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TB burden, DOTS

Tuberculosis

- A major public health problem for the past several

decades.

-A disease that many of us have come across with, maybe

from a former patient in the hospital where we worked in,

a neighbor, a relative, a friend or maybe even one of us has

experienced having TB

- Anyone of us can get TB.

-preventableand curable

Facts about TB:

Caused by a rod-shaped bacteria =

Mycobacterium tuberculosis

Commonly affects the lungs (pulmonary TB)

Can also cause extra-pulmonary disease (such as in

lymph glands, bones, joints, abdomen, brain,

kidney etc.).

Contagious disease (like that of common colds)

Spread through the air from one person to

another

Transmission:

Transmitted from person to person via:

coughing

sneezing

talking

spitting

TB is NOT spread by:

shaking someones hand

sharing food or drink

touching bed linens or toilet

seats

sharing toothbrushes

kissing

Natural Course of TB:

1/3 of the worlds population or around 2 billion

people are infected1

1 in every 10 of those people will become sick

with active TB2

When people become infected with TB bacilli,

some will develop the disease or become sick and

some will not. The immune system either kills the

bacilli or walls off the bacilli where they can lie

dormant or sleeping for years. But when the

immune system becomes weak, the bacilli will

multiply and will lead to active disease. Left

untreated, a person with active TB disease will

infect an average of 10-15 people per year.

Subject: MicrobiologyTopic: Symposium, TB Burden, NTPLecturer: Dra. DalayDate of Lecture: September 13, 2011Transcriptionist: JAK StatEditor: the jPages: 1

SY

2011-2012

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Signs and Symptoms:

Pulmonary TB is suspected if a person has:

o cough for 2 weeks or more

o With or without:

fever

chest and back pain

poor appetite

weakness

weight loss

night sweats

blood in sputum or phlegm

*The person should immediately seek medical consultation

and must have his/her sputum examined to detect the

presence of TB bacilli.

TB is CURABLE!

Tuberculosis is curable and can be treated with a

six-month course of antibiotics which are available

in DOTS facilities for FREE.

Drug Resistant TB:

Resistant TB develops due to improper use of anti-

TB drugs

improper treatment regimens

e.g. wrong dosage, wrong time,

patient does not complete whole

courseof treatment

Two Classifications of Drug Resistant TB:

a. Multi drug-resistant TB (MDR-TB) is a form of TB

that does not respond to the standard treatment

using first-line drugs. Specifically rifampicinand

isoniazid.

b. Extensively drug-resistant TB (XDR-TB) occurs

when resistance to second-line drugs develops.

Prevention and Control:

ALWAYS cover your mouth when you cough and

sneeze;

Do NOT spit anywhere;

WASH hands properly and;

Protect your family and friends from TB take

the correct kind and quantity of drugs and

complete the treatment!

The Burden of TB

Global Situation

National Situation

Local Situation

Tuberculosis in the World, 2007:

People infected 1/3 of global pop

2 billion

New TB cases 9.27 million(139/100,000 pop)

New ss+ TB cases 4.1 million

(61/100,000 pop)

Cases of MDR-TB 0.5 million

Deaths from TB (non-HIV) 1.3 million

(20/100,000 pop)

Deaths from TB (HIV positive) 456,000

SOURCE: WHO Global Tuberculosis Control Report 2009

This slide tells us about the Global situation of

Tuberculosis gathered last 2007 from the WHO Global TBControl report. It shows that there are about 2 billion

individuals infected with tuberculosis which is

approximately 1/3 the global population. Most of the

estimated number of cases in 2007 were in Asia (55%) and

Africa (31%). There were also 9.27 million new cases of all

types tuberculosis and 4.1 million of these cases are new

sputum smear positive meaning that they have Pulmonary

Tuberculosis.

There were an estimated 0.5 million cases of

multi-drug resistant TB (MDR -TB) in 2007. An estimated1.3 million deaths occurred among HIV negative incident

cases of TB (20 per 100 000 population) in 2007. There

were an additional 456,000 deaths among incident TB

cases who were HIV-positive; these deaths are classified as

HIV deaths in the International Statistical Classification of

Diseases (ICD-10).

