MATERIAL ON TUBERCULOSIS
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- Title
- MATERIAL ON TUBERCULOSIS
- extracted text
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RF_DIS_4_SUDHA
4
ius 4 ■ I
TUBERCULOSIS ANT BCG VACCINATION
TUBERCULOSIS is widely prevalent in India, and is one of the
foremost health problems. There are nearly ten million persons
suffering from this disease. Many of us have some knowledge about
this disease, its causation, its course, its prevention and
treatment. But generally, a large segment of the people do not
know much about this disease, not even the elementary facts.
Here are a few questions and answers which give
considerable facts about the disease-its nature, mode of spread,
preventive measures and treatment facilities.
Who can catch tuberculosis?
Any one can catch tuberculosis, The disease is no
respector of persons, Young or old, rich or poor, man or woman,
can catch tuberculosis, Tuberculosis is a highly infectious
disease.
Is a person born with tuberculosis?
Tuberculosis is not hereditary. No one has T.B. at birth
even the children of parents suffering from tuberculosis are free
from it at birth. They may catch the infection and develop
the disease after contact with persons suffering from the
disease.
What causes tuberculosis?
Tuberculosis is caused by a tiny germ which can be seen
only under a microscope. It is found mainly in the sputum of the
patients. When a tuberculosis patient coughs, sneezes or spits,
lakhs of these germs are released into the air. Breathing in of the
air contaminated by these germs, especially in ill-ventilated
rooms, may cause tuberculosis.
How can one suspect T.B.
In its early stages, tuberculosis may not reveal any signs
and symptoms. One can have T.B. even without being awate of it.
However, you can suspect TB. If you have cough that persists for
days, constant feeling of tiredness, gradual loss of weight and
appetite, constant pin in the chest, and occasional coughing
up of blood-stained sputum. Of these, cough persisting for
more than two weeks is the most predominant symptom.
What to do in case of tuberculosis?
If you have these simptoms, consult a competent doctor or
report immediately to the nearest primary health centre or
dispensary. If you are faraway from such a medical institution or
a doctor, please inform the multi-purpose health worker or the
health assistant of your area about your symptoms when they visit
your village. Request them to take your sputum for examination.
. .. .2
2
Cn tuberculosis be cured?
Yes, tuberculosis can be cured, if detected early and
treatment started quickly. Proper examination including
X-ray and laboratory tests by a competent doctor can detect
tuberculosis early. The presence of T.B. germs in the sputum
of the patient is the surest sign of the disease.
Tuberculosis can be effectively treated, if one takes
advice of a competent doctor and follows his instructions.
The medicines prescribed by the doctor should be taken
continuously and regularly till the doctor advises to stop it.
Where are facilities for diagnosis?
Facilities for detection of tuberculosis are available in
the nearest medical and health institutions, be it a T.B. clinic,
primary health centre, a hospital or a dispensary. In each
district, a District T.B. Centre has been established which
organizes T.B. case-finding and treatment in all the Bietsiet
medical and health institutions in the district.
Such primary
health centres, etc., will refer you to the District T.B. Centre
for X-ray and other investigations, if considered necessary.
All services are provided free of charge.
Where is tuberculosis treated?
Treatment also can be carried out by the nearest T.B.
clinic, primary health centre, hospital or dispensary in the home o
of the patient. All medicines for treatment are supplied free of
charge for the full period of treatment.
What are important facts for treatment?
1. The prescribed medicines must be taken continuously
and regularly till the doctor advises you to stop. The
medicines should not be stopped if the patient is relieved of
symptoms after taking medicines for a short time. This is very
important.
2. Admission to a T.B. hospital or a sanatorium is not
necessary except for certain serious or problem cases. In such
cases, the doctor himself will advise and arrange hospitalization.
3. Ordinary balanced diet is good enough for the patient.
Good food, bed rest, etc., are not that important.
4. Except for a short period of rest to be decided by the
treating medical officer, the patient can continue with his normal
occupation. There is no need for any dislocation of family life or
work schedule.
Infectious patients will be advised on how to avoid
spread of the disease to others in the family or neighbourhood.
But the most important thing is to take the prescribed medicines
regularly. This will make the infectious patient non-infectious
in a few weeks.
3
3
Can you prevent tuberculosis and how?
Yes, you can prevent tuberculosis by taking necessary
precautions. Avoid living in ill-ventilated rooms with those
suffering from tuberculosis.
Persuade all persons having symptoms of cough, pain in
chest, fever, spitting of blood, etc., to go to the nearest health
or medical institution for a check up.
Another factor necessary to avoid the disease is to keep
the resistance of your body at a high level. Careful living,
balanced diet, hygienic environment, proper exercise and rest
ensure this resistance.
The natural resistance can be further increased by
preventive vaccination with BCG. Infants and children particularly
need this preventive vaccination.
What about spitting?
Spitting here and there is a very bad habit, When you
cough or sneeze, use a handkerchief or a clean cloth to cover
your face.
A tuberculosis patient should spit in a particular spitoon
or container. The best way to dispose of the sputum is to burn
it or empty it into a water closet, The cloth or handkerchief
used while coughing should be burnt or boiled in water for 15 to 20
minutes before using it again.
What is BCG vaccination?
It is preventive inoculation, It helps the vaccinated
person in being protected against tuberculosis.
How to protect children from tuberculosis?
B.C.G. Vaccination protects them.
Who needs BCG Vaccination?
All young persons, espedially infants
and children, need
BCG vaccination.
All others who ,are in contact with tuberculosis patients
like nurses, attendants, etc.
may also require this vaccination,
irrespective of their age.
BCEcan protect an infant
or a child only if given before
being infected by a tuberculosis
patient. Therefore, the vaccination should be <given as early in life
as possible, preferably
within the first- year of life,
How is BCG vaccination given?
BCG vaccination is given in the c *
superficial layer of the
skin over the iupper arm (Shoulder) of the
child. The vaccination
is practically painless.
...4
4
What happens after vaccination?
No change is seen for some days at the place where
vaccination is given. But in three or four weeks’ time
(and in some dases, even within a week) a small but pinless
swelling may develop at the site of vaccination. In some
cases, this may increase slightly in size and may become
soft, and discharge a drop of pus. This is a sign which shows
that the vaccination has taken. It does not require any
treatment, and it heals on its own accord in a short time.
Where can you get BCG vaccination?
You can get your infants vaccinated by the multipurpose
health workers and auxiliary nurse-midwives (ANMs) of your
locality in rural areas. BCG vaccination can also be had at
tuberculosis clinics, paediatric hospitals, maternity centres
and well-baby clinics in any town or city.
FEME MBER
* Tuberculosis is a highly catching disease and is
caused by a germ called tubercle bacillus.
* Tuberculosis is not hereditary.
* Mostly; a patient suffering from the disease
tuberculosis.
spreads
* Tuberculosis is preventable and curable.
♦ Persistent cough is an important symptom of
tuberculosis.
* T.B. clinics, general hospitals,, ]primary health centres,
dispensaries, etc
etc., provide facilities for free
diagnosis and treatment.
«
Modern anti-tuberculosis drugs are very effective.
* Treatment should be continued for the minimum
period prescribed by the doctor.
* BCG vaccination protects against tuberculosis.
* All infants and children should be vaccinated with
BCG as soon after birth as possible.
Source ; Swasth HinS^ - September 1978
REVISED N.T.P FOR TRIBAL AREAS
INTRODUCTION
Schedule tribes <constitute 8.08% (1991 census) of total
population of the country,
. • They are amongst the weakest sections
of the society. r
“
For their
socio-economic development a broad
strategy was evolved and the concept of Integrated Tribal Development Projects (ITDP) and Tribal Sub-Plan (TSP)
wa
was adopted
during the Sth Five Year Plan. A district is said
to
be
--- --a
District if ]more than
*'
-- of the population in the District Tribal
50%
on a
uniform and contiguous basis is Tribal.
Such districts are
covered under the ITDP scheme, Depending upon the population of
the district it may have one or
_ more ITDPs. Similarly,
if the
population of the districts is ---small then one ITDP may cover even
two district, rDistricts which are partly Tribal are
covered by
the Tribal Sub-Plan,
During the 6th Plan Modified Area
—i Development Approach (MADA) was included to cover smaller areas of
tribal <concentrations having 10,000 population, 50% or more
of
whom were tribals.
During 7th Plan the T.S.P. strategy was
extended
n^the country' including dispersed
tribals, Most of bbe tribal v
habitations are concentrated in the
hills, forest lands far flung> areas and villages.
In conformity with the General Health Services and
special
attention being paid to these areas in the various
National
Health Programme, it was decided to accord special priority
to
the Tribal population under the Revised
-d N.T.P. The Tribal areas
need this special emphasis because of the following.
i)
ii)
iii)
iv)
v)
vi)
Their poor socio-economic status.
Poor educational background.
Living in hilly and far flung areas
Scattered population.
Poor health facilities, already existing
Poor utilization of- these
..
.health facilities
by the
tion.
popula-
Norms created in Tribal Areas in Relation to Health
The Ministry has relaxed norms in respect of
Establishment
of Institutions in tribal areas to remove the
imbalances
and
provide better health care. These are as under.
i)
One PHC ffor every 20,000 population as against
other areas.
ii)
One Sub centre for every 3,000 population as against
in other areas.
30,000
If a particular hamlet/village is 5 kms. or more free
nearest health delivery point, a separate Sub-centre may be
up for each.
1
in
5,000
the
set
iii) Out of every 4 PHCs one is to be upgraded to a CHC with 30
beds and 4 specialities, Medicine, Surgery, Gynae,Pediatrics.
iv)
Village r
' ' Guide
i _ __
Health
for a population of 1000. If
If population more than -------1500 then1 2 guides, one of whom should belong
to SC/ST.
DEMOGRAPHIC PROFILE
In the Five States where the Pilot Project is being started
under the Revised N.T.P. the various districts covered under the
Integrated Tribal Development Projects (ITDPS) and Tribal Sub
Plan (TSP) is as under.
ITDPS
1.
2.
3.
4.
5.
6.
Bihar
Ranchi
Lohardaga
Gulma
Dumka
Sahabganj
Singhbhum
Gujrat
Dangs
Himachal Pradesh
—Kinnaur
—Lahaul-Spiti
These districts in the three
1
states
Districts as per the definition.
are
totally
Tribal
The following districts which are covered under the TSP
only partly tribal.
are
TSP
Bihar
Gujrat
Palamau
Banaskantha
Dhalbhum
Bhahruch
Bhagalpur • Panchmahals
Dhanbad
Sabarkantha
Giridih
Surat
Hazaribagh Vododara
Katihar
Valsad
Monghyr
Rohtas
Santhal
Parganas
West Champaran
Deogarh
Kerala
Trivandrum
Quilon
Idukky
Ernakulam
Malapuram
Kozhikode
Wynad
• Cannanore
Palghat
H.P.
W.Bengal
>Chamba
Bankura
Birbhum
Burdwan
Darjeeling
Hoogly
Jalpaiguri
Maida
Midnapur
Murshidabad
Purulia
24 Parganas
W.Dinoj pur
2
State wise statements of ITDPs
MADAs and Cluster Areas.
State
ITDP
MA DA
Bihar
Gujrat
Himachal Pradesh
Kerala
West Bengal
14
9
5
5
12
41
20
2
Cluster Areas
7
4
Population of Schedule Tribes and their percentages
1991 Census
States
Total
S.T.
(fig.'000)
Bihar
Gujrat
Himachal
Pradesh
Kerala
West Bengal
S.T. as %
of total
% Decade variation
(1981 - 1991)
86,374
41,309
5,170
6,616
6,161
218
7.66
14.92
4.22
13.87
27.08
10.69
29,098
68,077
320
3,808
1.10
5.60
22.75
24.04
Existing General Health Services in Tribal Areas
It has been noticed that the level
achievement in setting
up of PHC/Sub centres in TSP areas of
is
is logging
logging <considerably
behind the level achieved for the general population,
,
in •same
states.
For the 5 states under review the figures are as follows.
PHC
States
Bihar
Gujrat
H.P
Kerala
W.Bengal
Required
per norm
489
294
10
55
107
SUB CENTRES
In position
208
183
15
58
91
%
Required
per norm
42.54
62.24
150
105.45
85.05
3522
2005
65
369
712
In position
1824
1632
97
174
417
%
51.79
81.40
149.23
47.15
58.57
Himachal Pradesh has exceeded the requirement in terms
of
establishing PHC and sub Centres.
This is probably due to the
fact that the hilly terrain <andZ poor mobility in their areas
has
led ito^ an increase in requirement
-;
of
health
facilities
over
and
above that of
-- the
—□ norms laid down for T.S.P.
--- ... areas.
3
THE PRESENT STATE OF N.T.P. IN TRIBAL AREAS
In the five States under review there are three states
are
namely rBihar, Gujrat and Himachal Pradesh which
have Tribal
which
DistrictsJ and are covered by the ITDPs. The NTP is operational
’ in only some of these Districts^in^its^r
the District
Tuberculosis Centres
Centres (DTCs)
(DTCs) ^These^^as^nder'":-9
the
District Tuberculosis
State
Bihar
Guj rat
Himachal
No.of Tribal Dist.
6
1
2
District having DTCs
3
1
1
Lahaulhqn?^TtTiCu-°f 2ulma, Sahabganj and Singhbhum in Bihar
Lahaul-Spiti
Lahaul
Spiti in Himachal Pradesh are not having any DTC.
and
'Trih.T,heSeJ fives states have some Districts which
are Partly
]
are covered bY the TSPs. m these
AT
Districts
J
the
distribution of DTCs is as under:State
Districts covered
by TSP
Districts having
:
DTC
Bihar
Gujrat
Himachal
Kerala
W.Bengal
13
7
1
9
12
10
6
1
7
12
The following Districts in
the States do not have a DTC/
Bihar ;: Dhalbhum,
—
Santhal, Parganas.
Gujrat : Vaisad.
Kerala : Idukky,Wynad.
In all those districts mentioned < ’
which do not have a
District T.B. Centre, the tuberculosis above
services
<
--; are
provided to
the patients through additional
--T
B
Clinics/Chest
Clinics,
z under
the
N.T.P..
in addition to these there are some
Voluntary
Health Organisations which
-- 1 run T.B. Clinics in these areas.
4
Special Problems pertaining to T.B. and its management
in Tribal areas
Unlike other infectious diseases which have a short disease
n^hTSS' tuberculosis as a disease presents certain specific
whlcb become accentuated in background of a tribal area,
me major problems are:
i)Diagnosis :
Specific diagnosis of the disease
disease microscopic
examination which needs to be repeated
repeated 3 times.
This involves setting up of microscopic centres in
the f
far
flung,
ar^fl
ung, hilly, tribal areas and also involves the patient visiting these centres freguently.
ii)Treatment : Treatment for tuberculosis is a
prolonged one 6-8
months at the minimum under Short
- - Course Chemotherapy. Further, this
* treatment has to be superfor the
thefirst
firsttwo
two months with intensive
Xh!!
phase. The patients need to come atleast 3 times
per week in this intensive phase and then subsequently m the follow up phase also.
Both these essential components of tuberculosis management
.. .
.
components of tuberculosis
require
Tn t-ho
K?^lent„
^S
visit the health centres frequently thm
tljeh?^
8^°Uld Visit
£°r
flung
very scantv
^nd4<f°
r flun
9 areas where population is
fo? diagnosis and
W°Uld re<5uire sonie special measures
diagnosis
and drug delivery
of the
Revised
e^iv®ry- Hence the Operational Aspects
the
p
—
----Th®
L,,
7 d NTP need to be revised for these Tribal Areas
pSpulatioi
OWin9 nOrinS h3Ve 136611 suggested for
the
Tribal
following
General Population
Tribal Population
Treatment
Organiser
1 per 5 lakh population
1 per 70,000 population
Microscopist
1 per 1 lakh population
1 per 30,000 population
iii) Supervision
Because of the difficult terrain and inaccessibility of various areas in the Tribal
population supervision
ou^ivibiun becomes
oecomes a <difficult
task.
strengthen the supervisory component of the Revised NTP
in these areas spe-- -.1
cial measures need to be taken. And alternative strategy for ensuring mobility in
these
4-^aS tO be devel°Ped.
Some of the
uggestions would be to provide Fixed T.A. or
Incentive to the Supervisory Staff.
5
tribal A^L
Deenv°
bSe5yed that th
therG
is xacK
lack OI manpower in the
has been
observed
eie 1S
variole a^
feas;’
.Even the sanctioned posts are lying vacant at
levels due to non-avallability
non-availability or
of staff in ?hese Jriba^
S
To
tide
over
this
problem
it
is
proposed that
SS
proposed
that the
the locaJ
.
.
J
some training, for diagnoses
(microscopists),
for treatment follow up (treatment organizer)
and supervision.
N.G.O.s
TribalO1deiel^pmSaniS?JiJnfa^VCaan ilnpor^ant role to
P^y
in
India
and
a
Centrallv
c
s
v
recognised
by
the
Govt,
of
voluntary o^saUoiL
tO
the
was formulated
Th^
nG yelfaYe of
Schedule Tribes
formulate schemes taking
• °nS are exPected to
needs of the area and the9taraet armn6173110" ^he develoPII’ental
N.G.Os working in the Tribf? LZI P concerned- Some of these
Aadim Jati Sevak tnnh T
as are' ^.K.Mission,
and ServJJL5:^^
Vikas Bhartiya
Parishad
tions have a 100% government assistancrwhilebsoi^o? the
organisaones are required to meet 10-20% of thel^^stTo^ Seir newer
resources.
own
In West ^thf
are SOme
some V
T"°l
1untary Organisation run
T.B.Clinics in
244 Par
Parganas
C 4-u
^anas District.
There are Naihate
T.B.Association 9 Southern
Improvement Samiti
Anti-TB
--- 1 Health Improvement
Association of Budge-Budge, Santi T.B. Control
society
and
Co»
r
prehensive Health Project, in this District these T.B.clinics
provide the services to theInT.B.patients in ’these
addition to the
addition
D.T.C. operating under the
—u N.T.P.
The primary role of N.G.Os in context
of the Revised
would be:
i)
Health Education:
ii) Drug
r
Delivery
4 Supervision
N.T.P.
The NGOs can play a vital role in edueating the Tribals for their effective
c
participation in implementation
.1 of
the
programme. This would rcreate confidence
amongst the Tribals and also promote
better understanding between the Tribals
and the Government and NGOs.
: During the initial Intensive
Intensive phase of
Short Course Chemotherapy the patient is
expected to visit thei Health Functionary
thrice a week for 8 weeks for the super
vised phase of chemotherpy. Subs equently in the Continuation also the
would be expected to come atleast patient
once a
month for his drugs, The NGOs
can
play
an important role in this drug
deli
very
and supervision.
6
The planning of the Revised
,
NTP for involving NGOs in Tribal
areas would have the following
components:
i)
ii)
iv)
v)
Identifying the NGOs to be included.
i. e.
IEC
aspects
tJ:
s
^eS
t
s.
“
orkers
in
various
Financial assistance.
for
Accountability
I-E.C. ACTIVITIES
In Tribal nf ^the
coinPonents has a special significance because The
m^JreV
ing ignorance
1gnorance and socio-cultural
backwardness. The “^sages conveyed through the I.E.C. should be
very
and i„
has tJ’T'0'! Wlth the Prevailing cultural methods used should
background.
Stress
given for utilising Folk Media for
conveying
these
qreat^infi Further' the village/community head
who exercises
volved
theniEC°2ctiCii? Cal P°Pulation should be actively
actively' inof tec
IEC activities. The exact methodology and <
l content
IEC forour^bjec^veJ
i-achieving
T
PoPulatio"' wi?h the
aim
—
-- 1 of
our
objectives,
]
to be undertaken in thXsfequlres special Research Acltivitles
1 in Jrlja?
these
--- tSe
different ror
The IEC “rategy would be
Tribal
population.
reas as compared to the general
BUDGET
Allocation for
contrgl and lt. utnization
-o . In_the S«v«nth Flan <19»5-90) out of RS.6O5 .lnlon aUooat.
ed for T.B Control,
was
Was for the TSP (9.17%).
(9.171). However out of this TSP
expenditure was only 43.43 million i.e. 6.971
of total allocation figures for 90—91 and 91—92
— _ ^2 are as under:
Total approved
(Rs. in million)
90- 91 .
91- 92
150
152.5
7
Total flow
for T.S.P.
% of total
approved
15.38
16.21
10.25
10.63
For
follows.
the 5 states under review the statewise break-up is
90
91
91
Total outlay Flow for
(Rs.in million) TSP
Bihar
Gujrat
H.P
Kerala
W.Bengal
10
9.5
3.8
3.6
9.8
1.3
1.75
0.2
0.04
0.3
8
as
92
%
Total out lay
( millions )
13
18.42
5.26
1.11
3.06
9.7
10.8
3.8
3.8
9.3
Flow for
TSP
1.2
1.9
0.2
0.06
0.25
%
12.37
17.59
5.26
1.58
2.69
FINAL POPULATION TABLE 2
TOTAL POPULATION AND SCHEDULED TRIBE POPULATION IN
DISTRICTS BY RESIDENCE - 1991.
SI.
00
01
02
03
04
05
06
07
08
19
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
- 29
- 30 '
31
32
33
34
35
• 36
37
38
39
40
41
42
State/Dist.
Total
Population
BIHAR
86374465
PATNA
3618211
NALANDA
1997995
BHOJPUR
2880447
ROHTAS
2900685
AURANGABAD
1539988
JEHANABAD
1174900
GAYA
2664803
NAWADA
1359694
SARAN
2572980
SI WAN
2170971
GOPALGANJ
1704310
PASHCHIM
CHAMPARAN
2333666
PURBA CHAMPARAN 3043061
SITAMARHI
2391495
MUZAFFARPUR
2953903
VAISHALI
2146065
BEGUSARAI
1814773
SAMASTIPUR
2716929
DARBHANGA
2510959
MADHUBANI
2832024
SAHARSA
2475254
MADHEPURA
1177706
PURNIA
1878885
KATIHAR
1825380
KHAGARIA
987227
MUNGER
3060027
BHAGALPUR
3202471
GODDA
861182
SAHIBGANJ
1201088
DUMKA
1495709
DEOGHAR .
933113
DHANBAD
2674651
GIRIDIH
2225480
hazaribag
2843544
PALAMU
2451191
LOHARDAGA
288886
GUMLA
1153976
RANCHI
2214048
PURBI SINGHBHUM 1613088
PARSHCHIMI
SINGHBHUM
1787955
ARARIA
1611638
KISHANGANJ
984107
Scheduled
Tribes
% of S.T. to
Total.Population
66616914
560094
336
7282
47076
504
238
1468
1246
3231
12650
19167
7.7%
0.15%
0.02%
0.25%
1.6-2%
0.03%
0.02%
0.05%
0.09%
0.13%
0.58%
1.12%
31104
1278
394
1156
1408
902
542
259
597
7359
8321
82145
101792
35
70660
110735
216047
507321
621484
119085
225282
271924
250586
443266
162964
816988
964422
466572
1.33%
0.04%
0.02%
0.04% '
0.07%
0.05%
0.02%
0.01%
0.02%
0.3% .
0.71%
4.37%
5.57%
0.01%
2.31%
3.46%
25.08%
38.99%
41.55%
12.76%
8.42%
12.22%
8.81%
18.08%
56.4%
70.8%
43.56%
28.92%
798069
20819
34830
54.70%
1.29%
3.54%
final population TABLE 2
TOTAL POPULATION AND SCHEDULED TRIBE POPULATION IN
DISTRICTS BY RESIDENCE~^~T99T~-----------
SI.
00
01
02
03
04
05
06
07
08
09
10
11
12
13
• 14
* 15
t 16
* 17
. 18
. 19
State/Dist.
gujrat
JAMNAGAR
RAJKOT
SURENDARNAGAR
BHAVNAGAR
AMRELI
JUNAGADH
KACHCHH
BANAS KANTHA
SABARKANTHA
MEHSANA
GANDHINAGAR
AHMADABAD
KHEDA
PANCHMAHAL
VADODARA
BHARUCH
SURAT
VALSAD
DANGS
Total
Population
41309582
1563558
2514122
1208872
2292026
1252589
2394859
1262507
2162578
1761086
2937810
408992
4801812
3440897
2956456
3089610
1546145
3397900
2173672
144091
Scheduled
Tribes
% of S.T. to
Total.Population
6161775
7154
4695
9481
3346
2032
11055
87723
149406
324199
10907
5602
42574
41023
1395050
821697
703956
1225080
1181404
135386
14.92%
0.46%
0.19%
0.78%
0.15%
0.16%
0.46%
6.95%
6.91%
18.41%
0.37%
1.37%
0.89%
1.19%
47.19%
26.60%
45.53%
36.05%
54.35%
93.96%
IN
SI.
00
- 01
02
03
04
05
06
07
? 08
09
10
11
' 12
State/Dist.
Total
Population
HIMACHAL
PRADESH
CHAMBA
KANGRA
5170877
216349
4.191
393286
1174072
369128
378269
295387
776372
302432
31294
617404
382268
379695
71270
111509
1628
223
53
7983
9417
10914
24088
8369
2449
6113
39609
28.35%
0.14%
0.60%
0.12%
2.71%
1.21%
3.61%
76.97%
1.3€%
0.64%
1 .61%
55.5<%
hamirpur
UNA
BI LAS PUR
MANDI
KULLU
LAHUL & SPITTI
SIMLA
SOLAN
SIRMAUR
kinnaur
IO
Scheduled
Tribes
% of S.T. to
Total.Population
FINAL POPULATION TABLE 2
ZOPOIATION ANP SCHEDULED TRIBE POPULATION TN
DISTRICTS by RESIDENCE z 1991,
SI.
00
01
02
. 03
04
05
06
07
08
09
10
11
12
13
14
State/Dist.
KERALA
KASARGOD
KANNUR
WYANAD
KOZHIKOD
MALAPURAM
PALAKAD
THRISSUR
ERNAKULAM
IDUKKI
KOTTAYAM
ALAPPUZHA
PATHANAMTHITTA
kollam
thiruvanantha PURAM
Total
Population
29098518
1071508
2251727
672128
2619941
3096330
2382235
2737311
2817236
1078066
1828271
2001217
1188332
2407566
2946650
Scheduled
Tribes
% of S.T. to
Total.Population
320967
29283
18243
114969
5407
10555
35465
4051
4941
50269
17996
2801
6922
3884
16181
1.11%
2.74%
0.82%
17.11%
0.21%
0.35%
1.49%
0.15%
0.18%
4.67%
0.11%
0.14%
0.58%
0.16%
0.55%
FINAL POPULATION TABLE 2
TOTAL POPULATION AND SCHEDULED TRIBE POPULATION IN
DISTRICTS BY RESIDENCE x 19917
SI.
00
01
... 02
. 03
04
05
06
07
08
09
10
11
12
13
< 14
. 15
16
17
State/Dist.
Wf BENGAL
KOCHBIHAR
JALPAIGURI
DARJILING
WEST DINAJPUR
MALDAH
MURSHIDABAD
NADIA
NORTH 24
PARGANAS
. SOUTH 24
PARGANAS
CALCUTTA
HAORA
. HUG LI
MADINIPUR
bankura
puruliya
barddhaman
birbhum
Total
Population
Scheduled
Tribes
% of S.T. to
Total.Population
68077965
2171145
2800543
1299919
3127653
2637032
4740149
3852097
7281881
3808760
13275
589225
179153
307487
171326
61513
90525
169831
5.60%
0.62%
21.04%
13.79%
9.84%
6.50%
1.30%
2.36%
2.34%
5715030
70499
1.24%
4399819
3729644
4355230
8331912
2805065
2224577
6050605
2555664
8593
10090
176401
869636
289906
427766
376033
177501
0.20%
0.27%
4.05%
8.28%
10.34%
19.23%
6.21%
6.95%
11
M 4 ■
T. B. Div./December 93
-■
■
■
'■■rK
• S:
; .p
IS!
technical
(guide
for
tuberculosis
control
■C. ", J
J,
■
• :: ■■
Directorate General of Health Services
Nirman Bhavan, New Delhi
—
1993
■v;:v
'
Page
5.
6.
4.6
Defaulter action
4.7
In-patient versa
4.8
Treatment during pregnancy and breastfeeding ...
4.9
Tuberculous meningitis
out-patient treatment
DRUGS AND REGIMENS
5.1
Drugs and their dosage
5.2
Short-course chemotherapy for newly
diagnosed cases
5.3
Short-course chemotherapy for
previously treated cases
5.4
Twelve-month regimen for newly diagnosed
cases of tuberculosis
5.5
Contacts of smear positive index cases
SIDE-EFFECTS OF ANTITUBERCULOSIS DRUGS
14
19
19
22
22
23
23
24
6.1 to 6.6 Isoniazid, Rifampicin, Pyrazinamide,
Thiacetazone, Ethambutol, Streptomycin....
7.
PREVENTION OF TUBERCULOSIS
7.1
8.
BCG vaccination
HIV AND TUBERCULOSIS
8.1
HIV and AIDS
8.2
Interaction between tuberculosis
and HIV infection
8.3
Diagnosis of HIV-associated
tuberculosis
8.4
Management of HIV-infected
tuberculosis patients ....
8.5
Prevention of HIV transmission in
health care settings
Page
9.
RECORDING AND REPORTING
25
10.
EVALUATION
.6
10.1 Evaluation of case finding
10.2 Evaluation of treatment
ANNEXURES
I-
II-
I
I
i
RECORDING, REPORTING AND EVALUATION OF
CASE-FINDING AND TREATMENT RESULTS
27
CARDS, FORMS AND REGISTERS
31
30
INTRODUCTION
The aim of the fight against tuberculosis is
for individual patients:
to cure disease, to preserve
and quickly restore work-capacity, to allow them to be
within the family, and the community, and, in this way,
to maintain their socio-economic status.
for a community:
to reduce the risk of tuberculosis
infection through case finding and their appropriate
management and cure.
The fight against tuberculosis is best conducted within
the setting of a National Tuberculosis Programme (NTP) integrated
with the general health services.
The first priority of NTP is the treatment, appropriate
management and cure of tuberculosis patients, especially sputum
positive cases detected through direct microscopy.
Smear-nega
tive patients should also be given chemotherapy if active tuber
culosis is diagnosed.
Control measures applied by any agency (voluntary or
other) shall conform with the NTP and should be implemented in
close collaboration with the national,, state or district health
authorities responsible for the NTP.
Close cooperation of Government authorities and all other
health care providers at all levels is essential for successful
implementation of the NTP.
Participation of village panchayat
and community health workers (CHWs), religious groups, political
leaders, other community representatives and voluntary agencies
is essential to achieve success in tuberculosis control.
It is
important that the community is made aware of the nature and
extent of the problem of tuberculosis and its prevention and
cureIt must be stressed adequately that the disease is nearly
100% curable,
and therefore there is no reason for panic within
the community and tuberculosis shall not be connected withi a
stigma.
Community participation will ensure achieving high
coverage with BCG vaccination, encourage people developing symp
toms of tuberculosis to seek medical advice for early case detec
tion and help enhancing cure rate by improving patient’s compli
ance with chemotherapy.
Case-finding through sputum smear microscopy and
treatment of tuberculosis can be carried out at the general
health facilities and be performed by paramedical workers, if
they are properly trained and regularly supervised,
Case-f inding
and cure of infectious cases of tuberculosis are the key to
effective control of the disease.
Case-finding followed by
proper treatment reduce suffering, disability and death from
tuberculosis.
I
1
1.
WHAT IS TUBERCULOSIS?
1.1.
Cause of the disease
1.1.1.
Infectious agents
Mycobacterium tuL rculosis ■primarily from humans and
M.bovis primarily from cattle are the aetiological agents in
India.
C‘ ’
Other
mycobacteria occasionally produce disease clinically indistinguishabl.e from tuberculosis but identifiable only
through culture.
1.1.2
Disease progression
Transmission is mainly through air via inhalation of drop
let infection.
Initial infection usually goes unnoticed. Tuber
culin sensitivity appears within a few weeks, lesions commonly
heal having no residual changes except occasional pulmonary or
tracheobronchial lymph node calcifications (primary complex).
Approximately, 95% of those initially infected enter this latent
phase from which there is life-long risk of reactivation.
In
approximately 5%, the initial infection may progress directly to
pulmonary tuberculosis or by lympho-haematogenous dissemination
of bacilli, to pulmonary, miliary, meningeal or other-extra
pulmonary involvement.
Serious outcome of the initial infection
is more frequent in infants, adolescents and young adults.
Extra pulmonary tuberculosis is much less common than
pulmonary.
It may affect any organ or tissue and includes TB
meningitis, miliary TB, involvement of lymphnode, pleura, bones,
joints, intestines, pericardium, kidney, skin, etc.
Progressive pulmonary tuberculosis arises from exogenous
reinfection or endogenous reactivation of latent focus remaining
from the initial infection and if untreated, leads to death
within 2-3 years In over half the patients.
1.2
Occurrence
The disease occurs
worldwide, with a higher incidence
in developing countries.
In India estimated prevalence of sputum
positive patients is 0.4% (3.5 million cases). Under the NTP,
approximately 1.5 million total cases are detected and put on
treatment every year.
An estimated 0.5 million deaths from TB
occur every year.
For infected infants, the life-time risk of
developing disease is around 10%.
For persons infected with HIV,
the annual risk has been estimated to be around 7% and the life
time risk of developing Tuberculosis is around 60%.
In developed
countries, the mortality and morbidity from TB has been declining
over the last few decades but in the 1980s morbidity has in
creased in areas or population groups with high prevalence of
HIV.
2
Prevalence of infection detected by tuberculin testing
increases with age an<. in India it is more than 40% in adults.
In most of the advanced countries, human tuberculosis due
to mycobacterium bovis i. rare, To prevent it, milk from animals
In India,
should be boiled or pasteurised before consumption,
raw milk is not consumed usually and is invariably boiled or
pasteurised before consumption, As such bovine Tuberculosis
is
practically non-existent in man.
1.3
Transmission
Route of infection
Forms of tuberculosis
Tuberculosis is most commonly transmitted by inhalation
of infected droplet nuclei. These droplet nuclei are discharged
in air when the tuberculosis patient coughs or sneezes.
If the
bacillus succeeds in infecting a person, the infection results in
active disease in only about 10% of individuals who have acquired
primary infection.
I
Infection occurs almost exclusively through the respiratory system.
Tuberculosis spreads from the primary lung lesion
to other parts of the body via blood stream, lymphatic and bron
chial systems or by direct extension, and in this way it may
affect any organ.
Pulmonary tuberculosis: Tuberculosis affects the lungs in
more than 80% of cases. Pulmonary tuberculosis in adults
is often sputum smear-positive and therefore highly
infectious.
Cases which are only sputum culture-positive but smear
negative, are 7 to 10 times less infectious than those
which are smear positive.
The outcome of smear-negative
cases, when not treated, is more favourable than that of
smear-positive cases.
|
Extra-pulmonary tuberculosis can affect any part of the
body, such as lymph nodes, bones and joints, the genito
urinary tract, the nervous system (meningitis), intes
tines etc.
Diagnosis is often difficult and it should be
made by a physician.
Patients with extra-pulmonary
tuberculosis (without concomitant pulmonary tuberculosis)
hardly ever spread the disease to other persons.
i
Tuberculosis in children: Sputum usually cannot be obtained from children and, in any case, it is often negative even on culture.
Diagnosis of tuberculosis in
children rests largely on clinical history, contact
history. X-ray examination and tuberculin testing,
The
decision whether or not to treat the child should be made
by a physician.
3
Generally, -ny tuberculin-positive child under 5 years of
age, who has not been vaccinated with BCG but has signs
or symptoms suggesting tuberculosis, should be regarded
as having active tuberculosis and should be given a full
course of treatment.
1.4.
When should tuberculosis be suspected?
The most common symptoms of pulmonary tuberculosis are
persistent cough, (usually with sputum, sometimes bloodstained),
fever and chest pain for 3 weeks or more.
For extra-pulmonary tuberculosis, symptoms depend on the
organs involved,
', for example:
swelling, occasionally with pus drainage when lymph nodes
are affected;
pain and swelling when joints are involved;
headache, fever, stiffness of the neck and mental confusion when there is tuberculous meningitis.
1.5
Health education
The general public should be taught the importance of
early attendance at a 1health facility when they have chest symptoms, especially productives <cough, persisting for 3 weeks or
more.
]Patients with these symptoms should undergo a sputum
examination at the nearest health facility.
It should be emphasized that Tuberculosis is 100% curable
with adequate treatment and also that if the treatment is not
taken as per the advise of the physician
ohvsician it would lead to spread
of the disease amongst’members of his household.
Efforts should
be made to make people aware of the nature of tuberculosis and
facilities available.
Persons infected with HIV often present with tuberculosis
and, therefore, educational message should be adequately directed
towards them and high risk groups for HIV infection.
1.6
A zzcasez/ of Tuberculosis
A case of Pulmonary TB
is a patient who is sputum
positive for AFB or is considered by a physcician to be suffering
the disease on the basis of clinical and radiological
from
evidence. All cases of tuberculosis should be registered in the
registry and all necessary details are to be recorded.
Reporting
and analysis will be done separately for sputum positive cases
and for sputum negative cases.
4
!
1.7
Classification of tuberculosis cases
Tuberculosis cases are classified as either pulmonary or
extra-pulmonary.
Cases of pulmonary tuberculosis are further
subdivided into smear-positive and smear-negative.
1.7.1
Pulmonary tuberculosis
i)
ii;
Smear-positive patient: a patient with at least two
sputum specimens positive for acid fast bacilli
(AFB) by microscopy, OR: a patient with one sputum
specimen positive for AFB and radiographic abnor
malities consistent with active pulmonary tubercu
losis ;
Smear-negative patient: a patie: t with three sputum
specimens negative for AFB by microscopy and radio
graphic abnormalities consistent with active pulmonary tuberculosis (i.e., a changing chest radio
graph) and decision by a pnysician
physician to treat with a
full curative course of anti-tuberculous chemo
therapy; in case of paediatric tuberculosis the
decision of the physician to treat with full course
of chemotherapy.
1-7-2
Extra-pulmonary tuberculosis: a patient with history
and/or clinical evidence consistent with active tuberculosisand
decision by a physician to treat with a full curative course of
anti-tuberculosis chemotherapy.
Patients who have taken anti—tuberculosis drugs for 1
month or more at any time in the past have an increased chance of
having drug resistant tuberculosis.
Therefore, it is essential
that all patients - especiallty smear-positive patients - be
carefully questioned about previous antituberculosis treatment
before current treatment is started.
Cases are, therefore,
further defined by treatment history as:
a*
N ew case: a patient who has never taken anti-tuberculosis
drugs before for more than one month.
Relapse
Re
lapse: a patient declared cured
physician) who again is smear-positive.
in the past,
(by a
c*
Smear-positve failure case: a patient on SCC who remains
or becomes sputum smear-positive 4 months or more after the start
of chemotherapy OR a patient who interrupted the treatment for
more than two months and is subsequently found to be smear posi
tive OR
a patient who was smear negative before initiating
treatment but has become sputum positive at two months smear
examination.
d.
Defaulter: a patient
|
who after negativisation, interrupted the treatment for 2 months
-- or more.
5
;■
e.
Chronic case: a patient who remains AFB smear-positive
after completing a retreatment regimen OR a patient who remains
AFB smear-positive for 2 or more years.
Although smear-negative pu . onary cases and extrapulmonary cases may also be failure, relapse, or chronic cases,
this should be infrequent.
When there is proven evidence of
active tuberculosis, these cases should be treated as smear
positive cases with the retreatment regimen.
2.
