Tuberculosis in Asia

1. Philippines: The development, expansion and maintenance of pilot area activities: Cristina B. Giango (Technical Division, Cebu Provincial Health Office, the Philippines) In 1994, the Department of Health developed the new NTP policies based on WHO recommendations and started a pilot project in Cebu Province in collaboration with the Japan International Cooperation Agency. To test its feasibility and effectiveness, the new NTP policies were pre-tested in one city and one Rural Health Unit. The test showed a high rate of three sputum collection (90%), high positive rate (10%), and high cure rate (80%). Before the new guidelines were introduced, the new policy was briefed, a baseline survey of the facility was conducted, equipment was provided, and intensive training was given. Recording/Reporting forms and procedures were also developed to ensure accurate reporting. Supervision, an important activity to ensure effective performance, was institutionalized. Laboratory services were strengthened, and a quality-control system was introduced in 1995 to ensure the quality of the laboratory services. With the implementation of DOTS strategy, barangay health workers were trained as treatment partners. In partnership with the private sector, the TB Diagnostic Committee was organized to deliberate and assess sputum negative but X-ray positive cases. The implementation of the new NTP guidelines in Cebe Province has reached a satisfactory level, the cure rate and positive rate have increased, and laboratory services have improved. Because of its successful implementation, the new NTP guidelines are now being used nationwide. 2. Nepal: The DOTS Strategy in the area with hard geographic situation: Dirgh Singh Bam (National Tuberculosis Center, Nepal) Three groups of factors characterize the population of Nepal: 1) Socio-cultural factors, e.g. migration, poverty, language; 2) Environmental factors, e.g. geography and climate; and 3) Political factors, prisoners and refugee populations. These factors pose particular problems for implementing DOTS in various ways. Socio-cultural and environmental factors are particularly important in Nepal, and several measures have been developed to overcome these difficulties. One is active community participation through the DOTS committee. The committee consists of a group of motivated people, including social workers, political leaders, health services providers, journalists, teachers, students, representatives of local organizations, medical schools and colleges, industries, private practitioners, and TB patients. One DOTS committee is formed in every treatment center. A key role of the DOTS committee is to identify local problems and their solutions. It increases public awareness about TB and DOTS; supports people with TB in the community by providing treatment observers and tracing late patients; and encourages cooperation among health institutions, health workers, NGOs, and political leaders. The case finding rate is now 69%, and nearly 95% of diagnosed TB cases are being treated under DOTS. The treatment success rate of new smear-positive cases is nearly 90%. Thus, DOTS increases the case finding and treatment success. 3. Cambodia: HIV/TB and the health sector reform: Tan Eang Mao (National Center for Tuberculosis and Leprosy Control, Cambodia) Cambodia is one of the 23 high burden countries of tuberculosis in the world. Moreover, HIV/AIDS has been spreading rapidly since 1990s, which is worsening the tuberculosis epidemics. To cope with the burden, Cambodia has started implementation of DOTS in 1994 and has expanded it to most of public hospitals across the country by 1998. NTP of Cambodia is now enjoying high cure rate of more than 90%. However, due to the constraints such as weak infrastructure and the poverty, it is proved that many of TB sufferers do not have access to the TB services, resulting in still low case detection rate. It is for this reason that the NTP has decided to expand DOTS to health center and community level based on the new health system. Its pilot program that has been carried out in collaboration with JICA and WHO since 1999 has achieved promising results with high detection and cure rates. All of the over 900 health centers across the country will be involved in DOTS strategy by 2005. In the fight against TB/HIV, National Center for TB Control is providing free TB screening for PLWH (people living with HIV/AIDS), and it is developing a comprehensive plan of TB/HIV care including home delivery DOT services. 4. China: The World Bank Project and the Prevalence Survey in China: Hong Jin DuanMu (National Tuberculosis Control Center, China) Since 1992, China has utilized a World Bank loan to implement TB control projects among 560 million people in 13 provinces. Free diagnosis and treatment services have been provided to all patients, and a fully supervised standard short-course chemotherapy was applied to all diagnosed tuberculosis patients. In 1999, more than 190,000 smear-positive cases, ten times the number in 1992, were detected, and the registration rate of new cases reached 30 per 100,000 population. From 1992 to 1999, a total of 1.40 million smear-positive TB patients were discovered. The cure rate of smear-positive TB patients has been improved to an overall cure rate of 93.6%. The cure rates for the new cases and re-treatment patients were 95.1% and 89.6%, respectively. The fourth nationwide random survey for the epidemiology of tuberculosis was conducted in 2000. The prevalence of active tuberculosis was 367/100,000, the prevalence of infectious tuberculosis was 160/100,000, and the prevalence of smear-positive tuberculosis was 122/100,000. The tuberculosis mortality was 9.8/100,000. 5. Vietnam: The road to reaching the Global Target: Le Ba Tung (Pham Ngoc Thach Tuberculosis and Lung Disease Center, Vietnam) TB control activities started in 1957 and were reorganized in 1986 with the technical assistance of IUATLD, KNCV and material assistance of Medical Committee Netherlands Vietnam (MCNV). The New National TB Control Program follows the main directives of WHO and IUATLD's procedures of case-finding, chemotherapy and management. Passive case-findings are based on sputum smear. Chemotherapy with priority for smear positive cases is 3SHZ/6S2H2 for new cases and 3HRE/6H2R2E2 for retreated cases, which is undertaken with directly observed therapy (DOT strategy) mainly at commune health posts. Since 1989, DOTS strategy with 2SHRZ/6HE for new cases and 2SHRZE/1HRZE/5H3R3E3 for retreated cases has gradually been introduced in districts and communes of every province. In 1995, the government established the National and Provincial TB Control Steering Committees and has provided incentives for detected smear positive cases and cured smear positive cases. The government has also started strengthening the program of managerial and supervisory capacity for TB staff and has promoted the cooperation of all associated organizations of TB control. The WHO global surveillance and monitoring project reports that in 2000 Vietnam reached the global target, i.e., 99.8% population covered by DOTS with 80% of expected new smear positive cases being detected and a high cure rate ranging from 85.3% in 1989 to 90.3% in 1999. A distinguishing aspect of TB control in Vietnam is the effective international partnerships combined with high political commitment of the government nationally and provincially as well as active participation of all organizations in the community.     