SOURCE:1

WHO Global Tuberculosis Control Report 20092

WHO 10 Facts About Tuberculosis

(http://www.who.int/features/factfiles/tuberculosis/en/)

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Aboveare the 22 High-burden Tuberculosis

Countries indicated by the blue areas. According to the

WHO, the 22 high-burden countries (HBCs) collectively

account for 80% of incident (new) TB cases globally.

Countries which have a high number of TB cases

are mostly found in India, China, Indonesia, Nigeria, South

Africa, and others including the Philippines which ranks 9th

among the 22 high burden countries.

Here is another map indicating the Estimated

number of new TB cases (all forms of TB which maybe

either extra-pulmonary or pulmonary) as of 2007

represented by the different colors depending on the

number of cases. It shows that India and China have more

than 1 million new cases indicated by the orange colored

areas, while the Philippines has more than 100,000 new

cases.

The Extent of the Problem:

1/3 of the global population is infected with

Mycobacterium tuberculosis

8 million suffer from TB annually

95 % of the cases in developing countries

2 million die of TB every year

14.8% of TB cases are co-infected with HIV

SOURCE: WHO Global Tuberculosis Control Report

2009

TB Burden in the Philippines, 2007:

9th

among the 22 High burden countries1

2nd

in the Western Pacific Region (New ss+ cases)2

6th

leading cause of Morbidity and Mortality3

115,000 per year (New ss+ cases)1

98 Filipinos die daily1

6 billion of annual income lost due to TB morbidity

27 billion pesos lost (foregone wages) annually

8 billion pesos in actual wages lost

Economically productive individuals who have the

disease make them unfit to work and must also impose

themselves to self-quarantine due to the highly

infectiousness/contagiousness nature of TB. This has a

very big impact economically because according to

Peabody and colleagues at least 27 billion pesos is lost

annually due to premature deaths and around 8 billion

in actual wages are lost (due to TB morbidity and

mortality).

SOURCE:

1WHO Global TB Control Report 2009

2Tuberculosis Control in the Western Pacific

Region 2009 Report

3FHSIS 2007

Source: The Burden of Disease, Economic Costs and ClinicalConsequences of

Tuberculosis in the Philippines, 2005, Peabody, John et al.

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Magnitude of TB: A Comparison of the (3)

National TB Prevalence Surveys:

2007 NTPS Conclusions:

The burden of TB disease in the country has

declined over the past 10 years since the

launching of the DOTS program.

Significant decline in TB disease:

o 35.5% decline in ss+ Pulmonary TB

o 42.0% decline in sputum culture + PTB

The rate of MDR-TB showed no significant

difference from 1997 indicating no increase in

generation, but ongoing transmission

NTP interventions in the past decade has lead to

better control, prevention, case management and

better survival of TB patients

Trend of TB* Mortality and Morbidity Rate

(Rate/100,000 Philippines 1993-2003) New SS (+)s by Gender and Age Groups, (2004 -2008):

According to the data from 2004-2008, there are

more males than females who have acquired TB. The

majority of those who have TB belong to the economically

productive group (25-54).

THE NATIONAL TUBERCULOSIS CONTROL PROGRAM (NTP)

Tuberculosis has been a major public health problem in the

Philippines for the past several decades. Successful TB

control depends largely on the capacity of various health

care facilities to administer TB management based on

technically sound, evidence-based, and consistent policies

and procedures. Thus, the National Tuberculosis Control

Measurement 1983

1st

NTPS

1997

2nd

NTPS

2007

3rd

NTPS

Prevalence of Smear

(+)/1000

6.6 3.1 2.0

Prevalence of Culture

(+)/1000

8.6 8.1 4.7

MDR-TB among New

cases

(-) 1.5 2.1

MDR-TB among

Re-treatment cases

(-) 14.5 13.0

This slide shows the 10 year trend

of TB Mortality and Morbidity rate in the

Philippines from 1993 to 2003. The pink

bars represent the morbidity rate while the

blue line refers to the mortality rate. From

1997 to 1998, there was a significantdecrease of the morbidity rate and

continues to decrease until 2003. For the

mortality rate, there also has been a

decrease from 1999 to 2003. Our goal is to

reach less than 10 deaths per 100,000

cases.

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Program (NTP) was established to address the problem of

TB in the Philippines.

VISION: A COUNTRY WHERE TB IS NO LONGER A PUBLIC

HEALTH PROBLEM

- which coincides with the UNs Millennium Development

Goals for Health.

