the village
night but who do not belong to any household in
the previous night. If the person was absent from
the village are treated as homeless persons eligible
the village for more than one year, he should be
for registration.
regarded as a permanent absentee and shall not be
registered. If the person is absent for less than a
(c) Permanent residents (P.R.)
year and has no intention of returning to the village
Permanent residents of the village are those who
within one year from now, he should be regarded
belong to households in the village as also homeless
as a permanent absentee and shall not be registered.
i
APPENDIX III
READING OF X-RAY FILMS
2. Middle zone-—area of lung lying between the
All readings of X-ray films will be recorded on a
upper and lower zones.
separate form. Each form will clearly indicate
3. Lower zone—area of the lung below a hori
the Group Number, Group Name, Film Roll No.,
zontal line drawn along the lower margin of
Date of X-ray exposure, the date of X-ray reading
the anterior end of the 4th rib.
and the name of the reader. This is done to ensure
The zones involved are recorded as Rj, R2, Rs> etc.
complete independence of the two readings. Indivi
dual cards are not available to the readers at the
11. The physical appearance of the lesion
time of reading.
Only one of the following is recorded in all cases
where a pathology is present.
X-ray code
(a) Infiltrate with cavity
The X-ray code is based main’- on the code
(Z>) Infiltrate with doubtful cavity
followed in NTSS. In all cases where pathology
(r) Infiltrate without cavity
ia present readings are recorded und i the following
(d) Pleural effusion
four headings.
(r) Hilar Adenitis. Only dense shadows with
distinct contours in the hilar regions are to
■I. Extent of disease
be considered abnormal. Particular care
Each lung (R=right; L=left) is considered to
should be taken not to react on confluenting
consist of three zones:
vascular and bronchial shadows which
1. Upper zone—area of the lung above a hori
are normally present in the hilar region.
zontal line drawn along the lower margin of
(f) Pulmonary scar—Fibrotic strands or bands in
the anterior end of the 2nd rib.
the lung fields.
■
i
!
h
i
(I
■
■
)
I
I
k
V*
j 'i
!
<♦
1
rf < •
i
iI
28
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
(/?) Pleural scar—Thickening of pleura or obli
teration of the castophrcnic angle.
(A) Pneumothorax or Pneumoperitoneum.
O') Cardio-vascular pathology—marked alterations
of the shape and size of heart or large blood
vessels.
(j) Thorocoplasty or Rib Resection.
(A) Other pathology of the chest—any pathology
of the chest which cannot be listed from
a—j-
If more than one of the lesions listed above are
found, only the main lesion from the point of view
of tuberculosis is recorded.
III.
Presence of calcification
Calcifications wherever present arc recorded
independent of any other pathology. End-on blood
vessels and foreign bodies are, as far as possible,
excluded.
IV.
I
Bl
H1-
Il ■
1 fr-*
lit
Ip
I"
w
if!'
M; A;
Impressions regarding aetiology
For all abnormalities (except for calcifications only)
the reader gives a judgment regarding the aetiology
of the lesion. The probability of finding tubercle
bacilli in the sputum of the examinee serves as a
guide. In making this judgment the nature of the
lesion is taken into account (presence of cavity,
location of lesion, etc.) and also the extent (size of
areas involved; uni-or bilateral distribution). The
radiological appearance of the lesion is also taken into
account. If the reader, in recording a lesion, feels
some doubt whether an abnormality really exists or
not, the degree of doubt and the probability of isolat
ing tubercle bacilli guide the ultimate judgment.
The following aetiological classification is used:
A.
Probably non-tuberculous
All lesions which are considered of non-tuberculous
origin. The probability of finding tubercle bacilli
judged to be near 0.
B.
Probably tuberculous but inactive
All scars and other healed lesions except calcifica
tions; some doubtful shadows, if they are recorded at
all may be classified as inactive. Probability of find
ing tubercle bacilli is judged to be small.
C. Probably tuberculous, possibly active Lesions
appearing to be of tuberculous nature but without
a definite cavity and not extensive. Tubercle
bacilli may be detected even with a single collection
of sputum.
D.
Probably tuberculous and active
The lesion appears to be of tuberculous nature,
may be extensive, may be bilateral, or a definite
cavity is present. The probability of finding
tubercle bacilli by a single collection is judged to be
high.
The last two categories namely C and D are
grouped together as Radiologically Active Tuber
culosis.
(For choice of index of disease used in this paper,
see text).
APPENDIX IV
Statistical note on the calculation of
without BCG scars. But in order to estimate the
incidence rates
incidence of natural infection in a community some
adjustment has to be made to account for the exclu
The incidence rates of infection can be estimated
sion of those with BCG scars. A method of making
from the prevalence rates of infection in various age
this adjustment, using the incidence rates among
groups with certain assumptioris viz:
those without BCG scar, is also given in this appendix.
1. Mantoux reaction of over 9 mm. is synonymous
Estimation of annual incidence among those
with infection with Myco. Bact. Tuber
without BCG scar:
culosis and hence the infection rates cal
The following three methods may be adopted:
culated on this basis reflect the true position.
2. The onset of infection within each age group
is similar in the two sexes.
(1) Logarithm method
3. Mortality rate is the same for both infected
Let Pt be the proportion of infected in the
and uninfected.
age ‘ t ’
4. The phase in the epidemiology of tuberculosis
Let Pt+i be the proportion of infected iim the
through which the community has passed
age * t + i’
has no influence on the annual attack rate.
Izct rt be the annual infection rate in the ag<c
5. The incidence of infection is uniform within
group ‘ t ’ to ' t 4- i ’
the several age groups specified.
Then non-infccted people in the age t + i
With these assumptions age specific annual
= (non-infected in the age t) —- (infected in the
incidence rates can* be worked out directly for those
interval t, t 4- i)
TUBERCULOSIS PREVALENCE
SURVEY IN TUMKUR DISTRICT
O-Pt+j) «= (l~pt ) (i^rt
Similarly,
(l-rt )i = Q-Pt+i)
2 S (AX’ 4- BX - y) X
o
dB
i e. S (AX’ 4- BX - y) X
0
A 2 X’ 4- B S X’ = s :
Xy...(2)
The normal equations then
i are given by (1) and (2).
By solving these
equations we can find out the
constants A and B and hence the equation of best
fit.
By substituting x = 1 2
„ •
of best fit we estimate the values of y (1 eVTat
different ages.
7 '
t } at
By using the formula
o-pt;
i ,
y iog
rt 23 1—antilog
.’-Pt + i )
’“Pt
(2) Approximation (Binomial) method
I
The annual incidence of infection h ■
order of 2 per cent, if ; is aJs’^X^v!
e ,
r, )t =l-irt (0<rt <]? approiiraatcJy
(1
l-irt =>(l-Pt+i)/(1_pt . x
l-pt
1
or
vt - JLpi±nPL
V
Pt4-i~~Pt
1 Ai
^Pt
■
Where A is ithe symbol of differencing
and i the
interval of diffe;fencing.
Incidence of
(Newly infected in the interval)
infection at age t
Interval x Uninfected at the
beginning of the interval
(3) Least square method
This method
uses the best mathematical fit to the
age specific infectioi•n curve.
y —• axa 4' bx 4- c be the <----to the age specific prevalence i
infection where y is* the nr
1 PreVaIehce rates
Y is the
the specified age x.
P
°f lnfection in
age x.
-nWeld^
that al!
are
of infection at birth
inthp
1 T ZerO) 8h°Uld be Zero and the the
term
n the above equation vanishes. Thusconstant
equation
to be fitted reduces to the type
rt “=
29
deu 21ati“ JtraXthVUrVC °f l,CSt fi' "> the
u
y^ax’q-bx
U.tng the method of least sq„arc, M„ „otc „
i
i-pt
Mustmenff
in,fCC,'On at
’’ -'-htted.
Most of th CJ1
n °f th°Se With BCG Sc»r:
bx M-s BCG cLXnfmb.^^re
bX:,,;^^^xfltbu:tfmewou,dha:’
X- -e PreXce o/lt^
“ntntumty would have been different from that
'ed among those without BCG scars. The
with^^yT^
11
Isf
nu. mo’.'h.'iccT j' 'J','
j
*r“P “
tt .
dM
+bX<
da
Oand 3b' “ 0 " ‘b’appropriate
condition, on the value of the second derivative,
etX“T
+ 5b
= 2 S fAYr _r ovdA
" (AX +
■ ~ y) x«
he. S (AX’ + BX-y) X’ = (
o
A £ X‘ + B 2 X’ = s X’y . . . (1)
scar
Fro
rt''
were worked
gained earlier.
•■•X = 5X
^bTmir.^um'25 “
has been estimated
should
Then
0
Th/
/
f the SUrvey
I
among t!’ose without BCG
b^^'T ra,e8’
rat«
if
n
But^h^'T'6
a tentative
of persons
vacctnated but for the vaccination are the BCG
calculated
ostable figure this
we get
■
j :
■N
i
I",
30
RAJ NARAIN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
APPENDIX V
■i
Details of findings for each group in the survey
h ■ ■
Group
No.
i
Im I-
III
r
I
i _... •
w-
■
I
■
4
I
I •
■I:
Total
registered
Total
Test
read
Infection rate
> 10 mm
Total
X-rayed
Radiologically
active disease
No.
Rate
*/•>
Bacillary ■
cases
No.
f
I
N
[
Rate
7>
1
2
3
4
5
6
7
8
9
501
502
503
504
505
506
507
508
509
510
511
512*
513
514
515
516
517
518
519
520
521
522
523
524
525
526
527
528
529
530
531
532*
533
534
535
536
537
538s
539
540
541
542
543
544
545
546
547
548
549
550
551*
456
966
273
220
103
874
377
1,427
93
351
3,021
560
897
480
1,056
769
266
347
242
306
113
347
140
630
491
428
568
1,803
467
625
49
512
501
897
447
836
510
540
239
516
117
321
145
442
84
205
227
102
336
506
537
387
799
251
185
97
738
295
1,196
75
331
2,276
423
723
409
888
593
217
314
186
272
85
265
129
553
402
401
509
1,479
401
563
39
404
410
665
383
677
432
407
200
437
99
252
118
341
59
182
194
83
282
430
369
49.9
47.2
48.2
61.1
30.9
47.8
34.2
41.6
37.3
36.6
51.0
51.8
61.0
40.8
55.5
26.3
35.9
19.4
28.5
32.4
35.3
21.9
41.1
35.1
46.0
32.7
41.8
45.4
29.4
35.9
25.6
41.8
25.1
22.0
25.6
34.4
34.3
56.6
27.0
33.2
29.3
34.5
28.0
32.0
40.7
20.3
22.2
50.6
37.6
26.7
38.9
303
630
176
152
69
581
200
961
64
239
1,906
345
637
338
714
488
160
218
147
212
73
220
87
453
328
295
373
1,279
271
440
32
285
352
606
320
543
339
318
177
350
10
13
3
7
2
19
2
15
3.3
2.1
1.7
4.6
2.9
3.3
1.0
1.6
4
3
2
4
1
5
1.32
0.48
1.14
2.63
1.45
0.86
6
0.62
2
53
12
24
9
16
4
4
2
1
5
3
1
3
5
4
9
6
23
2
12
0.8
2.8
3.5
3.8
2.7
2.2
0.8
2.5
0.9
0.7
2.4
4.1
0.5
3.4
1.1
1.2
3.1
1.6
1.8
0.7
2.7
6
4
5
1
5
1
0.31
1.16
0.78
0.3
0.7
0.2
4
4
3
3
8
9
9
1.4
1.1
0.5
0.9
1.5
2.7
2.8
4
3
1
6
1
2
2
5
2
4
10
• Town blocks
81
228
90
284
48
112
157
69
196
P342
12
1
1
1
2
7
0.3
0.34
0.54
0.55
4
0.91
1
0.35
1
1
3
2
0.31
0.18
0.88
0.63
1.1
1
0.29
1.3
1.1
2.1
2.1
1.8
1.3
7.2
1.0
1.3
2.9
1
0.44
1
2.08
1
0.64
2
0.58
31
TUBFRCVLOSIS PRirVALFNCH SURVEY IN TUMKUR DISTRKI’
Total
Group i
registered
No.
Total
Test
read
Infection rate I
j
> 10 mm
Total
X-rayed
1
'• v.
r
2
552
553
554
555
556
557
558
559
560
561
562
563
564
565
566
59
740
713
183
17
132
5
592
446
181
271
506
429
821
102
4
5
I
Bacillary
cases
Radiologically
active disease
No.
I Rx
6
7
Rate
No.
I
8
9
I
I
I
51
650
o9o
1-18
17
ICo
4
471
332
150
194
347
352
650
93
I
I
33.3
33.1
36.1
43.9
29.4
33.0
45
498
499
110
13
93
2
8
6
1
4.4
1.6
1.2
0.9
1
2
0.2
0.4
22.7
21.4
36.6
27.8
27.4
27.8
26.0
36.6
385
289
115
• 171
328
274
547
58
3
2
2
0.8
0.7
1.7
1
0.35
1
7
7
2
0.3
2.6
1.3
3.4
1
2
1
1
0.3
0.73
0.18
I
I
i
!
!
I
1.72
APPENDIX VI
Statistical note on the calculation of the co-efficient of
variation for the various prevalences
i
1
1
The villages or town blocks were selected randomly
in the manner described in the test and the entire
population of the selected villages and the town
blocks were included in the survey. It may, there
fore, be noted that, the sampling plan was that of
cluster sampling, each cluster being a village ot a
town block and not a random sample of persons
constituting the rural population of the district.
The parameter to be estimated ;n the population
is the prevalence rate, which may be denoted by p.
If the number examined and
number of cases
in any village of the district be der-oted by x, and
y- respectively then
p ■■ Sy. /S Xj where the summation extends over
all the villages of the district.
Let * and 6 x* be the mean and the variance
of X.. y and 6 7* the mean and the variance of
and let 6 xy be the covariance between xi and
over all the villages in the district.
Yi
The estimate of the population parameter P is
A
given by P where
where y a
the number of radiologically active cases
diagnosed among x a persons x-rayed in cluster a,
the summation in each case running over all the n
clusters (n —66). For simplicity, the town blocks
have been treated as villages randomly selected,
as the result is unlikely to be affected appreciably
by this procedure. It is known that this estimate is
biased but the bias is small and can be ignored.
The variance of this estimate is given by the
formula
hi
H>
‘
!
i t
V(P)”Pn’(C„-2Ciy + Cn.)
where Cm is the square of the co-eflicient of variation of x in the population, i.c. Cxx =»
similarly Cyy
6x i
x
I
- ,
U‘ and
y’
x y
Since the variances and the means are not known,
they have to be estimated. An estimate of. the
variance of P is furnished by the formula.
*
A
Sy’; -2P Sx, Xi + P'Sx’i
V(P)“
n(n-l)x»
P-Sya/2*a
.5
i
_ . v;-
r
[I .
-■.
32
..
.
'■ V-
i'"'1 ■
•
I-
'
■
(r
”
I
RAJ NARA IN, A. GESER, M. V. JAMBUNATHAN AND M. SUBRAMANIAN
These procedures applied to the data of the survey
furnished the following results.
’ '
•
-
b’j ■ <:
Category
I
i
u
w
%
%
r
i
!
•si ’E 1.2
.1!
sc- i! 11
. s’.:r4
V
I
o
.-%
r''
i ' r
l.i-
Infection
<
38.3
1.84
4.8
1.9
0.15
8.1
0.4
0.05
11.5
X-ray cases
Bacillary cases ...
p.'i
! -V.0
4 V.I
cir
Of the
V*
me total
weal nunwer
number ot
of 392
392 X-ray cases among
il.ra X-rayed, 35 belong to th.
re town blocks wherein
1290 -were
examined.
; These
fi appear
-■■ These
figures
make it
^at the prevalence rate in the towns is higher than
r
r:.-.
V
in the villages, but this inference is not to be regarded
as valid since the total number of persons X-rayed
in the towns is 1290 and this figure is rather inadequate for drawing any general conclusions.
■ K®
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Wesley Press, Mysore
!
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TB-Health education/d/chadner/550
Information on
TUBERCULOSIS., for NGO staff.
Prepared by S.J. Chander, Community Health Cell, Bangalore
1.introduction
Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. This disease is
systemic often affecting lungs but it can affect otner organs of the body also.
♦
One-person dies of TB every minute.
♦
TB affects more the people in the most productive age group
♦
Four out of every thousand people suffer from TB of (all forms) in India (prevalence)
♦
One sputum positive, infectious TB patient who is not on treatment infects 10-12 people
a year.
2. What are the common signs and symptoms of TB?
♦
Cough with or without sputum (kafa) for more than three weeks
♦
Rise of temperature in the evening for more than two weeks with sweating particularly at
night
♦
Coughing of blood
♦
Chest pain
♦
Less of appetite, loss of weight, and increasing fatigue.
♦
Children usually do not bring out sputum, but experience loss of weight even though they
eat well.
People with these symptoms should be referred to a doctor for diagnosis. Some of these
symptoms are common in other diseases and affect investigation, the doctor would be able
decide.
3.Who does TB affect more
TB can affect any one from any socio economic and cultural background but it most often
affects people between the age groups of 20-45. TB affects more people who live in a
overcrowded place, those who are underrated and women who are married early and have
repeated pregnancies. TB can cause serious complications among children. TB occurs
more in men than women, however women have less access to care and some times there
is a greater tendency to hide TB among girls of marriageable age due to stigma attached to
the disease. Older people with TB are some times neglected by the family and their
treatment may be delayed or irregular. Untreated elderly persons with sputum positive TB
are source of infection to others especially to young children in the family. Persons with HIV
positive are more likely to develop TB, but it shold be remembered that with treatment it can
be completely cured. Certain occupations such as mining and silicosis put people at greater
risk of TB.
1
TB-Health education/d/chadner/550
4. Is TB a curable disease?
Yes, TB is curable if the treatment is taken regularly without discontinuing for the duration
specified by the physician. Usually the duration is between 6-9 months. The patient would
begin to feel better within a few months .of treatment and some of them may want to
discontinue the treatment. This can lead to drug resistance, which means the signs and
symptoms would reappear and the patients would not respond to drugs, which he/she was
taking earlier. The newer drugs are costlier and would not be affordable by the poor, and not
many drugs are available. Which means patient would go to a chronic state and continue to
spread the disease as they go through a gradual and painful pathway to death.
5. Is TB an infectious disease and how is it spread?
Yes TB is a communicable disease. It spreads from person to person. The TB germ is
carried in air when a patient suffering from TB coughs, sneezes or while talking. It does not
spread through handshake or by using the same glass, plate and clothes of the infected
person.
6.How can TB be prevented from spreading to others?
Early diagnosis is important of persons with the symptoms mentioned earlier should be
referred to a health institution.
❖
A person suffering from TB must cover his/her mouth while coughing with a handkerchief
or a piece of cloth.
♦
He/she must take the treatment prescribed by ’he doctor immediately after diagnosis and
should not discontinue the treatment for any reason till treatment completion. The short
course chemotherapy is given for 6 months. In center cases decided by the doctor, it
may extend longer.
♦
BCG vaccination is not useful in preventing adult pulmonary lung TB and is not used as
a public health measure to control transmission of TB. It may however prevent
complications of childhood TB and is therefore used in the universal immunization
programme.
4
Adequate nutrition helps developing resistance against the disease.
4
Proper disposal of sputum of the patient by use of bleaching powder or any other method
as advised by the doctor.
7. Who should be approached when signs and symptoms are noticed?
One can approach the corporation health center nearest to his/her residence. If that center is
not under RNTCP, then the patient would be referred to the nearest RNTCP center for
diagnosis and treatment if found positive. Bangalore City Corporation has 7 TB units where
there is a medical officer Tubercles control, senior treatment supervisor and a senior
laboratory supervisor. Under each TB unit there are 100-120 DOTS (Directly Observed
Treatment Short course) treatment centers. There are 40 microscopic centers located
around the DOTS centers to help with the diagnosis.
2
TB-Health educatioiVd/chadnei7550
8. How TB is diagnosed
Usually TB is diagnosed by doing three sputum examinations. The patient just gives a spot
sample to the Lab during his/her initial interaction. He is given a sputum container to take
home. Next day he collects the early morning sputum (second) and brings it to the lab where
he/she again gives the third and final on the spot sputum sample.
The patient might have TB even when all the samples are negative. If doctor still suspects
i B, he/she might tell the patient to take a chest X-ray or other investigations to confirm his
doubts.
9. What is the cost of treatment?
It is absolutely free from the government run institutions through the Revised National
Tuberculosis Control Progarmme (RNTCP) The person suffering from TB has the right to
receive free diagnosis and treatment for whatever duration specified by the physician.
10. Treatment
Depending on the severity of the disease the patient has to take 3 to 4 drugs for duration of
6 to 8 months. (Category II patients have to take an injection for initial 2 to 3 months). The
first two months of starting the treatment is termed Intensive Phase in which patients have to
take the drugs on alternate days in front of a service provider or non family member (3 days
in a week, Monday, Wednesday, and Friday in BMP RNTCP centers). In the subsequent 4 to
5 months the patient will be given one week’s js o take home and can take it there only,
But he should come to RNTCP center for eve- we on a fixed given day to collect the next
weeks dose.
i hree sputum samples will be taken at the end of two months and if found positive then
intensive phase is extended by one more month.
For further information
In case of money demanded by staff in any corporation run TB center or if you face any
problem, it should be reported to
Dr. Narayanamurthy, Joint Director TB,
Lady Wellington TB center
Beside Sampanigi Ramnagar Police Station,
Mission Road
Bangalore - 550 027, Telephone: 2249364
Or
Dr. Sarojamma
Project coordinator
RNTCP
Bangalore Mahanagara Palika
Phone: 2217159
3
"pis- s&
___ Indian
_________ Perspect^.^
____________ _________
An
fro
Stop TB-Fight poverty : An Indian Perspective
Introduction:
Stop TB, fight poverty is the theme for World TB day 2002. TB imposes a
considerable economic toll on patients and their families. Because more than
three-quarters of people with active TB are in the economically active age
group (15 to 54), the economic and social costs to them and society are
huge. They are income providers of the family. They are the parents of
young children who need their economic and emotional support in order to
thrive. They have elderly parents and relatives who depend on them. They
are the citizens whose productivity and talents are essential to their
countries' development. The result of TB is that access to opportunities and
choices- a key principle of human development -is blocked.
Ill health, malnutrition and high fertility are three main reasons why
households become or remain poor. They cause poverty through diminishing
productivity, reducing household income and increasing health expenditure.
A more complete view of poverty incudes deprivation not only from money
income, but also human development, financial and physical security,
expanding opportunities and especia ly participation in key aspects of social
life.
Poor families have no buffer against ‘oss of income-no savings and very
limited access to borrowing. The wav they cope with this economic adversity
may provide short-term benefits -that is cash-but in long term makes them
and their children destitute. The sale of assets such as land is a common
response to large medical expenses.
Income poverty leads to ill health and ill health contributes to income
poverty. A more complete view of poverty includes deprivations from not
only money income, but also human development, financial and physical
security. Poverty is also seen as a la-ck of basic human development
indicated by poor health, malnutrition and educational development. Gender
is in particular an important variable affecting both health and poverty.
TB and Poverty Links
The global experience with TB control has been able to define certain clear
cut linkages between TB and poverr.’:
o
TB is more prevalent among ow-income groups than among high-
o
o
o
o
o
income groups.
The cost of TB care, if borne by families alone can be unaffordable.
TB is a chronic ill ness and requires care over a relatively long periodduring which productivity is reduced, leading to interruption of
education and work.
Household income is severely reduced, family dysfunction increases,
particularly if mothers are ill and poverty increases.
Lower productivity and more poverty impede social and economic
development and increase inequalities in society.
Lower income people are higher risk-as TB spreads in crowded
places-households, school, workplace, marketplace and commuting
between them.
The real stakeholders in TB control
o
A. The people: - the low-income groups are the most vulnerable
people with limited resources to over come poverty-related TB risks
viz:
Barriers in access to primary health acre ans appropriate
o
diagnosis and treatment forTB
Emerging HIV/AIDS -TB co-infection
o
Lack of knowledge about the disease
o
Overcrowded living and transport conditions
o
Urban congestion/pollution
o
Poor nutrition
o
o
B.Society: - as represented by politicians and policymakers, with
power to reduce risks.
Poverty in India
Statistics as provided Government of India show that about 240 million
people live below the poverty line. (The poverty line is really the line of
destitution. At this line, people just enough money to provide them with
food, converting to 2,200 calories and with nothing else. No roof, no clothes,
no security, no minimal comforts, let alone schools, medicines and any fruits
of industrial revolution.)
Poverty alleviation remains pronounced challenge before the Government.
Though there ahs been a steady decline in poverty over the last two
decades, the total number of poor people has remained more or less
constant due to growth in population. The inter-regional disparities in
poverty levels are quite alarming. According to National Sample Survey
Organization (NSSO) the poverty situation ins several states in India is
appalling: Orissa 47.15%, Bihar 42.6 %, Madhya Pardesh 37.4%, Sikkim
36.55% and Tripura 34.44%. In terms of numbers Uttar Pardesh has 53
million, Bihar 43 million, Madhya Pardesh 30 million, Maharashtra 22 million,
West Bengal 21 million, Orissa 17 million and Andhra Pardesh 12 million
people below the poverty line. (Economic Survey 200-2001)
Poverty alleviation programmes are still ineffective because they have not
reached the poor.
Surveys by the NCAER (National Council of Applied Economic Research)
reveal that almost 59% of all households, accounting for 526 million people,
have an annual income of less than Rs. 12500. This means a monthly
household income of Rs.1000 or about Rs. 200 per head. This by any
yardstick is abysmally low income.
Households with incomes between Rs.12500 and Rs.40, 000 per year
account for 331 million people.
Only 4.1 percent, accounting for 37 million have an income of over Rs
40,000 a year.
(Life above poverty line: Rs 264 per month is all you need -Mohan
Guruswamy, Courtesy www.tehelka.com)
Tuberculosis in India: (1)
General facts
o
o
o
o
o
o
o
o
o
o
India carries a third of global TB burden. An estimated one in two of
the adult population are infected with TB bacterium.
The estimated incidence of all cases of TB is whopping 185 cases per
10,000 population.
The TB epidemic continues to grow, every year, two million people
develop active tuberculosis (more than any other country in the
world).
More people now die from tuberculosis than ever before -nearly
4,50000 every year. More than 1000 persons die of the disease each
day.
Only one in four people with tuberculosis is treated with DOTS. The
current rate of DOTS expansion is still far too slow to reach the global
targets by 2005. Failure to reach these targets will condemn millions
of people to disease and death.
Tuberculosis is inflicting enormous socio-economic costs. In India the
estimated economic cost of TB is US $ 3 billion per year.
India's DOTS programme is mainly financed through a US$ 142
million low interest loan from World Bank with increasing costs
already being met by national and state governments.
The quantum of human cost of TB in the country is 4.56 -6.28
Disability-Adjusted Life Years (DALYS). (The DALY combines a
measurement of premature mortality and morbidity and reflects the
'burden of disease' in a population)
The cost to the patient for successful treatment of TB averages USS
100 to US$150, more than half of the annual income of a daily wage
labourer. The estimated cost of MDR-TB to an Indian patient is
approximately Rs 6500 a month (US$135).
Research shows that 20% of rural patients and 40% of urban
patients borrow money to pay for expenses due to TB.
Tuberculosis in India: (2)
Tuberculosis and Women's Health
Jackie Jackson Joint UK Coordinator of Institute for Indian mother and Child
(UK), in an article entitled Multiple disadvantages: India, women's health
and tuberculosis, enlists the factors that make Indian women more
susceptible to TB. Poverty whom she describes as the main cause of TB,
affects 70% of women worldwide compared to 30% of men. Poverty
predisposes women to poor living conditions and nutrition and renders them
vulnerable to disease and infection. Research has shown that in their
reproductive years (15 -49 years), women are at greater risk of developing
the disease after infection than men at the same age. They may also be
exposed more to TB than their men folk due to their particular duties and
tasks. Besides these physical consideration the shame and stigma of disease
affects women more-to the point where women commonly keep their
diseased state a secret and unmarried girls fear that it will affect their
marriage chances.
As regards the pattern of early marriage in both the major communities of
the country, young brides are encouraged to begin a family early on. It
reduces women's financial independence-which she would be able to use to
good effect were she to develop the disease.
Clearly tackling TB in India raises many questions about the socio-economic
and political structures within society. Can TB be tackled in India without
tackling behaviors in the society, such as the low status of female, she asks7
Certainly a husband or a father with TB puts an enormous strain on the
family whenever it threatens his wage earning powers, however she warns
that social cost to the family is much higher when the disease affects
mother. Her need to attend treatment programmes takes her away from the
children, the cost of treatment cuts into family budget and a child is at a 310 times greater risk of dying within two years if he/she loses their mother
than those with both parents alive. She suggests that TB programmes in
future shall not use the medical mode! instead tackle all factors operating on
women with respect to disease side by side. The multiple disadvantages for
women in India that operate through gender and associated factors will only
be addressed by first understanding their role in both infection, disease and
treatment stages and then formulating successful strategies to reduce their
influence. Therefore solutions that apply to both women and men should be
implemented.
