Cost of National Vector Borne Disease Control Programme in North India

Background & objectives: Despite significant resources being spent on National Vector Borne Disease Control Programme (NVBDCP), there are meagre published data on health system cost upon its implementation. Hence, the present study estimated the annual and unit cost of different services delivered under NVBDCP in North India. Methodology: Economic cost of implementing NVBDCP was estimated based on data collected from three North Indian States, i.e. Punjab, Haryana and Himachal Pradesh. Multistage stratified random sampling was used for selecting health facilities across each level [i.e. subcentres (SCs), Primary Health Centres (PHCs), community health centres (CHCs) and district malaria office (DMO)] from the selected States. Data on annual consumption of both capital and recurrent resources were assessed from each of the selected facilities following bottom-up costing approach. Capital items (equipment, vehicles and furniture) were annualized over average life span using a discount rate of 3 per cent. The mean annual cost of implementation of NVBDCP was estimated for each level along with unit cost. Results: The mean annual cost of implementing NVBDCP at the level of SC, PHC and CHC and DMO was ? 230,420 (199,523-264,901), 686,962 (482,637-886,313), 1.2 million (0.9-1.5 million) and 9.1 million (4.6-13.5 million), respectively. Per capita cost for the provision of complete package of services under NVBDCP was ? 45 (37-54), 48 (29-73), 10 (6-14) and 47 (31-62) at the level of SC, PHC, CHC and DMO level, respectively. The per capita cost was higher in Himachal Pradesh (HP) at SC [? 69 (52-85)] and CHC [? 20.8 (20.7-20.8)] level and in Punjab at PHC level [? 89 (49-132)] as compared to other States. Interpretation & conclusions: The evidence on cost of NVBDCP can be used to undertake future economic evaluations which could serve as a basis for allocating resources efficiently, policy development as well as future planning for scale up of services.

Outcome of community based planned intervention targeting perceptions, attitudes and health seeking behaviour regarding cancers in New Delhi, India

Background: Cancer prevention and control needs to be based on effective implementation of all approaches. Community as well as individual level interventions to increase knowledge and early reporting have shown effectiveness. A community-based intervention trial was conducted to design, implement and test short-term outcomes of evidence based preventive strategies.Methods: A mixed methods, three phased study was conducted in three districts of Delhi, which were selected by a random process. Two randomly selected districts out of these three were intervention districts while third was the control. A total sample of 500 in each district was studied in quantitative pre and post -intervention phases. Multistage, stratified, cluster sampling was utilized. Pre-tested and validated tools were used.Results: Post intervention, statistically significant higher scores were observed in all domains in intervention districts as compared to control (p<0.01). Though comparison of slum versus non-slum showed significant increment in knowledge and practice scores, with higher scores for non-slum respondents, the attitudes were very similar (p>0.05). The increment score changes between males and females was similar in all classes of society versus control district. Comparison within the intervention and control groups revealed increased scores in intervention districts and decreased scores in control district, in all domains (p<0.05).Conclusions: Our study has helped in understanding the determinants of perceptions, attitude and practices regarding cancer in the community, This, helped in formulating the need-based intervention strategies. Testing the short-term outcome of intervention showed it to be effective.

Analysis of Risk Factors Affecting Sputum Conversion at the End of Intensive Phase Under DOTS for Treatment of Pulmonary Tuberculosis

Introduction: Microbiologically confirmed pulmonarytuberculosis patients under Revised National TuberculosisControl Programme (RNTCP) are treated with a 6-monthshort-course chemotherapy (SCC) regimen irrespectiveof co-morbid conditions. The aim of present study was todetermine the time taken for SSC conversion with standardcurrent treatment with anti-tubercular drugs and analysis ofrisk factors if any delaying it. We undertook this prospectivestudy to compare sputum conversion rates (smear) at the endof intensive phase (IP) of Category regimen.Material and methods: was a prospective study which wasconducted for a period of eleven months from August 2018 toJune 2019 at Department of Respiratory Medicine, K.N ChestHospital, S.N Medical College, Jodhpur Rajasthan India.Patients visiting Department of Respiratory medicine and whowere diagnosed as pulmonary tuberculosis by sputum smearexamination were included in study.Result: Sputum smear-positive patients are infectious to closecontacts as well as to community as they continue to expelbacilli for a variable period of time after initiation of DOTSregimen. Most patients undergo sputum conversion by theend of 3rd month. Patients who have predominant cavitatorydisease in radiology, high smear grading before treatment, aprior history of DS/DR tuberculosis are more likely to havedelayed sputum smear conversion.Conclusion: There need to mandate DST at the starting ofDOTS in line with latest RNTCP guidelines to prevent thedevelopment of MDR strains and failures. Also there is astrong need to constitute strong infection control measures tillpatients are labelled as noninfectious.