2.1
DIAGNOSIS OF TUBERCULOSIS
Case-finding methods:
Examination of patients with relevant symptoms (produc
tive cough for more than three weeks with or without
haemoptysis, fever,
chest pain, weight loss or night
sweats)t
iwho
’
present themselves on their own initiative
at health facilities;
Promotion of awareness in the community, the medical
profession and all medical staff concerning the respira
tory symptoms, notably persistant productive cough;
Examination of household contacts (especially children
and young adults) of the smear positive tuberculosis
patients; and
Bacteriological examination of sputum of a patient who,
for any reason, has had a radiological examination of the
chest showing an abnormality consistent with active
tuberculosis.
2.2
Diagnosis
2.2.1
Bacteriological
is,f as u
t examination of- sputum
-r--- —
a „
rule, the
only way m which the diagnosis of pulmonary tuberculosis; can be
confirmed.
Whenever tuberculosis is suspected, at least three speci-
mens <of sputum should be collected and examined by microscopy,
If possible, they should be obtained within 2 days.
i
4-
First interview with the patient,
A spot specimen is
collected; this is a specimen obtained on the spot after
coughing and clearing the back of the throat, under
supervision of a staff member,
The patient is then given
a sputum container for collection
-1^.. of an early morning
specimen and to come on the next working day along with
the sputum sample.
Second interview with the patient.
co1lect ion
S1pecimen
‘brought
The early morning
.
by
the patient is taken and a
further spot specimen is collected.
6
£
[
All spec imens should be examined in the nearest
microscopy laboratory, as a rule, by the Ziehl-Neelsen method
(See Laboratory manual).
If the first spot specimen is positive by microscopy and
the patient does not return for the second inteview, an immediate
search must be made to f nd the patient to prevent dissemination
of infection in the community and deterioration of the patient’s
condition and a second and third samples of sputum must be
collected and examined.
I
A course of symptomatic treatment of antibiotics (if
indicated) suitable for non-tuberculous infection (but not strep
tomycin nor rifampicin) may be given, while awaiting the labora
tory smear reports on the specimens.
If the patient fails to
respond to this treatment and remains ill, even though the smear
is negative, the patient should be referred•for further investi
gation (clinical and radiological).
The extra-pulmonary cases
with productive cough should also be examined by sputum smear to
exclude pulmonary tuberculosis.
The treatment for tuberculosis will be started as soon as
two positive laboratory reports on smear examination are received.
Treatment for Tuberculosis in patients with a single
positive laboratory report should be determined by a Medica1
Officer.
Treatment will usually not be started in the absence of
a positive laboratory report unless it is prescribed by a Physi
cian on the basis of the clinical examination, chest x-ray film
suggesting tuberculosis and at least 3 negative smear results.
For Smear-Negative patients treatment should NEVER be started
without having done the smear examination THREE times.
On each supervision visit to the health centre, the
health worker in charge of tuberculosis control will check the
documents-;—of—all patients diagnosed as suffering from tuberculo
sis since the last visit, including those with either a single or
no positive laboratory report.
2.2.2.
X-Ray diagnosis of tuberculosis is unreliable, because
other chest diseases can look like tuberculosis on an X-ray, and
pulmonary tuberculosis may show many forms of radiographic abnor
mality.
It must be stressed that the determination of clinical
activity of tuberculosis by X-ray is totally unreliable. More
over, the cost of X-Ray examination is relatively high in rela
tion to case finding by smear microscopy.
Consequently, the
diagnosis of tuberculosis in adults must, as a rule, be confirmed
by smear examination.
In spite of this, X-ray examination can undoubtedly be
very helpful in clinical work when investigating tuberculosis
among patients with symptoms suggestive of tuberculosis, children
or young adult contacts of infectious cases, and in patients,
suffering from miliary or extra-pulmoi ary tuberculosis. Clinical
7
f ■
diagnosis of tuberculosis based on -ray examination alone should
alwa s be made by a competent physician.
2.2.3. The tuberculin test has a limited value in clinical work,
especially in high prevalence countries.
A "positive'* tubercu
lin test (10 mm or more induration) is infrequently followed by a
disease and a "negative" tuberculin test does not necessarily
exclude active tuberculosis (albeit only m a minority of cases).
Moreover, a "positive" tuberculin test may be due to infection
with mycobacteria other than M.tuberuclosis. However, the tuber
culin test is important in clinical work with children where a
positive test is more likely to reflect recent infection with
tuberculosis and a much higher risk of developing disease.
2.2.4
Depending1 on the organ involved diagnosis of extrapulmonary tuberculosis can usually only be made 'ey a physician.
2.2.5
1Diagnosis in children is made by a physician on the basis
of clinical symptoms,
a< positive Mantoux tuberculin skin test (in
non-BCG-vaccinated children)
,,, a chest x-ray and a history of a
contact with a tuberculosis case.
2.3
Complications of tuberculosis
a.
Pulmonary tuberculosis
Haemoptysis (coughing up of blood).
In all severe cases
the patients should be advised rest,, sedatives and antitussives and be referred to the nearest hospital;
spontaneous pneumothorax (collapse of the lung through
damage caused by tuberculosis).
The patient must be
referred to the nearest hospital for further management;
(
pleural effusion.
If the amount of fluid is not too
great, the clinical condition will improve with chemo
therapy alone. If there is too much fluid in the thorax,
aspiration may be necessary for relief of symptoms and
the patient should be referred to hospital;
cardio-pulmonary insufficien y (heart and lung disease
resulting in cor pulmonale) . A medical officer should be
consulted concerning therapy;
bronchiectasis, fibrosis of the lungs.
These are consequences of extensive tuberculosis disease and only symptomatic therapy is possible.
b.
Extra-pulmonary tuberculosis
Complications depend on the organs involved.
officer must be consulted.
8
A medical
[
3.
3.1
TUBERCULOSIS LABORATORY SERVICES
Aims of the bacteriological service
The a ims of the bacteriological service are, first, the
diagnosis oi cases nd, second the monitoring of their treatment.
The tuberculosis laboratory service consists of a network
of laboratories throughout the country which carry out, ;as part
of their work,/ imicroscopic examination of sputum smears stained
by the Ziehl-Neelsen method, and also includes Reference Laboratories for tuberculosis.
I
A practical description of all procedures related to
sputum examination by direct microscopy is given in Laboratory
Manual.
The Reference Laboratory of Tuberculosis should be capable of training and supervising the staff of the network of
microscopy centres,
It should provide quality control services
for smear microscopy,
Some reference laboratories should have
facilities for culture and sensitivityr tests.
Efficient peripheral laboratories play a crucial role in
the success of case-finding programme based on the detection of
smear-positive cases.
Microscopy centres for examination of
sputum for detecting tubercle bacilli are usually located in
hospitals and health centres.
I
3.2
Smear Examination
3.2.1.
Sputum positive cases
The sputum smear examination
diagnosis.
is done three times
for
During the follow-up, 2 smears have to be tested every
time as under:
I
a)
at the end of the intensive phase (2 months for new cases
and 3 months for retreatment cases), at the end of 4 months (5
months for retreatment cases)) and at the end of treatment.
b)
If the smear is positive at the end of the intensive
phase, it should be tested again at 3 months in new cases or at 4
months in retreatment cases.
i
I
\
The smear-positive slides should not be reused for tuberculosis microscopy.
9
r
3.2.2
Sputum negative cases
During the follow up 2 smears must be tested at the end of 2
months.
3.3
I-
Culture
Direct smear examination has the highest priority.
Culture of sputum from symptomatic suspects with abnormalities
compatible with tuberculosis on a chest X-ray, but smear
negative, may result in more frequent and earlier diagnosis.
Culture of tubercle bacilli is advisable in such cases.
Culture
and sensitivity is valuable for epidemiological surveillance,
treatment and planning for resistant/failure cases.
3.4
Quanity control
Quality control of every form of tuberculosis bacteriolo
gy, including direct smears, cultures and sensitivity tests, is
very important,
This is the task of the reference laboratories
at all levels.
It must be stressed that the priority is to
establish <a quality network of microscopy centres prior to setting up the culture and sensitivity test service,
The quality
control of sputum smear microscopy is ensured by;
the microscopists at every centre should keep all the
slides for two months.
the supervisor lab.technician during his visits will
review a sample of atleast 10% of the slides which have
been reported as smear positive by the microscopists and
2.5% of the slides which have been reported as smear
negative.
3.5
Supervision
The Medical Officer in charge and other staff supervising
the laboratory services should be appropriately trained so that
they have adequate knowledge of the techniques of smear examina
tion .
I
I
4.
GENERAL ASPECTS OF CHEMOTHERAPY
The objectives of chemotherapy are:
(a) to achieve a cure rate of at least 85% of all newly detected
smear-positive cases;
(b) to achieve at least 90% treatment completion rate of retreat
ment cases and sputum negative acutely ill tuberculosis cases
registered for treatment with short course chemotherapy.
10
r
The main iequirements for adequate chemotheraf
are:
an appropriate combination of antituberculosis drugs,
taken regularly by the patient.
for
i sufficient period of time.
Drugs should be available to every-tuberculosis case
registered.
The treatment includes an initial supervised inten
sive phase of two to three months followed by 4 to 5 months of
self-administered continuation phase.
4.1
Drug resistance
There are three types of resistance of tubercle bacilli
to antituberculosis drugs, namely natural, acquired and primary:
a Naturally drug-resistant strain is a wild stra in
(mutant) resistant to a [particular drug without ever
having been in contact with it.. Mutants resistant to two
drugs are rare;
Acquired or Secondary resistance :
It is due to incorrect chemotherapy in respect of its dosage, duration,
regularity or regimen.
Primary drug resistance:
If a patient with acquired
resistance to one or more antituberculosis drugs infects
a healthy individual, the tubercle bacilli in the infect
ed person are resistant to the same drug(s) as those of
the source of infection, even though the new patient has
never taken the drugs in the past.
Resistance is commonly due to inadequate qhemotherapy.
It is therefore, essential that chemotherapy in new smear-positve
patients starts with four drugs and continues,r after the initial
phase of 2 months with 2 or 3 drugs.
)
Sputum-positive patients who have previously taken anti
tuberculosis drugs are more prone to develop drug resistance as
compared to the general population.
Therefore, such patients
must be administered a retreatment regimen.
!
Before treatment is started, it is essential that all
patients should be closely and carefully questioned as to whether
or not they have previously taken antituberculosis drugs so that
they are appropriately registered for proper treatment regime.
I
4.2
Regularity of chemotherapy
With few exceptions, the regimens under 5.2.
newly diagnosed cases of tuberculosis, provided that:
will cure
11
t,;
they are administered for the required period of
months,
6
they aie taken regularly,
the patient on entry is not in a critical condition, and
I
the bacilli are not resistant to both
rifampicin.
I
isoniazid and
Regular supervision is required to ensure that the patient actually takes all the drugs prescribed,
Family members,
respected individuals in the community, e.g. village elders,
teachers or other Panchayat leaders, can be of g
great help to
health workers in their task of ensuring compliance.
4.3
Duration of chemotherapy
The duration <of chemotherapy is 6 months for the rr^w
cases, 8 months for retreatment cases and 12 months for
conventional therapy,
It is only of minor benefit to prolong
chemotherapy for more than this recommended period provided the
patient has taken the regimen without interruption.
Chemotherapy
should be stopped or temporarily interrupted only if severe drug
intolerance or toxicity occurs.
Patient will stop drugs ONLY on advise of treating physi
cian and not before.
The patient should be told that if he
follows the proper advice he will be CURED of the disease.
4.4
Procedures during treatment
Where injections are given,
ensured.
strict sterilization must be
Sputum microscopy is much more informative than radiology
m following the progress of chemotherapy.
The Erythrocyte
Sedimentation Rate (ESR) is unreliable and has no role in
evaluating the progress or results of treatment.
Sputum from smear positive patients treated with the
short course chemotherapy should be examined at 2 months
(3 months for retreatment cases), at 4 months (5 months for
retreatment cases) and at the end of treatment.
wf the sputum is negative at months 4 and 6 in patients
enrolled on short-course chemotherapy, the patient should be
discharged from treatment as cured at the end of the sixth month.
If the sputum is positive at the fourth month the patient should
be declared as a failure case and referred for retreatment
afresh.
12
r
4.5
Follow-up
No follow-up is required for a patient who has completed
and declared cured.
He should bp advised to report only if the
symptoms suggestive of tuberculosis recur.
4.6.
Defaulter action
Defaulter action is taken to bring the patient back on
treatment by visiting the patient’s home.
This should be done by
health staff or community health worker on the following day
after the patient did not come for treatment in the initial phase
or within a week in the continuation phase.
It is important to
take defaulter action immediately after determining that the
patient has defaulted.
4.6.1.
Motivation
The health worker should discuss problems with the pa
tient and find ways of preventing the patient from defaulting,
convince the patient that cure depends on regular drug taking and
convey the same message to relatives so that they can take an
interest in ensuring regular drug taking by the patient.
The
health worker should discuss with the patient, where he would
prefer to take his treatment.
4.7
In-patient versus out-patient treatment
Hospitalization in itself has little or no effect on the
outcome of treatment: a patient who really takes the drugs will
do equally well whether treated in or out of hospital.
In-patient treatment is indicated (often only for a few
weeks) for the severely ill, for those with complications of
tuberculosis (e.g. haemoptysis, spontaneous pneumothorax) or for
those with other serious accompanying diseases requiring hospi
talization.
Hospitalization is also recommended to ensure that
the initial intensive phase of chemotherapy (2 to 3 months) is
received without defaulting by patients who live far away from
the nearest health centre.
It is emphasized that if health staff
think that any smear-positive patient cannot manage to receive
ambulatory directly observed chemotherapy during the first 2
months, such a patient should be admitted to hospital, even
though the policy prefers ambulatory therapy.
4.8
Tuberculosis treatment during pregnancy and breastfeeding
Active tuberculosis in women who are pregnant or in
mothers who have small children presents a special problem.
Pregnant women with active tuberculosis should start or continue
their antituberculosis treatment.
(Streptomycin should not be
given during pregnancy because it crosses the placenta and may
cause damage to the fetus).
13
■g
r
r
r
Breast feeding of infants : ould continue irrespective of
the tuberculos
status of the mother,•
If the mother is sputum
positive for
r:: e child should be riven chemoprophylaxis for
as long as t:
■r remains inf cti . . s nd then vaccinated with
BCG if the c .
still tubere» In neg.-. ive.
4.9
Tube
Tuo
treated,
is done, t
sure, elec
cobweb if 1with high ”
confirms t
Th
regimen d<
given exte
Pyrazinamj
because i
Steroids r
which may
be made gr
::
?r.
itis
3itis
■ be *-
P- *1 i
n*
tur t
. ca' .
Class
.ow S’-ga.
s a f
•pec::
d iseef se if left unWhen _umbai puncture
j nde ■
increased pres•
clro fo**ms like a
sb jws
C:>:‘
Uy tevel?•
■’r“=id
-U
as
•
s
as possible.
The
patients
should
be
'o;
x to seven months.
4. C
-‘ul
’■
"'ulous meningitis
ti
-he CSF.
ammat ion
ki;.j
^ceroids should
r 6-S we*- - of treatment.
ve re 1y <
phase z
3•
\ND REGIMENS
Do
>_C^tuber
les7.
ThTZT"c ;---treatmRnt__unti 1 a firm diagnosis has been made
put;. mm smear ^xarriz nation should have
j^qe------ Three . sput
-----been done before starting cnemotherapy.
Priority treatment ’
iven to pulmonary smear-positive
cases, then to smear-negat
■nd
extrapulmonary cases.
Three
types of treatment
---- ; regimen are recommended in this guide:
Mew cases
1.
6
month supervised short-^uuise
course cnemotheraov
chemotherapy fSCC)
(SCC) for
pulmonary tuberculosis
cases.
Y 1ill1 smear negative tuberculosis
pUi»o„arythteurb:prycu}s
2.
12 month self administered regimen for treatment of other
smear-negative and c./
J
extrapulmonary
Pulmonary tuberculosis cases cases. Smear-positive
who refuse to take
supervised SCC or cannot comply with SCC due to drug
toxicity will also receive
a 12 month regimen.
Retreatment cases
i
3.
8 month short-course
chemotherapy for retreatment
smear-positive relapses and failure cases.
14
of
r
5.1
Drugs and their dosage
The most important drugs used in the treatment of
tut rculosis are isoniazid (H), rifampicin (R), pyrazinamide (Z),
Streptomycin (S), ethambutol (E)
nd thiacetazone (T).
Thiacetazone is also available in a combination preparation with
isoniazid.
The use of rifampicin or <of‘ streptomycin, for diseases
other than mycobacterial diseases,, should be limited to very
carefully considered indications.
The drugs are provided in blister packs for the 6 and 8
month regimens. Three different blister packs are available for
adult patients: one day pack for the intensive phase with isonia
zid, rifampicin, pyrazinamide and ethambutol.
Weekly pack for
the continuation phase with isoniazid and rifampicin for new
cases and with ^soniazid, rifampicin and ethambutol for retreat
ment cases.
For adults drugs will be given in the recommended number
of pills/tablets irrespective of body weight. For children the
drugs will be given in loose tablets according to the body
weight. The recommended dosages per kilo body weight for chil
dren are illustrated in the following table for daily and inter
mittent therapy (WHO recommendation);
Drug
Daily
therapy
Intermittent
therapy
Isoniazid
5 mg/kg
10 mg/kg
30 mg/kg
15 mg/kg
10 mg/kg
50 mg/kg
15 mg/kg
15 mg/kg
15 mg/kg
30 mg/kg
Rifampicin
Pyrazinamide
Streptomycin
Ethambutol
5.2
Short-course chemotherapy for newly diagnosed cases
Category I:
i
I
New^cases of AFB-smear positive pulmonary tubercu1osis and other newly diagnosed sputum negative
seriously ill patients with severe forms of tuber
culosis
(e.g. meningitis, disseminated tuberculosis, tuberculous
pericarditis, peritonitis, bilateral or extensive
pleurisy, spinal disease with neurological complications,
smear-negative pulmonary tuberculosis with extensive
parenchyma involvement, intestinal, genito—urinary
tuberculosis, etc.).
15
Lr.
r
Prior i ty: Highest for smear-positive pulmonary tuberculo
sis; treatment is vital for patients with the other forms
of disease because of the associated morbidity and mor
tality .
Recommended regimen
o
Initial intensive phase: 2 (HRZE)3
3 ,• i.e., isonia
zid, rifampicin, pyrazinamide and ethambutol in a
blister pack, adminstered three times a week for 2
months.
The medication has to be taken by the
patient under observation of health staff.
When the patient has completed the initial intensive phase of 2 months and the sputum is AB smearnegative, the continuation phase will start,
If
sputum is smear-positive at 2 months, the initial
intensive phase of 4 drugs daily is continued for
another month; then the continuation phase is
started, regardless of sputum test results.
The content of a blister pack is following:
o
I
Isoniazid
3 00 mg
Rifampicin
4 50 mg
Pyrazinamide
500 mg
Ethambutol
4 00 mg
2 tab.
1 cap.
3 tab.
3 tab.
Continuation
phase: 4 (HR)
i . e . , isoniazid and
rifampicin three times a week for four months.
For
patients with tuberculous meningitis, disseminated
or spinal disease with neurological complications
isoniazid and rifampicin should be given daily for
6 to 7 months (i.e., a total of 8 to 9 months
therapy).
The weekly blister pack contains the following drugs
administered three times per week with vitamins in the remaining
week days, for self administration:
I
i
Isoniazid 300 mg
Rifampicin 450 mg
2 tab.
i
1 cap.
Two weekly blister packs are given at a time to the
patient for self administration.
On the next collection the
patient should return the empty blisters.
16
[
5.3
Short Course Chemotherapy for picviously treated cases
Category II
These are patients who have received anti tubercular treatment for more than one month in the past
■and—are at an increased risk of developing multi
resistant disease.
These include smear posi
tive relapses and fai1ure cases.
Priority: Highest.
If reliable laboratory facilities are
available, a pretreatment sputum may be obtained for
culture and/susceptibility testing to isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin.
These patients should receive fully supervised treatment
atleast for the first three months.
Those hose sputum
remains positive at three months should continue to re
ceive supervised therapy until sputum conversion is
documented or until they are classified as a chronic
case.
Recommended req inen
o
i
Initial intensive phase: 2 (HRZES)3/1(HRZE)3, i. e.
rifampicin combined with isoniazid, ]pyrazinamide
---- and ethambutol, supplemented with streptomycin for
the first 2 months, ffollowed by the same drugs
without streptomycin for 1 month given three times
a week.
i
The initial intensive phase should be given for 3
months. .The tablets are given in the same type of
blister pack as for the new smear positive cases in
category I.
If the sputum is AFB smear-negative_at
3 months, the continuation phase is started.
If
sputum is smear-positive at 3 months, the 4 oral
drugs are continued for another month.
If the
patient is still smear—positive at the end of the
fourth month and culture facility is available ,
then after stoppage of the drugs for three days,
the sputum should be sent for culture and sensitiv
ity.
The patient should then start the continua
tion phase.
i
o
Continuation phase:5(HRE)3 i.e. 5 months of isoniazid, rifampicin and ethamoutol three
three times
times aa week.
If the patient remains smear-positive after the
completion of continuation phase he/she is no
longer eligible for the retreatment regimen.
I
i
I
i
The drugs are given in weekly blister packs.
Two weekly
packs are
■o given at a time.
rThe
~’
blister pack contains vitamins
on the days when antituberculosis drugs; are not given.
17
The three times weekly dosage of the blister pack
illustrated in the following table:
Isoniazid 300 mg
Rifampicin 450 mg
2 tab.
is
Ethambutol 400 mg
i cap.
3 tab.
Treatment after default
If the patient is smear positive
while returning to treatment then he
is put on a retreatment regimen given
above.
If he is smear negative for
AFB then he should complete the
course of treatment ,ie was on prior
to default.
Chronic cases:
These have to be reviewed by the
Specialist in detail before deciding
on the regimen.
They will have very
poor response to therapy.
r
5.4
Twelve-month regimen for newly diagnosed cases of tuber
culosis who are not selected for SCC or refuse SCC or SCC
——tP—be_ changed due to any other reason eg. drug reac
tion etc.
Isoniazid and thiacetazone are given self adminstered
daily for 12 months.
*
-.
Thiacetazone
should be replaced with ethambutol in case of intolerance.
S'
Ir‘
2
Streptomycin
should be added in
-----------the initial intensive phase for two months
----- in case of pulmonary
sputum positive cases who do not take SCC for any reason
The dosage for adults is one combined tablet of isoniazid
300 mg and thiacetazone 150 mg daily.
The dose for ethambutol is
800 mg per day.
rThe
~*
dose for injection Streptomycin is 0.75 gm.
per day (0.5 gm for■ over 50 years).
Daily doses for children is illustrated
table:
1
i
I
Pretreatment
weight
in the following
Number of tablets
Ethambutol
Thiacetazone
400 mg
50 mg*
Isoniazid
100 mg
Up to 10 kg
0.5 tab.
11 to 20 kg
1
21 to 30 kg
2
1
30 kg and over
3
1.5
0.5 tab.
1
tab.
★ Thiacetazone is always combined with is
niazid.
18
2
3
5.5
Contacts of smear-positive index cases
Any person who has productive cough and who is in contact
with a ssmear-positive index case should have three sputum examinations; as soon as possible for diagnosis and if negative, he
should be followed up three months later.
Children who cannot produce sputum should be examined
with other recommended investigations like chest x-ray and tuber
culin testing.
Children under five years: An unvaccinated contact with
a positive Mantoux test (10 mm or more) is to
be treated as a case if he is symptomatic. If
no signs or symptoms are there then he should
report if they appear.
Infants:If mother is smear positive and child not vacci
nated then give INH chemoprophylaxis for 3
months. After 3 months do a Mantoux test, If
this is negative stop INH and give BCG, if
this positive then continue for 6 months.
!
I
6.
SIDE EFFECTS OF ANTITUBERCULOSIS DRUGS
Side-effects of antituberculosis drugs are of two types:
Major side-effects are those giving rise to serious
health hazards;
I.
Minor side-effects cause only relatively little discom
discom-
fort; they often respond to symptomatic or simple treat
ment but occasionally persist for the duration of drug
treatment.
6.1
Isoniazid
Hepatitis, major side-effect, develops in about 0.5% of
cases.
If jaundice is observed, stop treatment, transfer the
patient to a hospital for further management.
Minor side-effects include: Peripheral neuropathy, Pellagra like syndrome and skin rash.
6.2
Rifampicin
=
u 2®. °f.the Ir,a3or side-effects of rifampicin is hepatitis,
although this is rare. Alcoholism,
pre-existing liver
Alcoholism, pre-existing
liver disease
disease or
the . simultaneous administration
of other
other hepatotoxic
hepatotoxic agents
agents seem
---------- a of
to increase the risk.
The development of jaundice requires
discontinuation of the drug.
19
The other minor side effects include:
- flu syndrome (fever with chills, malaise,
pains) seen more with intermittent therapy.
bone
skin rash
- gastritis
The Respiratory Syndrome with shortness of breath and
collapse and the Hemolytic Syndrome withl renal failure are very
rare
7Immediate stoppage of drugs and hospitalization is
; reguired.
i
6.3
Pyrazinamide
Hepatitis,
6.4
alone.
i
I
joint pains and sometimes gout.
Isoniazid/thiacetazone
Hepatitis, a major side-effect. occurs, as with isoniazid
Cutaneous reactions in
i. patients treated with this
medication
(due
to
thiacetazone)
i Y be more serious than with
. ,
,
.
) IBa
other drugs.
„ .
Exfoliative dermatitis or Stevens-Johnson syndrome
may occur and can be fatal.
Stevens-Johnson syndrome is a spe
cial type of hypersensitivity reactioni characterised
characterised by
by a
a generalised bullous eruption, sometimes haemorrhagic, involving skin
and mucous membranes.
when this occurs, medication should be
^topped, immediately and thiacetazone should never be given again.
Immediate cortico-steroid treatment is indicated; the patient
must be sent without
ithout delay for admission to hospital and
emergency treatment.
Cutaneous reaction of thiacetazone occurs
more frequently and is more severe in HIV-positive patients.
GIT upsets (nausea, ’vomiting, diarrhoea).
’
Symptoms
usually subside if the daily does is divided and given half: in
the morning and half in the evening for a week or so.
Sometimes
antacids are recommended.
6.5
I
i
Ethambutol
Ethambutol may produce impairment of''vision
a decrease
in visual acuity, blurring and red-green colour blindness.
However, ocular toxicity seems to be clearly dose-dependent and
occurs
rarely if 15 or 25 mg/kg body weight are given daily or
30 mg/kg body weight three times weekly.
Every patient receiving ethambutol should be warned that,
if visual symptoms occur, an ocular examination should be undertaken.
Impaired vision usually returns to normal within a few
weeks when the drug is stopped.Because of the risk of undetected
20
i
5
ocular toxicity ethambutol should not be given to children less
than 6 years of age.
6.6
Streptomycin
The main toxic side-effect of streptomycin is vestibular
damage. The risk increases with the dose and age.
The dose is
reduced to 0.5 gms for patients over 50 years of age.
Damage to
the vestibular system usually occurs in the first 2 months and is
manifested by ringing in the ears, giddiness and ataxia. The risk
is particularly high in patients with impaired excretory function
of the kidneys.
Stop the drug if the side effect appears.
Streptomycin should not be used in pregnancy.
I
Hypersensitivity reactions occasionally occur, like a
sue :en onset of fever often accompanied by headache, vomiting and
an irritative erythematous rash. Stop treatment (both streptomy
cin and Thiacetazone) and admit the patient to hospital.
Sterilization of syringes and needles for streptomycin injections
It is mandatory to avoid any transmission of blood-borne
diseases (especially HIV injection) by streptomycin injections.
Recommended procedures for sterilization of needles and syringes
must be strictly
\ enforced.
"
• The Medical Officers and tuberculosis
supervisors need to know proper sterilization practices to be'
able to supervise safe use of injections. Disposable syringe and
needles should be used, if available.
To ensure that transmission of blood borne diseases is
minimal the Streptomycin injection would be given only by gualified personnel.
Sterilization Rules
1.
2.
A health worker must use 1 sterile syringe and 1 sterile
needle for every patient for one injection.
The instruments should be thoroughly cleaned before
sterilizing them.
3.
When using a steam sterilizer, remember:
Heat instruments in the steam from the boiling
water for 15 minutes.
Do not cover instruments within the steam steriliz
er with water.
Do not use it on an open wood fire,
produce enough heat).
(It might not
In high altitudes sterilize the instruments for a
longer period of time.
21
I
4.
When using a boiling pan, remember:
Cover instruments with water.
Boil instruments for 20 minutes.
Keep cover on the pan at all times.
Do not add instruments after boiling starts.
Use instruments within 24 hours.
I
5.
Sterile syringes and sterile needles should be kept in
a
sterile covered container.
6.
Use sterile forceps to take sterile
the sterile-covered container.
7.
When holding a sterile syringe, 1touch only the safe parts
of the syringe i.•e. outside of the
—barrel
-- or the top of
the plunger.
8.
Wash your hands when you come in contact with body fluids
or infected material.
f
7.
I
7.1
i
i
i nst uments out of
PREVENTION OF TUBERCULOSIS
BCG vaccination
BCG is ran attenuated
' ‘
;strain of bovine tubercle bacilli.
It is given by intra-dermal injection
.
1 to non-infected children to
protect them from developing tuberculosis, especially severe
forms of the disease e.g. tuberculous meningitis and miliary
tuberculosis .
possible
glVen tO infants as e^ly in life as
is NT
included
in eKhe
the Expanded Programme on Immunization (EPI) ItThe
PC1fUd^d ln
vacci nat-iln The NTP follows the recommendations of the EPI on the
vaccination.
The dosaae
dosage of th^
the vaccine is 0.1 ml
Complications of vaccination are uncommon,
but include:
subcutaneous abscess at the site of injection.
ulceration at the site of injection.
swe11ing with or without ulceration
of regional
nodes.
systemic complications (very rare).
22
lymph
Treatment of the complications:
subcutaneous abscess and ulceration at the site of injec
tion may only require pain relief with simple analgesics
and cleaning of the ulcer.
A large abscess can be aspi
rated with a syringe and a needle.
Swelling of lymph nodes adjacent to the vaccination si
usually requires no treatment.
8.
8.1
HIV AND TUBERCULOSIS
HIV and AIDS
Infection with human immunodeficiency virus (HIV) leads
to a profound1 destruction of cellular i mmu n i ty.
As a
consequence, those infected become ill from severe,
severe, and often
deadly, diseases to which persons without HIV infection would
V
--- infection
* '
usually not be susceptible.
When
HIV
leads to such socalled ’"opportunistic
’opportunistic” diseases, the affected person is said to
1have "
the acquired
’
’ immunodeficiency
- -- syndrome (AIDS)
(AIDS)..
The interval
between infection with HIV and the onset on AIDS may be several
years.
8.2
Interaction between tuberculosis and HIV infection
Containment of tuberculous infection in an individual is
dependent on the integrity of cellular immunity.
It is not
surprising that HIV infection has emerged as the strongest yet
identified risk factor to allow latent, remotely acquired tuber
culous infection to progress to overt clinical tuberculosis.
It
is therefore common to find that tuberculosis patients are 4 to 6
times more likely to be HIV-seropositive than the general popula
tion.
The life time risk of developing tuberculosis in HIV-TB
infected individual is around 60% instead of 5—10% in persons not
infected with HIV.
Accordingly, in a number of countries with
Pattern II transmission of HIV infection, tuberculosis has in
creased annually from about the mid-1980s onwards.
Although HIV—associated cases may have more frequently
sputum smear-negative pulmonary or extrapuImonary tuberculosis, a
considerable proportion of HIV—associated tuberculosis cases are
sputum smear-positive, highly infectious cases.
HIV infection
thus may increase tuberculosis morbidity in affected countries in
three ways over and above the existing situation:
1.
by reactivation of pre-existing tuberculous infection in
persons who become infected with HIV.
2.
by new infection with tubercle bacilli and direct pro
gression to tuberculosis in persons infected with HIV.
(This is likely to be less important than 1.)
23
3.
additional cases ir the general population whose infec
i nf ec-
tion and disease originates from HIV-positive tuberculous
patients in groups 1 and 2.
a.3
Diagnosis of HIV-associated tuberculosis
Because HIV-associated tuberculosis
------------ may be in forms othfthan sputum smear-positive,z the
the diagnosis
diagnosis might
might be
be more diffiIn addition to the bacteriological examination (which is
still the most important method
of * diagnosis)
the use of x-rays
.
--- ------ ---and high index of clinical suspicion attains a greater than usual
importance for diagnosis.
I
i
I
8.4
Management of HIV—infected tuberculous patients
•urrent information suggests
that response to
chemotherapy is generally good,
However, adverse reactions to
antitubercu1osis drugs appear to be more common in tuberculous
patients with HIV infection,
In particular, thiacetazone
intolerance, including fatal toxic reactionsj to the drug is more
common and the drug should not be used in TB patients with HIV
infection.
Instead ethambutol is to be used,
In HIV-positive
patients who are pulmonary smear negative
negative or extra-puImonary
cases, short-course <'
chemotherapy should be strongly considered
and may be prescribed at the discretion
------1 of the medical officer in
charge,
instead of the 12 month treatment regimen.
The prognosis of HIV-infected tuberculosis patients is good in respect to
tuberculosis, but may be poor in respect to other‘ HIV-related
diseases, and therefore the case fatality rate may be expected to
increase.
8.5
Prevention of HIV transmission in health care settings
Tuberculosis patients in many countries have become the
group with the highest prevalence of HIV infection, high standafds
safetY for health care workers1 and strict adherence to
sterilization procedures^ must therefore be maintained.
Where
needles and syringes are used in the treatment of tuberculosis
(streptomycin injections) it is imperative that every health care
worker be trained to strictly adhere to the principle: 1 sterile
needle and 1 sterile syringe for only 1 patient for only 1 i?'Sec
tion, wherever possible disposable syringes & needles should be
provided.
1
IWorld Health Organisation/International
Council of Nurses,
Guidelines for nursingJ r
management
of people infected with human
immunodeficiency virus (HIV)..
WHO AIDS series 3 . World Hea1th
Organization, Geneva 1988.
' '
■■
World
Health Organisation.
Guidelines on sterilization and
disinfection methods <effective
~
against immunodeficiency virus
(HIV).
WHO AIDS series 2.
2. Worl
2.
r
24
T.B. Div./December,93
TECHNICAL GUIDE
FOR
TUBERCULOSIS CONTROL
Directorate General of Health Services
Nirman Bhavan, New Delhi
1993
CONTENTS
Page
INTRODUCTION
1
1.
2
6
6
8
9
10
10
14
2.
3.
4.
WHAT IS TUBERCULOSIS
1.1
Cause of the disease
1.2
Occurence
1.3
Transmission - Route of infection
Forms of Tuberculosis
1.4
When should Tuberculosis be suspected?
1.5
Health education
1.6
A "case" of Tuberculosis
1.7
Classification of Tuberculosis cases
DIAGNOSIS OF TUBERCULOSIS
2.1
Case-finding methods
2.2
Diagnosis
2.3
Complications of tuberculosis
TUBERCULOSIS LABORATORY SERVICES
3.1
Aim of the bacteriological service
3.2
Smear Examination
3.3
Culture
3.4
Quality Control
3.5
Supervision
GENERAL ASPECTS OF CHEMOTHERAPY
4.1
Drug resistance
4.2
Regularity of chemotherapy
4.3
Duration of chemotherapy
4.4
Procedures during treatment
4.5
Follow-up
*
Flash Cards on TB
Target Group - General Public
.
jd
pale oglin’ b 11 n jxv . . 3 ~ ?:.£ J u
1. A group of village youth
Gdis Mhg’s
:
‘•■•soxJnem d-'. ?pai Jd ; qa duodib
A group of youth are sitting under a tree and talking about
various things.
a bexsdms’nLfe'
A:
Did you hear about Raju getting Tuberculosis?
[ .5 ©vsH bfi
B:
Really?
Poor Raju." How did he get this dreaded disease at
. ....
erfjadnerfhoo
such a young age?
.nXHpe O; d
C:
He smokes a lot and drinks too. That must have caused TB.
flpHcxdJ’ .sieee £l.I ?.•. .
sqooBcrxoxm
D:
He doesn't go to the temple. The Gods must have cursed him.
SfE^rif
SnehJ bod io ea-xno
eeoio.- c- auFj I f
E:
Doesn't he eat lots of potatoes?
. io I. 5 aeXpmf;
iHT •^a.obo prtxXaoia J ' nesoG
F:
People with TB always die. There is no treatment.
live io boD io ea&uo Hdiw ob od prix Hi on a&s
.< -'do S.5BU5O yfiffF Jud v(Iox;a as
8T eatnsp ion eeob pni
___ edl .C .‘:sseaib adoia
2. Masterji approaching the group
3qi.>;-ao7oinr beil^o sesHel iui^ewoq yxav ripLfOxdd ■
The group is confused,
confused. Each person has a different
impression about this common disease, They see the school
teacher walking that way.
tb od pnlop at eH- SHT emi utsH dh/ld w )rvl DC
.sii.
C: Why don't we ask masterji? He should be knowing more
about
the disease.
bean enO .©idsiuo
biuow .eri .boi'xeq beiiupe'i arid xol eenioibem e/Xsl
Othersanu Yes^’Yes. Let us do that.3fl a'r
ediq
HT
xb
tsf> ei ST 1' bsbiovfi sd nso eiriT .sibnl
59
3 . A patient coughing, A healthy man inhaling
Masterji is happy to tell the group about TB.
M:
It is nice that you want to learn about a common disease. TB
is a communicable disease caused by a germ. It is spread by
coughing and sneezing. When a person with TB coughs, sneezes
or spits, the germs are released into the air. These germs on
entering the body of a healthy person can cause the disease
in him.
.Jripin, is i?vccbsxp wc-J.
4.
, b j o I d i: ■ o p ; .f * •’ p n o')
s slideggs io a&od
s n c 3 m o a b n 11 o
That means I can get TB too.
What can I do to avoid getting TB?
1
Coughing with mouth covered
. ■
E:
•dctpi
v
M:
As I mentioned, TB spreads when an infected person coughs or
sneezes.
If the person covers his mouth with a cloth while
coughing, the germs won't be released into the ait”.
E:
I will tell Raju to cover his mouth while coughing or
sneezing.
see od benxmsxe mi/duga exn even .nc
*: ik
: Y*i5Baj=3beh J •'
- §9^ Sidbite d'i' ^riivEri ic
fcrtfe dHsasig
’{ns iBHd
»*icJoob
1
S
£
5.
Spitting into a container with lid. Disposing into a hole
C:
What about spitting?
by spitting.
M:
Good that you remembered.
A person with TB should not spit
indiscriminately. He can spit in a container with some ash or
sand at the bottom. The container should have a lid. The
sputum can be disposed daily by digging a hole amd emptying
the contents of the container into the hole and covering the
hole again.
6.
Bacilli seen through>a microscope
D:
Isn't it due to curse of God then?
C:
He smokes a lot.
M:
TB has/Jnothing to dp with curse of God or evil spirit.
Smoking does not cause TB
as such, but may cause other
dangerous disease like cancer. TB is caused by germs that can
be seen through very powerful lenses called microscope.
7.
TB is curable
F:
Do you know that Raju has
M:
TB is completely curable. One need not die of TB today.
If
Raju takes medicines for the required period, he would be
cured. Inspite of TB being curable, every minute one person
dies of TB in India. This can be avoided if TB is detected
early and the person takes the required treatment.
8.
Symptoms of TB
D:
How can we know if someone has TB ?
M:
A person with TB usually has the following complaints :
You mentioned that it could also spread
Doesn't smoking cause TB?
TB?
He is going to die, isn't he?
Cough for more than one month,
Low grade fever at night,
iii) Chest pain.
iv)
Coughing out blood,
V)
Loss of appetite and weight,
If you find someone with any of the above
complaints, he should be suspected to have TB.
i)
mentioned
9.