Tuberculosis in India: (3)
TB and HIV
The Prime Minister of India in his speech at a meeting on National Program
for prevention and Control of HIV/AIDS on December 12th 1998, said," the
health ministry puts the figure of HIV infections in the country as of now at
three million to four million. In some states, the infection rate is one percent
of the populations. Since we have these three to four million infections today
from a base of just a few infections in 1986, imagine what the scene will be
in another twelve years from the base now of three to four million. I shudder
even to contemplate the numbers."
As per National AIDS Control Organisation estimates the total number of HIV
infections in the country at the end of year 2000 stood at 3.86 million.
A document on Revised National TB Control Program (RNTCP) published on
the official web site of the National TB Control Program sums up the
situation rather crudely: "while the size of the HIV epidemic in India is
presently not known, it is clear that HIV will worsen the TB epidemic". The
document makes no further reference to the problem
The Draft National AIDS Control Policy has only to say this much for the dual
HIV-TB epidemic "with about 14 million TB cases existing in India, HIV/AIDS
also poses a twin challenge of HIV/TB co-infection. Nearly 60% of the AIDS
cases are reported to be opportunistic TB infection cases. Treatment of TB
among the HIV-infected persons is a new challenge to the National TB
Control Programme, which has now adopted DOTS strategy for control of TB
infection. At the same time looking for HIV among TB infected persons will
also cause the problem of scaring away of a large number of TB infected
cases in the country from seeking treatment under the DOTS strategy. There
is no risk of any TB patient getting infected with HIV unless he or she
practices high risk behavior or gets infected from transfusion of HIV-infected
blood." The draft policy document makes no further reference to meeting of
two programs (National AIDS Control Program and Revised National TB
Control Program) to meet the twin challenge.
There is no reliable data available to determine how the HIV prevalence has
affected the TB epidemic in India. There are only apprehensions and
estimates. Even the NACO or RNTCP have not come out with any studies to
document the linkage. The extent of collaboration (or lack of it) between the
two programmes is reflected in the documents of two programmes available
on their web sites.
On surface they appear to be two divergent lines, emanating from a
common point but distancing from each other as they travel to states,
districts and community health centers.
Why tackle Tuberculosis ?
Potential economic benefits for India
Effective TB control can help break the cycle of poverty and disease. It cures
people and returns them to active, productive life, which in turn benefits
their children and contributes to the economic and social development of
their country. As more people are cured, the cycle of transmission is broken
and fewer people are infected. Ultimately this leads to fewer cases of active
TB.
TB control is rated by the World Bank as one of the most cost-effective
health intervention because of its potential to avert a large percentage of the
global disease, its low cost for each year of healthy life saved, the low cost
per capita, and the potential impact on socially excluded and poor people.
Ravindra Dholakia, Professor of Economics from Indian Institute of
Management, Ahmedabad in an artice. Potential Benefits of DOTS Strategy
against TB in India, divides these into two broad categories:
o
o
Pure social welfare increasing effects of DOTS, which do not generate
direct tangible economic benefits. These include reduced suffering of
TB patients, quicker and surer cure from the disease, lives saved and
disability reduced for dependents and non-workers suffering from TB,
poverty alleviation etc.
Direct tangible economic benefits of DOTS which include: reduction in
prevalence of TB due to DOTS which improves the efficiency and
productivity of workers, TB deaths averted among current and future
workers and release of hospital beds currently occupied by TB
patients.
He postulates that that even if the Indian government spends about US
$0.74 billion per year to ensure the success of DOTS strategy the
investment would fetch a return of 16% p.a. in real terms.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US 5 200 million per
year, compared to the tangible economic benefits of at least US S 750 per
year, the article notes.
Conclusion
India carries a third of global TB burden. Every year two million people
develop active TB. TB accounts for nearly 4,50000 deaths every year and
more than 1000 persons die of the disease every day. TB is inflicting
enormous economic and social costs on the country. The estimated
economic cost of TB is US $ 3 bullion per year.
In India 240 million people live below the poverty line. Poverty alleviation
remains a pronounced challenge before the government. Surveys reveal that
almost 59% of households accounting for 526 million people have an annual
abysmally low income of less than
12500 (US $260)
Income poverty leads to ill health and ill health contributes to income
poverty. The cost to the Indian patient for successful treatment of TB
averages US $ 100 to US $150. Research shows that 20% of rural and 40%
urban patients borrow money to pay for expenses due to TB.
Indian women have to pay much higher social and personal costs if suffering
from TB. Besides poverty the shame and stigma associated with the disease,
early marriage and social pressures to start a family early on and limited
access to treatment facilities makes them more vulnerable to disease more
so during the reproductive age group of 15 - 45 years.
The nation has not risen adequateiv to meet the twin challenge of TB and
HIV/AIDS. The number of HIV positive persons has risen above 3.86 million.
Nearly 60% of AIDS cases are reported to be opportunistic TB infection. This
is going to add to the national load of 14 million TB cases.
Effective TB control can help break :ha cycle of poverty and disease. It cures
I
people and returns them to active, productive life, which in turn benefits
their children and contributes to the economic and social development of
their country. A cost-effective health intervention exists for TB control and
treatment: DOTS. Increasing public awareness about proven, effective
interventions like DOTS and providing greater access and benefit to
treatment for those with TB, will help put billions back into the economy.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US 5 200 million per
year, compared to the tangible economic benefits of at least US S 750 per
year. The expenditure on health has declined in last decade and stood at
1.11% of GDP in 1998-99. Indian government will have to increase its
expenditure on TB control.
The three aims associated with World TB Day 2002 theme viz DOTS
expansion, efforts to raise awareness among political leaders, decision
makers and opinion leaders and mobilization of TB sufferers for demanding
greater access to treatment are more relevant to India than any other
country in the world.
Suggested further reading
Ministerial Conference : Tubeculosis and Sustamaole Deve oprWeb Site : http://w3.whosea.org/cds/pdf/16march00.pdf
Potential Economic Benefitys of the DCTS Strategy in Inc ?
Web Site: http://www.who.int/gtb/publications/pebdots/
: •uberculosis and Poverty: A PPT Presentation
WebSite : http://www.wpro.who.int/themes_focuses/themel/focus3/
POWERPOINTSTB/IMPO-TB-Poverty-Aviva%20Ron.ppt
•uberculosis in India : A Critical Ana .s s
Web Site :
http://apha.confex.com/apha/129am, techprogram/paper_27954.htm
Jfe above Poverty Line : Rupees 6-2 zer month is ail that you
Web Site : http://www.tehelka.com/cnannels/currentaffairs/2001/oct/30/
cal03001libl.htm
Multiole disadvantage :■ India, Wome" s Health and Tubemu
Web Site: http://www.fons.org/tb3.ntmi
Article Compiled by
Dr. Dinesh Kumar
Director Health and Development Imzative India
email: dinesh_kumar@vsnl.com ,
dinesh@healthinitiative.org
Dr. Jatinder Singh
Executive Editor, Health and Development Initiative India
mailto:dinesh@healthinitiative.org,
jatinder@healthinitiative.org
Article Designed by
VS Christopher
Webmaster Health and Development Initiative India
email : job340@hotmail.com ,
webmaster@healthinitiative.org
All Rights Reserved Hea
and Development Initiative India
56 Pink Plaza, Hall Bazar, Amrtsar, Punjab, INDIA, Postci Code 143001
Phone : +91-183-554467, Cellular (Director -91-98140-50065 , Executive Editor -91-98141-21605
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healthlink
fof
WORLDWIDE
Strengthening
TB treatment
How to implement DOTS
This guide is designed to give a basic overview of the
DOTS strategy, including the people who are involved
and the resources that are needed to set up a successful
programme. The Healthlink Worldwide website
(www.healthlink.org.uk) has a list of references where
you can find more information.
Why is DOTS
needed?
Although health workers in many
areas are working hard to diagnose
and treat tuberculosis (TB), the
number of people with TB is
increasing rapidly. Some of the
increase is due to the increasing HIV
epidemic, but the number of TB cases
is also increasing because of failures
in existing treatment strategies for
TB. People may be unable to access
diagnosis and treatment for many
different reasons (see below). Effective
treatment of TB is important for
individuals, their families and
communities. People with active TB
can spread TB to other members of
their families or communities. They
become sick, are unable to work or
fulfil family commitments, and will
eventually die if their TB is left
untreated. People who stop TB
treatment before completing the
course can continue to spread TB and
may develop drug resistance.
What is
DOTS?
DOTS (Directly Observed Treat
ment, Short course) is a new treat
ment strategy for TB that aims to
address these challenges. This
strategy is usually implemented
STRENGTHENING TB TREATMENT
through local or national pro
grammes. DOTS is based on the direct
observation of people taking their TB
drugs. However, the DOTS strategy
includes much more than direct
observation of treatment, as many
factors are needed to ensure adequate
and accessible TB care. These include:
• political commitment ensuring
adequate funding
• education for people with TB and
their communities
• reliable case detection using sputum
smear microscopy to identify people
with active TB
• standardised short course treatment
for all people with smear positive
TB
• direct observation and support for
people taking drug treatment
• a regular and reliable supply of free
drugs
• accurate record keeping to identify
people who do not complete
treatment
• effective monitoring both of people
who are receiving treatment and of
the performance of the DOTS
programme as a whole.
DOTS can be used to treat new TB
cases, people who have relapsed,
people who have previously had
treatment, but not finished the course,
and people who need retreatment.
What makes DOTS
different?
Many people cannot access TB
treatment or do not complete their
TB treatment because of:
• the need to take time off work or
away from family
• the cost of travel to the health
facility or of drug treatment
• a lack of available drugs
• the belief that because they feel
better they are cured and can
stop treatment
• having to take lots of different
pills for a long time
• a lack of user-friendly health
services (e.g. unfriendly staff or
unfriendly opening times)
• needing permission to travel or
to see a health worker (e.g. in
some cultures women may need
their husband’s or father’s
permission to travel or may need
to be accompanied by a family
member if they visit a health
worker).
Accessibility
The DOTS strategy aims to
improve access to TB treatment by:
• making treatment and diagnosis
free
• using standardised courses of
treatment
1
■*-<
§
£
so
£
• making treatment community
based, so people do not need to
take time off work or from
domestic responsibilities to go for
treatment
• providing community education,
so that people can recognise the
symptoms of TB and go to a
health worker for diagnosis and
treatment.
People are more likely to seek
diagnosis and treatment if treatment
centres are close to where they live.
People are also more likely to
continue with treatment if it does
not interfere with their work or
family commitments. DOTS is most
likely to be effective in a commun
ity setting. By training community
health workers or community
volunteers as treatment supporters
people can have their treatment in a
way that does not disrupt their
everyday lives.
Support
The person observing treatment is
called the treatment supporter.
Observing treatment is not the only
role of a treatment supporter, they
can also provide the support,
encouragement and counselling
necessary to help people complete
their course of treatment.
Currently, research confirms that
the DOTS strategy works. However,
it is unclear whether it is necessary
to observe every dose of treatment
or whether less frequent observation
(e.g. weekly) is equally effective.
Either way, the treatment supporter
needs to be someone who is
accessible, reliable and concerned
for the health of the person with
TB. The treatment supporter
provides encouragement, checks
that the correct number of tablets
has been taken, and follows up
people who miss treatment.
Monitoring
The recording and follow-up
systems that are part of the DOTS
strategy mean that both people
taking treatment and the DOTS
programme as a whole can be
monitored effectively. People who
stop treatment can be quickly
identified and health workers or
2
treatment supporters can work
with them to understand their
reasons for stopping treatment
and try to find a solution. At
district level, the TB officer can
use the records that are part of
the DOTS programme to assess
the programme and identify any
problems, which can then be
tackled effectively.
Making a difference
DOTS is not the final solution to
the TB crisis - diagnosis and
treatment still need to be made
easier for health workers and
people with TB. However, with the
current resources available, DOTS
is probably the most effective way
of treating TB and ensuring people
complete treatment. In resource
poor countries, DOTS can improve
the life of individuals with TB and
the whole community.
How a DOTS
programme
works
Community
education
What is it? The first step in
encouraging people to seek
treatment for TB is educating them
about TB, its symptoms and its
treatment, so people with symptoms
will go to a health facility to seek
diagnosis and treatment.
Community education plays an
important role in this process.
Helping people to understand the
importance of completing treatment
plays an important role in
encouraging them to continue
taking their TB drugs for the
complete six to eight month course.
Who does it? Health workers and
community health workers.
Case
detection
What is it? Screening people who
come to health facilities who have
had a cough for more than three
weeks is seen by many health
workers as the best way to identify
people who have pulmonary TB.
When the health worker suspects a
person has TB and has discussed this
with them, the person with
suspected TB needs to provide three
sputum samples.
§o
§
►
s
-ft
Donating sputum for a test
The samples are collected over a
24 hour period: one when the
person visits the health facility, one
early next morning, and the next
when the person with suspected TB
returns to the health centre the
following day. Samples are then
sent to the diagnostic centre (or the
person can travel to the diagnostic
centre to provide samples).
Who does it? Health worker at
DOTS treatment centre or
diagnostic centre.
Diagnosis of
sputum smear
positive TB
What is it? Diagnosis of people
with active TB is based on sputum
smear microscopy (see page 6).
STRENGTHENING TB TREATMENT
People who interrupt treatment
should be encouraged to re-start
treatment, but the management of
such cases depends on:
• type of person, e.g. first TB
treatment, multi-drug resistant
TB, repeat treatment
• length of time the person took
treatment
• length of interruption of treatment
• whether they are sputum smear
negative or positive when
returning to treatment.
People who interrupt treatment
should be referred to a trained TB
nurse or doctor, who can assess
them and prescribe appropriate
treatment.
Who does it? Treatment supporter,
late patient tracers (who may be
health workers at treatment centres
or community health workers),
health worker at a treatment centre.
Who does it? A treatment
supporter — usually a community
health worker or a community
volunteer, but in some cases a
health centre health worker or a
work place supervisor, if this is
more acceptable and convenient.
The laboratory staff complete a
laboratory register and return the
results of the sputum smears to the
treatment centre.
Who does it? Laboratory technician.
Treatment
Support for people
What is it? Treatment under the
DOTS strategy consists of a
with TB
combination of drugs taken over a
What is it? Treatment support is
six to eight month period. In the first
one of the most important features
two months (the initial phase), four
of the DOTS strategy. TB treatment
drugs are taken together, while for
continues for eight months and
the following four to six months (the
people with TB often need
continuation phase) fewer drugs are
encouragement to complete their
taken. If the treatment is carefully
course of treatment. This is one of
followed, a person with infectious
the most important aspects of the
pulmonary TB will stop being
DOTS strategy.
infectious within two to six weeks.
Who does it? Treatment supporter.
Doctors at the diagnostic centre
classify the person with TB and
Identifying people
prescribe treatment according to
who stop treatment
national programme guidelines.
What is it? It is important to
Assessing the
Counselling for people with TB
identify people who stop treatment
can focus on:
DOTS programme
before their TB is cured. People
• treatment and its possible side
What is it? Monitoring and
who stop treatment can continue to
effects
evaluation of the performance of
spread TB to others. Interrupting or
• the importance of continuing
the DOTS programme using the
stopping treatment can also lead to
treatment until complete
standard supervision and reporting
drug resistance.
• how to tell family members and
forms (see page 7). This allows
Treatment cards can help identify
encourage them to be screened for
early identification of problems and
people who stop treatment quickly.
TB.
improvement of the programme.
These people can then be followed
In some countries with a high burden
Who does it? District TB officer.
up and encouraged to continue with
of HIV, many people with TB will
their treatment.
also be HIV-positive. People with TB
can be counselled about this
possibility, offered an HIV test,
TB01
advised about the use of condoms
•reatnient CARD
3.7.2000 _—.—■
Date
Treatment
Started:.
------- TUBERCULOSIS ti
District TB No--------------- -----and advised to consult a health
■--------- Diagnostic Center.
F8lh9,syH^N8m..J!aS^^
------------------------------ Treatment Center
worker if they become ill with
Classification
I 1
Disease
Jamil___________ _—
patient s Name.
Extra-pulmonarv Q I I
rear dubious Q
scar seen Q
chest or other illnesses.
Address Cm full): ,
Pulmonary 0
BCG.
no
scar
Q
; Ol Contact Person^.
Site:
_
— I
Name & Address
name)
Who does it? Doctor at
23
Sex; M0 F O
Treatment Supporter __
Age:
23 _
Type of Patient
1
{7]
Relapse L-l
I
i. INITIAL iN-i-biiNSlVE PHASE
of tab«d dosage
diagnostic centre.
CAT 3
daily number or
Other
I—I
I
and
TickapP«oP'1”*hOXi
‘,”indicate
'“
Direct
observation
What is it? Direct observation
of tablet taking during the
intensive phase (at least in
people with smear positive TB)
is currently recommended in the
DOTS strategy. However, on
going encouragement from the
treatment supporter is the most
important part, helping to ensure
that people complete treatment
and are cured.
STRENGTHENING TB TREATMENT
CAT1
New case Q
HR
Z
Tis)
H: isoniazid
r: nlampicin
use following codes
ot dnig intake in
E
z
s
lonth
— I
1
52 ~l
--------
I
Drugs not taken
appropnate bo*
Drugs self administered
10
Oa^
0
Specify:
------------- Other
Weight I lnveshgalion
1 (kg) I (if advised)
pyrazinamide
E; etnambutol
ler direct observation
1 J I Oruas administered undt
x.
Smea, BesujT
Month
1
HR
HR
New
. - [J
ri __
I Transfer
Treatment alter default
New Case
(smear-neg,
axtra-pulm)
CAT 2
Re-treatment Q
12
IS
18
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Resources needed for a
DOTS programme
f I ’he decision to introduce DOTS
should be made jointly by the
national TB programme and the
district health or medical officer.
The areas most suitable for first
introducing DOTS are districts that
are accessible, have a high TB
burden and are already using
standard short course treatment.
A successful DOTS programme
needs: physical resources (e.g. a
laboratory, a treatment centre, a
reliable drugs supply) and human
resources (well-trained laboratory
staff and health workers).
Physical
resources
DOTS diagnostic centre
A diagnostic centre is the place
where people with longstanding
cough and other respiratory
symptoms are screened for TB and
where people with TB can start
their treatment. The centre should
be easily accessible, well-equipped
with a reliable supply of drugs and
materials (see below), and have
well-motivated and well-trained
staff (see page 5), so the DOTS
programme is likely to be successful
and can be a model for future
programmes.
What does a
diagnostic centre do?
• Screens people with TB
symptoms.
• Carries out sputum smear
microscopy.
• Diagnoses TB.
• Registers people with
active TB for treatment.
• Starts TB treatment.
• Works with person with TB
to identify DOTS supervisor.
• Traces people who stop
treatment.
Treatment centres
Many people will live a long way
from the diagnostic centre, so
treatment centres should be set up.
Treatment centres do not diagnose
people or start treatment, but are
places people can collect their
month’s supply of drugs and have a
monthly review meeting to check
their progress. Staff at treatment
centres also supervise treatment
supporters, refer people with
respiratory symptoms or side effects
to diagnostic centres and trace
people who stop taking treatment.
What does a treatment
centre do?
• Identifies and refers people
with suspected TB to
diagnostic centre.
Provides or arranges
community-based treatment
observation.
• Supplies TB drugs.
• Maintains case records.
• Traces people who stop
treatment.
• Refers people with major side
effects to diagnostic centre.
• Maintains stock books for
drugs and materials.
• Supervises treatment
supporters.
Laboratory and
laboratory supplies
Reliable diagnosis of TB is
important to identify everyone who
has active TB and who needs treat
ment. The best way to do this is
using sputum smear microscopy,
which involves looking under a
microscope to see if there are TB
bacilli in the sputum sample of a
person with suspected TB. Resources
needed for good sputum smear
microscopy include well-trained
staff (see page 7) and wellmaintained laboratory equipment.
Equipment needed includes
microscopes, refrigerators, clean
glass slides, sputum specimen pots,
fresh reagents, and a supply of
clean water. TB is highly infectious,
so laboratories should have
facilities to minimise the chances of
workers becoming infected (e.g. by
using fume cupboards, gloves,
masks). Laboratory managers
should ensure that there are enough
reagents, slides and containers for
the following three-month period
using the same criteria as detailed
below for maintaining a reliable
drug supply. A quality control
system should also be in place.
Arrangements also need to be
made for sputum specimen pots to
be available at all necessary health
facilities and for the safe delivery of
sputum specimens to the laboratory
and reliable delivery of results back
to the person prescribing treatment.
Laboratory managers should also
make sure there are guidelines for
safe disposal of slides, used reagents
etc and that staff follow these
guidelines. It is also important to
ensure equipment is used correctly,
taken care of (e.g. switching
microscope off at the end of the day
and covering it with a dust cover)
and maintained regularly. Routine
care and maintenance can improve
the efficiency of equipment and
keep it working longer. Managers
can set up a system for reporting
equipment defects and encourage
staff to report problems quickly.
Uninterrupted supply
of drugs
The most commonly used TB drugs
are isoniazid, rifampicin,
ethambutol, pyrazinamide,
streptomycin (given by intramuscul
ar injection) and thiacetazone.
Thiacetazone is not recommended
in areas where HIV infection is
common because of side effects.
Some of these drugs are available
in combination preparations, for
example isoniazid and rifampicin.
Courses of treatment that contain
both isoniazid and rifampicin are
the most effective. Programmes
should consult national guidelines
STRENGTHENING TB TREATMENT
*
for treatment regimes.
Depending on the combination of
drugs used, short course treatment
usually lasts six or eight months.
The treatment comprises:
• An initial intensive phase in
which a combination of four drugs
is taken daily for two months. This
is to eliminate as many TB bacilli
as possible and prevent the develop
ment of drug resistance. Most
people will be smear negative (and
non-infectious) after two months of
treatment.
• A continuation phase in which
fewer (usually two) drugs are taken.
This phase continues for four to six
months to ensure the person is
completely cured and does not
relapse.
People with TB often stop taking
medicines because the drugs are not
available. To prevent this, TB drugs
should be free and an uninterrupted
supply of drugs must be
maintained. If people have to pay
for drugs they may stop treatment
as soon as they start to feel better in
order to save money.
Treatment centres should hold
enough drugs to treat all patients
for four months and a ‘buffer’ stock
of drugs, so that treatment can be
continued if supplies are delayed.
As a guide to ensuring sufficient
stocks of TB drugs, the person who
manages the drug supply should
estimate the number of people who
will be diagnosed with TB at the
treatment centre over the next four
months. Then they can calculate the
quantity of drugs needed to provide
all these people with a full course of
treatment, double the amount and
subtract the existing stock. This
gives the quantity of drugs needed
for four months and an adequate
back-up stock in case of delays or
interruptions in supply. This should
be done for each of the drugs in the
treatment regimes.
If TB drugs are out-of-stock,
people should not be started on
treatment using only some of the
drugs in a recommended regimen,
as this may lead to drug resistance.
It is important to get all the drugs
required, before starting treatment.
STRENGTHENING TB TREATMENT
I
A
A health worker gives TB drugs to a patient
Human
resources
Commitment at all levels of
health service
Commitment to DOTS is necessary
at all levels to ensure that essential
resources, such as staff, drugs and
laboratory supplies, are allocated.
DOTS can involve public and
private health services, non-govern
mental organisations and mission
health services, private companies
who provide health care for their
workers, private practitioners, and
the local community.
The decision to introduce DOTS
is usually made jointly by the
national programme and the district
TB or medical officer. DOTS can
be phased in giving priority to
districts that are accessible, have a
high number of cases of TB, are
already using standard short course
treatment and where there is a good
chance of success.
Community involvement
Community co-operation is
essential for a successful DOTS
programme. DOTS committees can
serve as a link between health
services and local communities.
DOTS committees should include
motivated people including people
with TB, health service managers,
civic leaders, representatives of
local organisations and local
communities. Before DOTS is
introduced, the district health
officer can call a meeting with
community members and leaders to
introduce the DOTS programme
and suggest forming a DOTS
committee. The local community
should be involved in the decision
about who sits on the committee to
ensure that the DOTS programme
receives local support.
It is important that the DOTS
committee has a clear idea of the
activities and involvement required
from it.
DOTS committees can:
• increase public awareness about
TB in the community through
advocacy and education
• support people in the community
with TB by providing DOTS
supervisors and people to follow
up those who stop treatment
• identify local problems in DOTS
implementation and propose
solutions at community level
• encourage co-operation between
health institutions, health
workers and NGOs
• protect health workers at
treatment centres from undue
political pressures.
The best size for the committee is
about 10-15 people, who will need
to meet at least every four months
in the first year of the DOTS
programme and as necessary after
that. DOTS committees should
ideally include people from each of
the groups discussed below.
District TB officers
District TB officers have an impor
tant role to play in a successful
DOTS programme. It is district TB
officers who introduce the idea of
DOTS to the district and local
communities and suggest the idea
for a DOTS committee. District TB
officers are usually members of the
DOTS committee.
In addition, district TB officers
need to assess the training needs of
5
§
so
all those involved in the DOTS
programme and plan (and some
times carry out) training.
It is also district TB officers that
carry out supervisory visits to check
that guidelines are being followed
and that staff are carrying out
monitoring and recording proced
ures according to guidelines. Super
visory visits should cover feedback,
education, guidance, co-ordination,
problem solving and motivation.
Health workers and staff are
more likely to have questions and
encounter problems in the early
stages, so more frequent supervision
is needed during the first few
months after introducing DOTS.
After that, if there are no problems,
the frequency of supervisory visits
can be decreased.
A suggested timetable for
supervision visits is every month for
the first four months, every other
month for the next four months and
every quarter after that.
District TB officers will check TB
registers at treatment centres and
also compile and analyse case
finding reports, smear conversion
reports and treatment outcome
reports (see page 8).
Laboratory technicians
The role of laboratory technicians
is to correctly identify cases of
active TB from sputum samples,
using sputum smear microscopy.
Laboratory technicians examine
three samples from each person
with suspected TB. If TB germs can
be observed in a sample then the
sample is sputum smear positive. If
two of the three samples the person
supplies are sputum smear positive
then they are diagnosed as having
active TB. Poorly trained staff or
inadequate equipment can lead to
misdiagnosis meaning that people
with active TB do not receive
treatment (and in some cases that
people who do not have active TB
are treated). Laboratory technicians
also need to keep a register of
samples received and results and to
return a diagnosis report to the
treatment centre.
Health workers
Health workers (i.e. qualified
nurses and doctors at the diagnostic
centre) need training in collecting
sputum samples and giving people
results of their sputum smear test.
Doctors need to be able to classify
people with TB correctly (e.g. as
new case, retreatment, treatment
lapsed) and prescribe drugs
according to national guidelines.
Health workers at treatment
centres are involved in keeping
treatment cards for individuals,
detecting and referring people who
may have TB, reviewing individ
uals on a monthly basis and
identifying and tracing people who
stop treatment before it is complete.
At the treatment centre health
workers need to keep the TB
register up-to-date and to ensure
that the contents of the laboratory
reports are transferred to the TB
register. Health workers may also
provide regular and routine super
vision of treatment supporters, e.g.
weekly visits to the treatment
centre, regular meetings of all
treatment supporters. During these
visits the health workers check the
treatment support card, ensuring
that all treatments have been
observed, and update the treatment
card held at the treatment centre.
Community health workers
Community health workers, who
may include traditional healers, are
often involved in educating
communities and people with TB
about diagnosis and treatment.
They can help to identify people
with possible TB at community
level and encourage them to go for
diagnosis and treatment, Community health workers can also act as
DOTS treatment supporters.
Late patient tracers
A variety of different health
workers can be trained as late
patient tracers. Their job is to
identify people who have missed
treatment (using treatment records)
and follow these people up. Late
patient tracers need training to
ensure that they follow up people in
a sensitive way and can help them
identify why they have stopped
treatment (although this may also
involve other health workers) and
encourage them to resume treatment.
Community volunteers
Community volunteers can be
trained as treatment supporters.
Community volunteers need to be
reliable and accessible to the person
taking treatment. All treatment
supporters need to understand and
carry out the seven essential
components of treatment support.
1. Collect tablets on a monthly
basis and store drugs correctly.
2. Direct observation of treatment
(correct drugs and correct dosage).
3. Daily recording of treatment on
treatment support card.
4. Understand the need for the
person being treated to visit the
treatment centre at the end of the
intensive phase.
5. How to identify and refer side
effects.
6. Discussing difficulties of treat
ment and how to overcome them.
7. Helping to trace and retrieve
people who are late for or who
stop treatment.
Supervision checklist for a district TB officer
• Make sure all staff are following national policies and guidelines and are
maintaining records and reports correctly.
• Check that health workers strictly follow the First expired. First Out
approach to drug dispensing to avoid expiry of shorter shelf-life drugs.
• Ensure that regular reporting on drug use and stocks is carried out.