Study of demographic profile of animal bite cases and management practices in a dedicated anti rabies clinic of a tertiary care hospital, Hassan, Karnataka

Background: Animal bites cause a big burden in terms of morbidity and mortality throughout the world. These bites could be caused by rabid animals causing rabies. Annually about 59,000 persons die of rabies, of which 20,000 is from India alone. Rabies though 100% fatal is preventable with post-exposure prophylaxis which includes wound wash, anti-rabies vaccination (ARV) and rabies immunoglobulin. The objectives of the present study was to describe the demographic profile of animal bite cases and to assess the management practices of animal bite cases reporting to dedicated anti-rabies clinic (ARC) of a tertiary care hospital, Hassan, Karnataka.Methods: A cross-sectional study was conducted from the inception of anti-rabies clinic (12th October 2017) to August 2018 among animal bite cases reported to ARC. They were interviewed by using a semi-structured, pre-designed and pre-tested proforma. Data regarding socio-demographic profile were collected from the animal bite victims. All the animal bite cases were managed as per WHO guidelines.Results: The total number of animal bite victims reported to ARC during the study period was 3500. Majority of the bite victims belonged to adult population (20-60 years). Majority were males (66.2%). 77% belonged to the rural population. Dogs (97.1%) were the most common biting animal. 79% of the bites were provoked. Turmeric powder was the most commonly used irritant. Most bites belonged to Category III (84%). Category I, II, III bites were managed appropriately according to WHO guidelines.Conclusions: Knowing the burden, socio-demographic characteristics and the management of animal bite victims in the dedicated ARC of HIMS has helped the programme officer in implementing the National Rabies Control Programme in Hassan district.

Gender Differences in Treatment Outcome of Tuberculosis Patients under the Revised National Tuberculosis Control Programme

Aim: The present study was undertaken to find out the sex differences in the notification rates and treatment outcomes of Tuberculosis (TB) patients, registered under the Revised National Tuberculosis Control Programme (RNTCP) in a rural Tuberculosis Unit (TU) in Thorrur, Warangal Dist., Telangana. Methods: This is a retrospective record based study was carried out among a total of 585 cases registered under the RNTCP between January'2011 to December'2012. Notification rates of TB, clinical forms of Tuberculosis and disease treatment outcomes recorded in the registers were analysed. Based on genders outcomes were defined in accordance with the standard RNTCP definitions. Results: Among the total of 585 patients 220 (80%) were male and 55 (20%) were female with male female ratio of 4:1. In patients less than 20 years of age the notification rates among males and females were similar. In other age groups male were more likely to be notified compared to females and the difference was statistically significant, while new smear positive and retreatment cases were significantly more than females, among females new smear positive and new extra pulmonary cases significantly lower. Among the new smear positive in females 39.3% were cured compared to 49.4% males which was again significant statistically. Male patients outnumbered female in all unfavorable outcome like death, failure, and default. Conclusion: The present study demonstrates a gender difference in the notification rates, clinical presentations and treatment outcomes of patients with TB integrated research is necessary to find the reasons for these differences. Such studies will be helpful in improving the efficacy of the RNTCP

Intrapatient variability in plasma rifampicin & isoniazid in tuberculosis patients

