The editorial comments refer to the 1989 Ranbaxy-Robert Koch Oration given by Dr. William Fox, titled "TB in India - Past, Present and Future". Dr. Fox highlighted most of the major aspects of TB in India, being familiar with the TB scene in India for over 35 years. Emphasis was placed on the need to improve research, training and evaluation aspects of NTP and on improving programme administration and management based on these findings. However, Fox's recommendation to establish a long term National TB Standing Committee with various powers is considered to reveal his unfamiliarity with various aspects of the Indian administrative and political climate and the social upsurges prevalent at the time. The editorial suggests an alternative way to manage the TB programme, while supporting Dr. Fox's views, in general.

The article provides a detailed description of the urban TB programme established in 1986 in Bombay and covering the city. The existing health infrastructure was inadequate to deal with an estimated 1,50,000 cases of TB, of which 40,000 were infectious to others. The organizational structure of the city TB programme is explained and the duties of the city TB officer are listed. A review found that since 1986, about 70,000 newly diagnosed patients were put on treatment every year, of which, only about 205 were able to complete the treatment. While there was good public awareness and an excellent transport service, poverty among a majority of the city dwellers and constant rural-to-urban migration were major problems in TB control. Future plans to improve the TB programme are listed.

The editorial offers some considerations that should go into the making of a rational, National Drug Policy (NDP). Primacy must be given to the National Health Policy in the formulation of the NDP and the task of producing adequate quantities of essential/life-saving drugs, of good quality and at reasonable prices, must be placed as a challenge before the pharmaceutical industry under market-friendly controls. The production of non-essential/fancy formulations could be left to the demand-supply mechanism, at the same time, stressing rational prescribing practices as part of NDP.

This is an editorial on the Workshop organised by the DGHS, 11-12 September, 1991, to thoroughly review the NTP with respect to its overall achievements and shortfalls from expectations. Based on the deliberations, attended by representatives of various international agencies, several recommendations for action, to improve the NTP, were made. It was suggested that a Task Force be set up, with proper terms of reference and a suitable budget to oversee that the recommendations were implemented and that necessary corrective actions were taken, till the time of the next review.

The aim of the study was to test the assumption that mass miniature X-ray screening of the single, homeless (hostel residents) was a cost effective means of controlling pulmonary TB. The study was a prospective experimental screening exercise to identify new cases of active TB, completing treatment. The setting was eight hostels in South London. A mobile X-ray screening facility was set up outside the hostels. Subjects were 547 single, homeless residents in the hostels. They were encouraged to attend for chest X-ray and for active follow- up of abnormal X-rays. No new cases of active TB were found leading to the conclusion that mass, miniature X-ray was ineffective in controlling TB because of its unacceptability and increasing inaccessibility to this population.

Since 1978, in the United States, 28 metropolitan health departments initially reporting greater than 250 cases of TB per year were surveyed to determine the standard of practice in the control of pulmonary TB and factors affecting treatment policy. In this survey, results were compared with data obtained in 1978, 1980, 1984 & 1988. As in the previous years, all departments completed the survey. The predominant treatment regimen was 6 months of chemotherapy (64 + or - 1.33% of patients) involving isoniazid (I), rifampin (R) and pyrazinamide (Z). Estimated duration of treatment, which had decreased from 20.2 + or - 2.1 months in 1980 to 7.58 + or -1.02 months in 1988, increased to 9.34 + or -2.32 months in 1992 (p< 0.01). This was attributed to an increased incidence of HIV infection during the previous 4 years. In 1984, HIV infection was estimated to coincide with TB in 2.54 percent of all patients, 7.72 percent in 1988 and 17.42 percent in 1992. Several other major departures from prior perceived practices were reported. In 1980, 32.1 percent of all patients were hospitalized initially for TB treatment, and this number decreased progressively to 17.8 percent in 1988; in 1992, 34.2 + or -1.32 percent of patients with TB were hospitalized for initial treatment. In 1988, no program reported regular use of alternative therapy to isoniazid for chemoprophylaxis; in 1992, 21 programs used alternative regimens (predominantly R-containing). In 1992, nine programs reported increased funds for treatment of TB (27.2+/- 1.97 percent inflation), whereas 16 reported a mean decrease of 14 percent after inflation. The conclusions were that TB treatment in the major metropolitan health departments consisted predominantly of SCC utilizing I, R and Z and that overall mortality was not greater because of initially drug-resistant organisms. However, HIV-associated disease now was a major etiologic factor in TB, and the number of hospitalizations had doubled in 4 years. The lack of increase in funds for treatment was expected to exacerbate the problems in TB control, in the future.