Health in the Millennium Development Goals

Goal: To contribute to the attainment of the Millennium

Development Goals (MDG 6, Target 8)

MDG 6: To have halted and begun to reverse the

incidence of TB.

Target 8: Reduce the TB prevalence and death

rates by 50% by 2015

The eight UN Millennium Development Goals

(MDGs) which range from halving extreme poverty

to halting the spread of HIV/AIDS and providing

universal primary education, all by the target date of

2015 form a plan agreed to by all the worlds

countries and all the worlds leading development

institutions. The Millennium Project was

commissioned by the United Nations Secretary-

General in 2002 to develop a concrete action plan

for the world to achieve the MDGs and to reverse

poverty, hunger and disease affecting billions of

people.

One of its goals is to Combat HIV/AIDS, malaria and

other diseases and one of its specific targets is to

halt by 2015 and begun to reverse the incidence of

Tuberculosis, and also to reduce the TB prevalence

and death rates by 50% by 2015.

As we can see from the picture, the DOTS strategy

which stands for Directly Observed Treatment

Short Course was officially adopted by the NTP in

1996.

While in 2003, a 100% DOTS coverage in the public

sector was attained and this is also when the PPMD

was created.

Tuberculosis is curable and DOTS is a strategy which aims

to address this.

WHY TB D.O.T.S.?

Cost effective

Proven to reduce morbidity and mortality (e.g. Peru)

Science and evidence based

Shortest and most effective chemotherapy we have

Interrupts TB infection in populations since it treats as a

priority the sputum smear (+) cases

Can successfully and permanently treat > 90% of

identified TB cases

Can add years of life to an HIV-positive individual

DOTS prevents new infections and development of MDR -

TB

5 Elements of DOTS

Five key elements are essential for the DOTS strategy to be

successful:

1.Sustained political commitmentmeans to increase humanand financial resources and make TB control a nationwide

activity as part of a national health system. The

government must ensure continuous monitoring and

improvement of the quality of DOTS implementation.

2.Access to quality-assured TB sputum microscopyfor case

detection among people with, or found through screening

to have, symptoms of TB (most importantly prolonged

cough). Special attention is necessary for case detection

among HIV-infected people and other high-risk groups, e.g.

people in institutions. Since sputum microscopy remains to

be the most cost effective way to detect pulmonary TB,

there must be sufficient number of laboratories to carry

out quality microscopy services.

3. Standardized short-course chemotherapy to all cases of

TB under proper case-management conditions, including

the direct observation of treatment.

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4. Uninterrupted supply of high quality drugs with reliable

drug procurement and distribution systems. TB drugs must

always be made available, accessible and affordable.

5. Recording and reporting system enabling outcome

assessment of each and every patient and assessment of

the overall program performance. Records and reports are

the source of statistics on TB that are used to guideprograms.

DOTS is still the overarching framework of the NTP

Targets:

Case Detection Rate (CDR): 70% or more

Cure Rate:85% or more

Treatment Success Rate (TSR): 85% or more

The DOTS strategy focuses on the following

operational targets: to detect at least 70% of the

new smear-positive TB cases, cure at least 85% of

these cases, and with a treatment success rate of

85% or more.

With direct observation of treatment, it is

anticipated that 80% of deaths attributed to TB

worldwide will be prevented.

Targets for Fighting Tuberculosis

NTP:

Detect at least 70% of the estimated smear positive TB

cases.

Cure at least 85% of the detected cases

Global:

Reduce Morbidity and Mortality by 50% by 2015

In order to combat TB, specific targets were set by

the NTP and the MDG.

For the NTP:

Detect at least 70% of the estimated smear positive

TB cases.

Cure at least 85% of the detected cases

And the Global target for fighting tuberculosis is:

To reduce Morbidity and Mortality by 50% by 2015

This graph shows the trends since the 100% DOTS

coverage of the public sector of the operational

targets namely the Case Detection Rate (CDR), Cure

and Treatment Success rate of Tuberculosis from

2003 to 2008.

For CDR (indicated by blue line), there was an

increase from 61% in 2003 to 76 % in 2008.

While for the Cure Rate (indicated by red line), there

was an increase from 2003 to 2006 then slightly

decreased from 2006 to 2008.

The Treatment Success Rate (indicated by green

line), shows an increasing and high TSR.

