Potentials of Case-finding and case holding through
operational studies conducted by National TB Institute (NTI) and
elsewhere have been quantified. The potential of case holding is
not satisfactory and needs revision of strategy to obtain better
treatment completion. The present report reviews the programme in
its ability to meet the potential in Case-finding and treatment
(CFT), and bring about a reduction in the problem. Outcome at the
current levels of efficiency of activities as well as following
hypothetical changes in them, are studied. Further it identifies
the areas for carrying out studies on structural changes to be introduced
in the programme, so as to obtain higher results in terms of epidemiological
gains.
A set of hypothesis which have been used in constructing
the model are based on the currently available information on the
epidemiology of tuberculosis and performance of the programme. An
average Indian district as per 1991 census is considered to have:
(a) a population of 1.9 million; (b) 6460 smear and culture positive
patients (prevalence rate of 4 per thousand) in all at any time;
(b1) 2584 of the prevalence cases are smear positive; (b2) 2196
newly occurring cases every year (annual incidence of 34% of prevalence);
(b3) 879 of the b1 being the annual incidence of smear positive
cases; (c) 3230 of the prevalence cases who present themselves for
diagnosis (50% of b); (d) 2584 can be diagnosed if all the available
PHIs participate in the programme as per the manual. This is
called Case-finding potential (CFP). The Case-finding Efficiency
(CFE) is expressed as a proportion of the cases being diagnosed
out of the CFP by a DTP. The current CFE is calculated at 36% of
CFP, as 936 cases are being diagnosed (as per the periodic DTP reports
prepared by NTI). The result of treatment at the current treatment
efficiency TE1 for the cases on Standard Regimen (SR) (Compliance
45% at level 4) is 50%, TE2 for those on SCC (compliance 56% at
level 4) is 79%, TE3 WHO recommended 85% cure rate (compliance level
and regimen not stated). DTP efficiency (DTPE) is the proportion
of cases which could be cured with the respective TE, calculated
out of the CFP. DTPE under SR l8%, under SCC is 28.44%.
Epidemiological impact is calculated while
taking into consideration the natural dynamics of tuberculosis without
intervention and the dynamics of the programme where the cases are
diagnosed and treated with SR under the current efficiency, the
same is computed for the patients treated with SCC with present
level of efficiency. The cure and death rates among treated cases
is added to the natural cure without a programme (Case fatality
rate of 14% and cure rate of 20% is equal to 34% of incidence rate
which keeps the prevalence rate unchanged in natural dynamics).
With all the cases treated with SR, programme appears to show a
problem reduction of 4.6% annually and with SCC of 6.5%. The latter
shows a relative benefit of 41% over the former besides causing
prevention of deaths at the end of treatment.
Addl decline alternative in question
------------------------------------------------- X 100
Relative
Benefit
Decline with 36% CFE & on SR with 45% compliance
level IV
Intervention alternatives with fixed CFE by raising
compliance level 4 from 45% to two higher levels to 70% and 90%,
are studied. They give an additional decline of 2.1% and 3.0% respectively.
While raising compliance level 4 of patients on SCC from current
56% to 70% and 90%, the additional decline is marginal (2.6% &
2.9%). At the same time raising the compliance to the level 4 is
not only operationally a difficult task but does not commensurate
with epidemiological gains also.
Intervention Alternative Recommended by WHO
: To further epidemiological gains, it is obvious that CFE also
needs to be raised. The WHO has recommended the target of CFE as
70% of all smear positive cases, TE as 85%. For this alternative,
DTPE is 59.5%; epidemiological gain 13.7%, additional decline 9.5%
on SR with 45% compliance level and relative benefit of 206.5%.
This alternative appears to be feasible provided coverage of implementation
of PHIs and treatment compliance are high and use of SCC regimens
in the programme are ensuring for such achievements.
Operational Alternatives on Improving Treatment
Compliance To improve treatment compliance level it is essential
that patients are treated free, get supply of drugs regularly as
near to their homes as possible and may be given supervised treatment
specially in the intensive phase. Recent development of infrastructure
makes it possible to consider alternatives to ensure the supply
of drugs close to patients residence. Some of the health functionaries
below the level of PHIs are: Health Worker (HW) Anganwadi Worker,
Dai (Traditional Birth Attender), Community Health Volunteers (CHV)
and Private Practitioner. The possibility of involving them in some
or other manner in tuberculosis treatment activity under a programme
may be explored.
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