Objectives
 •Disseminate info on TB in India
 •Improve care of TB patients in India
 •Enable doctors and NGO's interested in TB control to interact

Evolution of TB programme concepts


Prior to the advent of chemotherapy, the management of tuberculosis consisted of good food including calcium, high proteins, cod liver oil and collapse therapy. There were no organized plans for prevention of TB infection and control of disease. In 1943 the central government appointed a health survey and development committee("Bhore committee") to review the country's health problems and recommend measures for their management. The recommendation for tuberculosis control consisted of establishing 100000 tuberculosis beds(1 bed for every 5 deaths),one main TB clinic at district headquarters town, and sub clinics at taluq towns, one mobile clinic per district. For the whole country the cost was estimated at 200 crores at 1946-47 prices. The recommendations being impractical were shelved. However BCG vaccination was accepted by the Planning commission for prevention of TB and was started in 1951 with WHO assistance. A sample survey was undertaken under the aegis of Indian Council of medical research in1955-58.In 1955 a 3 man BMRC group was asked by the WHO to advise the Indian authorities on studies relevant to the chemotherapy of Bathe tuberculosis chemotherapy centre(later renamed as Tuberculosis research centre.) was set up in Madras. In 1958 the National Tuberculosis Institute was started in Bangalore, and was officially opened in 1960.Its main objectives were
  1. To formulate an applicable, acceptable and economically feasible national programme for Tuberculosis
  2. To train necessary manpower to organize and manage the programme
  3. To continue research with emphasis on operational activities to evolve the programme
  4. To monitor the national Tuberculosis programme from the late 1970's
The strategy of our organized fight against Tuberculosis was developed by NTI based on the significant findings of its own research and research of Tuberculosis Chemotherapy centre(later renamed as Tuberculosis Research centre).The programme had taken into account the scarcity of resources, health seeking behaviour and the technological breakthrough that the results of domiciliary chemotherapy were comparable to that of sanatorium, there was no higher risk to contacts, bed rest and nutritious diet did not influence the outcome in a statistically significant way. The operational aspects of the strategy to deliver the services through primary health care was demonstrated to be both feasible and applicable. The programme in an average Indian district of population 1.5 million has a potential of finding about 2530 sputum positive pulmonary tuberculosis in a year.
Organisation of NTP
In India the administrative hierarchy is Central Government,state Government,district.The corresponding tuberculosis programme managers are as follows
Prgramme manager hierarchy
Level Unit Function
Centre Directorate general of Health services(DDG(TB) Overall policies, Programme formulation and planning, Logistic support(drugs, supplies etc),training
State State TB Centre(State TB Officer) Coordination at state level, Supervision of DTP's
District District Tuberculosis Centre(District Tuberculosis officer) Diagnosis both by microscopy and X-ray, Management of cases, coordination and supervision of NTP within the district. Monitoring and evaluation of DTP.Provision of logistics and referral services

NTP performance in January to September 1999 (Ind J Tub 2001,48,25-29)
Sputum positivity rate %
PHI DTC
Actual 5 13
Expectation 8 18%

Composition of cases
Smear positive Smear negative Extra pulmonary Total number
27% 67% 6% 791022

Treatment efficiency cohort period 1997
Standard Regimen(47029 patients) Short Course chemotherapy(79221 patients)
Per cent patients making satisfactory level of collections * expected 30% 57%
*Satisfactory level of collection is 10 collections or more in case of standard regimen
Availability of trained key personnel 13 of the 247 DTCs reporting on the availability of trained core personnel have full complement.73 have trained doctor,59 have trained statistical assistant,73 have trained laboratory technician, and 76 have trained treatment organizer. Non availability of trained key personnel at DTC may be due to lack of sanctioned post, posts remaining vacant, lack of budget to depute key personnel for training and diversion of manpower to other schemes/programmes.
The authors state that the performance of NTP is far below the expectations in all respects. Doctors at DTC still depend on X-ray diagnosis when it is well established that sputum microscopy is the preferred tool for diagnosis of pulmonary tuberculosis
Short course chemotherapy under national tuberculosis programme The advent of short course chemotherapy (SCC) in the seventies raised hope that the patient compliance would improve.SCC was introduced on a pilot basis in 18 districts in 10 states to study the operational aspects.Initially,4 districts were covered between 1983 and 1987,but by the end of December 1982,252 districts had been covered. The Scc regimens introduced were A-A fully supervised biweekly regimen of 6 month duration2S2H2R2Z2/$H2R2 B-A self administered oral regimen of 8 months duration 2EHRZ/TH Suryanarayana et al (Ind J Tub 1994,41,211)analysed the performance of SCC districts in terms of implementation ,reporting, performance of case finding and treatment for the year 1992 and the treatment outcome of the patients cohort for the year 1991.

Out of about 45000 smear positive patients put on SCC regimens during the cohort period Jan-Dec 1991(in 89 SCC -DTP reports analysed ) the final follow up smear results of only 15039 patients who had completed satisfactory level of drug collection were available for analysis. Among these 15039 patients 90% of patients on regimen A and 96% of patients on Regimen B had become smear negative.

Regarding drug collection out of about 45000 patients put on treatment under SCC regimens during 1-1-91 to 31-12-91 details of drug collection were available only for 36281 patients. About 45% and 53% of the patients put on Regimen A and B respectively had completed a satisfactory level of treatment.

The authors concluded that this gain is not substantial taking into consideration that even for standard chemotherapy 40% of the patients have satisfactory level of treatment completion.

The seven year findings of SCC in 18 districts under DTP have also been published(Ind J TUB 1996,43,131)

The 18 districts were divided into 3 groups of 6 each and allotted to one of the 3 policies described below
Policy A:-2RHZ/4RH2 a fully supervised 6 month intermittent regimen
Policy B:- 2RHZ/6TH a fully unsupervised daily 8 month regimen
Policy C:-2RHZ/4RH2 A partly unsupervised and partly supervised regimen
The results are shown below
Regimen Total patients Completed 80% of treatment Sputum examined % Sputum neg %
2RHZ/4HR2 12929 49 64 95
2RHZ/6TH 44383 54 80 99
2RHZ/4RH2 7417 61 84 99
The study concluded that in this situation the overall impact of the programme could only be around 22%.Thus there is a need to evolve strategies to improve case finding and case holding the two deficient components of the programme.

Abbreviations:
NTP:National Tuberculosis programme
DTP:District Tuberculosis programme
DTC:District Tuberculosis centre
SCC:Short Course chemotherapy

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