Can blinding trachoma be eliminated by 20/20?

Trachoma is the leading cause of preventable blindness in the world today. Long ago eliminated in North America and Europe, the disease is almost unknown, and indeed forgotten, in the West. Nevertheless, it continues to wreak havoc in the poorest parts of Africa, Asia, and other areas throughout the world. The World Health Organization (WHO) estimates that there are currently 7.6 million people who are visually impaired due to trachoma, and 84 million people with active infections. In 1998, WHO passed a resolution calling for member states to take action to eliminate blinding trachoma by the year 2020. The scale of what must be accomplished in order to reach this goal is daunting. However, the work of the International Trachoma Initiative together with national governments as well as other organizations in applying the WHO-recommended SAFE strategy for trachoma control has produced critical successes in challenging settings. This paper gives a brief history and description of trachoma, explains treatment options and the SAFE strategy, and discusses successes from two trachoma control programmes as examples of how to move forward in eliminating this devastating disease.

Global Partnership to Stop TB: a model of an effective public health partnership.

SETTING: The Global Partnership to Stop TB. OBJECTIVE: To describe the need for a partnership, its development, its aims and how it goes about its business. RESULT: The international health community finds itself working under new constraints and in the presence of new actors and opportunities, including globalisation, economic and cultural changes, lack of resources, and the need for intersectoral collaboration. The World Health Organization (WHO) declared tuberculosis a global emergency in 1993. However, political commitment to controlling the growing pandemic was lacking, and TB continued to exact its remorseless toll. The Global Partnership to Stop TB can be seen as the result of the development over the last century of progressively more powerful forms of international organisations against tuberculosis. An outline is given of the current Global Partnership to Stop TB, including its goals, its progress from values to achievements and how it functions through various bodies. CONCLUSION: The Partnership is potentially an effective model for other public health issues. As such, it can contribute to and catalyse a new era of international cooperation.

The Global TB Drug Facility: innovative global procurement.

The Global TB Drug Facility (GDF) is a new initiative to increase access to high quality tuberculosis drugs. The GDF, a project of the Global Partnership to Stop TB, is managed by its secretariat, in the World Health Organization (WHO), Geneva. It aims to provide tuberculosis drugs to treat up to 11.6 million patients over the next 5 years and to assist countries to reach the WHO global TB control targets by 2005. The GDF was launched on 24 March 2001. Six rounds of applications have been completed, with 46 countries and non-governmental organisations (NGOs) approved for support. The GDF is not a traditional procurement mechanism. It has adopted an innovative approach to the supply of drugs, by linking demand for drugs to supply and monitoring, using partners to provide services, using product packaging to simplify drug management and linking grants to TB programme performance. This paper describes the GDF operational procedures and experience gained so far. Key achievements to date are also outlined, including the creation of a flexible supply system to meet differing programme needs, rapid establishment of procedures, reduction in TB drug prices--a catalyst for DOTS expansion in countries, standardisation of products, and collaboration with partners. The GDF is flexible enough to meet the needs of countries with a TB burden. The GDF experience could be used as an example for global procurement of drugs and commodities for other diseases, such as HIV/AIDS and malaria. In the future it is likely that the GDF will expand to include second-line drugs and diagnostic materials for TB and could assist other partnerships to develop similar mechanisms and facilities to meet country needs.

Tuberculosis and health sector reform in Bangladesh.

In 1998 the Government of Bangladesh changed its health and population sector strategy from a project-oriented approach (the Fourth Population and Health Project--FPHP) to sector-wide management (the Fifth Health and Population Sector Programme--HPSP). This article describes the development and achievements of the tuberculosis programme during the FPHP, and discusses the potential opportunities and challenges anticipated by the programme from the reformed health service delivery of the HPSP. 'Further strengthening of tuberculosis and leprosy control services' was one of the 66 projects of the FPHP. As part of the FPHP, the National Tuberculosis Programme policy was revised in 1992 and the project was implemented in phases. By mid 1998, 90% of the population was covered, and more than 200,000 tuberculosis cases had been diagnosed and treated with 80% success. We describe the reasons for this success and analyse the pitfalls of the project. The objective of the reforms in HPSP is to provide cost-effective, sustainable, quality services to those in need through an essential service package that includes control of communicable diseases such as tuberculosis and leprosy. Tuberculosis services will become more accessible as community clinics deliver essential health services for every 6000 population. Non-public health care providers, who contribute significantly to health services in the country, will be involved in service delivery. The main challenge is to maintain the quality of successful projects, such as tuberculosis control, during the transition period.

Review of national tuberculosis programmes: the experience in Bangladesh.