• Check that the laboratory is working properly and that the laboratory
technician is keeping all the slides for quality assurance.
® Check supplies, materials, drugs and equipment are stored correctly.
® Check safe disposal practices for sputum specimens, used reagents, etc.
• Check that centres are ordering sufficient quantities of drugs, reagents,
equipment and forms.
STRENGTHENING TB TREATMENT
Training people
involved in DOTS
OTS programmes should not
be introduced until everyone
involved has received appropriate
training.
DOTS committee members
Training includes an introduction to
DOTS and reasons for implement
ing the strategy. Training takes
about one day at district level.
Laboratory technicians
Training in how to carry out
sputum smear microscopy and to
diagnose smears correctly. Training
takes about 10 days at regional or
district level.
Health workers at
diagnostic centres
Training in treatment regimes and
how to classify people with TB, and
managing people who do not
complete treatment or treating
difficult cases of TB (e.g. people
remaining positive after extended
intensive phase, or those with extrapulmonary TB). Training takes
about six days at district level.
Health workers at
treatment centres
Training in current thinking on TB
and its treatment and overview of
the DOTS strategy, community
education, how to take sputum
samples, how to observe treatment,
and how to keep records. Training
courses are about three to six days
long at district level.
Late patient tracers
Training will probably take about
one day. (This may be part of the
training for health workers at
treatment centres or community
level if they are responsible for
tracing people who stop treatment.)
Community health workers
Training in community education
and how to observe treatment takes
about one day at district level.
STRENGTHENING TB TREATMENT
DOTS treatment supporters
All treatment supporters should be
trained in how to observe
treatment, how to fill in treatment
support cards and how to support
and encourage the person taking
treatment. This training can be
done at the DOTS treatment centre.
After these initial training courses,
people will continue to benefit from
‘refresher’ training courses,
continuous on-the-job training and
support from managers and
colleagues.
Monitoring and evaluating
a DOTS programme
r I ’he two most important aspects
_L of monitoring are reports on
case finding and outcome of
treatment and evaluation. Regular
monitoring and evaluation are
essential to ensure that policies are
being followed, to provide on-thejob training and to help health
workers to solve problems at a
local level. Identifying and solving
problems locally can help health
workers to identify gaps in services
and encourage them to try to adapt
DOTS to suit people with TB (e.g.
by travelling to a person’s home or
choosing someone in their local
community to observe them taking
treatment, instead of the person
with TB having to travel to the
health centre).
Treatment
support cards
What are they? Cards filled in by
the treatment supporter as they
observe each dose of treatment.
What are they for? Provide a
daily record of direct observation.
Health workers can check the treat
ment support cards on supervisory
visits to the treatment supporter.
Who fills them in? Treatment
supporter.
Treatment
cards
What are they? Each individual
has a treatment card kept at the
treatment centre, which health
workers update at supervisory visits
to treatment supporters or monthly
review meetings with the person
with TB.
What are they for? A central
record of treatment observation,
drug supply and progress at month
ly review meetings. This process of
record-keeping ensures that people
who stop treatment can be quickly
identified and followed up.
Who fills them in? Health worker
at treatment centre.
TB
register
What is it? A record of everyone in
a district who is receiving treatment
for TB.
What is it for? To ensure that all
those with positive sputum smear
results (i.e. those diagnosed with
active TB) are receiving treatment.
Who fills it in? District TB officer.
Laboratory
register
What is it? A record of the results
of all the TB sputum smears carried
from the laboratory (the diagnostic
centre).
What is it for? For cross-checking
with TB register to ensure all those
with positive sputum smears are
receiving treatment.
Who fills it in? Laboratory
technicians.
Case finding
reports
What are they? Quarterly reports
on new cases and relapses of TB
diagnosed and registered during a
three-month period.
What are they for? Case finding
reports can show progress towards
improved detection and
identification of people with TB.
Who fills them in? A member of
staff at the diagnostic centre
(probably the district TB officer) is
responsible for filling in these
reports. The case finding report
needs to be checked against the TB
register and the laboratory register
to ensure it includes every person
on the TB register.
Smear
conversion reports
What are they? Every person
being treated for TB should have a
smear examination at two months
(new treatments) or at three months
(retreatments). The two-month
smear conversion report is for
people who were smear positive at
the beginning of treatment. Follow
up sputum examinations are
essential to reduce the risk of
treatment failure or relapse and to
be able to evaluate cure rate.
What are they for? Smear
conversion reports are a measure of
response to treatment, and also give
an early indication of the effective
ness of the treatment centre in pro
viding DOTS. A change in smear
conversion rates can help identify
problems quickly (e.g. new staff
who may not be properly trained)
and solve them quickly (e.g. by
8
Information recorded by health workers is a vital part of effective TB treatment
providing appropriate training).
Ideally the smear conversion
report should show that:
• the number of people with smear
positive TB in the smear
conversion report is the same as
the number in the previous case
finding report
• every person treated for TB has a
smear examination result at the
end of the intensive treatment
phase
• the smear conversion rate is
between 80 and 90%.
Who prepares them? Health
workers at the TB treatment centre
prepare the information for the
report. The district health officer
checks and analyses the results.
Treatment
outcome reports
What are they? Treatment
outcome reports include
information about how many of
people with pulmonary TB, who
were registered 12-15 months
earlier, have successfully completed
treatment and how many have not.
Successful treatments include cured
and treatment completed, while
unsuccessful treatments include
treatment failures, people who did
not complete the full course of
treatment, those who die, and
people who transfer out of the
programme.
What are they for? These reports
can help to identify whether
treatment arrangements are
working effectively or not.
Treatment outcome reports can be
used to assess whether programmes
are providing high level care or
whether quality of care needs to be
improved.
Who fills them in? District TB
officers, using information available
from previous reports, diagnostic
and treatment centre registers.
Acknowledgements
Many thanks to those who contributed to
this publication, especially Dr John Walley
and Dr Sarah Escott at Nuffield Institute
of Health, UK, Dr Amir Khan, Association
of Social Development, Pakistan and
Manjit Kaur, ECHO International Health
Services, UK.
Published in 2001 by
healthlink
WORLDWIDE
Healthlink Worldwide
Cityside
40 Adler Street
London El 1EE, UK
Tel: +44 (0)20 7539 1570
Fax: +44 (0)20 7539 1580
E-mail: publications@healthlink.org.uk
http://www.healthlink.org.uk
STRENGTHENING TB TREATMENT
c
I
£■
2
l-S- V-
Page 1 of 2
Main identity
rrom:
To:
"Paul Divakar" <ixjivakar@satyam.net.in>
<paivaKar@sstyarn. net. in>
Sent:
Tuesday, December 30. 2003 7:07 PM
Rally Flashes.
Subject:
b
jjjr
NATIONAL CAMPAIGN ON DALIT HUMAN RIGHTS
ATTN: BUREAU CHIEFS PRESS RELEASE DECEMBER 21,2003
DESPITE ODDS. DAT ITS SCRIPT TAT E OF VICTORY TN BIHAR
1
The Buddha P.oute of the Dalit Swadhikar R.ally came across examples of Dalits
lighting despite the odds slacked againsl lhemm.Bihar on December 20,
2003. The rallyisis started their day with a visit to Jhanar. wnere it was”
welcomed to the resounding beat of Dalit drums. The next stop was Balihadi.
home to 1200 Dalits. Till now, though, only four boys have passed their
maTriciilation exams, The tale of the school here buoyed the raiivists
greatly. The land on which the school building is, belonged to a
businessman. The Dalits here gathered enough money to buy this land and then
gave it over to the government so that a school could be buiit. Education
remains low though, and other problems also plague the people here. Most
neopie here make bidis - if they make 1000 per day. they get Rs 20. But 1000
; often an impossible, figure to reach. About 10 per cent of the people, here
were granted sonic land after independence, and arc paying tax for this land.
But they have been unable to till the land till now - some of it has been
taken over by the forestry department, some of it is hilly and uncultivable
and some has been taken over by others. In October, the Bihar government had
given out papers for these tracts of land, but these people = who are the
owners “ were not informed about it, and therefore have no documents to
prove that they own the land, Local mass organizations have, however,
started mobilizing the Dalits here. The rallyists then went to Charraiyan,
where 70 Dalit families live. They unveiled a statue ol Babasaheb here. This
area used to be a stronghold of Yadavs. Atrocities were often committed
against Dalit women. The Dalits here finally got together and decided that
as landowners Themselves, and given fhe fact that many of them were
. ducatcd. they did not have, to take, the oppression lying down. After a
struggle, the Dalit organizations have become strong here and Dalits in this
area have stopped labouring tor others. However, the atrocities continue :he village head is of the Yadav community and Dalits are often thrown into
prison on irumped-up charges. Tales of oppression by the Yadav community
came to light at Baanka too. A rape case registered against a member of this
community has seen no action so far. The DMD of the station tncrc is Dalit,
nut he is aiding the upper-caste inhabitants. At Baanka, the turn-out was so
h igh that locals said that ever- the chief minister of Bihar does not get
Audi aueiiiioii liom them.
On the Bliim Route, the rallyists went to Wazirpur Thikana in Haryana, where
fnev were welcomed bv been players belonging io the Adivasi community. The
women here saw the rallyists off till the border. The mllyists then moved
on to JuUna, Saffido and finally reached Jind. The people here had created
their own banners and posters to welcome the Really. A. procession was taken
out through the city. The rallyists then wended their way io Rohiak, where
12/31'03
Page 2 of 2
.
5
t
the Bharat Gyan Vigyan Jattha welcomed them. They visited a Dalit basti
here.' Many employee associations also participated in the rally here and
expressed their support for the Dalit cause. The rallyists got to know about
the kidnapping of the Dahl sarpanch of Behervar village on October 12. The
sarpanch had obtained the permission to build a school on a piece of public
land. But the high caste people opposed it and invited him for a dialogue.
He has not been heard of since then The Haryana government has done nothing
about this so far. Hie- Rally leaders then drafted a resolution in this
regard, to be read al a maliapanciiayai, scheduled for December 21. 2003.
Pudlyists on the Thiruvalluvar Route received heariy support from the people
on all their stops on December 20. At Kamr. i 200 people received them with
the support of local Dalit organizations. The rally then went to Terugumani
oil the Trichy border, whore it was greeted by people in four lorries, two
vaffs andTcar. The rally’s entry into Trichy was delayed due to the
presence of the President in the town. They were welcomed into town by the
South India Aravanigal Rights and Rehabilitation group. The rallyists held a
meeting in front of the Ambedkar statue at the town junction. The BHFT.
union, railway union and Dalit organizations had turned up in full strength
to support them The Rally then moved through Pudukudi to Thanjavur
Cultural programmes and meetings marked the Rally's activities here. The
next destination was Manakarau where 300 people received the rallyists. The
rally ists then went to Thiruvidaimarudu. a stronghold of the Hindu maths,
where the caste factor is very dominant. The meeting here was attended by
nearly 1000 people. After this triumphant stand, the rally moved on to
Mai 1 aduthurai. where employee and Dalit unions had organized a meeting
attending by nearly 500 people. The rallyists on this route are now headed
for Sirgazhi. Chidambaram and Mannargudi.
The Dalit Swadhikar Rally has been organised by the National Campaign on
Dalit Human Rights. Accompanying the Rally on its four routes is a
travelling poster exhibition, Hidden Apartheid*, which deals with the
issues confronting Dants m the country and has been conceived by ANHaI)
(Act Now for Harmony and Democracy). The Swadhikar Really aims to create
awareness about globalisation cutd Dalit rights among Dalit masses across the
country, in order to conveyTheiFviewoW^tliTWdfia Social Forum, to be
held in Mumbai in January 2004.
For more information contact 040552K1446 and 04027E01268
12/31/03
Page 1 of2
Community Heaith Ceil
From:
To:
Cc;
Sent:
Subject:
"ipsita Banerjee <nnpp@boi. net. in>
"pha" <oha-ncc@yahoogroups.com>
"VHA.I" <vhai@vsnl.com>; "Ritu Priya" <ritupriya@vsnl.com>; "Mohan Rao"
<mohanrao@bc!.net.in>; "navarro" <vnavarro®hsph.edu >; "frchpune@giaspn01.vsln.net.in"
<frGhbom@bom2.vsnl.nBt.in>; "mfc" <5amasaro@vsnl.com>, "Vandana Prasad"
^chaukhai@yahoo. com>
Friday, March 05, 2004 7:56 AM
[pha-ncc] Fw Article sent
Dear Friends
Fresh from the oveni The Medical Service Centre, headquartered at Koikatajiad asked for a note^from
me on RNTCP for their annua! conference Qn13/3/04? This might also be of onterest to you. Regards, D
Banerii
-----Original Message-----From: Ipsita Banerjee
To: Calcutta heart clinic
Sent: Friday, March 05, 2004 6:27 AM
Subject: Article sent
NTP/CHC
March 5,2004
SOCIOLOGY AND POLITICS OF IMPOSITION OF THE REVISED
NATIONAL TUBERCULOSIS PROGRAMME BY WORLD BANK AND WHO
Debabar Banerii.
Professor Emeritus,
Jawaharlal Nehru University,
B-43 Panchsheel Enclave,
New Delhi 110017
Tcl:649 0851 Email nhpp@bol.net in
The imposition of the Revised National Tuberculosis Programme (RNTCP) is a classic
manifestation of the quotation from the famous C heck author, Miian Kundera "‘Man’s struggle
oppression is a struggle between memory and forgetfulness”. Internationa! instruments of the rich
countries, such as the World Bank and WTIO had wiped out the memories of India's seminal
contributions to the field of dealing with tuberculosis as a public health problem. As a counter
attack against oppression by the rich countries it is necessary for us to remind’ them about some
of these contributions from India, which had brought about fundamental changes m the approach
that was being followed all over the world..
The research study which was carried out at the Tuberculosis Chemotherapy Centre at Madras in
the fifties had proved tliat treatment of tuberculosis patients at home is as efficacious at home as
m sanatoria. It was also proved at the National Tuberculosis Institute. Bangalore (NTI) that in the
sixties that the BCG vaccination, which was till then so strongly advocated by the rich countries,
does not provide any protecTion at least to adults. Perhaps a more fundamental work at the NTI
was to develop a people oriented approach to diagnosis and treatment of tuberculosis under the
conditions prevailing in the country at that time on the basis of data obtained by ' going to the
people and learning from them’. It was possible to bring down the cost of diagnosing and treating
patients from Rs 2,500 to as low as Rs 10. NTI made use of the relevant information to formulate
the National Tuberculosis Programme (NTP). It was asserted that the services should be available
3/5/04
Page 2 of2
free of cost and NTP should be integrated with the general health services - it should sink or sail
with the general health services’. The government of India had accepted the N IP for nationwide
implementation. The solid evidence produced at NTI also made the WHO Expert Committee on
Tuberculosis of 1964 to adopt this approach.
People’s struggle for health and health services culminated in the Declaration ol Alma Ata in
1978 bv all the countries of the world. Among others, the Declaration proclaimed health as a
fundamental right, people ought to be prime movers for developing their health services, there
should be social control over the health services and, as emphasized in the N I P, services should
be provided in an integrated form. The response of the rich countries to the declaration of selfreliance by the poor in the world was as sharp as it was swift. They ' invented’ what they called
Selective Primary Health Care (SPHC). RNTCP is one such programme fabricated by them and
made agencies like TO, UNICEF and the World Bank. Advocate this utterly unsubstantiated
approach, it was an awesome and shocking (the same shock and awe’ of Iraq!) use of raw power
by those who called themselves as children of European Enlightenment.
It is a grim irony that they first 'destroyed’ the NTP by destroying the infrastructure of the health
services in India by imposing vertical programmes like the Universal Programme of
Immunization (U1P), AIDS Control and Polio Eradication and then made a case for RNTCP by
blaming the victims the people. It had been emphasized on numerous occasions that, as
designed, the bi I P was not perfonning because of a virtual breakdown of the public health system
of the country. Proponents of RNTCP made the preposterous allegation that the tuberculosis
patients arc defaulters or non-complaints of the doctor’s orders and therefore the only way to
' save’ them from their doom is to offer them Directly Observed Treatment with Shortcourse
chemotherapy, using a battery of powerful and very expensive and toxic drugs - the notorious
DO I S. RNTCP is several times more expensive than N I P. Despite all the backing it has
received, it has fallen far short of the targets it had set for itself. It has further distracted attention
from providing other health services to the people. Because of reckless use of multi-drugs, now
there is a real danger of large-scale development of multi-drug resistance.
Those who are prepared to take the side of the people, who refuse to forget’, have not only to
expose the designs of the market-oriented rich countries and the exploitative ruling class in the
country, will have struggle for an alternative, self reliant health services as a pan of struggle for
health.
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3/5/04
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TUBERCULOSIS
1. Scenario/ situation/ statistics related to tuberculosis keeping in focus women and
gender relations
2. Efforts/ successes to improve the situation with practical examples
3. Technical information on tuberculosis - Fact sheets
4. Module for training
• Objectives
• Content
• Duration
• Training methodologies
• Teaching aids required
• Reference material for the trainer
• Material to the participants
• Any other
TUBERCULOSIS
This disease which affects large numbers of Indian people is a major problem in our
country because it is so closely linked to poverty and malnutrition. Every minute, two
more people in India are becoming ‘sputum positive’, that means their coughing makes it
possible to spread the disease further. Every minute, TB kills one more patient, and
although more men than women get TB, more women die of this completely curable
disease. In fact, more women die of TB every year than of causes related to
childbirth.
The average incidence of lung TB that causes holes or cavities to be made in the lungs is
about 2-3/1000 population. This means that if there are 10,000 people in your area,
about 25 patients should be taking the treatment for TB. Is it possible for you to find out
the numbers from your district TB centre and the groups of women you work with to
find out the facts for their local Primary Health Centres?
One important thing you will probably find is that it is not easy to find out who the
patients with TB are. People do not like it to be known that they suffer from this disease
because even though they can be completely cured, society does not accept patients on
an equal footing. They face a lot of problems, particularly in their workplace, sometimes
stopping work, and an already poor family is pushed even further into debt. In reality,
with the drugs available for the treatment of TB today, a patient becomes noninfectious within two weeks of starting the treatment. This information must be
shared with as many people as possible; changing society’s attitudes is a slow and
difficult process, but it has to be done in fighting diseases like TB.
TB becomes active when a person’s ability to fight germs, i.e. her immunity is at a low.
This is the reason that the women who are at greatest risk are those in the child-bearing
group, poor women who generally bear the triple burden of overwork, under nutrition
1
and motherhood. The first step in the treatment of any disease is the admission of the
patient that he/ she is ill, this step is influenced by a number of factors, predominantly
cultural. In this context a woman will often deny the seriousness of her symptoms,
because in the overall battle for survival in today’s world, her health is the least priority.
Seeking help is delayed, and this will be worse if she does not have financial
independence. This has an important bearing on another aspect of women TB patients
as well, there is pressure to become “well” as soon as possible. Hence as soon as the
symptoms subside, she will discontinue treatment, especially if there are costs (often
hidden) involved in collecting the medicines.
Cough is the most important symptom in lung TB and anyone with a cough of 2-3
weeks must be screened by a sputum test. (See Fact sheet). Chest x-rays alone are not
reliable in diagnosing TB, and if treatment with anti-TB drugs has been started without a
sputum test, a second doctor should be consulted. If TB has been diagnosed, it is very
important that the drugs be taken correctly and continuously for the six month period
(See fact sheet). Availability of these medicines is often a problem with the national TB
programme. Often the patient is required to travel a great distance every month and as
this is impractical and involves loss of a day’s wage, treatment is discontinued. The
revised programme that follows the DOTS regimen (the patient is supervised daily
swallowing the tablets) lessens these problems, but this facility is not available
everywhere and in some contexts , impractical. The follow up of patients to ensure that
treatment is completed is a very important input, and communities that are aware can
help to support and encourage a patient to complete the treatment. Loaning money for
travel, baby-sitting for young children and a helping hand with housework are small, but
useful ways in which women can support a friend in this illness crises. As a group, they
can also help with trying to avail of loans or grants in rehabilitating the patient.
Even when TB affects men, it is commonly in the wage- earning group that the disease
strikes, and women in their families who have not worked outside the home are now
forced to do so for sheer survival. This places them in a very vulnerable position and
they are victims of exploitation, doing the least comfortable jobs for the poorest pay.
Prevention of TB
Unfortunately there is no vaccine that is available that is fully effective in preventing TB.
The BCG vaccine that is routinely given to all newborns as part of the immunisation
programme helps in making severe forms of extra- pulmonary TB in young children (
such as TB in the brain) less severe, so there is less death and disability. The most useful
measures are those that improve the lifestyle and living conditions- good food and fresh
air. These are interlinked very closely with economic and environmental issues. With the
present AIDS epidemic, TB has become once more a very important cause of death and
disability.
TB control programme- RNTCP
The government has an excellent programme for the control of TB in our country.
Unfortunately the fact remains that out of every 100 patients with TB, 30 are detected
2
and of these 30,only 12 complete the course of treatment. This is despite the fact that
the drugs are entirely free.
Why 30% detection?
• Patients do not use the primary heath care system, as they have little faith in it.
• The doctors and other health care providers are not listening sufficiently to patients in
order to be able to make a diagnosis of TB.
• Private practitioners are not aware of the guidelines of the RNTCP, and no local links
in the system with generalists.
• Often there are no facilities to check sputum (microscopes and microscopists), or clear
instructions not given for taking a sputum sample.
Why do people give up and become defaulters?
<
•
•
•
•
•
Drug supply is not regular due to budgetary cuts and poor management.
Doctors under prescribe drugs( both dosage and duration).
Health care givers are not geared to motivating the patient to complete treatment
indifference
Patients are apathetic, cure seems too slow, they change doctors
Patients tempted to stop as they improve.
Financial and other social problems that are too difficult to handle prompt patients
to give up.
Note to trainer
It is important that all the above facts are shared with the participants so that they see
the links between the system and the patient, enabling them to intervene with the
providers and the receivers.
3
Case Study- The story of Arasinga Sabar
Source: <eThis One Child” — Dr. A.
Samani, Health Action, Vol 11, No. 6, June 1998.
I met Arsinga Sabar in July last year at the Gangabada ‘Swasthya Mela’. With much
fanfare, the state Government had organised this health camp, trumpeting this “special
attempt to deliver health care to remote areas”. The Gram Vikas staff had been asked to
inform people in the surrounding villages about the camp.
I had gone to the camp to help. Having spent the entire morning alone, trying to cope
with a crowd of over three hundred patients, I was both angry and relieved when the
government doctors arrived past noon. Angry that they could be so indifferent as to
turn up so late for this; relieved that the patients could now be seen faster and return
home earlier.
But my relief was short-lived. The government doctors were prescribing medicines
without even examining the patients — “you see, there is no time to see each patient
properly”, they said. They prescribed injections for everyone - “you see, this camp is for
the patient’s satisfaction”, they said.
And I felt like shouting, “No, I don’t see.”
So I walked out of the steaming hot classroom which was being used as the examination
room. I sat on the floor of the verandah of the school building and took my time to
examine patients that the field worker, Jaya, referred to me. He had asked several
patients with suspected tuberculosis to come for a check-up. One of them sat a short
distance away, on the edge of the verandah: a 7 year old boy.
By 2 pm, the sky was overcast with monsoon clouds. Soon, there was a heavy
downpour accompanied by thunder and strong gusts of wind. Everybody ran into the
shelter of the classrooms, but I did not move because I was quite dry and protected.
And I noticed that the little boy was still sitting there on the edge of the verandah, even
though he was getting drenched by the rain. Then his father ran back out, picked him
and brought him to me, saying he could not walk.
That was how I met Arsinga.
He was thin, pale, and wasted. In obvious pain, he was also hunched by TB of the spine.
It had caused his vertebrae to collapse and left him unable to use his legs. The disease
had also affected his lymph glands, so that the right side of his neck was full of sores.
My heart sank as I examined him, as I saw how weak he was, how severe the disease was
in him. He was with Kutukudi, his grandmother, who had a hacking cough herself. I
weighed Arsinga, took a sputum sample from Kutukudi and went on with my
examinations. But I could not stop thinking of the boy and his grandmother Both were
seriously sick and all that the government could offer them was this farce of a clinic.
4
We started them both on anti-TB drugs which Jaya used to deliver to their home each
month. Kutukudi had sputum-positive TB and died in October last year, Arsinga
continued with the treatment.
I was in Gangabada again in February, examining malnourished children. The first child
1 saw was Arsinga. But this was a smiling Arsinga. He walked towards me, steadily, on
his own two feet, while his proud father looked on. He still had a back deformity, but
his neck wounds had healed and he had put on weight. “He even goes to the forest to
fetch firewood,” Jaya told me happily.
I looked at Jaya, at Arsinga and at his father. And I realised once again that all the
months of hard work, the frustrations, were worth this one moment. This one child,
back on his feet again, on the road to recovery.
TRAINING MODULE
Qbjectives of this module
1. Trainers be able to visualise the picture of a patient with lung TB and share it with the
participants in order that they can guide suspects in their communities to the
appropriate centres.
2. Trainers internalise and share key messages in preventing the spread of this curable
disease like
♦ Early detection
♦ Sputum testing
♦ Regular and complete treatment — infectivity of germ lost within a month of
starting drugs.
with the participants so that these messages filter through the community.
3. Trainers are sensitised to the cultural and social factors that come in the way of
achieving the above due to certain gender dynamics in families and communities.
These must be articulated in the discussions with the women’s groups, so that they
may think of ways to handle these problems.
4. Trainers can focus on the way this disease affects women, financially, socially, and
that deaths occur due to poor access to care and lack of support systems. They can
then, using examples, explore solutions with participants.
5. Trainers are exposed to the deficiencies in the implementation of the national TB
programme so that they can enable the women’s groups to act as pressure points as
they become aware of their rights.
5
Duration
session
of
Skills
Methods that can be
used________________
TB Group discussion
Experience
with
Case study from their
patients , what is TB?
experience___________
Qs and answer , role
Who gets TB?
Symptoms that should alert play of a woman
seeking care__________
you to visit the HC
Flashcards/ board
Diagnosis of TB
Materials/
required
Treatment of TB including Lecture
drugs and duration of
therapy
Pamphlets in local
language
Blackboard
Drugs
dynamic
Group
skills
Content of session
Why does treatment fail?
Cover factors
related to system
related to patients
Women and TBSpecial factors acting which
affect the outcome of
therapy in a woman’s life
What can the participants
do- evolution of an action
plan
Brainstorming
Case study
Group discussion/ role
play
Charts/ posters/
qs and answer
and
Microscope
slides
cc
Focus on finding
solutions
dynamic
Group
sharing Group
skills
positive experiences
Follow-up
6
References and further reading suggested
1.
2.
3.
4.
5.
6.
Tuberculosis, Still Killing, Health Action Vol 12, No 2
What you should know about TB , (1995) GOI —NTI pamphlet
TB its diagnosis and treatment (1985), NTI pamphlet
TB —A guide for the health provider (1998) RNTCP pamphlet from NTI
Better Care of TB (1998) — VHAI publication
A Lady Doctor’s Anxieties —3, “This One Child” by Dr. A.V. Ramani, Health
Action, Vol 11, No.6, June 1998.
The following material is suggested to be part of the trainers kit
1.
2.
3.
4.
TB Its diagnosis and treatment
Flashcard set on TB — CMC Vellore
A set of tablets of the drugs used in the treatment of TB
A treatment card
7
nd
Page I of 1
s:
Main Identity
From:
To:
Cc:
Sent:
Attach:
Subject:
"Ritu Priya" <ritupriya@vsnl.com>
"Thelma Narayan" <sochara@vsnl.com>
<abhayseema@vsnl.com >
Thursday, July 31,2003 4:41 PM
Synopsis RP.doc; TB ISHA (PART).doc
Cehat report on health
Dear Thelma,
Attached is a very brief synopsis of the section I have promised to do for
our joint chapter. Please give comments/suggestions.
Attached is also an article on the TB programme which contains some data
which might be relevant. In any case I would value your comments on the
article.
Warm regards,
Ritu
8/1/03
Synopsis
Section I of chapter on Public Health System in India
This section of the chapter will give a broad overview, dealing with development
of public health services in the post-independence period with greater focus on the
developments since 1990 and the present situation. It will relate to the institutional
framework for public health services, manpower development and deployment, research,
surveillance, and regulation of the health sector including drugs and equipment, research,
quality of services.
Health service development will be described over time with state-wise
differences and some comparative international data. The quality of services, their
relevance in the morbidity profile of the country, and their implications for access and
utilization as well as links with private and NGO sectors will be discussed. Finally,
efforts at improving performance of public health services will be examined, such as
decentralisation, control by PRIs etc.
ETHICAL ASPECTS OF THE TUBERCULOSIS PROGRAMME
[Published in Health Administrator^ vol. XV, No.s. 1&2, 2003, pp. 156-168]
Ritu Priya & Kaushal K. Singh
Health activities can be broadly grouped into three for consideration of ethical issues
public health, clinical medicine and research. Public health as the over-arching discipline,
which develops policy for the health sector as a whole, considers all three spheres together.