What is the limit to case detection under the DOTS strategy for tuberculosis control?

In year 2000, the WHO DOTS strategy for tuberculosis (TB) control had been adopted by 148 out of 212 countries, but only 27% of all estimated sputum smear-positive patients were notified under DOTS in that year. Here we investigate the way in which gains in case detection under DOTS were made up until 2000 in an attempt to anticipate future progress towards the global target of 70% case detection. The analysis draws on annual reports of DOTS geographical coverage and case notifications, and focuses on the 22 high-burden countries (HBCs) that account for about 80% of new TB cases arising globally each year. Our principal observation is that, as TB programmes in the 22 HBCs have expanded geographically, the fraction of the estimated number of sputum smear-positive cases detected within designated DOTS areas has remained constant at 40-50% although there are significant differences between countries. This fraction is about the same as the percentage of all smear-positive cases notified annually to WHO via public health systems worldwide. The implication is that, unless the DOTS strategy can reach beyond traditional public health reporting systems, or unless these systems can be improved, case detection will not rise much above 40% in the 22 HBCs, or in the world as a whole, even when the geographical coverage of DOTS is nominally 100%. We estimate that, under full DOTS coverage, three-quarters of the undetected smear-positive cases will be living in India, China, Indonesia, Nigeria, Bangladesh and Pakistan. But case detection could also remain low in countries with smaller populations: in year 2000, over half of all smear-positive TB cases were living in 49 countries that detected less than 40% of cases within DOTS areas. Substantial efforts are therefore needed (a) to develop new case finding and management methods to bridge the gap between current and target case detection, and (b) to improve the accuracy of national estimates of TB incidence, above all by reinforcing and expanding routine surveillance.     