Patient being examined by a Doctor
A:
What do we do then ?
M:
The diagnosis of TB can be made by a doctor. He will examine
the person, have his sputum examined to see if the TB germs
are present and may take X-ray if necessary. So it is
necessary that any person suspected of having TB should see a
z** f-t +- -vdoctor.
2
10. Take medicines regularly
B:
Will Raju have to be admitted in the hospital ?
M:
It is not necessary. Raju can take the medicines at home, He
will have to take it as long as the doctor advises. It is
usually upto 6-12 months, depending on the drugs given and
the response of the germs to the drugs. It is very important
to complete the whole course or it will lead to a stronger
germ that will not be easily treatable. So all of
you should
i
ensure that Raju takes the treatment for the complete
duration.
All: Yes we will ask Raju to take medicines regularly.
11. Community bearing part of the expense
C:
But the medicines are usually costly, aren't they ?
M:
Medicines are jslightly expensive.
2
Most of the drugs should be
available at the A
health
' ’ are not available,
1---centre.
-*--- If 7"
they
it
would be a good idea if all of you could1 help Raju in this
regard.
Others:
Yes, we can collect some imoney and help Raju to buy
medicines, After all, Jhis taking medicines is important for
us too. otherwise he will spread At to us.
12. Separate plate and glass for the patient
D:
Does a TB patient have to take any special foods ? Or are any
food products to be avoided ?
M:
There is no restriction on food intake. If possible, Raju
should take vegetables, fruits and milk. If it is not
available or affordable, he can take whatever is being
prepared at home. It will be good if he kept a separate plate
and glass for himself.
13. Collage of previous cards
A:
This means we can help Raju and others with TB.
B:
Yes, we can ask anyone suspected of having TB to attend a
health centre.
C:
We can encourage
duration.
D:
We can even collect some ]money to
‘
buy
not available at the health centre.
E:
We can ask the affected person to cover his mouth while
coughing and sneezing. We can also tell him how to spit in a
container.
him
3
to
take
medicines
for
the
whole
medicines if they are
F:
In this way we can help the patient and prevent ourselves
from getting the disease.
14. Masterji leaving the group
All: Thank you Masterji
M:
for telling us so much about TB.
It is really nice that you learnt about a common disease and
what you can do to control it. TB can be controlled if
everyone contributes his bit. Namaste, I must leave now.
All: Namaste Masterji and thank you.
*****
Please give your comments and suggestions on the script.
Dr.Anil P
pr28061994/
4
N6 4 : 3
f
4
Slide on Tuberculosis
Target Group - Health Workers
1.
A Health worker making house visits
This is the story of Saroja bai, a health worker in a
village of India. She is on her routine visit to houses in
her^village. She is, entering the house of Ram Prasad.
2.
Saroja bai, with the family
Ram Prasad lives in a :small ‘house with *his parents, wife
Radha devi and his children Suresh
—Z_ and Sudha?
----- - "Ramu kaka,
you have become weak and thin" Saroja bai tells Ram "Don't
you eat well now-a-days?"
"Behanji, I do feel tired and have lost interest in work"
replies Ram.
"He has lost interest in food too" chips in Radha devi, his
wife. "He doesn't eat his favourite dishes anymore".
3.
A man coughing
Saroja bai starts thinking - what could be wrong with Ramu
kaka?
"Do you have any other complaints?"
she asks.
"I do cough a lot. I have been coughing out sputum for
almost 2 months now. I have tried a number of medicines but
it just doesn't go. Must be due to the dust. My chest also
pains while coughing".
"Do you cough out blood?"
Saroja bai queries.
"No, No.
There is no blood, Once there was a small streak
ofired in the sputum about 2 weeks back, After that there
has been nothing of that kind".
Saroja bai does some quick thinking. A clearer picture
is
emerging. "Let me ask one more question", she tells herself.
"Do you have fever, especially in the evenings?" she asks.
"Yes, his body is warm at night. He does not have high fever
though", Radha devi added.
4.
4 Pictures- Coughing, Chest pain. Losing weight & Fever
Saroja bai thinks over what she has heard.
Ram Prasad has
been having cough for more than a month with one episode of
red colour in sputum (probably blood), chest pain, fever
more at night, loss of appetite. He is alsq
losing weight.
All these indicate towards
Tuberculosis. But
she can not
1
be sure without getting him examined by a doctor.
2 a-i doctor. Once he
"Ramu kaka, I feel that you should see
to
take medicines as
finds out your disease, you will have
per his advice".
If there is
"I am all right. I don't need to see a doctor,
any medicine you can give me, let me have it".
situation.
"You don't understand the seriousness of the
bit
more
serious
and
Kaki, why don't you tell him to be a 1
take care of himself?".
5.
Saroja explaining to the shocked couple
I hope it is not
Radha:.. i ( "Why, what is wrong with him?
he suffering
is
anything dreadful.
Please tell us what
T..—
from?"
oi j
But
' Saroja: "The disease has to ’bej confirmed by the doctor,
I feel that it could be Tuberculosis".
0 God what did we do to get
Ram & Radha: "Oh no, not TB.
this curse. Our lives are ruined now".
Saroja: "Please try to understand, TB is not due to any
And
curse. It is a communicable disease caused by a germ.
taken
as
advised
TB is completely curable if medicines are
--• •
for'the specified duration.
What is important is that
treatment should start early to prevent its spread to other
members of your family and community .
Ram & Radha: "We shall go with you to the doctor tomorrow"
6)
boctor examining the patient
He
, Ram.
All three of themi visit the doctor who examines
back the next
asks Ram to get his sputum examined and come I--day.
7)
Doctor explaining to the patient
8)
“
TB., You don't have to
Doctor: "Ram, you are suffering from
the
medicines I give you.
worry. TB is curable if you take
2
months
of medication,
You will feel better -after about
You should
stop taking medicines then.
but you shouldn't
i--- have it for the complete duration of treatment".
.
s'-.pn>
Then to Saroja devi he says "You can tell them more about TB
and clear, •theix ^apprehensions" .
r -z
Microscopic view of the Tubercle bacilli
Ram and Radha: "Tell us more about TB’.
Saroja;;> VAs I mentioned earlier, TB is not ai curse of God or
due to fate/..< It is .caused by germs in sputum (shown in the
J.r
J
2
picture)
rPreadS
by Atting and--- coughing. TB kills
about one '"inn
Indian
everv
every minute. Butand
frightened. ndian
AntATdrug^lf
?ave to be
have
Anti TB drugs if taken
prescribed period completely
cures thl h’
3 7 for the
completely
r
the treatment in between
tr
th dlsease. If you ston
between, TB
dangerous form (drug resistant bacteria?^ latSr in
in a
9)
Some Anti TB drugs
Ram: "What are the drugs I win
long?"
have to take and for how
Some^are fS^sV monSs^Xe011^^!^
availab*ecourses of treatment
Tor nine
more than a year. The exact dur-Abi
ne months
^OHths rand some for
i of treatment
But whatever the
whole duration and not leave it in take
b +- medicines
---- ; for
the
The
medicines
Pyrazinamide,
10)
Coughing with mouth covered
Ram: ’’Can I go to work while
on treatment?”
Yes' but you will have to take
care not to spread
coughing6^ snSg. You
^his^wTll cover your
mouth while
This
prevent the germs from
spreading to other people”.
11)
Spitting into a container with a lid
Radha: H What about the family?
Can the children be affected
too?”
Saroja: "Yes, care has to be taken to
see that your children
don't get the disease,
It would be nice if Kaka could sleep
in a separate room or
^y_.fyoin children for the initial 2-3
months, He should cought'into
> la container and cover it with
a lid. The sputum collected should
—-'—.—■J be discarded everyday. ”
12)
Patient taking Medicines
Ram: "Where will I get the drugs from?
the medicines for TB are very expensive.
I understand that
Saroja: "Yes, medicines for TB are a bit expensive. But you
will have to take them. Medicines are usually available at
Govt, hospitals. Even if they are not available,, you should
try and take the medicines.
Radha, you should ensure that
he takes the medicines regularly”.
13)
Patient looking better
Ram Prasad started taking medicines. After £2 months, he was
feeling much better. He didn't cough out sputum,," his fever
3
felt tired and was
eating well
had come down, he. no longer
again.
Saroja encouraging the patient
14)
15)
•’ r and encourages him to
visited Ramprasad regularly
1B=i, Ram didn't want to take all the
Saroja ’
taking
medicines.
Ram
continue
feeling better.
^dlcines since he was
'. You should take
* ’ had warned,
Saroja:
"Remember
what
the
doctor
the
dangerous kind
■ ; "Remember
duration
or -ba
J
.
for
the
whole
<
--the medicines L-later”.
of TB will
1—-- affect you
^2-- . Fam a9reed
the medicines.
duration.
Radha also encouraged Ram to take for the \whole
--and took the medicines regularly
A happy and contended Saroja
Saroja is very
cured of TB today.
significant
Ram has been declared
played
a
very
has
She
knows
that
she
Ram
happy.
early and
<-- encouraging
diagnosing the disease
<—
role in
to complete the treatment.
*****
Please give your comments and suggestions.
Dr. Anil P
4
ths 4 ■ 4
t
TUBERCULOSIS IN CHILDREN — SOME ISSUES
Dr Varinder Singh
Pediatrician,
L.R.S. Institute of Tuberculosis and allied Diseases,
1
Sri Aurobindo Marg, New Delhi 110030.
/
NATIONAL. CONSULTATION ON TUBERCULOSIS
ORGANISED BY VHAI
I
Tuberculosis remains a major health problem in the world, to date
causing 1—2 million deaths annually. Epidemiological data further
indicates that it is more prevalent ,in the younger population.
Childhood tuberculosis contributes significantly to the morbidity
and the mortality of this age group. The prevalence
of
active
disease in the overall population is 15 - 25 per 1,000 population
with about 25% of them being open or infectious cases. Prevalence
of
primary
Nearly
3.4
infection
population
in child
million children
is
also very
high.
in the country have tuberculosis
while 94 million are at risk of infection. In India, 40% of the
children by the age of 6 years and 80% by the age of 16 have
gathered tubercular infection. The annual rate of infection is
about 3% (Table 1).
Table 1
Age Group
ARI
0-4 years
2.8%
5-9 years
4.4%
10-14 years
5.8%
(Tripathy et al 1986)
Childhood tuberculosis is commonly a result of contact with a
tubercular case. A contact study carried out in British Columbia
and Saskatchewan (Canada) in late 1960s and early 1970s (Table 2)
showed
significant risk of developing
active
disease
even
in
casual contacts, risk being highest with a sputum positive case
contact.
1
I
Table 2
Bacteriological status of source
Sputum +
Culture +
C
s
Intimate contacts
No of contacts
% active Ds
549
38
143
15
72
10
Casual contacts
No of contacts
% active Ds
308
23
52
17
24
A child in close contact with a tubercular adult is at a greater
risk
if he also has
or whooping cough
measles
(preventable
communicable diseases also occurring with high incidence in the
country). Further there is enough evidence to show that children
having
primary
infection
are
likely to
go
into progressive
severe disease. Even BCG vaccinated children can develop tubercu
lar disease following infection. Unfortunately there is a narrow
difference between infection and disease in very young children
who incidentally are also at a higher risk to develop severe
disseminated
form of the disease. About 10
dren
with
infected
tubercular
bacilli
15 % of the chil-
develop
disease
and
a
similar percentage of those with disease are infectious. Nearly 4
- 10% of the deaths in children are related to tuberculosis.
Diagnosis of Childhood Tuberculosis
There is no gold standard for the diagnosis of tuberculosis in
children in the absence of significant sputum or gastric aspirate
positivity.
This
problem is
further
compounded
by the
master
mimicker nature of the disease, which can involve any part of the
2
body. Diagnosis of tuberculosis in children is primarily based on
- Clinical history and Examination,
- Family or contact history,
- Immunization status.
- Radiological findings.
- PPD test,
- Sputum / GA for AFB,
- FNAC / Biopsy
Tuberculosis
even
though being
a
common
disease
yet
poses
a
problem for definitive diagnosis. More often than not the diagno
sis is based on indirect evidence. Symptomatology of the disease
is
often
vague
general
illhealth
and
failure
to thrive.
The
diagnosis may be further confounded by other childhood problems
of repeated chest infections, back to back viral
infections,
cough variant asthma, etc. all presenting as chronic
cough.
Similarly
physiological
hyperplasia
of
the
lymphnodes
may
be
misdiagnosed as tubercular on the basis of concomitant PPD posi
tivity. Diagnosis of primary pulmonary complex is also difficult
and often soft fluffy shadows in a little under penetrated expi
ratory film are wrongly labeled as PPG.
Tuberculin positivity
though actually a mere index of infection, is frequently used as
an evidence of disease in the presence of other features. Tuber-
culin test, however, can be negative in a significant proportion
of proven tubercular cases (Table 3) due to a variety of factors
like
severe malnutrition. measles, immunosuppression or milliary
tuberculosis.
Table 3.
3
Hogj-tivity in Proven Cases Qf Tuberculosis
Types
% Positivity
Ramchandran et. al. (1971)
All
60
Choudhury et. al.
(1971)
All
46
Udani et. al.
(1971)
All
73
Udani et. al.
(1974)
Miliary
38
Bhave et. al.
(1977)
TBM
39
Agarwal et. al.
(1979)
All
51
BCG vaccination and its relationship to PPD positivity has
been
another area of confusion. Mean size of induration
in vaccinated
children between 3 mo to 3 years of age in vaccinated children is
between 5.1 - 8.9 mm compared to 3.5 - 6.5 mm in
non vaccinated
group. About 25% of children have reaction
between 10
16 mm
just 3 months after vaccination. A positive
tuberculin test
should not be ascribed to BCG because the skin reaction conver-
sion in vaccinated children is < 100 %, the mean reaction is < 10
mm and the tuberculin sensitivity tends to wane with time.
There has been a tendency on the part of the clinicians to treat
children with strongly positive PPD reaction. Tuberculin reaction
is merely an index of infection, the degree of its positivity and
local ulceration are no indication of an active disease. Some of
the studies have however suggested that stronger reactions may be
associated with higher risk of developing disease later on (Groth
Peterson 1959, Heath 1959). The relationship between tuberculin
reaction and the size of infective inoculum is not well estab-
4
lished and at present there is little evidence to suggest treat
ment of such strongly positive individuals.
There is a distinct group of tuberculin positive individuals who
need to be given chemoprophylaxis as they are at a higher risk of
developing the disease e.g.
any child on immunosuppressive drugs
or severely malnourished child below 3 years, a recent converter,
child with measles or whooping cough, child below 2 years of age
in contact with a sputum positive individual irrespective of his
nutritional status.
In the absence of any consensus or definitive method of conclusively diagnosing tuberculosis in most children certain scoring
systems (Table 4) have been devised for diagnosing tuberculosis.
However
these
scores
isolation which is
heavily weigh
towards
or
AFB
frequently not possible due
granuloma
either to
the
nature of the disease or due to operational difficulties. These
can at best be used as a research tool.
Table 4
Scoring System for the Diagnosis of Tuberculosis
Stegen et al
AFB seen
Tubercle
PPD positive
Suggestive Xray
Compatible Signs
Sput 4- in family
Age < 2 years
Nonspecific S/s
Nonspecific Xray
BCG in last 2 yrs
+3
+3
+3
Nair et al
4-5
4-5
4-3
4-3
4-3
4-2
+1
4-1
4-1
+2
4-1
4-2
4-1
4-1
-1
Score >= 7 TB Certainf
Score 5-6 Probable TB
5
Seth V
4-5
4-5
4-3
4-3
4-3
4-2
4-1
4-1
4-1
Treatment of Childh;
Tuberculosis
Short course chemotherapy in children has as yet not been fully
evaluated. The existing data though encouraging has shown certain
shortcomings like partial clearance of pulmonary lesion radiologically or need for extended therapy in children with lymphnode TB
(Varudkar 1985).
The controversy regarding correct dose of INH (5mg/kg vs lOmg/kg)
is still continuing. The. newer studies have shown the lower dose
to be as efficacious with advantage of lesser side effects par-
the cumulative hepatotoxicty of the various combina-
tions presently in use. There is an increasing load of multidrug
resistance cases in children and the need for developing treatment modalities for such cases atleast in the tertiary centres.
The parental attitudes towards the disease and its treatment are
the major limiting factors in completion of therapy.
The rarity
of the horrifying symptoms such as hemoptysis
delays the utili-
sation of proper health facilities.
National Tuberculosis Program and Childhood Tuberculosis
Under the revised strategy of National Tuberculosis Program there
is a focussed emphasis on the management of the sputum positive
cases so as to decrease the pool of infectious cases as a strate
gy to decrease the tubercular transmission. This strategy, though
very sound, doles out a poor deal to children as most of them can
not produce sputum.
The short term therapy as planned under the
program for the tubercular lymphadenopathy may not be sufficient
in the light of existing experience.
6
The
various
areas
requiring
special
effort
and
strategies as they emerge today for the control
operational
of childhood
tuberculosis are:
i)
Study of prevalence and risk of infection in the country.
particularly the
baseline estimates
in the
areas of
planned
intensification.
ii) Estimates of ARI and prevalence in the under privileged and
vulnerable sections like urban slums.
iii) Increased emphasis on tuberculosis in the medical curricu
lum,
iv) Training and inservice orientation programmes,
v) Evaluation of short course chemotherapy and multi drug formulations,
vi) Treatment modalities for drug resistance cases,
vii) IEC
to understand parental attitudes and knowledge and also
to identify the barriers to treatment.
7
LE FIGARO
premier quotidien national franc^ais
A XX MARDI 6 JUIN 1W5(N° 15 799) - tOTION DE 5 HEURES - PRIX : 6,00 FRANCS
MEDECINE
Le constat de catastrophe de I’OMS
La tuberculose dopee
par I’epidemie de sida
Les souches de bacille resistantes aux medicaments les plus courants se multiplient
et I’explosion de la maladie estfarorisee par la multiplication des cas d’infection par le HIV.
L ’infectionprogresse actuellement au rythme d’un nouveau Caspar seconde.
■k
I
t
4
GENEVE:
Laurent MOSSU
« Le probldme de la tuber
culose n'est plus maitrisd. •>
Selon le Dr Paul Nunn, chef de
la recherche au programme
mondial de lutte centre cette
maladie & I'Organisation mon
diale de la santd (OMS), la si
tuation va s’aggravant. Renforc6e par I'dpiddmie de sida, la
tuberculose reprbsente, b ses
yeux, une menace toujours
plus forte, notamment en rai
son des negligences dont on a
fait preuve dans le passd.
L'OMS, qui s'efforce depuis
plus de deux ans d'alerter et
de mobiliser les gouvernements, avail rassembld la semaine dernidre a son sidge de
Genbve des experts des deux
infections, les appelant a ddfinir une nouvelle stratdgie de
recherche. II importe, selon
I'institution, de determiner les
principales activitds de re
cherche et les mesures susceptibles d’amdliorer la lutte
antituberculose dans les zones
ou I’infection a HIV est majeure
ou en progression.
Dans I’air ambiant
L'urgence n'est plus discutable. La tuberculosa est devenue la principale cause de d6ces chez les sdropositifs. Et,
pour I’OMS, la menace d'une
tuberculose incurable se pr6cise. Alors que des pro
grammes inefficaces de lutte
favorisent la propagation de
souches de bacille phatmacordsistantes, le moment n'est
pas loin, craint I’OMS, oil,
faute de reactions, on se trouvera & nouveau sans traitement, & part I'isolement des
malades dans des sanato
riums.
La tuberculose (era 30 mil
lions de victimes au cours de
la prochaine ddcennie. Elie
frappera 90 millions de personnes, et des centaines de
millions d’autres rejoindront le
1,9 milliard d’individus infectds.
Pour I’OMS, les perspectives
sont claires. Faute d’une campagne mondiale de grande envergure que le monde a
jusqu'ici hesitd & entreprendre.
les chiffres augmenteront au
siecle prochain ; et, si les ma
lades contagieux ne sont pas
gudris, I’infection continuera de
progresser au rythme d’un cas
par seconde.
Les chercheurs estiment
ddsormais que 50 <1 100 mil
lions de personnes pourraient
etre infectdes par une forme
de tuberculose rdsistante 4 un
ou ptusieurs des medicaments
courants. Une dtude mende
en 1991 dans la ville de New
York a rbvdle qu’un tiers au
moins des malades etaient tou
La tuberculose fera 30 millions de victimes au cours de la prochaine decennie. (Photo Vogel/Reuter.)
ches par une forme pharmacor6sistante. Et 5 % d’entre eux
I’avait ddveloppde A I'encontre
de six voire sept medicaments.
D’ici le tournant du eidcle,
un tiers environ des ddcds des
seropositifs au virus du sida
seront dus a la tuberculose.
Certaines statistiques font
d’ores et ddje 6tat de pourcentages supdrieurs. Ainsi, a Abid
jan, on estime a 32 % la pro
portion des cas de sida morts
par tuberculose. C’est desormais en Asie que le HIV se
propage avec la plus grande
rapiditd. Dans cette region du
monde, I’infection par le bacille
tuberculeux est encore plus r6pandue qu'en Afrique.
Diagnostic
plus difficile
Le germe de la tuberculose
est transmis dans I’air ambiant
par une personne qui tousse
ou meme a la faveur d’une
simple conversation. II est ma
nifesto que les HIV-positifs risquent davantage d'Atre infectes par I’inhalation. Et I’OMS a
pu dtablir que le risque de tubercufose evolutive est 30 fois
plus 6lev6 chez les sujets infectes par la tuberculose et le
HIV que chez les sujets tou
ches par le seul bacille tuber
culeux.
II y aura a I'avenir, dit
I’OMS. davantage de porteurs
et de propagateurs du germe
de la tuberculose dans les po
pulations auparavant non
contamindes. II suffit pour s en
convaincre de constater que le
nombre accru de cas de conta
mination par le virus du sida
entraine une augmentation des
tuberculoses infectieuses.
Cette situation est d’autant
plus alarmante que la pre
sence du HIV rend le diagnos
tic de la tuberculose beaucoup
plus difficile a dtablir. Et I'expdrience montre. de plus, que les
sdropositifs font souvent un
test ndgatif pour la tubercu
lose, alors qu'ils sont bel et
bien atteints par la maladie.
Pour le Dr Nunn, les activitds actuelles de recherches
sont bien souvent trds dloigndes des prioritds actuelles.
« On alloue des fonds d des
projets qui n'auront aucune efficacite ou utility pratique. On
privilegie des travaux qui ne le
meritent pas en saenfiant ceux
qui devraient etre soutenus. Ainsi. dit-il. les bailleurs de
fonds ont-ils contribud a financer des activitds de recherches
biombdicales dtroitement ciblees. Elies n'auront gudre
d’utilitd pratique dans la lutte
centre la co-6pidemie de sidatuberculose.
Le groupe d'experts a, dans
ses conclusions, trace la route
4 suivre. II prdne la reconnais
sance de cinq actions prioritaires : 1) amdliorer le diagnos
tic et le traitement de la
tuberculose chez les sujets in-
fectes par le HIV . 2) evaluer le
rdle et la ndcessitd d’un traite
ment antituberculeux chez les
populations vulnerables ; 3) coordonner et intdgrer les activitds de recherche menees par
les services charges de la tu
berculose et ceux du HIV au ni
veau du district dans les zones
a forte prevalence de sida. no
tamment en mettant I’accent
sur le role du secteur priv6 ; 4)
explorer les obstacles empechant les tuberculeux de demander des soins ou de conti
nuer e se faire soigner dans les
zones a forte prevalence de
HIV ; 5) entreprendre une
dtude critique des ddpenses
actuelles de lutte antituberculeuse dans les communautes
durement touchdes par le sida.
Ces orientations devraient
nous aider a eviter une catas
trophe plus grande encore,
note le Dr Arata Kochi, responsable du programme tubercu
lose de I’OMS. Tous les partici
pants ont par
ailleurs
longuement souligne que les
pays en ddveloppement
n'etaient pas les seuls concernes par cette evolution catastrophique.
<• Avec le developpement
des transports modernes et de
I'immigration et la progression
de I'epidemie d'infection a HIV,
la tuberculose a retrouve une
tete de pont importante dans le
monde industrialise. »
LM.
I
i
U ork
SUNDAY, JUNE 4, 1995
8
AIDS and Tuberculosis Epidemics Rise in Deadly Combination
By WARREN LEARY
WASHINGTON, June 3 — Tuber
culosis has become the leading
cause of death worldwide among
people Infected with the virus that
causes AIDS, the World Health Or
ganization says.
International health officials met
last week In Geneva to determine
how to cope with the growing threat
of the deadly combination of AIDS
and tuberculosis. They said that the
dual epidemics are not only causing
more deaths, but that they also are
undermining efforts to control each
of the diseases.
As the incidence of infection with
the virus that causes AIDS,
rises in Asia and other parts of the
world where tuberculosis is com
mon, the highly contagious lung dis
ease will take an even greater toll on
people whose protective immune
systems have been weakened by
the officials said Friday. By
the end of the decade, they said,
about one-third of all deaths among
H.I.V.-infected people will result
from tuberculosis.
“Because of past neglect in diag
nosing and treating tuberculosis, the
disease Is out of control in many
parts of the world,” Dr. Paul Nunn,
Participants at the W.H.O. meet
chief of research for the W.H.O.
Global Tuberculosis Program, said ing called for more cooperation be
in a telephone interview. “Now the tween H.I.V. and tuberculosis re
H.I.V. epidemic has made tuberculo search programs*as well as more
sis an even greater menace, includ studies on how to improve the diag
ing reversing many of the gains we nosis and treatment of tuberculosis
had made against tuberculosis over in H.I.V.-infected people.
Tuberculosis Is a bacterial disease
the years.”
The presence of H.I.V. Infection transmitted through the air. Those
also makes diagnosing tuberculosis infected with the tubercle bacillus,
harder, he said. H.I.V.-infected peo which produces symptoms that in
ple often falsely register negative clude fever and violent coughing,
for tuberculosis with common tests can spread the germ to others
that require an immune response, through sneezing, coughing or even
resulting in delayed treatment and talking. The disease, in active or
increased chances of passing the . latent form, infects hundreds of mil
lions worldwide and kills three mil
lung disease on to others.
lion people a year, health officials
say.
An estimated 16 million people
worldwide are Infected with H.I.V.,
including about 10 to 12 million peo
ple in Africa and up to 1 million in
the United States, Dr. Nunn said.
Those infected with the virus be
come increasingly susceptible to dis
eases like tuberculosis that prey on
weakened immune systems.
The diseases that exact the greatest toll among H.I.V.-infected people
vary from country to country, ex
perts said. Tuberculosis is the major
killer In Africa, where it Is responsi
ble for the deaths of about 40 percent
of those infected with H.I.V. In the
United States, where tuberculosis
also is on the rise among those who
are H.I.V.-positive, the major killers
are pneumonia and kaposi's sarco
ma, a cancer.
The United States Centers for Dis
ease Control and Prevention re
leased^ report last week that said
there were 24,361 new cases of tuber
culosis in the United States in 1994,
down 3.7 percent from 1993. This was
the second year of a decline follow
ing an eight-year surge from 1985 to
1992, when new tuberculosis cases
rose 20 percent.
The increase has been blamed on
cutbacks In control programs, in
creased immigration from countries
where tuberculosis is prevalent, the
emergence of drug-resistant strains
of the tuberculosis bacteria and the
rise of AIDS.
Press Release WHO/43
Page 2
TB germs are transmitted through the air, spreading from person-to-person through coughing,
sneezing or even talking. As the disease progresses it is characterized by fever, weight loss and violent
coughing which effectively disperses the bacteria to infect surrounding individuals. People who are HIV
positive are probably more likely to be infected with TB than people who are HIV-negative when inhaling
TB germs. And people who are co-infected with TB and HIV are 30 times more likely to become sick with
TB than people infected only with TB. Because increased HIV cases result in increased cases of infectious
TB, larger numbers of people will carry—and spread—this germ to previously healthy populations.
Additionally, the presence of HIV also makes diagnosis of TB much more difficult. People who are HIV
positive often falsely test negative for TB, even though they are ill with the disease.
K
"As a result of past neglect, TB has already spiralled out of control," said Dr Paul Nunn, Chief of
Research for the WHO Global TB Programme. "But today, fuelled by the HIV epidemic, TB represents an
even larger menace. That is why it is vital that today's narrow TB research agenda be broadened to reflect
the complications caused by HIV/TB infection."
Nunn believes that around the world much current research does not come close to reflecting today's
priorities. "Money is being wasted on projects that will be neither practical nor effective," he said. "There
is widespread misallocation as well as underfunding. For example, donors have continued to fund narrowlydefined biomedical research that will simply be too costly to be practical in battling the HIV/TB co
epidemic."
To address this situation, the Global TB Programme is seeking a new partnership with leading
scientists and academics from the TB and AIDS communities to help communicate these priorities to leading
agencies.
"It is vital that TB and HIV programmes work together in research efforts. This interaction would
greatly benefit everyone involved," said Dr Hans Moerkerk of the Netherlands’ Ministry of Welfare and
Chairperson for the WHO research meeting.
The group agreed upon a set of the most pressing research needs surrounding the HIV/TB co
epidemic. These are to: 1) improve diagnosis and treatment of TB in HIV-infected individuals, 2) assess
the role of and need for preventive TB therapy for vulnerable populations, 3) research coordination and
integration of TB services with HIV services at the district level in areas of high HIV prevalence, including
emphasis on the role of the private sector, 4) explore the barriers which impede TB patients from seeking
and continuing care in high HIV prevalence areas, and 5) conduct a critical study of current expenditures for
TB control in communities badly effected by HIV.
"These research priorities will hopefully help us avoid an even worse TB catastrophe in the future,"
said Dr Kochi. "We already know that directly observed treatment, short-course (DOTS) cures TB," he
continued. "DOTS is inexpensive, and it works. But the numerous barriers to proper treatment of HIV
positive people must be addressed."
Consensus existed in the group that there is still limited time to take action. With correct research
priorities, progress can be made towards lessening the devastating impact of the HIV/TB co-epidemic,
especially in Asia where the problem is multiplying.
For further information, contact Mr Kraig Klaudt, WHO Global TB Programme, Geneva, telephone (4122)
791 4627.
I
M 4'
World
Health
Organization
e
Pr
1211 Geneva 27 Switzerland • Telephone: 791 2111 • Cables: UNISANTE-GENEVA • Telex: 415 416 • Fax: 791 0746
Press Release WHO/43
2 June 1995
TB HAS BECOME WORLD’S LEADING KILLER OF HIV-POSITIVE PEOPLE
Medical Community Ill-Prepared to Cope with Rising Threat
Tuberculosis is the leading killer of HIV-positive individuals on a global scale. Health programmes
are currently ill-prepared to tackle the crisis. In response, a special meeting of AIDS and TB research experts
was convened this week by the World Health Organization's Global Tuberculosis Programme to identify the
most relevant research and action to improve TB control in areas where HIV infection is prevalent or
increasing.
"The HIV/TB dual epidemic is undermining efforts to control TB," warned Dr Arata Kochi, Director
of WHO's Global TB Programme. "As the incidence of HIV rises in Asia, tuberculosis will take a deadly toll
on those dually infected, killing almost one-third of HIV-positive people, and infecting many of their contacts
with TB including those who are HIV-negative. Appropriate research and action are urgently needed to
tackle this problem."
The Global Tuberculosis Programme, in cooperation with the Global Programme on AIDS, is
mobilizing medical experts from industrial and low-income countries to develop a new HIV/TB research
strategy. This strategy will seek to improve TB control programmes already disabled by growing HIV
prevalence and to prevent devastation of TB programmes in countries with a newly emergent HIV problem.
The new Joint UN Programme on AIDS (UNAIDS), which will become operational in January 1996, intends
to further cooperate with the Global TB Programme.
By the end of the decade, around one-third of all deaths among HIV-positive people will result from
TB, according to Global TB Programme estimates. In Abidjan, for example, 32 percent of AIDS cases were
considered to have died from TB. HIV is now spreading most rapidly in Asia where TB infection is even
more widespread than in Africa.
"The co-epidemic complicates efforts to care for AIDS patients and to identify and treat TB patients,"
said Dr Anthony Harries, a physician at Queen Elizabeth Central Hospital in Blantyre, Malawi. "Health
workers are having to deal with ever-increasing caseloads of patients with HIV and TB, and are struggling
to manage their programmes while limited by a shortage of manpower and funds, and hampered by a lack
of appropriate technology."
♦
—.
HEALTH
1
■
11 BI RCl I (ISIS
|
t j
Raising
Hopes
of a New
Cure
[■ I
kx.
I
I
Pilot TB-control projects run along WHO guidelines report
significant success. But can they be replicated nationwide?
By ARtIN SUBRA.MANI/\M
w
sr
st
iy.
all
1
3
fe:
w
I,L along, the news has been
grim. With 16 million cases.
India accounts for almost
half of the world's burden of
pulmonary tuberculosis. Every year.
5.00.()()() die of the disease. The na
tional TB-control programme has
proved largely ineffective, unable to
check the spread of the disease. On an
average, barely 35 per cent of patients
get cured while unequal number get in
fected each year. Last fortnight, how
ever, there appeared a glimmer of hope.
Significant successes were re
ported in five pilot TB-control projects
covering 2.35 million people in Delhi.
Bombay, Calcutta, Bangalore and
Mehsana in Gujarat. These projects,
initiated in 199 3 under a new strategy
recommended by the World Health Or
ganisation (who), have been able to
cure 83 per cent of the patients. And
according to Rohit Sarin, national con
sultant onTB-control with the Centre’s
Directorate of Health Services, after
just two months of treatment, 95 per
cent of sputum-positive cases—those
in a highly infectious state of the dis
ease—had turned sputum-negative.
The who strategy is simple but a
radical break from traditional methods
of treatment: instead of relying on the
patient to take the right dose of the
right medicine, who recommended
that health workers directly administer
the drugs. The strategy, called dots (Di
rectly Observed Treatment short
course), which refers to a six-month
regimen of chemotherapy, has proved
successful in countries as diverse as
Tanzania and the US.
"
Encouraged by the success, the Gov
ernment has sought World Bank help
to extend the pilot programme to cover
15 project sites in 10 cities and five states.
i :
■x't;
Radiological evidence is often misleading
which does not have any measureable
impact and which appears to function
far below its potential." The major rea
son for the ntp’s failure, the review con
cluded. was its confusion over priorities:
the ntp has been detecting cases and
then treating them when it should have
given priority to treating the most infec
tious (sputum-positive) cases.
There were other drawbacks as well.
Although microscopic examination of
sputum is the recognised technique to
diagnose TB. enormous resources were
being squandered treating cases diag
nosed on clinical and radiological evi
dence. Result: many respiratory disor
ders
have
been
wrongly diagnosed as
TB. Worse, treatment
based on a misdiagno
sis of the stage of the
disease led to the development of drug-resistant strains of the
bacteria. The programme has also been
critically underfunded. Drugs for treat
ing the 3.4 million infectious cases—at
Rs 500 for each patient—cost Rs 170
crore, but the ntp was provided less than
1 per cent of that.
The review team suggested a shift in
the ntp’s emphasis from case detection
to what it called treatment completion.
Also, it recommended improvement in
diagnosis, adoption of six-month,
short-course chemotherapy, better
Successful pilot projects highlight
the limitations in the Government’s
three-decade-old TB-control policy.
covering a population of 14 million. But
can the WHO strategy be replicated na
tionwide with the same success?
There are no definite answers yet.
What's clear is that the success of the pi
lot projects has highlighted the limita
tions in the Government’s three-decadeold National Tuberculosis Control
Programme (ntp) . In September 19 92, a
review of ntp by a government and who
team had recognised its shortcomings.
“Recent trends'are discouraging,” the
review said, "indicating a programme
a
.
■
■■
OCTOBER 15. 1%5 ♦ INDIA TODAY
111
—
HEALTH
monitoring of patients and an uninter
rupted supply of drugs. Much of this has
been implemented in the pilot projects.
But can these methods be extended
to every clinic and health centre dealing
withTB? Quite unlikely. For one, almost
50 per cent of allTB cases are treated by
private practitioners who employ a va
riety of treatment methods. A survey of
102 practitioners in Bombay found as
manding". Experts say that not only
does dots appear impractical for a
highly scattered rural population, it
also requires financial, technical and
manpower support on a scale far be
yond what the ntp—with an annual
budget of about Rs 50 crore—can offer.
The Government has sought a $ 2 00
million loan from the World Bank to
fund the revised ntp over the next five
unique programme in the backward
and drought-prone district of Banaskantha in Gujarat. Started in 1984
and run by the Bhansali Trust, the TBcontrol programme now has 1,800 pa
tients and has achieved who targets at a
fraction of the cost. Over 80 per cent of
the patients go through the entire
course of treatment, a figure perhaps
unmatched anywhere else in rural In
dia. How? Primarily be
cause it has been able to
raise awareness and
greatly involve health
care workers.
In Banskantha, over SO per cent of the
patients undergo the entire treatment,
a figure unmatched in rural India.
I
| '^or instance, it gets
1—4 referrals from forJL mer patients and anganwadi workers of the
Central Government’s In
tegrated Child Develop
ment Scheme, who are
paid Rs 15 for every case
detected. A villageTB reg
ister is maintained by the
unganwadi worker who
visits patients regularly.
Before treatment begins,
l
t
workers visit the family to
explain the importance of
A patient at the BhansaliTrust clinic: benefiting from awareness and health workers’ involvement
its completion. Whenever
a patient fails to collect the
REVISIONS IN CENTRE’S TB-CQNTROL PROGRAMME
drugs, the anganwudi
THEN
NOW
worker is informed and
OBJECTIVES
one of the Trust's 20 TB
•J
Case detection & treatment
Case holding & cure, priority
workers visits the patient
to infectious cases
for counselling.
Uplekar attributes
... . .
. ..DIAGNOSIS ’ ...
this success to the trust’s
Clinical and X-ray. minimal use of
Sputum microscopy backed
high credibility—it has
sputum microscopy
by X-ray
served the community for
: treatment
s.
several years—and to theShort course for infectious cases,
Six-month. multi-drug therapy
fact that all patients are di
one year multi-drug therapy
(short course) for all
agnosed using both spu
DRUG ADMINISTRATION
tum microscopy and chest
Left to patient
Supervised by health worker
X-ray. The latter is an im
portant psychological aid
as patients appear to have
\
.
RECORDS
.
great faith in it. something
Focus on targets
Focus on treatment results
that the n it's revised strat
J® . .
.^^ORGANISATION
. '■
egy doesn't appreciate.
District TB centre and general
; Additional medical officer and laboratory
But perhaps the pro
health workers
supervisor at sub-district level and
gramme's greatest stren
i decentralised treatment in community
gth lies in its novel mode of
MANAGEMENT
educating and motivating
Assistant DG. Health Services (TB)
Deputy DG+4 Assistant DGs+
patients, their peers and
Consultants
their families. This does
away with the need to ad
many as 80 different drug regimens be years. But as Sarin points out. that’s minister the drugs under supervision as
ing prescribed. But equally, the efficacy barely sufficient to cover 20 per cent of advocated by the revised ntp, thus saving
of dots on a wider scale is open to ques allTB cases. Moreover, some experts fear on money and manpower. As trustee
tion. According to M.W. Uplekar, re that overemphasis on DOI'S will drain re Ashok Bhansali sums it up. "Banaskansearch consultant at Bombay’s Foun sources from alternative, less expensive, tha might be one of the most illiterate dis
tricts in the country, but we’re highly ed
dation for Research in Community local strategies forTB control.
One such strategy is evident in a ucated as far as TB is concerned."
