Targets and TB Control

Dr.A,K.Avasarala MBBS, MD
Professor of Public Health Medicine, 
Mamata Medical College, Khammam (AP) India

I am offering my opinion and doubts about TB control policy& targets. I request readers to clarify my doubts & comment on my opinion. I am of the opinion that both the TB control policy & the WHO targets are not adequate rather they are ambiguous. CDR (Case Detection Rate) of 70% and cure rate of 85% are not adequate.

Firstly, with a CDR OF 70%, we are missing about 30% of cases, which will spread the disease, as TB is a highly communicable disease. Why should we leave 30% knowing that they can be infectious? What is the scientific rationale? Is there herd immunity? I cannot understand WHO reason that we should not expand case detection unless and until we achieve high cure rate (WHO, TB, Clinical Manual WHO/TB/960200(SEA) (pp 78), while the strategy is to treat all infectious cases. This indicates indirectly that we cannot fight (the disease) and treat it if number of cases detected is very high. Whatever may be the reason, we should not leave the cases undetected, in the interest of individual, family& community at large.

Secondly, coming to the target of 85% of cure rate. Why 85% only? What do we do about the remaining 15% of the known (sputum) positive cases? Why an opportunity to treat a case be missed who has come all the way spending their meager resources? Is it humane, not to treat remaining known infectious cases. Is it not a medical negligence? Is it ethical? Will it not contribute to spread of the disease? In total, we are leaving 45% of the disease (30% undetected and 15% untreated) without attention.

Some countries (e.g. India) are concentrating more on the number of cases treated, rather than detected. For example, in India, DOTS is a grand success, having achieved a cure rate of 83% while CDR is 55-66%. G.R.Khatri Deputy Director (TB) in his article "Rapid expansion of DOTS in India"(WHO bulletin Vol.80. No.6 2002 (pp457) says that more than half of global increase in number of patients were treated in 2001 & more than a million cases were treated in 2002 and in India 1300 new patients were being treated daily. It indicates that disease load is still very high. In India HIV is increasing the disease load by adding fuel to the fire.

Lastly, the policy of 'passive case detection among self-referrals' is also not proper. TB is mostly a poor man's disease and a patient cannot afford to come for detection. The poor and illiterate patients are ignorant (about the TB control program) and do not turn up for sputum examination. Probably, this is the main reason for poor case finding. With a high defaulter rate we cannot expect poor people to come on their own (for diagnosis and treatment). Some people may argue that WHO targets are lowest margins of targets and high achievements are not discouraged and they are based on practical feasibility. But TB/HIV combination is like a wild fire and we cannot take chances with halfhearted detection and treatment. 

I do not agree with Holger Steward (WHO) that the targets are not ambiguous, but fully endorse his suggestions for improving case-finding especially, community based approach, high risk approach and public /private mix (his paper presented at TB and Poverty Symposium at Montreal). 

With regards

Dr.A,K.Avasarala MBBS, MD
Professor of Public Health Medicine, 
Mamata Medical College, Khammam (AP) India 91507002
Phone-+91 08742246286

(Readers are welcome to send their comments to webmaster@healthinitiative.org )