The National Tuberculosis Programme and its implementation

India has formulated a nationally applicable, socially acceptable, and epidemiologically effective National Tuberculosis Program (NTP), which served as an example for many other countries. In the 1940s, the New Delhi Tuberculosis Center pioneered organized domiciliary treatment of TB cases; the Union Mission Tuberculosis Sanatorium, Madanapalle, had started conducting epidemiological surveys in the late 1930s; the 1954-56 national sample survey of TB is still considered a classic; and this was followed by outstanding longitudinal surveys and epidemiological studies demonstrating that BCG does not provide protection to adults against TB. Halfdan Mahler joined P.V. Benjamin in launching the National BCG Campaign in the 1950s. India demonstrated in the 1950s that home treatment of patients is as efficacious as sanatorium treatment. The National Tuberculosis Institute was set up in 1959 with the specific mandate of making TB services available to larger masses of people. Social science data were also collected to show that TB patients were seeking help from health institutions; they helped diagnose patients in remote rural areas, they proved that the TB program had to be part of the general health services, and they demonstrated the epidemiological potential of a felt-need oriented TB program. The NTP diagnosed TB cases in rural institutions by sputum examination and treated them with chemotherapy. The Tuberculosis Center at district headquarters (DTC) was responsible for providing training to health workers, keeping track of all TB cases and referring them. By 1983-84, the NTP program had been implemented in 353 districts and during that year 1,308,880 cases were treated. Nevertheless, hundreds of thousands of infectious patients are not treated because health authorities put priority on child immunization and are preoccupied with malaria and family planning. The indifference of the bureaucracy and public health leadership is to be blamed for thousands of TB deaths. The solution lies in strengthening the practice of public health.     

National Tuberculosis Control Programme

Tuberculosis (TB) continues to be a major public health problem in India, since there are an estimated 2.5-3 million sputum positive cases and 5-6 million noninfectious cases in the country. The National Tuberculosis Program was established in 1962 with the main objective of reducing the disability and death from TB by effective treatment. Under the District Tuberculosis Program, district TB centers (DTCs) were set up for referral diagnosis, treatment, and community control of TB. Nationally, there are 390 districts with fully equipped DTCs staffed by a team of medical and paramedical personnel. Another 330 TB clinics are mostly located in big cities, caring for the local populace. In addition, 17 tuberculosis training and demonstration centers provide basic training to paramedical personnel, including general practitioners. There are a total of about 47,000 beds available nationwide for TB patients. The majority of patients are treated at home, thus only serious cases or those requiring surgical treatment are admitted. The NTP also stresses health education aimed at the community and general practitioners. Booklets, pamphlets, radio, TV, and newspaper advertisements are utilized for this purpose. International assistance has been provided by UNICEF, WHO, and the Swedish International Development Agency since the 1950s. The National Tuberculosis Institute was established in 1959 in Bangalore and it has engaged in research on epidemiological, sociological, and operations aspects, along with monitoring of the program. Other TB research institutes are the TB Research Center in Madras and the LRS Institute of TB and Allied Diseases in Delhi. BCG vaccination of children up to the age of 1 year continues, although a study showed that vaccination did not protect from adult TB. Evaluation of the NTP comprises quarterly reports for DTCs and countrywide assessment. NTP achievements include 85% coverage of districts, diagnosis of 1,500,000 new cases a year, and short-course chemotherapy implementation in 252 districts. Problems are also faced in implementation of DTCs and lack of trained personnel and materials.     

Improving detection and notification of tuberculosis cases in students in Shaanxi province, China: an intervention study

Background  

Cooperation between different public and private health institutes involved in tuberculosis (TB) control has proven to enhance TB control in different settings. In China, such a mechanism has not been set up yet between Centers for Disease Control (CDCs) and university hospitals despite an increased TB incidence among students. This study aims to improve arrival of TB suspects identified by universities at the CDCs in order to manage them under standardized, directly observed treatment-short course (DOTS) conditions according to the National Tuberculosis Programme (NTP) guidelines.     

Investigation of presumptive tuberculosis cases by private health providers: lessons learnt from a survey in Pakistan

Pakistan''s National Tuberculosis Control Programme (NTP) is missing data on many tuberculosis (TB) cases who visit private providers. A survey on the incidence and under-reporting of TB in Pakistan provided a database for exploring the investigation and referral of presumptive TB cases by private health providers. The survey showed that private health providers requested both sputum smear and X-ray for diagnostic investigations. Of 2161 presumptive TB cases referred, 1189 (55%) were sent for investigations to a district NTP TB centre, of whom only 314 (26.4%) were registered. This indicates an urgent need to strengthen the link between private health providers and NTP to enhance TB notification.     