From the given data, it shows that we have achieved

the Global targets in CDR and Treatment Success

Rate in 2004.

Data gathered last 2007 for the Treatment Outcome shows

in this pie chart that 81% were cured using the DOTS

strategy while 9% completed the chemotherapy which

gives a total of 90% for the Treatment Success Rate.

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This slide demonstrates that among the 22 high-burden

countries with Tuberculosis in 2007, the Philippines is

within the target zone together with China and Vietnam.

This indicates that not only have we achieved the set

targets for CDR and TSR, but also surpassed the given

targets.

To summarize what has been discussed for this topic:

The National Tuberculosis Control Program (NTP)

was established to address the problem of TB in

the Philippines.

The NTP adopted the DOTS strategy in 1996 which

is proven to be the most successful and cost-

effective treatment strategy.

The DOTS strategy focuses on the following

operational targets:- to detect at least 70% of the new smear-positive

TB cases and;

- to cure at least 85% of these cases.

The Five key elements that are essential for the

DOTS strategy to be successful include: political

commitment; sputum microscopy; directly

observed treatment; uninterrupted supply of

drugs; and recording and reporting.

Since the 100% DOTS coverage of the public

sector, the Philippines has achieved the globaltargets for Case Detection Rate (CDR) and

Treatment Success Rate (TSR) in 2004 and has

surpassed these targets last 2007.

The Need for Public-Private Collaboration

PPMD (private public mix DOTS) strategy

Structure of PPM (private public mix) DOTS

Implementation

PPMD (private public mix DOTS) Installation

PPMD (private public mix DOTS) Accomplishments

Future direction of PPMD (private public mix

DOTS)

NTP External Evaluation

July 2002 by WHO, JICA, USAID, CIDA-World Vision

and Medicos del Mundo

Findings:

Acknowledged the remarkable expansionand coverage of public sector DOTS

Need to focus on quality-control as far as

DOTS implementation is concerned

Correct some problems in drug supplies

Focus on promoting private-public mix

(PPM) in DOTS implementation

WHY ENGAGE THE PRIVATE SECTOR

WHY ENGAGE THE PRIVATE SECTOR

(This pie chart represents the Action Taking Behavior of TB

Symptomatics in 1997 wherein large proportion

approximately 36% of TB patients seek the care of private

MDs followed by those seeking care in health centers)

TB Case Load in the Private Sector (2000)

Country Retail Sales (USD

Million)

Cost/

Course

(USD)

Estimated

Cases

India 85.3 100 853000

36.2

19.924.5

10.09.4

Action Taking Behaviorof TB Symptomatics

Private MD Hospital

Health Center Traditional Healer

Family Member

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Indonesia 12.3 100 123000

Pakistan 11.7 100 117000

Philippines 16.6 200 83000

Bangladesh 2.3 100 23000

(Further evidence of the significant role played by theprivate sector is shown in this table which estimates TB

drug sales. Studies have shown private MD tend to over

diagnose and over treat TB patients but that perhaps half

of TB patients default after going through treatment and so

for the Philippines, we can probably double the figure of

83,000 as far as private sector is concerned)

Survey of KAPs of Private Practitioners

(This table shows two surveys that were independently

conducted about the Knowledge, Attitudes, and Practices

(KAPs) of Private Physicians regarding Tuberculosis. These

surveys were conducted by Medicos, which did a telephone

survey of over 1300 private physicians, and PhilCAT

(philippine coalition against TB) which did a more limitedstudy in the NCR and Cavite areas covering 188 MDs.

Both studies showed similar findings in that private MDs

see an average of 5-10 new TB patients per month, 88 to

95% use X-rays and only 17 to 59% use sputum microscopy

as a method to diagnose TB.

Adherence to NTP guidelines ranges from 10.7-16% and

practice treatment variations can be as much as 64 to 80

variations.)

Need for Private Sector Involvement

As government reaches almost 100% coverage in

the public sector, it is apparent that global and

national targets of 70% detection rate cannot be

reached without active involvement of the private

sector;

The Philippines has a large private sector (for

profit and non-profit );

Private sector is a valuable resource available and

widely utilized even by the lower income groups.

The PPMD Strategy

It is a strategy adopted by the Department of

Health (DOH), in partnership with the Philippine

Coalition Against TB (PhilCAT) and other various

organizations, in addressing the problem of TB in

the country.