Implementation of the DOTS strategy in prisons at provincial level, Thailand.

SETTINGS: Sixteen prisons located in four geographic regions in Thailand. OBJECTIVES: To assess treatment outcomes of tuberculosis (TB) patients under the DOTS strategy in a prison programme. METHOD: The programme prospectively included 1412 consecutive TB patients registered during Year 1 (June 1999-May 2000), Year 2 (June 2000-May 2001) and Year 3 (June 2001-May 2002). DOTS implementation consisted of government commitment; passive detection by sputum smear microscopy; standardised short-course chemotherapy, including directly observed treatment by prison nurses; maintenance of drug stocks at provincial health offices; and a recording and reporting system. Data were collected using prison TB registers. RESULTS: The number of TB patients increased from 348 in Year 1 to 490 in Year 2 and to 574 in Year 3. New smear-positive patients accounted for 82.0% of the total. Of the 1158 new smear-positive cases, 68.7% were cured, 17.6% died, 10.6% were transferred out, 2.6% failed, and 0.5% completed treatment. CONCLUSIONS: DOTS implementation in these prisons could not achieve the national target to cure 85% of new smear-positive cases. More interventions are needed to help reduce the deaths and transferred cases that mainly affected the treatment outcomes in these settings.     

DOTS implementation in a post-war, United Nations-administered territory: lessons from Kosovo

SETTING: The WHO-recommended strategy of tuberculosis control (DOTS strategy) has been shown to be effective in reducing tuberculosis incidence in a variety of countries/ settings. Little evidence exists on the implementation, and effectiveness of DOTS in a transitional, post-war setting OBJECTIVE: To describe the process of establishing a National Tuberculosis Control Program (NTP) and implementing DOTS throughout Kosovo, and the outcomes achieved by this international collaboration in a post-war transitional setting during 1999-2005. METHODS: In 1999, as part of the re-organization of health services, a DOTS-based NTP was established and operationalized through a collaboration of several international partners in Kosovo. Five key steps supported these activities. RESULTS: Kosovo has reached the World Health Assembly targets, having achieved 75% case detection rate (sputum smear-positive cases) and 93% treatment success rate. During 2000-2005, new smear-positive tuberculosis case notifications decreased by 44.5% (median annual decrease for all cases: 7.6%). CONCLUSIONS: Kosovo's success story is a collaborative tale, each partner involved playing a unique role in supporting NTP activities. The Kosovo example provides yet another setting in which DOTS implementation has resulted in successful patient outcomes. The international TB control community would be well-served by formal guidelines for implementing DOTS and the new STOP TB Strategy in these settings.     

Implementation of the DOTS strategy for tuberculosis in the Leningrad Region, Russian Federation (1998-1999).

SETTING: The DOTS pilot project for tuberculosis control in the Leningrad Region of the Russian Federation, supported by the Finnish Lung Health Association and the World Health Organization (WHO). OBJECTIVE: To assess the efficacy of WHO-recommended standard short-course chemotherapy in newly detected pulmonary tuberculosis cases positive by smear or with extensive lung lesions suggestive of culture positivity, under project conditions. METHODS: Analysis of data on case detection, sputum smear conversion and treatment outcome based on standardised (WHO) registers from districts and a central computerised database. RESULTS: Of 859 adult pulmonary tuberculosis cases (292 smear-positive) notified in the Leningrad Region in the study period, 312 new cases were included in the project. The sputum conversion rate at the end of the second month was 82.8% and 91.1% at the end of the third month. Of bacteriologically confirmed cases, 71.3% were successfully treated, 4.9% died, 11.7% defaulted and 8.1% failed. CONCLUSION: In the first year of the pilot project in the Leningrad Region, the DOTS strategy revealed feasibility and moderate efficacy among new pulmonary tuberculosis cases who were either smear-positive or showed extensive lung lesions on chest X-ray, and who were therefore of high epidemiological and medical priority.     