■
Health, dots is "operationally more de-
rnnaa
5/FP/069
OCTOBER 15. 1995 ♦ INDIA TODAY
113
I
tyis 4 '-7
'W
M
Rapid Assessment TB
Data Collection Guidelines
Dr.W.Dechering, Femconsult,
The Hague. Netherlands
/
1
Data Collection Guidelines Rapid Assessment TB
Dr.W’.Dechering, Femconsult
Objectives of the TB study
The project will have two components with the following objectives:
1. To earn' out a social assessment in selected area of urban slums. This will entail identifying, in
conjunction with the research institutes, the incidence of symptomatic cases (potential project
beneficiaries) in selected urban centers with a focus on slum areas in the cities of bangalore, Pune,
Jaipur, Lucknow and Hyderabad; the availability and the quality of services for TB treatment, the
individuals ’perceptions and attitudes towards TB, their understanding of the disease and its
curability, their health seeking behavior, and the availability and utilization of health services for TB
treatment, the studies should take into account gender differences, socio-economic status and other
relevant demographic and social factors.
Specifically, the studies would involve:
a) Identifying two or more urban areas of different characteristics, including slums, in each of the
five cities and develop a sampling procedure to obtain representative populations from each area.
b) Identifying symptomatic patients (i.e. patients with productive cough for more than two weeks)and
obtaining information on their perceptions and interpretations of the symptoms, knowledge of causes,
transmission and cure of TB, attitudes towards TB and health seeking behavior of individuals who
become symptomatic with special attention to gender differences.
c) Identifying individuals who have been treated for TB to determine if, when and where they sought
treatment, type and duration of treatment, expenence with health providers and current health status.
d) Determining the current distribution, capacity and accessibility of health facilities in the study area
and Identifying the referral sytems at work, if any. This would involve obtaining information on the
knowledge, attitudes and perceptions of health staff regarding TB and TB patients.
e) Assessing the bcneficaries’ utilization of existing public health care facilities( public, private and
those run by non-governmental organizations (NGO’s), traditional healers and other health care
providers when they become symptomatic by following up through exit interviews with users of
selected health facilities.
f) Determining the reasons for failure to complete treatment by reviewing the records of defaulters
’from healtlrinstitutions and following up with them at their home or workplace.
The most important goal of this study is to come up with ideas on TEC!. What is the
information people use; rely on; what decision is based on what information; what are the
information channels (friend; neighbour; health worker; radio; tv; newspaper; pamphlet,etc.)
How is the communication between doctor and patient? How between health staff and patient?
In all these situations that are part of this study, make always a in depth study how information
is used and what communication has taken place.
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
2
f
I
>
Data collection guides
Emic approach to TB and related concepts
method : interview/conversation
City:
Slum area:
Household (identification):
Informant(s):
Date of interview:
Education: number of years
Ethnic group:
Language:
Ofcc p ft U t>
H (. o r\A
What names do people use for cold/cough/bronchitis/pneumonia/wheeze/whooping cough/etc.?
X
a A-1
■=’Make a list like:
KSHAYA Rt)G (Maharati + Hindi A
KHAY ROG = rural maharati slang
p VoA < _
RAJ Yakshma = upper class
BAD BIMARI (Hindi). j'/’e-o'A A/’ A 7^.
CHOOTH KI BIMARI (used for leprosy /TB both)
TAPEDIC
Ask what the relation is between the terms. Is A related to B and how?
E.g. is bronchitis a form of pneumonia? Is cold more serious than bronchitis?
Ask the people to describe symptoms of the terms or other relevant characteristics.
When we do some of these interviews, we gather information on the beliefs that people have on TB.^
Once these are known we can make use of them in a more systematic way by making belief
frames.We can make-up a list of belief frames.
For example :
(name of disease) can you get from other people.
...(name of disease) is transmitted by air
...(name of disease) is transmitted by food
...(name of disease) is transmitted by sex.
The informant is asked whether a belief is correct or not:
- Utensils or cloths of patients with TB have to be kept separated.
Correct: yes/no
- TB is curable. Correct: yes/no
- If you feel better, can you stop the treatment? Correct: yes/no
Among the beliefs check these opinions:
- TB can be treated in 3 months/6 months/9 months/12 months/18 months?
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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- Drugs from TB clinics are different than the drugs from the private doctors?.In what sense?
- A person with TB has to be avoided (stigma)
- TB destroys the chance of marriage for a girl.
Perceived gravity or seriousness of each illness
Appropriate remedies or treatments inclusive home remedies
^Expenses associated with treatment (Sample hypothetical questions: "What would you do?
would you do if you had more money?"
What
What can be (is,was) done to prevent each illness?
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechenng, Femconsult
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r
i
Slum Selection
selection of two areas:
One area where the people have been living for a
longer time; where they experience a sense of security and start investing in their houses, where they
have a good knowledge about the health institutions available; where there is some regularity of
work.
The second area is more characterised by recent settlements: people have not regular income; lack of
basic amenities; probably low level of knowledge of health institutions.
A map must be made for the area: on the map the doctors, dispensaries, govt, institutionshave to be
indicated. Also the shop with medicines against a cold; and the pharmacies.
Housing characteristics.
For all interviews that take place in the slum we want to check for the different characteristics of the
building material for the house.
The following checklist give some ideas:
walls/roof
wattle/matting with and without mud
jute cloth
plastic
mudbrick/stone
raw brick
plaster of joints
plastered
tin sheet/asbestos sheet
cement
doors
cloth
wattle/mat
tin sheet
wood
floor
rough ground
smoothed earth
stone/bricks rough or fitted
cement
-—number of floors: 1,2 storey
Washing space
token wall-rag
frame wattle'
wall
wattle/matting
mud brick
cement
road patu
mud
packed earth/drain ditches or not
brick
stone
C^Data' Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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cement
- What is the area in square feet of the rooms?
- Is the house damp?
I
v "I
i or^
T /^or .1 4 C
e-toob s
SAmitaT/oH
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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Household survey of symptomatic cough cases.
™ xs xsSiXxxs.-xrx X'sx
main street are selected and the houses interior.
We have also discussed the possibility of taking all houses along a spiral. The width of the spiral is
about 2 houses.
In the questionnaire the following questions have to be asked.
1. Are vou concerned about the plague?
2. With how many members do you live here?
3. Had any members cough during at least the last 14 days.
Who?
4. What action has been taken:
- Home remedies
- Private doctors: MBBS
Ayurvedic
Homeopaths
- Govt. Hospital/dispensary:
which?
5. What was the diagnosis? cold/pneumonia/TB/other
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
7
T
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Use of and experiences with official health resources
methods: interviews, conversation’s
City:
Slum area:
Household (identification):
Informant(s):
Date of interview:
When did you last use the official(govemment) health resource? What for?
Dispensary/ Maternity Home
Hospital
District TB Centre
Is it easy for you to go there? (transport facilities; cost; duration)
What do you think about the services?
Has any health worker visited your household in the last two weeks? In the last month? In the last
year? ever?
When was the last visit? What was it for? What advice was given? materials left?
Where did you go to for sputum research?
Was this always done at a govt, clinic ? Or did you also go to private clinic/lab?
What instruction was given for the production of sputum? Was it clear? -
Did you produce the sputum at home or under supervision of the doctor or. lab technician/staff?
Did they ask you for an X-ray?
Was it clear what you had to do at the health institution/ Did they explain it to you?
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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Interview with head of the government -sponsored health service(s).
Method; Interview
City:
Location in city:
catchment area:
Head’s characteristics: age, sex, diploma; function; duration of stay in this job
Schedule: regular clinic hours and special hours for certain services (indicate each by day of the
week)
Sendees offered:
diagnose (sputum /X-ray/both)
treatment (3 regimens under short course chemotherapy=scc/other regimens)
home visits by health workers
postcards for patient-retrieval (ask how many were send last month; if not, why? stigma of
postcard?)
incentives for treatment? like NGO’s do?
culture growing of sputum
testing for sensitivity ( for drug resistance)
Personnel: number of persons w<'orking full-time and part-time (including volunteers) and their
responsibilities.
Equipment, materials, and medicines available specifically for treating TB (type of drugs) and
reagents for diagnosis f
c.
PLecf < •
d a.®-* .
Cost of services and medicines to the patients (booklet for TB)
method of payment : token for TB (? Kps);
Utilisation: Average number of patients seen daily, normal waiting time, range of waiting times. In
relation to the personnel and available equipment are there few patients; too many patients; or enough
patients? Are there enough ’ resources’ for the patients coming (e.g. none, very few, few, enough).
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
9
)
Interview with health staff.
method : interview
City:
Name institution:
Staff member background:
age,
sex,
Marital status (single, married, common-law)
Speaks and writes language of the community (if applicable)
Lives in the community where service is located/ lives elsewhere.
Education (number of years completed in primary or secondary school)
Professional training (technical studies/university/diploma);
other courses
number of years in the health field
number of years in this health service
Do you like your job? Why? Why not?
What gives you the most satisfaction in your job?
What obstacles or problems confront you in your job?
How do you get along with other staff members? With supervisors? With subordinates?
What do you think are the principal health need and problems of the community? If aids is
mentioned: Is TB less important?
How do you see TB? Is it increasing/stable/decreasing?
Why?
Do you feel you need additional training or updating in the health field/ In what specific areas? What
do you think of see? ' ;
Given the problems discussed, how can you improve your job situation? What changes do you
suggest? What4IEC-messages are important to who?
Wnat do the people of the community think of the health service? Why?
How do they see TB? Why? What problems are here?
Do have ideas for solutions? Which?
I/-I
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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Physical Characteristics of Health Resource.
Method: observation
City:
Name Institution:
Location:
Date:
make a plan and map (including scale to show approximate size) of the installation (clinic, pharmacy,
etc.) Draw the route the patients follow in being treated by the various doctors/nurses.
Are their signboards showing the patient where he has to go to? -=■
Describe the visual aids and graphic materials in the facility (realistic, abstract, cartoons, etc.)
Are there printed materials available? Are the walls printed with relevant graphics? Are there posters
on the walls? Are they hand-done or printed? What are the dominant colours? Where did the graphic
and visual material come from? Visit the Health Education Bureau with regard to their activities on
TB. Who is responsible for preparing it? What are the messages? Like "Be aware of aids " as text
messages to people that can’t read!!
To whom are the messages directed?
Is there other educational or audio-visual material? Is there a radio? Do patients listen to it while
waiting?
Describe the light, water, and drainage. Does the plumbing work/ Are there toilets for staff and for
patients?
Is the facility basically clean? Dirty? Is it new? Old? How Old?
Is it nearby a road or busstop?
Is it good ventilated? Is it easy to find?
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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The waiting room
Method: observation
City:
Name Institution:
Location:
Date:
Number of patients waiting and under what conditions (privacy, crowding, size, chairs, etc..)
Length of time patients wait and the total time they spend at the centre.
Activities that take place while patients wait
Is there a radio in the waiting room? Do the patients listen to it while they wait ?
Are lectures or demonstrations given? Form and content.
Is there a question/answer session? Are educational materials or visual aids used during the lecture?
Interaction between staff and patients.
Who initiates the interaction/
Form (verbal greeting, questions, orders, request for
Content
Forms of courtesy
Level of respect
Tone of voice
Language
Degree of privacy
Noise level in waiting room
Means of advising patients that it is their turn
information, scolding, etc.)
Positive and negative aspects of waiting room environment
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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►
<
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The consultation
(F
Method : Observation
City:
Name Institution:
Date:
Setting, surroundings, location:
Participants (subjects)
Sequence of events during the consultation
Who(doctor, nurse, etc..) interviews the patient to gather data on symptoms, history, etc.?
Who(doctor, nurse, etc..) examines the patient?
Physical examination
Diagnostic examination
Treatment prescribed and by whom
Effect on the patient of each of the following factors:
Cold, impersonal contact
Neutral approach
Friendly/interested approach
Visual contact
Tone of voice
Physical contact
Patient /provider interaction
Form (verbal, questions, orders, request for information, encouragement, scolding, etc.)
Content
Who talks and who listens?
health Education (Prevention of illness)
Form
Content
Provider
Explanations and instructions given to the patient
Clear and_understandable
Do they cover "What?’, "Why?" and "How?"
Is the patient asked to repeat the instructions for confirmation?
Materials presented (e.g. prescriptions ,written explanations)
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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Summary of patient visit to health resource
method: observation
City:
/ -•
Name Institution:/ j
Date:
Summarise the user’s visit to the health resource , by recording information in a table like that below.
Example data are shown. If user is referred to another health service, try’ to follow and record the
sequence of events and interactions.
Interactions
Sequence of Visit
Step
Duration
1. waiting to register
gave, user a number
Actors Did, said, etc..
1 hour user, clerk
user talked with other users while waiting; check
lab tech give cup and tell to produce sputum at
15 min user, lab tech
2. sputum sample
window;
lab tech writes down details of user
cannot find section
3. to X-ray section
15 min user
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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Pharmacies and Stores selling medicines
City:
Type of Business:
Location:
Informant(s):
Date (s):
interview the owner or manager of each pharmacy or store(if it sells medicines)
Regular and special store hours
daily hours
system of shifts with other pharmacies (night hours?)
number per month
what time span?
Sen’ices available
sales of medicines, medical treatment, preventive treatment and advice, etc.
.a.
Staffing
number of part-time and /or full-time employees
Equipment and medicines
Specifically to treat TB (types of medicines:
streptomycin
rifampycine^
Isoniazide
pyrazinamide?
VvOnch are TB medicines are sold most?
WQiat are the costs of the different medicines?(Rifampicin went
up from 3.5 to 4.50)
If you are of stock what do you recommend? Other
drugs(describe.
to other drugstore? Do you ask the
patient to wait until you have stock again?
) or referral
If people complain about side effects what do you advise?
Utilisation
On the average, how many patients do you handle a day? Of those, what percentage are TB
patients? WhaLpercenbige-have other .respirator)'-illnesses? Where dolhe .majority_of_the people live
who use your services?
Do you refer patients to another service? Which ones? Where?
Communication
Do you think people believe what they hear on the radio?
Has there been (within the last year) an effective campaign to promote a health behaviour, treatment
(medicine) or method in regard to TB? Which ones? What methods are used to promote it?
Pharmacy Staff
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
7\ A ’A
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f
Method : Interview
City:
Type of Business:
Location:
Informant(s):
Date (s):
Interview each staff member at the pharmacies and stores (that sell medicines) in the community
Sex
Age
Ethnic group (if applicable)
Speaks and writes language of the community (if applicable)
Education (number of grades completed in primary and secondary school)
Professional training (technical studies, university, etc.)
Other training
Number of years in job
How did you learn this work?
How was present work learned?
Job responsibilities and tasks
Do you like your work or not? Why?
What do you think of TB?
What do you think of TB patients?
'I
Exit Interview
Method : Interview
City:
Type of Institution:
Location: hA’fcf1
Informant(s):
Date (s):
• >
T G cu.5- ♦
Interview patients as they leave the health resource
What is the diagnosis (problem, illness)! ?
Who decide you should go to the health resource?
Where do you come from? Distance travelled from home.
How did you get to the health resource (transportation)? Cost of transportation (if applicable).
Who accompanied you?
Who did you want to see /consult (doctor, nurse, etc.)? Were you seen? By whom? If you were not
seen, why?
Before coming to the health resource, had you taken any medicine or consulted elsewhere for the
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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same illness? What was the result (if applicable)?
What illness did they say you have (diagnosis) 2 Do you understand the diagnosis?
Did you receive medicines, a prescription, or anything else?
Were you seen and nothing was done or said about what to do? Do you understand how to take the
medicine? Will you buy the prescribed medicine/ If not, why? Did you receive any other instructions?
If so,on what? Why? Understood?
Total cost of service.
What is your opinion of the services? Would you use the health resource again? What for?
What do you think should be done to make the service better? Easier to use?
Do you have health needs that are not being met by the service/ What are they? What should be done
to meet those needs?
1) some of the questions can be asked in the waiting room if the researcher is following the patient
through the sequence of the visit.
2) one can also check the patient’s record if time allows. It is possible to do this on a sub-sample.
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
17
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C-
Health institution
Private Doctor
Type of doctor (homeop/allop/ayurv)
Whether treating th patients
How do you diagnose that he is suffering from TB
Ask him how he treats the following patient:
"40 year old male patient, weight 50 kg; diagnosis TB
Ask for the regimens he prescribes.
What tests are carried out for diagnose?
Where do you send them for the tests?
How do you react with the patient when you came to know that he is a tb-patient? (refenral or
treatment?)
Do you tell illiterate patients where he has done something wrong (what is wrong)
Reaction of patient after knowing that he is suffering from tb
How do break the news
Do the patient continue to come to him after he has been assigned TB patient
What are the chances that a patient can be cured?
How do psychologically handle patient suffering from TB
What is cost/duration of treatment
What stage do patients come generally
What is the stage of the disease? When can it be detected?
What is the cost of the treatment/test?
How do you know that the patient is cured now ?
And when do you stop the treatment?
What advice does he give to the patient and his/her family and do they follow it or not?
What is the age group of your patients
Do you have more male or female patients
Do people give more emphasis on the treatment of male patients
Is there a gender bias?
Are female patients coming alone or are always accompanied by somebody else?
Society’s perception about TB patients
Major symptoms and causes
What is the % of defaulters and what are their causes of defaulting?
Why do the patients come to private doctors instead of going to govt, doctors?
Data Collection Guidelines Rapid Assessment TB
Dr.W.Dechering, Femconsult
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(M
p Cz1-VI
Health seeking Behaviour
Treatment
What is your name
how old are you?
how many family members do you have?
whether anybody of your family is ill or not (M/F)
what is age of patient?
what disease ?
when did it start?
have you taken any treatment for this disease?
from did you get treatment (P/G)
If private, whether MBBS, Ayurvedic or Homeopath
what types of medicine have you taken?
how did you feel after treatment?
If he is not cured fully, what steps he has taken or wants to take?
whether doctor asl^ed you to have an X-ray?
how long you was under treatment?
whether govt, facilities are available or not?
what type of govt facilities are available from Govt, hospital?
whether your family members5 are encouraging you to take the treatment or not?
what is the name of the disease according to the doctor?
whether you are taking home treatment or not?
o Sj
s
O'; /
4
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DrAV.Dechering, Femconsult
19
COMMUNITY HEALTH CELL
326, V Main, I Block
Kotamcng’h
Bangaiore-&$0034 *
COMMONLY OBSERVED ADVERSE REACTIONS TO ANTI-TUBERCULAR ..DRUGS AND THEIR MANAGEMENT
India
Sr. Drug and its
No. abbreviation
Adverse Reactions
Monitoring indices
Management
1.
ISONIAZID
(H)
Peripheral Neuritis
(common)
Hepatitis (rare)
Psychosis (rare)
Pricking pain. Burnings of
feet and hands, etc.
Phyridorine
2.
RIFAMPICIN
(R)
Gastro-intestinal upset
Loss of appetite, anusea,
vomitting and pain in
abdomen
Itching all over the body,
face, eyes with or without
rashes
If symptoms persist
To take drugs after meals;
symptomatic treatment
Cutaneous Reactions
(mild & transient)
Hepatitis
Flu like syndrome
3.
STREPTOMYCIN
(S)
Clinical jaundice...
Liver function tests
Fever, chills, malaise
Headache & back pains
Orange urine, tears,
saliva, mere yellow
colouring of skin &
eyes
No other symptom present
Vestibular damage
(Sth nerve damage)
Vertigo, ataxie &
Giddiness
Hypersensitive reactions
Fever, Rash, circumoral
parasthesi s
Anaphylactic shock (rare)
In pregnancy & kidney disease
drug should be avoided
10 mg daily
Antihistamines daily; reassure the
patient
Withhold drugs desensitize.
Withhold all drugs till complete recovery.
Reintroduce all other drugs (in -usual
dosage). Then add Rifampicin 150 mg daily.
Increase dose by 150 mg on every 3rd day
till usual dose is reached.
Reassure the patient by informing that it
is normal phenomenon due to colour of drug.
Discontinue the drug till complete
recovery and resume in reduced dosage.
To prevent the toxicity, use only
0.75 g dosage
Symptomatic treatment.
Terminate the drug or desensitize the
patient.
I
2
4.
ETHAMBUTOL
(E)
Optic neuritis
5.
PYRAZ IN AMIDE
(Z)
Arthralgia,
6.
7.
THIOACETAZONE
(T)
P.A.S.
(P)
Dimness of vision due to
reduction in visual acuity,
field of vision and colour
discrimination or all the
three
Terminate the drug: recovery is good
(dose related, more common in patients
with renal insufficiency)
Pain joints, swelling joints
Limitation of movement of
j oints
Salicylates, oxyphenyl butazone.
Reduction in dosage or discontinue the
drug till symptoms disappear, start
with reduced dosage.
Hepatitis
Clinical Jaundice
Gastro - intestinal upset
Loss of appetite, nausea,
vomitting and pain in
abdomen
Same as in hepatitis due to any drug
Same as in Gastro-intestinal upset due to
any drug.
Gastro-intestinal upset
Loss of appetite, nausea,
vomitting and pain abdomen
Same as in gastro-intestinal upset due to
any drug.
Cutaneous reactions
Itching all over the body
Symptomatic treatment
Exfoliative dermatitis
Terminate the drug, if not may lead to
Steven's - Johnson's Syndrome.
Gastro-intestinal upset
Loss of appetite, nausea.
and pain abdomen
Same as in gastro-intestinal upset due to
any drug.
Cutaneous reactions
Itching, rashes
Same as in cutaneous reactions due to any
drug
Hepatitis
Clinical Jaundice
Same as in hepatitis due to any drug.
acute gout
"NTI" Newsletter
Vol. 20/4, December 1984
Circulated for GVHA Convention 1985.
♦
p
M ^’8
GUJARAT VOLUNTARY gEALTH ASSOCIATION
Newman Hall, P.B.4OO2, Ahmedabad 380 009
of th6 ? GVHA Convention Theme:
’’TUBERCULOSIS”
Introduction:
The GVHA held its 10th Annual Convention and General Body Meeting
at the Farmer’ Hostel of the National Dairy and Development Board,
Anand, on November 30th and December 1st, 1983-
After the registration
(by about 60 persons) and tea, the group met around 4.00 p.m. on the
30th November.
The theme for this meet was ’’Tuberculosis”.
Drs. Anil Patel of
ARCH, Mangrol, and Lalit Shah of SEWA-RURAL, Jhagadia, were identified
as the resource persons to initiate and lead the discussion.
They
both had prepared brief write-ups on the theme and the GVHA had circu
lated them in advance to the members, so that the members had time to
reflect on the issues involved in understanding, diagnosing and treating
tuberculosis, at the individual as well as at community level.
The
group actively participated in the discussion by reporting the field
level experience.
Anil Patel made a very provocative but lucid presentation from an
/
epidemiological perspective, with the group drawn into discussion at
every juncture.
The first question he posed before the group was: what causes
tuberculosis ? and what socio-cultural factors are found associated
with TB ?
The group responded by listing malnutrition, poor housing,
overcrowding, social problems, air pollution and certain occupations
as the major factors responsible for causing TB.
Infection vs. Disease:
To understand fully the causal relationship between each of these
factors and TB and its spread in the community, Anil Patel indicated
that it is important, to distinguish between TB infection and the
disease, and the control of infection and the treatment of the disease,
TB is a unique infectious disease whose germs, once they enter the
human body, can remain in a dormant state or viable for years, whose
J
2
bodies have not killed them without resulting in an active case of the
disease.
Yet, once infected, an individual can become diseased any
time during her or his lifetime.
In other words, TB disease has a very
long and highly variable incubation period.
It is thus possible that
disease in old age may result from a childhood infection that has been
latent in the interval.
In a country like India, the load of TB infection is so heavy that
at any time one third to half of the total population (500 to 500 per
1000 population) is infected.
According to some estimates, at age 25,
about 80 percent are already infected.
However, only 4 to 6 per 1000
population have active tuberculosis among whom the infection manifests
into the disease.
The second important distinction is between the control of the
infection at the community level and the treatment of the disease at
the individual level.
Again tuberculosis is unique and the treatment
of individual TB cases alone can help control the infection in the
community.
Unlike other infectious diseases (such as small pox,
poliomylitis, measles), there are no preventive measures to control
the TB infection in the community, because the load of infection is
very heavy and also because the efficacy of BCG vaccine is in doubt.
Treating of individual cases, however, helps reduce the spread of
infection.
Route of Transmission:
It is important to understand how exactly the TB infection spreads
or its routes of transmission,
through air.
It has been established that TB spreads
When an individual with active tubercle bacilli in his
sputum coughs or sneezes, a spray of secretion may be expelled.
Tiny
particles, known as droplet nuclei, dry quickly when exposed to the
air, and then take the form of aerosole and keep the TB bacilli suspended
in the air for a long time.
When inhaled, they usually pass directly to
Thus persons who come in contact with TB patients over
over a
long period of time become infected because the germs enter their lungs
the alveoli.
through breathing in air which has TB bacteria,
may or may not become active TB patients.
The infected persons
However, the germs which are
excreted in the sputum of the TB patients, in the form of a blob on the
floor or in the spitoon, cannot easily enter another human body,
contrary to the popular belief.
3 -
It is important to know that the factors which are responsible for
causing TB infection are, not necessarily the same as those which cause
the disease.
The necessary conditions for getting infected with TB germs are
largely extrinsic.
(1)
They are :
contact with an open case of TB patient in the family or the
At the same time, a patient whose condition
immediate environment.
is detected early and treated effectively will stop infecting other
This is very important from the view point
members of the family.
of TB control programme.
(2)
poor housing or overcrowding, measured in terms of square feet of
space per person.
The less square feet per person, more over
crowding, more the chance of spreading infection, should there be
a case of TB in the family.
For TB infection to result in the active disease, the risk factors lie
largely within the individual.
Poor housing condition or overcrowding,
which is an important factor in spreading TB infection, is not important
in the manifestation of the disease,
According to some studies, poverty
per se is not found to be related to developing the disease, but the way
family spends its income is found to be significant,
The nutrition
level of the individual in terms of her or his body weight is important.
Persons who weigh less than the average for the population (controlling
for age, sex and body frame, are found to be more prone to develop the
disease compared to those with above average weight
Diagnosis
The next important question is how do we diagnose the disease or
identify an active TB patient ?
According to the group, a TB patient
normally has the following symptoms
1.
a rise in body temperature in the evenings;
2.
loss of appetite;
3.
4.
5.
6.
78.
slow decline in weight;
chest pain;
sweating at night;
lethargy
blood in sputum;
and
cough of long duration with or without expectoration.
- 4
Anil Patel pointed out that many of these symptoms are found in
the cases of chronic malaria also; so how does one distinguish a TB case
from a malarial case ?
Once a case of TB is suspected on the basis of clinical examination,
one can resort to a battery of tests available to ascertain whether the
patient is indeed a TB patient or not.
The various procedure are: X-ray,
screening, ESP, TC-DC, gland biopsy (if it is an extrapulmonary case),
Mantoux test, AFB, (Acid Fast Bacilli) sputum culture, mass detection
campaign using mini-X-rays (MNP), sputum examination, etc.
The group discussed the merits and limitations of each of these
instruments of diagnosis, especially in the context of the rural
community, efficacy, affordability, as well as availability or easy
access to individual patients.
It was strongly felt that objectively
speaking examination of sputum under microscope was the best diagnostic
test of TB.
Further, cough and chest pain and/or low grade fever for
more than one month are the most important symptoms of TB.
Also
important is the bringing out of sputum with or without blood.
About diagnosis of TB, Anil Patel reported that according to one
study out of 53 active TB cases, ^6 were found sputum positive through
sputum microscopy during first examination itself.
An additional 9 were
detected as positive during the second examination.
Thus in 85 percent
of the cases (45 out of 53)» two examinations gave positive result.
(Reference: K. Toman, Tuberculosis: Case Finding and Chemotherapy (Ques
tions and Answers), WHO, 1979.)
Isolation:
Having diagnosed a TB case, the question is: should one isolate
the patient so that the infection does not spread ? While it is true
that person to person transmission of TB occurs through cough, it takes
about 3 months of treatment before most of the patients stop excreting
bacilli in the sputum and almost all stop in 6 months,
the patient that long ?
Is it feasible ?
Can we isolate
Is it necessary ?
It is
pointed out, however, that when a patient is under treatment, the tiny
droplets in aerosole carry medicines with which the patient is beingtreated along with the bacilli.
As the droplets in aerosole rapidly
evaporate, the concentration of drug in the droplets rapidly rise to a
lethal level, killing almost instantly the bacteria.
Thus, very soon
after the treatment the patient ceases to be infective although he is
still bringing out bacilli in the cough.
- 5 -
The medicine or the treatment thus provides chemical isolation
such that the other members of the family do not get infected.
Moreover
effective treatment considerably reduces the intensity and the frequency
of cough which helps reduce the number of bacilli being coughed out.
Dr. Lalit Shah’s presentation touched upon the whole gamut of
identifying or detecting TB, making sure that the patient continues to
be treated or case holding, and finally
the actual treatment.
Case Detection:
According to Lalit Shah, out of 100 cases of TB in a community,
only 30 are in fact detected; the rest go undetected.
Out of those who
are identified as TB cases, only 30 percent complete the course or
chemotherapy, of which 2 to 5 percent are failures or in which there is
a relapse.
It means that out of 100 TB patients only about 9 are
effectively treated in our country.
Therefore, at the community level,
both identification of TB patients and making sure that they-hold on to
treatment are very important first steps in the treatment of tuberculosis.
The question is: In order to control TB effectively, how do we
increase case detection ?
Among the various ways suggested by the group
were the following :
1.
Screening of symptomatics through MMR (mass miniature radio
graphy) .
2.
Camp approach or a clinical examination of every individual by
setting up camps in communities.
3-
If a case is detected, contact all his family members immediately.
4.
Finding out symptomatics through home visits.
5-
Health education.
6.
Mass mantoux test for children under age 3«
Follow-up of old cases to detect whether there is a relapse.
However, an opinion was voiced that the best way of case detection is
through good treatment i.e.
1)
Continuous supply of medicine.
2)
Educating and encouraging the patient to complete the treatment
course for one year.
3)
A sympathetic approach.
6
It was also mentioned that if a sputum positive case is detected,
it is very important to contact the family members of that person and
check them out.
Case Holding:
«>
Case holding is by far the most crucial link in the whole TB
programme, and yet it is the weakest one in practice.
If the TB centre
or the health centre can hold the cases successfully for the entire
duration of treatment, not only will these patients be cured, they will
stop infecting others.
Further, the health centres will be able to
attract more new cases and thus indirectly improve the case detection
rate also-
Yet, the defaulting rate is generally very high.
One needs
to understand the causes of defaulting, if we want to improve case
holding.
Some of the readily identifiable causes of defaulting are :
(1)
Patient feeling good within short time (1 to 2 months) after
treatment; most of the obvious symptoms disappear.
(2)
Side effects or toxicity of drugs.
(3)
Patient does not realize the importanc e of taking or continuing
treatment for long.
No stock of medicines at the PHCs or dispensary.
(5)
Long distances from the centre or inconvenience .
(6)
Cost of medicines (cannot afford if not given free of charge).
(7)
The diagnosis could be wrong.
Treatment:
The actual treatment »r chemotherapy for TB has become so
effective that virtually every patient can now be cured if the necessary
medication is taken.
Not only can the disease be cured but as stated
earlier the patients are quickly rendered noninfectious .
Two important aspects of treatment which need some careful
attention and were discussed are
1.
The actual treatment or chemotherapy and the regimen or
schedule to be followed by the patient.
2.
When do we say or declare a patient as cured ?
- 7 -
1.
The drugs used for treating TB are :
(1)
INH
(2)
Streptomycin
(3)
TXN Thircitazon
(4)
ETH/RFM
(5)
Rifampicin
(6)
PAS
There are two phases of TB control of treatment; intensive phase
lasting 1-2 months when bacteriocidal drugs such as INH, with SM
or RFM are used with one bacteriostatic drug and the other phase
is a maintenance phase of about 10 months duration when bacterio
static drugs such as ETH/TZN are used with one bactericidal drug,
i.e. INH (See Table 1).
The major controversies in the field of actual treat ment or the
drugs are : (1) merits and demerits of streptomycin and its
advantage, if any, over rifampicin, another antitubercatic;
(2) the duration of treatment-whether the conservative approach of
treating TB patient for 12 to 18 months should be followed or
whether a short duration therapy of about 6 months is adequate or
not.
The merits and demerits of streptomycin are as follows :
Merit
Demerits
- free supply in
Govt. PHCs
- distance (injection requires patient
visit OPD clinic everyday)
- very effective
- pain
- injection abcess
- cost
- hepatitis possibility
- toxicity^j^
deafness
giddiness
case holding deteriorates.
On the other hand, the other drugs, which are orally administered,
have certain advantages from the patient’s point of view.
fortnight’s supply can be given to the patient.
A
However, it is
difficult to ensure that the patient actually takes the required
amount of drugs regularly.
If he fails to turn up for another
8 Table 1
7
Recommended dosages of Anti-Tuberculosis Drugs
1.
Drug
Action
1
2
(I.U.A.T. 198.2)
______ ____ D 0 S E __ ______
Daily phase
Intermittent
phase
3
4
Adverse
Reactions
5
I.N.H. (H)
Bacteri
cidal
3-8 mg/Kg
Maximum
300 Mg
12-15 Mg/Kg
Maximum
700 Mg
Polyneuritis
Rarely,
Hepatitis &
Psychosis
Rifampicin (R)
Bacteri
cidal
9-12 Mg/Kg*
Maximum
600 Mg
Same as in
daily phase
Hepatitis
Pyrazinamide(Z)
Bacteri
cidal
30 Mg/Kg
Maximum
2 Gm
50 Mg/Kg
Maximum
3 Gm
Arhralgia
Ethambutol (E)
Bacterio
static
25 Mg/Kg for
6 weeks 15
Mg/Kg there
after
40 Mg/Kg
Maximum
2 Gm
Optic neuro
pathy
Streptomycin (S)
Bacteri
cidal
20 Mg/Kg
Maximum
1 Gm
Same as in
daily phase
Giddiness/
Deafness
Skin reaction
and Hepatitis,
Rarely
6.
Thiacetazone (T)
Bacterio
static
150 Mg**
-do —
Exfoliative
Dermatitis
7.
PAS (p)
Bacterio
static
5 Gm B.D.**
-do-
Anorexia,
Vomiting,
Diarrhoea
etc .
4.
* Usual daily dose for adults is 450 Mg if the patient’s weight is less than
50 Kg, and 600 Mg if the weight is 50 Kg or above. Dose for Children is
adjusted suitably. In intermittent phase, usual dose for adults is 600 Mg.
* * Maximum adult dose,
proportionately.
For children and under-weight adults, reduce dose
9 -
fortnights’ quota, then he has to be followed up at home as well.
The issues involved in these two treatments were discussed at
some length, but the group was indecisive as to which of these two
should be preferred.
About the duration of treatment, the group did not arrive at any
consensus. However, several members felt that it is safer to be
conservative, and continue the treatment for a longer period,
rather than opt for minitherapy because the experience with the
short duration therapy is relatively new.
However, research for the
short course therapy is encouraging and seems promising for the
future -
Lalit Shah, through a wall chart gave a list of possibilities of
mini therapy, where the combination of drugs (3 to 4 days)
were
alternated, and the total cost of each of these treatment (Chart
attached).
2.
The next most important question is: when do we declare a patient
cured ?
What is "cure" clinically and epidemiologically ?
Clinically, a check-up of the patient would involve :
- signs of healing
- no cough
- no fever
ESR normal
- Chest X-ray clear
- Sputum negative
- weight gain
H.wever, most of the improvements occur within a month or two of
the treatment and as a patient starts feeling good, his persistence
declines and he may even stop the treatment.
This is an issue
which we have to somehow tackle.
Well designed trials have shown that 95 to 97% TB cases get cured,
if they complete the 12-18 month standard treatment. And, those
who become sputum negative in the first 6 months of treatment
and
continue to be sputum negative for the rest of the duration of the
treatment also get cured completely, The value of other tests
including X-rays is doubtful to say the least.
(GVHA thanks Mrs. Leelaben Visaria for the preparation of this report
with the help of Drs. Anil Patel and Lalit Shah).
Appendix - I
TREATMENT
THE DRUGS USED IN TREATMENT OF TUBERCULOSIS:
Recommended dosages of Anti-Tuberculosis Drugs
(I.U-A.T. 1982)
DOSE_______
Intermittent phase
Daily phase
Adverse
Reactions
Drug
Action
1
2
3
Bacteri
cidal
5-8 Mg/Kg
Maximum
500 Mg
12-15 Mg/Kg
Maximum 700 Mg
Polyneuritis
Rarely,
Hepatitis &
Psychosis
2. Rifampicin(R)
-do-
9-12 Mg/Kg *
Maximum
600 Mg.
Same as in daily
phase
Hepatitis
3« Pyrazinamide(Z)
-do-
30 Mg/Kg
Maximum
2 Gm
50 Mg/Kg
Maximum 3 Gm
Arhralgia
4. Ethambutol(E)
Bacterio
static
23 Mg/Kg for
6 weeks
15 Mg/Kg
thereafter
40 Mg/Kg
Maximum 2 Gm
Optic
neuropathy
5- Streptomycin(S)
Bactericidal
20 Mg/Kg
Maximum
1 Gm.
Same as in daily
phase
Giddiness/
Deafness
6. Thiacetazone(T)
Bacterio
static
150 Mg**
Skin
reaction and
Hepatitis,
Rarely,
Exfoliative
Dermatitis
5 Gm B.D.**
Anorexia,
Vomiting
Diarrhoea
etc .
1. I.N.H.(H)
-do-
7. PAS(P)
4
5
* Usual daily dose for adults is 4^0 Mg if the patient’s weight is less
than 50 Kg, and 600 Mg if the weight is 50 Kg or above. Dose for
Children is adjusted suitably. In intermittent phase, usual dose for
adults is 600 Mg.
** Maximum adult dose,
proportionately.
VARIOUS REGIMENS:
For children and under-weight adults, reduce dose
There are two phases of T.B. Treatment :
The intensive phase when bacteriocidal drugs such as INH, Streptomycin,
Rifampicin and Pyrazinamide are used.
The other phase is maintenance phase
when Bacteriostatic drugs like ethambutol, Thiacetazone, PAS etc. are used
with either one or two bacteriocidal drugs.
-2-
2
DBUG REGIMENS KEC0MI1ENDED UNDER NATIONAL TUBEECTLOSIS FEOGRAMME:
(A)
For Sputum Positive Tuberculosis Patients (Adults)
Code No.
R1
R2
R3
Drugs and Dosage
Moae and""Rhythm"’of
Administration
Isoniazid 300 Mg +
Thiacetazone 130 Mg
Both drugs in a
single dose or in
two divided doses
orally, Daily
Bi-Weekly regimen
inj-streptomycin
0-75 0/1 0 +
Isonizaid 600 to
700 Mg (13 Mg/Kg
body weight with
pyridoxine
Intramuscularly
Orally
Instructions
Self-administered at
home after meal
Both drugs given at
the same time under
supervision of the
treating physician
twice weekly at
intervals of 3 &
days
Isoniazid 300 Mg +
PAS 10 G
In a single dose,
in two divided doses.
Both drugs orally,
Daily
Self-administered at
home after meal
Isoniazid 300 Mg +
Ethambutol 20 Mg/Kg
body weight,
i.e. 800 Mg for
patients weighing
30 Kg and 1000 to
1200 Mg for 30 Kg
Both drugs in a
single dose orally
Daily
Self-administered at
home after meal
Biphase Pegimen
R5
A) Intensive Phase
First Two Months
Inj. Streptomycin Intramuscularly.
0^.75 0/1 G +
Daily
Isoniazid 300 Mg
In a single dose
Thiacetazone
orally
daily.
ISO Mg.
(PAS
&
Thiacetazone
OR
be given in two
Ethambutol 20 Mg
divided doses)
per Kg. body
weight i.e. 800 Mg
for HS
50 Kg. & 1000 to
1200 mg for those
50 kg
OR
PAS 10 G.