Therefore it has to take into consideration the issues relevant to each. However, the
perspectives of the three may often be contrary to each other, sometimes making it very
difficult to reach decisions about interventions. Clinical practitioners diagnosing and treating
TB cases too, often face difficult decisions amidst the multiplicity of diagnostic tests and
drug regimens, their differential costs and the social constraints of patients. Often there are
diverse perspectives and opinions on the best option. Therefore it would be useful to have a
general, commonly shared framework to guide the process of decision-making by policy
makers, programme administrators and service providers.
Bio-medical ethics and social
ethics can provide such a framework. The ethical guidelines could provide a benchmark
against which to test the available options, develop and implement the programme.
This paper first sets out an ethical framework for public health and then uses it to
examine issues for the national programme against tuberculosis and the delivery of medical
services to persons suffering from tuberculosis.
An Ethical Framework for Public Health
There is an on-going discussion around ethics in public health policy-making in
general (Kass, 2001) and tuberculosis control in particular (Porter & Ogden. 1999; Priya.
1999). However ethical issues have been formulated more for biomedical research than for
provision of medical care or the practice of public health (CIOMS, 1993). Four principles for
ethics of biomedical research on human subjects currently provide the basis for much of the
discussion on ethical guidelines for all health interventions (Box - 1).
__________ BOX - 1_________
General Principles for Bio-ethics
i)
ii)
iii)
iv)
Autonomy - of individuals to decide about biomedical interventions for
themselves. Consent of individuals for participating in any research becomes
important here. Similarly, in clinical practice it requires participation of the
patient in decisions about management of their problem. For a mass programme,
responding to the expressed needs of the affected persons/community and
allowing for initiation of action by them would allow for their autonomy.
Non-maleficence - the intervention must not have negative impact, or have only
minimal negative impact that is outweighed by the benefits to the participating
persons.
Beneficence the intervention must give benefit to those participating.
Justice the benefits must be equitably distributed, to each according to his/her j
need.
(Based on Beauchamp & Childress, 1983)
These general principles can be taken as universally applicable. However they are open
to very different interpretations when translating them into concrete action. A common
source of disagreement and controversy in the translation of such ethical principles is the
dichotomy existing between the operational spheres of public health as intervention at
population level and clinical medicine as intervention at individual patient level. This applies
very centrally to debates on the tuberculosis progamme.
There is an inherent professional logic of each of the three operational spheres, depending
upon their respective primary objectives. Sources for interpretation of the general ethical
principles into concrete plans and practice can be the internal logic of the operational sphere
and external influences. While it is generally the internal logic by which decisions are taken
within each sphere, it is being proposed here that the final translation of the principles into
implementable decisions requires a mix of the internal and external logic. External influences
on decisions within each sphere include the overlap with other spheres as well as social
values that influence all spheres. It is also being proposed that, as ethics have to be practiced
in very diverse real life settings, decisions must be made with due consideration to the given
situation so that the spirit of the ethical principle is brought into effective practice (Table-1).
When applying the principles in a specific context, ethical decisions will have to take into
consideration the local epidemiological condition, the existing health services, and the
economic, social and cultural context. For actual decision taking, it will have be a mix of the
various kinds of logic, maximising the points of convergence and resolving points of conflict
between them, in the real life situation.
Table - 1
Sources for Interpretation of General Ethical Principles
Mixed
External to operational
Internal to operational
Sphere
sphere
Inter-sphere logic (i.e. An attempt to practically
Dominant professional logic
public health logic for integrate both internal and
clinical issues and external logic for achieving
desired outcome in the real
clinical logic
for
life situation.
public health issues).
Social values.
in
Ground
reality
specific context.
2
Among the differing social value positions relevant to bioethics, two of which are
considered central to public health are the utilitarian and the deontological perspectives.
These can help understand the implications of various options better. The utilitarian
conception is one that provides public health its inherent logic of maximum good for the
maximum number. The utilitarian evaluation of an intervention is based purely upon its
consequences for the larger number in the physical sense, without emphasis on the process
and moral implications of the means employed. In contrast the deontological conception ol'
’moral imperative’ places a focus on each individual as an end in himself/herself, not to be
viewed as the means to an end. This conception gives importance to the motivation for an
intervention, not only its consequences, demands adherence to universal and absolute moral
imperatives such as ‘do not kill’, ‘do not lie’. (Schuklenk U, 2000). The former taken to its
logical extreme can even justify coercion in the name of ‘larger good’, lor example as was
seen in the family planning programme of the 1975-77 Emergency. The latter can, similarly,
lead to victim blaming at individual level, while allowing for non-action at the mass level.
Yet both are of value for health service decisions if all of the four general principles are to be
adhered to. Table 2 outlines the dominant principles for the public health and clinical sphere
that are directly relevant to the discussion on tuberculosis.
Table-2
C onceptual Basis of Interpretation of General Ethical Principles in the
Operational Spheres of Public Health and Clinical Services
Tech n ical Ten ets
Internal
Disciplinary Logic
Areas of DecisionMaking
Basis for Operational Principles
Clinical
Public Health
Healing and
Maximum good to
maximum number in prevention at
individual level
a society
Treating all diseases
through Accurate
Diagnosis & Choice
of Most Effective
Treatment Regimen
Treatment Efficacy
in ideal situation
Prioritising
Problems,
Interventions and
Delivery Systems
Common
Non-maleficence
Beneficence
Autonomy
Justice_____________
Determining Relative I
Effectiveness of
Various Options
Decrease in
% Coverage x
Morbidity and
Treatment
Mortality
Completion Rate x
Regimen Efficacy
Social Perspectives in Ethical Considerations
Common
Clinical
Public Health
Conceptual Basis of
Social Values
Deontological
Positivist,
Utilitarian
Dominant Internal
Reductionist, Science
Logic
Social Science
Utilitarian
Deontological
Supplementary
Determined Context
External Logic
Measure of
Effectiveness
Basis for a Holistic
Caring and
Caring and
3
Laypeople’s
-■
Praxis
Cooperation
Cooperation
Perspective and
Action
While the utilitarian and deontological conceptions seem diametrically opposed to each
other, it is being argued here that neither of them can effectively retain their basic ethical
spirit when applied in practice without the other. There appears to be the need for public
health to somehow bring them together in practical terms. The former reflects the basic tenet
of public health from a population perspective, while the latter does so for clinical practice
where the duty to treat the individual patient to the best of ones ability is the basic tenet. If
the processual dimension is ignored, the utilitarian ends up excluding one or more sections of
the population through bureaucratic categories, thereby minimising the spread of benefits.
On the other hand the deontological perspective remains limited in practice as it ends up
giving maximal service to a few and denying any service to many. It is being proposed here
that the two can be brought together in a common framework by incorporating two other
kinds of ethic that have been proposed in the context of health services - the ethics of caring
and cooperation (Table 2). The utilitarian emphasis is on the role of experts in making
rational choices to be applied for maximum good of the maximum number. Deontological
conceptions rely upon the performance of ‘duty’ to individuals by detached rational
professionals. Both are thus based on technocratic abstractions. When these become the
basis for planning the health services, notions of a human relationship between service
provider and patient, of ‘responsibility’ and ‘caring’ slide downwards. The ethic of caring.
as developed by women scholars and feminists since the 1980s (Gilligan. 1982; Tronto,1987)
is a response to this bureaucratisation of dealing with human suffering in the liberal welfare
state and its services. It is also responding to the abstract discourse of rights and justice
which allows this bureaucratisation to occur. It is not for women alone but as an input into
conceptualising ethics beyond that of‘rights’ and ‘justice’ (Visvanathan, 2000). The ethics of
caring includes the practice of equity, non-discrimination, a sympathetic and responsible
attitude towards the suffering of patients, and a relationship of trust. This implies a
transparency in decision-making and implementation. Its practice beyond bureaucratic
services structured by the ‘larger good’ requires cooperation between public action and civil
society, with public services not being rolled back or absolved of their responsibility. Caring
health care providers could act as the bridge between the public service programme with a
utilitarian basis for mass programmes and civil society initiatives that could supplement it
with resources for the fewer number requiring additional inputs.
Finally there is the issue of work culture and the ethics of cooperation becomes
significant here. “Cooperation throughout a health care system can produce better outcomes
and much greater value for individuals and for society. Such cooperation requires agreement
across disciplinary, professional, and organizational lines about the fundamental ethical
principles that should guide all decisions in a truly integrated system of health care delivery.”
(Tavistock Group, 1999). It has been well documented even for health systems of several
European countries that shifting from public services to market mechanisms as part of the
present health sector reforms led to disenchantment with competition. There was a sense of
conflict between the culture of public service and the culture of the market, the greater
demands for ‘efficiency’ making health care providers cut corners that went against their
professional ethics, and finally leading to a shift back from competition to cooperation”
(Segall, M, 2000). The deontological perspective of individual doctors would benefit by a
utilitarian understanding e.g. in making them more conscious of the issue of access for all.
and in their cooperating with the public health programme, in appreciating the logic of its
regimen for their own patients. Thus the ‘caring and cooperation’ discourse is not mutually
4
exclusive or conceptually opposed to ‘rights and justice’, but their complementarity in
practice is the ideal public health needs to strive for. Accountability to the wider community
has to be a corner- stone of any programme espousing these ethics.
Ethics of the Tuberculosis Programme
The ethical framework for public health outlined above, can be applied to several debated
issues within the national programme for tuberculosis, where it can help evaluate
interventions and improve the programme. It needs to be recognised that in India the
providers of tuberculosis treatment include the public services and the private sector in equal
measure. The public health programme must therefore address both. Secondly, the public
services have two different management structures, the Revised National Tuberculosis
Control Programme (RNTCP) and the National Tuberculosis Programme (NTP), and at least
three different regimens in use Directly Observed Therapy Strategy (DOTS i.e. patients
come to the TB center and take the short course chemotherapy under observation of the TB
health worker), (non-DOTS i.e. patients take away drugs for a fortnight to a month) with
short course chemotherapy (SCC) and non-Dots with the longer standard regimen (SR).
The districts under RNTCP with DOTS-SCC and non-DOTS-SR, and the districts with
NTP with non-DOTS-SCC and non-DOTS SR are as given in Table 3. The private
practitioners use an even greater plethora of combinations of drugs, some rational by
pharmacological principles and others which are irrational (Uplekar & Rangan, 1996).
Currently the dominant understanding being propagated among service providers and to the
general public is that SCC with DOTS is ‘the best’. It is being implemented with wide
international and national support, additional funding coming as loans to the government of
India. It is in this whole context that the ethical principles are being applied to the
tuberculosis programme.
Issues
!. Criteria for Inclusion ami Exclusion
Ideally, all persons needing treatment should be able to get it. However, that being an
unreachable goal, the principle of justice demands equitable distribution, i.e. the resources be
evenly distributed so that each one has an equal chance of getting treatment, without any
structural exclusion. But exclusion often occurs due to resource constraints, operational
feasibility and epidemiological or technological rationale. The basis of exclusion in any
programme is therefore a primary ethical concern. The criteria used for analysing cost and
benefit in order to maximize the impact of resources used are crucial arbiters here. If cost
and benefit take only the supply side considerations then the differential impact of social
context on access and utilisation of programme services is ignored. This excludes the most
vulnerable in society in the name of cost-effectiveness. The tuberculosis programme
currently demonstrates such exclusion at different levels.
The tuberculosis programme, working through the District Tuberculosis Programmes
(DTPs), still does not cover all parts of the country. The rationale earlier (i.e. in the 1960s
when the NTP was initiated) was primarily ‘operational problems’ (lack ol roads etc.) that
now no longer holds. Decades ago the understanding was also that hill regions have little
tuberculosis relative to other regions. Now this too does not hold. The first ethical task in
5
strengthening the programme should be to remove this exclusion by expanding the
programme to all districts. But this exclusion by geographical area still forms a primary basis
of exclusion of over l/5th of the country’s population as there is no District Tuberculosis
Programme (DTP) in 119 districts (Table 3).
Table 3
Coverage of Districts by the National Programme against Tuberculosis
149
Districts with RNTCP (DOTS-SCC + non-DOTS-SR)
Districts w ith NTP (non-DOTS-SR + non-DOTS-SCC)
320
Total DTP districts
469*
Districts with No DTP
I ] 9**
Total districts
588*
* Total more than total districts (457 DTP districts and 576 total districts) due to
overlap of NTP and RNTCP in some.
** Districts not implementing a TB programme largely in J&K, Uttaranchal. 5 N-E States. Chhattisgarh. Goa.
Sources: NTI. Annual Report 2001, pp 57-58
Ministry of H&FW, Annual Report 2001
Among the districts where DTPs are operational, the DOTS programme covers less
than one-third of total population of the country because of‘operational feasibility’ (Khatri.
2002). The criteria used for choosing districts to implement SCC and DOTS are those that
lead to selection of the better ones (WHO, 1999). So the already endowed get even better
services and the deprived remain with what are considered poorer service structures. The
ethics of justice requires just the reverse.
Further in areas with DOTS implementation, several criteria lead to exclusion of
diagnosed patients from the DOTS scheme (Priya, 1999): -
a) inability to produce proof of stable residence (most difficult to obtain by the migrant
poor)
b) lack of acquiescence or ability to come to the DOTS center every alternate day (which
is difficult for daily wagers and the severely ill)
c) the health care provider’s (TBHVs, Treatment Organisers, Supervisors and medical
officers) assessment of the patients’ incapacity to complete treatment. Many therefore
are then sent to what is considered ‘second rate’ regimen and services, the non-DOTS,
6
and often end up going to the private sector. This leads to an increased time lag in
starting treatment and to a higher default by those outside the DOTS programme.
The bases for discouraging registration in DOTS are justified on the grounds that any
patient who does not complete treatment is likely to acquire multi-drug resistant tuberculosis
(MDR-TB) i.e. the ethical ground of‘non-maleficence’. So to ensure good completion rates,
those who are most likely to default are excluded. However, this is a distorted utilitarian
perspective, as leaving out the most vulnerable (through a system such as that of DOTS that
does not allow for continuation of treatment by migrants and the poorest) is likely to create
conditions of greater number of cases with incomplete treatment in the community and an
increase in MDR. The outcome would thus be contrary to the very reason for developing such
a Tigorous’ discipline into the programme. This is a violation of the principle of justice and
of non-maleficence from the public health logic (see measure of effectiveness given in fable
2). The low level of primary resistance even after 40 years of the earlier strategy of giving
home-based treatment to all (Central T.B. Division 2002; Paramasivan, 1998; Paramasivan et
al, 2000; Sharma & Mohan, 2001) demonstrates the low risk of MDR developing with an
open strategy based on convenience and initiative of the patient.
And thus the DOTS centers provide services to only 9% of total estimated cases in the
country (calculated as given in Table 4).
Table 4
Calculation of Percentage of Total Estimated Cases Treated Through DOTS
7
Expected Break-up of cases" :
N/erv smear positive cases: New smear negative cases :: 1:1
New smear positive cases: Re-treatment smear positive cases :: 1:0.5
New smear positive cases: Extra Pulmonary :: 1: 0.2
Total cases =230/ 100,000 population annually
60 % (^community load is expected to come into RNTCP = 135/100,000 annually.
1 % Annual Risk ofInfection (ARI): 50 New Smear Positive Pulmonary Cases/
100,000 annually
In India, Average ARI = 1.75%.
Therefore New Smear Positive Pulmonary Cases = 85 / 100,000 annually
(Chakraborty 1997, page 16)
Expected ratios'^
Estimated Cases in Expected Cases
under RNTCP"
the
/100.000
Community
/100,000
(Cl)
New smear positive
cases: New smear
negative cases
1:1
85:85
New smear positive
cases: Re-treatment
smear positive cases
New smear positive
cases : Extra
Pulmonary
Total
Estimation for the
whole country (109
population)
Performance of
RNTCP
1: 0.5
85: 43
1.0.2
85:17
85+85
(New smear positive
+
New smear negative
cases)
43
(Retreatment smear
positive cases)
“IT(Extrapulmonary
cases)
(b)~ 6()(%)of (a)
50+ 50 '
25
10
^230
Total cases treated
2,11,751$
135
13.50.0(H)
Cases=23,00,000
Cases
211751/23,00,000 x
100 =
211751/13,50,000 x
100 =
15.69 %
9.2%
_
Source: (ci DGHS, Central TB Division, RNTCP at a Glance'
S World TB report 2002 (calculation based on data provided for year 2000)
ChakrabortyAK, 1997.
There is in effect also an exclusion of the multi-drug resistant (MDR) cases on economic
grounds, as there is no provision for specific treatment of MDR cases. The treatment is
extremely expensive and not feasible in the mass programmes based on utilitarian principles.
This denies treatment to the individuals with MDR-TB and increases the risk of spread of
MDR-TB in the population. One possibility of providing treatment to such cases comes from
8
the ‘ethics of caring’ of the TB programme personnel, leading them to utilise community
mobilisation to obtain treatment for such cases. The onus would then be on the programme to
inculcate an ethics of caring in its personnel. We examine this aspect in the next section. The
other could be a more efficient programme i.e. one which gives similar returns for less input.
The financial resources thus conserved could then be used for treatment of MDR-TB cases.
We will examine the possibility of this in the section on technological options.
Thus one of the first ethical imperatives is to limit the processes of exclusion that are
operating at each level, as they deny justice to the individual emd lead to negative
consequences for disease in the population.
II. Providers’ Attitudes
Some processes of exclusion arise out of the health care provider’s attitudes and
practices, which are shaped by the structure of the programme, their training and the wider
social attitudes. The training of workers emphasizes the seriousness of the disease and the
problem of MDR-TB in order to enthuse them for their tasks. The Information. Education and
Communication component, undertaken to make patients adhere to the alternate day DOTS
regimen, does the same. This is bringing back the fear and stigma of the disease, which the
stable, low key, NTP had helped to decrease, even when inadequately implemented. The
doctors have now started insisting on patients covering their mouth and, as observed in
DOTS centers and T.B. Hospitals, often maintain a physical distance from them as far as
possible, despite the scientific irrationality of such behaviours. This fear conveys itself down
the line and stigmatisation increases (Priya et al, 2000; H.T.. 2002). This hinders early
diagnosis, accessing and continuation of treatment.
Non-DOTS regimens have been declared ‘second rate’; in training manuals, popular
IEC and technical papers (WHO, 1996; DGHS, 2002). Focus is shifted to ‘the best'. The
pre-existing services under NTP get discredited as a second grade service in the minds of
providers and patients. Morale of workers in it plummets and the patients catered to by it
become only those unable to go elsewhere and most vulnerable to default. The performance
thereby further declines. Those filtered out of DOTS now have an even poorer option left for
them in the public system. Turning to the private sector, many drop out soon due to the
inability to continue payments. Strengthening the drug supply to the NTP as well in recent
years has been an extremely positive outcome of the RNTCP, but the perception of this as
‘second rate’ colors its implementation and prevents it from achieving its potential.
Autonomy of the patient is decreased with DOTS as the patient is now not trusted and
needs ‘policing’ in the name of ‘observed therapy’. However it is also true that for complete
treatment of a disease like tuberculosis, support is often necessary for the patient to keep up
morale and persist with treatment. A caring attitude, rather than policing for ensuring
compliance, would provide this without violation of the ethical principles and limit the
stigmatising attitude.
However the structure of the programme does not allow inculcation of an ethics of
caring. The programme literature, guidelines, regimen and structure all communicate a very
straitjacketed technocratic approach to the programme personnel. There is little sense of
‘dealing with suffering’. When they are expected to turn the most vulnerable over to what
has been communicated as ‘second rate services’, the sputum negative T.B. cases are shunted
back and forth between microscopy centers and T.B. clinics, when they leave the MDR cases
9
with no real option, it does not cultivate a sense of dealing empathetically with patients.
Ensuring implementation according to the technocratic logic becomes the sole purpose.
Further, inability of the T.B. treatment providers in the T.B. centers to cater to any of the
patient’s other health problems, whether co-morbidities or side-effects of the anti-1 B drugs,
tells them that the programme is ‘non-caring’ of suffering and only concerned about
decreasing the ‘pool of infectious cases’. A number of the problems in this regard arise out
of non-integration of the TB services with the general health services. If integrated, many of
the ethical problems, e.g. non-treatment of co-morbidities and side-effects or stigmatizing
behaviour, could be automatically dealt with.
When they themselves are insecure (as contract workers which is an integral part of
the programme’s management structure) or feel compelled to ensure fulfilling of quantified
targets, they become more concerned with the programme evaluation criteria rather than
well-being of the patients. They adopt even more rigorous criteria for registration of cases
under DOTS than demanded of them by the programme guidelines, and add to the exclusion
of the more vulnerable that are likely to default.
With all this they themselves see no ‘caring’ in the system and so do not trust its
intentions. Then, instead of being able to convince the skeptics among other medical
treatment providers of the public health logic of the programme, they imbibe their skepticism,
e.g. about efficacy of an alternate day regimen relative to a daily regimen, which they still
have to continue to propagate. Thus the system generates a work environment of ‘non
caring’. The management sciences too emphasise that work ethics arise out of what the
management structures communicate. It is important to acknowledge the significance of this
deontological dimension for implementation of public health programmes and incorporate
considerations of the ethic of caring in the tuberculosis programme as well.
III. Technological Options
At population level, the benefit of any tuberculosis programme, with current
technological capacity for diagnosis, can at best be ‘containment’ of the problem, not even
expecting a decline in prevalence, leave alone elimination or eradication (Banerji, 1981;
Chakraborty, 1993). Any claim of‘control’ is therefore epidemiologically unjustifiable. Il
must be remembered that the declines in prevalence in the industrialized countries had
occurred as a consequence of socio-economic development and the natural cycles of the
disease in any population, not any medical technological intervention (Dubos & Dubos,
1954). So the programme is more to deal with the suffering being caused by the disease than
decreasing the number of persons getting infected. In this context ‘caring’ becomes
important again.
The options for treatment regimens lie in the drugs to be used and the strategy for
their administration. Relative to DOTS with 82% success rates among the registered patients,
the use of SCC in unsupervised programme (non-DOTS) has shown a rate of 72% with
assured drug availability (Chaudhari et. al 1993). In the situation of erratic drug availability,
as prevailing in the old non-DOTS situation, completion rates were found in a TRC study to
be 54% with unsupervised SCC treatment and 49% with fully supervised regimen (TRC.
1996).
A 7-year feasibility study by the Tuberculosis Research Centre, providing 3 different
regimens in 3 different groups covering 18 districts found that the completion rate of
unsupervised treatment is similar, and in fact better, than the supervised one (table 5;
comparing regimens 1,2 and 3). Also that the inclusion of Rifampicin for only two months of
10
the intensive phase gives either same or better rate of sputum conversion (comparing
regimens 1 and 2). The third regimen’s mechanism of delivery, i.e. self-administered for the
first two months and then observed therapy for the next four, takes patient behaviour pattern
into account (as maximum stoppage of treatment by patients occurs after 2 months when they
start feeling relief from symptoms) and minimizes patients coming to the center for treatment
on that basis, so treatment is higher than for the other two regimens. However sputum
negativity by the end of treatment is similar in groups 2 and 3. The point is that programme
managers should examine these options for their suitability to extend the benefit to a
maximum through rational options of regimen and flexibility in treatment choices.
Table 5
Results of A Seven Year Feasibility Study Introducing SCC under Existing NTP Conditions
and Comparing Three Optional Regimens
f, nd of tie a t m e n t
Complete
Patients
Total
Delivery
Drugs
available
Sputum
Sputu m
Regimen
patient d
No
for
Sputum
treatment
negative
examined
s
0/
(>80 % of examinatio
%
No.
/() No.
total days) n
nHT- %
3276 9
5334
3441 6
6349 4
Drugs being
1.
2RHZ2
5
4
9
given twice a
/4RH2
12929
week under
supervision
for 2+4
months
2394 5
22609
X806 8
1784 9
Drugs being
2.
2RHZ/
2
5
9
4
6 TH
self4
0
44383
administere
d for 2+6
months
Self4374
4541 6
3665 8
3643 9
3.
2RHZ/
administered
9
1
4
4 RH2
daily for the
first 2 month
7417
and under
supervision
for the next 4
month twice a
week
SOUI'Ce ’ Tuberculosis Research Cenire (ICMR), Madras 1996
Technological reasons for exclusion from ‘full treatment’ have been three
Sputum positive cases getting greater importance because they are infectious to
(i)
others, and therefore sputum negative and non-pulmonary cases being put in
category 3-DOTS, to get INH + Eth/Thia without Streptomycin or Rifampicin,
i.e. getting one drug less in the combination therapy than sputum positive new
cases and two drugs less than retreatment cases and the non-DOTS regimen.
Another reason for this approach to sputum-negative pulmonary cases has been
(ii)
that they are more likely to be false positive cases. It has been argued by many
11
that radiologically active cases should be given the same treatment as sputum
positive ones, now that X-ray facilities are available. As only 35% of all new
pulmonary cases are estimated to be sputum positive, not doing so is a form of
exclusion. Diagnosis of the other 55% i.e. radiologically active cases needs to be
simultaneously strengthened so that the over-diagnosis occurring on radiological
grounds can be minimised and so greater reliance can be placed on radiological
diagnosis even in the programme (Banerji, 1998). (10% of TB cases have non
pul monary disease).
(iii)
Focus of DOTS being preventing default rather than increasing diagnosis, because
Rifampicin regimens are expensive and because if resistance develops to these
drugs there is little to offer, leading to exclusion of the most vulnerable. This we
have already discussed.
It can be argued that the additional ‘cost per patient cured' due to the shift from N IT
to the DOTS within the programme structure itself (Chakraborty, 1997; Qadeer, 1994) could
be more profitably utilised for support to radiologically active cases and to MDR cases.
Table 6
Additional Cost Of Cure in Sputum Positive Cases Under DOTS System
i. Total likely smear positive cases in 5 years in project area= 1.9 million*_____
ii. Total cured in 5 years of project =1.08 million5
///.Total project cost in RNTCP Area phase 11= 5459.6 million
Cost of Dots strategy = 4094.0 million
Cost of NTP in the phase II = 1365.6 million
iv. Additional cost of cure per smear positive case under DOTS system +0.38
X 4094.0 / ii = 1307.00 (the cost of curing each patient under DOTS including
those for drugs, special supervisory staff at TUs, training, etc., for category one
cases. This cost is in addition to that already spent for basic DTP operation and
services, including maintenance at services in a given area.)
Source: Chakraborty 1997 app. 16
*( Incidence of smear positive cases 50/100.000 p.a., corresponding to ARI of l%.i.e 437.5 100.000 say 450.in 5
years at 1.75% ARI) x project population. 271.21 million= 1.9 million
S Cure rale 85% in Smear positive cases under DOTS X 1.9 million
Proportional expenditure under RNTCP on smear positive new cases
There is no treatment for MDR cases in the public programme as the only available
regimens are exorbitantly expensive. The denial of treatment because of economic cost
justified on grounds of maximum good for maximum number violates the deontological logic
and the ethics of caring, besides increasing the maleficence of MDR. While upholding the
validity of the utilitarian principle for a mass public programme, the ethic of caring can be
applied here. The technical guidelines state that MDR cases should be sent to ‘specialised
institutions’ (DGHS, 2001). The same document then argues that TB Hospitals are not cost
effective and implicitly discourages a policy for their use. The widely reported closure of a
TB Hospital in Bhopal and another in Chennai, in the recent past, throwing out the indoor
patients in a most callous manner, then becomes a natural consequence.
IV. Com in unity Involvement
12
Social and economic support to patients is an important input to prevent default by the
most vulnerable but is not part of any official programme strategy. Some programme
implementers have attempted to provide such support and find it very useful (personal
communications). Community resources can be mobilised for this by a caring system.
The WHO estimates 2-6% cases of failure to cure even with complete treatment
through DOTS in the Indian context (WHO, 2001). The caring health system should also be
able to mobilise civil society for the more expensive treatment for these cases.
Community mobilization for both these tasks requires a shared understanding of
ethical principles between the programme and the community. The onus on the programme
fonnulators would therefore be to consciously make efforts to know the community's
perception of ethics of a health service and to relate to it, even while communicating its own
ethical logic. A process of organic linkages and dialogue between the providers and the
community would make this possible.
Often there is a conflict of views on the management of TB cases between public and
private providers as well as between providers and patients. Shared ethical considerations
could help resolve the conflicts. The programme itself would have to be more flexible to
incorporate local innovations developed to improve access and utilisation in specific contexts.
This can be witnessed in the DOTS adaptation of adopting members of the community as the
'observers’ for DOTS rather than health workers only.
Besides giving information to the community about TB treatment and how it can be
accessed, the collective family process of decision-making about treatment will have to be
considered. With 'passive case finding’ i.e. the patient coming to the TB centers upon
suffering the symptoms, the extent of trust in the public programme will determine utilisation
to a large extent. Generating this relationship of trust is important for community
involvement and giving access to the most vulnerable.