Tuberculosis control in the Caucasus: successes and constraints in DOTS implementation.

SETTING: The pilot projects for tuberculosis (TB) control, supported by the World Health Organization (WHO) and based on the WHO recommended control strategy, directly-observed treatment, short-course (DOTS) in the Caucasian countries (Armenia, Azerbaijan, Georgia). OBJECTIVE: To evaluate the results 2 years after the implementation of the pilot projects. METHODS: Analysis of data on case detection, sputum conversion and treatment outcome reported quarterly to the WHO from the Ministries of Health in each country. RESULTS: Since the establishment of the project, 1330, 764 and 4866 new cases and relapses, respectively, of TB have been detected in the pilot areas of Armenia, Azerbaijan and Georgia. In Armenia and Azerbaijan, respectively 46% and 57% of all cases were smear positive, whilst in Georgia, the corresponding figure was only 12%. After 3 months' treatment, 93% of new smear-positive patients had become smear-negative. The sputum conversion rate for relapses and other retreatment cases (failure, treatment interrupted) was 85%. In Armenia, 78.1% of new smear-positive patients were treated successfully (cured or completed treatment). The corresponding percentages for Azerbaijan and Georgia were 87.9% and 59.6%. Treatment success rates among retreatment cases was generally low, at respectively 46%, 64%, and 35%, in Armenia, Azerbaijan, and Georgia. CONCLUSION: The results of the implementation of the WHO TB control pilot projects in Armenia, Azerbaijan and Georgia suggest that the DOTS strategy is feasible in emergency situations in general, and in the Caucasus in particular.     

Health sector reform in Brazil: impact on tuberculosis control.

This paper comments on the reform process of the health sector policies that took place after 1986 in Brazil, and its negative impact on the National Tuberculosis Control Programme (NTP). Decentralisation was followed by a slow transition from a vertical programme to an integrated programme. In 1990, the NTP was dismantled due to fiscal constraints, and in 1992, the NTP component was reorganised, with national and regional coordinators and subsequent increased support to state programmes. In 1996, the health sector reform continued its process, but this consisted mainly of cuts in health budgets and rapid decentralisation from federal level to unprepared states and municipalities, leading to the weakening of local tuberculosis control programmes. Only recently has government commitment been secured, with a new National Plan on Tuberculosis Control which includes the World Health Organization strategy for TB control--the implementation of the DOTS strategy (directly-observed treatment, short-course)--and efforts are being concentrated in 5500 municipalities. The programme has a centralised administration which supports decentralised implementation through out-patient clinics, and resources will be focused on local service delivery.     

Scaling up TB DOTS in a fragile state: post-conflict Afghanistan.

SETTING: Afghanistan. OBJECTIVE: To describe the results of rapid expansion of the DOTS strategy in a post-conflict environment, with a focus on the experience of the Rural Expansion of Afghanistan's Community-based Healthcare (REACH) Program. RESULTS: Despite the destruction of the National Tuberculosis Program (NTP) and basic health services by war and an uncertain security situation, the NTP, with assistance from many partners and REACH, increased the number of patients receiving DOTS by 136% in 4 years (from 9261 cases in 2001 to 21851 in 2005), with an 86% treatment success rate. By focusing on rapidly expanding the number of facilities capable of providing tuberculosis (TB) diagnostic and treatment services and involving community health workers in case detection, referrals and home-based DOTS, REACH showed a 10-fold rise in the number of facilities providing TB services and a 380% increase in the number of sputum smear-positive pulmonary TB cases detected in 2 years (from 251/month in 2004 to 818/month in 2006) in 13 provinces. CONCLUSION: At the current rate of expansion, case detection and successful treatment of TB cases in Afghanistan will continue to expand rapidly. The NTP and REACH have demonstrated that expansion of TB services in Afghanistan is possible despite the challenges.     

