Effective participation of TB sanatoria in Revised National TB Control Programme (DOTS) in a metropolitan city.

BACKGROUND: Revised National TB Control Programme has been implemented since 1998 in Bangalore metropolitan city which has several big general hospitals, including two TB sanatoria which attract a large number of respiratory symptomatic and TB patients. Till recently there was significant loss of patients for follow up because of lack of mechanism to reach the patients, good recording practices and linkage with district TB control office. OBJECTIVE: To establish an effective referral mechanism between TB sanatoria and peripheral health institutions of the government for providing un-interrupted supervised treatment (DOT) to all newly detected TB patients. METHOD: TB sanatoria remain as "islands" when Reyised National TB Control Programme (RNTCP) with DOTS strategy is implemented. Damien Foundation India Trust (DFIT) provided a Technical Support Team (one medical consultant and three supervisors) to assist in implementation of RNTCP in the district. DFIT liaised with both partners and established procedures for recording correct address, informing health institutions and Senior TB Supervisors (STS) and monitoring referrals. Referral slip and a copy of treatment card were given to patients. One copy of treatment card was sent to respective health facility. Initially the number of STS was not adequate to follow up the patients. The supervisors of Technical Support Team ensured that they were treated in peripheral health institutions or near patients' residence. All STS were in position one year after initiation of this effort. RESULTS: The referral system is functional. Case holding improved from about 50% to 85% during 2002-2005 by effective transfer through referrals. CONCLUSION: Interfacing of NGO between district TB control office and TB sanatoria enabled the establishment of effective collaboration. Initial reluctance was replaced by complete participation in the TB control programme.

Trends in new case-detection leprosy in Bihar, India.

Multi-drug therapy (MDT) has been successfully implemented in all leprosy endemic countries. Prevalence of leprosy has declined remarkably after the introduction of MDT. Detection of new cases did not show expected decline in many endemic and low endemic situations. Bihar in India started implementing MDT in 1993. The Damien Foundation India Trust (DFIT) supported the leprosy control programme in Bihar by providing a district technical support team (DTST) for each district assigned to DFIT. Effective coverage was achieved in 1996-98. Data for the period 1996-2004 from 10 districts are presented in this paper. The total population in these districts was 29.4 million. Deformity among newly detected leprosy patients declined to 1% indicating effective early case-detection. Intensive new case-detection activities were in vogue contributing to high new case-detection rate (NCDR). The NCDR remained high during the 9-year period reported here and did not show any declining trend.

"Instant" new leprosy case-detection: an experience in Bihar State in India.

The National Leprosy Eradication Programme (NLEP) is based on survey, education and treatment, including coverage of all the registered cases with multi-drug therapy (MDT). The Government of India introduced MDT in all leprosy endemic districts through a vertical set-up, and through mobile leprosy treatment units in low endemic districts. Anti-leprosy work has not been uniform in all the states and needed push-start in some, such as Bihar. There have been spurts of leprosy elimination activities and the entire populations of the regions have not been covered because of various administrative reasons and logistic problems. In Singhbhum district of Bihar, a successful attempt was made to cover the maximum population by campaign approach. The strategy was to involve all the field workers of the leprosy programme in the district, supported by a small group of experienced personnel. The campaign, lasting for 39 working days, resulted in detecting leprosy cases equivalent to 64% of cases detected during the previous one full year. The entire operation helped the local staff to gain experience that would be useful for the future of the NLEP, and also provide an insight into working practices. Similar campaign approach can be used in situations where case-detection activities are feeble and the implementation of MDT is slow. If such campaigns are repeated at appropriate intervals, it will be a great support to achieving the goal of leprosy elimination.

Utilizing primary health care workers for case detection.

Under the National Leprosy Elimination Programme it takes at least one year for the paramedical worker to survey the allotted population for case detection. An alternative strategy in warranted for States like Bihar still having a high case load and poorly functioning leprosy programme. An intensive case finding programme using Primary Health Care (PHC) workers was organized in Bhojpur district, Bihar State, India. The whole population (3, 173, 701 in 1996) of the district was screened within a period of four days and confirmation of suspected cases was carried out in four days. During this screening procedure, 1586 new leprosy cases were detected (NCDR = 5 cases per 10,000) and all were started on MDT. The new cases constituted 26.4% of active cases existing on record before the screening. After this experience, the prevalence rate of active cases increased from 19 to 24 10,000. If such rapid screening programmes are done at least twice a year, it will greatly hasten the process of elimination of leprosy.

Study of the problem of hidden cases of leprosy among "inaccessible" section of urban population in Madras City.

A questionnaire survey was conducted amongst 1300 general practitioners (GPs) of Madras city to assess the magnitude of leprosy problem amongst the upper middle class and upper class populations who are getting treatment from these GPs. A total of 2944 leprosy patients were being treated by 200 GPs. One third of these patients belonged to the upper middle/upper class section of the population living in the city of Madras.

Hidden cases of leprosy (in prison)

Leprosy survey conducted in eight prisons in seven districts of Bihar State revealed a prevalence of 13.3 per 1000 which was 12 times more than the recorded prevalence of leprosy in the State. Thus this finding supports the view that prisons could form a hyperendemic pocket for leprosy. Regular NLEP services need to be extended to the inmates of the prisons.

Leprosy among inmates of a prison.

A leprosy survey carried out in a district prison revealed a gross prevalence of 20 cases per 1000, and active prevalence of 10 cases per 1000 whereas, prevalence of leprosy in the state was 1.12 per 1000. Such prisons thus form hyperendemic pockets. The inmates are a closed community and there is a risk of cases among inmates spreading infection to others inside the prison during their sojourn there and to the community when they are released from the prison. Special efforts are required to identify and eliminate all identifiable sources of infection, especially at this point of time when we are aiming at elimination of leprosy as a public health problem.

A leprosy survey in a taluk headquarters town and the role of dermatological services and active health education in its success--a preliminary report.

A report of two general surveys done in 1984 and 1987 in Gudiyatham town, is presented. The first survey covered 89.2% and the second survey 82% of the population. The new case detection rate was 3.4 per 1000. The success of the survey was due to the co-operation obtained from the public, most probably because of the intense and sustained health education, combined with leprosy services integrated with a dermatology clinic.

Incidence of "chance" smear positivity among MB leprosy patients after MDT.

Multidrug therapy (MDT) was introduced in 1982. Nine hundred eighty multibacillary (MB) leprosy patients had successfully completed the MDT administered for a minimum of two years or till skin smear negativity, whichever was later, as recommended by the World Health Organisation (WHO). During surveillance, 2.24% of them revealed presence of acid-fast bacilli (AFB) in the skin smear. They did not have any clinical evidence suggestive of relapse. Subsequent followup (without antileprosy chemotherapy) for periods ranging from one to eight years was uneventful. We have called this as "chance smear positivity" where a few bacilli, yet to be cleared by the immune system, were picked up by routine skin smear examination.