Programmatic approaches to screening for active tuberculosis.

Passive case finding, the detection of tuberculosis (TB) cases among persons presenting to health facilities with symptoms suggestive of TB, has remained the principal public health approach for TB diagnosis. While this approach, in combination with improved treatment, has led to substantial global progress, the overall epidemiological impact has been inadequate. Stagnating case notifications and sluggish decline in incidence prompt the pursuit of a more active approach to TB case detection. Screening among contacts of TB patients and people living with human immunodeficiency virus infection, long recommended, needs scaling up. Screening in other risk groups may also be considered, depending on the epidemiological situation. The World Health Organization (WHO) has recently produced recommendations on systematic screening for active TB, which set out principles and provide guidance on the prioritisation of risk groups for screening and choice of screening and diagnostic algorithms. With a view to help translate WHO recommendations into practice, this concluding article of the State of the Art series discusses programmatic approaches. Published literature is scanty. However, considerable field experience exists to draw important lessons. Cautioning against a hasty pursuit of active case finding, the article stresses that programmatic implementation of TB screening requires a systematic approach. Important considerations should include setting clear goals and objectives based on a thorough assessment of the situation; considering the place of TB screening in the overall approach to enhancing TB detection; identifying and prioritising risk groups; choosing appropriate screening and diagnostic algorithms; and pursuing setting-specific implementation strategies with engagement of relevant partners, due attention to ethical considerations and built-in monitoring and evaluation.

Systematic screening for active tuberculosis: rationale, definitions and key considerations.

The impact of current interventions to improve early detection of tuberculosis (TB) seems to have been saturated. Case detection trends have stagnated. TB incidence is falling in most settings worldwide, but the rate of decline is far lower than expected. There is growing evidence from national TB prevalence surveys and other research of a large pool of undetected TB in the community. Intensified efforts to further break down access barriers and scale up new and rapid diagnostic tools are likely to improve the situation. However, will these be enough? Or do we also need to reach out more towards people who do not actively seek care with well-recognisable TB symptoms? There have recently been calls to revisit TB screening, particularly in high-risk groups. The World Health Organization (WHO) recommends screening for TB in people with human immunodeficiency virus infection and in close TB contacts. Should other risk groups also be screened systematically? Could mass, community-wide screening, which the WHO has discouraged over the past four decades, be of benefit in some situations? If so, what screening tools and approaches should be used? The WHO is in the process of seeking answers to these questions and developing guidelines on systematic screening for active TB. In this article, we present the rationale, definitions and key considerations underpinning this process.

A rapid assessment of prevailing policies on tuberculosis contact investigation.

Contact investigation contributes to improving early case detection of tuberculosis (TB). However, its implementation in low-income, high TB burden countries remains limited. A multicountry survey of contact investigation policies was conducted to evaluate the extent of their implementation. Our results showed significant heterogeneity in definitions and procedures, with over 25% of countries unable to provide a clear definition of a contact. Estimates indicate that routine implementation of contact investigation policies globally could help detection of over a quarter of a million cases. International guidelines should be developed to support national TB programmes to initiate and scale up systematic TB contact investigation.

Intensified scale-up of public-private mix: a systems approach to tuberculosis care and control in India.

SETTING: India's Revised National Tuberculosis Control Programme (RNTCP) implemented an intensified scale-up of public-private mix (PPM) DOTS covering 50 million population in 14 major cities. OBJECTIVES: To describe the processes and outcomes of the systems approach adopted. METHODS: National schemes for engagement with different providers were applied. Additional human resources were provided to assist with implementation. All health care providers were mapped, a concise training module and advocacy kit were developed, and sensitisation and training activities were conducted. National advocacy efforts complemented local initiatives. Data were captured in a PPM-focused surveillance system. RESULTS: Intensified PPM resulted in a 12% increase in notification of new smear-positive pulmonary TB cases. Contribution to case notification by providers varied widely: health department 67%, medical colleges 16%, private practitioners 6%, non-government organisations 7%, and the rest 4%. Treatment success was above the 85% target for all sectors combined. Strong public sector implementation and differentiation of roles and responsibilities among providers played major roles. The lessons learnt have been used by the RNTCP to inform future policy development. CONCLUSION: The systems approach to the intensified PPM scale-up used in the 14 cities was productive. However, many challenges and barriers to scale-up of PPM DOTS in India remain.

Tuberculosis and noncommunicable diseases: neglected links and missed opportunities.

Globally, the incidence of tuberculosis (TB) is declining very slowly, and the noncommunicable disease (NCD) burden for many countries is steadily increasing. Several NCDs, such as diabetes mellitus, alcohol use disorders and smoking-related conditions, are responsible for a significant proportion of TB cases globally, and in the European region, represent a larger attributable fraction for TB disease than HIV. Concrete steps are needed to address NCDs and their risk factors. We reviewed published studies involving TB and NCDs, and present a review and discussion of how they are linked, the implications for case detection and management, and how prevention efforts may be strengthened by integration of services. These NCDs put patients at increased risk for developing TB and at risk for poor treatment outcomes. However, they also present an opportunity to provide better care through increased case-detection activities, improved clinical management and better access to care for both TB and NCDs. Hastening the global decline in TB incidence may be assisted by strengthening these types of activities.