National Tuberculosis Programme in Romania 1997-2000: how it works

Romania displays one of the highest epidemiological parameters of tuberculosis among European countries: the incidence reached 113.3 per 100,000 in 1998, the prevalence of chronic cases was 18.9 and mortality 11.5 per 100,000 in 1996. A National Tuberculosis Programme aimed at decreasing the present burden of the disease has been elaborated according to the WHO strategy in 1997 and for its implementing. The National Committee on Pneumophtisiology and the Central Unit of the National Institute of Pneumophtisiology were made responsible. Tuberculosis managers and supervisors were nominated in each of the 48 counties and a total of 18,000 family doctors were involved in this programme at the primary health care level. Tuberculosis has been declared the second health priority in Romania and the following budget providers for its effective control were acquired: Ministry of Health, World Bank, Open Society Foundation, Funds of Romania and World Health Organization. The following achievements can be mentioned so far: A technical manual on the National Programme has been published, WHO modules on DOTS strategy were translated into Romanian, a training course on the WHO-DOTS strategy was organized for tuberculosis managers and laboratory chiefs, a pilot project on the WHO-DOTS strategy started in lasi, first control visits in counties and pneumophtisiologists were implemented, training for family doctors was organized and a project for health education with video shots was presented on the national TV channel.     

Oral health information systems--towards measuring progress in oral health promotion and disease prevention

This article describes the essential components of oral health information systems for the analysis of trends in oral disease and the evaluation of oral health programmes at the country, regional and global levels. Standard methodology for the collection of epidemiological data on oral health has been designed by WHO and used by countries worldwide for the surveillance of oral disease and health. Global, regional and national oral health databanks have highlighted the changing patterns of oral disease which primarily reflect changing risk profiles and the implementation of oral health programmes oriented towards disease prevention and health promotion. The WHO Oral Health Country/Area Profile Programme (CAPP) provides data on oral health from countries, as well as programme experiences and ideas targeted to oral health professionals, policy-makers, health planners, researchers and the general public. WHO has developed global and regional oral health databanks for surveillance, and international projects have designed oral health indicators for use in oral health information systems for assessing the quality of oral health care and surveillance systems. Modern oral health information systems are being developed within the framework of the WHO STEPwise approach to surveillance of noncommunicable, chronic disease, and data stored in the WHO Global InfoBase may allow advanced health systems research. Sound knowledge about progress made in prevention of oral and chronic disease and in health promotion may assist countries to implement effective public health programmes to the benefit of the poor and disadvantaged population groups worldwide.     

The role of the privatization process on tuberculosis control in HoChiMinh City Province, Vietnam.

In Vietnam, tuberculosis is a major health problem, especially in HoChiMinh City Province where living conditions are marginal and HIV infection is increasing. As Vietnam has gradually shifted to a market economy, this also has implications for the health care system. More and more private practitioners are emerging. At present, case-finding and treatment of tuberculosis is under the control of Vietnam's National Tuberculosis Program (NTP). The authors argue that the process of privatization might have consequences for the implementation of a public health program such as the NTP. This argument has been illustrated by using a case study on the functioning of the NTP in HoChiMinh City Province.     

Potential yield of pulmonary tuberculosis cases by direct microscopy of sputum in a district of South India

In the District Tuberculosis Programme in India, which is part of a national programme, case-finding and treatment of pulmonary tuberculosis are integrated into the general health services. With such an integration, it is desirable, in order to forecast possible achievements, to understand the additional work-load that the programme will impose upon the existing health institutions and to assess the potential of these institutions for case-finding and treatment.     

High levels of multidrug resistant tuberculosis in new and treatment-failure patients from the Revised National Tuberculosis Control Programme in an urban metropolis (Mumbai) in Western India

Background  

India, China and Russia account for more than 62% of multidrug resistant tuberculosis (MDRTB) globally. Within India, locations like urban metropolitan Mumbai with its burgeoning population and high incidence of TB are suspected to be a focus for MDRTB. However apart from sporadic surveys at watched sites in the country, there has been no systematic attempt by the Revised National Tuberculosis Control Programme (RNTCP) of India to determine the extent of MDRTB in Mumbai that could feed into national estimates. Drug susceptibility testing (DST) is not routinely performed as a part of programme policy and public health laboratory infrastructure, is limited and poorly equipped to cope with large scale testing.     

