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.

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
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               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.