Background & objectives: Large variability in anti-tuberculosis (TB) drug concentrations between patients is known to exist. However, limited information is available on intrapatient drug levels during the course of anti-TB treatment (ATT). This study was conducted to evaluate intrapatient variability in plasma rifampicin (RMP) and isoniazid (INH) concentrations during ATT at start of the treatment, at the end of intensive phase (IP) of ATT and at the end of ATT in adult TB patients being treated in the Revised National TB Control Programme (RNTCP). Methods: Adult TB patients (n=485), receiving thrice-weekly ATT in the RNTCP, were studied. Two-hour post-dosing concentrations of RMP and INH were determined at month 1, end of IP and end of ATT, after directly observed drug administration. Drug concentrations were estimated by high-performance liquid chromatography. Results: The median (inter-quartile range) RMP concentrations during the first month, at end of IP and end of ATT were 2.1 (0.4-5.0), 2.4 (0.6-5.5) and 2.2 (0.5-5.3) ?g/ml, respectively. The corresponding INH concentrations were 7.1 (4.2-9.9), 7.2 (3.9-10.9) and 6.7 (3.9-9.5) ?g/ml. None of the differences in drug concentrations obtained at different time points during ATT were significant. RMP and INH concentrations at different time points were significantly correlated. Age and body mass index caused significant variability in drug concentrations. Interpretation & conclusions: Plasma RMP and INH estimations in adult TB patients at two hours after drug administration remained unaltered during ATT. Clinicians can consider testing drug concentrations at any time point during ATT. These findings may assume significance in the context of therapeutic drug monitoring of anti-TB drug concentrations.

Equine infectious anaemia in equids of Southern Pantanal, Brazil: seroprevalence and evaluation of the adoption of a control programme / Anemia infecciosa equina em equídeos do Pantanal Sul, Brasil: soroprevalência e avaliação da adoção de um programa de controle

The working equid population in Corumbá, Southern Pantanal, is very large and has a crucial role in the main economic activity of the State of Mato Grosso do Sul, the beef cattle industry. The aim of the present study was to estimate the prevalence of equine infectious anaemia (EIA) in working equids of ranches in the municipality of Corumbá, by the official agar gel immunodiffusion (AGID) test, and evaluate the adoption of the Programme for the Prevention and Control of Equine Infectious Anaemia proposed by Embrapa Pantanal and official entities in the 1990s. From September to November 2009, forty ranches distributed through the area of the municipality were visited, and serum samples were obtained from 721 equines and 232 mules. According to previous publications and the present data, it was concluded that the prevalence of EIA in this population has increased from 18.17% to 38.60%, which represents at this time approximately 13,000 infected animals. There was no significant difference between the apparent prevalence of equines and mules. It was also verified that the control programme was not known by the greater part of the interviewed ranch owners, managers and foremen and, in their perception, EIA is not a primary threat to address. Among the studied variables, the serologic testing practice significantly reduced the risk for the presence of EIA seropositivity, as well as the separation of riding equipment and segregation of seropositives.(AU)

A população de equídeos de serviço em Corumbá, Pantanal Sul, é muito numerosa e tem um papel crucial na principal atividade econômica do estado de Mato Grosso do Sul, a pecuária de corte extensiva. O objetivo deste trabalho foi estimar a prevalência atual da anemia infecciosa equina (AIE) em equídeos de serviço em fazendas do município de Corumbá, pelo teste oficial de imunodifusão em gel de ágar (IDGA), e avaliar a adoção do Programa de Prevenção e Controle da Anemia Infecciosa Equina proposto pela Embrapa Pantanal e entidades oficiais nos anos 1990. De setembro a novembro de 2009, quarenta fazendas distribuídas na área do município foram visitadas, e amostras de soro obtidas de 721 equinos e 232 muares. De acordo com publicações anteriores e os dados obtidos neste trabalho, concluiu-se que a prevalência da AIE nesta população aumentou de 18.17% para 38,60%, o que representa atualmente cerca de 13.000 animais infectados. Não houve diferença significativa entre as prevalências aparentes de equinos e muares. Verificou-se, também, que o programa de controle era desconhecido pela maior parte dos produtores, gerentes e capatazes entrevistados e, na percepção dos mesmos, a AIE não é uma ameaça importante a ser enfrentada. Dentre as variáveis estudadas, a prática da realização de testes sorológicos reduziu significantemente o risco para a presença de soropositividade para AIE, assim como a separação dos equipamentos de montaria e a segregação dos soropositivos.(AU)

How better is random blinded re‑checking results in Revised National TB Control Programme, India.

