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.

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.

Case holding in patients with tuberculosis in Botswana.

OBJECTIVE: To evaluate the effectiveness of daily supervised short course chemotherapy in a national tuberculosis programme. DESIGN: Observation of programme during 1984-90. In October 1986 short course chemotherapy was introduced with patients receiving treatment daily from staff in their nearest health facility. SETTING: Botswana national tuberculosis programme. SUBJECTS: All patients with tuberculosis. MAIN OUTCOME MEASURES: Proportions of patients complying with and defaulting from treatment (missing > or = 43 days' treatment). RESULTS: 2938 cases of tuberculosis were recorded in 1990, 1528 of which were of sputum positive pulmonary disease. 2711 (92.3%) patients complied with treatment and 227 (7.7%) defaulted. Before introduction of short course chemotherapy compliance was about 60% compared with over 90% in 1987-90. CONCLUSIONS: A programme using daily supervised short course chemotherapy integrated into the primary health care system is an effective method of treating tuberculosis. The costs of the programme need to be evaluated.

An experience in the control of plague in Botswana.

In October 1989, cases of human plague started to occur in Boteti district of Botswana. One hundred and seventy cases were recorded in total from 15 October 1989 to 6 April 1990. There were 12 deaths, giving a case fatality rate of 7%. All cases were of the bubonic type. A concerted control strategy based on sentinel surveillance, involving public education, flea and rodent control, chemotherapy and chemoprophylaxis controlled the epidemic.

Seasonal and spatial trends in the detectability of leprosy in wild armadillos.

A survey for leprosy among 565 armadillos from Louisiana and Texas found IgM antibodies to the phenolic glycolipid-1 antigen of Mycobacterium leprae in 16% of the animals. There were no geographic trends in the distribution of prevalence rates between the sites and the disease probably has a much greater range. Repeat observations in one location showed significant seasonal variations in the observable antibody prevalence rate, but the yearly average remained similar. Infected armadillos tended to be heavier, and the females usually had plasma progesterone concentrations indicative of sexual maturity. Using these characteristics to stratify the populations into adult and sub-adult cohorts, variations in the observable leprosy prevalence rate were seen to be proportional to changes in the age structure of the populations. Leprosy appears to be maintained in steady state within some regions, and nearly a third of the adult armadillos in Louisiana and Texas harbour M. leprae.