Two extremes of the TB propagation cycle taking place simultaneously in different areas of the United States are illustrated. One illustration represents hypothetical, ideal epidemiological conditions wherein the applied TB control measures bring about the desired cure in the expected timeframe. Actual conditions prevalent in the US, over the past several decades until recently and still existent in many areas, have been similar to this scenario. The other, more complicated diagram illustrates some of the factors responsible for the current TB resurgence and for the emergence and transmission of multi-drug resistant organisms in the US. Under these conditions, lack of health insurance and other barriers to primary health care often delay the diagnosis of active TB, allowing longer-term transmission. After diagnosis, many potential barriers exist to successful therapy including homelessness, financial and cultural barriers. Patients, not on effective treatment, often transmit multi-drug resistant TB (MDR-TB) in a variety of settings including hospitals and clinics, homeless shelters, jails, chronic care facilities etc. Based on different studies, it was found that among patients with AIDS under treatment for TB, the time period between infection and active disease was so short as to preclude treatment. Studies using genetic finger-printing showed new drug-resistant disease could result from exogenous infection. Vastly different strategies and resources are suggested to achieve control in the two different TB scenarios.

The TB situation in Massachusetts and two features of the control efforts are described in detail. The article by Graves et al (1993) on drug-resistant TB in Puerto Rico is also elaborated. Based on these two sources, it is urged that four-drug (Isoniazid, Rifampicin, Ethambutol and Pyrazinamide) initial therapy and universal drug susceptibility testing be given for all patients. DOT is recommended for previously treated persons and those living outside Puerto Rico and the US mainland. A progressive, step-wise, case management approach to TB treatment, from least to most restrictive, is listed.

Keeping the list of drugs available in the market to the bare essentials, reducing practices (such as hosting of conferences, advertising, peddling of samples and literature, etc.) which add huge overheads to the cost of production of drugs, rational drug prescription policies and consumer awareness as well as education are the essential ingredients which can ensure availability of low priced drugs.

In Denmark, treatment of TB is generally recommended only if the diagnosis is confirmed bacteriologically. This policy may cause a delay in treatment if the patients are smear negative. The duration of the treatment delay, and whether the delay would cause any serious health problems for the individual or risk of contact infections, in a retrospective examination of 324 cases of pulmonary TB was investigated. The mean treatment delay was longer in the oldest age group. Concerning death due to delay, there was no risk for those patients who were not weakened by other disease or old age. Only 11 patients (3.6 percent) over the age 10 years were treated without bacteriological confirmation (1 percent for Danes). The infection risk from the smear- negative but culture-positive patients was minimal as only one subject was definitely infected from a smear-negative patient. However, a risk of transmission exists from patients who are initially culture-negative but later become smear-positive. In conclusion, the epidemiological and individual risks were sufficiently low to continue the rather restrictive treatment policy.

The setting is Homeless and other fringe groups are a priority in the global strategies of TB prevention and control in big cities, as a consequence of their generally poor adherence to treatment and concurrent multiple social and health problems. The objective is to evaluate a social care and health follow-up programme targeting homeless TB patients in Ciutat Vella District, Barcelona, which covered 210 patients from 1987 to 1992. During directly observed treatment, primary health care and, if necessary, accommodation was provided. The design of the study is the differential TB incidence rate between Ciutat Vella and the other districts of Barcelona, the percentage of successfully completed treatments and the days of hospitalization saved by the programme were measured.

There was a significant decrease in the TB incidence rate among homeless patients in Ciutat Vella (from 32.4 per 105 inhabitants in 1987, to 19.8 per 105 in 1992, P=0.03), compared to an unchanged rate elsewhere (1.6 per 105 inhabitants in 1987, compared to 1.7 per 105 in 1992, P=0.34). A smaller than expected proportion, 19.6%, of patients failed to complete their treatment, and a decrease in the mean period of hospitalization for TB in the district hospital was recorded, falling from a mean 27.1 days in 1986 to a mean 15.7 days in 1992. The programme appears to be both effective and efficient, as it has enabled a large number of homeless patients to complete their treatment successfully, at the same time saving twice the amount of funds invested.