PPMD is broadly defined as any initiative or

collaboration involving the public and private

sector working towards TB Control. This strategy

integrates private practitioners in the NTP

(national TB control program) through referral of

TB patients to PPMD units.

Medicos del

Mundo* 2001

n=1300

PhilCAT/CDC

2002

n= 188

Total surveyed 1355 188

Area nationwide NCR-Cavite

X-rays 87.9% 95%

Sputum AFB 17.4 59

Treatment

adherence to NTP

10.7 16

Ave # new TB pxs

seen/month

5-10 5

Practice tx variations 64 >80

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PMMD BACGROUND

(1994) = Philippine Coalition Against Tuberculosis was

established

(1995) = First PPM DOTS : UST

(1996 ) = Public sector introduced DOTS

(1997) = Private Sector management of the National TB

Prevalence Survey

(2001-2004) = CDC implemented and evaluated 5 PPMD

Models

(2003) = PPM DOTS was officially adopted as a strategy

(March 2003) = Declaration of CUP on TB

= Comprehensive and Unified Policy (CUP) -

management was declared and signed by the public,private, academic, other government agencies than DOH,

NGOs, academia and corporate sector.

What are the Objectives of the PPMD?

Increase case detection and synchronize

management of TB among all health care

providers

Ensure compliance to the National Tuberculosis

Program policies for case finding, case holding,

recording and reporting by all health care

providers

What are the Approaches for a PPMD?

Public-initiated PPMD (LGU provincial and city

coordinators)

Private-initiated PPMD ((UST, MaDocs, MMC,

DLSUMC)

A PPM DOTS unit shall implement the NTP in

consonance with its existing operational policies, standards

and guidelines.

The PPMD Strategy

Accomplishments

The total Coordinating structures and PPMD units

that have been established in the country as of

2009 are: 1 NCC (national coordinating

committee), 16 RCCs (regional coordinating

committee), and 221 PPMD units with a coverage

of 36 million or around 40% of the total

population.

The list of units that are green in color represent

Round 2 units, while those that are color blue

belong to Round 5 units. The units that are red in

color are Non-Global Fund PPMD units.PPMD

Contribution to CDR

in Areas Covered (2004 2008)

PPMD Contribution to National CDR (2004 2008)

(Since the implementation of the PPMD strategy from

2004 to 2008, there has been a significant contribution to

the Case Detection Rate (CDR) of TB. This graph basically

shows that there is an increase in CDR from 7% in 2004 to

14% in 2008.)

PPMD Contribution to National CDR (2004 2008)

7%

11% 11%

14%14%

0%

5%

10%

15%

20%

2004 2005 2006 2007 2008

2.5M

7 units

30 M

168 units

14 M

70 units

6 M

28 units

36 M

220 units

0.2%

0.8%

2%

3%

2%

1%

3%

1% 1%

5%

6%

0%

2%

4%

6%

8%

10%

2004 2005 2006 2007 2008

Percentage

R2 R5 NGF Total

83.5

84.2

86.2

88.7MR2 - 70units

90.4MR2 - 70units

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(The graph shows the PPMD contribution to the National

CDR from 2004 to 2008. There is an increase in CDR as the

number of installed PPMD units also increases)

Trend of CDR: Public and with PPMD (2004 2008)

(The trend of CDR when combining the public and

with PPMD shows that the PPMD (represented by

the red line) by itself has contributed an additional

6% to the total CDR of the country last 2008. This

illustrates the important role of the PPMD in the

control against TB)

What is the Direction of PPMD

in the Country

Country wide engagement of health care providers

using the ISTC;

Expand TB services to cover TB in children & MDR-

TB.

Proposed PPMD Expansion Sites

The picture Illustrates the proposed PPMD expansion sites

shown by the yellow dots while the purple areas

represent the proposed 44 Provincial Coordinating

Committee Sites or PCCs for PPMD.

The Provincial Coordinating Structure for PPMD

A new program has been started early the year of 2009

for which there had been a recent Situational Analysis

Workshop during the month of July. Ladies and gentlemen,

may we introduce the Provincial Coordinating Structure for

PPMD, which launched last December 2009.

Objectives of the PCC

General

Help reduce the prevalence, incidence

and mortality of TB by 50% in 2015 and

beyond 50% from a baseline establishedin 2000 in support of the Millennium

Development Goals (MDG) for poverty

alleviation.