V. Transparency and Accountability
Trust can come only with transparency. Complete and conect information to the
patients and their relatives is one ethical requirement. Providing complete and clear data on
the programme, showing both its achievements and limitations is just as important an ethical
public health requirement. The published reports do not provide data on the number or
proportion of cases put on non-DOTS regimen in RNTCP areas, which is essential lor any
evaluation of impact of RNTCP. On the other hand there is discrepancy in report of di flereni
agencies (DGHS, NTI & WHO) creating doubts about the mechanisms for monitoring and
transparency of the programme (Table 7).
13
Table 7
Non-Transparency and Discrepancy In Published Data On DOTS And Non-DOTS
Programme Performance. 2000-2001
Source
Information
RNTCP District
R.NTCP Districts
Reporting Non DOTs
Patients Diagnosed
and Registered
Central T.B.
Division, DGHS,
MOHFW,
Quarterly reports
2001 and Others
(about DOTS)
212
Annual Report
NTI, 2000-2001
WHO Report.
Global
Tuberculosis
Control, 2002
(about nonDOTS)*
149 (^57)
207 (page 58)
1,29,328
8,98,807
(Non DOTS)
2/1, "5/ (DOTS)
903.967 (Non DOTS)
(Table 9)
Treatment
Completion and
Success Rates
Cure Rate
83%
Noh DOTS
63% (SCC)
41% (SR)
DOTS: 82%,
Non DOTS: 10 %
(Table 11B)
82%
Non DOTS: 7 %
Table 11 B
(Mol evaluated 82%)
DO TS: 80%We" '
(Base year 2000)
*NTI analyses NTP and non-DOTS component of RNTCP
In Conclusion
Ethical principles are very general and universally applicable but their translation into
concrete practice requires a consideration of specific context and a holistic rather than a
technocratic perspective. Here we have dealt with the case of a public health programme
dealing with a serious communicable disease in a resource poor social setting. The current
context is also of a resource intensive internationally backed strategy being introduced along
with new management structures replacing the old ones of an indigenously developed
programme.
For any health service, exclusion from treatment on non-medical grounds is
undebatably unethical, Some exclusion is justified in mass programmes on grounds of
resource constraints. But the basis of exclusion on the medical or economic grounds must be
transparent so that others can assess them and ideas can be pooled to minimise the exclusion.
The utilitarian logic of maximum good for the maximum number, and the
deontological logic of doing the maximum possible for each individual, appear in
contradiction to each other. However what experience shows, for example with HIV/AI DS
14
or tuberculosis, is that one cannot be effective without the other. Curative care cannot he
effective if it is inaccessible and a mass programme cannot succeed if it does not provide
a caring attitude towards each patient.
Good management of a health programme cannot focus only on the supply side
issues. A rigorous service delivery structure can become exclusionary and coercive if it is not
flexible to adapt to local context and individual needs, or sensitive to the ethical principles of
autonomy, justice, and non-maleficence simultaneously. Complete transparency on financial
and technical assessments with the professional peers and lay public alike, is necessary for
sustaining ethical action.
Finally, it needs to be acknowledged that good ‘management’ alone is inadequate for
a democratic system. Priority setting is a political task as it mediates between different
sections of society and their interests. What are the ethical considerations of international
programme managers in ‘generating political will’ at the top of the administrative and
political leadership in individual countries for specific programmes? Doing so through
enticement of foreign currency loans for adjusting the country’s balance of payments and not
as a way of dealing with suffering of their people cannot generate a ‘caring’ programme.
‘Education funds’ for such generation of‘will’ led to the Enron phenomenon. It can
be viewed as interference in the local social and political dynamics for determining priorities
and thereby antidemocratic and unethical. Each health administrator and health care provider
therefore needs to understand and weigh the technological options and possible delivery
systems against a comprehensive, shared ethical framework. It is hoped that this paper will
contribute to developing such a framework.
Ritu Priya, MBBS, Ph.D.
Associate Professor
Centre of Social Medicine & Community Health
Jawaharlal Nehru University
New Delhi-110067
Email: r i t u pr iya(£/' \• s n1. c o m
Kaushal K. Singh. MBBS, MCH
Research Scholar
Centre of Social Medicine & Community Health
Jawaharlal Nehru University
New Delhi-110067
Emai 1: kaushal_kishore9@rediffmail.com
15
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Welfare, Govt, of India, New Delhi, www.tbcIndia,org
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8. Choudhari K., Jagota P, Parimala N 1993, Results of Treatment with Short Course
Chemotherapy Regimen Used under Field Conditions in District Tuberculosis
Programme, Indian Journal of Tuberculosis ,40, 83-89
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10. Gilligan, C.(1982): In a Difference Voice-Psychological Theory and IVomen's
Development, Harvard University Press, Cambridge. Cited in Visvanathan, N. 2000,
‘Care and Health Policy: Women’s Movements Mobilize for Change', in Shobha
Raghuram (ed) Health and Equity- Effecting Change. HIVOS, Bangalore.
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Government of India, New Delhi.
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(2000): Surveillance Of Drug Resistance In Tuberculosis In The State Of Tamilnadu.
Indian Journal of Tuberculosis. 47, 27-33.
17. Paramasivan ,CN (1998), An Overview on Drug Resistance In Tuberculosis In India,
Indian Journal of Tuberculosis, 45, 73-81.
18. Porter .IA, Ogden J (1999), Public Health, Ethics and Tuberculosis, Indian Journal of
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19. Priya R (1999), Public Health, Ethics and Tuberculosis, Indian Journal of
Tuberculosis. 46, 273-277.
20. Priya R. (2000): Impact of Implementation of DOTS on Tuberculosis Services
Preliminary Findings from a Study on Tuberculosis Patients among the Poor of Delhi.
1.
16
Presentation at the International Workshop on Impact of SAP on Health in South
Asia. Centre of Social Medicine & Community Health, JNU, New Delhi.
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presented at a workshop on the Tuberculosis Programme, Centre of Social Medicine
and Community Health, School of Social Sciences, Jawaharlal Nehru University.
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Situations”, Post Graduate Medicine Vol. 15 2001, The Association of Physicians of
India, pp 75-87.
23. Tronto. J.C. (1987): Beyond Gender Difference to a Theory of Care. Signs 12(4).
Cited in Visvanathan, N. 2000, ‘Care and Health Policy: Women’s Movements
Mobilize for Change’, in Shobha Raghuram (ed) Health and Equity Effecting
Change. HIVOS, Bangalore.
24. Tuberculosis Research Centre,ICMR (1996): Seven Year Findings Of Short Course
Chemotherapy in 18 District in India Under District Tuberculosis Programme, Indian
Journal of Tuberculosis, 43, 131-141.
25. WHO (2002): Global Tuberculosis Control 2002 - Surveillance. Planning,
Financing. WHO, Geneva.
26. WHO. Regional office of South East Asia, New Delhi 1999 (SEA/TB/211),
Combating Tuberculosis, Principles ofAccelerating DOTS Coverage, p. 5- 8.
Completed list of references and corrections for list of missing references
sent by Journal of ISHA*-
a) Schuklenk, U. (2000): ‘Protecting the vulnerable: testing times for clinical research
ethics', Social Science & Medicine, 51 , 969-977.
b) CIOMS (1993): International ethical guidelines for biomedical research involving
human subjects. Geneva, Council for International Organisations of Medical Sciences,
WHO.
c) Beauchamp. T.L., & Childress, J. (1994): Principles of biomedical ethics. New York.
Oxford University Press.
d) Tavistock Group (1999:. A shared statement of ethical principles for those who shape
and give health care. Br. Med. J. 318, 249-251.
e) Segall. M. (2000): ‘From Cooperation To Competition In National Health Systems
And Back?: Impact On Professional Ethics And Quality of Care’, International
Journal of Health Planning And Management, 15, 61-79.
f) Uplekar, M. & Rangan, S. (1996): Tackling TB: The Search for Solutions. 1 he
Foundation for Research in Community Health, Bombay.
g) same as ref. 24 in the paper sent earlier. Please change suitably in the text
h) Please delete from the text.
17
i) Wrong year given in the text. It should be WHO, 1999. Please change in text accordingly.
Table 4
j) Dubos R. and Dubos J. (1952): The White Plague. Boston, Little Brown.
k) Chakraborty AK (1993): ‘Tuberculosis Situation in India: Measurement Through Time',
Indian Journal oj Tuberculosis, 40,pp215-224.
1) Same as ref. 3. Please change suitably in the text.
m) The year is wrong. It should read (WHO, 2002) ie. Ref. 24. Please change accordingly in
the text.
18
Table 4
Calculation of Percentage of Total Estimated Cases Treated Through DOTS
Expected Break-up of cases .
Neyv smear positive cases: New smear negative cases :: 1:1
New smear positive cases: Re-treatment smear positive cases :: 1:0.5
New smear positive cases: Extra Pulmonary :: 1: 0.2
Total cases =230/ 100,000 population annually
60 % of community load is expected to come into RNTCP = 135/100,000 annually
I % Annual Risk of Infection (ARI): 50 New Smear Positive Pulmonary Cases/100,000 annually
In India, Average ARI = 1.75%. Therefore New Smear Positive Pulmonary Cases/ 100.()()()
Annually = 85
Expected ratios®
Estimated Cases in
the
Community
Zl 00,000
(Cl)
New smear positive
cases: New smear
negative cases
New smear positive
cases: Re-treatment
smear positive cases
New smear positive
cases : Extra
Pulmonary
Total
Estimation for the
whole country (109
population)
Performance of
RNTCP
1:1
85:85
1: 0.5
85: 43
1.0.2
85:17
85+85
New smear positive
+
New smear negative
cases
43
Retreatment smear
positive cases
/100,000
(b)= 60%of (a)
50+ 50-
25
TtExtrapulmonary
cases
230
Cases=23,00,000
Total cases treated
2,11,751s
Expected Cases
under RNTCP^
211751/23,00,000 x
Cases
135
13750,000
100 =
211751/13,50.000 x
100 =
9.2%
15.69 %
Source: @ DGHS, Central TH Division, •RNTCI* at a Glance',
S World I B report 2002 (calculation based on data provided for year 2000)
19
10
<1 XL/.
^■1
An Indian Perspect^
Stop TB-Fight poverty : An Indian Perspective
Introduction:
i
Stop TB, fight poverty is the theme for World TB day 2002. TB imposes a
considerable economic toll on patients and their families. Because more than
three-quarters of people with active TB are in the economically active age
group (15 to 54), the economic and social costs to them and society are
huge. They are income providers of the family. They are the parents of
young children who need their economic and emotional support in order to
thrive. They have elderly parents and relatives who depend on them. They
are the citizens whose productivity and talents are essential to their
countries' development. The result of TB is that access to opportunities and
choices- a key principle of human development -is blocked.
III health, malnutrition and high fertility are three main reasons why
households become or remain poor. They cause poverty through diminishing
productivity, reducing household income and increasing health expenditure.
A more complete view of poverty includes deprivation not only from money
income, but also human development, financial and physical security,
expanding opportunities and especially participation in key aspects of social
life.
Poor families have no buffer against loss of income-no savings and very
limited access to borrowing. The way they cope with this economic adversity
may provide short-term benefits -that is cash-but in long term makes them
and their children destitute. The sale of assets such as land is a common
response to large medical expenses.
Income poverty leads to ill health and ill health contributes to income
poverty. A more complete view of poverty includes deprivations from not
only money income, but also human development, financial and physical
security. Poverty is also seen as a lack of basic human development
indicated by poor health, malnutrition and educational development. Gender
is in particular an important variable affecting both health and poverty.
TB and Poverty Links
The global experience with TB control has been able to define certain clearcut linkages between TB and poverty:
o
TB is more prevalent among low-income groups than among high
o
o
o
o
o
income groups.
The cost of TB care, if borne by families alone can be unaffordable.
TB is a chronic ill ness and requires care over a relatively long period
during which productivity is reduced, leading to interruption of
education and work.
Household income is severely reduced, family dysfunction increases,
particularly if mothers are ill and poverty increases.
Lower productivity and more poverty impede social and economic
development and increase inequalities in society.
Lower income people are higher risk-as TB spreads in crowded
places-households, school, workplace, marketplace and commuting
between them.
The real stakeholders in TB control
o
A. The people: - the low-income groups are the most vulnerable
people with limited resources to over come poverty-related TB risks
viz:
Barriers in access to primary health acre ans appropriate
o
diagnosis and treatment for TB
Emerging HIV/AIDS -TB co-infection
o
Lack of knowledge about the disease
o
o Overcrowded living and transport conditions
o Urban congestion/pollution
Poor nutrition
o
o
B.Society: - as represented by politicians and policymakers, with
power to reduce risks.
Poverty in India
Statistics as provided Government of India show that about 240 million
people live below the poverty line. (The poverty line is really the line of
destitution. At this line, people just enough money to provide them with
food, converting to 2,200 calories and with nothing else. No roof, no clothes,
no security, no minimal comforts, let alone schools, medicines and any fruits
of industrial revolution.)
Poverty alleviation remains pronounced challenge before the Government.
Though there ahs been a steady decline in poverty over the last two
decades, the total number of poor people has remained more or less
constant due to growth in population. The inter-regional disparities in
poverty levels are quite alarming. According to National Sample Survey
Organization (NSSO) the poverty situation ins several states in India is
appalling: Orissa 47.15%, Bihar 42.6 %, Madhya Pardesh 37.4%, Sikkim
36.55% and Tripura 34.44%. In terms of numbers Uttar Pardesh has 53
million, Bihar 43 million, Madhya Pardesh 30 million, Maharashtra 22 million,
West Bengal 21 million, Orissa 17 million and Andhra Pardesh 12 million
people below the poverty line. (Economic Survey 200-2001)
Poverty alleviation programmes are still ineffective because they have not
reached the poor.
Surveys by the NCAER (National Council of Applied Economic Research)
reveal that almost 59% of all households, accounting for 526 million people,
have an annual income of less than Rs. 12500. This means a monthly
household income of Rs.1000 or about Rs. 200 per head. This by any
yardstick is abysmally low income.
Households with incomes between Rs.12500 and Rs.40, 000 per year
account for 331 million people.
Only 4.1 percent, accounting for 37 million have an income of over Rs
40,000 a year.
(Life above poverty line: Rs 264 per month is all you need -Mohan
Guruswamy, Courtesy www.tehelka.com)
Tuberculosis in India: (1)
General facts
o
o
o
o
o
o
o
o
o
o
India carries a third of global TB burden. An estimated one in two of
the adult population are infected with TB bacterium.
The estimated incidence of all cases of TB is whopping 185 cases per
10,000 population.
The TB epidemic continues to grow, every year, two million people
develop active tuberculosis (more than any other country in the
world).
More people now die from tuberculosis than ever before -nearly
4,50000 every year. More than 1000 persons die of the disease each
day.
Only one in four people with tuberculosis is treated with DOTS. The
current rate of DOTS expansion is still far too slow to reach the global
targets by 2005. Failure to reach these targets will condemn millions
of people to disease and death.
Tuberculosis is inflicting enormous socio-economic costs. In India the
estimated economic cost of TB is US $ 3 billion per year.
India's DOTS programme is mainly financed through a US$ 142
million low interest loan from World Bank with increasing costs
already being met by national and state governments.
The quantum of human cost of TB in the country is 4.56 -6.28
Disability-Adjusted Life Years (DALYS). (The DALY combines a
measurement of premature mortality and morbidity and reflects the
’burden of disease’ in a population)
The cost to the patient for successful treatment of TB averages US$
100 to US$150, more than half of the annual income of a daily wage
labourer. The estimated cost of MDR-TB to an Indian patient is
approximately Rs 6500 a month (US$135).
Research shows that 20% of rural patients and 40% of urban
patients borrow money to pay for expenses due to TB.
Tuberculosis in India: (2)
Tuberculosis and Women's Health
Jackie Jackson Joint UK Coordinator of Institute for Indian mother and Child
(UK), in an article entitled Multiple disadvantages: India, women's health
and tuberculosis, enlists the factors that make Indian women more
susceptible to TB. Poverty whom she describes as the main cause of TB,
affects 70% of women worldwide compared to 30% of men. Poverty
predisposes women to poor living conditions and nutrition and renders them
vulnerable to disease and infection. Research has shown that in their
reproductive years (15 -49 years), women are at greater risk of developing
the disease after infection than men at the same age. They may also be
exposed more to TB than their men folk due to their particular duties and
tasks. Besides these physical consideration the shame and stigma of disease
affects women more-to the point where women commonly keep their
diseased state a secret and unmarried girls fear that it will affect their
marriage chances.
As regards the pattern of early marriage in both the major communities of
the country, young brides are encouraged to begin a family early on. It
reduces women's financial independence-which she would be able to use to
good effect were she to develop the disease.
Clearly tackling TB in India raises many questions about the socio-economic
and political structures within society. Can TB be tackled in India without
tackling behaviors in the society, such as the low status of female, she asks?
Certainly a husband or a father with TB puts an enormous strain on the
family whenever it threatens his wage earning powers, however she warns
that social cost to the family is much higher when the disease affects
mother. Her need to attend treatment programmes takes her away from the
children, the cost of treatment cuts into family budget and a child is at a 310 times greater risk of dying within two years if he/she loses their mother
than those with both parents alive. She suggests that TB programmes in
future shall not use the medical model instead tackle all factors operating on
women with respect to disease side by side. The multiple disadvantages for
women in India that operate through gender and associated factors will only
be addressed by first understanding their role in both infection, disease and
treatment stages and then formulating successful strategies to reduce their
influence. Therefore solutions that apply to both women and men should be
implemented.
Tuberculosis in India: (3)
TB and HIV
The Prime Minister of India in his speech at a meeting on National Program
for prevention and Control of HIV/AIDS on December 12th 1998, said," the
health ministry puts the figure of HIV infections in the country as of now at
three million to four million. In some states, the infection rate is one percent
of the populations. Since we have these three to four million infections today
from a base of just a few infections in 1986, imagine what the scene will be
in another twelve years from the base now of three to four million. I shudder
even to contemplate the numbers."
As per National AIDS Control Organisation estimates the total number of HIV
infections in the country at the end of year 2000 stood at 3.86 million.
A document on Revised National TB Control Program (RNTCP) published on
the official web site of the National TB Control Program sums up the
situation rather crudely: "while the size of the HIV epidemic in India is
presently not known, it is clear that HIV will worsen the TB epidemic". The
document makes no further reference to the problem
The Draft National AIDS Control Policy has only to say this much for the dual
HIV-TB epidemic "with about 14 million TB cases existing in India, HIV/AIDS
also poses a twin challenge of HIV/TB co-infection. Nearly 60% of the AIDS
cases are reported to be opportunistic TB infection cases. Treatment of TB
among the HIV-infected persons is a new challenge to the National TB
Control Programme, which has now adopted DOTS strategy for control of TB
infection. At the same time looking for HIV among TB infected persons will
also cause the problem of scaring away of a large number of TB infected
cases in the country from seeking treatment under the DOTS strategy. There
is no risk of any TB patient getting infected with HIV unless he or she
practices high risk behavior or gets infected from transfusion of HIV-infected
blood." The draft policy document makes no further reference to meeting of
two programs (National AIDS Control Program and Revised National TB
Control Program) to meet the twin challenge.
There is no reliable data available to determine how the HIV prevalence has
affected the TB epidemic in India. There are only apprehensions and
estimates. Even the NACO or RNTCP have not come out with any studies to
document the linkage. The extent of collaboration (or lack of it) between the
two programmes is reflected in the documents of two programmes available
on their web sites.
On surface they appear to be two divergent lines, emanating from a
common point but distancing from each other as they travel to states,
districts and community health centers.
Why tackle Tuberculosis ?
Potential economic benefits for India
Effective TB control can help break the cycle of poverty and disease. It cures
people and returns them to active, productive life, which in turn benefits
their children and contributes to the economic and social development of
their country. As more people are cured, the cycle of transmission is broken
and fewer people are infected. Ultimately this leads to fewer cases of active
TB.
TB control is rated by the World Bank as one of the most cost-effective
health intervention because of its potential to avert a large percentage of the
global disease, its low cost for each year of healthy life saved, the low cost
per capita, and the potential impact on socially excluded and poor people.
Ravindra Dholakia, Professor of Economics from Indian Institute of
Management, Ahmedabad in an article, Potential Benefits of DOTS Strategy
against TB in India, divides these into two broad categories:
o
o
Pure social welfare increasing effects of DOTS, which do not generate
direct tangible economic benefits. These include reduced suffering of
TB patients, quicker and surer cure from the disease, lives saved and
disability reduced for dependents and non-workers suffering from TB,
poverty alleviation etc.
Direct tangible economic benefits of DOTS which include: reduction in
prevalence of TB due to DOTS which improves the efficiency and
productivity of workers, TB deaths averted among current and future
workers and release of hospital beds currently occupied by TB
patients.
He postulates that that even if the Indian government spends about US
$0.74 billion per year to ensure the success of DOTS strategy the
investment would fetch a return of 16% p.a. in real terms.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US $ 200 million per
year, compared to the tangible economic benefits of at least US $ 750 per
year, the article notes.
Conclusion
India carries a third of global TB burden. Every year two million people
develop active TB. TB accounts for nearly 4,50000 deaths every year and
more than 1000 persons die of the disease every day. TB is inflicting
enormous economic and social costs on the country. The estimated
economic cost of TB is US $ 3 billion per year.
In India 240 million people live below the poverty line. Poverty alleviation
remains a pronounced challenge before the government. Surveys reveal that
almost 59% of households accounting for 526 million people have an annual
abysmally low income of less than Rs 12500 (US $260)
Income poverty leads to ill health and ill health contributes to income
poverty. The cost to the Indian patient for successful treatment of TB
averages US $ 100 to US $150. Research shows that 20% of rural and 40%
urban patients borrow money to pay for expenses due to TB.
Indian women have to pay much higher social and personal costs if suffering
from TB. Besides poverty the shame and stigma associated with the disease,
early marriage and social pressures to start a family early on and limited
access to treatment facilities makes them more vulnerable to disease more
so during the reproductive age group of 15 - 45 years.
The nation has not risen adequately to meet the twin challenge of TB and
HIV/AIDS. The number of HIV positive persons has risen above 3.86 million.
Nearly 60% of AIDS cases are reported to be opportunistic TB infection. This
is going to add to the national load of 14 million TB cases.
Effective TB control can help break the cycle of poverty and disease. It cures
people and returns them to active, productive life, which in turn benefits
their children and contributes to the economic and social development of
their country. A cost-effective health intervention exists for TB control and
treatment: DOTS. Increasing public awareness about proven, effective
interventions like DOTS and providing greater access and benefit to
treatment for those with TB, will help put billions back into the economy.
Projected incremental costs to the government for successful DOTS
implementation throughout India are of the order of US $ 200 million per
year, compared to the tangible economic benefits of at least US $ 750 per
year. The expenditure on health has declined in last decade and stood at
1.11% of GDP in 1998-99. Indian government will have to increase its
expenditure on TB control.
The three aims associated with World TB Day 2002 theme viz DOTS
expansion, efforts to raise awareness among political leaders, decision
makers and opinion leaders and mobilization of TB sufferers for demanding
greater access to treatment are more relevant to India than any other
country in the world.
Suggested further reading
Ministerial Conference : Tubeculosis and Sustainable Development
Web Site : http://w3.whosea.org/cds/pdf/16march00.pdf
Potential Economic Benefitys of the DOTS Strategy in India
Web Site: http://www.who.int/gtb/publications/pebdots/
Tuberculosis and Poverty: A PPT Presentation
Web Site : http://www.wpro.who.int/themes_focuses/themel/focus3/
POWERPOINTSTB/IMPO-TB-Poverty-Aviva%20Ron.ppt
Tuberculosis in India : A Critical Analysis
Web Site :
http://apha.confex.com/apha/129am/techprogram/paper_27954.htm
Life above Poverty Line : Rupees 640 per month is ail that you need
Web Site : http://www.tehelka.com/channels/currentaffairs/2001/oct/30/
cal03001libl.htm
Multiple disadvantage : India, Women's Health and Tuberculosis
Web Site: http://www.fons.org/tb3.htm
Article Compiled by
Dr. Dinesh Kumar
Director Health and Development Initiative India
email: dinesh kumar@vsnl.com ,
dinesh@healthinitiative.org
Dr. Jatinder Singh
Executive Editor, Health and Development Initiative India
mailto:dinesh@healthinitiative.org ,
jatinder@healthinitiative.org
Article Designed by
VS Christopher
Webmaster Health and Development Initiative India
email : job340@hotmail.com ,
webmaster@healthinitiative.org
All Rights Reserved Health and Development Initiative India
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_ ■■III ■ B
■ Uli
piS - sPage 1 of 7
Main identity
"Suniiha Srinivas" <s.srinivas@ru.ac.za>
INDIA DRUG" <india-drug@usa.heaithnet.org>
Wednesday. September 03 2003 2:02 PM
• india-drug] TE News from India
From:
To:
Sent:
Subject:
TB News from India: September-October 2003
Health arid De velopment Initiate e-India, (ww w.healtliinitiative.org-),
publishes IB News from India’ once every7 two months. The
objective of newsletter is to highlight issues related to
i ubercuiosis and HIV/AIDS eonijot in India and enlist political,
public, professional and administrative support for its cause. Health
and Development Initiative-Iiidia is a not-for-profit organization and
the news items have been quoted from various sources for fair use and
in public interest. Reproduction of the material published is welcome
provided a reference is made to the original source of the news item
and TB News from India;
Fditorial Note:
Where there’s smoke there’s fire
A landmark study conducted to study the relationship between smoking
and mortality from tuberculosis in India has come out with shocking
results. The authors of the study concluded that three-quarters of
*hc smokers who became ill with TB would not have done so if they had
not smoked. "Almost 200.000 pec?pte a. year in India die from TB
because they smoked, and half of the smokers killed by TB are still
only m their 30s. 40s or early 5os when they die," says Dr. V
n;d-uaks!imi, lead researcher with the Epidemiological Pesearch Center
i‘i \_hciiiiai. India.
Smoking and tuberculosis “are too huge and two preventable
epidemics." says Dr. Thomas R. Frieden. who is credited with kick
starting the Revised National Tuberculosis Control Programme (RNTCP)
in India. He and other experts in tuberculosis and public health say
that the new findings underscore the need to reinforce the tobacco
uoaty that the niembci vomitiks of the World Health Organization
approved in May 2003.
Sounding a note of caution Dr. Frieden says that tobacco companies
are intensifying their effort^ to increase the market for cigarettes
in third world countries, panicularly among women. "Asian women are
IheNo. 1 largel of ihe, hjhacco indnsirv.” he warns
Countries like India need to do more in order to ban cigarette
aT/citising, increase cigarette taxes and educate the public about
me hazards of smoking. Feopie also need io he informed about the
P^rd^vs connection between «mokinn and death due to tuberculosis.
TUm.>c who manage fEC
in the Central TB Division cannot
7
9z3/''O3
&&h
ITT
The Indian isiikd ■ 1’r- demonsiraics dial, die combination of
cigarette smoking
?nbcrculosi$ is far deadlier than previously
LJkvcd.
k.\*
acch micrcsi amongSi. public health experts
the world over.
Smokers are lour limes as likely as nonsmokers to die of tuberculosis
in India, the smdy
The researchers estimated that nearly
200,000 pcopk ■/ :•_
Ifom lubcrcidosis every year because they
have been sin-:
A; every age, smokers in the study had twice the
risk of dying as n: . mokers. The study also found that Indian
smokers, on average, die about 20 years earlier ftom all causes than
the}' would if they did not smoke.
Smoking and iubciculosis ' are two huge and two preventable
epidemics/’
Dr ? homas R. Fricdcn. who investigated tuberculosis
in indiabefoic he
New York Chy s current health
commissioner. > he two epidemics kill more than five million people
worldwide each, y car, Dr. Fricdcn said.
'it’s a dynamite study,: said Dr. Lee Reichman, a leading
tuberculosis expert at the University of Medicine and Dentistry of
New Jersey. ’’Eveiyvnc knows that cigareHe smoking is bad and causes
all soils of terrible things/’ Dr. Reichman said, “but none of us
thought that ix could bo stretched to enhance an infectious disease
like tuberculosis, especially one that is responsible for so many
deaths/*
Developing couuuics account for about 95 percent of the world’s
tuberculosis chscs said Dr Marcos A. Espinal, the acting director
of iubcrcuhxds u. h.bo’ ai the World Health Organization. China and
India head the list ot 22 countries that account for about 80 percent
c-f all the care'?..
5 We are iar away ircm conquering tuberculosis1’ m the world. Dr.
Espinal said Pm India is one country where the situation seems to
be improving.
"India is well on its way to controlling tuberculosis, if the AIDS
epidemic does not take off." Dr. Fricdcn said in an interview. A new
control program (RN1 CP) in India "is drastically reducing deaths from
TB/1 Dr. Frieden said. But smoking is a different matter.
Tobacco companies are intensifying efforts to increase the market for
cigarettes in third world countries, particularly among women. In
India and elsewhere in Asia, the vast majority of smokers are
men. “Asian women are the No. 1 target of the tobacco industry,” Dr.