B) Continuation
Phase
As for each regimen
With R1 R2 K3 OR R^
(B)
Injection given
under supervision
and the rest to be
self-administered
at home.
As for each regimen
For the Sputum Negative Tuberculosis Patients (Suspect Cases)
Tuberculosis Patients in whose sputum AAFB are not seen,
seen , are advised
Regimen R^ i.e.
Isoniazid 300 Mg + Thiacetazone - single dose orally daily for 1 to
l/a yrs.
Patients allergic to Thiacetazone can be treated with R^
- 3 DURATION OF TREATMENT;
All patients should be treated for a minimum of one year and optimum of
1/2 years duration irrespective of their disease status.
Intensive efforts
should be made to keep the patient on regular treatment for at least one year.
Treatment can be continued upto 2 years after review at the end of 18 months
but continuation beyond two years has no added advantage.
Domiciliary treatment is the treatment of choice and hospitalisation for
short periods is recommended only in the following conditions :
(A)
Patients requiring surgical treatment.
(B)
Management of serious complications like spontaneous pneumothorax,
haem .optysis, diabetes, etc.
(C)
Manifestations like miliary and meningeal tuberculosis.
SHORT-COURSE CHEMOTHERAPY:
The duration of treatment for a long period of one to two years with standard
anti-tubercular drugs, is believed to be one of the important causes for
irregularity and premature stoppage of treatment by the Patients.
advent of Rifampicin and Pyrazinamide.
duration of treatment of Six months.
With the
It has become possible to reduce the
There are three different types of
bacterial population on which anti-tubercular drugs can act.
(a)
Majority of the bacterial population are of actively multiplying type
which responds to Isoniazid and Streptomycin.
(b)
Second type of bacilli are intra-cellular and slow multiplying and the
drug of choice against this group is pyrazinamide♦
(c)
The third group of bacilli are extra cellular and multiply slowly and
intermittently (Spurter group) and the effective drug is Rifampicin.
Both Rifampicin and Pyrazinamide quickly eliminate the slow multipliers as
well as the intermittently multiplying bacilli and help in sterilising the
lesion.
There is a fourth group of dormant bacilli which do not multiply
at all and hence no drug on them.
At least three bactericidal drugs are used for the initial two months
followed by two drugs in the continuation phase, in order to reduce the
duration of treatment of treatment to six months.
Bacteriostatic drugs have
no place in short-course chemotherapy excepting that Ethambutol may sometimes
be used to replace any bactericidal drug in case of drug intolerance.
Clinical trials with short course regimen of Six Months durations have given
encouraging results.
A number of short-course chemotherapy drug regimens have been tried out
in various countries of the world, in different combinations and for varying
periods.
However, in any short course drug regimen, Rifampicin and Isoniazid
have essentially to be administered, and the most effective regimen appears
to be combination of Rifampicin.
.. 4 Isoniazid and Pyrazinamide of which Pyrazinamide is for the initial period of
2 months.
Similarly if Streptomycin is also administered, it may be given
for the first two months only.
After the intensive daily phase of about 2
months with three or four bactericidal drugs, the subsequent treatment in the
second phase may comprise of Eifampicin + Isoniazid daily or even intermit
tently. (thrice or twice a week).
The ultimate results of use of short-course chemotherapy regimens containing
Eifampicin and Pyrazinamide would, however, depend on ensuring that proper
doses of the drugs in accordance with recommended regimens are given to the
patient, which he also takes •. regularly for the optimum period.
Haphazard
used of drugs like Eifampicin in inadequate doses, for short-course periods
would not be useful and is bound to create more technical problems and must
Some of the recommended short-course chemotherapy drug.
be avoided.
Eegimens, which have been tried out in various controlled clinical trials in
different countries of the world and have given good, results, are as follows:
£HOHT~COUESE
Total duration 6 months
1)
SHRZ
for 2 months plus PH daily for 4 months.
2)
SHRZ
for 2 months plus PH biweekly for 4 months. Total duration 6 months
3)
4)
5)
6)
7)
8)
9)
EHRZ
for 2 months plus EH daily for 4 months.
EHRZ
for 2 months plus PH biweekly for 4 months. Total duration 6 months
SHRZ
for 2 months plus SHZ daily for 4 months. Total duration 6 months
SUEZ
for 2
months plus HT daily for 6 months.
RHZE
for 6
months thrice weekly. Total duration 6 months
EH ZS
for 6
months thrice weekly. Total duration 6 months
SHE
for 2
months plus HP daily for 4 months.
Total duration 6 months
10)
EHE
for 2
months plus HE daily for 4 months.
Total duration 6 months
11)
HEZ
Twice weekly for 2 months plus HE twice weekly for 4 months
12)
HEZ
for 2 months plus HE for 4 months.
Total duration 6 months
Total duration 8 months
Total duration 6 months.
In the daily phase of the regimen, the dosage of E,Z is according to the
body weight, namely patients weighing less than 30 Kg. would receive - 430 Mg
of Eifampicin while a patient weighing 30 Kg or more would receive 600 Mg.
Drugs like Streptomycin, Isoniazid, Eifampicin, Pyrazinamide are equally
effective if given intermittently twice or thrice a week because after a
short exposure to these drugs, the bacilli do not start multiplying for
3 or 4 days i.e. till the next dose becomes available.
Addition of Strepto
mycin in the initial phase of treatment helps in reducing toxaemia and may be
given initially with Eifampicin, Isoniazid and Pyrazinamide.
-x:0:x-
7
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J
A
COMPLIANCE * OEFAjlUT IN TUBEftCUL, -Hu PRQGRAfWE,
INTRODUCTI^M
Tha iHoortanca of tubsrculosis as ono of ths most Inportant health problems naeds
no eSaais. Such has boon the progress made in tho epidemiology the
«nd wneeiallv the treatment of tuberculosis during th© past throe decadoe that
m ild killers of mem has at last become a pr vontable and arable disease.
th. ...d ret
or «« druoo,
«,«.?. Of
but how to apply successfully the available knowledge*
Mattern matheda of tuberculosis control are based on the following principle*-
- case findga as early as possible.
- chemotherapy
- preventive measures
- Rehabilitation
-ourveilance
Thua.caee findings ie an as ential coiiponont in tha programme but it in itself has
little purpose unlasa it is followed by chemotherapy. Case finding is always
““.J IhS to treat/ th.. wocoruU,. th. “J" ptobl.. of onahooo.orul
anti tuberculosis chemotherapy is - NON COtFLlA J-c./O-fAULT.
Default means-failure to do aoraathing required by duty or law.
Sy National Tuberculosis Institute,drug defaulter is a patiant who
tur*n
up within 3-4 days of his due date for collection of drugs. In short ^urso
Xmotharapy if patient fails to turn up with in 24 hours of duo date ha or she
is lebollsd as defaulter*
In li coursetherapy, i*f patient fail to collect etleast 80% of tha medication in
24 months time he is listed in the end non coiRjliance list.
Compliance is defined as the extent to which a persons health rolated behaviours,
i.e. taking medication keeping appointments etc.,coincide with medical advice.
Magnituejs of th© PWbloM
82 case© WWN lo©t in th® follow up*
In an South Indian studyt1 ©4 of pationt had di®d or loft the district by tho end of
teiateant £riod. 27% refused to attend
J*"***^"
^nd of the remainder only 47% col acted four —fifths of their modicamonts*
National figures era TBC caaodatection rate la 50% and out of this only 50% co up lute
the treatment with a ragimen 90% effective. The total efficacy will be only 9%.
Thors sra two basic methods of measurings cot^iiance.
(1) Direct method* This consists of measuring tho blood levels and/or urine
levels of drugs and their metabolstes at the time uh*n the drgus and
mstabeliotes are espectod to bo present in tho blood or urine several specific
methods using reagents and dipsticks are in vogue and the appropriate time of
testing urine level is between 4-6 hrs. after the drug was expected to have
been taken.
2. Indirect method*
(a) Response to therapy* This is based on ths finding that sputum has not
bacome AF0 negative/there is no radiological or symptomatic improvement when you
expoct these to secure if the therapy was taken faithfully .8ut this method is
unsatisfactory becauset
(1) mnths may slaps© after initiation of therapy Jhen you reallea that odoquato
* response has not occured*
(li>alient may develop complications and die
(iii) factors other than non compl;ancetsuch as drug resistance might distort tho
estimation*
(iv) Patient mey take just enouoh drug to bscom culture or smear negative but
might not have taken enough to prevent relapse in tho later date*
(b) Interview technique! The patient is askod in e non thura^ening manner>□!>.)/(thor
he/she has missed taking any of the proscribed dosaa. "Many people have
•••2
--j.il uni
& OE FAULT IM TUI^RCUL
PRQGJW^€.
INTBQOUCTIONl
The iisportence of tuberculosis as one of tha most important health prob lows needs
no sr.phasis. Such has been the progress made in tho epidemiology the prevention,
and especially the treatment of tuberculosis during the past three decodes that
this age old killore of man has at last become a pr.ventable and curablo disease.
The main problem is not tha mud for mear regimens of treatment or near drugs,
but how to apply successfully the available knowladgo.
Modern methods of tuberculosis control are b&sed on the following principle!®’
- case findga as early as possible.
- chenso therapy
- preventive measures
- Rehabilitation
-ourveilance
Thus,case findings is an es ential conponent in tho programme but it in itself has
little purpose unless it is followed by chemotherapy. Case finding is always
easier than to treat/ them successfully. The main problem of unsuccessful
anti tuberculosis chemotherapy is — NUN COMPLIANCE/O^fAULT.
Default msona-failure to do somathing required by duty or law.
By National Tuberculosis Institute,drug defaulter is a patient who fails to tur$n
up within
days of his due dato for collection of drugs. In short course
chemotherapy if patient fails to turn up with in 24 hours of duo date he or she
is labelled as defaulter.
In 1i coursQtherapy, itf patient fail to collect atleast 80% of the medication in
24 months time he is listed in the end non compliance list.
Compliance is defined as the extent to which a persons health ralatsd behaviours,
i.e. taking medication keeping appointments etc.,coincide with medical advice.
Magnitude of the nroblgjsl
Non compliance ie a protean features of all self administered therapeutic
regardless of tho medical conditdns for which they ure prescribed. Xn *a®^Jrtia^^dcno
T.B.Clinic 272 cases wore followed up. During a period of one year. Of these 112
patients defaulted 219 times during a period
ranging from 4 months to 1 year
82 cases were lost in tha follow up.
In an South Indian study,10% of patient had died or loft the district by tho and of
the 12 month treatment period. 27% refused to a;tend the treatment services
and of the remainder only 47% col acted four -fifths of their medicaments.
National figures ars TBC caaedetection rate is 3CF% and out of this only JO/* comply as
the troatmant with a regimen 93% effective. The total efficacy will be only 9%.
Measurement of ca>ml|ancei*
There era tao basic mathods of measurings compliance#
(1) Direct methods This consists of measuring tho blood levels and/orurino
leveTe of drugs and their mstabolotos at the time »Mn the drgus and their
metabolletes are espected to bs present in the blood or urine several specific
methods using reagents and dipsticks aro in vogue and the appropriate time of
testing urine lavel is betaken 4-6 hrs. after the drug aas ejected to have
boon taken.
2. indirgQt methP-dt
(a) Rasponsa to therapy! This is based on the finding that sputum has not
bacome AFB negative/there is no radiological or symptomatic improvement ahen you
axpact those to secure if the therapy was taken faithfully .But this methed is
unsatisfactory because!
.. .
(!) Months may elapse after initiation of therapy uhen you realise that ar^quete
* response has not occured.
(il)Patient may dovelop complications and die
(iii) Fsctors other than non compl ancsjsuch as drug resistance might distort the
estimation.
(iv) Patient may take just enough drug to becomo culture or smoar ncgc^iv® but
might not have taken enough to prevent relapse in the later date.
(b) Intorviw tschniquo* The patient is asked in a non thre^ening manner,utr/thar
he/she has misaad taking any of the proscribed doses. "Meny^poople hove
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: > i
(8) 0.^ ^1-
and ha© boon informoa ano
>
sida eff cta-pationt may nuthava
□putum aahadule© af
sa^ Jly be too aata«x shocked to loam
ixtnes ^wstood
failad to*grasp esitial information. Thus omphasis
SSuld Z laid on the essentials of hisdicuass and its treatment through clear
easily underatendaoIs moans of communication.
K
J.
Th... le a cateoory of patient who are given chomothorapy,though
(9) improper diagnosis! Ihera i- a -a ga J t £
bacterologicel examination. In
the diagnosis of Tgc M.
of not continuing the therapy,
such cases Pliant
ahouJd
calied defauiterS. Unfortunately
2S
«. WWUX, n~« to*-* “ «•
,
. x
*
In Kasturba TB clinic of Lucknow approximately 25^
t1W ™ STistaS Cabot’s ^lliton/chronic fronchitia
”•«' bM"allorgic rhsultis
t0 ‘J and
ri°”
!wiXlr‘«. paU^talght .telbuta then to .>»ff.oUv.n.«> of mUTBC therapy and dljcontinua^
(1,1 Oroa roolotonC Potto* W F.U to obtain ooll.r du. to drug »U.t». of the
bacille he is harbouring and thia may ctecroasa cosplianc •
(12) Migration/marriagVdeath /festival etc.may prevent the patient from coming to
clinics to obtain d^ugs*
bTRATEGlE^ FOR IMPHOVIbS-CO^UXANgEt
No ?®r«act solution is availabia but certain stops can be takani/ v. •r.*fmitjfc first knoui sshat is expected of him or her® Th© basis
<1of d2e^SprOB^SlS,^ortf.n-.a of flying with nodical advice should be
explained in simple native ia^Q^
J^ortwUon first presented to
material presented later.
Th® eneraction should ba a two way communication and writtsn instruction should be
handed over to the patients*
(2) Improving appointment keeping!
A postal reminder card,mailed so that it arrives 1 or 2 days in advanca of the
scheduled ^spointment is probably the best initial approach to solving the
problem. IF the patient does not turn up within 4 days of the due date another
latter should be sent or his homo should bo visited.
(>) IMPROVING gjfPLIANCE, WITH TR£ATM£b|T«
Fftr reposted or chronic cotspllancc problem,intstructiona,raeAjcatlon and sinple
reminders ©ill produce only transient benefit, in such crsbsi(a) discuss the problem with the patient and ahuu your genuine concern
about non compliance. Try to identify the causa of non compliance and
that ^tould bo elaminated by a combined effort.
(b) With the patients permission,identify family membera,friends who will support
compliance and give them encouragament.
(c) The drug ragltngn should be design two patients life stylo. Find a daily
ritual that the patient finds plaasant and schedule medication taking Just
before or after that activity.
(d) For patlsnta who lack motivation,providing small glfts,monatary incentives or
reearde for reaching therapeutic goals nay be helpful. More than monetary gifts,
words of praise or commendation letters end to these patients on such
occasion will ba more logical and effoctive.
(e) Writtend,agreement of compliance can be attained at the beginning of the tharapj
(F) Use of extended suparvisioni it is more expensive but it is affective*
(i) Dlreet supervision of admiusion-daikly regime or t»ice uoekly regime*
(ii) t
visit to follow up broken appointment aan be axtr .moly helpful. Sputum
col oction,urir>e tests can be done and problems can be discussed with the patior
first hand.
j)is 4 I Io
1
Nepat J. 1984t 3.(1) 61-73
coMmunjty h-auth
CELL
^7/1,(Fjrst Fl
- - looDSc.
BANGAt0a£ .5bo 0Q1
Tuberculosis In Children :
Diagnosis, and Follow-Up
Dr. Si/S/e Grahart-Jones*
Introduction
L- Diagnosis of TB in children
'• The incidence and prevalence of tuber
culosis (TB) in children in Nepal is not
known. The adult prevalence is about 1.6%
Sputum-positive) Diagnosis in children is a
problematic affair, as there are no reliable
diagnostic tests. Chest x-rays are not diagno
stic in children; Mantoux tests are unreliable,
especially in malnourished children; and the
pick-up rate from laryngeal swabs and gastric
vashings is poor, even when facilities are
available. Sputum tests arc rarely of any uSe
in children.
Following Wiseman (1980), we look first
for a history of illiiiess of more than one
month in duration, and make enquiries for a
suggestive family history of chronic illness?
On examination, wc look for signs of loca-‘
lized disease in lymph nodes and lungs, and1'
for chronic atypical skin lesions. We also
maintain a high index of suspicion in chikU
ren who are chronically undernourished or
unwell, but who do not have localized symp
toms or sjgns. These children may show
deterioration and anorexia after measles on
whooping cough. There are also the children
who do not respond td .conventional treat-,
ment for chest infections, diarrhoea, or skin
lesions.
. Nevertheless the experience of the Save
the ^Children Fund (SCF) Mother and Child
health clinics in 4 districts in Nepal shows that
childhood TB is common and carries a high
mortality. This report of the TB cases diagno
se^ tb? new 3CF chide in Sindhupalchowk
between Srawan 2039 and Kartik 2040 (15
months) is a follow up to a report on TB
child patients at the Surkhct SCF clinic
(Wiseman, 1980). We emphasise that health
workers can be trained to make a clinical
diagnosis of TB without any laboratory
investigations, and that progress can be
jnonitored by weight gain as well as regress-"n of symptoms. A search has been made,,
We rarely diagnose TB, except for obvi
ous gland TB, on a child's first visit to the
clinic. But if we suspect it, we call patients
back to the clinic within 2- weeks for a repeat
history and examination. Family history is
often elicited more fully at this second inter
view, and we ask for sputum tests from sus
pect adults. We also use the BCG vaccination
as an abjunct to diagnosis. Unfortunately,
scarpositiye BCG does not seem to give very
good protection against TB’ if) children ip
for factors associated with good or poor outSouth .India; (WHO, J979 b) But an early
come of treatment.
• . reiction to BCG, taking the form of skin
*
Medical Officer, Save the Children Fund, Chautara 'Project, Sindhupalchowk.
——-
61
.J J
SoUVBi
S. Graham. Jones
ulceration over the injection site within 2 weeks of vaccination (as opposed to the normal
reaction which takes 1-2 months to develop as a small scar) may indicate active tuberculosis.
This is a rather more sensitive test than the standard Mantoux test (Miller, 1978).
Training for clinic staff, health post staff and field workers in our programme has
included much discussion and comparison of the signs and symptoms of TB in adults and
children. We use posters and flip charts including emphasis on BCG vaccination for .childreg
and referral of patients to health services. These visual aids, and training booklets produced by
the Britain-Nepal Medicai Trust, (BNMT) Biratnagar, and by the Shining Hospital, Bokhara^
are also used in health education sessions in schools, for patients at health posts, and in th?
clinic. We encourage health workers and field workers to attend the weekly TB follow up clinic^
at the Chautara clinic to see patients at various stages of treatment. The parents of these TB
patients are often the most enthusiastic teachers.
II. Treatment
We continue to use the standard TB drugs available to hospitals and health posts
through the Tuberculosis Control Project (HMG). The mainstay of treatment in children is
ISONIAZID (Isonex) which is both bactericidal and bacteriostatic, and causes very few side
effects in appropriate doses. It is combined with THIACETAZONE (TB 1) in most cases, a
convenient formulation being RD-ZONE FORTE (isoniazid 300 mg + TB 1 150 mg) : but in
order to avoid the side effects associated with thiacetazone we use the following dosage schedule
according to the child’s weight, including extra isoniazid and a relatively smaller dose of
thiacetazone.
occasi
fcympt
Skpec
start.
for a
given
Anen
paiaren
HI. I
are si
r -i
.^si
(Wist
AGE
0 -
12-
TABLE i
Dosage of TB Drugs (Oral) According To Child’s Weight
WEIGHT less than 5 kg
6- 14 kg
15 — 20 kg
21 kg upwards
Rb-ZONE Forte 4- Extra Isoniazid
50 mg
1/4 tab
+
100
mg
1/4 tab
4100
mg
1/2 tab
41 tab
This oral regimes seems hifflcient for many children with pulmonary disease, gland TB,
skin TB and for those with nori-Specific signs, and avoids the necessity for injections and
frequent clinic atteridances. IK seriodsly ill children, especially those with bone or. meningeal
disease, we start streptomycin injections (40mg / kg up to a MAXIMUM dose for children, of
500 mg) daily for in-patients, or 3 times weekly for out-patients, always combined with the
above oral regime. Streptomycin is iiVeri for 2 months, if pOssibfe. isbniaild alonb is §iven
^2
3660-
Zota
OfV
for a
than
2. r
all i
Souvenir Nepas J, 1984, 3, (1)
es
is.
occasionally to children less than two years old who r ’
- are not seriously ill, have no localized
U>ik^: “I reVe'°P reSrStant StrainS °f bacteria. All patients are
expected to continue treatment for a minimum of 12 months and this is made clear at the
start. A special review iS’uhdeftaken at 12 months do decide which' patients should rn f
IS
given for a two month trial period at 20-25mg / kg.
al
In.
. ^6
pt„.sle.„0f.4x“2:
h $ bC n
id
n
y
b
e
s
3
mininium in order
t0 “ —
Anemia^MSS'Tr
to confuse the parents
?Ulphate’ and nutrition is discussed with all
III. Presenting Features of Children Diagnosed as Having TB
The 130 cases diagnosed in the 15 - months study period in the Chautara Mrw rf ■
are summarised below under various headings.
CH 1,nlC
i.
on^“!osis
s
(W.seman, 1980) may simply reflect the difficulty in classifying childhood TB.
i
TABLE 2
AGE (months)
Gland
Pulmonary
Abdominal
Bone Meninges
eye
Skin
Total number
in age group
0 - 11 months
1
6
3
0
12 - 35 months
1
7
1
32
72
12
1
2
36 - 59 months
2
11
13
56
6
0
60 - 120 months
0
10
0
17
30
3
0
1
0
Jotal
32
29
68
24
1
4
3
130
22%
51 %
18%
0.8%
3%
2%
100%
51%
34%
7%
?
?
100%
'% °f total
Of Wiseman '80
for ages less
than 10 yrs
0-8%
2. Nutritional Status
...
63
y-. y
■
'■ 7
,^V,
..
s. Graham-Jones
sign of excessive thinness,
drytXda wrZS- tte conjunctivae, Bitot’s.-spots, and conjunct^ xerosu.
Tinkling of the conjunctivae, Bitot’s spots.
-■.3
TABLE 3
.
I.
.1-
*-
Overall percentage of
new clinic patients affected
% of TB cases
Signs of Malnutrition
- 'iffcbted*
•
10%
3%
2%
42%
Weight-fbr-height < 80 %
Nutritional oedema
Vitamin A deficiency
■
17%
8%
... i
3. BCG Immunisation Status of TB Patients
quarter of our TB patients had scarpositive
The BCG figures in Table 4 show that a
Recent studies in South India (WHO, 1979b) have
reassuring cither.
prevalence of malnutrition, and our figures are nt,ot
-----
TABLE 4
BCG given
previously
Number
Percentage
Quick reaction
to test, BCG
Never given
BCG
Uncertain
\
Total
36
28%
47
36%
100%
100%
16
31
24%
12%
4. Family History of TB
It is assumed that most cases of Childhood TB are transmitted from sputum positive
r adults now-a-days, since in our experience most parents boil milk and this lessens the
transmission of bovine TB. The percentage of cases with a definite or suggestive family ,
hisiory of TB is shown in Table 5,
•
r
TABLE 5
Definite FH
ofTB
Number
■ Percentage
•’ 44
34%
Suspected FH
of TB
, ■
?
43
33%
----
Uncertain Total
No FH
ofTB,
27!;
21%
A
■
' ‘
130 .
100%
16
12%
64
—-..
■
-
■
1:
■
>5
•
Souvenir Nepas J, 1984, 3, (1)^
es
Thus it was possible to elicit a positive family history in 67% of our 130 newly diagno
sed TB cases.
a)
Je
5. Sex
There were 61 boys and 69 girls in our 130 cases; the sexes are evenly distributed (47%
boys, 53% girls). This is also true of a sample of 500 unselected, consecutive new clinic
patients studied in the same period.
ed
6. Caste / Ethnic Group
Patients were -classified into 5 broad ethnic groups, and the 130 TB patients were
compared with 500 unselected consecutive new clinic patients as follows:-
TABLE 6
vc
ve
-h
Brahmin / Chhetri
Newar Tamang
Low-caste
Ghalc/Magar
Total
TB patients
Number
53
23
31
17
6
130
Percentage
41%
18%
24%
13%
5%
100%
237
129
50
68
16
500
47%
26%
10%
14%
3%
100%
Unselected new patients
Number
tai
Percentage
’%
1%
Compared with the unselccted control group, the TB patient group appears to contain
relatively more Tamangs and relatively fewer Newars. The differences between the two distri
butions is highly significant, using the complex chisquare test (x* = 282, df = 4, p <0.001).
ive
7. Distance of Home from Clinic
the 7
•ily..
The distances are expressed in ‘kos', where 1 *kos’ is approximately an hour's walking
distance. TB patients living in Chautara bazaar panchayat constitute 21 % of the TB patients
so far. A further 48% of TB patients live in the six surrounding panchayats, within 2 kos.
Another 18% live approximately 3 kos distant, and the remaining 13% come from 4-8 hours’
walk away.
IV. Follow up of TB patients
Of the 130 patients in this study, 70% (91) were followed up to at least 2 months after
diagnosis. 30% (39 children) were lost to follow-up withiri the first month and not retraced.
65
5
L•\
j
ill
||||
■
■
j
381:
IKK- w
S. Graham-Jones
So
majority with pulmonary or meningeal disease.
Of the 82 children known to have survived at least 2
is available as follows:
months after diagnosis, information
TABLE 7
Follow-up Rate
No. of children
followed up
No. diagnosed
as having TB
11 months or more
10
14
6 months
52
81
71%
64%
67
121
55%
Treatment period for which
information is available :
2 months
The follow-up rate has thus fallen as the programme
has enlarged.
V. Outcome assessment
information relating
Besides the 'presenting features’ analysed for all TB patients, extra
of treatment is available on the 91
to treatment regime, side effects of drugs, and outcome c-------patients in the follow up study.
One major aim of the outcome studies is to clarify the factors associated with good or
bad prognosis. In this retrospective study, the following assessments of treatment outcome
have been used
I
a)
CLINICAL IMPROVEMENT. Each patient’s progress was assessed at the end pomt
nf the iudy (Poush 2040). Clinical progress with reference to presenting symptoms
of the study (rousn
>
.pOOR’.‘GOOD’Progrees, meaning
and signs was assessed as GOOD, rA
natients
virtually complete regression of signs + syrr.potoms, was found
40/o
p
followed up to at least 2 months.
1 as a percentage of 'reference’ weight gain
b) TWO-MONTH WEIGHT GAIN expressed
reference weight gain (WG 2) was defined as the expected
(WG 2%). The 2-month
- a “well-nourished” child of the same age. ('‘Well nouri
weight gain in two months of
shed h^ere defined as 100% of reference weight-for-age). The reference figures for
66
rr
1
u
Souvenir Nepas J. 1984, 3, (1)r
weight gain and weight-for-age were taken from USA National Centre for Health
Statistics growth curves as recommended by WHO (WHO, 1979 a)
Then : Actual/Expected 2-month weight gain x 100 = ‘WG 2%’.
c)
SIX-MONTH WEIGHT GAIN expressed as a ]percentage of ‘reference’ weight gain
(‘WG 6%’), calculated in the same way as for (b).
So : Actual/Expected 6-month weight gain x 100 = ‘WG 6%’.
Since there is no single ‘right’ way of classifying outcome of treatment in these children.
many of whom have received only a few months of treatment, all three methods of assessment
were used.
The ‘Contrast’ Method : Analysis of Results
Patients, records were coded and sorted several times into different outcome groups
using the d Base II, data handing package on a Sirton Z80 microcomputer.
Sort 1.
On clinical grounds, the patients’ records were sorted into those with ‘GOOD’,
‘FAIR’, and ‘POOR’ outcome at the endpoint of the study. Deaths were included
in the POOR’ outcome group.
Sort 2.
Class'fication according to 2-month weight gain. It is assumed that better-thanavarage weight gam is an indicator of improvement in most TB patients, many of
whom are undernourished when diagnosed (see presenting features’),
‘GOOD’ WG 2% was taken as >200% of reference WG 2.
‘FAIR’ WG 2% was taken as 101-199% of reference WG 2.
‘POOR’ WG 2% was anything up to reference WG 2, and included patients who
lost weight or died within the 2-month period after treatment.
Sort 3.
Classification by 6-month weight gain. The criteria are slightly altered since relatfc
‘FAIR’ WG6% taken as 101-149% of reference WG6.
‘POOR’ WG6% was taken as anything up to reference WG6, including those who
lost weight or died 2-6 months after starting TB treatment.
Having sorted the records, comparisons between the ‘GOOD’ and ‘POOR’ outcome
groups were made, picking out the additional features which discriminated between these
groups. To maximise contrast, the intermediate ‘FAIR’ outcome groups are not presented here
67
S. Graham-Jones
5 ou
The results of four separate comparisons between contrasting subgroups of patients were
analysed using Student’s test for comparison of means, and the test for the significance of the
difference between two independently computed proportions.
a) Comparison of‘GOOD’ and ‘POOR’ clinical outcomes aS of Poush 2040
The attributes studied are listed in the left hand column of table S. The number of
children in the 'GOOD’OUTCOME’ group with these attributes in shown alongside that from
the ‘POOR OUTCOME’ group in the centre, and the respective percentages^ for comparison,
in the right hand column.
A ‘GOOD1’ outcome implies that all or most presenting symptoms and signs have been
cured.
TABLE 8
Attribute
Sex == Male
Age less than 36 months
Home 3 hours distance
Positive family history
Previous BCG
Caste Brahmin / Chhetri
Newar
Tamang
low - caste
Weight-for-height <80%
TB of lung
glands
abdomen
meninges
Given Streptomycin as well
as oral drugs
Early defaulter
Number in group
Mean age ± S.E.M,
No. of children
Percentage of Group
‘GOOD’
'POOR'
’GOOD’
‘POOR’
16
19
10
14
6
46%
54%
20%
60%
26%
46%
29%
U%
9%
31%
66%
14%
14%
0%
50%
70%
30%
50%
25%
30%
25%
30%
15%
30%
45%
20%
10%
10%
7
21
9
10
5
16
6
10
4
5
3
10
23
5
5
0
6
3
6
9
4
2
2
Sex
Age
Cas
Wei
TB
Giv
wel
Ear
Nu:
19
17
35
40.9±5 mth4
9
54%
13
49^
20
100%
30.8±4 mths
45%
65%
100%
Me
68
♦^.**WW**
.• , :- .a-ax r y
31 .
Souvenir Nepas J. 1984, 3, (1)
None of the differences shown in Table 8 was statistically significant. The differences
- •>■»•<■“ “f >»“»'«
wh,J«0h=d .tan~.ee
age is younger, including a higher proportion of
(I) age: (poor outcome group mean
children uuder 3 years);
(II) caste: there is a higher proportion ofTamangs in the poor outcome group; an _
(III) TB type: in that there is a higher proportion of meningeal TB, and a ower proper
tion of lung TB, in the poor outcome group.
b)
Comparison of ‘GOOD’ and ‘POOR’ Weight gains at 2 months.
A similar tabulation and analysis to that used in ta) above was made. The salient
points are summarised in Table 9.
TABLE 9
Number of children
Attribute
Percentage of group
Good WG 2%’
‘Poor WG 2%’
‘Good WG 2 %’
‘Poor WG 2 %’
Sex--Male
18
14
60%
40%
Age less than 36 months
10
27
33%
77 %*
Caste Tamarg
Weight-for-height <80%
5
4
16%
11%
15
10
50%
29 %*
18
18
60%
51%
5
5
17%
14%
abdomen
7
6
23%
17%
meninges
0
2
0%
6%
well as oral drugs
16
17
53%
49%
Early defaulter
11
21
37%
60%
Number in group
30
51 ± 5 months
36
100%
100%
*
TB for lung
glands
Given Streptomycin as
Mean age ± S. E- M-
29 ± 4 months
This compasison of groups showing high vs low weight gain in the first two months
of TB treatment does yield some significant comparisons*. The age difference is hig y
69
-
- ._
_ mummtW------------- 1.......... - —
... .
1
-
&
■
-
■
> -ST
•
9&
SOuvenir
s„ Graham. Jones
significant (comparison of means by t. test t = 3.72, df =63, P < 0.001) and reflects a
preponderance of children under 3 years in the‘poor weight gain’ group (comparison
of proportions by z test, z = 2.83, P < 0.002). In the 'good weight gam’ group, 50/o
of the Children were wasted at the time of diagnosis, a significantly higher proportion
than the 29% in the ‘poor weight gain’group (comparison of proportions, z = 1.97.
p C 0 05). During the early months of treatment, these wasted children are indeed
those who gain most weight in ‘catch-up’ growth, although they are on average OLDER
than the ‘poor weight gain’ gioup (the rate of weight gain is normally higher in younger
children), Thus the rate of weight gain for sick, wasted children during treatment can
on Gb
COIBjh
diifaZ
-rellp
chill
stagtT
thesg
J
overtake that of a relatively better-nourished and younger group.
The other differences shown in Table 9 did not reach significances. Tire suggested
discriminating features of caste and TB typs derived from Table 8 are apparently not
powerful factors in determining weight gain in the eatly months of treatment.
Comparison of ‘GOOD’ and ‘POOR’ Weight Gains at 6 months.
This comparison excludes the early deaths, and is based on a smaller number of
patients on whom information at the 6-month point is available. The relevant points are
summarised in Table 10; findings on all other attributes were not useful discnmmants
c)
there
fori
groif
i
VI. Treatnt
between these two groups.
Not
had to be
2 months 6>
TABLE 10
. Attribute
feattPted
witK
gro^.
obsP
Number of children
‘GoodWG 6%’
‘Poor WG 6%’
9
Sex = Male
10
G ste Tamang
Newar
Brahmin/Chhetri
Low - caste
Weight-for-height <80%
TB of lung
glands
abdomen
Early defaulter
Number in group
Mean age ± S.E.M.
3
2
3
12
6
6
9
17
6
1
13
24
43^5 months
9
1
4
12
2
3
11
18
31±5 months
Percentage of group
‘Good WG 6% ‘Poor WG 6%’
42%
5Q%
13%
13%
50%
25%
41%
71%
25%
4%
54%
100%
ll°/o
33%
50%
6%
22%
67%
11%
17%
61%
100%
/
70
tt 3
T** ■
1
......................................
>’
'■.•
.• ’i;.' ’ Gf-U
1)
2)
3)
4)
5)
This
related to t
The
been follow
regime car
SOuvenir Nepas J, 1984, 3, (1)
The only statistically significant comparison between these two groups is the t test
on the mean ages* (t = 1.68, df 40, P < 0.05). As in the two-months weight gain
comparison, the ‘good’ group contained more‘wasted’ children at the outset, but the
difference is not significant in these smiler groups (z *= 1.29). Nor are the apparent caste
-related differences shown in Table 10 statistically significant. There is a suggestion that
children abdominal TB may do less well (at any rate in terms of weight gain) at this
stage, but the difference between the proportions shown does not reach significance on
these numbers (z — 1.34, not significant).
i
n
o
a
1
r
n
d)
Comparison of ‘BEST and ‘WORST outcome groups.
Because the preceding analyses has failed to elucidate any definite discriminant
features other than age, one further extreme example of the contrast method was attem
pted - comparing the ‘best’ group, who had all had at least 11 months of TB treatment
with the ‘worst’ group, who had all died. Since the numbers in these two contrasting
groups were small (10 and 9 respectively) this was done merely to see if any previously
obscure factor emerged as relevant, rather than as a quantitative exercise. However,
there were again no obvious discriminating features, other than age (mean 41 months
for the ‘best’ group and 23 months for the ‘worst’), and a suggestion that the ‘worst’
group was somewhat more malnourished at the start.
1
t
3
s
VI. Treatment regimes and side effects of TB drugs
No severe side effects have been reported during the study period, and drugs have not
had to be changed because of side effects. Mild side effects were reported in 5 cases within
2 months of starting treatment:
1) vomiting in a three - year old on oral INH and TB 1
2) vomiting in a 9 month old on streptomycin and oral INH and TB 1.
3) diarrhoea and vomiting in at 2 - year old on oral INH and TB 1.
4) itchy rash at 2 weeks after starting oral INH and TB 1 in a 2 - year old.
5) fever in a five - year old on streptomycin and oral INH and TB 1.
This low incidence of side effects is probably due to the care with which dosage is.
related to the child’s weight.
The isoniazed only regime has been used in 4 children under 2 years of age who have
been followed up. Two have done well, and two have shown only slight improvement. This
regime cannot yet be properly assessed.
71
p’***’^^
I
■—
mW
tea
-
i
Sv . .
—...
—
S. Graham-Jones
Souvc
The
grou
powt
no side effects.
is fo
of ti
poor
vn. DISCUSSION
first
com
of '
poo
Xantme for HMG health workers at the Chautara MCH project.
Follow up of TB in children - whose job ?
are disappointing, since patients have to be
Follow up rates
in most
TB programes
tivaled
to continue
attending when symptoms have subsided. In this study
exceptionally well mo
30% of newl,
there was a 45% drop-out
running for 15 months.
Ack
At present, the defa^ch^
are restricted to sputum-positive adu
In this field
MCH/Fp workers, and
,
S* «• »<■*»'•«»“ »- ‘n
-be
rapidly contacted.
Outcome of Treatment
patients followed up to at least 2
Symptomatic improvement wa
15_month study period. Improvement
months in this study. The mortanA raof newly diagn0Sed TB cases,
in nutritional status was well defin .
6°/in those followed up at 6 months.
WtonlyM-/.!. .hose
"P •' ’ ““‘““t rf.“o« X gaM
Once «lgM 8*« >"
ZXTfiZ
“»eigM
«2
up pW ..W P..« .ha»
16’% “ ‘
"r"”“
of weight gain for children of similar ages.
CmMk.
"P”'"1 01’lin“‘ ‘’T’feo
This Is partly due to nporlihg
lllnass. and partly also
reporting «f
of mtmurrent
intercurrent illness.
to weight gain.
72
trea
teris
—
not reliable,
”
improvement unrelated
Souvenir Nepas J, 1984, 3, f 1)
cs
The search for factors indicating likely outcome of treatment
In this study, factors such as sex, previous BCG immunisation, family history, ethnic
group, presenting symptoms, and different drug regimes were found not to carry predictive
power. The only useful indicator so far discovered is age of the child TB patient.
:n
Younger children definitely bear a higher risk than older ones, A poor clinical outcome
is found in 21 % of the TB patients under 3 years old at the time of diagnosis, but in only 9%
of those aged between 3 and 10 years. And there are relatively more ‘under-threes’ in all the
poor-outcome groups than in the good-outcome groups, whichever outcome measure is used.
ut
30
Malnutrition at the time of diagnosis may be followed by rapid weight gain during the
first few months of treatment, and is not per se an indicator of poor prognosis. When out
come is assessed clinically the good-and poor outcome groups both contain approximately 30%
of wasted children. This percentage falls faster in the good-outcome group than in the
poor-outcome group.
:d
ig
There may be a small group of wasted children who do not gain weight well on TB
treatment. Further analysis on a larger sample will be needed to see if there are other charac
teristics of this group which would help to detect them early on as needing special care.
)e
y,
id
Acknowledgements.
- Thanks to the staff of the SCF Chautara Mother and Child Health Care project and
TBCP staff in Chautara for their cooperation.
- The Britain Nepal Medical Trust has provided help and encouragement and expertise
in TB work over a number of years, while SCF staff have been taking the plunge into
TB diagnosis in children - many thanks.
- The Sirton computer used for the analysis of TB records in this study was purchased
with financial help from the Overseas Development Administration, UK.