The missing cases of tuberculosis in Malawi: the contribution from cross-border registrations

Low case detection rates of new smear-positive pulmonary tuberculosis (PTB) patients globally are a cause for concern. The aim of this study was to determine for patients registered for TB in Malawi the number and percentage who lived in a neighbouring country and the registration, recording and reporting practices for these 'foreign' patients. All 44 non-private hospitals, which register and treat all TB patients in the public health sector in Malawi, were visited. Ten (23%) hospitals in 2001 and 14 (32%) in 2002 maintained a separate register for cross-border TB cases. Patients recorded in these registers were not formally reported to the Malawi National TB Programme (NTP), the neighbouring country's NTP, nor to WHO. They therefore constitute missing cases. In Malawi, the number of cross-border new smear-positive PTB cases was 77 in 2001 and 91 in 2002, constituting about 3% of missing smear-positive cases in those hospitals that maintain cross-border registers and about 1% of missing cases nationally.     

Tuberculosis: a snap shot picture

In India almost 40% of the population is infected with tuberculosis (TB); 0.4% are sputum-positive infectious cases, 2-2.5 million new cases occur annually, and mortality amounts to 50/100,000 population. The National Tuberculosis Program (NTP) and its District TB Program (DTP) aim to detect all TB cases and treat them effectively as part of the general health services, to vaccinate most children with bacillus Calmette-Guerin, to manage planning and implementation, and to carry out proper recording and reporting of cases. Health education is also carried out in order to enlighten the community, patients, children, students, and medical personnel on various aspects of TB using booklets, pamphlets, TV, and newspaper advertisements. Among resources rendering anti-TB services are 390 district TB centers, 17,850 rural health centers, 330 other clinics, and 17 TB demonstration and training centers; there are approximately 47,000 beds available. International assistance has been obtained from the Swedish International Development Agency, who has supplied X-ray units, anti-TB drugs, and vehicles, since 1979. The World Health Organization (WHO) has assisted by providing consultants, fellowships, and equipment for the National TB Institute in Bangalore and the TB Research Center in Madras. These are also helped by WHO to conduct short courses and training courses for health administrators and college teachers. Some of the problems the NTP faces include: completion of implementation of the DTP in 80 districts and in 25% of peripheral health institutions; nonavailability of trained personnel and vehicles in DTP clinics; overburdened laboratory technicians in 25-30% of primary health care; lack of adequate quantities of drugs, material, and equipment for TB treatment; and lack or shortage of beds. The trends of TB demonstrate that cases tend to concentrate in higher age groups; prevalence in younger people and in newborn children is low and on the decline; and there is a shift from the acute type to the chronic fibrotic type.     

Experience of active tuberculosis case finding in nearly 5 million households in India

In India, to increase tuberculosis (TB) case detection under the National Tuberculosis Programme, active case finding (ACF) was implemented by the Global Fund-supported Project Axshya, among high-risk groups in 300 districts. Between April 2013 and December 2014, 4.9 million households covering ~20 million people were visited. Of 350 047 presumptive pulmonary TB cases (cough of ⩾2 weeks) identified, 187 586 (54%) underwent sputum smear examination and 14 447 (8%) were found to be smear-positive. ACF resulted in the detection of a large number of persons with presumptive pulmonary TB and smear-positive TB. Ensuring sputum examination of all those with presumptive TB was a major challenge.     

Progress toward tuberculosis control--India, 2001

Every year, approximately 2 million persons in India develop tuberculosis (TB), accounting for one fourth of the world's new TB cases. Organized TB control activities have existed in India for 40 years; however, the quality of diagnosis and treatment of TB in the public and private sectors has been variable, and TB incidence and prevalence trends have not changed substantially over this time. In 1992, the Indian government established a Revised National Tuberculosis Control Programme (RNTCP) using the directly observed treatment, short-course (DOTS) strategy recommended by the World Health Organization (WHO) (3). The DOTS strategy consists of sustained government commitment, effective laboratory-based diagnosis, standard treatment given under direct observation, secure drug supply, and systematic monitoring and evaluation. RNTCP was implemented in pilot areas beginning in 1993; large-scale implementation of the program began in late 1998. This report summarizes the process, outcomes, and challenges of RNTCP in India. RNTCP has implemented DOTS rapidly and has yielded positive results in TB control; however, continued commitment from Indian government authorities and the international community is needed to sustain and expand this ongoing program.     