Fricdcn said.
there are about a billion women in Asia, where about 30 percent of
men smoke. Dr. Fricdcn said. If cigarette companies could get the
same smoking rale among women, "ihai’s another 300 million smokers
and a lot of money.” Dr Frieden said.
Dr. Fricdcii and Dr. Espinal said there were methodological problems
with the Lancet study, which could affect the figure for the death
rale from smoking. Bui they said they agreed with the authors of the
study, who said. Smoking is a cause, and an important cause, of
death from tuberculosis/’
Illness l und May Bring 1 lappy hdmgs tor TB Patients.
9/3/03
Page 4 of 7
(limes of India, New Delhi, Augusi 19, 2003)
Underprivileged patients with multi drug-resistant tuberculosis
IMDR I B ) may get financial assistance if a proposal to divert funds
allotted to the Government Chest Hospital, Erragadda situated in
South Indian state of Andhra Pradesh, wins approval. At the Erragadda
hospital, 10 percent of the TB patients are diagnosed as MDRTB cases.
On average, 10 MDRTB patients are admitted to the Government Chest
Hospital every month and most cannot afford the expensive dings that
must be admimstcicd for up to two years. MDRTB patients are
prescribed a three-drug therapy, and m the case of HIV-positive
patients, therapy can include up to five drugs. A MDRTB committee has
been established at the Erragadda hospital to address these issues.
(Source: CDC HIV 'STD TB Prevention News Update Week of August 24 to
30, 2003)
TB is enemy no. 1 Ibr India’s health: WHO report says more than
45 million people in India are suiiering from the disease.
(iouilq Rashid, Ihe Indian Express, New Delhi, July 16,2003)
If you thought AIDS would be India’s Enemy Number One, think
again. A World Health Organisation (WHO) report released in Pans m
July this year says more than 4.5 million people in India are
suffering from Tuberculosis, making it home to the highest number of
TB cases reported in the world.
With about 1 X million new cases detected every year and about
460,000 deaths so far, there seems to be no end near to the disease
in me countiy'. 1 hough the report credits India with having the most
rapidly developing free DOTS (Directly Observed Therapy) programme in
the world, it rues die ilict dial about 900 million people hi India
nnd China do not have access to the programme. Only 55 percent
Indians were covered by DOTS in 2002, says the study WHO Stop TD
iniTiauve ihai recommends DOIS as the ideal mode of treatment.
Calling India the most-challenging environment for implementation of
DOTS, it identifies the massive intra-country migration levels as the
“iMikiC biggest liUidic. CDiCv Uhiic huic from odiC) cities, other
villages, looking for work. Manv find employment in the textile
mdusli}, thousands w ork as porters or vegetable-sellers. Those
people stay together in groups, live m congested and unhygienic
environments and stand a high risk of contracting TB,” the
report quotes Jayashree Farab, who runs KARIvi, an NGO hi Mumbai.
WHO squarely blames India’s healthcare.sector as
under-funded? and notes: Unless both public and
private doctors participate,the disease will continue to spread. Patients pay for any medication they are given, which means private
practitioners may see DOTS as a threat.”
Navi Mumbai is the hope that WI IO identifies as a model for India.
9/3/03
Page 5 of 7
Citing it as on example for hov/ altitudinal changes can make a
difference in die inipiemenution of DOTS, it says: Here the heal th
muhnnn*'« nrp more rw'.'.nir- and tcrr\.'irr-.^,rsrnTrn Thr Hnnirkrc
Hi MtC SiUiih> iue DC > i C> pK>\i idciti. iHCiC bail liidiicci
benefit to these private doctors involved in the programme, the
patients whom they help combat TB become their regular patients and
go to them lor other ailments. '
I B Control Programme io Cover Entire Karnataka by Year-End.
(The Hindu (Chennai, India), August 22, 2003, By Nagcsh Prabhu)
The Revised National Tuberculosis Control Programme (RNTCP) will be
extended to cover the entire South Indian state of Karnataka by the
end of 2003, This extension will make Karnataka the 10th state in the
u)uiiUy io be fully covered under the comprehensive TB prevention
program. Currently 22 districts are covered under the program. The
Central TB Division approved the extension of RNTCP to Haven, Utlara
Kannada, Udupi, Kodagu, and Chamarajanagar districts. Upgrading of
laboratories, training for volunteers and Health Department
officials, insiallalion of equipment, and civic works are ongoing.
Thr World B:jnk-a$xixTed RNTCP w;i$ lannched as a pilot project in
UiCUS COtCivv* ij y LliC -LJUilgaiOiC IVltilUlliagai.U Pallku iBIvxf) ill 1994, Uild
has gradually extended ro other parts of the State. A total of 77,782
'TB patients have been healed through the RNTCP since 1998, and
22,011 paiienis have been administered drugs during the past six
months
(Source. CDG HIV/STD/'i’B Prevention Ne ws Update Week of August 24 to
30,2003)
National AIDS Control Organization prepares a Draft on Guidelines tor
Management of TB in HTv Infected
National AIDS Control Organization (NACO) has prepared a draft on
guidelines for management of TB and HIV infected and has invited
comments and suggestions from members of public, public health
experts and clinicians. This initiative deserves to be applauded and
supported.
I he drai I proposes that in view of the fact that tuberculosis is one
of the commonest infectious disease seen in IIIV infected individuals,
there is a clear case for active collaboration between the IIIV and TB
control programmes to ensure the early diagnosis and successful
treatment of tuberculosis and extending adequate care and support
survival of patients with HIV infection and accelerates the
progression of HIV as observed by a six-to seven-fold increase in the
HIV viral load in IB patients, in fact
IB is the cause of death
for
one out oi every three people with AIDS worldwide.
In order io ensure optimal synergy between the NACO and RNTCP the
draft guidelines put forward an Action Plan for
//t *5
y/j/ uj
Pacre A of* 7
Co-ordination’. It calls for service deliver/ coordination and
cross-referral at local level and joint efforts at 1EC particularly
with regard to de-stigmatization.
; ne urao maxes omv a passing re Terence io the aeueaxe issue or
Voluntary Counseling and Testing (VCT) for diagnosis olTlIV infection
in a tuberculosis patient, i nis vital issue needs to be discussed
threadbare so that clear-cut guidelines can be framed and passed on
to healih care piovidcis hi ihe field.
The draft ouidclin^ can. be accessed at NACO website at the following
UKL:hi.ip: www\nacp.mcjn/,announcemenT.&Tbmy 1zip
Web Cali- a visit to Joint izffoii to jbradieaie I ubercuiosis web site.
Oui.JEET.com (Joinl EiToii io Eliminate Tuberculosis) is a website
hosted by the trans-national pharmaceutical giant Novartis through
its Indiim olllccs. A number of common facts on the disease, its
pathogenesis and epidemiology both in the global and Indian context
arc provided. The association of TB with HTv and diabetes is explored
ihioiigh septtraie links, as are the connotations that the ailment has
in context to social circmnstances like poverty^ women in children
DOTS is explained on another link in a rather elementary manner for
professionals. 1 he pages that are meant for patients are well
designed and easily readable but are heavily biased in favour of an
urban audience. Novartis, in a page highlighting its products could
have added FAQs regarding dmg therapy and its pitfalls, which would
have enhanced the usability of the link. The banner and other
messages displayed throughout the website aim to shock rather than
allay doubts; whether this has been done lor a certain design is best
ieii to die visitor to ponder upon. 1 he website has certain links
which are only accessible from the sitemap and consist of case
studies, div ihvliiiy io upload cases and require a password and
login information. On the whole a usetbl site to visit if one is
locking fbi vuilew of mfbimatioii iclatlng to TB.
hditors: Dr. Dinesh Kumar Sharma, dinesh kumariWsni.com
Dr Jatindcr Singh, j atindcrsingh^vsnl. com
Yahoo! India Promos: Win TVs. Bikes, DVD players & more!
Go to hn.p://m.promos.yahoo.com
Access kssential Drugs Monitor #32 at http;//'www. who.ini medicines/mon/moii32.shtml
The INDiA-DRI JCr discussion group is a partnership between SATELLFrE
(www.heafrhnet.org). W« IO Essential Drugs and Medicines Policy
9/3/03
Page 7 of 7
(^vv/.who.cKk and the Delhi Society for the Promotion of the
Rational Use of Drugs (DSPRUD) in India.
I o send a message io india-drug. write io: india-drug@hcaithnci.org
Id subscribe or unsubscribe, write to: maiordomor^healthnet.org
>'.k
V
Diagnostic strategies
under RNTCP
Reliable and early diagnosis
with effective treatment
to control tuberculosis
National Tuberculosis institute
Bangalore
Diagnostic Strategies
• Priority to Sputum Smear Positives
• Passive Case finding
• Chest symptomatic (cough of Jweeks with or
without other symptoms) subjected for
investigation
• Diagnosis by Smear Microscopy
• Confirmation based on three sputum
examination
■ Diagnostic algorithm
• External quality7 assurance
1
TUBERCULOSIS
10% Life
time: HIV r
*^9 t
J |7%-10% /Year^
HIVPos.
Tuberculosis
infection
1O-15/yr.
Tuberculosis
disease
I j Preventive treatment j
EfTectiye
treatment
Smear
positive
pulmonary
tuberculosis
Smear
negative
pulmonary
tuberculosis
Extrapulmonary
tuberculosis
Priority to sputum smear
positive cases
Fig 3
Tuberculous InfecScn Among Close Cortads (CJsMren <15 yr)
by Badertotogic Status of Inciex Case
70
GO
I
I’
Mt*
20
10
0
1M8-1952
1987-1969
1988-1971
e? al Am
Re^ D»s 1054.80
van Gems HA at W M ini (Jmon TubtiK 1975.50 W7-2f
q
’jJ
&*b0*3it
Satai BuHInt Umon Tuban 1975.509^106
2
Fig 6
Prevalence of active disease among contacts of Index
cases
16%
14%
• 12%
110%
f 8%
i
in
5 «
I,s*
g a
o%
SmeygCutirepM Snwi’tejiCte Sn’erSCutrefeg
pas
TcW
Index cases
I All cases S smear/ culture posAwe |
Grzybowsta S. Barnett GO and Stybio K. Bull IUAT, 1975; 50, 90
Transmission of infection
Ml
.71---------- -
I
Suvrtw iteg-.Hive
OS on -i
c
04
I
02 -
Fraction due to
smear negatiw
cases
Fruetinn due U»
smear positive
cases
Sntcui iK'salivi.
Cuhitcv (Misiti w
0.0
ba’ceied
contacts
•<15 years
Cases of
puimnnuiy
itibeixuluMs
Fig. 2. Proportion of transmission attributable to smear-positive
and to culture- only-positive pulmonary fubetvulvsis in
British Columbia and Saskaictnnvan 16)
MORTALITY AMONG TB PATIENTS
Years of
Ty pe of
patients
Death
(%)
4
Smear pos.
53.4
10
'Open' 113
59.84
Connin'
Year
observa
tion
USA
1919
EUROPE Before 1939
INDIA
1960
1.5-2
Smear Pos.
48.0
INDIA
1960
1.5-2
Culture Pos.
31
Active v/s passive case finding
Mode of detection of sputum-positive
tuberculosis cases (8.9)
r
i
I
I
i-
I
I
i
i
i
i
Button of IUAT 1971.4S: 5-54
Bullutu ofWHO 1974.51. 59-69
Cost and Efficiency of Case finding in Rural
Areas in an Operational Study (1961 -1962)
Cost per Case • found
RupeesfProporti onate Values
with Value of dispensaiy metlud
as"l" showmn bracket
Proportion of
Prevalent Cases
found
16.00(1)
33
Mass Examination of
population by Sputum
685.00(43.1)
26
Mass examination of
Symptomatic by Sputum
133.00(8.1)
39
Method of Case finding
Examination of
Symptomatic at
Dispensary
%
* Sputum Positive Cases
4
Awareness of Symptom and Action Taken
too
90
80
704
Q
aSi 60 z
504
4030
20 •z
10 z
52
I
5
o-U
Think TB
• Chest symptomatics - cough of 3 weeks
duration with or without other symptoms
• Contacts of smear positive cases having
cough
• Extra pulmonary TB with cough
Definition of chest symptomatics
5
Prevalence of Four Main Symptoms, By
Bacteriological and X-ray Classification
Category
No.
Inter
viewed
Sputum
Positive Cases
Chest
Haemoptysis
19.4
33.3
11.1
46 I
22 3
92
541
21.8
153
3.1
4.3
290
916
9.4
8.6
2.0
1.0
15.4
%
Pain
36
69.4
X-ray active or
Probably
active Case
282
X-ray inactive
Cases
Non Cases
Presence
of at
least one
symptom
Fever
Cough
___ L
%
%
J
%
69.4
518
PROPORTION OF CS AND CASES BY DURATION OF
COUGH (COMPARSION OF 1966 ANDI991-1993
DATA)
1966
%
%
CS
n
25774
CS
cases
724
6.7
6.2
949
3.7
9.4
Cough of >2
weeks
381
3.5
11.3
944
3.7
9.4
Cough of >3
weeks
275
2.5
13.5
722
2.8
11.1
Symptomatic
out-patients
%
1991-1993
%
Cases
n
10792
Rationale of duration of cough
under RNTCP
• Cost effective
Reduction in work load
• 24%* to 28°
reduction from 2wks to 3wks
- Yield of cases not changed
• 9.4*-ll.l%@ for 2wks vs U.3*-13.5%@ for 3wks
Maintain the quality
• More time available for sputum examination
•OVJ Baty « at Bull WHO. !9fl.37.875-897
Jagotn, B Mahadev, N Sredvanianimu, VHBalnstngameihvram, TR Sr«nivas, Ind J TB, 19^3, 45, 39 >
6
How do you diagnose
pulmonary tuberculosis
Diagnostic tool
• Smear microscopy
• X-ray
Microscopy is more objective
and reliable than X-ray
100
Inter-observer
agreement
80
70%
60 |
40 '
20 |
_____ •
0 1
AFB Microscopy
X-ray
7
(Correlation of the yields of X-ray Examination and
Sputum Culture
Sputum Culture
X-ray
TB
Positive
Negative
Total
Y'es
142
85
227
No
20
1982
2002
Total
162
2067
2229
Source: BuUetincf WHO 1970.43: 17-34
NTI, Bangalore Study on X-Ray
Diagnosis of TB
100 .
• A systematic evaluation of well
functioning District TB Centres by
the National TB Institute.
80 I
Bangalore found tlwt nearly "0%
of the eases diagnosed and put on
60 ■
treatment on the bass of x-ray. did
not have tuberculosis at all
40
• The proportion of cases diagnosed
on the basis of x-ray alone and put
on treatment unnecessarily is likely
to be even higher in many centres
Over- i
diagnosis
20
0
Diagnosed byxrayalone
A:tual cases
NTI, UT, 1074
Limitations Of X-ray As A Diagnostic Tool
• Interpretation purely subjective
• Etiology - difficult to ascertain
• Activity difficult to judge
• Operational disadvantages are many
- delay in results- non-applicability on large scale.
special training, costly equipment & consumables
^-Unreliable for diagnosis & monitoring treatment
8
IUATLD International Study
Indices of disagreement on X-ray classification
Abnormality in lymph nodes?
60
Abnormality in lung, probably tuberculous
45
Calcification in lung ?
42
Non-calcificd abnormality, probably tuberculous
37
Is the film abnormal?
Need for medical action?
34
31
kwrvt Bulletin oflUATLD. 1968.41:110-114
IUALTD International Study
• 5% of smear positives reported as - normal X ray
• 17% of smear positive as - non TB abnormality
• 24% TB patients as - no need for clinical action
• 50% of experts as - omit 2/3rd of smear positives
• 50% diagnosing TB would initiate on treatment 4-5
times bacteriologically negative persons compared
with smear positives.
Source. Bollttn oflUMUJ. 1968. 41.110-114
Problems with Over-Reliance on Xray for TB Diagnosis
• Misclassification of non-TB as TB, resulting in unwarranted
treatment and avoidable expenditure
• Inability to distinguish between smear+ and smear-negative
patients, resulting in inadequate priority to true smear+
patients
• Failure to give appropriate treatment
• Inability to monitor progress accurately
=> Lower cure rates and increased spread of TH
9
Indications for X-ray
o
J
Clinical work up of:
- Only one Smear out of three are positive
- all three smear are negative
- Household contacts of smear positive cases,
especially children of
Pulmonary TB with complications like
pnuemothorax
• Miliary TB or Pleural effusion
• Suspected HIV infection
Diagnosis of pulmonary tuberculosis
• Patients with TB feel ill and seek care
promptly
• Active case finding is unnecessary and
unproductive
• Microscopy is appropriate technology,
indicating infectiousness, risk of death, and
priority for treatment
• X-ray is non-specific for TB diagnosis
• Serological and amplification technologies
(PCR, etc.) currently are of no proven value in
TB control
Yield in cases from concurrent smear and
culture examination
No. of cases according to serial No. of
specimens yieldii^ first positive result
Bactenologi No. of
cal categoy cases .
Smear and
culture
positive
-16
viii
1
1
2
(2)
(2)
(4)
iii
IV
1
1
C?4) (15) (2)
34
vi
vii
ii
( ) percentage
Proceedmgs ofdie 9^' Eastern Region TB Conf and 2Sr Nal Conf
on IB nd Chest Dis. Dehi. Nov 1974
10
Three sputum smears
are optimal
93%
>• 100% !
I8
81%
O-
* 50% j
§
E
Z5
o
I
0%
-
First
Second
Third
Diagnosis of Pulmonary TB
Cough 3 weeks
n
---------
If 1 positive,’ <? AFB X 3 i> If 2l3positive
X-ray and
Anti-TB Rx
evaluation
-y If negative
Broad-spectrum antibiotic 10-14 days
r
i
If symptoms persist, repeat AFB smears, X-ray
If consistent with TB
•,iAnti-TB Treatment
Fl DW CtWRT
QUAMTV ASSURANCE N&TWuan th*
I SPUTUM UXROSCQi' V
■ r~
I
11
Quality Assurance Network In Sputum Microscopy
National Institution
STDC LTs
I
1
| STDCLT | _
| PTC LT |
50 blinded QA slides
once in 6 months
25 blinded QA slides approved by
National Institutions once in 3 months
Results to STLS for
feedback to MCs
| TB Unit STLS |
One slide per patient selected for
blinded re-reading - 20 slides per MC
I Microscopy Centre |______
Slides and sealed envelope to STLS for
blinded re-reading arranged by DTO
once a month (supervisory visit)
Quality Assurance Network In Sputum Microscopy
STLS
j Designated MC [ once in a month
______________________ i
11. Inspects microscope, supplies and lab using checklist - Annex - B
2. Re-examines all positives and 5 negatives - feedback on quality of
' smear, staining, reading and reporting
j 3. Gives LT 3 unstained smears for staining & reading
! 4 Collects selected slides (1 per patient) sealed envelope with Annex - A
j
from LT
5 Clear labeling of box and sealed envelope
|
' TB Unit
|
I 1 DTO receives sealed envelope with Annex-A and slide boxes
| 2. DTO interclianges slide boxes among STLS retaining sealed envelopes
I 3 STLS reads & records 20 slides per box using Annexure - C
14. Umpire reading organized by DTC by DTO
I 5. STLS/DTO/MO-TC evaluates results & gives feedback to MCs/CMOs
International Definitions for TB Control....
• Smear Positive pulmonary TB
Two or more initial sputum smear examinations
positive for AFB. or
- One sputum smear examination positive for AFB
plus radiological abnormalities consistent with
active pulmonary tuberculosis as determined by a
clinician, or
- One sputum smear positive for AFB plus sputum
culture positive for M. tuberculosis.
Revijul iutuudiuiial dcfiuitiuua u tubcrculiuis cmtiul, hit JTubeiv Lmg Dis 5 (3(^13-215.
12
International Definitions for TB Control....
• Pulmonary tuberculosis - sputum smear
negative for AFB.
At least three sputum specimens negative for
AFB. and
No response to a course of broad spectrum
antibiotics, and
Decision by a clinician to treat with full course
of anti-tuberculosis chemotherapy.
Revised ntemaional defmitions in lubercuiosts ccntroL lot J luberc Luig Du 5 (3(:213-2U.
International Definitions for TB Control....
• Extra-pulmonary tuberculosis
- Diagnosis based on one culture positive
specimen, or histological or strong evidence
consistent with active extra-pulmonary
tuberculosis.
Followed by a decision by a clinician to treat
with a hill course of anti-tuberculosis
chemotherapy.
Revised htonaiaial detiniions in tuberculosis coitroL int J luberv Lung Dis 5 (3(213-215.
Challenges in diagnosis
i. Diagnosis of TB in persons infected with HIV
- Clinical pattern contacts with the immune
status
2. Extra pulmonary TB
- Difficulty in diagnosis and lack of facilities
- Empirical diagnosis
3. TB in children
13
Quality diagnosis under RNTCP ensures;
Reliable diagnosis
Identification and treatment of infectious cases
of tuberculosis
Reduction in the over-dependence on x-ray
Ratio of smear positive: smear negative (xnray
suspects) to 1:1.2
Indicators of Case finding in
RNTCP
• Proportion of chest symptomatics among
outpatients - 2% to 3%]
• Sputum positivity rate among = 10%
• New smear positive eases - 45-85/100,000
• Ratio of smear positive to smear negative =1:1
• Extra pulmonary = 20% of new smear positive
KNTCP
14
Composition of new cases from 1993-2001
200000
180000
160000
140000
120000
1
100000
80000
60000
40000
20000
0
199 J
1994
1995
1996
1997
1998
1999
2000
2001
sm +ve —sm -ve------- ep
j
R*TK) O SMEAR POSITIVE TO SMEAR MBATWE RIMOMART TUKCUIOSS FROM 1983 TO 2N1
1.3
I
I
•4J
4 11 ------ «<1
''-■Y-tr"
to
rO.9
h”
s
04
i
02
«Q7
col
1993
1994
1995
1995
1907
1906
1999
3D0
am
YEAR
Smear Positive Case Detection rate/Lakh & Treatment
Success Rate during the year 1996-2002
100
34
87
82
SOO
34
34
84
500
75
o
50
a:
14
25
54
in a
1996.
1998
i CD Population Covered
1999
»
I
2000
i I
2001
Smear PosiSire Case Drteclion Rate
Ii
400
2
3£H3
£
8
§
200
100 o-
0
2002
Success Rote]
15
RWTCP pof>»ilfH>on Cowhand Tomi TubiMrutofds prttr*n*s ptit on tT**>rn«*n»
2X2
4v
/
4»
ANMJ
3WSXDOO t,
I-
420202 2
XOXB ®
* KO
no
1DODOD
SD
0
rrt6
!W3
1SS?
Ynr
S98
AMD
19®
2D01
[r~lPcpL’tr!tr:n Covered fm milwm; -'-Total Patrents Treated I
Case-'iKteCti®!? 1.2001) 3rd trestraent iRtoss rates
ts RNTCP ereiw
I
■*
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Role of Medical Colleges
Partners in RNTCP:
1. Diagnostic algorithm to be advocated and practiced
2. Establishment of microscopy centres
3. Efficient & streamlined referral system within and outside
4. Involvement in quality assurance network
5. Diagnosis of extra pulmonary TB
6. Operational research:
-For case detection of smear positive
-To develop guidelines for diagnosis of extra pulmonary TB
16
17
Chapter 21
Educational Approaches in
Tuberculosis Control: Building on
the 6Social’ Paradigm
Thelma Narayan and Ravi Narayan
Introduction
I’Yoin the orthodox biomedical perspective, tulxn’culosis is a chronic
mycobacterial infection’ ixxpnring early diagnosis by sputum microscopy
and culture; radiological investigation; and chemotherapy, consisting
of prompt, regular and extended treatment by a combination of anti
tuberculosis drugs. This perspective generates a restricted view of the
challenges of educational approaches in tuberculosis control as it focuses
primarily on motivating patients to take regular treatment and not to
become ‘defaulters’.
There is an urgent need to broaden the understanding of the dis
ease by applying a socio-epidemiological perspective, which focuses on
the larger socio-economic-political-cultural context in which the disease
spreads and thrives in the community. This paradigm shift in under
standing would lead to a recognition of a multi-disciplinary and multi
dimensional educational response that should become a major part of
the control effort. The most significant aspect of this proposed change
would be the contextualisation of tuberculosis control efforts to the im
portant policy imperatives of equity and social justice — helping initia
tives to reach those who are not reached by our present educational or
health care efforts.
489
490
T. Narayan and R. Narayan
In this chapter this broader understanding is explored and a frame
work for a multi-pronged educational initiative that addresses these im
peratives is evolved.
Recognising and Evolving the ‘Social’ Paradigm
The Medico Friend Circle is a national network of doctors and health
workers in India concerned that health care and medical education in the
country should become more relevant to the needs of the poor and the
marginalised. In 1985, it organised an interactive dialogue on ‘Tuber
culosis and Society’ which brought together 110 doctors, social workers,
health and development activists, and many others concerned about
(
I
Patient related
•
•
•
Seeking strength/cures
Patients fears/anxieties
Patients belief systems on the
illness
(
4
Doctor related
*
•
•
*
Drug related
Poor doctor-patient communication
Doctors impatiencc/attitudes
Mystification of doctor’s role
Misinformation or absence of
information for patient regarding
medical condition
>
♦
•
Inaccessibility of treatment (distance)
Inaccessibility of treatment (cost)
♦
•
*
•
Incomplete issue of drugs
Unnecessary/additional medications
Siphoning of drugs for private practice
‘Speed money* for free injections/tablets
I
1
*
Stigma of illness
*
*
*
*
*
Social milieu at homc/marginalization
Malnutrition, poor housing, poor sanitation
Gender bias
Economic exploitation
Occupational hazards
I
Society related
Fig. 1. The Social Paradigm
Some Significant Social Factors.
Source: Sadgopal (1983) and Medico Friend Circle (1985).
(
Educational Approaches in Tuberculosis Control
Table 1,
401
Responding to the Social Paradigm — Some Suggestions.*
System Development
•
•
•
•
Increasing health budget and reducing urban bias.
Increasing accountability and responsiveness in the health care delivery system.
Training paramedicals and community-based health workers to enhance
accessibility.
Reorienting medical/nursing education towards the social paradigm.
Community Involvement
•
•
•
Interactive, culturally sensitive health education efforts.
Tackling stigma of disease among health professionals, community and patients.
Enhancing community participation at all levels.
Tuberculosis control linked to grassroots peoples’ movements.
Seeking New Partnership
•
•
•
•
Involvement of Trade Unions and the ‘Womens movement’.
Involvement of local healers and practitioners of all systems of medicine.
Involvcment/orientation of community leaders, politicians, policy makers.
Introducing ‘Tuberculosis Control’ in High School Science syllabus.
Tackling the Determinants of the Disease
•
•
Intersectoral action to improve nutrition, housing, sanitation, working
environment and wages.
Minimum Wages Act and Right to Work.
Land Reform.
* Source: Sadgopal (1983) and Medico Friend Circle (1985).
the tuberculosis problem in India. While the discussions explored the
challenges of case-finding, case-holding and the alternative ‘regimens of
chemotherapy’ there was also an identification of a large number of sig
nificant social/societal factors and issues of concern, from the field expe
rience of the participants, that constituted a ‘social paradigm’ (Medico
Friend Circle, 1985).
Figure 1 lists some of the factors that appear to play a key part in
the patient’s experience of the disease and the response of various types
T. Narayan and R. Narayan
492
of health care providers to the disease (Sadagopal, 1993; Medico Friend
Circle, 1995). Table 1 lists a series of ideas and initiatives that were
suggested during the group discussions as ways and means of addressing
the social factors and issues of concern listed in Figure 1 (Medico Friend
Circle, 1985).
It was evident at this meeting that if the factors responsible for
the occurrence, spread and maintenance of the disease were social and
societal, then the responses needed to be social/societal as well. This
shift of emphasis would not only change the framework of tuberculosis
control but would lead to a broader framework of educational effort to
support action towards control.
Table 2.
Tuberculosis and Society — Levels of Analysis and Solution.
Levels of Analysis of
Tuberculosis
Causal Understanding
Solutions/Control
Strategies
Surface phenomenon
(medical and public
health problem)
InfrctioUH diH(MiH<i/g<*im
theory
IKXI, ( iiHe finding, mid
domiciliary chemotherapy
Immediate cause
Undernutrition/low
resistance, poor housing,
low income/poor
purchasing capacity
Development and welfare
income generation/
housing
Underlying cause
(symptom of inequitable
relations)
Poverty/deprivation,
unequal access to resources
Land reforms, social
movements towards a
more egalitarian society
Basic cause (international
problem)
Contradictions and
inequalities in socio
economic and political
systems at international,
national and local levels
More just international
relations, trade relations,
etc.
* Source: Narayan (1998).
