Bharathi Jones: NTI Newsletter 1981, 18, 22-26.

Under the District Tuberculosis Programme, the key personnel at the District Tuberculosis Centre are expected to supervise the Peripheral Health Institutions (PHIs) periodically in order to assess and improve the programme activities. A supervision form is used for the purpose of recording the observations made during supervisory visits. This procedure is subjective and does not offer an objective assessment. In this paper, an objective scoring method has been described for supervision of PHI laboratories. The total score suggested is 200 which is apportioned as follows: cleanliness-15, registration & recording-35, sputum collection-10, smear preparation-30, staining-35, microscopy-35, and maintenance of microscope-40. Each category in turn is subdivided according to specific task performed. Minimum satisfactory score is 75% for each topic individually. High level of efficiency is thus recommended, as microscopy is the mainstay in casefinding of tuberculosis. A similar scoring procedure can also be used at the State TB Centre for the purpose of supervising the DTCs. However, this is only a quality control procedure and does not reflect the quantum of work.


P Jagota, AK Chakraborty & VH Balasangameshwara: NTI Bulletin 1993, 29, 1-9.

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.