Controlling tuberculosis in India.

BACKGROUND: Tuberculosis kills nearly 500,000 people in India each year. Until recently, less than half of patients with tuberculosis received an accurate diagnosis, and less than half of those received effective treatment. METHODS: We analyzed the effects of new policies introduced in 1993 that have resulted in increased resources, improved laboratory-based diagnosis, direct observation of treatment, and the use of standardized antituberculosis regimens and reporting methods. RESULTS: By September 2001, more than 200,000 health workers had been trained, and 436 million people (more than 40 percent of the entire population) had access to services. About 3.4 million patients had been evaluated for tuberculosis, and nearly 800,000 had received treatment, with a success rate greater than 80 percent. More than half of all those treated in the past 8 years were treated in the past 12 months. CONCLUSIONS: India's tuberculosis-control program has been successful in improving access to care, the quality of diagnosis, and the likelihood of successful treatment. We estimate that the improved program has prevented 200,000 deaths, with indirect savings of more than $400 million--more than eight times the cost of implementation. It will be a substantial challenge to sustain and expand the program, given the country's level of economic development, limited primary health care system, and large and mostly unregulated private health care system, as well as the dual threats of the human immunodeficiency virus and multidrug-resistant tuberculosis.

The status and prospects of tuberculosis control in India.

SETTING: India, where much of the global strategy for tuberculosis control was established, but where, every year, there are an estimated 2 million cases of tuberculosis. OBJECTIVE: To describe the policies, initial results, and lessons learned from implementation of a Revised National Tuberculosis Control Programme using the principles of DOTS (Directly Observed Treatment, Short-course). DESIGN: A Revised National Tuberculosis Control Programme (RNTCP) was designed and implemented starting in 1993. With funding from the Government of India, State Governments, the World Bank and bilateral donors, regular supply of drugs and logistics was ensured. Persons with chest symptoms who attend health facilities are referred to microscopy centres for diagnosis. Diagnosed cases are categorized as per World Health Organization guidelines, and treatment is given by direct observation. Systematic recording and cohort reporting is done. RESULTS: From October 1993 through mid-1999, 146,012 patients were put on treatment in the programme. The quality of diagnosis was improved, with the ratio of smear-positive to smear-negative patients being maintained at 1:1. Case detection rates varied greatly between project sites and correlated with the percentage of patients who were smear-positive among those examined for diagnosis, suggesting heterogeneous disease rates. Treatment success was achieved in 81% of new smear-positive patients, 82% of new smear-negative patients, 89% of patients with extra-pulmonary tuberculosis, and 70% of re-treatment patients. CONCLUSION: The RNTCP has successfully treated approximately 80% of patients in 20 districts of 15 states of India. Treatment success rates are more than double and death rates are less than a seventh those of the previous programme. Starting in late 1998, the programme began to scale up and now covers more than 130 million people. Maintaining the quality of implementation during the expansion phase is the next challenge.

Impact of national consultants on successful expansion of effective tuberculosis control in India.

SETTING: India, during a period of rapid expansion of DOTS services. DOTS expansion has been slow in many countries. OBJECTIVE: To document use of consultants to expand DOTS effectively. DESIGN: Staff were contracted to monitor DOTS expansion and implementation. To estimate the impact of these staff, we compared areas with and without consultants, and individual areas before and after consultants were assigned. Consultants were preferentially assigned to the more difficult areas; the temporary absence of consultants reflected non-availability of candidates. RESULTS: Areas with consultants met pre-defined criteria and began DOTS service delivery faster (median 9 vs. 18 months of preparation) than areas without consultants. Rates of sputum conversion (87% vs. 83%, P < 0.001) and treatment success (83% vs. 78%, P < 0.001) were significantly higher in areas with consultants present. CONCLUSION: Assignment of consultants resulted in much more rapid implementation of the DOTS strategy, and better quality performance. Continued effective performance in these areas will rely on many factors, but the need for consultants appears to be decreasing, suggesting that they have provided sustainable improvements. The effectiveness of local consultants may have important implications for efforts to scale up public health interventions for tuberculosis, malaria, AIDS and other diseases in developing countries.