Economic evaluation of public-private mix for tuberculosis care and control, India. Part I. Socio-economic profile and costs among tuberculosis patients.

SETTING: Bangalore City, India. OBJECTIVES: To assess the socio-economic profile, health-seeking behaviour and costs related to tuberculosis (TB) diagnosis and treatment among patients treated under the Revised National TB Control Programme (RNTCP). DESIGN: All 1106 new TB patients registered for treatment under the RNTCP in the second quarter of 2005 participated. Interviews at the beginning and at the end of treatment were conducted. A convenience sample of 32 patients treated outside the RNTCP also participated. RESULTS: Among the TB patients, respectively 50% and 39% were from low and middle standard of living (SL) households, and 77% were from households with a per capita income of less than US$1 per day. The first health contact was with a private practitioner in the case of >70% of patients. Mean patient delay was low, at 21 days, but the mean health system delay was 52 days. The average cost incurred by patients before treatment in the RNTCP was US$145, and during treatment it was US$21. Costs as a proportion of annual household income per capita were 53% for people from low SL households and 41% for those from other households. Costs during treatment faced by patients treated outside the RNTCP averaged US$127. CONCLUSION: Patients treated under the RNTCP through a public-private mix approach were predominantly poor. Many of them experienced considerable health expenditures before starting treatment. Additional efforts are required to reduce the delays and the number of health care providers consulted, and to ensure that patients are shifted to subsidised treatment within the RNTCP.

Economic evaluation of public-private mix for tuberculosis care and control, India. Part II. Cost and cost-effectiveness.

SETTING: Bangalore City, India. OBJECTIVES: To assess the cost and cost-effectiveness of public-private mix (PPM) for tuberculosis (TB) care and control when implemented on a large scale. DESIGN: DOTS implementation under the Revised National TB Control Programme (RNTCP) began in 1999, PPM was introduced in mid-2001 and a second phase of intensified PPM began in 2003. Data on the costs and effects of TB treatment from 1999 to 2005 were collected and used to compare the two distinct phases of PPM with a scenario of no PPM. Costs were assessed in 2005 $US for public and private providers, patients and patient attendants. Sources of data included expenditure records, medical records, interviews with staff and patient surveys. Effectiveness was measured as the number of cases successfully treated. RESULTS: When PPM was implemented, total provider costs increased in proportion to the number of successfully treated TB cases. The average cost per patient treated from the provider perspective when PPM was implemented was stable, at US$69, in the intensified phase compared with US$71 pre-PPM. PPM resulted in the shift of an estimated 7200 patients from non-DOTS to DOTS treatment over 5 years. PPM implementation substantially reduced costs to patients, such that the average societal cost per patient successfully treated fell from US$154 to US$132 in the 4 years following the initiation of PPM. CONCLUSION: Implementation of PPM on a large scale in an urban setting can be cost-effective, and considerably reduces the financial burden of TB for patients.

Public-private mix for control of tuberculosis and TB-HIV in Nairobi, Kenya: outcomes, opportunities and obstacles.

SETTING: Nairobi, the capital of Kenya. OBJECTIVE: To promote standardised tuberculosis (TB) care by private health providers and links with the public sector. DESIGN AND METHODS: A description of the results of interventions aimed at engaging private health providers in TB care and control in Nairobi. Participating providers are supported to provide TB care that conforms to national guidelines. The standard surveillance tools are used for programme monitoring and evaluation. RESULTS: By the end of 2006, 26 of 46 (57%) private hospitals and nursing homes were engaged. TB cases reported by private providers increased from 469 in 2002 to 1740 in 2006. The treatment success rate for smear-positive pulmonary TB treated by private providers ranged from 76% to 85% between 2002 and 2005. Of the 1740 TB patients notified by the private sector in 2006, 732 (42%) were tested for human immunodeficiency virus (HIV), of whom 372 (51%) were positive. Of the 372 HIV-positive TB patients, 227 (61%) were provided with cotrimoxazole preventive treatment (CPT) and 136 (37%) with antiretroviral treatment (ART). CONCLUSION: Private providers can be engaged to provide TB-HIV care conforming to national norms. The challenges include providing diagnostics, CPT and ART and the capacity to train and supervise these providers.

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.

Private health care.

During the last decade there has been considerable international mobilisation around shrinking the role of States in health care. The World Bank reports that, in many low and middle-income countries, private sources of finance comprise the largest share of total national health expenditures. Private sector health care is ubiquitous, reaches throughout the population, preferred by the people and is significant from both economic as well as health perspective. Resources are limited, governments are weak, and a new approach is needed. This paper provides a broad overview and raises key issues with regard to private health care. The focus is on provision of health care by private medical providers. On the background of the world's common health problems and interventions available to tackle them, the place of private health care in the overall context is first discussed. The concept of privatisation within the various forms of health care systems is then explained. The paper then describes the genesis and key elements of rapidly enhancing role of the private sector in health care and points to the paucity of literature from low and middle-income countries. Common concerns about private health care are outlined. Two illustrative examples--tuberculosis, the top infectious killer among the poor and coronary heart disease, the top non-infectious killer among the rich--are presented to understand the current and possible role of private sector in provision of health care. Highlighting the need to distinguish between health care as a public good or a market commodity, the paper leaves it to the reader to draw conclusions.