韶关市涂阳肺结核病人化疗效果分析

目的分析涂阳肺结核病人的化疗效果。方法采用两阶段全程间歇的短程化疗方案,对初复治涂阳病人实施全程督导管理,完成疗程后判定疗效。结果1992~2001涂阳肺结核病人登记率由1.5/10万上升到31.58/10万;初治涂阳病人治愈率由11.11%上升到97.25%,复治涂阳病人治愈率由36.84%上升到93.20%。结论合理的化疗方案,全面落实全程督导管理,保证病人规则用药,是提高治愈率的关键。     

Hospital DOTS linkage in Indonesia: a model for DOTS expansion into government and private hospitals.

BACKGROUND: To accelerate DOTS expansion, the hospital sector and specialized chest clinics must be engaged. OBJECTIVE: To develop a model for public-private partnership through DOTS expansion into public and private hospitals in Indonesia. DESIGN: Model development included gaining commitment from stakeholders, stepwise training of hospital staff, and developing unified networks for case management, patient referral, laboratory quality assurance, supervision and evaluation. RESULTS: The number of notified tuberculosis (TB) cases (all forms and new smear-positive) increased dramatically from baseline. Together, hospitals and chest clinics accounted for a significant proportion of the total cases notified by the province (51% of total TB cases and 56% of new smear-positive cases in 2004). Compared to health centers and chest clinics, hospitals reported lower cure and success rates. Despite the option for referral to health centers, the majority of patients diagnosed in hospitals and chest clinics in 2002-2004 opted to be fully managed by the diagnosing facility. CONCLUSION: The roles and strengths of hospitals differ with regard to health centers, providing a rational basis for linkage of these health service components. In Yogyakarta, linkage became effective only after establishing a stakeholder-based provincial coordinating (DOTS) committee as the recognized interface between the National Tuberculosis Programme and various providers.     

Ten-year experiences of the tuberculosis control programme in the southern region of Ethiopia.

SETTINGS: The tuberculosis control programme, southern region of Ethiopia. OBJECTIVE: To assess the impact of the expansion of the DOTS strategy on tuberculosis (TB) case finding and treatment outcome. DESIGN: Reports of TB patients treated since the introduction of DOTS in the region were reviewed. Patients were diagnosed and treated according to World Health Organization (WHO) recommendations. Case notification and treatment outcome reports were compiled quarterly at district level and submitted to the regional programme. RESULTS: Of 136,572 cases registered between 1995 and 2004, 47% were smear-positive, 25% were smear-negative and 28% had extra-pulmonary tuberculosis (EPTB). In 2004, 94% of the health institutions were covered by DOTS. Between 1995 and 2004, the smear-positive case notification rate increased from 45 to 143 per 100,000 population, the case detection rate from 22% to 45%, and the treatment success rate from 53% to 85%. The default and failure rates decreased from 26% to 6% and from 7% to 1%, respectively. DISCUSSION: There was a steady increase in the treatment success rate with the decentralisation of DOTS. Although 94% coverage was achieved after 10 years, the stepwise scale-up was important in securing resources and dealing with challenges. The programme achieved 85% treatment success; however, with the current low case detection rate (45%), the 70% WHO target seems unachievable in the absence of alternative case-finding mechanisms.     

Tuberculosis control in Sudan against seemingly insurmountable odds.