Tuberculosis control efforts should be evaluated periodically to assess progress made by national programmes and to plan for the future. Simple and reliable tools are required for such assessments. This paper summarises the methodology and results of the review of the national tuberculosis programme in Bangladesh conducted in 1997. The authors conclude that similar reviews would not only help to verify the reports from the routine recording system, but would also assist policy development and future planning.

Tuberculosis control in Bangladesh: success of the DOTS strategy.

SETTING: Tuberculosis (TB) has been a major public-health problem in Bangladesh for many decades. National control efforts in the past have not been successful, with less than half of detected cases being cured. In 1993, a project based on the DOTS (directly observed treatment, short-course) strategy was initiated for a population of approximately one million in a rural setting. Following a 78% cure rate in the initial cohort of new smear-positive patients, the project was expanded in phases to cover a rural population of 67 million in 1996. OBJECTIVES: Routine programme data on all new sputum smear-positive patients registered in the TB project since its inception until 1996 were analysed. Case finding results are presented until 1996, as are results of sputum smear conversion after 2 months of treatment in new smear-positive patients for the same cohort of patients. Final treatment outcome results were analysed for new smear-positive patients registered up to 1995. RESULTS: A total of 41,525 patients were registered in the project during the 3-year period. Two-thirds of these were new smear-positive cases and 27% were new smear-negative patients. Sputum smear conversion in 26,151 new smear-positive patients at 2 months was 85%; 5% remained smear-positive, 3% had died and the rest had no sputum examination. Final treatment outcome results in 10,142 new smear-positive patients registered during 1993-1995 showed that 75% were cured, 4% completed treatment but did not have a sputum smear result, 2% remained smear-positive, 6% died, 10% defaulted and 3% were transferred out. CONCLUSION: The DOTS strategy can be successfully implemented in phases in large countries with a high tuberculosis burden. This success is due to decentralizing sputum smear microscopy and treatment delivery services to peripheral health facilities, utilizing the existing primary health care network. High cure rates can be maintained despite rapid expansion of coverage, with proper implementation of the strategy and regular monitoring of reports on case finding, sputum smear conversion and treatment outcome. Case detection needs to be further increased by informing and involving the community in TB control efforts through social mobilization.

National tuberculosis programme review: experience over the period 1990-95.

Since 1990 the WHO Global Tuberculosis Programme (GTB) has promoted the revision of national tuberculosis programmes to strengthen the focus on directly observed treatment, short-course (DOTS) and close monitoring of treatment outcomes. GTB has encouraged in-depth evaluation of activities through a comprehensive programme review. Over the period 1990-95, WHO supported 12 such programme reviews. The criteria for selection were as follows: large population (Bangladesh, Brazil, China, Ethiopia, India, Indonesia, Mexico, and Thailand); good prospects of developing a model programme for a region (Nepal, Zimbabwe); or at advanced stage of implementation of a model programme for a region (Guinea, Peru). The estimated combined incidence of smear-positive pulmonary tuberculosis was 82 per 100,000 population, about 43% of the global incidence. The prevalence of infection with human immunodeficiency virus (HIV) was variable, being very high in Ethiopia and Zimbabwe, but negligible in Bangladesh, China, Nepal and Peru. The programme reviews were conducted by teams of 15-35 experts representing a wide range of national and external institutions. After a 2-3-month preparatory period, the conduct of the review usually lasted 2-3 weeks, including a first phase of meetings with authorities and review of documents, a second phase for field visits, and a third phase of discussion of findings and recommendations. The main lessons learned from the programme reviews were as follows: programme review is a useful tool to secure government commitment, reorient the tuberculosis control policies and replan the activities on solid grounds; the involvement of public health and academic institutions, cooperating agencies, and nongovernmental organizations secured a broad support to the new policies; programme success is linked to a centralized direction which supports a decentralized implementation through the primary health care services; monitoring and evaluation of case management functions well if it is based on the right classification of cases and quarterly reports on cohorts of patients; a comprehensive programme review should include teaching about tuberculosis in medical, nursing, and laboratory workers' schools; good quality diagnosis and treatment are the essential requirements for expanding a programme beyond the pilot testing; and control targets cannot be achieved if private and social security patients are left outside the programme scope. The methodology of comprehensive programme review should be recommended to all countries which require programme reorientation; it is also appropriate for carrying out evaluations at 4-5-year intervals in countries that are implementing the correct tuberculosis control policies.