Background: The Revised National Tuberculosis Control Programme (RNTCP) is implementing the External Quality assurance (EQA) and Random blinded re-checking (RBRC) as one of its important component. This nationwide study was conducted to determine (1) the number and types of RBRC errors and (2) the sensitivity and specificity among rechecked slides. Materials and Methods: The study was based on the monthly RBRC reports submitted by ~13,000 designated microscopy centres (DMCs) across the country under routine programmatic settings in 2010. The DMCs reports were compiled at district, state and national level. Results: A total of 11, 89,564 slides were rechecked from 11,039 DMCs. Of which 99.5% of rechecked slides did not have any errors. The sensitivity and specificity of the rechecked slides had 98% sensitivity and 100% specificity. Conclusion: RBRC is the crucial component of EQA and the results from the programme are found to be satisfactory. Based on the study findings, the earlier value of 80% sensitivity used for calculation of annual sample size for RBRC has been increased to 90% sensitivity. The annual RBRC sample size for DMCs has been increased by 1.5–2 folds.

The influence of the Great East Japan Earthquake on tuberculosis control in Japan

In Japan, tuberculosis (TB) control activities are conducted by public health centres (PHCs) and treatment support is provided by public health nurses (PHNs). This study describes the TB situation in the affected areas and assesses the effectiveness of Japan’s TB control efforts after the disaster.

Iodine deficiency disorders (IDD) control in India.

Iodine deficiency disorders (IDD) constitute the single largest cause of preventable brain damage worldwide. Majority of consequences of IDD are invisible and irreversible but at the same time these are preventable. In India, the entire population is prone to IDD due to deficiency of iodine in the soil of the subcontinent and consequently the food derived from it. To combat the risk of IDD, salt is fortified with iodine. However, an estimated 350 million people do not consume adequately iodized salt and, therefore, are at risk for IDD. Of the 325 districts surveyed in India so far, 263 are IDD-endemic. The current household level iodized salt coverage in India is 91 per cent with 71 per cent households consuming adequately iodized salt. The IDD control goal in India was to reduce the prevalence of IDD below 10 per cent in the entire country by 2012. What is required is a “mission approach” with greater coordination amongst all stakeholders of IDD control efforts in India. Mainstreaming of IDD control in policy making, devising State specific action plans to control IDD, strict implementation of Food Safety and Standards (FSS) Act, 2006, addressing inequities in iodized salt coverage (rural-urban, socio-economic), providing iodized salt in Public Distribution System, strengthening monitoring and evaluation of IDD programme and ensuring sustainability of IDD control activities are essential to achieve sustainable elimination of IDD in India.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): Lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of ‘new smear-positives’ diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Assessment of College student’s awareness about tuberculosis in Ahmednagar.

Lack of knowledge and awareness about tuberculosis (TB) as well as Direct observed therapy short course (DOTS) area persistent and major community problem due top which suffering and mortality rate increases tremendously. So it is responsibility of pharmacists to develop a common awareness for prevention, care and treatment of TB in the community. This survey is strictly based on assessing the awareness about TB among undergraduate (UG) and postgraduate (PG) students of nonmedical stream in Institute of Foreign Trade and Management Ahmednagar (MH) India. In the present study 59.41% were male and 52.78% were female, 60.81% P.G. students and 54.31% U.G. students were answered among them. It represents that male student’s awareness were higher than the female students. The survey results also revealed that both U.G. and P.G. students of H.S.B.P.V.T., C.O.P. &.C.O.M. possed very poor knowledge about type of TB. Multi drug resistance (MDR) & mantaux test and the knowledge of UG students was very poor as compared to PG students. Pharmacists should realize their role in health education programs in the community to improve the public awareness about the health burden diseases like tuberculosis.

ICMR’s tryst with HIV epidemic in India: 1986-1991.