3)
Id
id
be
REFERENCES
- Wiseman, David (1980) J. Inst Med, 2, 31-36 Tuberculosis Report
for Surkhet District.
- WHO (1979b) Bull. Wld Hlth Org. , 57, 819-827
Trial of BCG vaccinations in South India for tuberculosis prevention; first report.
- WHO (1979a) Publication FAP / 79.1, Geneva.
A guideline for the measurement of nutritional impact of supplementary
feeding programmes aimed at vulnerable groups.
- Miller F J W (1978) Tuberculosis in Children. London: Churchill Livingstone
- Shining Hospital, Bokhara (1979) TB Handbook (English and Nepali versions)
- Britain Nepal Medical Trust (1981) Treatment of Tuberculosis.
- Ratliff, W. (1981) d Base II. California: Ashton Tate Ltd’
2
nt
•s,
is.
he
is.
ts
e.
o
73
|.3|
tai
raw?
A Study Of "Tuberculosis" as present d in various training
manuals a®d health education ku*tcrials
Rewurces
1. Manu 1 K'-r Community Health
workers (Ministry of H&FM
Chapter 3.4
Responsibilities of CHW
regarding tuberculosis
Chapter 11.1.4
Cough and cold
2
Manual for Health worker
(Female) Vcl.l
(Ministry of H&FW)
Chapter 12.il
BCG Vaccination
3^
for Health
(Fd»ale) Vol.2
(Ministry of H&F )
Chapter 20.6
Tuberculosis
4. Manual for He 1th Workers
(male) Vcl.l
(Ministry of HfrFW)
Chapter 12.11
BCG Immunization
5. Maimel for Health workers
(Male) vol.II
(Ministry of H&rw)
6. Manual for Health Assistants
(m&le ani female)
(Ministry of Hfefw)
’ I Si:- 4
Chapter 20.6
Tuberculosis
Chapter 15
Tuberculosis
7. Where there is no Doctor
(Indian reprint)
(VHAI C.20)
He lti> Education Materials
Apart from the health education pamphlets, slide sets and films
of TB Association of India (national and State level brandies)
contact them for further details.
1 Set of slides produced by TRACE (Marie •souza)
2 Child hood tuberculosis t TALC set of sli es (VHAI TBnH)
3 BC< vaccine and tuberculosist Reprint VHAI D.32
4 TB can be curb'd t OX Poster (VhAX .12)
5 Tuberculosis is curable t Flash c rds (VHAI D.80)
6 Tuberculosis is curallei Film strip (VHAI D.82)
7 Tuberculisis is curable* Slides (vhai D.81)
8 IB patient retained record (VHAI HR3)
for Ant nva^is
9 Recognition of lowr respiratory infection t Chart
(PGI Chandigarh)
ptlwr
of information.
1.* Refer
Journals (Ir. la)< for
rvs,, itsi. to
vw TB w
—r— 1984-85 an
about any Health education materials
2.
collect Inf oration
rite to Ms Seethe, national Tuberculosis Institute, Bellary
Road, Ban^lore 560003
3. ./rite to UMICBr Office New Delhi
3.
rite to liAi New Delhi for information later than that
given in their blue catalogue (1983)
/
COMMUNITY HEALTH CELL
326. V Main. I Block
4-’ >'
Korimangala
Bingalort-560034
tadia
TUBERCULOSIS IS CURABLE
VOLUNTARY HEALTH ASSOCIATION OF INDIA
C-14, Community Centre, Safdarjung Development Area
New Delhi - 110016
And
THE FOUNDATION FOR RESEARCH IN COMMUNITY HEALTH MANDWA
This is Ram and his wife Rukmani.
They share the joys and
sorrows of bringing uj their children*
Krishna and Shoba*
2*
They have two children,
They have been living happily together but
For a month or two, Ram has not been feeling well*
has fever*
He often
He used to enjoy Rukmani’s cooking, but now he has
lost his appetite*
He is losing weight*
He has cough.
Rukmani
is worried*
Rukmani s
’’You should show yourself at the health centre”
Ram
”0h its just the change of season.
I’ll be better
in a few days.”
As the days pass. Ram gets thinner*
His cough gets worse.
He
coughs up thick sputum eveiy morning* Ram’s coughing keeps
Rukmani awake at night.
Ram feels very tired.
Rukmani 2
’’You should show yourself at the health centre."
Ram
’’All right.
I’ll go tomorrow.
I am still having
fever and I don’t feel well."
At the health centre the doctor examines Ram’s chest.
Doctor
”Ram how long have you been coughing sputum*”
Ram
’’For about one month,,doctor. 11
Doctor
2
"I will give you some cough medicines*
like you to come back again.
And I would
Before you come, please
spit some sputum into a clay pot and bring it with you
next time.
We will test the sputuip then* it
...2/-
-2-
5.
After a few days, Ham is still feeling ill.
He has fever.
gets a clay pot and spits some sputum into it.
to the doctor.
He
Then he goes
The doctor first examines the sputum under
a microscope.
Doctor
”Ram you are very sick.
Do you know why?
tuberculosis in your chest.
You have
This is why you are
feeling ill.”
Ram (to s
himself)
"Just as I feared."
Rukmani s
"This was our fate from the beginning. tt
She begins
to cry.
Doctor
”TB is not due to fate.
Tuberculosis is caused
by germs in the sputum.
The disease spreads to you
from a person ill with tuberculosis.
Tuberculosis
spreads by spitting and coughing."
6.
Doctor
"Look, I see that you do not believe me.
So I want
to show you both the tuberculosis germs.. This is
a microscope.
It 3s like a veiy strong pair of glasses.
When you look through the microscope, you can see
small small things which you cannot see just with
your eyes.”
First Rukmani looks and then, Ram looks through the microscope.
■He sees; these germs which are shown on the right of this picture.
Ram
”0h, I can see some long kind of worms here.
Are they
the tuberculosis germs?"
Doctor
i
"Yes they are the germs which are living inside your
lungs, and they are growing there.
But the medicine
I will give you will kill the tuberculosis germs."
Rukmani wasn’t listening (She kept on crying quietly).
Ram
"How did these germs get into my lungs?"
I
1
-5”Some months ago, I think, someone with tuberculosis
Doctor
coughed and coughed near you, then the germs went inside
when you took a breath.
The germs then made their
home in your lungs.”
7.
Ram,?;
s
”0h yes, last year my brother stayed with us for
He also had
several months.
He was always coughing.
a lot of sputum.
Just last month my brother died.
We went to his village for his funeral.”
”Yes it is quite possible that you caught tuberculosis
Doctor
from your brother.
But don’t worry now,”
Ram
’’But my brother died of this disease. ii
Doctor
”1 am giving you all the medicines.
get well.
You will surely
But it will take a long time.
It is veiy
important for you to take the treatment for the full
18 months.
Otherwise you may become sick again. t!
”Yes, but if I have to take so much medicine it will
Ram
cost a lot of money,”
Doctor
s
’’The INH tablets for treatment of tuberculosis cost
three rupees for a month’s treatment.
Usually you can
get them free from any government health cnntre.
You
will need streptomycin injections for one month.
They
will cost you at least one rupee for each injection.
Usually you can get them free from the government
health centre.”
8.
Rukmani ;
’’Here is your medicine.
You must take this eveiyday.
I would never have thought it was true what the* doctor
said, that ;we could buy INH tablets for a whole month
for three rupees.”
t
-4-
Ram
"Well it is still expensive, Rukmani, especially when
I cannot earn properly.
But if I get well, then I can
work again, and earn money.
So it is good if I get well
quickly."
Rakmani
§
"Yes, doctor said that in a month or two you will feel
better and be able to work a little.
Then our worries
will be less."
Ram did not want to spread the disease to his children.
So
whenever he coughed and wanted to spit, he did not spit on the
ground where the children played.
Instead he spat into an old clay
pot in the fire, and left the pot on the fire for 10 minutes to
kill the germs.
Thei he used the same pot for spitting into the
next morning.
He was also careful to cover his mouth with his hand
when he coughed so that he did not cough over the children.
10.
Ram did not want his children to get tuberculosis.
So he slept
on the verandah until his cough and sputum went away,
Then the
children did not have to breathe up his air when he coughed.
After
taking his tablets every day for two months his cough became much
less, and his sputum disappeared.
He felt very relieved.
He went
to tell the doctor.
Ram
s
"Now I am feeling much better, and my cough is muc& less.”
Doctor
s
"That is very good.
You are getting well again.
But it
is important to take the treatment for the full 18 months.
If you stop the disease will come back again.
And it wilx
be much worse then.”
11.
The doctor did not want the chiIdren to get tuberculosis.
So J*
the doctor asked Rukmani to bring the children for a check up.
.found that Krishna and Shoba were both healthy,
an injection of BCG.
He gave them both
This injection is given on the shoulder, and
it helps to protect the child from tuberculosis.
not cause fever."
He
The injection does
community'c6U*
326, V Main I * ac*
Koranvng
Bangalore-560034
-512.
India
Ram had not been working for the past two months.
Ram
He was worried.
’’For these past two months I have not been earni ng any
money,"
Rakmani s
"Yes, there is very little money left.
And we only have
grain enough to last for another month."
Ram3
The doctor advised me that we should consider famj1y
planning, so we do not have another child.
Another
child in the family would be one more to feed."
Rukmani
"And think how healthy Krishna and Shoba are.
And they
are both doing so well at school."
Ram
15.
"So I shall ask the doctor about it when I go next week."
After a few months of treatment for tuberculosis Ram is back to work.
He feels much stronger.
food again.
He is not so thin.
Now he is enjoying his
He has gained several kilos weight.
sure that he takes his tablets regularly.
disease to come back again.
Rukmani makes
She does not want this
She wants Ram to take the tablets for
18 months as the doctor said.
14.
Eighteen months go by.
Doctor
Ram visits the doctor fO.r a final check up.
"Oh how are you, Ram.
How are you feeling now?"
Ram
2
"I am feeling very well 9 thank you doctor."
Doctor
2
"You certainly look well.
I am glad that you have recovered
Have you any cough or sputum?"
Ram
2
"No.
And now I can work all day without getting tired.
I am completely well again. M
15.
Ram is glad.
The children are well, and did not get tuberculosis.
The doctor had given them good advice.
Ram knew he was 1alive
and well only because he took the treatment for the full 18 months.
The tuberculosis is cured.
The tuberculosis will not come back.
The whole family is happy and healthy again.
DRUG
REGIMENS
Recommended in National Tuberculosis Programme
For sputum positive TB patients
a)
Code
No.
R
1
R
2
R
Drugs and Dosage
4
Both drugs in a single dose or
in two div'ded doses orally
daily
Self— administered at home
after meal. Collected monthly
from DTC/PHI
Bl weekly regimen
Inj Stieptomycin
0.75 g I 1 g._}_
Intramuscularly
Both drugs given at the same
time under supervision at DTC/
PHI twice weekly at intervals
of 3 and 4 days.
Isoniazid 600 to
700 mg (15 mg/kg
body weight) with
Pyridoxine 10 mg
Orally
Isoniazid 300
PAS 10 g.
In a single dose.
In two divided doses
Both drugs orally,
daily
Self-administered at home after
meal. Collected monthly from
DTC/PHI
Both drugs in a
single dose,
daily,
orally
Selt-administered at home after
meal. Collected monthly from
DTC/PHI
mg +
Isoniazid 300 mg
Ethambulol 20 mg/kg
body weight, i.e.
800 mg for pts.
weighing >50 kg and
1200 mg for > 50 kg
Biphasic regimen
a. Intensive phase
R
5
Inj. Streptomycin
0.75 g / 1 g. _|_
Isoniazid 300 mg _|_
Thioacetazone 150 mg or
Ethambutol 20 mg
per kg body we’ght
i.e. 800 mg for
pts. weighing <50
kg and 1200 mg for
those >50 kg or
PAS 10 g.
b.
b)
Instructons
Isoniazid 300 mg
Thioacetazone 150 mg
3
R
Mode and Rythm of
________ administration
First two months
Intramuscularly,
daily
8 In a single dose
8 orally, daily.
g (PAS and Thioacetazone
g may be given in two
8 divided doses)
g
g
Injection given under supervi
sion and the rest to be self
administered at home.
8
Continuation phase
Remaining period
With Rj , R2, R3, or R 4
As for each regimen
For the sputum negative TB patients
As for each regimen
(Suspect cases)
TB patients in whose sputum AFB are not seen, are prescribed Regimen R
1 i.e.
Isomazid 300 mgm_|Single
dose
orally
8
Thioacetazonc 150 mgm
daily for 1 to 1J years
g
Patients, allergic to Thioacetazonc can be treated with R4
Duration of Treatment
All patients should be treated for a minimum of I year or optimum of 11 years duration irrespcctive of their disease status, By duration of treatment for 1 year to J >- years is meant that
intensive efforts should
should be
be made
made to keep the patient on regular treatment for [atleast one year,
Even if patientss at
the
at the end
end of
of one year are regular, treatment should be continued upto 18
months in order to prevent relapses.
Treatment can be continued upto 2 years after review at the end of 18 months but continuation
beyond two years has no added advantage.
From:
National
TB
Institute
BANGALORE-560 003
Published by:
Karnataka State Tuberculosis Association
No. 3, Union Street, Bangalore-1
Tel, No. 564387
DRUG
REGIMENS
Recommended in National Tuberculosis Programme
For sputum positive TB patients
a)
Code
No.
R
1
R
2
R
Drugs and Dosage
Both drugs in a single dose or
in two divided doses orally,
daily
Self— administered at home
after meal. Collected monthly
from DTC/PHI
Bl weekly regimen
Inj Stieptomycin
0-75 g I 1 g.+
Intramuscularly
Both drugs given at the same
time under supervision at DTC/
PHI twice weekly at intervals
of 3 and 4 days.
Isoniazid 600 to
700 mg (15 mg/kg
body weight) with
Pyridoxine 10 mg
Orally
Isoniazid 300 mg _|_
PAS 10 g.
In a single dose.
In two divided doses
Both drugs orally,
daily
Self-administered at home after
meal. Collected monthly from
DTC/PHI
Isoniazid 300 mg
Both drugs in a
single dose,
daily,
orally
Self-administered at home after
meal. Collected monthly from
DTC/PHI
Ethambulol 20 mg/kg
body weight, i.e.
800 mg for pts.
weighing >50 kg and
1200 mg for > 50 kg
4
!
Biphasic regimen
a. Intensive phase
Inj. Streptomycin
0.75 g/ 1 g. _|_
I Isoniazid 300 mg _f_
Thioacetazone 150 mg or
I1 Ethambutol 20 mg •
R
per kg body we’ght
5
i.e. 800 mg for
pts. weighing <50
kg and 1200 mg for
those > 50 kg or
PAS 10 g.
b.
First two months
Intramuscularly,
daily
§ In a single dose
S orally, daily.
g (PAS and Thioacetazone
g may be given in two
8 divided doses)
Injection given under supervi
sion and the rest to be self
administered at home.
§
g
8
Continuation phase
Remaining period
With R, , R2, R3, or R4
As for each regimen
I.
b)
Instructons
Isoniazid 300 mg
Thioacetazone 150 mg
3
R
Mode and Rythm of
________ administration
For the sputum negative TB patients
As for each regimen
(Suspect cases)
TB patients in whose sputum AFB are not seen, are prescribed Regimen
Ri i.e.
Isomazid 300 mgm-L
Single dose orally
3
Thioacetazone 150 mgm
daily for 1 to H years
g
Patients, allergic to Thioacetazone can be treated with R4
Duration of Treatment
All patients should be treated for a minimum of 1 year or optimum of
1J years duration irrespective of their disease status, By duration of treatment for 1 year to
I j years is meant that
intensive efforts should
should be
be made
made to keep the patient on regular treatment for [atleast one year.
Even if patients at
at (lie
(he end
end of
of one year are regular, treatment should be continued upto 18
months in order to prevent relapses.
Treatment can be continued upto 2 years after review at the end of 18 months but continuation
beyond two years has no added advantage.
From :
National
TB Institute
BANGALORE-560 003
Published by:
Karnataka State Tuberculosis Association
No. 3, I hr ii Street, Bangalore-1
Tel, No. 564387
yus 4 ■ 12
Vol. 2 No. 3
liilHClilosis
u
R
E
I
N
U
S
An Excerpta Medica publication endorsed by the Tuberculosis Association of India
High rate of
transmission of
in an office:
impact of delayed
diagnosis
Source: MacIntyre CR, Plant A,J, Hulls J, et al. High
rate of transmission of tuberculosis in an office: impact of
delayed diagnosis. Clin Infect Dis 1995;21:1170-4.
Outbreaks ofTB typically occur in high-risk set
tings such as hospitals, prisons and other institu
tions. However, sporadic outbreaks have been de
scribed in other closed environments including of
fice buildings, schools and aircraft.
These authors report an outbreak in an office in
Melbourne, Australia. Initially, two co-workers were
The major factor associated with the
spread of infection w as the delay in diag
nosis of the first case, which resulted in
inadvertent spread over several months
reported to have the disease and were shown by re
striction length polymorphism to be infected with
identical Mycobcicterium tuberculosis isolates.
Contact screening was performed on 195 of 210
workers at the office by means of the tuberculin
skin test, which was read in 189 cases. Subjects
with a positive reaction subsequently underwent
chest radiography.
All skin-tested employees also completed a
questionnaire concerning demographic details, in
cluding where they had worked within the office
during the period of exposure, whether they had
rotated to more than three sites druing the same
period and other risk factors for TB.
Office contacts were exposed to TB for four
months. Seventy-five per cent had received bacille
Calmette-Guerin (BCG) vaccination, 19% had not
and 6% were unsure of their status.
Based on Australian standards, 46 (24%) of the
189 employees were shown to be infected. Of those,
i
one converted from a negative to a positive reac
tion during the test period, 36 had a history and/
or evidence of BCG vaccination, five had no such
history and five were unsure of their status. No ra
diographic abnormalities were detected.
There was mi association between infection and
sitting in proximity to the index case during the
period of exposure. On-site workers had a higher
risk of being infected than did visiting workers
(Table).
No significant association was detected between
infection and rotating to three or more desks dur
ing the period of exposure, foreign birth, smoking,
BCG vaccination or history of overseas travel.
The major factor associated with infection was
the delay in diagnosis of the first case, which re
sulted in inadvertent spread over several months.
The patient concerned had acted responsibly mid
sought medical attention on several occasions, yet
despite a typical clinical presentation of pulmonary
TB, chest radiography and sputum examination
were not performed until she had been sjinptomatic
for at least four months.
The authors conclude that efforts to raise the
awareness of medical practitioners about the pos
sibility of TB should be part, of every TB control
programme. In addition, details of public health
measures aimed at the control mid prevention of
infectious diseases such as TB should be an inte
gral part of undergraduate medical education. ■
Table. Factors associated with TB infection
Factor
Proximity to index
case
Rotation to three or
more desks
Foreign birth
History of overseas
travel
Smoking
History of BCG
vaccination
Working on site
OR (95% CI)
P
value
4.24 (1.06-19.67)
< 0.05
1.85 (0.68-5.01)
0.2
1.95 (0.68-5.01)
1.22 (0.48-3.15)
0.1
0.05
0.72 (0.26-1.58)
2.10 (0.70-6.69)
0.6
0.2
5.48 (1.51-23.54)
0.005
OR = odds ratio; CI = confidence interval. Reprinted
with permission.
1
)l
)^6
Difficulty of
diagnosing 1
chifahoocl
in
Source: Schaaf IIS. Beyers N. Gie RP, et al. Respiratory
tuberculosis in childhood: the diagnostic value of clinical
features and special investigations. Pediatr Infect Dis J
1995:14:189-94.
The diagnosis ofTB in childhood continues to be
surrounded by considerable uncertainty. Diagnosis
is seldom confirmed by culture and usually relies on
a constellation of symptoms, clinical signs, tubercu
lin testing, chest radiography and a history of close
contact with an adult case of puhnonaiy TB. The
World Health Organization has suggested provisional
guidelines that make use of these and other clinical
features when diagnosing pulmonary TB in children
(Table). The authors review their experience of the
value of some of these criteria.
Over a 16-month period, children presenting to
a paediatric outpatient facility^ from an area of high
TB incidence (more than 400 per 100,000) were
evaluated for close contact with adult pulmonary TB,
weight loss, symptom duration, respiratory signs,
lymphadenopathy and hepatosplenomegaly. They
were also assessed by chest radiography and tuber
culin testing (Mantoux or tine).
Probable TB was diagnosed in 258 children and
confirmed in 109 (42%, mean age 31 months) by cul
ture of Mycobacterium tuberculosis from gastric as
pirate or another source. Eleven children with con
firmed TB had normal chest radiography.
After review of special investigations, clinical
course and follow-up of the remaining 149 children,
86 (58%, mean age 32.4 months) were considered to
have probable TB and 63 (42%, mean age 27 months)
not to have TB.
Significantly fewer children in the ‘not TB’
group than in the confirmed and probable groups
had close adult pulmonary’’ TB contact. There was
no difference between the ‘not TB’ group and the
confirmed and probable groups in the proportion
presenting with weight loss, cough or other respi
ratory’ symptoms, symptom duration of more than
two weeks, the presence of bronchial breathing,
wheeze, hepatomegaly or splenomegaly or periph
eral lymphadenopathy.
Many of the signs and symptoms com
monly used to aid the diagnosis of child
hood TB are, in fact, not very specific
when used in an endemic area
Final diagnoses in the ‘not TB’ group ineluded
bacterial or viral pneumonia or bronchopneumonia
(37 cases), asthma often accompanied by segmental
collapse (nine cases) and cavitating pneumonia (three
cases).
This study highlights, once more, the difficulty
of accurately diagnosing TB in childhood. Many of
the signs and symptoms commonly used to aid the
diagnosis are, in fact, not very specific when used in
an endemic area. Even in the presence of sufficient
clinical criteria supporting the diagnosis of TB, con
tinual reassessment is necessary.
CliaUen
treating
Source: Cohn DL. Treatment of multidrug-resistant
tuberculosis. J Hosp Infect 1995;30 (suppl) :322-8.
Numerous studies have demonstrated the ex
traordinary efficacy of six- and nine-month regimens
Table. World Health Organization provisional guidelines for the diagnosis of pulmonary IB in children
A. Suspect TB
1. An ill child with history of contact with a confirmed case of pulmonary TB
2. Any child:
2.1. Not regaining normal health after measles or whooping cough
2.2. With loss of weight., cough and wheeze not responding to antibiotic therapy for respiratory disease
2.3. With painfill swelling in a group of superficial nodes
B. Probable TB
A suspect case and any of the following:
1. Positive (> 10 mm) induration on tuberculin testing
2. Suggestive appearances on chest radiograph
3. Suggestive histological appearance of biopsy material
4. Favourable response to specific anti-TB therapy
C. Confirmed TB
1. Detection by microscopy or culture of tubercle bacilli from secretions or tissues or
2. The identification of tubercle bacilli as Mycobacterium tuberculosis by culture characteristics
2
Table. Drags used to treat multi drag-resistant TB
Drug
Amin oglycosid es
Streptomycin
Capreomycin
Kanamycin
Amikacin
Quinolones
Ciprofloxacin
Ofloxacin
Other compounds
Ethambutol
I’yraz inamid e
Common adverse events
zVlult daily dosage
15 mg kg1 5-7 days/week
15 mg kg1 5-7 days/week
15 mg kg1 5-7 days/week
15 mg kg 1 5-7 days/week
Ototoxicity, nephrotoxicity
750 mg two times/day
Nausea, abdominal paui,
tremulousness
4-00 mg two times/day
15-25 mg kg1
30 mg kg'1
Ethionamide
250 mg two to three times/day
Cycloserine
Clofazimine
250 mg two to three times/day
100-300 mg one time/day
Para-aminosalicylate
3 g four times/day
Optic neuritis, nausea
Nausea, abdominal pain, rash
h epatotoxicity, hyperuricemia
Metallic taste, abdominal
pain, heptotoxicity, arthralgia
Depression, seizures, psychosis
Skin and body fluid discolouration,
abdominal pain
Nausea, abdominal pain, rash
Reprinted with permission.
containing isoniazid and rifampicin in the treatment
of pulmonary TB. However, multidrug-resistant TB
(MDR-TB) represents a major clinical challenge.
Mortality rates of 72-89% have been reported in
HIV-infected individuals, with median intervals
from diagnosis to death of only four to 16 weeks.
Poor outcomes are attributable to delayed diag
nosis, slow reporting of antimycobacterial suscep
tibility results, inadequate treatment regimens and
pro found inummosuppression.
No prospective clinical trials have evaluated the
optimal treatment of MDR-TB. However, a retro
spective study has shown that only 56% of immu
nocompetent patients with secondary MDR-TB re
sponded to prolonged courses of multiple-drug
regimens, and 22% died ofTB. Even fewer patients
with AIDS responded, with median survivals of
two to four months.
MDR-TB is best prevented by directly observed
therapy of patients with susceptible organisms and
rigorous infection control practices in areas of high
incidence. Effective treatment regimens await the
development of novel compounds which have bet
ter in vitro activity against MDR-TB than currently
available agents.
■
Disinfectants are
not necessarily as
mycobactericidal as
they should be
Source: Sattar SA. Best M. Springthorpe VS, et al.
Mycobactericidal testing of disinfectants: an update.
J ilosp Infect 1995;30 (suppl) :372-82.
If possible, patients with MDR-TB should
receive at least three drugs to which their
isolates are susceptible for at least 24
nionths
If possible, patients with MDR-TB should re
ceive at least three drugs to which their isolates
are susceptible for at least 24 months. These regi
mens are likely to include ethambutol, pyrazmamide, a quinolone and an aminoglycoside. The Ta
ble shows the list of candidate dings used to treat
MDR-TB and the most common adverse events.
Selected patients benefit from surgical interven
tion combined with aggressive chemotherapy.
TB is the most important life-threatening bac
terial disease. Soon, the annual number of cases is
expected to rise from the present eight million to
more than 12 million due to the combined impact
of AIDS, immunosuppression and demographic
changes. Outbreaks of multidrug-resistant TB
(MDR-TB) are particularly alarming.
Against this background, there is an urgent need
to review infection control procedures, including the
claims made for the mycobactericidal activity of dis
infectants.
Mycobacteria are more resistant to disinfection
than enveloped viruses and other types of vegeta
tive bacteria, but a proper comparison with noncontinued on p. 8
3
Genitourinary I B
Source: Halim A, Gow JG. Genitourinary tuberculosis:
epidemiological resurgence and new advances. Asian J
Surgery 1995;18:3-7.
TB is an important diagnostic consideration in
any patient with an imcxplained urinary tract ab
normality. Causative agents are Mycobacterium tu
berculosis, Mycobacterium bovis and Mycobacterium
africanum. Among them, M tuberculosis is the most
virulent and infective.
In the kidney, the organism causes microscopic
foci showing classical features ofTB. The focus, pri
marily in the glomerulus, invades the collecting sys
tem which may ulcerate and be destroyed.
Low-virulence organisms produce a fibrous tis
sue reaction, resulting in stricture of the calyceal
stem, obstruction and abscess formation. Fiftythree per cent of patients may also show calcifica
tion for w hich there appears to be no clear cause.
An association has been reported between renal
TB and hypertension.
TB ureteritis is an extension of the disease, com
monly affecting the uterovesical junction. Bladder
lesions are invariably secondary, and inflammation
leads to bullous granulation mid patchy cystitis.
The diagnosis may be confirmed primarily by
isolation of M tuberculosis from three consecutive
early morning urine specimens that should be cul
tured with and w ithout pyruvate to exclude rare
cases of bovine TB.
Genitourinary TB lends itself to effective short
course treatment, as the organisms are fewer in
number than in other areas of infection and high
concentrations of chemotherapeutic agents are
achieved in urine.
A
Pyraz inamide
Isoniazid
Rifampicin
lg
300 mg
450 mg
Daily
600 mg
900 mg
Three times a week
B
Streptomycin
Pyrazinamide
Isoniazid
Rifampicin
lg
1g
300 mg
450 mg
Daily
600 mg
900 mg
Three times a week
0
2
Mont hs on treatment
4
6
Figure. Courses of chemotherapy in the treatment of
genitourinary TB: (A) standard course, (B) alternative
course in fulminating infections. Both cotuses may be
effectively terminated after four months. Reprinted with
permission.
4
Both isoniazid mid rifampicin pass readily into
renal cavities at concentrations high enough to kill
any M tuberculosis. The figure outlines the recom
mended regimens. Streptomycin may be added in
the initial two months if there is miy suggestion of
resistance or if symptoms are intense.
Genitourinary TB lends itself to effective
short-course treatment, as the organisms
arc fewer in number than in other areas of
infection and high concentrations of*
chemotherapeutic agents arc achieved in
urine
The use of steroids is justified hi severe disease,
pariicularly when the bladder is aflccted. High doses
(20 mg three tunes a day) are recommended. Sur
gery can have mi important role hi removing diseased
tissue mid for reconstructive purposes.
■
Eleven years of
community-based
DOT
Source: Chaulk CP, Moore-Rice K. Rizzo R, et al.
Eleven years of community-based directly observed
therapy for tuberculosis. J Am Med Assoc 1995;
274:945-51.
These authors assessed the value of eommunitybased directly observed therapy (DOT) for TB in
Baltimore, Maryland, USA, a city historically known
for its high case rate. Three comparisons were made:
• An 11-year retrospective comparison ofTB case
rates, sputum conversion rates (SCRs), rates of
therapy completion, mid confounding factors (AIDS,
immigration, unemployment mid poverty) between
Baltimore and five major cities in the USA with
the highest TB incidence in 1981 but no compre
hensive DOT programmes.
• An 11-year trend ofTB in Baltimore and the
19 major USA cities w ith the highest TB incidence
in 1981.
• A seven-year trend ofTB in both the live-city
group and the 19-city group between 1985 and 1992.
Betw een 1981 and 1992, Baltimore experienced
the greatest decline in TB incidence (from 35.6 to
17.2 per 100,000 population; -51.7%) and dropped
from the sixth ranked city to the 28th (Figure). In
contrast, the average incidence ofTB increased by
2.1% hi the five-city cohort and 1.8% in the 19-city
cohort. Since 1985, TB incidence increased by
35.5% in the five cities and 28.5% hi the 19 cities,
but declined by 29.5% in Baltimore.
From 1986 to 1992, Baltimore’s DOT-mmiagcd
k
I*
r
□ Miami, Fla
• Atlanta, Ga
■ San Franciso, Calif A Washington, IX'
O Newark, NJ
a Baltimore, Md
0
5
10-
152025-
31981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992
Year
Figure. Eleven-year trends in ranking among six cities
(population > 250,000) udtli the highest TB case rate in
1981. Reprinted with permission.
cases had the highest annual SCRs at three months
(mean, 90.7%), and the highest therapy comple
tion rates (mean, 90.1%) when compared with the
five cities. These trends could not be attributed to
differentials in the confounding factors.
Over time, more and more Baltimore cases were
treated with DOI' (86.5% by 1993). Relapse rates
remained low, even among IIIV-infect cd patients.
Within Baltimore, the documented SCRs were sig
Despite highly prevalent medicosocial
risk factors, Baltimore experienced a
substantial decline in TB following imple
mentation of community-based DOT
nificantly higher among DOT-managed cases than
others. Multidrug-rcsistant I'B remains rare (0.57%).
Thus, in contrast to the national increase in TB
recorded in the USA during the 1980s, Baltimore
experienced a substantial decline following imple
mentation of community-based DOT, despite highly
prevalent medicosocial risk factors. DOI' facilitated
high treatment rates and bacteriological evidence
of cure. It may help reduce TB incidence elsewhere,
particularly in cities with high case rates.
■
WHO calls for action
against I B
Source: Nowak R. WHO calls for action against TB.
Science 1995:267:1763.
In a report released last year, the World Health
Organization (WIK)) revealed that an old scourge,
TB, is still rampaghig out of control, despite WHO’s
campaign to prevent its spread. Most alarmingly,
multidrug-rcsistant (MDR) strains ofMycobacterium
tuberculosis are being isolated at an increasing rate.
In the West, elTorts to combat TB have largely
relaxed due to the mistaken belief that the disease
was brought under control with the introduction of
effective drugs in the 1940s. In fact, the epidemic
had simply been pushed into the poorer reaches of
society — the inner city dwellers and the homeless
— and is now re-emerging with a vengeance, partly
due to the spread of IIIV infection.
In developing countries, governments have been
slow to channel resources into TB control, even
though studies have showm it to be cost-effective
in terms of productive lives saved.
Because only patients with active TB can trans
mit the disease, WHO argues that control pro
grammes should focus on people with symptoms
(usually chronic cough) rather than wasting re
sources on screening programmes that also pick
up people with inactive forms of the disease.
Governments in both the developed and
the developing world need to be made
aware that TB is a huge problem, but that
there is a cost-effective treatment
It is essential that patients complete tlieir course
of treatment in order to limit the spread ofTB and
prevent the emergence of resistance. The most ef
fective way to ensure that this happens appears to
be the use ofdirectly observed therapy programmes.
Governments in both the developed and the de
veloping world need to be made aware that TB is a
huge problem, but that there is a cost-effective
treatment.
■
Cost-effectiveness of
anti-1B interventions
Source: Castelo A. Mathiasi PA. lunes R. et al. Cost
effectiveness of antituberculosis interventions.
I’li armaco Econc > mics 1995:8:385—99.
The treatment of TB is ranked as the most costeffective of all therapeutic programmes in terms of
cost per year of lives saved. Nevertlieless, TB kills or
debilitates more adults between 15 and 59 years of
age than any other disease; liuthermore, about 24% of the burden of all disease, 7% of all deaths and
26% of all preventable deaths are directly attribut
able to TB.
About one-third of the world’s population is in
fected with theTB bacillus. In the developing world,
more women of childbearing age die from TB than
from causes directly associated with pregnancy and
childbirth. The deaths of adults in their prime, who
are parents, community leaders and producers in
most societies, represent a major social burden and
continned on p. 7
.X
>0>G
’
)
0'
y 7'
5
Kditorial
Primary Treatment
of Tuberculosis
Dr. D. R. Nagpaul. honorary technical adviser. The
Tuberculosis Associat ion of India
It is not sufficiently appreciated in India, mid per
haps elsewhere, that proper primary treatment of
TB should occupy the centre stage of our endeavoius. All the other concerns that are being pushed
forward with a good deal of justification, such as
multidrug-resistantTB and/or HIV-TB nexus, are of
secondary importance. In fact, the rising trend in
the emergence of chug resistmice is a reflection of
the frequently misconceived mid mismanaged pri
mary chemotherapy mid, indirectly, mi index of how
“unconcerned” mid “ill prepared” we in the profes
sion generally are about providing good primary treat
ment to our TB patients. The reasons commonly ad
vanced to explain this important shortcoming, by
blaming patients and calling them defaulters, be
trays how defensive we are about our failure to cope
with this important requirement. Several studies in
Indian medical literature have shown that doctors
as well as public health sendees are as much to blame
for poor treatment as are patients themselves. Per
haps we really do not care enough; but we must, bi
dealing with the consequential grave problems, re
ally of our own making, we are using the same proce
dures, practices mid attitudes that led to them in
the first place. Are we ready to accept actual mid
moral responsibility’ for treatment failures mid chug
resistance?
Newly discovered fresh cases of TB yield
the best treatment results possible —
almost 100% in trials and 85% under field
conditions
Proper primary treatment of TB has two great
advantages. Newly discovered fresh cases ofTB yield
the best treatment results possible — almost 100%
in trials mid 85% under field conditions. Thus, re
ducing mortality mid suffering can become a power
ful tool for social happiness and economic develop
ment. Simultaneously, converting positive sputum to
negative status can help control the spread of infec
tion. It is true that by the time an infectious case is
discovered, cither by a private medical practitioner
or the health services, some degree of spread of in
fection to close contacts has already’ taken place.
However, it has also been shown that in some devel
oped countries, good treatment programmes speed
up the observed natural decline in TB cases from
about 2% to over 10% per annum. The decline of cases
under cjqierimental conditions in the relatively small
but closed communities of Eskimos in Canada and
Greenland was around 15%. We stand to lose both
(5
of these advantages because of an ambivalent atti
tude to the importmice of primary treatment of TB,
not to mention the gravity of precipitating drug re
sistance.
Several assessments of the Indian National Tu
berculosis Programme (NTP), the last carried out
by a joint team of the Government of India, the
World Health Organization and World Bank, have
convincingly shown that no more than 30% of the
cases in the community are being found. The stand
ard 12- to 18-month treatment regimen is achiev
ing about 30-40% treatment completion that im
proves to 40-50% with six months, short-course
chemotherapy. How many patients become noninfectious at the end of treatment is not reliably
known. The conditions prevailing in the private
sector are perhaps worse, but largely unknown. A
recent study carried out by t he Foundation for
Research in Community Health, Bombay, in the
state of Maharashtra, and published as a mono
graph entitled “Tackling TB: The Search For So
lutions”, is an eye opener. Knowing that approxi
mately 60% of patients with chest symptoms first
contact a private medical practitioner in search of
diagnosis and treatment, only deepens the gen
eral feeling of disquiet.
No useful purpose is served by separating
case-finding from treatment and allotting
them different priorities, as is sometimes
done by programme planners
No useful purpose is served by separating case
finding from treatment mid allotting them differ
ent priorities, as is sometimes done by programme
planners. An infectious patient who lives, suffers
and dies without being properly diagnosed should
be as much our concern as the one who is placed
on treatment but does not become infectious li ce.
Both are a danger to the community. The treat
ment of resistant cases with every costly and toxic
drug gives generally poor results, and t he expense
incurred from treating one resistant case can be
sufficient for treating 10 fresh cases that yield
more satisfying residts. The revised strategy of NTP
has laid down definite objectives for case-finding
and treatment: detecting 70% of the estimated
case-load in the community through quality spu
tum microscopy and achieving at least mi 85% cure
rate among infectious cases put on treatment for
the first time. It will benefit the community, pro
fessional programme planners and executors, not
to lose sight of these objectives.
■
As a part of their endorsement of Tuberculosis:
Curren t Issues, the Tuberculosis Association of
India will, from time to time, provide editorials.
2
T\v() patients with a
lump in the neck
Two patients presented with a lump in the neck.
The first was a male, aged 24. The lump was in the
left side of his neck, just above the clavicle. It had
enlarged gradually over the preceding eight weeks.
Otherwise, he had been generally well, although on
one or two occasions he had awakened at night
bathed in sweat, and his skin felt itchy. Six years
earlier, he had had a similar but smaller lump re
moved from the other side of his neck. On examina
tion, the scai’ from that operation could be seen in
the right anterior triangle. The new lump was in the
left anterior triangle, arising from behind the clavi
cle. It was 6 cm wide and 2 cm from front to back.
The surface of the mass was not fixed to the skin
and felt lobulated, and the consistency was firm and
rubbery. The mass seemed fixed to deeper structures.
The second patient was a 30-year-old male who
had no noteworthy past history. The lump was on
the right side of his neck, under the ear. He had
suddenly noticed it four days previously, but his
wife said she had seen it three weeks before. He
had been more concerned about pain and weak
ness in his right arm that had become progressively
worse over the last four weeks. He had lost some
weight and had suffered night sweating attacks.
Examination showed a firm fixed tender mass 3
cm x 2 cm behind the right stemomastoid, with
weakness and wasting of the muscles of the right
arm supplied by the seventh cervical nerve and mi
absent triceps jerk.
QUESTIONS
1. Give at least three possible diagnoses that
would fit either case.
2. What is the one investigation that would be
most likely to establish the diagnosis in
either case?
Night Sweats
A 26-year-old man presented with night sweats.
Chest radiograph showed bilateral hilar mid me
diastinal lymph node enlargement. General exami
nation revealed no abnormality. Investigations
showed:
Hl) 12.6 g/dl
WBC 7.3 x 109/l
ESR 55 mm in the first hour
QUESTIONS
1. Give three possible diagnoses.
2. Give five further tests likely to establish the
diagnosis.