Clinical and electrophysiological evaluation of nerve function impairment following cessation of multidrug therapy in leprosy.

Seventeen multibacillary (MB) and 15 paucibacillary (PB) cases of leprosy who had had regular and adequate multidrug therapy (MDT) were examined clinically and electrophysiologically at periodic intervals for 1 year following cessation of MDT. All the major nerves were assessed for nerve function impairment (NFI). Overall, two MB (13.3%) and three PB (20%) cases showed signs of deterioration clinically and/or electrophysiologically. The nerve conduction (NC) follow-up studies revealed no significant improvement in the sensory conduction in both the MB and PB groups of nerves, whilst motor conduction showed a significant improvement at the first 6-monthly follow-up among the MB group of nerves. At the study onset, sensory impairment (MB = 62%, PB = 25%) predominated over motor in terms of both severity and frequency. The lower extremity was more frequently and severely affected than the upper in both groups of patients. As an individual test, NC measurement proved to be more sensitive in detecting NFI, but the combination of physical palpatation for nerve thickening and graded nylon test (GNT) was closely comparable to measurement of nerve conduction.

Higher incidence of viable Mycobacterium leprae within the nerve as compared to skin among multibacillary leprosy patients released from multidrug therapy.

As identified by a significant growth in the footpads of immunosuppressed mice, the incidence of viable bacteria in a group of 26 multibacillary (BL-LL) patients released from multidrug (MDT) treatment was found to be two times more in the nerves (46%) as compared to skin (23%). Evidently there was a positive correlation between the overall bacterial load and the incidence of viable organisms. Bacterial growth was also observed in two out of five cases where neither the skin nor the nerve homogenate had shown any presence of acid-fast bacilli. Histopathology of biopsies, skin as well as nerve, including those having viable bacteria did not show any features of active disease.

Primary resistance to single and multiple drugs in leprosy--a mouse footpad study.

Skin biopsy homogenates obtained from three cases of lepromatous leprosy with no prior history of antileprosy treatment were tested in the mouse footpad for the sensitivity of Mycobacterium leprae to multiple drugs. One of the inocula was sensitive to all the three drugs tested using the highest concentration each of DDS 0.01 g%, RFP 0.03 g% and CLF 0.01 g%. The 2nd inocula showed growth in the presence of 0.01 g% DDS only. While the 3rd inocula (Pt. KU) tested resistant to all the three drugs in the first, i.e. man to mouse, as well as in the second passage, i.e. mouse to mouse.

Private doctors and tuberculosis control in India.

Over three quarters of the 8 million registered doctors in India are engaged in private medical practice. In urban and rural areas alike people prefer private doctors to public health services for their health care needs. A majority of patients and those with suspected tuberculosis also report first to private doctors. Nevertheless private doctors seem to be alienated from national efforts towards control of tuberculosis, there being no well-defined role for them in the National Tuberculosis Programme. This study of private doctors practising in the low income areas of a metropolis of India reports on the knowledge of private doctors about diagnosis and treatment of tuberculosis and their awareness and perceptions about the public health services available for tuberculosis control. The study reveals gaps and weaknesses in the private doctors' reported practice of managing lung tuberculosis, the most important and persistent problem of public health concern in India. The need for organized efforts towards involving private doctors in disease control programmes wherein their curative functions could contribute significantly is stressed.

Clinical and histopathological observations on pure neuritic leprosy.

Pure neuritic leprosy is a well accepted clinical entity. In the absence of skin lesions there is a greater possibility of missing the diagnosis of leprosy due particularly to a wide variety of pure neural manifestations that may mimic other peripheral neuropathies. Histopathological studies of pure neuritic leprosy have received less attention for ethical reasons and limitations of surgery. Classification of pure neuritic leprosy poses problems since the histological spectrum (e.g. Ridley-Jopling scale) is based chiefly on the skin picture. Review of the past literature shows conflicting reports about comparability of the skin and nerve pictures. This paper presents clinical and histopathological observations on twelve patients of pure neuritic leprosy, the interesting observations being that all the patients showed lepromin positivity and a narrower histological spectrum, ranging from TT to BB only.

Dapsone dependent nodular panniculitis.

A patient recorded to be suffering from tuberculoid leprosy since 1973 and on regular Dapsone monotherapy for about nine years developed asymmetrical, erythematous, subcutaneous, nodular swellings restricted chiefly to the extensor aspects of lower limbs two months after discontinuation of Dapsone therapy. During the course of Dapsone treatment, the patient had developed similar swellings twice previously each time when he stopped the drug for about a month. The swellings disappeared on commencement of Dapsone Treatment. This has been reconfirmed under our supervision. The biopsy of one of the lesions revealed panniculitis with vasculitis. The original diagnosis of leprosy was probably invalid.