There is a wide spread prejudice among the staff of health centres that patients invariably prefer injection and it was felt by many health workers that streptomycin containing intermittent regimens would be more acceptable to rural patients. A study was carried out to find out the acceptability and applicability of an intermittent supervised drug regimen containing streptomycin 1 gm and INH 650 mgm once a week in a rural area as well as the regularity with which the rural folk took this treatment. Association between the observed regularity and factors like age, sex etc., was also analysed. 107 rural patients of tuberculosis, diagnosed at 5 taluk hospitals in Ananthapur district of Andhra Pradesh on the basis of sputum examination by direct smear and/or X-ray examination with the help of mobile X-rays, consented to treatment with intermittent regimen mentioned above. About half of them were new patients and the rest were old patients who were mostly regular on an earlier oral regimen. 94 of the above were available for analysis.

The regimen was found quite practicable in the sense that at no centre the study was interrupted or discontinued because of the inability of the health centre staff to give injection. If regularity is expressed as a proportion of patients who at any given time had taken the optimal amount of treatment (no. of injections), then 40 patients (42%) were found regular on the intermittent regimen, 36 patients were classified as lost and the remaining had 3 or less injections due and had not yet had the chance to become lost according to the definition adopted. Thus, the regularity of those accepting the regimen was quite low. There was very steep fall in regularity during the first 10 weeks of treatment, nearly a half of the total cases became irregular during the first 6 weeks. Beyond 4 months of treatment, patients who continued to attend centres regularly for treatment became negligible, thus pointing that injection was not a key variable in the treatment regularity of tuberculosis.

In the formulation and evolution of a National Tuberculosis Programme some assumptions are made which require to be tested under the normal administrative set up with minimum interference by the investigating team. The objectives of the study were to understand some operational aspects of Case-finding in the Peripheral Health Institutions (PHIs) in an integrated programme. First, what is the frequency of persons showing symptoms suggestive of pulmonary tuberculosis among the normal out patients attendance (OPA), how many cases can be found by direct microscopy of sputum of those symptomatics, what will be the workload of TB Case-finding at a PHI and, what proportion of symptomatics will be willing to and will actually attend the District TB Centre (DTC) when referred there for X-ray examination. The study was conducted in a district with a population of 1.5 million having one DTC and 55 PHIs. 15 PHIs were selected on the basis of stratified random sampling. At each PHI an National Tuberculosis Institute (NTI) investigator worked for a period of one month. All new out patients were questioned for symptoms (non- suggestive and suggestive) and any patient with chest symptoms mainly cough for more than one week fever, chest pain and haemoptysis was subjected to a sputum examination and also referred for X-ray examination at the DTC.

It was found that 381 (2.5%) of the 14881 total new out patients of all age groups complained of cough for 2 weeks and more. From these chest symptomatics, 11% were new cases of pulmonary tuberculosis. When the symptomatics were referred for X-ray examination, although 66% agreed to go for X-ray to DTC but only 16% (of the total referred) actually went for X-ray. Each PHI had to examine only one or two sputum specimens per working day. As the study was conducted in a representative sample of PHIs for a representative duration of time, the material permits the estimation of the potential yield of cases in a District TB Programme (DTP) during a period of time (say one year). It was estimated that about 45% of the total estimated prevalence cases in a district can be diagnosed in a DTP during a period of one year, if all PHIs function according to the programme recommendations. The workload due to tuberculosis Case-finding is small and can be managed with the existing staff and Case-finding by direct smear examination of sputum at the PHI has to be relied upon.

An operational study to understand the influence of training of Peripheral Health Institution (PHI) Medical Officers (MOs) at District Tuberculosis Centre (DTC) in comparison to on the job training in their own PHIs in carrying out case-finding activity, was carried out in districts of Mysore, Mandya, Bellary and Hassan of Karnataka State in 1980 81. These districts are now being referred as I, II, III and IV respectively. From each district, 20 Microscopy Centres (MCs) were selected. All the selected MCs of the above four districts after stratified random allocation were divided into two groups, i.e., A & B. The MOs of Group A of each district were trained for 2 days in Case-finding activity at the respective DTCs by District Tuberculosis Officer and District Health Officer, while the MOs of Group B were given on the job training as per manual. In all, 108 MOs: 52 in Group A and 56 in Group B were under study. The performance of each PHI was monitored in terms of number of new Out patient Attendance, selection of chest symptomatics for sputum examination and number of smear positive cases detected, for a period of 12 months after the training.