Answers on p. 8
Source: These case studies were taken from Gillmar
MDG, Gordon D, Sever PS, el al. 100 cases for stu
dents of medicine. 2nd edn. Churchill Livingstone,
1991; and Hawkins RL. ed. Pocket Series for MRCP
Part 2, Book 1: Cardiology and Respiratory Medicine.
Knutsford: Fastest, 1990.
CASE STUDIES is a regular feature of Tuberculosis: Current Issues. Doctors’ contributions will be
accepted for publication subject to review. Please send your case study to Excerpta Medica Asia Ltd.
continued from p.5.
public health problem. Unfortunately, in the poorest
countries, where the TB problem is greatest, control
strategies that are economically feasible tend to be
less effective.
Operationally, the main components of a TB con
trol programme are: (i) detection and treatment of
the disease; and (ii) prevention through vaccination
and prophylaxis. Priority should be given to ensur
ing that patients complete their prescribed course
of chemotherapy, as effective treatment is the most
effective way of preventing TB from spreading and
controlling the emergence of drug resistance.
Health units that achieve high cure rates
should be able to attract most patients in their
catchment areas for treatment and prevention. It
does not seem warranted, therefore, to divert en
ergy and resources away from treatment towards
active case-finding or chemoprophylaxis before a
cure rate of at least 85% is achieved.
Short-course chemotherapy, ideally via directly
observed therapy (DOT), is preferable to standard
anti-TB regimens in virtually all cases. However, the
DOT programme adopted should be cost-effective
in the context of local conditions and culture.
It does not seem warranted to divert
energy' and resources away from treat
ment towards active case-finding or
chemoprophylaxis before a cure rate
of at least 85% is achieved
With the exception of HIV-infected patients,
chemoprophylaxis is unlikely to be justified on t he
grounds of cost-effectiveness in countries falling
far behind the goal of an 85% cure rate among newly
detected smear-positive TB cases.
Finally, bacille Calmette-Guerin vaccination is
an important public health tool that should be used
as part of a comprehensive strategy against TB,
not as an isolated measure.
■
7
continued from p. <3
enveloped bacteria requires more data.
Flaw s in current protocols for mycobactericidal
activity are shown in the Table. Furthermore, these
authors report that a product meant for 14-day
Table. Shortcomings of current mycobactericidal
protocols
Lack of proper quantitation
Unrealistically long contact times at higher than
ambient temperatures
Absence of a suitable organic load
Ineffective neutralisers
Unsuitable surrogates for Mycobacterium tuberculosis
Improper recovery media
Inappropriate types of carriers
reuse (2% alkaline glutaraldehyde) wras nonmycobactericidal after only one week of actual use
in an endoscopy unit. Taken together, these con
siderations make the available data on product ef
ficacy unreliable, particularly in view of the increas
ing threat from MDR-TB.
Available data on mycobactericidal effi
cacy arc unreliable, particularly in view of
the increasing threat from MDR-1'B
Recent findings suggest that the following
should make mycobactericidal tests more precise
and reliable: the use of Mycobacterium terrae as a
surrogate, better recovery media, flat surfaces as
carriers, elimination of neutralisers, proper removal
of cell clumps and a required > 4 log™ reduction in
the number of colony-forming units of the test bac
terium after disinfectant treatment. All of these
make product selection and registration easier.
There is also mi urgent need to develop stand
ardised protocols to determine the mycobactericidal
activity of disinfectants under conditions of reuse. ■
ANSWERS TO CASE STUDIES
Case I and II
1. From their descriptions, the lumps in both cases
almost certainly arise from lymph nodes, and
the problem is that of the differential diagnosis
of chronically enlarged cervical lymph nodes.
Chronic lymphadenopathy is likely to be due
to chronic infection or to infiltration with neo
plasm. The lymphadenopathy of infectious
mononucleosis, secondary sjqihilis or toxoplas
mosis is transient, rather than persistent and
and progressive. Lymphadenopathy secondary
to a pyogenic infection elsewhere could present,
as in these cases, except that the nodes would
be very tender and would not tend to mat to
gether as in the first case. Also, the site of the
primary infection should have been found on ex
8
amination. The chronic infection that is most
likely is TB. The past history in the first case
is a little suggestive of TB, with previous exci
sion of a lump that may have been a tubercu
lous node. Both cases have had night sweats,
typical of a tubercular infection.
Possible neoplasms are many. Primary neo
plasms oflymphoid tissue include lymphatic leu
kaemia, lymphosarcoma and reticulum cell sar
coma. In this age group, these arc all less com
mon than Hodgkin’s disease. Hodgkin’s disease
often starts in cervical nodes that typically feel
rubbery, as in the first indMdual, who also shows
fever mid pruritus, common systemic manifesta
tions of Hodgkin’s disease. The second case, with
fever and weight loss, could also have Hodglcin’s
disease, with the additional problem of a deepseated mass of Hodgkin’s tissue compressing the
seventh cervical nerve root. Both cases could also
have a secondary neoplasm growing in their
nodes, with a primary carcinoma elsewhere. This
is perhaps the most likely diagnosis in the sec
ond case, as carcinoma is more prone to invade
and compress neural tissue than is primary
neoplastic lymphoid tissue or a simple inflamma
tory or tuberculous mass.
2. The one investigation likely to give a definite di
agnosis in either case is biopsy ofmi affected node.
This was performed. The diagnosis in the first
case wras nodular sclerosing Hodgkin’s disease,
and m the second, rather unexpectedly, was TB.
Case III
1. Lymph node TB, sarcoidosis and lymphoma can
produce this appearance on chest radiograph
and are the most likely diagnoses in this man.
2. Fibreoptic bronchoscopy and transbronchial bi
opsy might show7 evidence ofpulmonary involve
ment in lymphoma or TB and will reveal noncaseating granulomata in 80% of cases of sar
coidosis, even in the absence of abnormaility hi
the lung fields on chest radiograph. Tuberculin
skin testing might be helpfill because it is likely
to be positive in TB but negative in sarcoidosis.
If the diagnosis remains unclear, mediastinos
copy and lymph node biopsy are indicated.
The scrum angiotensin converting enzyme may
be elevated mid Kveim test positive in sarcoido
sis, but the delay inherent in obtaining the lat
ter is unacceptable in this patient.
■
Tuberculosis: Current Issues is supported by an
educational grant from Glaxo Pharmaceuticals. It is
prepared and published by Excerpta Medica Asia Ltd.
Subscription enquiries should be addressed to:
Exceqjta Medica Asia Ltd, 19/F, Eight Commercial
Tower, 8 Sun Yip Street, Chai Wan, Hong Kong.
© Excerpta Medica 1996
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J. Com. Dis., 27 (2): 107-111, 1995
W 4:
Profile of Tuberculosis - An Army Experience
(/ieceiuedforpublicacion : 13 December, 1994)
L.S. VAZ’, PK DUTTA", W.P. THERGAONKAfT*
abstract
Ii
With the advent of IUV infection an increased
awareness has
attsen on its effect on the incidence of various diseases. 1_
In the Indian
context an increased incidence of Tuberculosis has been
—.1 expected.
.‘.h,y
g“”-
lu'XeXi .s"MZro"dh.'"T'"”?‘ K
'“™- '‘■P
p, lh.
INTRODUCTION
developing countries1. Despite rapid Advances
Health lntervention in
of this dreaded disease, it continues to be n
of investigation and treatment
tubercuiosis has been hampered Ly the potential 3.7“
COUntlyU' C°ntr01 °f the
country.
potential of the large reservoir of infection in this
During World War I, tuberculosis played a large role in the Tndi
ian Armed Forces with
In7nibr Ot l"dl,vldQals beinS evacuated from the theatre < of1. war due to the disease. The
. idian troops had an incidence far in excess of British troops
In the Armed forces the control of tuberculosis has been I
arresting the spread and also as a means of decreasing the w- ' taken up in earnest for
wastage
of trained manpower,
Hence it was the decided to study the secular trends of tube)
’
since independence,
infec^opu^^n.150"'"
elaborate -arculosis
^e
- Aa age distribution of the
material and methods
Pf.'pwi. annual health reports of th. Ara,™ "th.X
2pmn7rrCnmin“dingStatiOnHealth O^i^tion, Secunderabad
S was collected.
“
Vaz et al
108
"fresh admissions were considered and cases admitted for review, release on medical
grounds etc. were ignored.
Data of pulmonary tuberculosis (being the single largest form of tuberculosis) were
analysed for the past decade.
The average bed days spent in hospital by service personnel were calculated, on the
basis of total duration of stay in hospital during year 1993.
The data received from hospitals was also screened for invalidments (i.e. release from
service on medical grounds) and mortalities in the past one decade.
A study was also carried out of the age distribution of tuberculosis cases in the year
1993. The denominator in this case was the population size in the various age groups.
RESULTS AND DISCUSSION
From available data it is evident that tuberculosis has not declined in this country’2.
However, due to the mode of recruiting only fit individuals in the army, higher doctor
patient ratio and rigorous implementation of control measures the disease incidence in the
Army is much lower than in the country as a whole.
The incidence of tuberculosis in the army has not altered significantly in the 45 years
since independence (Fig.-I). This compares favourably with reports of some other workers
who have not found any change in the incidence in the country2. The increase in incidence
is in conformity with the study carried out be Styblo et af which shows an increased
incidence of tuberculosis in the entire South-East Asian region in the years 1985-89:
The trend in tuberculosis has not been similar in officers and non-officers (Ors). The
rate in officers is much less than that of Ors. The general tendency is for the rate to
fluctuate in a narrow spectrum between 0.6 - 1.1 since 1972. Prior to 1972, the rate varied
from 0.3 - 0.7/1000. The sudden rise since 1972 could be due to better diagnostic facilities,
increased reporting and awarness in the population th-i the disease is amenable to
complete cure. Retrospective epidemiological studies in the matter to pinpoint the reason
for the increased incidence require to be carried out.
Pulmonary' tuberculosis is the main form of tuberculosis in troops. The rate in last
decade has varied between 0.2 - 0.7 in case of officers and 0.7 - 1.5/1000 for non-officers.
representing approximately 50 to 60% of all cases of tuberculosis (Table 1).
TABLE 1—TREND OF TB (PULMONARY)
YEAR
OFFICERS
MCOs/OR
TOTAL
1985
0.75
1.37
1.36
1986
0.24
0.68
0.68
1987
0.26
0.94
0.92
1988
0.51
0.97
0.95
1989
0.53
1.08
1.07
1990
0.41
1.29
1.26
1991
0.51
1.39
1.36
1992
0.78
1.58
1.56
1993
0.73
1.35
1.33
•Junior Commissioned Officer & Other Ronks
TB in Army
109
The rate of hospitalisation among the non-officers varied from 1.2 - 2.4/1000/ No
specific trend was noticed in the incidence. The 1992 incidence of 2.42/1000 for nonofficers and 2.41/1000 for all personnels reflects the highest incidence since independence.
However it is not a significant increase as compared to the previous few years. A gradual
increase has taken place since 1989 onwards from 1.62 in 1989 to 2.41 in 1992.
The increase in tuberculosis has been linked in the West with an increase in the HIV
positive population6'*. The number of cases with such an association have been estimated
to be 10% of the tuberculosis cases10. Estimates for the SEARO region have been put at 6%
of the cases detected in the year11.
1992 has seen the highest tuberculosis incidence in the army since independence
(2.41/1000). However, whether the present increase in tuberculosis in the Army could be
due to better diagnostic facilities or is due to HIV infection is purely a matter for
conjecture as HIV testing of all TB cases was not being carried out earlier. Such a study
carried out nt Grant Medical college and JJ Group of Hospitals revealed a prevalence of
5,1%U U. Studies at Haftkine Institute have shown that 37% of HIV positive cases present
with Tuberculosis while 5.3% of AIDS deaths were due to TBW. A more detailed
prospective study into the matter would hence be definitely a meaningful exercise.
Manpower wastage due to hospitalisation was calculated and the average mandays
spent in hospital was 204.37. Though figures for mandays spent for the disease in civil
hospitals in the country are not readily available. The high manpower wastage is due to
the general policy in the Armed Forces to give 6 months hospitalised treatment for service
personnel prior to sending individuals to the unit.
Farther loss to manpower occurs in the disease due to invalidments (individuals
released from service on medical grounds) and mortalities (Table 2). A reflection of the
efficacy of therapy is the decrease in the incidence of invalidments after 1989. The
mortality due to the disease (complicated forms of tuberculosis, TB meningitis,, miliary
tuberculosis) has not exceeded 0.01/1000 in the past decade while it has been below 0.005
in the past 3 years. (Table-2). Both these features reflect an improvement in the control of
the disease.
TABLE 2—INVALIDMENTAIORTALITY-TB CASES
_______ OFFICERS_____________ JCOs/OR_______ TOTAL
*1NVLD_____________ -___________ 0.41_________ 0.39
0.01
**MORT
0.01
INVLD_____________0.03__________ 0.34_________ 0.33
1986
0.01
MORT
0.01
INVLD______________ -___________ 0-24_________ 0.23
1987
0.01
MORT
0.01
INVLD_____________0.03__________ 0.16_________ 0.15
1988
0.01
MORT
0.00
0.00
INVLD_____________0.03__________ 0.12_________ 0.12
1989
0.00
MORT
0.00
0.00
INVLD____________ 0.03__________ 0.14_________ 0.14
1990
0.00
MORT
0.00
0.14
INVLD
____________
0.05
0.05
__________
0.14
_________
1991
0.00
MORT
0.00
INVLD______________ 2___________ 0.15_________ 0.15
1992
0.01
MORT
0.01
INVLD______________ :___________ 0.13_________ 0.14
1993
__________
MORT______________ 2___________ 0 01_________ 0.01
* INVLD - Invalidments (Discharge from service due to medical grounds)
** MORT - MORTALITIES
YEAR
1985
Vaz et al
110
Sometime there has been a gradual shift in the age groups involved in tuberculosis
from the younger group to the older age groups. The present study shows that in the
armed forces there is a steady incidence of tuberculosis from 20-25 years. (Fig.-2). A dip in
incidence in the group below 20 years and above 55 years may be due to the population of
this group being relatively very small. The findings are consistent with the general trend
of the disease world over11.
TB-AGE
DISTRIBUTION
30 (12.47.)
25 (14.097.)
35 (12.57.)
25 (5.57.)
40 ( 12.17.)
55 ♦ ( 5.67.)
45 (12.17.)
55 ( IB.57.)
50 (11.17. )
T B-SECUL AR TREND - ARMY
RATE / 1000
YEARS ( 1947- 1993
■ - OPFICFRS
□ - JCOs/OR
TB in Army
Ill
Despite a large amount of effort and resources being poured into the National
Tuberculosis Control Programme, no major dent has been made in the incidence of the
disease in the country. Due to the high doctor patient ratio and meticulous control
measures in Armed Forces it was expected that there would be decline of tuberculosis in
the forces. However the same has not taken place.
The rate of tuberculosis in 1991 has been the highest since independence which is
cause for concern keeping in view the onslaught of AIDS in the country and the likelihood
of further increase in the disease. Increased control measures/strategies require to be
designed and implemented so as to curtail the disease at this stage.
REFERENCES
2.
Murray CJL - Tuberculosis disease control - Priorities in developing countries. Health Policy
Rrtni-U’, 1991 Oxford University Press, New York.
BB Surpal, Tuberculosis - Yesterday, Today & Tomorrow - bit. Conf. Health Policy, 1986, New
3.
Delhi.
Park JE and Park K, Tuberculosis. In Park’s Text book of Preventive and Social Medicine, 1991,
•I.
131.p.
CDC /Vtlanta, Tuberculosis Morbidity in US - Final data 1990, MMWR, 1990, 40, SS-3, PP 23-27.
5.
Anon. Army HQ Medical Dte, Indian Armed Forces in World War (1939-1945) 1995. PP 527-29.
(i.
Sly bio K, The global aspects of tuberculosis and HIV infection, Bullettin International Union
against Tuberrnlusis and Lung diseases, 1990, 65: 28-32.
7.
Barnes PF, Bloch AB and Davidson PT, TB in patients with HIV infection, Neuj Eng. Jour Medi.
1991, 234 : 1644-50.
Bloch AB, Cauthen GM and Hayden CH, The epidemiology of TB in U.S - Seminar Resp infect;
1989, 4 : 157-60.
('DC Atlanta, Tuberculosis and AIDS - Florida, MMWR, 1986, 35: 587-90.
I.
8.
9.
10.
11.
12:
13
14.
CDC Atlanta, Tuberculosis and HIV infection - Recommendations of Advisory Committee for
elimination of tuberculosis, 1989, 38:243-50.
Selwin PA et al - A prospective study of the risk of TB amongst IV Drug users with HIV infection Neiu Engd. Jour. Med., 1989, 320 : 545-550.
Sudre P et al - Tuberculosis a global overview of the situation - Bull Wld Hlth Org 1992, 70, (2):
149-159.
Dalal PJ - Prevalence of HIV Infection in patients with active Pulmonary Tuberculosis - Paper
presented at Second International Congress on AIDS in Asia and the Pacific Nov. 92, 1992, New
Delhi.
Par PK ; Prevalence of HIV Infection in patients with persistent Pulmonary Tuberculosis - Paper
presented at Second International Congress on AIDS in Asia and the Pacific Nov. 92, 1992, New
Delhi.
15.
Gharpune HM, Chandelem NG, Sengupta SR - Serosurveillence of HIV Infection in immigrant
workers - Paper presented at Second International Congress on AIDS in Asia and the Pacific Nov.
92, 1992, New Delhi.
JH5 4 '
DIAGNOSIS AND TREATMENT OF TUBERCULOSIS
Under the revised national tuberculosis control programme,
emphasis is placed on (1) sputum diagnosis of tuberculosis;
chemotherapy;
(3) observation
direct
c--- ---(2)
short
course
treatment (DOT).
SPUTUM DIAGNOSIS
Any chest symptomatic is made to undergo sputum examination.
" • more than
The criteria for sputum examination being cough for
weight z night sweats,
3 weeks with or without fever, loss of weight,
are
examined
as
follows: 1st sample
Three samples of sputum
2nd one being an
on reporting at the health facility;
overnight sample; 3rd sample when the patient comes with 2nd
All the three samples are stained by Ziehl Neelsen
sample.
If two out of three smears are
stain and examined for AFB.
found to be positive, the patient is put on anti-tuberculosis
drugs.
If one smear out of the three is positivez the
patient is referred for X-ray examination andI if X-ray is
t reated with
tuberculosis, the -patients is treated
suggestive of ------____ ; drugs.
If negative for all the> three
anti-tuberculosis
drugs,
examinations and the patient has symptoms, he is sent
sputum c..
of antibiotics.
for X-ray examination after a course
SHORT COURSE CHEMOTHERAPY
For this purposez patients
into three categories:
with
tuberculosis are
classified
under this category: (a) new cases of pulmonary
Category I
tuberculosis - AFB with two smear positives out of three
anti-tuberculosis drugs for more
(patient who has never taken
smear negative seriously
than one month); (b) newly diagnosed of
tuberculosis,
eg.,
severe
forms
ill
patients
meningitis cdTc,
6 months
Recommended regimen - Treatment is for a period of
months
4
months
intensive
phase
and
consisting
of
2
t
4
drugs
are
During the intensive phase,
continuation phase,
Monday,
Wednesday
given on 3 fixed days of the week ( i . e . , I'
direct
and Friday or Tuesday, Thursday and Saturday) under At the
of 2 months.
observation therapy (DOT) for a period
If the smears are
end of two months, 2 smears <are examined.
If the smear is
negative, continuation phase> is started.
At
more month.
positive, intensive phase is continued for 1 examined
again,
are
smears
monthsz
2
of
3
the
end
negative or positive,
are
whether
the
smears
irrespective of
continuation phase is started.
At the end of 2 months of intensive phase
pnase,z 2 smears are taken
If
for sputum negative seriously ill cases and examined.
II
treatment.
found positive, the patient is put on category
The drugs given are: Isoniazid z
Ethaubutol.
Dosage: For adults
Rifampicin - 450 mg;
INH - 600
Ethambutol
Rifampicin,
Pyrazinamide and
Pyrazinamide - 1500 mg;
mg;
thrice weekly.
1 200 mg
Isoniazid & Rifampicin given
4(HR)3;
Continuation phase
thrice a week for the next four months.
‘
! - 450 mg - thrice weekly,
HR - INH - 6C0 mg and Rifampicin
given to the patient.
:
Blister packs for 1 week is
Sputum at 5th month is done,
is categorised as failure
started.
r?treatment is
-------
If
and
it is positive, the patient
category II treatment or
2
Category II or retreatment regimen : The following patients
(1) patients who have
are put on Categofy II treatment:
one
month;
received ATB drugs for more than
(2) patients who
have remained smear positive after 5 months of Category I
treatment; or (3) those patients with EP and smear negative
pulmonary who have become smear positive at the end of 2
months;
(4) those patients who have become smear positive
after being declared cured (relapse).
These
patients require
months.
Drug regimen:
fully
INH
Rifampicin
Pyrazinamide
Ethambutol
Streptomycin
600 mg
450 mg
1500 mg
1200 mg
0.75 9
INH
Rifampicin
Pyrazinamide
Ethambutol
600
450
1500
1200
supervised
mg
mg
mg
mg
treatment
for
3
thrice weekly
for
2 months
Thrice weekly for
one month
Sputum examination is done at the end of 3 months.
If it
remains positive, 4 drugs are continued for 1 more month,
If
it
is
positive,
the
patient
is
sent
for
culture
and
sensitivity.
If the smear is negative, continuation phase is
started.
Continuation phase
3 oral drugs, viz . ,
INH - 600 mg;
1200 mg : thrice weekly
Rifampicin - 450 mg and Ethambutol
for 5 months.
Category III - This category consists
consist s of:
(1) AFB smear
negative
new
cases
of
pulmonary
tuberculosis,
i . e. ,
radiologically positive; (2) Extra-pulmonary tuberculosis.
This group is classified as a low priority group.
consists of:
INH - 600 mg; Rifampicin thrice weekly for 2 months.
Continuation phase - IN H
thrice weekly for 4 months.
450
600
mg;
mg;
Treatment
Pyraz inamide
1500
mg
Rifampicin
450
mg
SIDE EFFECTS OF ATB:
INH
major side effect are: jaundice occurs in 0.5%.
If it
occurs, stop treatment.
Refer the case to hospital.
(A ejK/tvUn
Rifampicin - : Major side effects: a It is rare but can occur
in
alcoholics,
hepatic
disease.
Discontinue
drugs.
Occasionally respiratory distress and haemoptysis can oc c u r.
Discontinue drugs and hospitalise.
Minor side effects:
(1) Fever,
intensive therapy; (2) skin rash;
malaise - more
(3) gastritis.
common
in
Pyrazinamide : Arthralgia.
cutaneous reaction
Thioacetazone
:
Hepatitis,
may be
exfoliative
dermatitis
or
Stevens
Johnson
Syndrome.
Medication should be immediately stopped and thioacetazone
should never be given again.
Ethambutol
t CfX i c i t y .
- may produce impairernent of vision and1 occular
Should never be given to children below 6 'years.
Streptomycin
main side effects are:
vestibular damage.
Hypersensitivity - occurs occasionally and consists of fever,
head ache, vomiting and erythenatous rash.
Discontinue drug
and admit the patient.
VIS
medico friend
circle
bulletin
OCTOBER 1983
RURAL NUTRITION EDUCATION:A FUTILE EFFORT ?
Padma Umapathy*
It is a weil-known fact that malnutrition
is a public health problem in our country and
affects the vulnerable section of population
comprising pregnant and lactating women,
and children. Causative factors include poverty,
large family size,
' i
ignorance,
unhygienic
conditions,
and superstitious beliefs and
Customs. These form a vicious cycle. Now,
for a nutritionist or extension worker the
question arises-where to break this cycle
and enter ? In other words, what should be
giyen priority?’ What should a p
—3-------- :
programme
to control and prevent malnutrition contain?
Recent experiences of the
Post-graduate
Department of Home Science, University of
Mysore in this area are worth sharing.
(4) Villagers were also taught about treatment
of diarrhoea with oral rehydration solution;
(5) Efforts were also made to improve the
economic level of a few families through
income generating activities.
Outcome of the programme
One of the two severely malnourished
children receiving the supplement recovered
and showed significant improvement within
six months.
However,
the mother failed
the mother
------However,
to continue to feed the child on her own. In
the case of other child, the mother could not
be motivated.
A training programme for students coupled
with a service component to improve the
nutritional and health status of a village
community was started in Hejjige in December
1980. A clinic was established and visits
were made to the village twice a week.
The programme had the following components ?
(a) Lack of resources for
for preparing
preparing sufficient
sufficient
quantities for all the children.
(1) A base line survey was conducted to assess
the nutritional status of pre-school children;
(b) Non-acceptance by the child since it was
not shared by other family members.
(2) Nutritional rehabilitation through supple
mentary feeding and an intensive nutrition
education programme were carried out
by the faculty members. Ready-to-mix
food-supplement using locally available
food grains was prepared and diets of
two children suffering from PEM was
supplemented with it;
(c) Lack of time or cenergy on the part of
the mother to prepare the mix, or "illness
of the mother.
(3) In the case of moderate and mild cases
of malnutrition, the concept of providing
additional
food was imparted through
nutrition education;
Of the 34 families which received nutrition
education for five months, only six mothers
prepared the mix once or twice. Reasons
for this disappointing outcome were several.
(d) The time of introduction of the supplement
coinciding
with
occurences
such as
diarrhoea, cough or cold.
(e) The child refusing other foods and demand
ing only the mix.
(f)
Monotony
children.
•Home Science Faculty; Manasa Gangotri, Mysore.
in
the
case
of
a
few
J
However, many were willing to accept
the food supplements as long as they were
supplied. After a gap of about four months,
one visit was paid to observe any possible
residual impact of our efforts. It was dis
heartening to see that not even a single family
was practicing what we had preached about
nutrition. The children who had been either
fully or partially rehabilitated were moving
in the reverse gear. It was surprising to
note that successful rehabilitation of a severe
form of PEM had no impact either on the
family or on the others in the village. With
this response to an intensive approach, one
cannot but wonder about the benefits of
nutritional rehabilitation when introduced at
the PHC level with the existing set-up(. It was
obvious that the people of Hejjige had missed
the curative medical service given by us.
Otherwise, the programme had made not the
slightest dent in their lives.
In the present context of low standards of
living, nutrition education and rehabilitation
programmes without improvement in the
purchasing power of the families make little
sense. Although food is a basic necessity of
life, poor people are probably more concerned
about their overall survival and day-to-day
existence. Until and unless there is a rise
from the present-day rock bottom level
of living to a certain minimum standard,
nutrition education of the type which has so far
been attempted* will remain a futile exercise.
Cholera Vaccine: Inappropriate Aid?
i
...............................
A brief report in a recent issue of the New
Scientist focusses on the massive amounts of
inappropriate aid that arrives in disaster areas.
During the ‘70s this aid included items such as
expired drugs, tins of pork curry sent to
Muslim areas, expensive X-ray equipment in
areas where no one could operate them, and so
on. But, according to the director of the Inter
national Disaster Research Institute, London, a
more serious case of inappropriate aid was the
practice of vaccinating flood victims against
cholera. He says that cholera vaccines are
usually a waste of time and resources because
the population is usually dispersed, already
immune and is likely to encounter new risks,
such as hepatitis, because of the injection. More
over, studies have apparently shown that floodr
ing actually decreases the incidence of cholera.
Reporting of Adverse Drug Reactions In Britain
In Britain, the Committee on Safety ofMedicines has been trying to keep track of
adverse drug reactions for 19 years. Now,
reports New Scientist, a working party enquiring
into the system has found that only one
in ten adverse drug reactions are reported
by doctors despite measures to facilitate
the reporting. The working party was set
up when the Committee came in for heavy
criticism for delaying the withdrawal of an
arthritis drug in spite of the adverse reactions
to it having been reported. The working party,
however, rejected the idea of allowing patients
to make their own reports or of making
it mandatory for doctors to report adverse
drug reactions.
HEALTH "CARE" VS. THE STRUGGLE FOR LIFE
Mira Sadgopal
(Part II)
Numerous groups and individuals are
muanng
..with others, to
challenge the might of the establishment.
The outlook of all at this point is at best,
partial. Again, the problems of tuberculosis
can serve as a useful reference point for
illustration. Action is occurring at national,
regional and local levels. We will mention
a few of these efforts known to us which
we consider significant.
(VHAI) is at present carrying out a countrywide
investigation, with the help of a number of
local and regional groups, of the widely
reported shortage of first-line anti-TB drugs
in the market and in the Government TB
treatment centres. This effort has arisen
from a couple of workshops on issues related
to rational drug therapy organized in 1982
in joint collaboration with the Medico Friend
Circle. During the workshop held in Jaipur
in August, evidence from within the pharma
ceutical industry was presented by spokesmen
The Voluntary Health Association of India
2
of the Federation of Medical Representatives'
Associations of India (affiliated to the All
India Chemical and Pharmaceutical Employees
Federation, a non-party trade union organisa
tion) to show that the large multinational
drug companies are manipulating the supply
of anti-TB drugs by producing essential firstline drugs far below their licenced capacities
and promoting the newer second-line drugs
which are at present imported from abroad.
A number of field groups, including members
of the Medico Friend Circle, members of
the State Voluntary Health Associations,
and local units of the Federation of Medical
Representatives are collecting data to assess
the magnitude of the problem and whether,
as many suspect, the incidence of TB among
the people is on the increase.
garh Mukti Morcha (CMM). The CMM, an
organisation drawing strength from agricultural
labour is constructing a peoples' hospital
and both organisations launched a joint move
ment in 1981 which they call "Struggle for
Health". At present, understanding of health
issues is crude: primarily a realisation of
what is grossly wrong and a struggle against
blatant injustice. Slowly and painfully these
two organisations are struggling to overcome
their own inadequacies, faulty habits and
traditional beliefs to build up a viable and
just health care alternative.
At the local level in areas where there
is no established mass organization, small
activities and micro-initiatives are being
carried out which begin to challenge parts
of the health establishment. This has been
the case in our own group's work. In the
form of a series of three block-level "Yputh
Leadership Training Camps" sponsored by
the Nehru Yuvak Kendra (Government Qi
India) of Hoshangabad, we organized groups
of literate youth to study the social aspects
of the problem of tuberculosis by moving
among the people and listening to men and
women with the disease tell their stories.
The campers compared the people's experience
with the provisions of the National TB Control
Programme and analysed reasons for the
discrepancies. They organized a diagnosis
camp, poster exhibition and cultural programme
and a public question-and-answer meeting
in the presence of the government doctor
and thej district TB Control authorities.
Many contradictions arose which could not
be resolved.
The first weapon against the establishment
information. A second can be formed
from a "network of socially conscious health
workers" (quoting from VHAI's appeal for
cooperation in collecting field data on TB
drugs and incidence). The ultimate weapon
is a conscious movement within the masses.
is
As in many parts of the world, we see
in India today, various attempts being made
in the direction of building a conscious peoples'
movement. Only thus will it be possible
to really challenge the establishment on
issues of health care and more important,
to gather the necessary power and democratic
perspective for evolving a real scientific
alternative which rests on social justice,
At present these initiatives are small and
fragmented, particularly in 1the sphere of
health action. Therefore theyr are weak in
comparison to the total strength of the esta
blishment. However, the experience steadily
being built up and the link with other demo
cratic developments is significant.
At the village level, we • initiated an
interesting experiment with the women of
the labouring class. The male villagers of
one large village had formed a labourers'
union about eight months previously. One .
day, knowing that I am a doctor, a woman
named Bhagwati suffering from untreated
advanced TB dragged her emaciated frame
to my door. She related a story of neglect
and desperation. Her husband was an inactive
member of the union, although she was not
even aware of the existence of the union.
Her husband Kaliram had failed to take
her to the government hospital for diagnosis
and she insisted that the elders in her family
wanted her to die. We brought up the case
in the union meeting, but were shocked to
find total apathy towards her plight. The
only concern was that her husband, who
failed to attend meetings, was a scoundrel
and a coward and not worth any attention
at all. It appeared as if his wife was only
On the regional and national level is
the surprising example of the Federation
of
Medical
Representatives'
Associations
of India, a healthy, growing non-party-affiliated
trade union organisation with a vision of
society which is somehow startlingly free
from the blindfold of narrow economism.
This group's role in collecting vital information
about the TB drug situation has ajready
been mentioned. Some of its regional units
are particularly active.
Another regional example is that of
two other non-party organizations in the
seven districts of the Chhatisgarh region
of eastern Madhya Pradesh - the Chhatisgarh
Mine workers Union (CMU) and the Chhattis-
3
frequently. At their next meeting, the women
who had already visited the house described
Bhagwati's condition and observed that there
were obstacles to her treatment at home.
Her mother-in-law was being nasty and un
cooperative, refusing to give her food and
continuously commenting that she would
be better dead. The rest of the family was
demoralised and the house was messy. 1
told them that it was a problem for mt
as a doctor to keep on giving necessary
advice to improve diet and hygiene which
had gone unheeded for a week. They decided
to control the mother-in-law and had a lively
discussion about a proper diet for a
TB
patient
and about
fixing up
Bhagwati's
surroundings to make the place liveable
and hygienic. The next day one woman tackled
the feisty old mother-in-law and convinced
her to draw a truce in the battle with her
daughter-in-law until
Bhagwati
would be
fit to fight back again. Another woman sat
on the edge of the cot explaining to her
husband and eldest daughter what she could
be fed, how to arrange that p^rt of the
hut, and how to dispose of infected sputum.
an appendage of him. Up until that time, no
women had been involved in the union meetings.
We decided to see how the women would
react to this woman's problem.
Approached individually and in small groups,
the women's response on hearing that TB is
curable and the treatment provided for through
the Government PHC was spontaneous. They
decided to hold a meeting of their own to build
up pressure for her treatment. This they did. In
the meeting I agreed to act in a supervisory
capacity to see that the treatment given
through the PHC was correct and was properly
understood. Kaliram took his wife to the PHC
and the treatment was started. At the time I
was working there voluntarily on a once-a-week
basis, so I was able to intervene to some extent.
We trained a local person to inject Strepto
mycin and, on my responsibility, a month's
supply was issued from the PHC.
The initial phase of treatment was stormy.
Bhagwati had high fever and severe lung
damage. We held an emergency meeting
one night to help the family, now alarmed,
to decide whether to take her to the Govern
ment TB Hospital at Chhindwara. Four women
related stories of their relatives who had
gone to the TB Hospital. In three cases,
the victims had died anyway. The fourth
person, alive and well, had gone there twenty
years before when the hospital was run by
a mission. Nowadays the hospital is ridden
with corruption at all levels and over-crowded
so that the expense is great. It was pointed
out that the modern treatment would be
no different from that she was getting at
home from the PHC. So it was decided that
the wisest course was to continue to take
care of her at home.
The heat was sweltering. The next day
we were surprised to find that Kaliram,
a bamboo worker, had woven a large overhead
fan and attached a long grass rope to it.
The small children were kept at a safe distance
pulling the rope to and fro in turns, singing
songs to the rhythm of the fan. The house
was tidy and clean. The sick woman's fever
was much less. She was smiling. Her motherin-law was grumbling, but about other things,
and in masked good humour. The family
had got the taste of self-respect through
social concern.
Recovery was steady for some time
thereafter. At the end of one month, Bhagwati
was anxious to get her sputum re-examined .
because she wanted to be able to hold her
four-year-old son on her lap, and she wanted
to sit-in at the women's weekly meeting.
She had lost her one-year-old daughter a
year previously, probably because of having
infected her with TB. To collect her sputum,
she scrubbed a Streptomycin vial thrice
with soap and boiled it in water (so as not
to kill any bacilli!) and waited for the bus
on the road from eight in the morning. The
eight o'clock bus did not come. The eleven
o'clock bus did not come. At 11.15 she began
walking in the scortching sun barefoot. The
PHC was seven kms. away, and she was afraid
it would close, so she nearly ran the whole
distance. One hour later, she reached the
PHC to find that it had closed at 12 o'clock.
In the first ten days, one or two women
began to visit her daily along with me, turn
by turn. This was a hurdle for them, as Bhagwati is a Harijan and, although all the women
were poor, they were nearly all non-Harijanstribals. Muslims and low-caste Hindus who
were used to strictly abiding by the code
of untouchability when relating to Harijans.
They had never set food on the aangan of
Bhagwati's hut, and they had not seen her
about the village for several months. It was
and unforgettable sight when one woman,
seeing her shrunken form on the cot, irresistably lifted aside her veil, with which she
had covered her face in shame, and exclaimed,
•'Oh, my sister, what has happened to you!,-!'
two
The women were so excited at the first
meetings that they decided to meet
1
Regd. No. P.N.C. W-96
mfc bulletin : OCTOBER 1983
RN.27565/76
LETTERS TO THE EDITOR
arriving at ’community' solutions to health
suggestion
for
Dr. Nabarro's
problems.
to
delimit
is
dilemma
this
resolving
health for all to 'medical
the goal of
care for all', But ' even this slogan will
the health professionals
not really take
’ out
of situations where he 1has to face
the tension inherent in a social system
oppression.
and
exploitation
on
based
> Health for All?
Dear Friend,
Dr. David Nabarro's critique of the Primary
Health Care Approach (June and July issues
of the Bulletin) echoes the experience of many
health care workers and also raises relevant
questions. But, although it throws light on
the difficulties of implementing the solutions
proposed by the Primary Health Care (PHC)
movement, some of the basic assumptions
of the movement are left unquestioned.
Should we not also question the content
and natures of the problem of health care as
stated by the PHC movement?
The international
organisations'
call
to achieve health for all is hardly a polemic.
It is more in the nature of a trite, but emotive
and populist slogan. As such, is it any wonder
that it has dissolved into platitudes? Health
for all cannot be achieved through collective
action from technicians and administrators
together with political backing, but through
the generation of alternative social and
political forces.
For instance, the main cause of ill health
among the world's 'least healthy populations'
is seen as- their exposure to large numbers
which in turn, is a consequence of living
in 'contaminated' environments. It is also
acknowledged that people living in such condi
tions are likely to be undernourished, to
lack fuel to 'sterilise foods they prepare'
and cannot obtain enough water to keep
themselves clean. Thus the problem of illhealth becomes confined to factors which
are either 'removable' or 'alterable' without
in anyway altering the dynamic forces that
trap people in the ill-health maze. The PHC
approach is therefore to direct efforts at
protecting the population from pathogens
(immunisation programmes etc.) and at altering
health behaviour of the people to suit pre
determined goals, through health education.
Although the article recognises the limitations
of such health education, it does not quite
come to grips with the reasons why its benefits
are uncertain.
Amar Jesani, Padma Prakash
Bombay
More on Aspirin
>
Dear Friend,
I entirely agree that Aspirin is still
the cheapest and the best analgesic and anti
inflammatory agent, but a word of caution is
necessary against its common use in our
country.
The incidence of hyperacidity and peptic
ulcer is quite high in’ our country, partly
because of dietary habits (spices,, rice, macca),
partly because of addictions (tobacco, alcohol),
and because of 'hurries and worries' of fast life.
In all such cases a single dose of Aspirin may
prove fatal by causing haemorrhage or perfora
tion. It is, therefore, important to exclude
the presence of hyperacidity and peptic
ulcer before prescribing this so-called Cheap
and versatile remedy. It is being said that
with the use of microfined Aspirin the chances
of such complications are minimal, but the
fact remains that Aspirin is a potent gastric
irritant.
Dr. Nagendra Nath Nagar
Specific components of social behaviour
cannot be modified without changing social
relations and the existing power balances.