The Indian Council of Medical Research (ICMR) undertook screening of asymptomatic persons from high risk group with the ELISA test for HIV infection in 1986 and found that HIV infection has reached India. ICMR in collaboration with the central and State health services initiated the national sero- surveillance programme for HIV infection in 43 surveillance and five reference centres to determine the major modes of transmission and magnitude of infection. Data from the sero-surveillance showed that HIV infection was present in all the known high risk groups and in the general population in all the States both in urban and rural areas. HIV was getting transmitted through all the known modes of transmission. In most States heterosexual transmission was predominant but in Manipur intravenous (iv) drug use was the most common mode of transmission. Prevalence of HIV infection in high risk groups was not high and that in low risk groups was quite low. ICMR initiated hospital based sentinel surveillance in high risk groups and general population to obtain time trends in seroprevalence. Between 1986 and 1991, National AIDS Programme was carried out as a collaborative effort of ICMR, and central and State health services. As the dimensions of the epidemic unfolded, rational evidence based interventions which could be implemented within the existing health system, were initiated. National AIDS Control Programme (NACP) continued and upscaled all these interventions. Effective implementation of a multi-pronged, rational strategy for HIV infection containment and control right from the initial stages, and dedicated work done by committed professionals belonging to government and voluntary sectors, cultural ethos of the country, responsible behaviour of the population and relatively low iv drug use have resulted in rapid decline in new infection and in prevalence of infection within a quarter of a century after the initial detection of HIV.

Survival analysis and risk factors for death in tuberculosis patients on directly observed treatment-short course.

Background : Tuberculosis is a disease with a high case fatality of 4.65%. Objectives : To describe the survival pattern of patients on Directly Observed Treatment-Short course (DOTS) according to categories, age and sex of patients. Settings : Tuberculosis unit (TU) at District Tuberculosis Centre (DTC), Yavatmal, India Design : Retrospective cohort study. Materials and Methods : Data of patients registered for DOTS in the year 2004 were collected from the tuberculosis register. Statistical Analysis : Kaplan Meier plots and log rank tests to assess the survival pattern. Cox proportional hazards model for multivariate analysis. Results : A total of 716 patients were registered at the TU. The survival rates by the end of the intensive phase were 96%, 93% and 99% in categories I, II and III of DOTS, respectively. The cumulative survival rates were 93%, 88% and 96% in the three DOTS categories, respectively. There was a significant difference in the survival curves amongst the three DOTS categories (log rank statistic= 7.26, d.f..= 2, P=0 0.02) and amongst the different age groups [log rank statistic= 8.78, d.f.= 3, P= 0.012). There was no difference in the survival curves of male and female patients (log rank statistic= 0.05, d.f.= 1, P= 0.80) and according to type of disease (log rank statistic= 5.63, d.f.= 2, P= 0.05). On Cox proportional hazard analysis, age groups of 40 to 60 years [adjusted hazard ratio= 7.81 (1.002-60.87)] and above 60 years [adjusted hazard ratio= 21.54 (2.57-180.32)] were identified as significant risk factors for death. Conclusions : Age above 40 years is a significant risk factor for death in patients of tuberculosis. There was a significant difference in survival curves of the three DOTS categories and age groups.

Performance of a Non-Government Institution, working as a 'District Tuberculosis Centre' under RNTCP.

Background: The RNTCP has envisaged the role of non-governmental organizations (NGOs) in the control of tuberculosis in India, and five schemes have been developed. The RK Mission Free TB Clinic, as an exceptional case, was included under Scheme- 5, known as the ‘tuberculosis unit model’, with additional independent status of a District Tuberculosis Centre (DTC), to provide all RNTCP services. Aim: To assess the performance of the RK Mission Free TB Clinic as a full-fledged independent DTC over a 4-year period from 1999 to 2002. Material and Methods: A total of 5209 patients were initiated on anti-tuberculosis therapy under DOTS during 1999-2002. The yearly data in terms of case detection, follow-up and treatment outcome of new and retreatment cases were compiled. Results: Of the 5209 patients initiated on ATT under DOTS, 4125(79%) were new patients and 1084(21%) were retreatment cases. Of the 4125 new cases, 3049(74%) had pulmonary tuberculosis while 1076(26%) were treated for extra-pulmonary tuberculosis. In the newly detected pulmonary tuberculosis cases, the ratio of smear positive to smear negative patients was 1:0.65. The sputum conversion rates at 3 months in the new smear positive patients were 86% (1999), 85% (2000), 88% (2001) and 91% (2002). The cure and treatment completion rates in the new smear positive patients with pulmonary tuberculosis were 79% and 81% respectively in 1999. These rates were comparable for the years 2000, 2001 and 2002, with the respective values being 83%, 86% and 87%. The treatment completion rates in the new smear negative pulmonary tuberculosis cases as well as in the new extra-pulmonary tuberculosis patients were always greater than 85% in the study period. Conclusion: These results serve as a successful example of an NGO functioning within the parameters of the RNTCP.