SETTING: Sudan, Africa's largest and one of its poorest countries, in which civil disturbance, resource limitation and communications difficulties are substantial impediments to delivery of health services. OBJECTIVES: To 1) illustrate the burden of tuberculosis; 2) review measures taken to control the disease; 3) outline the introduction of the DOTS strategy; and 4) demonstrate the trend in the output of the DOTS strategy. METHODS: Published information on general health, tuberculosis and health structure provide the setting. Routine reports illustrate the trend in case notification in Sudan, and outcome of treatment by period of enrollment on treatment (cohort). RESULTS: Since 1992, sputum smear microscopy centres have been established in existing health facilities (179 of a total 290 targeted centres). By the end of the second quarter of 1998, 82,860 cases of tuberculosis had been reported, of whom 52% were sputum smear-positive cases. Of these, 89% had no history of previous treatment for as much as one month. The treatment outcomes for 11,000 new smear-positive cases were reported by the end of the second quarter of 1997; the proportion of notified cases for whom treatment results were available increased from 16% in 1994 to 63% in 1996. Of these, 72% were successfully treated, increasing from 62% in 1994 to 73% in 1996. CONCLUSIONS: Despite seemingly overwhelming odds, the DOTS strategy has been successfully commenced and is in the process of expansion throughout the country, with monitoring of the quality of diagnostic examinations and improvements in treatment outcome. Further improvement is necessary, but appears feasible.     

惠州市区涂阳肺结核病例化疗效果分析

目的　分析涂阳肺结核病人的化疗效果。方法 采用两阶段全程间歇的短程化疗方案,对初复治涂阳病人实施全程督导管理,完成疗程后判断疗效。结果 728例初治涂阳病例完成疗程后的治愈率达97.7%,159例复治涂阳病例的治愈率为90.6%,取得满意的疗效。结论 提高化疗效果,除了需要制定合理的化疗方案外,还必须全面落实全程督导管理,保证病人规则用药。     

Progress in global tuberculosis control 1995-1996, with emphasis on 22 high-incidence countries. Global Monitoring and Surveillance Project.

OBJECTIVE: To review global tuberculosis case notifications and treatment outcomes, and to assess progress in TB control 1995-1996, especially in the 22 countries that carry 80% of all incident cases. DESIGN: Compilation of case notifications; cohort analysis of treatment outcomes in DOTS and non-DOTS programmes. RESULTS: The 181 of 212 countries (85%) that reported data to WHO in 1997 covered 97% of the global population. They reported 3.81 million cases of tuberculosis, of which 1.29 million were smear-positive, representing case detection rates of approximately 39% and 51%, respectively. DOTS programmes diagnosed 67% of new pulmonary cases to be smear-positive (65% expected), compared with 30% in other control programmes. They evaluated a higher fraction of registered cases (94% vs 55%), achieved higher treatment success rates (78% vs 45%), and a higher fraction of patients was shown to be cured by smear conversion (72% vs 23%). Despite the apparent advantages of DOTS, only 12% of all estimated cases, and only 15% of smear-positive cases, were treated in such programmes. CONCLUSION: With the exceptions of Vietnam, Peru and Tanzania, none of the 22 highest-incidence countries achieved WHO targets for TB control. The slow progress is of greatest concern in 16 countries, including India, Indonesia, Nigeria and Pakistan.     

1500例复治涂阳肺结核成因及疗效分析

目的 分析复治涂阳病例成因 ,探讨WHO推荐的复治化疗方案及管理方式 (DOTS)成效?方法收集全省 1.992～ 1.998年完整的复治涂阳病历 1 50.0份?结果 化疗方案不合理 81.3 % ,治疗不规则或未完成疗程 82.0%?实施复治涂阳方案后 ,2?3个月末痰菌阴转率达 91.9%?95.4% ,治愈率达 94.7%?结论 造成复治涂阳原因是用药不合理?间断或无规律用药?未完成疗程?采用WHO推荐的 8个月短程方案?严格执行DOTS ,治疗复治涂阳病人合理?有效 ,可推广应用?     

Is quarterly cohort analysis useful for assessing treatment outcomes in a low incidence country?

