Academic journal article Bulletin of the World Health Organization

DOTS-Based Tuberculosis Treatment and Control during Civil Conflict and an HIV Epidemic, Churachandpur District, India

Academic journal article Bulletin of the World Health Organization

DOTS-Based Tuberculosis Treatment and Control during Civil Conflict and an HIV Epidemic, Churachandpur District, India

Article excerpt

Voir page 455 le resume en francais. En la pagina 455 figura un resumen en espanol.


In 1994 WHO declared that tuberculosis (TB) constituted a global emergency (1). It developed a rive-point strategy known as DOTS in order to combat the increasing incidence of the disease. The main aims were to detect 70% of smear-positive TB cases and to treat 85% of smear-positive new cases successfully. The strategy has improved worldwide cure rates, but there are situations in which the implementation of DOTS programmes is difficult. This is true among refugee and displaced populations and in areas of civil conflict.

TB is an increasingly important cause of morbidity and mortality in refugee and displaced populations, particularly during the post-acute phase of complex emergencies (2). Until recently, little was done to address this problem, principally because of the difficulties of implementing control programmes where patients could not remain atone site long enough to undertake a full course of treatment (3). Furthermore, drug supplies are often irregular and donors may prefer to spend limited resources on shorter-term programmes with more immediate benefits. There has also been a lack of concise guidelines on controlling the disease among refugees. In 1997 WHO recognized the special situation of refugees and the lack of published guidelines, and, in conjunction with the Office of the United Nations High Commissioner for Refugees, developed a field manual on TB control in refugee situations (4). Strict criteria were indicated for the initiation and management of treatment and control programmes based on DOTS. These guidelines have hot previously been piloted outside a refugee-camp setting or in a conflict setting.

The aims of the present project were to evaluate strategies based on WHO guidelines for achieving a cure rate of 85% in smear-positive TB cases in a context of civil conflict, an HIV epidemic and inadequate TB treatment and control services in Churachandpur District, Manipur State, in northeast India. The proportion of HIV-associated TB cases in Manipur State Hospital was 138/1000 in 1992-96, almost nine rimes the national rate of 16/1000 (5, 6). During the same period there was also an increase in TB cases in the general population that was not associated with HIV. Government drug supplies for the district were erratic and the main drug used to treat the disease, isoniazid, was unavailable for periods of several months. Of the patients who began treatment under the Churachandpur District Tuberculosis Programme in 1996, fewer than 6% were documented as completing the full course.

From June 1997 to October 1998 two ethnic groups in Churachandpur District, the majority Paite group and a minority group, the Kuki, originally displaced from the north of the state, were involved in open conflict. Firearms were widely available and sporadic fighting occurred, largely between young men belonging to opposing factions, although random killings and sniper tire were also common. There were 10 ethnic communities in the district, each with its own language. Smaller tribes lacking the strength or influence to remain neutral were drawn into the conflict. Over 50 villages were destroyed and some 13 000 people were displaced. The majority moved to areas surrounding the district capital of Churachandpur, where they were housed in makeshift refugee centres in schools, hospitals, and other buildings; some were given shelter by relatives. Several hundred Indian Army soldiers were moved into Churachandpur early in 1998 with the purpose of restoring order. This was not successful, however, and outbreaks of violence continued until the church brokered a ceasefire in October 1998.

The conflict severely affected the provision of health care: most community health programmes, including TB control, malaria control, and the Expanded Programme on Immunization, were abandoned in rural areas. …

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