PIP: Over the period 1990-95, the World Health Organization (WHO) conducted 12 reviews of national tuberculosis programs, with emphasis on passive case finding; directly observed treatment, short-course (DOTS); drug supply; and treatment outcome monitoring. Criteria for program selection were: large population (Bangladesh, Brazil, Chile, Ethiopia, India, Indonesia, Mexico, and Thailand); good potential for developing a model regional program (Nepal, Zimbabwe); or advanced stage of implementation of a model program (Guinea, Peru). The 2-3-week review process included interviews with authorities, document reviews, field visits, and discussions of findings. The estimated combined incidence of smear-positive pulmonary tuberculosis was 82/100,000 population--about 43% of the global incidence. These reviews suggested the following observations: 1) program review is a useful tool to secure government commitment, reorient tuberculosis control policies, and replan activities on a more solid basis; 2) the involvement of academic and public health institutions, cooperating agencies, and nongovernmental organizations secures broad support for new policies; 3) program success is linked to a centralized direction that supports a decentralized implementation through the primary health care system; 4) monitoring and evaluation of case management function well if based on the correct classification of cases and quarterly reports on cohorts of patients; 5) a comprehensive program review should include teaching about tuberculosis in medical, nursing, and laboratory workers' schools; 6) good quality diagnosis and treatment are essential requirements for expanding a program beyond pilot testing; and 7) tuberculosis control targets cannot be achieved if private and social security patients are excluded from program coverage.

Socio-cultural dimensions of leprosy in north-western Botswana.

A study to determine some socio-cultural factors influencing knowledge and attitudes of the community toward leprosy was carried out in north-western Botswana, where cases of leprosy have been known to exist over the years. The study was largely qualitative, using ethnographic approaches. The research was tailored in a way to capture the ethnic diversity of the region, in particular two ethnic groups, namely Bayei and Bambukushu. The name or symptom complex associated with leprosy was 'ngara' or 'lepero' and this was associated with bad blood. Knowledge on disease causation was lacking, which in turn influenced health seeking behaviour of patients. Patients were well integrated and accepted into the social structure of communities. Women caring for these patients did experience some additional burden and identified time as their major constraint in caretaking. It was apparent that the degree of rejection correlated with seriousness of the disease and extent of disabilities and dysfunction. The present pattern of health seeking behaviour needs to be altered, so that an early diagnosis can be made at the health facility. This will aid appropriate management and prevent occurrence of deformities and disabilities, which in turn will reduce rejection and isolation of patients. Education of community, patients, traditional and religious healers on various aspects of the disease, especially causation, is essential to achieve a change in the health seeking behaviour.

Knowledge and attitude of health workers towards leprosy in north-western Botswana.

The knowledge and attitude of health workers in north-western Botswana towards leprosy was determined by interviewing ninety nine health workers from various health institutions. Knowledge on causation of leprosy was generally lacking. Although majority of respondents knew that the disease is curable, less than half knew the correct duration of treatment. The attitude of service providers was influenced by poor knowledge, and more than a third claimed that patients should be isolated. The pattern of health seeking behaviour, initially traditional or religious healers and then modern health facilities, was a significant finding. In order to ensure early case detection and prevent deformities, it is vital that education of community, patients and health workers is provided to an extent that health seeking behaviour is altered. Traditional and religious leaders must also be included in such training sessions.

Case finding survey for leprosy in Botswana.

A baseline survey to establish the point prevalence of leprosy was carried out in July and August, 1991 in northern Botswana, where cases of leprosy have existed over the years. A total of 799 contacts of 127 index cases and 8235 school children from 18 schools were clinically screened for leprosy. In all, 44 active cases of leprosy were registered and started on multidrug therapy recommended by World Health Organization. Of these cases, 32% were newly identified during the survey. Due to the moderate outcome, surveillance and control of leprosy has been integrated with existing TB control programme. This is the first time ever a systematic attempt was made to establish a programme for control of leprosy in Botswana.

PIP: During July-August 1991, health workers conducted leprosy screening in Ngami, Okavango, Chobe, Boteti, and Mahalapye in northern Botswana to determine the point prevalence of leprosy. They screened 799 contacts of 127 index cases and 6235 school children from 9 secondary and 9 primary schools. During the contact survey, they detected 42 active cases of leprosy, whom they started on multidrug therapy. Only 2 students had active leprosy (paucibacillary cases). They lived in Okavango subdistrict. The health workers also started them on multidrug therapy. The surveys identified 14 (32%) new leprosy cases. Multibacillary leprosy was more common than paucibacillary leprosy (68% vs. 32%). Most cases (84%) were older than 25 years old. Most leprosy cases lived in Ngami and Okavango subdistricts (43% and 41%, respectively). The point prevalence of registered leprosy cases on multidrug therapy in the 5 subdistricts in northern Botswana was 0.18/1000. Since the surveys showed that leprosy prevalence is low, surveillance and control of leprosy activities have been integrated into the existing tuberculosis control program. This integration was the first time that a leprosy control program has been systematically attempted in Botswana.