KT
Educational Approaches in Tuberculosis Control
493
More recently, a comprehensive review has once again stressed that
the level and depth of analysis of the problem of tuberculosis and its
causative factors* influence the construction of the solution. Table 2
indicates different levels of analysis and different solutions and control
strategies, highlighting once again the shift from a ‘biomedical’ to a
‘social’ paradigm (Narayan, 1998).
Widening the Educational Framework: Reaching All
The orthodox biomedical paradigm usually results in an educational
effort that has a two-pronged focus: on the patient and on the health
team. Health education efforts are directed at the patients to make them
more informed and aware of all aspects of the disease and its treatment
and the basic rules to prevent spreading the infection to others in the
family or the community.
Instruction in all aspects of tuberculosis, including epidemiology,
clinical, laboratory, therapeutic, preventive and public health aspects,
has been an important part of medical and nursing education as well
as a component of the curriculum of paramedical workers and health
auxiliaries for many years.
The biomedical paradigm also stresses the technological component
of tuberculosis control — BCG vaccine, sputum microscopy, radiologcal diagnosis, and varying regimens of chemotherapy. It focuses on
individual patients, stresses only physical aspects of the illness, high
lights mainly the role of the health care provider — doctor or nurse
and considers the role of the patient as a passive beneficiary of a
top-down providing system who must be prevented, through health ed
ucation, from becoming a ‘defaulter’. Finally, the biomedical paradigm
also stresses the challenges of research in molecular biology or pharmacotherapeutics.
The new ‘social paradigm’ discussed in the previous section and
increasingly recognised in the last decade (CHC, 1989; Qadeer, 1995;
Nikhil, 1995; Uplekar and Rangan, 1996; Narayan T, 1997; Narayan R,
r' ! '
494
T. Narayan and R. Narayan
1997; Chaturvedi, 1997) requires a totally different framework of educa
tion that is both multi-dimensional and multi-pronged in its orientation.
While neglecting neither the patient nor the health care provider, the
focus of such education goes beyond to a larger section of society and a
broader range of groups in the community so that tuberculosis control
efforts get the support, encouragement and involvement of many people.
These include:
The patients’ family. This is particularly important because tuber
culosis has psycho-social dimensions that need family support for their
amelioration. Care providers are therefore an important focus group.
The people of the community in which the patient lives. These
include community leaders — both formal and informal, school teachers,
non-governmental organisations, women’s groups, other community
based organisations and educational institutions (Kaul, 1996).
Occupational groups. Those in which the patient works and, par
ticularly, the occupational groups in which the risk of tiiberculoHiH Is
higher.
Health care providers. This focuses beyond education of doctors
nurses and paramedical personnel to a host of other formal and infor
mal health care providers including practitioners of alternate systems
of medicine, traditional birth attendants and other types of local folk
healers, private practitioners and health teams, and technicians of the
large number of private laboratories and health institutions.
Marginalised social groups. The ‘social paradigm’ should also lead
to a special educational effort focused towards high risk groups and
marginalised groups in society, including residents of urban slums, those
who are HIV positive and those with AIDS, the homeless, destitute and
pavement dwellers, ragpickers and street children, addicts
both drug
users and alcoholics — and refugees, including those displaced by war,
ethnic conflicts and development projects.
Educational Approaches in Tuberculosis Control
495
Policy makers. Most significantly, however, the recognition of the
‘social paradigm’ leads us to focus educational/awareness building ef
forts towards those within society who make decisions, those who are
involved in policy planning and implementation, as well as those who
support the programme initiatives. These include political leaders at
all levels — particularly elected representatives at state, district and
municipal corporation levels, government bureaucrats and technocrats,
the pharmaceutical industry, and civic society. Finally, all those groups
who are contributors to the ‘watch dog’ role of civic society also need
to be addressed through educational efforts: these include the me
dia, consumer groups/organisations/associations and non-governmental
organisations.
Content of Educational Approaches: From ‘Biomedicine’
to ‘Socio-epidemiology’
The recognition of the ‘social paradigm’ will necessitate a different
framework of tuberculosis education and so the focus and content will
have to experience a paradigm shift. The focus will move from individual
tuberculosis patients, increasingly to focus on a community of potential
sufferers. It will move beyond the physical dimension and explore the
psycho-social-economic-cultural and political dimensions of tuberculosis
including relationship to poverty, the problem of stigma and marginal
isation, and the ‘social burden’ of the disease. It will move beyond
vaccine/drug distribution to include components that enhance aware
ness, motivation and empowerment of patients through counselling. The
focus will therefore be on educational and social processes and other en
abling and autonomy-building skills, and will emphasise the supportive
role of family members, other care providers, community leaders and
grassroots and community-based health workers. It will also emphasise
a change of role of the patient from a passive beneficiary of treatment to
an active participant of the control strategy whose autonomy and sense
of responsibility is to be respected and enhanced.
’ TSE""
496
T. Narayan and R. Narayan
Clearly, such a framework of education must emphasise the key
contributions from behavioural science and a qualitative approach to
research, including both action and participatory research, and must
encourage attempts to understand attitudes, belief systems, knowledge
levels and practice options at the community level. This would also
encourage an increasing shift from the orthodox ‘clinical’ and ‘molecu
lar biology’ fixation of tuberculosis researchers to a more broad-based
sphere of interest.
Table 3.
The Paradigm Shift.*
Parameter
Biomedical Approach
Social/Community Approach
Focus
Dimensions
Individual
Physical (tuberculosis
pathology)
Technology
Type of service
Drugs / vaccines
Providing/Dependence
creating
Passive beneficiary
Molecular biology
Pharmaco-therapeutics
Community
Psycho-social, economic, cultural,
political and ecological (stigma,
poverty, social burden)
Education and social processes
Enabling/Empowering
Autonomy building
Active participant
Socio-epidemiology
Behavioural sciences
Patient
Research
—>
* Adapted from CHC (1989).
Table 3 summarises this shift so that the broadening of the frame
work and content is clearer. It is important here to emphasise that a case
is being made not for a biomedical versus a community/social model of
public health dialectic, but for the broadening of the orthodox biomedi
cal approach by the inclusion of a social/community/societal dimension
(CHC, 1989). This will make the tuberculosis control initiative more
holistic, more responsive, more relevant and definitely more effective
in the complex environment and societal reality in which tuberculosis
thrives and continues to be a major public health problem today.
An important feature of this recognition of the social paradigm in
tuberculosis is the consequent need to give socio-economic-political-
Educational Approaches in Tuberculosis Control
497
cultural determinants an important role in policy review and programme
planning.
Many determinants of tuberculosis have been known for some time
(Narayan, 1997):
(1) Tuberculosis is related to industrialisation, which resulted in
a process of urbanisation with overcrowded, unhygienic living
conditions for the working class in the new industrial and mining
towns. These were further complicated by low wages and longer
hours of work. Research has indicated that, in the USA and
Africa, there was an increase in the prevalence of tuberculosis
at a time of industrial and urban growth.
(2) Population growth, migration, colonialism and war-initiated
epidemic waves of tuberculosis in different regions of the world.
(3) The incidence of tuberculosis often increases in times of war and
during ethnic conflicts and among refugees. In India, tubercu
losis was a big problem among post-partition refugees.
(4) Disrupted social conditions, malnutrition, poor housing and
physical and emotional stress are predisposing factors. In India,
it is not surprising that the incidence of tuberculosis is relatively
high among Tibetan refugees in the resettlement colonies.
(5) Housing is a key factor, especially small, overcrowded tenements
in shanty towns and urban slums.
(6) Poor sanitation and unregulated growth of hazardous industries
further compound the problem.
(7) Smoking, pollution and rapid industrialisation driven by an eco
nomic imperative which sacrifices safety procedures and com
promises regulatory mechanisms are all contributory factors.
(8) Finally, there is growing -evidence that new economic trends
that promote ‘globalisation’-, liberalisation and privatisation —
increasingly have an adverse effect on the health of the poor by
making health care more and more inaccessible (Chaulet, 1998).
In Africa and the Philippines, the documented ill effects include
a higher incidence of tuberculosis. State-run health services
498
T. Narayan and R. Narayan
experienced cut-backs in expenditure which particularly affects
services for the poor.
While these factors are all very significant, it is equally significant
that most of the literature, pamphlets and reports from the World
Health Organization (WHO), the Government of India and non- gov
ernmental organisations ignore these dimensions (National Tuberculosis
Institute, 1994; Government of India, 1995; World Health Organization,
1995a, 1995b; World Health Organization/UNAIDS, 1996; Voluntary
Health Association of India, 1994, 1996; Chakraborthy and Choudhury,
1997). Hence the narrow biomedical perspective continues.
Educational Approaches — What Do We Seek to
Achieve?
While all educational approaches at all levels, and for all the target
groujjs mentioned earlier, must emphasise these broader factors in ad
dition to the biomedical ones, the objectives of education will shift from
enhancing case-detection, case-management, and tuberculosis treatment
per se to a host of initiatives that would address the determinants and
deeper causes of the illnesses. Tuberculosis treatment and control will
become part of a wider social movement that seeks to address poverty,
illiteracy, poor environment, marginalisation, unplanned urbanisation
and industrialisation, poor housing and to increase access to, and op
tions of, health care for the poor.
In 1981, the Indian Council of Social Science Research and the In
dian Council of Medical Research in their Health for All Strategy in
India, outlined a prescription for Health for All, which included such a
broad concept of health action (ICSSR/ICMR 1981). They emphasised
the need for a mass movement to reduce poverty and inequality and to
spread education, to organise the poor and underprivileged to fight for
their basic rights, and to move away from the counterproductive con
sumerist Western model of health care and replace it by an alternative
based in the community.
*
Educational Approaches in Tuberculosis Control
499
More recently, echoes of this broader action are seen even in the
writings of oi;thodox epidemiologists who stress that medicine and pol
itics should not be kept apart. The late Professor Rose wrote, in what
was perhaps his final work after decades of extensive epidemiological
research, that “Medicine has indeed delivered effective answers to some
health problems and it has found the means to lessen the symptoms
of many others. But by and large, we remain with the necessity to
do something about the incidence of disease, and that means a new
partnership between the health services and all those whose decisions
influence the determinants of incidence. The primary determinants of
disease are mainly economic and social and therefore its remedies must
also be economic and social. Medicine and politics cannot, and should
not, be kept apart” (Rose, 1992).
The objective of a comprehensive educational initiative — compre
hensive both in target groups and in content — is to facilitate a more
comprehensive anti-tuberculosis programme that would locate program
matic action in a mosaic of multi-dimensional and multi-sectoral action
impacting on all aspects of the problem. Such a programme would
include an increase in health budgets — including funding for tubercu
losis control, poverty alleviation programmes focused on marginalised
peoples, housing and planned urbanisation programmes, occupational
safety focused on high-risk individuals and high-risk occupations, per
sonal and social support to affected people and their families — par
ticularly those from the marginalised sections and initiatives to address
social and economic inequality and injustice.
Such a broad based, social/societal-oriented model of a health pro
gramme for tuberculosis would then strike at the roots of the prob
lem and not fritter away resources in superficial biomedical reductionist
strategies that have a limited impact on the disease.
It is rather unfortunate that, in more recent times, the WHO and
other international funding agencies have failed to establish their pro
grammes for tuberculosis on a broad base and have advocated ideas
such as DOTS that are at best ‘reductionist’ and at worst totally inade
quate for the treatment of the complex social pathology of tuberculosis
"
■
■
■
■
.......... ........... .
•^■^1
T. Narayan and R. Narayan
500
• tv This continued ‘technomanagerialism’ at the cost of a com-
Educational Initiatives - Moving from Content to
Process
In the earlier sections of this
■why’ of educational initiatives m tu
section, the ‘when’ and
the ‘social.paradigm’UveX^nXcational response are explored,
‘where’ of some aspec
headings of basic and continuous
Broadly, these are described under theeducation,
health professional education and patient/commun y
Health Care — Professional Education
;n the framework of tuThere is urgent need to enhance and strengthe
and nurses. To make an
berculosis education for medical P-^Xed to focus both on ‘basic
impact on professional education, there is need
education’ and continuing education.
Basic Education
There a is need to make
grated, mniti-system10,
‘‘ Stated. Doctors and nurses must be
ically and epidemiologica y
cultural factors in the dissensitised to the wider socio-econom
actiVe participants
ease causation and encouraged to see
and not as passive beneficiaries o
6 derstanding of the disease pro
Increasing patient awareness a
^^nication and, rather than
cess is a challenge in doctor-patien co
‘potential defaulter’,
‘victim blaming’ and considering the patient as a potenti
■
1
Educational Approach^ in Tubcrculanifi Control
501
an attempt must be to enable and empower the patient to adhere to
treatment and other procedures.
Skills in listening, motivation and supportive counselling need to
be enhanced and humane attitudes and behaviour towards patients,
which are primarily non-stigmatising, must be emphasised. Education
in pathology and therapeutics must be balanced by instruction in ethics
and the social sciences. This is particularly important because the avail
ability of effective chemotherapy has often tended to emphasise the cu
rative aspects of the disease control strategies while disregarding the
caring aspects. Tuberculosis is a very stressful disease and, although
the clinical manifestations are irksome and often very discomforting,
the patient suffers more than just physical illness. It is very important
that the curing aspect of disease control strategies becomes more effec
tive, but it is equally important that the caring aspects of the strategies
are enhanced.
It is also important to ensure that training moves from didactics
and a focus on minutiae? to a more interactive, bedside and community
based education that emphasises the practical aspects of the disease and
enhances skills in patient care and counselling. Where necessary case
studies may replace case demonstrations. But the training must always
be rooted in the human problem.
While stressing the component of tuberculosis in medical and nurs
ing education will enhance the leadership of the tuberculosis control
team, it is equally important to impart proper knowledge, skills and
attitudes in tuberculosis treatment to all grades of health care workers
— multi-purpose and community-based — who are often the peripheral
health workers. They are most in touch with those who suffer from tu
berculosis. An initiative at this level will strengthen first-line/first-level
care and will ensure that the patient, who according to most socioepidemiological surveys is already ‘knocking at the health service door’
(Narayan, 1998), will be given a supportive and relevant response by
adequately sensitive and skilled health workers.
rsz
»
II-’—
hiiii
mi in
nt
502
T. Narayan and R. Narayan
Continuing Education
While the focus on basic professional education will ensure that health
professionals of the future will be better informed, better skilled, and
better orientated to the socio-epidemiological challenges of tuberculosis
control strategies, an urgent need today is to reach the present gener
ation of health care providers with relevant, meaningful, authentic and
practical information and updates on tuberculosis to enhance their in
volvement in, and contribution to, the fight against this disease. For it
to be effective, this must be sponsored by professional associations or
colleges and the National Health Programmes.
Much of the ongoing education on tuberculosis in many developing
countries is presently done by the pharmaceutical industry. The focus
and content of education is often orientated towards the promotion of
specific prescriptions or remedies over others that are available in the
market; to enhancing brand choice and subtly promoting the ‘me-too’
drugs that have additional, and usually unnecessary, components such
as cosmetic embellishments or they may contain irrational combinationH
of drugs. In addition, they are often inadequately evaluated. Depend
ing on the skills and vigilance of drug controlling agencies and the level
and extent of legislation in each country, this ‘drug’ education is often
supported by the subtle misinformation in which indicators for treat
ment are enhanced and side effects and contraindications are played
down, thereby enhancing profits and sales, often at the cost of patient
safety. It is not at all surprising that the Report on Health for All
Strategy of ICMR/ICSSR (1981) exhorts us that “eternal vigilance is
required to ensure that the health care system does not get medicalised,
that the doctor-drug producer axis does not exploit the people, and
that the ‘abundance’ of drugs does not become a vested interest in ill
health”.
In the area of anti-tuberculosis drugs, however, sometimes other
forms of irrationality creep into the situation. If such drugs are included
in the essential drug list and the prices are controlled, tfien the mark
up allowed on them is often reduced, leading to a decreased incentive
Educational Approaches in 'Tuberculosis Control
503
for drug manufacturers to produce them. Shortages of anti-tuberculosis
drugs have not been uncommon in the past.
Another challenge in current continuing medical education (CME)
is to ensure the emphasis on the use of standardised regimes for treat
ment which have often been evolved at the national level by expert
committees who have considered clinical and epidemiological factors in
the situation analysis and have looked at other relevant factors includ
ing the availability and cost of drugs and the logistics of their supply
and distribution.
A number of very effective drug regimens for tuberculosis have been
evolved on the basis of extensive and good clinical and field trials. Un
fortunately, private practitioners and even hospital-based clinicians in
most countries tend to evolve their own very individualistic, and often ir
rational, regimes based on what they consider to be ‘clinical experience’.
Costly and therapeutically unsound regimens, supported by a host of
complementary and supplementary medications that are invariably un
necessary, ineffective and irrational are all part of regular practice. At
best, these are merely symptomatic and play on the psychology of the
patient. A good CME programme in tuberculosis should not only em
phasise rational and therapeutically sound regimens but also discourage
the use of all types of irrational and unnecessary complementary medi
cation and always stress the social context as well.
Patient/Community Education
Education of the patients, their relatives and those caring for them
within the family is an important challenge in tuberculosis control.
While making the patients aware of all aspects of the disease, its
prevention and cure, the challenge is to do so by means and orientation
that primarily enhance their autonomy, provide informed choices and
options for treatment, and enable and empower them to abandop su
perstition and stigmatising concepts and to take responsibility for their
own health. Motivation and supportive counselling must be built into
504
T. Narayan and R. Narayan
the whole educational effort so that the patients build up confidence in
‘cure’ in an environment of ‘care’. The effort must also emphasise ‘care’
after ‘cure’.
Such effective education is best achieved by culturally sensitive, in
teractive, low-cost approaches including puppetry, street theatre, folk
methods, role play or even flipcharts and flashcards, and planned games
whereby the patients learn in small groups, at their own pace, supported
by other adult learners in an environment of collective trust and sharing.
Whether clinic or community-based, the process of health education is
as important as its content (Kaul, 1996).
Case Study: Health Education for Tuberculosis in Urmul
Trust (a non-governmental organisation in Rajasthan)
Health education is working on three fronts (Kaul, 1996):
(1) Street theatre and puppet hIiown in the villages highlight the
symptoms of the disease and the need to identify it as early as
possible. It also gets the message across that irregular treatment
is not only detrimental to the patients but also to people around
them so that they must chip in to ensure that the patients take
the full course of treatment without a break.
(2) The importance of the regimen and its regularity and duration
and what to do in case of side effects arc explained to the pa
tients and their relatives in groups. All this is done with the
help of television, puppet shows or playlets on the day of the
tuberculosis camp held on a fixed day of the month.
(3) The doctor spends at least 15 minutes with each new patient
and at least 5 minutes with each old one.
In addition, every few months, some cured patients are assembled to
talk to the newer patients. The camp-like atmosphere on a single day
of the month encourages the patients to share experiences.
Educational Approaches in Tuberculosis Control
505
In a country such as India and in most other parts of the developing
world, the large majority of the people are illiterate or semi-literate
and ‘adult learning’ techniques need to be used, moving away from the
didactic approaches of orthodox education.
Recent studies and experiments done by a group of non-governmental
organisations in India have demonstrated that even visual aids used in
pamphlets, posters, flipcharts and flannel graphs need to be culturally
sensitive and geared to the perceptions of illiterate adults which are
rather different from those of urban literate adults. While an under
standing of ‘magnification’ and ‘depth perspective’ by those who have
had some school education including an exposure to scientific concepts
nd experimentation and demonstration may be taken for granted, these
are not comprehended in the same way by adults without a basic school
education.
Health education materials must therefore be developed locally and
must relate sensitively to local socio-cultural realities. Decentralised
health education efforts are therefore a very important component of
any health programme strategy.
The centralised production of DOTS-related educational materi
als and the attempts to distribute so-called standardised, top-down
guidelines on contents and messages are the very antithesis of current
understanding of adult education for health and are another example of
the overemphasis of the ‘global’ approach in what is essentially a local
pproach or strategy.
Much health educational material including that currently available
for tuberculosis is still rather urban in orientation, context and visual
content. A concerted effort needs to be made to ensure that material
more relevant to rural and indigenous populations is evolved so that the
process of learning and motivation is greatly enhanced.
There is, nowadays, a tendency to get on the ‘electronic bandwagon’
and videos, slides, cassette sets and even computer software programmes
are being promoted. While they have their uses in situations where
there is electricity and where people are habituated to such adjuncts to
learning and recreation, they are not as widely relevant or as effective as
-
506
T. Narayan and R. Narayan
they are often perceived to be. To an illiterate audience, they are often
more a source of entertainment than an effective tool for learning and, of
course, the absence of continuous electricity in a large number of urban
towns and in most rural and tribal areas in many developing countries
limits their use and effectiveness. Even in this era of space and cyber
technology, traditional and time-tested folk methods and interactive
approaches still have great relevance and their importance must not be
underestimated or inadvertently played down.
bnclusion: Towards an Alternative Strategy
In these reflections on educational approaches to tuberculosis control,
an attempt has been made to highlight the following:
• Tuberculosis control initiatives need to move from the ortho
dox biomedical approach to a more social/community-oriented
approach.
• This shift of emphasis will depend upon a creative educational
initiative that helps to broaden the understanding of the prob
lem and locate it in the wider social paradigm.
• The focus of education must expand beyond patients and health
providers to a wide range of other involved persons including the
patients’ families, the people in the community where the dis
ease occurs, occupational groups, health care providers includ
ing those in the private and alternative sectors, marginalised
social groups, policy makers and society at large.
• The educational process must be primarily enabling and em
powering and must transform the role of the patients from pas
sive beneficiaries to active participants in the programme.
• Treatment and control of tuberculosis must form part of the
wider social movement that seeks to address poverty, illiteracy
and poor environment, marginalised peoples and uhplanned ur
banisation and to increase access to, and options for, health care
for the poor. Such a broad-based model would then strike at
Educational Approaches in Tuberculosis Control
507
the roots of the problem and not fritter away valuable resources
in implementing superficial, biomedical, reductionist strategies.
• Health care professionals must be sensitised to the wider socio
economic and cultural factors in the causation of disease and
are encouraged to see the patients as active participants in the
control strategy rather than passive beneficiaries.
• Skills in listening, motivation and supportive counselling must
be enhanced and humane, primarily non-stigmatising, attitudes
and behaviour towards patients must be emphasised.
• An initiative at this level will strengthen primary health care
and ensure that the tuberculosis patient will be given a sup
portive and relevant response by sensitive and skilled health
workers.
• A good continuing medical education programme in tuberculo
sis should not only emphasise rational, epidemiologically sound
treatment regimens, but also de-emphasise all sorts of irrational
and unnecessary complementary medication, as well as stressing
the social context.
• Culturally sensitive, interactive, low-cost educational appro
aches, such as puppetry, street theatre, folk methods, role play
or even flipcharts, flashcards and planned games, that enable
the patients to learn in small groups, at their own pace and
with the support of other adult learners in an environment of
collective trust and sharing, must be promoted.
• Health education materials must be locally developed and be
both sensitive and relevant to local socio-cultural realities. De
centralised health education efforts are therefore a very impor
tant component of any health programme strategy.
• All this will lead to the tuberculosis control initiative becom
ing more holistic, more responsive, more relevant and definitely
more effective in the complex environment and societal reality
in which tuberculosis thrives and continues to be a major public
health problem today.
508
T. Narayan and R. Narayan
The continuing problem of tuberculosis has been accepted all over
the world as a major public health issue of our times. Much is planned
and much is being done. The sustained success of our efforts will, how
ever, be determined by the extent to which we understand and respond
to the challenge of the ‘social paradigm’ and the creative nature of our
supportive educational response. The way forward is a paradigm shift
from ‘Directly Observed Therapy, Short Course’ (DOTS) to ‘Commu
nity Orientated Tuberculosis Service’ (COTS).
Are we ready for this paradigm shift?
References
Banerji, D. (1996) Serious Implications of the Proposed Revised National Tuberculosis
Control Programme for India. Voluntary Health Association of India /Nucleus
for Health Policies and Programmes. New Delhi: Voluntary Health Association
of India, pp. 1-100.
Banerji, D. (1997) Voice for the Voic<d<*HH
The Hevlsed National 'I'uInnt uloHlH
Control Programme: A negligent approach. Health for the Millions 23(MarchApril), pp. 30-32. (Published by Voluntary Health Association of India, New
Delhi.)
Chakraborthy, A. K. and Choudhury, S. (1997) National Tuberculosis Programme:
Stopping the Killer. Bangalore: Action Aid.
CHC (Community Health Cell) (1989) Community health in India. Health Action 2,
5-25. (Published by Health Action For All Trust, Secunderbad).
Chaturvedi, G. (1996) Tuberculosis Programme in India: Some social issues. In:
Chaturvedi, G. et al., eds. Tuberculosis Control in India — Developing Role
of NG Os. (Theme in Development series, No. 4). Bangalore: Action Aid,
pp. 96-102.
Chaulet, P. (1998) After health sector reform, whither lung health? Int. J. Tuberc.
Lung Dis. 2, 349 359.
Government of India, (1995) Revised National Tuberculosis Control Programme with
World Bank Assistance. New Delhi: Government of India.
ICSSR/ICMR (Indian Council of Social Science Research/Indian Council of med
ical Research) (1981) Health for All: An Alternative Strategy. Pune: Indian
Institute of Education.
Kaul, S. (1996) Tuberculosis Control under an NGO in Western Rajasthan. In:
Chaturvedi, G., et al. eds. Tuberculosis Control in India — Developing Role
«
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Educational Approaches in Tuberculosis Control
of NC1O3. (ThemeH in Development Series No. 4). Bangalore: Action Aid,
pp. 37-44.
Medico Friend Circle.,(1985) Tuberculosis and society. Medico Friend Circle Bulletin
No. Ill (March), pp. 1-6 (Published by Medico Friend Circle, Bangalore).
Narayan, R. (1977) Editorial: Resurgence of malaria. Nat. Med. J. IndialO, 157-158.
Narayan, T. (1997) Tuberculosis: Persistent Killer. Chennai, India: The Hindu Sur
vey of Environment, pp. 71-75.
Narayan, T. (1998) A Study of Policy Process and Implementation of the National
Tuberculosis Control Programme in India. Doctoral Thesis, London School of
Hygiene and Tropical Medicine.
National Tuberculosis Institute, (1994) Facts and figures on tuberculosis and the
National Tuberculosis Programme. Bangalore: National Tuberculosis Institute,
Government of India.
Nikhil, S. N. (1995) Socio-cultural dimensions of tuberculosis. Health For the Millions
21 (January-February), pp. 43-46 (Published by Voluntary Health Association
of India, New Delhi).
Qadeer, I. (1995) National Tuberculosis Control Programme — A social perspec
tive. Health For the Millions 21 (January-February), pp. 10-13 (Published by
Voluntary Health Association of India, New Delhi).
Rose, G. (1992) The Strategy of Preventive Medicine. Oxford: Oxford Medical Pubheat ions, pp. 1-138.
Sadagopal, M. (1983) Health care versus the struggle for life. Medico Friend Circle
Bulletin. No. 93 (September), pp. 1-5, and No. 94 (October), pp. 2-5 (Pubfished by Medico Friend Circle, Bangalore).
/
Uplekar, M. and Rangan, S. (1996) Tackling Tuberculosis: The Search for Solutions.
Bombay: The Foundation for Research in Community Health.
Voluntary Health Association of India (1994) A Report on the National Consultation
on Tuberculosis. New Delhi: Voluntary Health Association of India.
Voluntary Health Association of India (1996) Tuberculosis: A Critical Public Health
Challenge (ANUBHAV Series). New Delhi: Voluntary Health Association of
India, pp. 1-28.
World Health Organization (1995a) Stop Tuberculosis at the Source: WHO Report
on the Tuberculosis Epidemic. Geneva: World Health Organization.
World Health Organization (1995b) Tuberculosis Fact Sheet No. 93. Geneva: World
Health Organization.
World Health Organization/UNAIDS (1996) Tuberculosis in the Era of HIV. Geneva:
World Health Organization.
I
TWiTBT
Ill II HIM III III I
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i
Dr.G.Visweswaraiah
Hon.Secretary, KSTBA.
Karnataka State Tuberculosis Association, Bangalore.
Understanding the Nature and magnitude of TB in India and Karnataka
Tuberculosis in India happened to be the major public health problem. The National
sample survey was conducted in India in 1955 - 1958, as per the report of NSS
prevalence of Tuberculosis was 20 /1000 and incidence of Bacillary Tuberculosis Cases
was 4 / 1000. Men are more suffering than women, old age than young age. The
distribution of Tuberculosis is almost equal in urban and rural areas. However since 4
times the population lived in the villages than the urban areas. The burden of
Tuberculosis in the rural areas could be 80% as compare to that of about 20% in urban
areas. This means that the resources for the control programme has to be reallocated
proportionately.
40% of Indian population are infected, by TB in the community . Among the infected
10% of them may get TB at any time during their life time, if their natural resistance to
the disease is reduced.
14 million Tuberculosis patients are there in India. Out of this 3.5 million are actually
coughing out TB Bacilli in their sputum for the spread of Tuberculosis in the community.