SETTING: In the Czech Republic, a country regarded as having a low incidence of tuberculosis (TB), short-course chemotherapy (SCC) of TB has been implemented in routine practice country-wide. OBJECTIVE: To assess the outcome of SCC by quarterly cohort analysis of patients using the methodology recommended by the World Health Organization (WHO). DESIGN: Patients with newly detected bacteriologically confirmed pulmonary TB notified in 1998 were treated according to local recommendations (SCC) or with the WHO-recommended DOTS strategy. The type of chemotherapy and its outcome were evaluated 12 months later by quarterly cohort analysis. RESULTS: A total of 731 patients with bacteriologically confirmed pulmonary TB, 403 of them smear-positive, were assessed. The proportion of those treated under the DOTS strategy increased from 56.2% to 75.1%. Favourable treatment outcomes (cure or treatment completed) were achieved in 69.0% of patients in the first quarter and 74.0% in the fourth quarter. Only four treatment failures and 21 defaulters were recorded. A total of 129 patients (15-21% in different cohorts) died before or during treatment, mostly from causes not connected with TB. If this proportion were not taken into account, treatment efficacy would have attained 85%. CONCLUSIONS: Analysis of SCC based on quarterly cohorts proved feasible in routine conditions in a country with a low incidence of TB and ongoing TB control, and provided more information than once yearly analysis.     

Private GPs contribute to TB control in Myanmar: evaluation of a PPM initiative in Mandalay Division.

SETTING: Mandalay Division, Myanmar. AIM: To assess the effect of an initiative to involve private general practitioners (GPs) in the National Tuberculosis Programme (NTP) and to identify lessons learnt for public-private mix scale-up. METHODS: Source of referral/diagnosis and place of treatment were included in the routine recording and reporting systems to enable disaggregated analysis of the contribution of GPs to case notification and treatment outcomes. Case notification trends were compared between the intervention and control areas over a 4-year period. RESULTS: Private GPs contributed 44% of new smear-positive cases registered during the study period (July 2002-December 2004). The notification of new sputum smear-positive TB in the study area increased by 85% between the year prior to the GP involvement and 2 years after (from 46 to 85/100,000). Case notification increased by 57% in the control townships and by 42% in all of Mandalay Division. The treatment success rate for new smear-positive cases treated by GPs was 90%. CONCLUSIONS: The involvement of private GPs substantially increased TB case notification, while a high treatment success rate was maintained. Success factors include a well-developed local medical association branch, strong managerial support, training and supervision by the public sector and provision of drugs and consumables free of charge by the NTP.     

How to cope with the global tuberculosis burden--experiences and perspectives for Japan's international cooperation