Intensified tuberculosis case finding amongst vulnerable communities in southern India

India mainly uses passive case finding to detect tuberculosis (TB) patients through the Revised National Tuberculosis Control Programme (RNTCP). An intensified case finding (ICF) intervention was conducted among vulnerable communities in two districts of Karnataka during July–December 2013; 658 sputum smear-positive TB cases were detected. The number of smear-positive cases detected increased by 8.8% relative to the pre-intervention period (July–December 2012) in intervention communities as compared to an 8.6% decrease in communities without the ICF intervention. ICF activities brought TB services closer to vulnerable communities, moderately increasing TB case detection rates.     

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.     

A Bayesian approach to health project estimation.

This paper illustrates how a Bayesian statistical approach was used to estimate the outcomes of the National Tuberculosis Program in India. Such an estimate, it is argued, is necessary for a proper judgement about a project's social usefulness. The process of medical care delivery is reduced to a set of conditioned probabilities. The numbers are estimated using as source material medical records, the results of medical research, and the opinion of experts. Bayesian methods of estimation are used and their value is discussed. The final discussion contains a brief treatment of the role of project analysis in public decision making. The place of Bayesian methods in project analysis is briefly illustrated, demonstrating their operational value in the field of public health decision making.     

Tobacco control policies in India: implementation and challenges

Tobacco use is a major public health challenge in India with 275 million adults consuming different tobacco products. Government of India has taken various initiatives for tobacco control in the country. Besides enacting comprehensive tobacco control legislation (COTPA, 2003), India was among the first few countries to ratify WHO the Framework Convention on Tobacco Control (WHO FCTC) in 2004. The National Tobacco Control Programme was piloted during the 11 th Five Year Plan which is under implementation in 42 districts of 21 states in the country. The advocacy for tobacco control by the civil society and community led initiatives has acted in synergy with tobacco control policies of the Government. Although different levels of success have been achieved by the states, non prioritization of tobacco control at the sub national level still exists and effective implementation of tobacco control policies remains largely a challenge.     

National tuberculosis programme review: experience over the period 1990-95.

Since 1990 the WHO Global Tuberculosis Programme (GTB) has promoted the revision of national tuberculosis programmes to strengthen the focus on directly observed treatment, short-course (DOTS) and close monitoring of treatment outcomes. GTB has encouraged in-depth evaluation of activities through a comprehensive programme review. Over the period 1990-95, WHO supported 12 such programme reviews. The criteria for selection were as follows: large population (Bangladesh, Brazil, China, Ethiopia, India, Indonesia, Mexico, and Thailand); good prospects of developing a model programme for a region (Nepal, Zimbabwe); or at advanced stage of implementation of a model programme for a region (Guinea, Peru). The estimated combined incidence of smear-positive pulmonary tuberculosis was 82 per 100,000 population, about 43% of the global incidence. The prevalence of infection with human immunodeficiency virus (HIV) was variable, being very high in Ethiopia and Zimbabwe, but negligible in Bangladesh, China, Nepal and Peru. The programme reviews were conducted by teams of 15-35 experts representing a wide range of national and external institutions. After a 2-3-month preparatory period, the conduct of the review usually lasted 2-3 weeks, including a first phase of meetings with authorities and review of documents, a second phase for field visits, and a third phase of discussion of findings and recommendations. The main lessons learned from the programme reviews were as follows: programme review is a useful tool to secure government commitment, reorient the tuberculosis control policies and replan the activities on solid grounds; the involvement of public health and academic institutions, cooperating agencies, and nongovernmental organizations secured a broad support to the new policies; programme success is linked to a centralized direction which supports a decentralized implementation through the primary health care services; monitoring and evaluation of case management functions well if it is based on the right classification of cases and quarterly reports on cohorts of patients; a comprehensive programme review should include teaching about tuberculosis in medical, nursing, and laboratory workers'' schools; good quality diagnosis and treatment are the essential requirements for expanding a programme beyond the pilot testing; and control targets cannot be achieved if private and social security patients are left outside the programme scope. The methodology of comprehensive programme review should be recommended to all countries which require programme reorientation; it is also appropriate for carrying out evaluations at 4-5-year intervals in countries that are implementing the correct tuberculosis control policies.