Evaluation of Directly Observed Treatment Providers in the Revised National Tuberculosis Control Programme.

Background: Non-governmental personnel such as Anganwadi workers and community volunteers have been used as directly observed treatment (DOT) providers in the Revised National Tuberculosis Control Programme (RNTCP), but their effectiveness has not been documented. Aim: To assess the treatment outcome and problems encountered by patients managed by different DOT providers in the RNTCP. Material and Methods: Patients diagnosed with tuberculosis at 17 Primary Health Institutions (PHIs) in Tiruvallur District during a 3-year period received DOT from one of the four types of trained DOT providers (PHI staff, governmental outreach workers, Anganwadi workers, community volunteers), and their treatment outcomes were compared. Of the 1131 new smear-positive patients treated between May 1999 through June 2002, 199 (18%) received DOT from PHI staff, 238(21%) from outreach workers, 496 (44%) from Anganwadi workers, and 170 (15%) from community volunteers. Twenty-eight patients (2%) collected drugs for self-administration. Results: Treatment success rates among patients treated by different DOT providers, Anganwadi workers (80%), governmental outreach workers (81%), community volunteers (76%) and PHI staff (76%), were statistically similar. Patients who received drugs for self-administration were significantly more likely to fail to treatment or die than patients who were treated by a DOT provider (5/28 versus 84/1103; odds ratio=4.1; 95% confidence interval=1.2-12.6; p=0.02). Conclusion: In addition to governmental staff, Anganwadi workers and community volunteers can be effectively utilized as DOT providers.

Journey of tuberculosis control movement in India: National tuberculosis programme to revised national tuberculosis control programme.

The presentation passes through the saga of important landmarks of the past dealing with Era of prechemotherapy, Conventional and Short Course Chemotherapy (SCC) over two decades and the present era of Directly Observed Treatment Short course (DOTS) spanning more than a decade. It also touches upon the likely challenges to be faced in the near future for Tuberculosis (TB) control.

A double-blind study of oral salbutamol supplement and repeat sputum smear microscopy in enhancing diagnosis of smear-negative pulmonary tuberculosis in south India.

Background: As routine culture facilities are not available in TB control programme in low income countries like India, there is an urgent need to improve the sensitivity of sputum microscopy, especially in diagnosis of smear negative pulmonary TB. Methodology: In a double blind placebo controlled study, the role of repeat sputum microscopy after antibiotics and oral salbutamol supplement in improving the diagnosis of smear negative TB suspects was investigated in an urban TB clinic. We undertook culture examinations for all study patients to find out proportions of TB cases in this series. Results: Of 206 enrolled, (101 salbutamol (S), 105 placebo (P) groups) 26 were positive by repeat sputum smear examination; similar in two groups (S 16, P 10, p = 0.25). In all, 40 (S 23, P 17) including 26 smear- positives, were culture -positive for M. tuberculosis. Conclusions: Two thirds of initially smear negative but culture positive TB patients were smear positive on repeat sputum examination. Thus, repeat sputum smear microscopy for TB suspects improved the diagnosis, nevertheless oral salbutamol therapy was not beneficial. In resource poor settings, repeat sputum smear microscopy after a trial of antibiotics, could significantly improve the diagnosis of smear-negative PTB patients.