.5million ( 5 lakhs) deaths are caused by tuberculosis. One TB patient can spread the
disease to 10 - 15 healthy persons in a year. Thus there are 10 lakhs of new TB
patients added every year. One person in India die of TB every minute.
Tuberculosis is killer number one in the community. Of every 100 death due to all
causes in the community 10 are estimated to be due to infectious forms of pulmonary
tuberculosis. There could be many more deaths due to TB in children.
Tuberculosis
causes more deaths in women in child bearing age and even among the men in the
productive age group of 15 - 49 years
( productive age group ).
■
■
Proportion of Tuberculosis cases remains same year to year
Every year 1 / 3 of existing cases either die or cure . But the same number join the
existing cases maintaining the same number in the community.
National Tuberculosis programme ( NTP) was started in the year 1962 in India to meet
the felt need of patients in community. It could not achieve its objectives as there was
30% treatment completion and 70% were dropouts and with other technical,
administrative and inadequate budgetary outlet^ It was reviewed by a committee of
National and International experts in 1992 as a failure programme. The WHO declared
tuberculosis as the global emergency in the year 1993 and formulated the Revised
National TB Control Programme ( RNTCP) providing all feasible requirement to run the
RNTCP in India in a phased manner in the states, through District TB Centres, to be
delivered through the primary health care infrastructure, to achieve 85% cure rate and
to detect atleast 70% estimated smear positive Pulmonary TB Cases.
In Karnataka the RNTCP was launched in 10 districts including Bangalore Mahanagara
Palike in the first phase covering 218 lakhs population. The 12 districts were taken in
the second phase covering 257 lakhs population. The remaining 54 lakhs population
has been covered in the third phase having 5 districts in the state by the end of 2003.
I
The Role of the Private Sector in TB
Community Health Cell, June - August 2000
Notes on the Study : Non Governmental Organizations in Tuberculosis Control: A
study in Western India (by Sheela Rangan, Aditi Iyer, Sushma Jhaveri)
Objective :
To investigate the role of the Private Sector in Tuberculosis control. This includes
launching an organized effort aimed to understand the nature and role of the private
sector in health care in the arena of Tuberculosis control. (TB control has three main
parts : case finding, treatment, and case holding. The private sector would be defined as
including non governmental organizations (NGO’s), including voluntary organizations,
for-profit establishments, grant-in-aid funded projects and finally a range of private
physicians who practice anything from tribal to allopathic medicine.
Importance of Understanding this Project:
Although the National Tuberculosis Program (NTP) has been in existence for
more than 30 years, many health care providers and patients are unaware of the benefits
and reaches of the program, thereby encouraging the notion that the programs must be re
vamped and revitalized. The focus of the revitalized programs is the detections of at least
70% of the incident cases and ensuring cure of 85% of the detected cases. (This is what is
projected to favorably alter the course of TB worldwide) In addition, plans are underway
to involve the non governmental sector (NGO’s), voluntary and non-profit sectors that all
constitute the private sector. NGO participation in the social sector ranges from
assistance to policy making to actual field based service delivery.
With the onset of HIV, TB has renewed global interest, and a large percentage of
cases occur in India. However, despite the urgency of prudent action, a lack of interest
has rendered NTP programs ineffective. Furthermore, although the Private Sector takes
care of most TB programs nationwide, they have not been involved in the NTP programs.
However if their input is taken, information could be provided that would improve the
performance of the NTP as well as the quality of TB care available to patients
nationwide.
Stages in the study:
Compile complete lists of the NGO’s working in TB from lists of NGO’s in the
health field. This was then narrowed down to include those that had a significant TB
component to their agenda.
A survey undertaken using a mailed questionnaire to understand the number
of and nature of private sector health care providers as well as approaches to
TB control, (obtains a directory of NGOs in the area with their profiles)
Case studies of a few selected NGO’s to document the effectiveness and
implementation of TB control programs, (from this, a detailed report can be
prepared identifying the strengths and weaknesses)
Here, it is important to document the foilwing categories :
Exact response rates (% replied, etc)
t
The Role of the Private Sector in TB
Community Health Cell, June - August 2000
Location / Geographical Distribution (Rural/Urban ... etc)
Source of Funding for NGO’s (including individual donors, state govt, and
municipal govt., international funding agencies, other NGOs, central govt.,
public/private corporation, etc)
Nature of Support Received from the Government (including supply of drugs,
grants, supply of stationary, deputation of workers, etc)
Nature ofTB Work (including only providing assistance, only case finding ,
only follow-up, case finding and treatment, treatment and follow-up, only
health education, case finding, treatment and follow up )
Case Load and Number ofNew Patients registered in Previous year, and
Case Detection.
Diagnosis, Treatment and other Facilities (including X-rays or Sputum
examinations conducted by organization, referred to private laboratories, or
referred to government facilities.
Treatment Methods of TB Patients (Regimens, Medicines, etc)
Case Holding and Methods to Improve Regularity and Treatment Adherence
Comparative Performance of NGOs and State TB Programs
Nature ofAssistance Provided to Patients
Problems in Conducting Cohort Analysis :
Poor Record Keeping contributed to the majority of problems in the study
o Treatment Outcome was not usually recorded . This leads to
inaccuracies in completing optimum period of treatment (COPT)
numeric values.
o Cohort analysis was not restricted to sputum positive patients and so
it’s all bunched up.
o No continuity in collecting sputum samples. Hard to get patients to
comply when treatment starts to work As a result, the cure rates could
not be accurately assessed in all cases.
Important as a factor in the NGOs that deal with TB include the case load that they
handle (usually from a third to a half of all state cases), the amount of reach that they
have the urban and rural areas, as well as their infrastructure and ability to handle
massive loads of cases. Many NGO’s have more of a clinical approach rather than a
public health approach : in these cases, there is not much concept of case holding nor
treatment completion rates. The emphasis is placed on case detection.
Not many of the NGOs deal only with TB cases — here, TB is usually only a component
of the overall health activities. Some of the NGO approaches to tackling TB included :
Institution/Hospital/Clinic Based Programs : outreach programs from clinics,
hospitalization facilities and ambulatory treatment,
Use of Community Based Workers in well integrated programs : incentives
were given to workers for case finding and treatment completion. This was
found to be fairly successful provided that there was adequate monitoring and
supervision.
*
The Role of the Private Sector in TB
Community Health Cell, June - August 2000
Using Public Health Services and dependence on governmental services, (i.e.
diagnostic and treatment facilities), but taking care of the drug dispersion.
This lead to higher treatment completion rates.
Involving Private Doctors : trying to including this sector in the TB program
by setting up a proper referral system.
There is a hesitation in relying on sputum examinations for the diagnosis of TB, and
patients prefer the chest X-Ray.
i
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Bangalore Mahanagara Palike
Society for Revised National
T.B. Control Programme
Dot Directory
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BANGALORE MAHANAGARA PALIKE
R.N.T.C.P.
opulation
50 Lakhs
No of T.B. Units
7
Formation of T.B. Society
No. 145/97-98, Dated 19-06-97
No of D.M.C
36
No of Dot Centers
133
Health Facilities
1)
General Hospitals (Govt.)
4
2)
General Hospitals (NGO)
5
3)
No of Mat. Homes
31
3)
No of Health Centers
75
4)
No of P.H.U. Govt, of Karnataka-
21
5)
No of Anganavadies
350
BANGALORE MAHANAGARA PALIKE SOCIETY
FOR R.N.T.C.P.
Bangalore
Dated :19-06-97
Registration No.: No.145/97-98
Chairman
Commissioner
Bangalore Mahanagara Palike
Vice Chairman
Chief Health Officer
Bangalore Mahanagara Palike
Member Secretary Project Co-ordinator T.B
Member
Bangalore Mahanagara Palike
1) Joint Director (T.B) LWSTC, Bangalore.
2) Director, National Tuberculosi’s Institute, Bangalore.
3) Chief Auditor, Bangalore Mahanagara Palike.
4) Surgeon, Bangalore Mahanagara Palike.
5) Chief Accounts Officer, Bangalore Mahanagara Palike.
6) Hon. Secretary, K.S.T.B.Association, Bangalore.
7) Director, Hope Foundation, Bangalore.
8) Executive Engineer, Bangalore Mahanagara Palike.
BROAD WAY UNIT
CENTERS
DR.NAME
LAB-TECH
ADDRESS
Broadway T.B. Disp.
Dr. Gayathri Devi
Prabhakar
Behind C.S.I. Hospital
5551442/3476217 (R)
Broadway Road,
Shivaji Nagar.
STLS: Etsy Abraham
STS : Guruprasad M
MICROSCOPIC CENTRES
.. Broadway T.B. Disp.
Dr. Gayathri Devi
Prabhakar
5551442/3476217(R)
2. Coxtown Mat, Home
Dr. Girija
Behind C.S.I. Hosp.
Broadway Road.
Sugandhi
5486091
Coxtown Main Road
Opp. Market, B’lore.
5484373 (R)
3.D.J. HalliM.H.
Chamundeshwari
Dr. Rabat
5469931/3536147 (R)
4. Thimmaiah Road M.H.
Dr. Chandrashekar
Theatre, DJ.Haiti.
Jyothi
Sepping Road Cross,
5510551/5658080 (R)
5. B.S.A.Road, Dispensory Dr. Gayathri Devi
Behind Anand
Thimmaiah Road.
Srinath
3476217(R)
Tannary Road,
Near Ambedkar Statue
Bangalore.
DOT CENTRES
1.K.G. Haiti H.C.
Dr. Sarojini
Behind K.G.Halli, PHC.
3102387
2. Taskar Town H.C.
Dr. Kalavathy
Behind Shivajinagar,
Police Station,
Habeeza School.
3. Nehrupuram Disp
Dr. Narayan swamy
Near Mosque
3476217 (R)
4. Robertson Road, H.C.
Dr. Shobha
Behind Ashoka Theatre
5490278
1
5. Bagalur Layout H.C.
Dr. Nayan Thara
5490851 (R)
Opp. Charles School
6. Coxtown Disp.
Dr. Girija
Coxtown, M.M.Road.
7. Frazer Town P.H.U.
5486091
Dr. Kalyani
8. Vasanth Nagar Disp.
8460636 (R)
9. Ambedkar Medical College
Dr. Huliraj
10. Bowring Hospital
Dr. Chandramma(Supt.)
Vasanth Nagar,
Near KodavaSamaj,
Shampur Main Road Busstop.
Shivaji Nagar, Kamaraj Road.
Bradway Road, Shivaji NagarPolice Station.
11. Aurvedic Disp.
12. Unani Corporation Disp.
Kamaraj Road
13. Velu Mudhaliyar Disp.
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CENTERS
HANUMANTH INAGAR
DR.NAME
LAB-TECH
Hanumanth Nagar Disp. Dr.MohanKumar
ADDRESS
Opp.Gavigangadhareshwara
Niloferjan
Temple, Gavipuram, B’lore.
Stls: Dasegowda K.
Sts : Babu.H
MICROSCOPIC CENTRES
1. Hanumanth Nagar Disp.
2. Azad Nagar Mat, Home
Dr. Mohan Kumar Niloferjan
Dr.Usha
Opp.Gavigangadhareshwara
Latha Kumari
Temple, Gavipuram, B’lore.
Mysore Road
I
Vasudha
Near Gavigangadhara Temple
Indira
Mysore Road, Sirsi Circle
Brunda
J.J.R.Nagar
6744175
6611087 (R)
3. Gavipuram Guttahalli M.H. Dr. Sridevi
6611231
4. Sirisi Road Mat. Home Dr. Indira
6703533
5. Goripalya Mat. Home Dr. Nalini Kumari
6748467
Bangalore -
DOT CENTRES
1. Bapuji Nagar H.C
Dr. Bhagyalaxmi
Bapuji Nagar
6748450 (R)
2. Avalahalli H.C
3. Vidhyapeetha H.C.
Dr. Muktha Bai
Avalahalli, Near
6696856 (R)
Venkateshwara Theatre.
Dr. Anusuya
Vidhyapeeta Circle
6525523 (R)
4. Panthra Palya H.C.
Dr. Sudha
Mysore Road, B-26.
3355668(R)
5. Gangondanahalli H.C.
6. Bangarappa Nagar H.C.
Dr. Surekha
Azeezsait, Industrial Area
6741267(R)
Mysore Road, Bangalore.
Dr. Padmavathy
Rajarajeshwari Nagar,
8602450 (R)
Bangalore.
7. Mallathanahalli H.C.
Dr. Shailu
Opp. Ambedkar Engineering College
S.T.R.MillH.C.
Dr. Muktha Bai
Near Dobhi Ghat,
Opp. Green Park, Srinagar.
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CENTERS
HOSAHALLI T.B.UNIT
DR.NAME
LAB-TECH
SukanyaG.
Hosahalli Referal Hospital Dr.Susheelamma
(Suptd.)
3300812 (R)
3350810(0)
Stls : Santhosh Kumar D.
Sts : Ramesh H.C.
ADDRESS
M.C.Layout,
Near Jai Munirao Circle,
Vijayanagar, B’lore.
MICROSCOPIC CENTRES
1. Hosahalli Referral Hosp. Dr.Shivanandha Sukanya
3350810
2. Kamakshipalya H.C.
Dr. Shoba
3. Rajajinagar Mat. Home Dr. Mangala
(Dr.H.Nagaraj Memorial 3352215
Hospital)
4. Magadi Road Mat.Home Dr. Thriveni
Mat. Home
3350282
Lokesh
Suguna
Chandrakala
M.C.Layout,
Near Jai Munirao Circle, ’
Vijayanagar, B’lore.
Kamakshipalya,
Opp.Rudreshwara Takies
Magadi Road, B’lore.
Near Bashyam Circle,
3rd Block, Rajajinagar,
Bangalore-10.
Magadi Main Road,
2nd Cross, B’lore.
DOT CENTRES
1. Govindaraj Nagar H.C.
2. MoodalpalyaH.C.
Dr. Komala
3380546
Dr. Dhanalakshmi
3287465 (R)
3. A.D. Halli H.C
Dr. Poornima
3380004 (R)
5. Rajajinagar P.H.U
Dr. Yogi raj
6. Police Colony P.H.U
Dr. Ramdev Naik
7. N.P.K, P.H.U
Dr. Mahendra
8. Nandini Layout H.C.
Dr. Bharathy
9. Suraksha
Dr. Harinikakkeri
lO.Geleyara BalagaH.C.
Dr. Shivananda
6
Near Mahalakshmi Temple
Govindaraj Nagar, B’lore.
Saraswathi Nagar,
Near Kanaka Nagar Slum,
Moodalapalya, B’lore.
Near RBI Colony, A.D. Halli,
Basaveshwaranagar, B’lore.
z
I
Near ESI Hospital, llnd Block,
Rajajinagar, Bangalore.
Police Quarters Compus,
Magadi Road, Tollgate, B’lore.
Beggar’s Colony, Magadi Road,
Tollgate, Bangalore.
Slum Board Quarters Campus
Nandini Layout, Bangalore.
Near last Bus stop, Kamala
Nagar, B’lore.
Near Geleyara Balaga Bus Stand,
Mahalakshmi Layout, Bangalore.
Hosahally Mat.Home. T.B.Unit
M.C.
6
Dot Centre
f
KamakshiPalya
I
X6
Hosahalli
Mat.Home
E.S.I. Hosp.
A A.D.Halli
QH.C.
Govindarajnagar
Disp. /\
Mudalapalya
H.C.
Vijayanagar
Mat.Home
xa
Magadi
X/
Rajajinagar Mat.Home
Okalipuram
JAYAWAGAR T.BJJINiT
CENTERS
DR.NAME
LAB-TECH
ADDRESS
Jayanagar Dispensory
Dr. Mahadevaiah
6564172(R)
Bharathi
Ashoka Pillar,
Kanakanapalya,
Jayanagar, B’lore.
Stls : Ravi K.M.
Sts: Pundalika A.N.
6. Thavarekere H.C.
Dr. Renuka Rani
Last Bus Stop Thavarekere.
7. Yelachanahalli H.C.
Dr. Anitha
Kanakapura Main Road,
6669717(R)
Bangalore.
< *
8. Uttarahalli H.C.
Dr. Latha
Uttarahalli Last
Bus Stop, B’lore.
i
9. Yarab Nagar H.C.
Dr. Shobha
Near Masjid & Monotype
Bus Stop, Banashankari,
II Stage, B’lore.
W.Rupena AgraharaH.C
Dr. Sanmithra
Bommanahalli
Main Road, B’lore.
11. Arakere
Dr. Viji
Near Belikalli,
Bannerghatt Road, B’lore.
12.N.S. Palya
Dr. Veena
Bannerghatta Road,
B’lore.
MICROSCOPIC CENTRES
Ashoka Pillar,
Kanakanapalya,
Jayanagar, B’lore.
Dr. Mahadevaiah
6586644 (R)
Bharathi
2. Wilson Garden
Mat. Home
Dr. Parvathy
2236891
Jabeen Taj
Near Police Station
Xth Cross, Wilson
Garden, B’lore.
3. Yediyur Mat. Home
Dr. Prakash
Shashikala
Near Deepak Nursing Home.
Yediyur, B’lore.
1. Jayanagar Disp.
6769886
4. Banashankari
Mat. Home
Dr. Prema (Suptd.)
6716596
Vijayalaxmi
Near B.D.A. Complex &
Police Station,
Banashankari llnd Stage.
5. Madiwala Disp
Dr. Ramadevi
Ramesh
Near Madivala,
Hosur Road.
DOT CENTRES
Near Bus Stop,
j
Kumaraswamy Layout,
Bangalore.
1. Kumaraswamy Layout H.C.
Health Centre
Dr. Anuradha
2. C.T. Bed H.C.
Dr. Prathiba
Near SSV School,
B.S.K. Thyagaraj Nagar, B’lore.
3. J.P.NagarH.C.
Dr. Radha
Near KEB Office, 6th Phase,
J.P.Nagar, B’lore.
4. GandhiBazar Disp.
Dr. Saraswathi
Near Vegetable Market,
Gandhi Bazar, B’lore.
5. Agara H.C
Dr. Nirmala
Last Bus Stop Agara,
Surjapura RoadBangalore.
6667827
8
9
Jayanagar T.B. Unit
M.C.
Wilson Garden
Mat. Home
Dot Centre
■L 6
Jayanagar Gen.
Hosp.
N.R.Colony
Mat. Home
? •
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1 6
X 6
Jayanagar
Mat. Home &
Disp.
X6
Vidyapeeta
HC- 6
Yediyur
Mat. Home
X 6
Thavare Kere
H.C.
6
Madlwala
Dlsp.
J.P.Nagar
Yediyur
Mat. Home
Kumar Swamy
Layout
.
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NEELASNDRA T.B. UNIT
CENTERS
DR.NAME
LAB-TECH
ADDRESS
Neelasandra Disp.
Dr.Ragunath War Wattli
Devika
Anepalya Road,
Opp. Military Policegate,
5296360(R)
Neelasandra, B’lore.
StlsUsha R.
StsGovindarajulu G.R.
MICROSCOPIC CENTRES
1. Neelasndra Disp.
Devika
Dr.Ragunath War Wattli
Bangalore.
5296360 (R)
2. Audugodi Disp.
Anepalya road,
Ramakrishna Hosur Road,
Dr. Padmavathy
Post Office Beside,
5531318 (R)
Audugodi, Bangalore.
Susheela
3. Shanthi Nagar
Dr. Shantha Kumari
Mat.Home
2239534/2228904 (R)
4. UlsoorMat.Home
Shanti Nagar, B’lore.
Shobha
Dr. Lakshmamma
Near Nanjappa Circle,
Cambridge Road,
Near Police Station,
5551324/6521649 (R)
Ulsoor, Bangalore.
^^istin Town
Mat.Home
Annapoorna
Dr. Sarojini
5514464/2273040 (R)
Near Bus Stand &
Ambedkar Statue,
Austin Town, Bangalore.
DOT CENTRE
1. Kodihalli H.C.
Kodihalli Bus Stop,
Dr. Shobha
Airport Road, Bangalore.
2. Vibhuthipura H.C.
Dr. Kalpana
Annasandra Palya,
5231968 (R)
Vibuthipura, B’lore.
11
3. Byappanahalli H.C.
4. L.R.Nagara H.C.
5. Sonnenahalli H.C.
Dr. Lakshmi
Near Rly. Level Crossing
5268526/5491260 (R)
Byappanahalli, B’lore.
Dr. Manjula
Near National Game H/B
5714460
Bangalore.
Dr. Dhanalakshmi
Vivek Nagar Bus Stop,
Bangalore.
6. Murphy Town H.C.
Dr.Sunitha
Near Murphy Town Market,
5241930/5244551 (R)
Bangalore.
7. Bhuvaneshwari Nagar H.C. Dr. Vedavathi
8. Audugodi H.C
9.0.M.S. Hospital
Near Nagawara Palya
2233600/5280458 (R)
C.V.Raman Nagar Bus Stop.
Dr.Manjula
Koramangala Road,
3372018(R)
Bangalore.
Dr. Malikarianna (Supt.)
Old Madras Road,
Bangalore.
10. St. John’s Medical College Dr.George
Koramangala,
Chest Clinic, Room No.5
5530724
12
Bangalore
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LWSTC - T.B. UNIT
CENTERS
DR.NAME
LAB-TECH
ADDRESS
LWSTC - TU
Dr. Vijayalakshmi
2267093
Mallannachar
K.G.Road,
Opp.Sagar Takies,
Bangalore.
Stls: B. Shashikumar
Sts : D. Lashmanarao
MICROSCOPIC CENTRES
1) Dasappa Mat. Home
Dr. Ambika
2220584
2) Manavarthpet Mat.Home
Dr. Chandrakala
6700832
3) Pobbathi Mat.Home
Dr. Geetha
S.J.P.Road,
A
Near Town Hall,
Bangalore.
B.N.Premalatha Near K.V.Temple&
Balepet Circle,
Bangalore.
Sajjan Rao Circle,
Sowbhagya
V.V.Puram, B’lore.
Ramakrishna,
6675277
Dr. Shashikala
Micro Biology
Near Lions Eye Hosp.
Siddaiah Road, B’lore.
Nrupathunga Road,
2275081
Dr. Veena
B’lore.
4) H.Siddaiah Road Hospital Dr. B.Sarojamma Manjula
5) St. Marthas Hospital
6) Victoria Hospital
Micro Biology
Dr.Ravindra
Lect.Dept.of Medicine Room No. 15
Near City Market,
Bangalore.
7) Kempegowda Institute of
Dr.Neelakantachar Micro Biology
Dept.of Medicine
Near Makkala koot;
Bangalore.
Medical Science
TB & Chest.
DOT CENTRES
1) MavallyP.H.U
J.C.Road, Near Minerva
Circle, Bangalore.
Dr.Rajanna
2) Ganigarapet P.H.U
3) Kalasipalyam P.H.U
Dr.Veerashetty
14
Opp. Cauvery Bhavan,
Bangalore.
Kalasipalyam Bus
Stand, Bangalore.
DOT CENTRES
4) Cottonpet Mat.Home
Dr.Chandrakala
Adinarayana gudi
6699832
Street, Cottonpet Main
Road, Bangalore.
5) Director of Health Services
Dr.Prabhudev
Anand Rao circle.
Directory of Health
Campus Disp.
Services Campus, Bangalore.
6) Anjanappa Garden Health Centre
Dr. Jalaja
Near Banana Mandi,
Binnypet, Bangalore.
/^btoria Hospital
Dr.Ravindra
Room No. 15
(Lect.Dept.of Medicene)
Micro Biology Dept.
Victoria Hospital.
8) Kims
Dr. Neelakantachar Near Makkalakoota, Bangalore
(Dept, of Medicine
TB & Chest desease)
9) H. Siddiah Road Refral Hospital
Dr. B. Sarojamma
Near Lions Hospital,
Siddiah Road, Bangalore.
11) Pobbathi Mat.Home
12) Dasappa Mat.Home
13) St.Marthas Hospital
Ph:2235037
Dr.Geetha
Ph: 6675277
Dr.Ambika
Ph: 2220584
Dr.Shashikala
Sajjan Rao Circle, V.V.Puram.
S.J.P.Road, Near Town Hall,
Nrupathunga Road,Bangalore.
Ph:2275081
Opp. Cauvery Bhavan
14) Gangigarpet P.H.U
Bangalore.
15) Mavally P.H.U
Dr. Rajanna
Near Minerva Circle,
Bangalore.
16) Kalasipalyam P.H.U
Dr.Veera Shetty
Near Kalasipalya Bus Stand.
17) Cottonpet Mat.Home
Dr. Chandrakala
Adinarayana Gudi Street,
Ph:6699832
Cottanpet Main Road, B’lore.
Dr.Prabhudev
Campus Dispensory
18) Directory of Health Services
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YESHWAKTHPUR T.B.UMT
CENTERS
DR.NAME
LAB-TECH
ADDRESS
Yeshwanthpura
Dr.Usha Javali
Thara
Yeshwanthapura,
Mat.Home
3372940
Near Railway Station.
Stls : Mohan Shankar D.
Sts : Surendra Naik
MICROSCOPIC CENTERS
^Jjeshwanthapura
Dr.Usha Javali
Mat.Home
3590333 (R)
Thara
Yeshwanthpura,
Near Railway Station.
3372940 (Hosp.)
2) P.G.Halli Mat.Home
Dr.Najrath Banu
Vijaiya
Near N.T.I, Ballari Road,
Mohan
Near Police Station,
3447672
3) Sri Ramapura
Mat.Home
4) Ganganagar
Mat.Home
5) M.R. Palya
Mat.Home
6) K.C.General Hospital
Dr.Fathima
3128447 / 3631906 (R)
Dr. Jayanthi
Sri Rampura, B’lore.
Srivas Kashyap Near Bus Stop
Ganganagar, B’lore.
3338373 / 3314883 (R)
Vijayalaxmi
Dr.Sarojini
Near Ganesh Temple,
3332891/3436242 (R)
M.R.Palya, B’lore.
Dr. Jagadish (supt.)
Near Police Station,
Malleshwaram, B’lore.
Mathikere, Gokula, B’lore.
^^.S.Ramaiah Hospital Dr.Mohan Rao
DOT CENTRE
D
Kodandaramapura H.C.
Dr. Sadhana
Malleshwaram, B’lore.
9845012015
2)
Nelmaheshwari H.C.
Dr. Manjula
T.Dasarahalli Temple,
Bangalore.
3)
4)
Mallasandra H.C.
Shankar Pura H.C.
Dr. Shobha
Hesarghatta Road,
3305345 (R)
Bangalore.
Dr. Sumithra
Mahalakshmi Layout,
3323611 (R)
Bangalore.
17
5) Laggere H.C.
Dr. Annapoorna
Laggere, Bangalore.
6) PeenyaH.C.
Dr. Mamatha
Peenya Entrance,
6529253 (R)
Bangalore.
Dr.Nirmala Buggi
M.R.Palya
6715596
Bangalore.
Dr.Uma
Yalahanka Upanagara,
3492039 (R)
Bangalore.
Dr.Usha Rani
Vidhyaranyapura,
3417779(H)
Bangalore.
Dr. Mala
Vidhyaranyapura,
3535030(H)
Bangalore.
Dr.Amitha
Yelahanka.
7) M.R.PalyaP.H.C
8) AtturH.C.
9) TavidlaH.C.
10) M.S.PalyaH.C.
11) Kodige Halli H.C.
W
5483248(H)
12) Cholanayakanahalli H.C.
Dr. Pramila
Cholanayakanahalli,
5522228(H)
Bangalore.
Dr.Sumithra
Shankar Nagar,
3323611 (R)
Bangalore.
Dr.Fathima
Gayathri Nagara,
3631906
Bangalore.
Dr.Sandhay
DinnurMain Road,
3535326
Bangalore.
Dr.Sujatha
Byatarayanapura,
3341245
Bangalore.
17) Okalipura H.C. (Lions)
Dr.Mangala
Sriramapura, B’lore.
18) MariyappanapalyaH.C
Dr.Sapna Revadi
Devaiah Park,
6722221
Sri Ramapura, B’lore.
Dr.Savitha
Near Keshava Theatre,
3386573
Mathikere, Bangalore.
13) Ashokapura Disp.
14) Nagappa Block Disp.
15) Sulthanpalya H.C.
16) Amruthahalli H.C.
19) Mathikere H.C.
18
A
Yeshavanthapura Mat.Home. T.B. Unit
^M.C.
Dot Centre
a
H.C.
Laggere
H.C. Nandini
Layout
CD
Muthyal Nagar
H.C. Mathikere
6
6
Yeshavanthapura
Mc-Mat.Home
I
H.C. Mahalakshmi
Layout
H.C. Heggana Halil
6
Ashoka Pura
Disp
Sri
Ramapura
Mat. Home
Suithan Palya
H.C.
16
Munireddy Palya
Mat. Home
J-6
Ganganagar
Mat.Home
K.C.General
Hosp.
|^| P.G.Hally
Mat.Home
Ramachandra Pura
H c fz)
16/
Position: 2567 (2 views)