Specific

Detect an additional 6% of smear (+) TB

cases existing nationwide and maintain a

treatment success rate of 85%.

Strategy

Establish a Provincial Coordinating Committee

who will initiate and sustain the engagement of all

non-NTP care providers both in the public and the

private sectors using the International Standards

of TB care (ISTC);

Link existing DOTS facilities and all care providers

to ensure universal access to quality DOTS services

by all TB patients and

Generate political commitment towards the

attainment of Millennium Development Goals for

TB control.

Engagement Process of Non-NTP Providers

Through the PCC Core Team and the committees,

the engagement of non-NTP care providers

becomes a step-by-step process. On this diagram,

the engagement process is symbolized by the

horizontal arrow pushed forward by steps 1

0

20

40

60

80

2001 2002 2003 2004 2005 2006 2007 2008

Public

PPMD

6%

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through 8, with each step mostly prepared and

performed by the core teams.

Step 1: the preparatory visit by central/regional

teams, is done to explore possibility of partnership

with LGU to establish Provincial Coordinating

Committee for PPM DOTS.

Step 2 follows, which trains the committees on

situational assessment for their respective

provincesthis is in preparation for PCC members

to learn competencies in conducting the

situational assessment phase, which is step 3 of

this process.

Once data has been gathered and analyzed, step 4

the strategic planning workshopfollows. This

aims to incorporate what data has been gathered

from the situational assessment with strategies for

the engagement of non-NTP providers.

Next is step 5, which is the DOTS advocacy

symposium to promote awareness on the global,

local, and provincial situations on TB control and

care. This targets DOTS providers and private care

providers.

Step 5 precedes step 6, which is a DOTS training

for referring physicians and also includes an LOA

signing.

Step 7 is the launching of Provincial PPM

Initiatives and the signing of their respective

Memorandums of Understanding.

Lastly would be step 8: the monitoring and

evaluation of provinces.

Organizational Structure of PCC

The Regional Coordinating Committee, in accordance with

NCC directions, policies, and standards, oversees the

establishment of the (Provincial) PCC, providing technicaladvice to the PCC as necessary in conduct of their functions

and plans, along with enforcing the policies, guidelines, and

standards set in their respective regions while ensuring that

these are consistent with the direction, strategy, and

policies of the NTP DOTS.

The PCC is comprised of a chair- an LGU representative who

is also the provinces PHO (provincial health office), co-

chaired by the provinces private health sector

representative.

On one hand, the chair leads in identifying, targeting, and

engaging all public health practitioners in the province,

while on the other hand, the co-chair does the same with

the target focused on soliciting commitment from the

private health services, NGOs (Non Govt Org) targeting

vulnerable sectors as beneficiaries, medical schools,

pharmacies, practitioners of traditional/alternative

medicines, and other organizations that can help in

attaining the over-all goal and purpose of the NTP.

Both share equal status and are supported by a vice-chair,

who is elected by, and from among, the representatives of

the national governments, a secretariat is made up of the

NTP provincial team from ones PHO, and a secretarywho

is the provincial NTP medical coordinator.

Principal Functions of PCC

The PCC has three principal functions to be able to achieve

the projects goals.

Primarily, the PCC engages all non-NTP care providers in

the province, both public and private using the

International Standards of TB Care by developing a plan for

the engagement of all non-NTP care providers and monitor

this. The PCC also reports on the non-NTP care providers

engaged and address issues related to sustaining the said

engagement.

The PCC will also provide all TB patients access to quality TB

care by linking existing DOTS facilities and all care providersby developing strategies to provide vulnerable and special

population groups, like indigenous people and prisoners, to

access quality TB care and its monitoring. The Committee

also ensures the availability of laboratory supplies and anti-

TB drugsand ensures the overall quality of DOTS services

provided.

Also, the PCC generates political commitment to sustain

PPM initiative beyond the project life by developing a PPM

sustainability plan and the mobilization of resources from

private and public sectors as well as the community andthe monitoring of sustainability direction.

TB Control Initiative is like a puzzle. If one piece of the

puzzle would be lost, the beauty of the picture would not

be appreciated. Each piece can represent each of us here

in this room, if are not with us in TB Control Initiative, then

the puzzle of controlling tB in our midst could not be

possibly done.