Assessing options for an innovative malaria control program on the basis of experience with the new Colombian Health Social Security System / Evaluación de opciones para un programa innovador de control de la malaria, con base en la experiencia del Sistema de Seguridad Social en Salud de Colombia

OBJETIVOS: Diseñar y proponer modelos alternativos para los programas municipales y Departamentales de control de la malaria, con base en evidencias obtenidas sobre el proceso de la malaria en la Costa Pacífica de Colombia y sobre las problemáticas claves del programa de control de la malaria antes y después de la reforma del sistema de salud de 1993. MÉTODOS: Se realizó un estudio evaluativo, de comparación antes y después de la reforma de 1993, y de diseño de modelos. Por programa de control se entendió la institución, el grupo humano y la administración que están a cargo de las actividades de control. El estudio se llevó a cabo durante el año 2002 y 2003, en los Departamentos de la Costa Pacífica colombiana. Se incluyeron las cuatro capitales departamentales, 28 municipios maláricos y 5 de control. Se obtuvo información primaria y secundaria, por medio de encuestas y entrevistas semiestructuradas, reuniones comunitarias y revisión documental en secretarías de salud, programa de Enfermedades Transmitidas por Vectores-ETV, Programa Ampliado de Inmunizaciones-PAI, Empresas Promotoras de Salud-EPS, Administradoras del Régimen Subsidiado-ARS e Instituciones Prestadoras de Servicios-IPS. RESULTADOS: Se obtuvieron los siguientes resultados: 1. Ilustración y análisis de las tendencias de la malaria en el país y la Costa Pacífica, y las correspondientes transformaciones institucionales del programa. 2. Caracterización del programa de control antes de 1993. 3. Modalidades departamentales de la descentralización del programa. 4. Identificación de los efectos de la reforma del sistema y caracterización de las problemáticas del programa de control. 5. Comparación con el programa PAI6. Análisis comparado del programa e identificación de brechas actuales en la capacidad de manejo. 7. Percepción de los actores sobre el programa de control. 8. Valores y retos de un programa de control innovador. 9. Diseño de un modelo para adecuación del programa de control. DISCUSIÓN: Las problemáticas y debilidades de los programas de control de la malaria se atribuyen con frecuencia, y de manera desarticulada, a la falta de conocimiento y habilidades gerenciales del personal que labora en el programa, a la carencia de un sistema de información y comunicación, a la debilidad de los municipios o del personal. Si bien estos factores han incidido, una aproximación más global e institucional permite ubicar los programas en un contexto social, político y cultural.(AU)

OBJECTIVES: Designing and proposing alternative models for municipal and Departmental malaria control programmes based on evidence obtained concerning the process of malaria on the Colombian Pacific Coast and regarding key problems in the malaria control programme before and following health system reform in 1993. METHODS: An evaluative study was carried out, comparing the situation before and following the 1993 reform; model design was also compared. Control programme is understood as being the institution, the human group and administration in charge of control activities. The study was carried out in 2002 and 2003, in the Departments along the Colombian Pacific Coast; the four departmental capitals, 28 malarial and 5 control municipalities were included primary and secondary information was obtained by means of surveys and semi-structured interviews, community meetings and reviewing documentation in the secretariats of health, the Vector-borne disease control programme-VBDC, the Expanded Immunisation Programme-EIP, Health Promoting Entities-HPE, Subsidised Regime Administrators-SRA and Service-Providing Entities-SPE. RESULTS: The following results were obtained: 1. Illustrating and analysing malarial tendencies in the country and on the Pacific Coast, and the corresponding institutional transformations in the programme; 2. Characterising the control programme which existed before 1993; 3. Characterising departmental modes of decentralising the programme; 4. Identifying the effects of reforming the system and characterising control programme problems; 5. Comparing the programme with the Expanded Immunisation Programme (EIP); 6. Comparative analysis of the programme and identifying current gaps in management capability; 7. Actors' perceptions regarding the control programme; 8. Values and challenges for an innovative control programme; and 9. Designing a model for up-dating/adapting the control programme. DISCUSSION: Malaria control programmes' problems and weaknesses are frequently and inarticulately attributed to the lack of knowledge and management skill of personnel working in such programmes, the lack of an information and communication system or weaknesses in the municipalities or personnel. These factors may well have had an effect; however, a global and institutional approach leads to locating the programmes within a social, political and cultural context. This allows interpreting control programmes' current problems, amidst decentralisation and reform processes, and linking this interpretation to modelling and opening a space for innovation in such programmes. The study's main limitations spring from particularities regarding Pacific Coast control programmes and weakness in health information systems.(AU)