A survey of tuberculosis hospitals in India.

SETTING: Hospitals with beds for tuberculosis (TB) in India. OBJECTIVES: To assess diagnostic and treatment practices at institutions offering secondary or tertiary level care for TB patients, and to determine the resources being used at these institutions. DESIGN: Countrywide cross-sectional survey of TB hospitals using a mailed semi-structured questionnaire sent to all 105 hospitals with 100 or more beds and to all State Directorate Health Services. RESULTS: The 94 hospitals that returned the questionnaire had 15773 TB beds, one third of the total TB beds in the country. Nearly 1 million patients sought treatment in the TB hospitals and one third were diagnosed with TB; the ratio of smear-positive to smear-negative patients was 1:2.7. Sixty-four per cent of hospitals prescribed unobserved rifampicin in the continuation phase, and 56% of sputum smear-positive patients were hospitalised. The annual expenditure for the TB hospitals was more than the total annual budget for the TB control programme of the country. CONCLUSIONS: In view of the high number of patients seen and the suboptimal practices observed, urgent steps should be taken to ensure implementation of correct diagnostic and treatment policies in hospitals with TB beds.

National tuberculosis control programme.

PIP: In 1962, the government of India launched a National Tuberculosis Control Program to detect as many tuberculosis cases as possible, provide effective treatment, establish district tuberculosis centers, extend short-course chemotherapy, and strengthen existing state tuberculosis training and demonstration centers. To date, district tuberculosis centers have been established in 454 of India's 496 districts and a total of 330 tuberculosis clinics are in operation. The tuberculosis mortality rate dropped from 80/100,000 population in 1970 to 53/100,000 in 1993. However, a 1992 review of the national program revealed inadequate budgetary outlays and drug shortages, an overemphasis on clinical and radiologic diagnosis, insufficient utilization of sputum microscopy facilities, an emphasis on case detection rather than cure, and a lack of consensus on treatment regimens. On the basis of these findings, the national strategy has been revised to achieve an 85% cure rate through administration of short-course (6-8 months) chemotherapy and to detect 70% of estimated cases. Strategies for achieving these objectives include use of sputum testing as the primary diagnostic method among self-referred cases, a standardized treatment regimen, an uninterrupted supply of drugs at all levels of the health system, increased budgetary outlays, creation of a sub-district supervisory unit, and greater emphasis on training and operations research. A pilot project testing this approach in five areas in 1993 resulted in significant improvements in the pulmonary smear positive to negative ratios and cure rates. As a result, the government of India will expand the project strategy to 17 sites covering a population of 15.83 million.^ieng

Rapid DOTS expansion in India.

Since late 1998 the coverage of the DOTS strategy in India has been expanded rapidly. In both 2000 and 2001 the country probably accounted for more than half the global increase in the number of patients treated under DOTS and by early 2002 more than a million patients were being treated in this way in India. As a result, nearly 200 000 lives were saved. The lessons learnt relate to the importance of the following elements of the programme: (1) getting the science right and ensuring technical excellence; (2) building commitment and ensuring the provision of funds and flexibility in their utilization; (3) maintaining focus and priorities; (4) systematically appraising each area before starting service delivery; (5) ensuring an uninterrupted drug supply; (6) strengthening the established infrastructure and providing support for staff; (7) supporting the infrastructure required in urban areas; (8) ensuring full-time independent technical support and supervision, particularly during the initial phases of implementation; (9) monitoring intensively and giving timely feedback; and (10) continuous supervision. Tuberculosis (TB) control still faces major challenges in India. To reach its potential, the control programme needs to: continue to expand so as to cover the remaining half of the country, much of which has a weaker health infrastructure than the areas already covered; increase its reach in the areas already covered so that a greater proportion of patients is treated; ensure sustainability; improve the patient-friendliness of services; confront TB associated with human immunodeficiency virus (HIV) infection. It is expected that HIV will increase the number of TB cases by at least 10% and by a considerably higher percentage if HIV becomes much more widespread. India's experience shows that DOTS can achieve high case-detection and cure rates even with imperfect technology and often with an inadequate public health infrastructure. However, this can only happen if the delivery programme is appropriately designed and effectively managed.