At the end of one year it was observed that there was a boosting in case detection in districts I and III, no effect in district II and negative effect in district IV. The efficiency in districts I and III was higher by methodology A. It was enhanced from 7.6% pre-training efficiency to 16.7% after training and in district III, 18% to 65.8%. The enhancement with methodology B was from 5.5% to 8.1% in district I and from 19.1% to 43.2% in district III. The average increase by amalgamating all the four districts was from 8.5% to 17.8% with methodology A and from 9.7% to 12.3% with methodology B. There was a suggestion of better improvement through methodology A, which, however, did not attain statistical significance.

In the districts under study, Case-finding was at a very low ebb. Systematic training by either of the two methodologies, did improve the activity in I and II i.e., in two of the four districts. In districts II and IV other variables might also have been at work e.g., training variables of knowledge, skill and communication abilities of DTOs who were trainers could have influenced the outcome.

A study was designed to evaluate the outcome of holding sputum camps. The chest symptomatics referred by Peripheral Health Institutions (PHIs) to the camp were compared in terms of proportion of chest symptomatics registered and number of cases found with routine Case-finding actually carried out in the PHIs of an average District Tuberculosis Programme (DTP) and any educative effect of camp on the PHI staff. The study was carried out in 15 PHIs with wide range of performances in Case-finding. A team consisting of Medical Officer (MO), Treatment Organiser and Laboratory Technician of National TB Institute conducted sputum camps by involving the local staff and MOs of PHIs. The MOs of PHIs registered all the eligible symptomatics from the daily outpatients for a period of one month before the due date of the camp. The sputum was collected, slides prepared and patients advised to come on the camp date. A total of 528 chest symptomatics who reported at the PHIs during camp month were registered. Of them, 380 patients' sputum smears were prepared and 25 were found positive. Of the 528 symptomatics referred to the camp, only 86 (16.3%) actually turned up and 4 (16%) were positive. Prior to the sputum camp, 54 smear positive cases were diagnosed by these centres in 6 months. In the subsequent 6 months, 112 cases were diagnosed.

The study clearly shows that the efficacy of Case-finding by the sputum camp method is very low in comparison with integrated Case-finding at PHIs. More than 80% of the cases were missed by the camp by way of loss due to referral on the camp day. However, there was significant increase in the total number of cases diagnosed during 6 months after the camp, in comparison to 6 months prior to camp, thus, indicating the educative effect of the camp on the PHI MOs. The integrated sustained Case-finding activity in the PHIs cannot be substituted with the periodic Case-finding camps or holding of 'specialised clinics'.

This is a conceptual account of the District Tuberculosis Control Programme. The District Tuberculosis Programme (DTP) was formulated by the National Tuberculosis Institute in 1962 to form the basis of a community-wide programme to deal with the challenge of a large, predominantly rural tuberculosis problem in the country. The limited resources in the form of funds, trained personnel and equipment, made it necessary that the programme be simple, easy to apply and widely acceptable.

The DTP includes provision for tuberculosis Case-finding, treatment and prevention throughout the district from the health institutions in an integrated manner. Case-finding is carried out among the symptomatics attending the health institutions primarily by sputum examination and treatment is offered on ambulatory domiciliary basis. District Tuberculosis Centre (DTC) represents the pivot around which the integrated DTP revolves. DTC takes up all the responsibilities in respect of the programme on behalf of the District Health Authority. It undertakes planning, implementation, coordination and supervision of the DTP in the entire district besides offering the usual diagnosis and treatment service to the population, under its direct care. Health institutions other than DTC which participate in the DTP are called "Peripheral Health Institutions" (PHIs). These are categorised into "Microscopy Centres" and "Referring Centres" depending upon possession of microscope or otherwise. Both categories are full-fledged "Treatment Centres". Sputum examination is offered to all chest symptomatics reporting at "Microscopy Centres" and if found positive for AFB the patient is motivated and put on treatment immediately. DTC maintains the important "District TB Case Index" and offers "referral" X-ray examination to the sputum smear negative symptomatics referred by the "Referring Centres". One BCG Vaccination Team also works under DTC. There is one DTC in a district and the already existing TB clinics become just one of the PHIs under one DTC. Key staff consisting of a District Tuberculosis Officer (DTO), a Treatment Organiser (TO), a Laboratory Technician (LT), an X-ray Technician (XT), BCG Team Leader and a Statistical Assistant (SA) are required to provide service from the DTC and to organise the programme of Case-finding and treatment in an integrated manner throughout the district from all available institutions of General Health Services.