Tuberculosis is a global burden disease, most possibly ranking high among diseases over the coming several decades, with 2 million deaths and over 8 million new cases annually. How can TB be controlled and eradicated quickly in the world? A major answer will be the wider application of the most effective control programme, i.e. DOTS recommended by WHO. But it has been developed in the long try and error efforts, including the ones by Dr. K. Styblo of IUATLD in African countries. The key components of successful TB programme are summarised as follows, which Dr. Kochi of WHO adopted as a global policy package. They are; 1) political commitment, 2) case finding by sputum microscopy, 3) use of short course chemotherapy under supervision, 4) a secured supply of anti-TB drugs, and 5) a standardised recording, reporting and monitoring system. The targets by 2005 are set 85% cure rate and 70% detection rate. By 2002, however, only half the targets have been achieved, and global expansion of DOTS with other strategies need to be strengthened. Emerging threats are HIV epidemic, MDR-TB increase and health sector reform taking place in the world. Stop TB partnership with its office in WHO has been formed to strengthen a global capacity, mobilizing various technical and financial partners. Japan's contribution to the global TB problem started in early 1960s. In the last 40 years, technical cooperation in national TB programme (NTP) has been made through JICA in over 15 countries, including United Arab Emirates. Thailand, Nepal, Afghanistan, Tanzania, Indonesia, Solomon Islands, Yemen, Philippines, Cambodia, Myanmar, Pakistan, Zambia, and China (TB project is on-going in underlined countries). In these projects, capacity strengthening of NTP has been given priority, including construction of national TB center, a model area development, nationwide DOTS expansion in collaboration with WHO or others, supply of anti-TB drugs, TB laboratory network with QA, collaborative operational research. An operational research for community based DOTS and ART is newly started in Zambia under JICA project. Besides, over 1800 doctors and technologists from 90 countries have been trained at Research Institute of Tuberculosis (RIT) through its international training courses in the last 40 years. These courses are organised collaboratively with WHO or other agencies, inviting globally renowned lecturers and ex-participants, and have been reputed widely. We aim not only to teach skills and knowledge but also to motivate them to do something new. This becomes possible only through human relationship in the course. I may need to mention about my personal commitment: First, I have worked to develop a community based TB programme model utilising village health volunteers in Bangladesh in 1980s. This system has now covered over 70% of the total patients in the country through BRAC, local NGO. Secondly, the application of participatory action research (PAR) method in introducing or expanding DOTS in Bangladesh and other countries. Staff members of NTP and local/ peripheral workers participate in the trials and discuss actively in the workshops periodically. This PAR approach empowers both NTP managers and peripheral staff. Through the international cooperation, we aim ultimately at 1) support for self-reliance, 2) empowerment (capacity building for problem finding and solution) of the people concerned, and 3) promotion of global peace without arms.     

Private practitioners and tuberculosis case detection in Jogjakarta, Indonesia: actual role and potential

BACKGROUND: Indonesia has a high tuberculosis (TB) prevalence and a large private health sector. OBJECTIVES: To explore the potential of private practitioners (PP) in TB control in Jogjakarta by assessing their load of TB suspects and case-management practices. METHODS: We conducted a cross-sectional telephone survey of a random sample of 164 PP, weighted to the local proportions of specialists, general practitioners (GP), nurses and midwives. We investigated their knowledge of directly observed treatment, short-course (DOTS), whether they see TB suspects, whether they refer such patients and how they possibly diagnose and treat TB. RESULTS: We sampled 174 PP, of which 164 (94.3%) completed the interview. Most PP (63.4%) reported to have seen TB suspects in their private practice, and 62.8% were also employed in a DOTS facility. Specialists saw on average 18 suspects, GP 11 suspects, and nurses-midwives three suspects in a year. Many PP (45.2%) always relied on National Tuberculosis Control Programme (NTP) services for diagnosis. Fewer PP (41.5%) used, by themselves, diagnostic procedures complying with the NTP guidelines. The majority (63.6%) always referred confirmed cases for treatment, mainly (71.4%) to NTP services. Most PP (72.7%) who treated TB patients themselves did not prescribe the NTP standard regimen. CONCLUSION: The study shows that the TB case load per PP is low in Jogjakarta, where the NTP already involves public and private hospitals besides public health centres. Initiatives to engage all PP might only marginally contribute in increasing the TB case detection.     

大连市实施肺结核归口管理的作法与成效

目的　探讨归口管理在结核病控制中的作用。方法 在卫生行政部门的干预下,依据《大连市结核病防治管理办法》开展归口管理工作。对转诊发现的涂阳病例全部予以全程监督化疗。结果 综合医院可疑肺结核报卡由1997年448张上升至2000年2533张。肺结核截留率由1997年74.0%下降至2000年2.8%。1997～1999年登记的新发涂阳病例中转诊发现分别占65.9%、88.0%、90.7%,新发涂阳登记率较归口前上升显著。新发涂阳病人登记满一年转归队列分析,1997～1999年初治涂阳治愈率分别达93.9%,95.3%,94.9%。结论 1 病人发现水平与归口管理力度呈正比。2 综合医院可疑者转诊是发现新发涂阳病例的主要途径。3 归口管理与DOTS是保证新发涂阳病人高发现,高治愈的有效措施。