The status and prospects of tuberculosis control in India.

SETTING: India, where much of the global strategy for tuberculosis control was established, but where, every year, there are an estimated 2 million cases of tuberculosis.

OBJECTIVE: To describe the policies, initial results, and lessons learned from implementation of a Revised National Tuberculosis Control Programme using the principles of DOTS (Directly Observed Treatment, Short-course).

DESIGN: A Revised National Tuberculosis Control Programme (RNTCP) was designed and implemented starting in 1993. With funding from the Government of India, State Governments, the World Bank and bilateral donors, regular supply of drugs and logistics was ensured. Persons with chest symptoms who attend health facilities are referred to microscopy centres for diagnosis. Diagnosed cases are categorized as per World Health Organization guidelines, and treatment is given by direct observation. Systematic recording and cohort reporting is done.

RESULTS: From October 1993 through mid-1999, 146,012 patients were put on treatment in the programme. The quality of diagnosis was improved, with the ratio of smear-positive to smear-negative patients being maintained at 1:1. Case detection rates varied greatly between project sites and correlated with the percentage of patients who were smear-positive among those examined for diagnosis, suggesting heterogeneous disease rates. Treatment success was achieved in 81% of new smear-positive patients, 82% of new smear-negative patients, 89% of patients with extra-pulmonary tuberculosis, and 70% of re-treatment patients.

CONCLUSION: The RNTCP has successfully treated approximately 80% of patients in 20 districts of 15 states of India. Treatment success rates are more than double and death rates are less than a seventh those of the previous programme. Starting in late 1998, the programme began to scale up and now covers more than 130 million people. Maintaining the quality of implementation during the expansion phase is the next challenge.