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.

The unit of NTP is known as District Tuberculosis Programme (DTP). The name is derived from the area, as each unit covers a district which is geographically, administratively, politically independent. The performance of the DTP from its inception till 1977-78 was monitored continuously by two centres, Northern Regional Centre (NRC) and Southern Regional Centre (SRC) situated in north and south India respectively. Later on in 1978 when these centres were abolished, National Tuberculosis Institute (NTI) was given the responsibility of monitoring the programme in the entire country. NTI monitors the performance of the programme through the quarterly and annual reports received from DTPs. The results of cohort analysis based on treatment cards of patients under DTP, are reported by the DTC through annual reports, which needs expertise. As a result, not only limited number of reports are received but also some of them are not up to the mark. Hence, it was felt to have a base line study of cohort analysis of treatment pattern of various categories of TB patients treated under DTPs. With the assistance from WHO, a pilot study was carried out in two districts of Mysore & Hassan of Karnataka State for the cohort period of Jan Dec 1991. On the basis of District Case Index Registers, 4053 treatment cards were collected from both the DTPs, of which 3877 were considered for analysis.

Results of analysis are being given separately for each district. In Hassan out of 1564 patients, 259 (16.5%) were smear positive, 1256 (80.3%) suspect cases and 49 (3.1%) extra pulmonary cases. The treatment completion rates for different categories of patients were: smear positive treated with SR 26.2%, with SCC 47.5%, suspect cases 23.3% and extra pulmonary 51%. In Mysore district, there were 2313 patients. Of them, 203 (8.8%) were smear positive, 1706 (73.8%) suspect cases and 275 (11.9%) extra pulmonary. Treatment completion rates for smear positive treated with SR 17%, with SCC 43.8%, X-ray suspect cases 18.8% and extra pulmonary 24.7%. Information on outcome of treatment i.e., cure rates, deaths etc., could not be collected due to incomplete recordings on the treatment cards. It could be concluded that a very small percentage of smear positive cases were detected. Treatment completion rates were very poor for all the categories of patients. There was no difference in the treatment completion rates obtained from the study and reported by these centres to NTI through annual report.

District Tuberculosis Programme (DTP) was formulated in 1962 with one of the objectives of diagnosing maximum number of tuberculosis patients. The rural health institutions implemented as Peripheral Health Institutions (PHIs) are expected to play a major role. The PHIs according to the type of facilities available, are classified into X-ray Centres (XCs), Microscopy Centres (MCs) and Referring Centres (RCs). While all centres provide treatment, XCs offer chest X-ray and sputum microscopy examination; MCs offer only sputum microscopy and from RCs sputum slides are prepared and referred for further examination to DTC/XCs/MCs. The performance of DTP activities at PHIs are collectively reported. Hence, it was worth studying categorywise performance of PHIs, which may help in developing strategy for improvement in the performance of the National Tuberculosis Programme.

OBSERVATIONS : DTP is operational in 390 (89%), out of the 438 districts in the country. Of the 17,850 implemented PHIs, 2390 (13.7%), 8717 (48.8%) and 6740 (37.8%) are functioning as XCs, MCs and RCs respectively. In all, 208 DTP reports for October to December 1993 quarter received at National Tuberculosis Institute, were analysed. Reporting efficiency of XCs, & MCs was 85%, whereas of RCs, 54%. Of the 33.1 million self reporting outpatients belonging to various PHIs, 35% attended XCs, 43% MCs and 22% RCs. Of the total sputum examinations performed during the study period, XCs examined 39%, MCs 52% and RCs 9%. Selection of chest symptomatics worked out to 1.8% for XCs, 2.0% for MCs and 0.7% for RCs. Out of the total 28,654 smear positive cases diagnosed, 56% were detected by XCs, 37% by MCs and only 7% by RCs. It is seen that XCs diagnosed 56% of the total cases by doing 39% of the total sputum examinations. The sputum positivity rate at XCs is 7.8% which is almost double that of 3.8% at the MCs and 4.4% at RCs.

Sputum Examination Efficiency (SEE) and Case Detection Efficiency (CDE) (percentage of achievement compared with expectation) have also been compared according to the category of PHIs. SEE of XCs & MCs were 70% & 78% respectively as compared to only 26.5% in RCs. The CDE of XCs, MCs & RCs were 69.1%, 36.9% and 14.1% respectively. It is observed that XCs are working satisfactorily as 35% of the total out patients attend the XCs, their reporting efficiency being 85%, sputum examination efficiency 70% and sputum positivity rate 7.8%, indicating good performance, while MCs had a low sputum positivity rate of 3.8%, suggesting that there is a large scope for qualitative improvement in Case-finding activity. While RCs cater to about 20% of the total out patients had poor performance on all account and need a great deal of technical supervision.

Some important aspects for consideration at the time of formulating the curriculum of orientation training programme for tuberculosis have been discussed in this paper. At the time of formulation of District Tuberculosis Programme, planning for training of manpower was taken simultaneously. The essentials of job orientation training are to change with the change in the requirements of the programme. Defining Objectives in clear terms is one of the important aspects to be considered while formulating the curriculum. This helps in preparing the contents, methods of teaching and developing effective assessment. Profile of Trainees is another important aspect. Factors which have to be considered at the time of formulation of curriculum are age, educational qualifications and professional experience of the trainees. Changes occurring in the general health services, introduction of multi purpose workers scheme and participation of community health workers in the health services, would require a thorough revision of the training organisations and contents of training.