Dr. Nabarro recognises this when he points
out that the implementation of PHC activities
inevitably involves conflict and that the
the
concerned
literature usually ignores
financial, political and other barriers to
improving people's health. Nor does it provide
health workers with appropriate direction
in how to deal with conflicts. This results
in the confusing medical professionals’ when
Dahod
X MFC ANNUAL MEET
The X MFC Annual Meet will take place at January-end, 1984. The first two days will be devoted to a discussion on
the theme: "Why alternative medical education is necessary". The third day will be reserved for the Annual General Body
Meeting of the Medico-Friend Circle. Those interested in attending this Meet are requested to reserve the last five days of
January 1984 for this. Details of the Meet will be announced in the November issue of the Bulletin.
- Anant Phadke
Editorial Committee:
Anant Phadke
Padma ‘Prakash
Ravi Narayan
Shirish Datar
JR
Ulhas Jajoo
Editor
Kamala Jayarao
Views and opinions expressed in the bulletin are those of the authors and not necessarily of the
organisation.
Annual Subscription - New rates from July 1981 - Inland Rs. 15/-. For Foreign Countries - By Sea
Mail US $ 4, by Air Mail - Asia US $ 6, Europe, Africa - US $ 9, U.S.A., Canada - US $ 11.
Edited by Kamala Jayarao, A-9, Staff Quarters, National Institute of Nutrition, P.O. Jamai Osmania,
Hyderabad 500 007. Xerox-Offset by Padma Prakash at Abhyankar's SIT Inst., Bombay 400 004.
Published by Anant
Pune - 16, INDIA.
Phadke
for
Medico
Friend
Circle;
50
LIC
Quarters,
University
Road,
the women of her caste. An orphan, she
had started her midwifery career at the
age of seven, as she described to me later.
In the same month, some other villagers
reported to me that she was catching fish
in the river with her nephew.
She waited until it reopened at 4.30 p.m. and
proudly offered the vial of sputum to the
compounder-technician. He grabbed the vial
and threw it on the ground shouting, "We won't
do your sputum test seventeen times. Bring
it after three months!". Then she asked for
her month's supply of drugs, only to be told
that the doctor had gone and she would have
to come the next morning.
In the fifth month, Kaliram discovered
that Bhagwati had brought back only white
tablets from the PHC. Streptomycin had
been discontinued, but he knew that anti-TB
drugs were necessary, and she had been
receiving both Isoniazid (white-coloured) and
Thiacetazone (yellow-coloured) in the form
of combined light - yellow coloured tablets.
He took the pills back the doctor the next
day complaining- squarely that she had been
given "only one" anti-TB drug by mistake.
He didn't flinch when the doctor's cold gaze
hit him, and after a moment's hesitation,
the compounder was called and told to
exchange the white tablets for the familiar
light-yellow ones.
Bhagwati returned home exhausted, down
cast, but amazed at herself that she had
been able to make the journey. Next day,
she had fever, but she was determined to
go back to get her medicines. Kaliram accom
panied her. He decided in addition, to take
her to the next town and get her first X-ray
done and the sputum test repeated privately.
When they faced the PHC doctor, they had
to tolerate his sarcastic comment that they
had "become big people now". All the drugs
were given, but no amount was recorded
on the card. In the next town, they paid Rs.5/for the sputum exam and Rs.24/- for an X-ray.
The sputum test was negative. The X-ray
showed cavitation, but signs of active healing.
And so her treatment will go on, may
be without serious lapse until she. is totally
cured. Kaliram now attends union meetings
when he can manage it. Bhagwati attends
the women's meetings. He farms his small
piece of land, and plays music at weddings.
They make bamboo baskets. She delivers
babies. They are people of courage, like the
others. In the meetings they don't talk about
TB, but of the struggle to survive and thrive
against the forces of the establishment.
Probably because of the heavy exertion,
Bhagwati was not well for about two weeks,
but again began to pick up. The following
month she went to a wedding and took her
vials of Streptomycin and pills along with
her, getting them injected by an available
doctor. In the fourth month she started work
again. She is a traditional dai as are all
JOURNAL OF RURAL PEDIATRICS (MONTHLY)
Achievements of the Journal
Why this Journal
* Circulated to 2000 doctors in Maharashtra
* Inadequate training in pediatrics at the
and other States.
MBBS level.
« Has got many pediatricians involved in
* Pediatrics is not a subject for the MBBS
writing articles.
Examination.
Burroughs Wellcome has given advertise
* 70% of the doctors practicing allopathic
ment.
medicine are not MBBS degree holders. They
Appreciation by authorities throughout India.
have ayurvedic or homeopathic qualification.
An original
activity unique in India.
* Continuing medical education for the rural
Problems before the Journal
doctor is our aim.
To Increase the Readership
* Urban pediatrics differs from rural pediatrics.
To stabilise the Economics.
We want to develop 'Rural Pediatrics' as
We expect Rs. 7000 loss per year.
a subspeciality.
************
What we expect from you
A helping hand to reach many rural doctors
Your help will be vital for the health of the Journal
ooooooooooo
Annual Subscription Rs. 12/-(Add Rs. 2/- if by cheque)
Please send your subscription today to:
Dr. Anil Mokashi, MDDCH, Editor, Journal of Rural Pediatrics
BARAMATI, Dist. Pune, Maharashtra State 413 102
5
93
medico friend
circle
bulletin
SEPTEMBER, 1983
HEALTH "CARE" VS. THE STRUGGLE FOR LIFE
Mira Sadgopal*
(January 198 3)
Part - I
India's
people, and the world's people,
are faced with a gigantic health "care"
establishment. It is far from being a vacuum,
a situation of "neglect" as most politicians
and planners would have us believe, or some
time themselves believe. Like a huge and
ungainly bureaucracy, it is both organised and
unorganised.
Its
various parts are linked
with each other in both gross and subtle ways;
equally, the parts function in contradiction
with each other. Some of the parts of the
establishment succeed in holding away in
certain spheres by virtue of historical advan
tage and the forces that back them at the
moment.
Any group claiming to explore
"alternatives" must understand human health,
and likewise any other sphere of human welfare
(like education, economic development, legal
justice, etc.) in this perspective. The individual
man, woman or child is powerless and thus
always prone to being sucked, duped or dragged
into the establishment system.
India provides a magnificent panorama of
such a health care establishment.
Most
obviously, we have in this country a giant
multi-tiered
Government-operated public
health
infrastructure,
the bottom levels
of which are organised into something called
the "primary health care" system. It is topped
by a spread of state hospitals and national
medical institutes as well as various large
central public health agencies. Ultimately,
this government system is empowered through
finance by
international organisations and
agencies like the WHO, UNICEF, DAN1DA,
etc.
Second in consequence is the vast body
of "qualified" Private Practitioners which,
although itt is less organised and partially
thrives on its own disorganisation, also exhibits
a hierarchy of influence and power largely
___
f
u to the proximity of its parts
corresponding
to the'cities and the drug industries. It includes
graduates of "allopathic" medicine as well
as
graduates of
the
ayurvedic colleges,
although most of the latter depend on the
use of modern allopathic medicines, The
to
minimum requirement
for
organisation
their
the
interests
of
promote and protect
members as a class is fulfilled by the Indian
Medical Association.
Taking third place in visibility, although
it exerts the most pervasive and devastating
influence, is the huge drug industry complex.
Thei e is a polarisation within this group
between competing indigenous and multinational companies which is unequal, so
that indigenous industry either succumbs or
adopts policies in tune with the multinationals.
The multinational drug industry profoundly
controls
policy
and
practice
within
the
Government health system as well as the
behaviour of Private Practitioners by plying
central government committees and deploying
a large army of medical representatives.
Fourth is a large group on the fringeof the health establishment power structure,
loudly names "Quacks" by the Private Practi
tioners. It is a very interesting group without
any real political power or legal sanction
which thrives on the contradictions of the
* Kishore Bharati Group, P.O. Bankhedi, Dist. Hoshangabad, M.P. - 461 990
establishment, the extreme powerlessness of
the masses and the total culture of mystifica
tion which maintains this. This group finds its
niche in the rural areas and the lacunae of the
towns.
they seek quick help from private practitioners,
knowing it will cost, but anxious to get
well and back to work. They hope to get by
with a strength-giving injection, a few pills
may be, and a bottle of life-giving tonic
which the doctor will prescribe. So a couple
of chickens
cu.:z!:z-£ and
-.J some grain is sold to raise
money.
A fifth group exists in the twilight beyond
the fringe, often indistinguishable from the
masses but merging into the category known
as ’’quacks”. They cannot really be called part
of the establishment, but they are quite
often the first, last, and sometimes the only
recourse of the poor. These are the village
dais, the bonesetters, the guinas, ojhas and
bhagats (faith healers and magicians). They
are traditional, indivisable from the belief
system of the masses. The larger health care
establishment
has an ambivalent attitude
towards this section - it is largely ignored
or ridiculed. Recognising their hold over
the people, some members, such as the dais,
are sought to be co-opted by government
training into the primary health system.
The doctor well recognises the story
and the appearance. He suspects it is tuberculosis. He knows the capacity
of
the
,
_
...j poorthey will pay for the belief that they will
get well, and as long as that belief can be
sustained, they will keep on paying the same
doctor. He also knows that this disease,
if properly managed, has a good chance
of continuing without cure for several years
before the patient dies. Furthermore, the
widespread attitude that TB is incurable,
supported by the vast majority of cases
which eventually end in death, and the doctor's
own observation that patients cannot sustain
regular treatment does not lead him to nurture
any professional interest in obtaining a cure.
Therefore, neither is he interested in proving
the diagnosis. A private practitioner will
avoid telling that he is treating a man for
TB as long as possible. Otherwise he is sure
to lose his patient to another doctor. Likewise,
sending him for sputum test or X-ray, which
may be available through the nearest govern
ment hospital, would be giving him away, or
privately done would use up available funds.
He is not interested in prognosis either it will be sufficient to see that the man gets
temporary relief and is kept fluctuating within
a safe margin between cure and death, with
an occasional dramatic rescue from death's
clutches, for as long as possible.
Also according to establishment values,
organised health services are operated to
a greater or 1lesser extent by large public
and private industries and by
/ the central
government for its employees.
employees, These are
all subject to the same pressures of the
health care culture which bear on society
in general and are only partially modified
by local or specific political conditions.
For practical purposes,, we may add to this
category the attempts of a number of voluntary
agencies to provide proper and uniform health
services in project areas.
Seeing the larger interconnecting structure
of the health establishment in this way gives
us an intellectual idea of its magnitude,
but what does it mean for the common man
and woman in India?
What does the doctor’s treatment consist
of, aside from its psychological content?
First on the list is Streptomycin injections,
one daily if possible, which is more likely
impossible if the patient lives far away.
(He may be given tablets of Isoniazid in
various proprietary preparations
in place
of streptomycin, in which case he is certain
to be sent off with a couple of impressive
on-the-spot injections, such as liver extract
and red-coloured vitamin Bl 2.) Next, he
will be prescribed ethambutol tablets (under
one of the marketed brand names), a secondline drug for TB which is comparatively
expensive but which is being promoted by
multinational companies through their medical
representatives as a first-line drug. Third,
a corticosteroid hormone like betamethazone
(again, under numerous brand names) will
For a start, we can listen to the stories
of hundreds upon thousands of men and women
suffering from tuberculosis in our cities^
towns and villages. Over and over again
we can see a plot thus exposed in stark
nakedness, as each tells of the struggle to
get treated and cured by any possible means.
For instance, a villager who gins cotton
has noticed a gradual loss of weight and
energy and may be a cough for several months.
But so many of the poor are already exhausted
and emaciated by life - they find the line
between relative health and disease is imperceptively crossed - and they think it is only
’’weakness”. When work becomes impossible
2
be routinely given or prescribed by most
private practitioners at the start of antiTB treatment, as it is expected to bring about
rapid relief from symptoms and a specific
false
sense of physical well-being which
may be the major factor in hooking the patient.
Fourth will be a large bottle of mineral
and vitamin tonic which also ironically contains
something to stimulate the appetite of the
person who is basically dying of hunger anyway.
Fifth, a syrup will be added to suppress
the cough.
to follow up. After a varying number of
visits to the doctor, and especially after a
marked improvement, he stops going - he may
go back to work. He also meanwhile consults
a gunia of his community about wording off
the risks of getting TB, and after certain
divination the gunia advises i.im to carry
out certain rituals and sacrifice, which are
usually done.
After some time, he again loses weight,
and his cough worsens. He thinks absut return
ing to the doctor. The doctor's mention
of TB has scared him, and he is ambivalent.
He may do one of three things: he may go
to another private doctor or a quack, he
may go to the government doctor, or he may
return to the same doctor after all. If he goes
to another doctor, he goes with a blank
slate - he doesn't mention that he has seen
another doctor, or flatly denies previous
treatment. Hence, a second version of his
first experience is likely to unfold.
The expense of the first week of such
treatment works out as follows (approximately):
1.
Inj. SM @ Rs. 3.00/day x 7
21.00
2.
Tab. Ethambutol 1 twice/day
@ Rs. 2,.50/day x 7
17.50
Tab. Betamethazone 1 thrice/
day x 7 = 21 tablets
8.00
Vita-mineral tonic - single
large bottle
20.00
Cough syrup - single bottle
8.00
3.
4.
5.
A streak of realism may hit him. He
may realise that the chance he has TB is
high now, and decide to see the government
doctor. At least he may get a clear answer
even if he doesn't have faith in the government
treatment.
74.50
The doctor's initial fee will vary, but he
will also take a daily fee for injecting strepto
mycin. If he is a good dramatist and psycho
logist, and the family is obviously prepared
to pay, he may set up an intravenous drip
and charge heavily.
The government doctor is a strange kind
of super human. He is invested with the
power to treat when he pleases at the Govern
ment's expense. (He also carries out a respec
table private practice in his home at the
Government's expense.) A patient approaches
him in fear and trembling. Diagnosis for
purposes of initiating government treatment
is obtained through sputum exam or X-ray,
whichever is feasible. Anti TB treatment is
started on the doctor's orders, He tells the
patient he has TB, or he says, "There is a
chance of it turning into TB!" depending
on the role he wishes to play in the drama
with the Patient - Government Doctor or
Private Practitioner. Sometimes he adopts
a dual' role, issuing government drugs from
the Primary Health Centre for seeing him
privately at home, too.
Quite often, the person does not have
enough cash to buy some of the medicines,
Typically, the tonics and non-TB medicines
will be bought and the anti-TB medicines
will be partially or totally dropped from
the list. (A survey done by Veena Shatrughna
has shown that many doctors write the tonics
and less necessary medicines first, perhaps
to oblige the drug companies, and the specific
curative medicine last.).
How long is this to go on? We have found
that a doctor tells the patient initially that
his treatment may take a varying period
between two weeks to three months. He may
decide
Government rules for the treatment of
new cases of TB are clear and rational,
the full treatment of eighteen months provided
for under the National Tuberculosis Control
Programme. After positive sputum examination,
treatment is started. Streptomycin injections
are to be given daily for one month, then
on alternate days for two months more.
(An abbreviated schedule which is medically
to further prepare a mental frame by
stating that the man is lucky that the doctor
has caught the "disease" at this stage because,
although he doesn't have TB yet, "There is
a chance of it turning into TB!"
Even if a man has collected enough funds
for the initial treatment, he m^y not be able
3
acceptable is 'daily x 15 days, then alternate
days x 2 weeks, then twice weekly x 2 months,
again totalling 3 months.) Daily Isoniazid (INK)
tablets are also given.
d)
e)
f)
3.
After three months, sputum examination
is to be repeated (if the patient is still cough
ing up sputum). There should be no more
tuberculosis bacilli detectable in the sputum.
Then, if not before, an X-ray screening is
called for if feasible from the nearest TB
X-ray facility. The reduction in the extent
of lung damage is thus monitored every
six months until six months have passed
since disappearance from the X-ray of the
signs of damage, when treatment may be
officially discontinued.
b)
c)
d)
e)
4.
I
Problems of Drug supply and Regular Issue.
a)
If progress is satisfactory, Streptomycin
injections are to be replaced after three
months by another drug, usually Thiacetazone
(THZ) but it might be Para-Amino Salicylic
Acid (PAS). The PHCs dispense Isoniazid
and
Thiacetazone in combined INH/THZ
tablets to be consumed daily for the total
remaining period of treatment. To ensure
that a patient keeps up regular treatment,
he is supposed to be called every month on
a particular date three days before the drugs
with him are due to finish. In case he does
not turn up within a few days, a printed
postcard reminder is to be sent to him.
If he does not respond to three such reminders
(and he has not died), he is known as a
"defaulter".
b)
c)
b)
c)
There are innumerable obstacles in the
way that ensure failure of treatment or
"default". We can list* these, as follows :
1.
Problems of Diagnosis
a)
b)
2.
6.
Failure
Doctor
a)
b)
c)
of
Communication
to
brainwashing of doctors by medical
representatives
overproduction beyond licenced capa
city of tonics, etc., by large and
multinational drug companies
mystification among the masses about
tonics and the desperation for quick
life-giving cures
Problems of Local Arrangement to Inject
Streptomycin
a)
sputum exam: technician not available,
or refuses
distant,
facility
x-ray/screening
expensive, out of order, or x-ray
plates not available.
high/rising prices of essential firstline drugs, especially Streptomycin
injections
shortage of all first-line drugs in the
market due to gross under-production,
increase in market supply of expensive
second-line anti-TB drugs like ethambutol, rifampicin
Unnecessary Medicine Cost on Vitamin and
Mineral Injections and Tonics, and costly
Cough Mixtures
a)
But what really happens to the ordinary
patient, or to our villager friend who gins
cotton ?
genuine short supply to PHC from
District HQ
siphoning off of TB drugs into the
market
siphoning off of TB drugs into private
practice
incomplete issue of drugs
doctor's failure to indent (maladminis
tration)
Problems of Medicine Cost from the
Market when unavailable through govern
ment supply
a)
5.
doctor's impatience
mystification of doctor's role
poor
relations/faulty
communication
between PHC staff
b)
c)
unavailability of doctor/health worker
to inject
fee for injection daily
PHC may refuse to issue injections
to patient to take home
Problems of Transport
Patient by
a)
b)
c)
intention, or lack of intention of
doctor to inform
patient's fear
contradictions in the belief system
in society about disease
distance
cost in time, energy, fare
irregular
public transport
services
• >
8.
4
The Social Milieu at Home
a) poverty - poor shelter, starvation
b)
c)
d)
9.
demoralisation
sex-bias in case of women, especially
when childless or without living male
offspring
belief in magic and lack of scientific
concept of disease
b)
c)
d)
economic exploitation
conditions,
noxious
physical
inhalation of cotton fibre and
ventilation, etc.
lack of safety standards
lack of alternatives
10. Specific
Doctor
a)
Malpractices by
PHC
misinformation
c)
patient
failure to
of drugs
d)
e)
f)
Conditions of workplace and Occupation
a)
b)
or
record
non-information of
(incomplete)
neglect of monitoring schedule
failure to maintain treatment card
failure
to contact defaulters
postcard.
issue
by
Now, it is sufficient to say that the
average poor man of India who gets TB
today° is likely to face every single one of
these obstacles, except 8(c) as he is not a
woman. Inevitably, ne
he becomes a defaulter,
or he dies, or more likely both. Are there
really any alternatives ?
like
poor
Staff and
(to be continued)
Private practice
ANTIBIOTICS IN DEVELOPING COUNTRIES
A second type of combination is antibiotics
with enzymes, claimed to improve uptake by
inflammed tissues. Some preparations for
gastrointestinal infections contain Kaolin and/
or pectin. A third combination is antibiotic
with a mucolytic and/or cough suppressant.
'Bisolvon Eritromicina' with bromhexine is said
to increase immunoglobulin A. Antibiotics
are claimed to be effective against influenza
and viruses. A preparation meant for infants
tetracycline with
streptomycin,
contained
enzymes.
1977,
1977, the
the WHO provided a list of
210 essential
drugs,
to help developing
essential
drugs,
countries choose a limited number of drugs
that are inexpensive but of high quality.
in
___ o._
such lists have been in use
Though
Scandinavian countries, the drug industry was
highly critical of the WHO list. A survey
studied marketing of antibiotics in Central
Lancet
in
America
and
was
published
in
In
(Jan 3, 1981).
in Mexico, 430 brands of antibiotics were
marketed, of which 180 were combinations. In
comparison, Sweden has 90 brands with only
2 combinations.
The Survey shows that in each country of
Central America, not less than 200 brands of
antibiotics are marketed. The investigators
say ”how can doctors in these circumstances
become familiar with the essential properties
of important drugs. A reduction in the number
in
of drugs might improve antibiotic use ir.
clinical practice".
The stated reasons for use of combinations
are that they have a broader spectrum of
action and that antibiotics reinforce each
other or that they will be effective even if
resistance against one occurs.
[Do Bulletin readers have any such information for India? - ED]
NATUROPATHS IN THE USA
(Extract from Pediatrics 68:407, 1981)
Despite the availability of a highly develop
ed, formal -medical care system, many Ameri
cans place substantial reliance on folk medicines
and unorthodox practitioners. We often encoun
tered families who indicated that a naturopath
was a major source of their health care.
"holistic
medicine".
Today’s naturopathic
colleges require 3 or 4 years of undergraduate
study for admission with a basic premedicine
background. The graduate is expected to be
skilled at performing minor surgery, and
assisting in all phases of obstetrical care
for natural child birth and home deliveries.
Schools of naturopathy reached a peak
around 1950 and declined by 1960. The fortunes
of naturopathy took a dramatic upturn in
the 1970s, along with the increasing popularity
of natural
foods, organic gardening, and
Fasting-from days to weeks-is recommen
ded for many ailments, including arthritis
and sinusitis. The symptomatic treatment of
fever is thought to interfere with natural
5
i
curative processes. The efforts of naturopaths
are therefore directed toward strengthening
the individual’s resistance to disease. Through
optimal
nutrition and hygienic practices,
the need for vaccinations could be totally
obviated. Several practitioners also expressed
the belief that injecting antigens was an
abnormal form of exposure, an invasion of
the patient's defenses, and therefore poten
tially harmful. True exposure to some of
the infectious diseases was often considered
the preferred method of obtaining long term
immunity. "The inoculations are not known
to give life-time protection, whereas actually
contracting the disease does. In the old days,
they used to have a 'measles party' in order
to deliberately expose children. I would like
to see the Public Health Department make
this kind of exposure available".
subservient to the authority. Injections are
only available on a prescription basis. When
we teach people to live well, to eat property
that doesn't require a pinnacle-type structure.
Homeopathic remedies are an important
component of many of the naturopaths' inter
ventions.
While defending homeopathy
as
efficacious, many naturopaths acknowledged
the placebo effect of these remedies.
The emphasis by naturopaths on patient
teaching, individualized care, and 'natural'
remedies, and their aversion to scientific
medicine have become increasingly valued by
medical care consumers. Because many ail
ments are minor and self-limited, and many
naturopathic remedies are without obvious
harm, encounters with naturopathic practi
tioners are often benign, if not clearly bene
ficial. In the case of childhood infectious
diseases, however, immunizations can be life
saving. Specifically, immunization programs are
preventative, and their efficay involves stimu
lating the body's natural defense mechanisms.
Such
approaches
were
also defended
on egalitarian grounds. "The vaccine route
was chosen because of the medical orientation,
essentially a pinnacle type hierarchical system
with a very clear authority figure and people
LETTER TO EDITOR
Dear Friend,
How are we going to establish the divine image
we had once upon a time ?
Medical Ethics and Practice
We have come to a stage where thorough
re-evaluation and redefining of ethical values,
to suit the present day problems of our system,
has become absolutely essential.
Medical
Ethica
has
become the talk
of the day both inside and outside the medical
community. A large section of people are
frustrated with the treatment they get from
hospitals, medically and otherwise. Private
treatment is expensive and even the mjddle
class is neither able to afford the specialist
nor his prescription. The common man is
becoming more and more sceptical about
the professional integrity of medical men.
On the other hand, medical men of eminence
and professional integrity are also very much
puzzled as to why such a curse has fallen
upon such a noble profession. People in power
also lose no opportunity to accuse us of
erosion of values, perhaps to shirk their
own responsibilities. .
Medical ethics involves seeing that patients
get proper and adequate treatment. Looking
back, we find that the emphasis of traditional
ethical codes was on the responsibility of
doctor towards his patient. But with the
progress
of
science,
particularly medical
science and society, the effectiveness of
health services is primarily decided by how
best the medical system is organised, though
responsibilities of the doctor towards the
patient continue to remain fundamental. In
modern days, when medical science is capable
of eliminating certain diseases altogether and
can prevent the occurrence of many others
it is not only the individual doctor’s compe
tence, but mainly the effectiveness of the
medical policy and its implementation over
a social plane that ensures the health of
the society. Hence, maintenance of medical
ethics has become more of Governmental
responsibility.
While confronting different adverse condi
tions in our profession, doctors are also
thrown into an ethical dilemma. Circumstances
force doctors to compromise with medical
ethics every now and then.
Why at all such an ethical crisis today?
What has gone wrong with our system? What
are the real factors behind all these maladies?
Moreover, institutionalisation of medicine,
0
6
specialisation, team (or) group practice
etc., are the outcome of progress of medical
science and practice. Hence under conditions
of
institutionalised
medical
care,
ethical
responsibilities also rests on the institution
and is shared by other medical personnel,
like
nurses,
assistants,
technicians,
etc.
These developments have opened up new
ethical questions which cannot be solved
by traditional codes of medical ethics.
conditions and scientific advance? What is
going to be our attitude towards these grave
problems facing our community? Is it going
to be one of coming to over-simplified conclu
sions, superficial judgement and ill-motivated,
escapist accusations of people in power?
Or are we going to analyse the problems in
the overall context of the medical system
and strive to evolve proper medical policies
and their
1
effective implementation, thereby
evolving
!~j a new code of medical ethics, that
will suit present day conditions ?
Is the erosion of medical ethics, accidental
and isolated or is it a reflection of the poli
tical, economic, social and cultural crisis
that has engulfed our country? Is our ethical
dilemma due to our own individual vacilla
tions or is it due to the contradiction between
personal and social interests, between backward
We invite you to
suggestions and opinions.
give
yvur
valuable
Medical Action Foev*'!
Madras
WHY SOYA BEAN ?
K. T. Acharya
During the current year, nearly 8 to 9
lakh hectares appear to be under soya bean
cultivation mainly in Madhya Pradesh, with a
yield expectation of perhaps 6 lakh tonnes
of soya beans. These figures are expected
to double in the next three years (M.P.
Mansingka,
Chairman,
Soyabean
Processors
Association of India; quoted in The Hindu,
September 29, 1982).
from earning foreign exchange to the tune of
some Rs. 80 to 100 crores, there are such
attractions to individual producers as export
entitlements.
But there is another side to this success
story. For long it was convenient to argue
that soya beans were being additionally grown
on land that would otherwise lie fallow during
the Kharif season, thus ensuring sufficient
soil moisture for the following rabi wheat
crop. Growing soya, a leguminous crop, on such
land was said to fertilise the land, while
shedding of its leaves helped to conserve
needed moisture. Today, however it would
appear that two-thirds of the land under soya
in Madhya Pradesh was what once used to
raise
jowar,
millets,
several lentils, and
groundnut (India Today September 30, 1982,
p. 127). All these are foods that can be directly
cooked and consumed by common people,
which is not true of the soya bean.
What has led to these rapid and remarkable
developments in what is after all an unfamiliar
crop? One is the support price offered by
the government to the soya bean, which
ensures a profitable return to the farmer.
There is no such attraction for the groundnut,
our major oilseed crop, which continues to
languish. It • is stated that the profit per
hectare of soya considerably exceeds that
derived from the groundnut (India Today,
September 30, 1982 p. 127). Industrialists are
well content too. Processing soya yields about
16 to 18 percent oil, and any edible oil today
fetches an excellent return because of des
perate shortages and high oil prices. The oil
cake which results is an excellent protein-rich
cattlefeed with a well-established international
demand. The high lysine level of 6.2 percent
is exceptional among oilcakes, though it is
well to remember that many common dhals
(bengal, gram, masoor, tuvar and mung) have
even higher levels. There is no worrisome
problem of aflatoxin contamination. All of it
is exported, earlier largely to Southeast Asia
and to the Gulf countries, and more recently
to European countries as well (Dattu Hegde,
Economic Times, August 19, 1981). Apart
Undoubtedly soya oilcake1 is edible. It is
now exported, but even were it to be used for
humans in India, this would necessarily be in
processed foods that will not reach everyone
as will jowar, millets or pulses. The value of
processed foods in India is just two percent
that of total foodstuffs. The oil yield of the
soyabean is small, just 16 to 18 percent,
against 40 to 45 percent for all groundnut.
So unless the yields of the soyabean are 2.5
to 3 times that of the groundnut, there is
little advantage to the oil economy (A.C,
Chhatrapati, Economic and Political Weekly,
1980, 15 No. 37, Sept. 13, 155.7). In practice,
7
The National Tuberculosis Programme
— What our experts say
sociological basis
village guide or the multi-purpose workers of a PHC
sub-centre or by the treatment organiser at the
health institution.
“Even with the present extremely limited and
inadequate facilities available for the diagnosis and
treatment of the disease, over half of the sputum
positive persons and over one third of the persons
with radiologically active disease have actually sought
assistance at government medical institutions moti
vated by their symptoms. The provision of elemen
tary diagnostic facilities, such as a district referral
x-ray unit and staining and microscopy facilities at
primary health centres, and the distribution on a
domiciliary/ambulatory basis, of suitable chemothe
rapeutic drugs would make it possible to treat a
sizeable number of cases. The cost and problems
of organising such a tuberculosis programme would
be almost negligible in comparison with those involved
in providing a system based on sanatorium treat
ment of similar magnitude or in combing the whole
country with hundreds and hundreds of mobile x-ray
units. ”
-— Banerji and Anderson, 1963 .
A district tuberculosis centre (DTC) supports
the tuberculosis work at health institutions by train
ing personnel at HIS, providing referral diagnostic
and treatment (including hospitalization) support,
by having a district wide information system and by
providing drugs and other supplies to HIS.
The Directorate General of Health Services and
the National Tuberculosis Institute, Bangalore are at
the apex, with facilities for a national information
system, training of key workers and monitoring,
evaluation and research. ”
— D. Bonerji, 1984
evalution
“There are deficiencies in equipment, manpower
and there is human apathy. DGHS reports on diag
nosis and treatment activities are totally false.
epidemiological dimensions
Microscopes are there in many centres but these
are not used or are out of order. A large number of
cases are diagnosed without sputum examination.
Periodic examination of sputum of patients under
treatment is not carried out regularly with the result
the estimates of patients completing treatment or
sputum conversion rates of initially bacillary cases
are liable to be inexact...............
(i) Prevalence: This is about 40% in all ry
age
groups rising from about 2% in the youngest
age group to about 70% at age 35. There
after it remains almost constant.
(ii) Incidence of infection is highest in indivi
duals between the ages of 5 and 20 years.
(iii) Risk of infection is about 2-4% per annum.
(iv)i X-ray
confirmed disease
uv
^x-iuy cunurmea
aisease is about 2%
270 among
total population aged 10 years and more
and of these about 20% are bacillary.
(v) Age/sex difference: The prevalence and
incidence are higher as age advances and
again higher among males than among
females, male to female ratio varying from
3:1 to 5:1.
(vi) Time trends: The trend of tuberculosis
appears to be almost constant over the
years except in some cities where better
services for diagnosis and treatment have
been available for some time.
(vii) Distribution: Tuberculosis infection as well
as disease are more or less uniformly dis
tributed in urban, 'semi-urban and rural
areas. Thus the vast majority of pulmo
nary tuberculosis cases are to be found in
rural and semi urban areas, where more
than 80% of the country’s population lives.
— DVJ Bally, 1983
..... Reports are received on sputum exami
nation from centres where no smear is examined
.... In many States the staff sanctioned for DTC
is less than the minimum laid down under DTP ....
Full quota of NTI trained key personnel were in
position in only two of 10 districts visited ....
There is general lack of interest or even aware
ness of responsibilitues by the doctors working in
peripheral health institutions (PHI) in connection
with TB work . . . PHI doctors do not send all
patients with suggestive symptoms to the laboratory
for collection and examination of sputum even if a
microscope is available and microscopist is in posi
tion ................... NTP manual meant for PHIs is not
available in any PHI.
Some cooperative patients go on taking the
treatment for over 2-3 years. In any case it seems
treatment is always stopped by the patient rather
than by the doctor whatever its duration................
The position regarding drugs were satisfactory.
No centre experienced
shortage of drugs except
streptomycin and PAS.
Organizational plan
Tuberculosis diagnosis facilities are made
available in far flung rural health institutions (HIS).
Treatment of the diagnosed cases is organised by the
There is also a craze for using second line drugs
by the profession.
4
medico friend
232 circle
233
bulletin
July-August, 1996
The Revised National Tuberculosis Programme
Sham Ashtekar
I am no TB expert but have been associated with the
programme as a medical officer at a Primary Health
Center and then in a municipal corporation, plus as a
student of community medicine. This article is a product
of my brief interaction with a section of the central TB
programme community, as a resource person for review
ing the training modules. I had an access to the technical
documents they had produced and had a thorough
discussion on many points that nagged me.
*
When I joined a PHC as a medical officer in ’78, the TB
programme was entrenched in the PHCs also, but not as
much as the leprosy programme. The latter gave an
impression of a neat job with purpose and dedication
which its father Dr R N Wardekar at Wardha had so
carefully built and nursed for a disease that far out
weighed TB both in stigma and the deprivations of the
sufferers. While in a PHC I could not help feeling rather
helpless while treating some fifty odd patients we had on
our list, the difficulties they had to undergo and the
problems of compliance.
We now run a small private nursing home in a remote
Maharashtra township and have occasional TB patients
in our private clinic. The usual image is that of a man or
woman in the mid years of their lives, suddenly realising
that they have a dreaded disease inside them and that
they have one more mean fight on their hands apart from
their uphill struggles to earn a living. Even now we feel
helpless to see TB patients referred to PHC-OPDs being
fleeced for anything like a hundred rupees on the pretext
of a saline infusion, before they can get their monthly
medicines. Most often the clinically obvious TB fails to
pass the ill performed and ‘insensitive’ sputum tests and
patients have another round of cheating from waiting
bazaar doctors.
A new realisation came to me in our private clinic about
problem of childhood tuberculosis. Just because it is not
infective to others the whole issue of childhood TB is
swept under the carpet and children suffer silently over
long months— at times subclinical and at times a faintly
recognisable illness. First of all the problem is hardly on
the mind of rural medical community. Then all kinds of
fake trials are offered and the family is already hooked
on to the doctor. The frustrated family opts out of the
game and finds another doctor mostly of the same type.
Frustrated with the tuberculosis programme over these
two decades, I had started feeling that the situation is
unlikely to improve and there has to be something better,
may be some social organisation can take up the issue,
organise TB patients in the Block and offer honest
services at affordable costs. I was just toying with tins
idea when this opportunity for interaction with the
revised programme presented itself.
In mfc I first came across the sputum vs X-ray debate in
a big way. Due to very low sensitivity ( failing to detect
mfc bulletin / July - August. 1996
as many cases as there are) sputum test, I had developed
a bias for X-ray diagnosis in TB. This got corrected in due
measure .
Though TB is essentially a social problem rather than a
medical problem I have hardly come across anyone who
pooh poohs its medical management. But deep within me
I have nursed a feeling that TB seems to be an issue far
beyond our current and projected medical services. T)iis
has thrown up a number of dilemmas that I will refer to
later in this discussion. Let us now see the TB problem
in cold statistics.
infected children have a possibility (risk) bf developing
actual illness anytime during their life.
2. The Revised National Tuberculosis
Programme (RNTCP)
Government of India was feeling the heat of the failing
programme with an added risk of HIV taking it to a
rather high scale. With Joint help from WHO and some
other agencies like the World Bank and Overseas
Development Agency of UK, a new programme has been
chalked out and is already in the pilot phase.
The main thrusts of this programme are:
1. The Planners Perspective of the TB
TB, predominantly affecting the underprivileged classes,
is estimated to infect arodnd 50 % of the population. India
has an estimated 14 million cases of TB of which 3-5
million are highly infectious. Half a million die every year
due to this dreaded disease. Every year about 1. 5 million
new cases are detected, of which 25 percent are sputum
positive (hence infectious) and others are diagnosed
radiologically. The document also states that alnjost
equal number of cases are detected by non Govt doctors.
Further, HIV is going to compound the problem. Already
60 per cent of HIV positive people have active TB . In the
general population, around 3 per cent are harbouring the
disease—confirmed either radiologically or by sputum
test in both Govt and non Govt establishments. India has
the highest incidence of TB cases
At the subcenter level it is estimated that there are
around 75 cases in a 5000 population. Thus in a village
of 1000 population there are around 15 individuals with
active disease. This includes about 3-5 sputum positive
and others diagnosed otherwise. For a 30, 000 population
under a PHC there are 400-500 TB patients to treat if all
were to report and avail of the services.
There is bound to be a lot of variation and there may be
(and are) clusters where the prevalence of active cases is
of the order of 200 in a subcenter population.
I believe that non pulmonary TB is not counted in this,
which is practically outside the serious concern of
Revised National Tuberculosis Programme (RNTCP) and
in any case its incidence must recede with BCG being
universal. Size of pediatric tuberculosis is also largely
unknown but what is known is that about 10% of the
- Effectively treat as many cases of TB as do report to
the health staff and health centers.
- No active case finding is advocated, but effective
management — diagnosis and regular short course
chemothearpy — should attract more patients .
- Short Course Chemotherapy (SCO with 3-5 anti TB
drugs given intermittently every week, is the main plank.
- DOT (Directly Observed Therapy) in the intensive
phase will ensure compliance and regularity. The pills in
the blister pack will be swallowed in the presence of the
health worker three times every week for two months.
This will rapidly make the patient non infective .
- Then follows the continuation phase wherein the
patients will collect weekly medicines, of which she/he
will swallow one dose in the presence of the health
worker.
- A strong unit for RNTCP will be created for every one
lakh population -this is the sub district unit and will take
care of sputum collection, microscopy and getting X-rays
done for sputum negative cases with the help of district
TB units that already exist. The Supervisors placed at the
sub district unit will ensure about sending the patients
back to village health staff with drugs and case cards.
This card will carry the regimen and duration of therapy.
- The cutting edge of the RNTCP will be the health
workers trained and supported and equipped to carry out
DOT and continuation phase therapy.
- A strong point of this programme is simplification of TB
therapy to a standard and uniform pattern. There are
three categories of patients as follows: a) New sputum
4
infc bulletin / July - August 1996
positive cases and Seriously ill sputum negative cases, b)
Re-treatment candidates to be started on fresh treatment
regimen and c) Non sputum positive cases and non
pulmonary cases.
*
All these categories will be offered intensive phase DOT
therapy and continuation phase treatment by Health
Workers. The details and differences depend upon the
results of sputum tests at the end of the intensive DOT
in case of first category and if other categories show
sputum positivity at later stage.
3. Positive Trends
Some of the initiatives are welcome. For instance,
standardizing the treatment regimens on sound citeria is
a very pertinent thing.
I have read some criticsm of the DOT approach making
it look like an assault on the privacy of people and
reducing patients to helpless swallowers of drugs at the
hands of health workers. But technically, this is a
substantial strategy in a country which has failed to take
care of the spread of TB due to social determinants of TB
being untamed. Here are seeds of a debate on ethicality
of such approaches but this I will take up later.
With RNTCP, it is the first time that we are ever thinking
of doing the TB programme some justice as a vertical
^programme, something that happened in Leprosy long
ago, a good back up and committed and well trained cadre
of health workers.
This is also an attempt to reap the benefit of an improved
technical solution to a national problem that TB is.
The creation of subdistrict units will take the programme
nearer the community, practically at every taluka center,
and decentralise the function of district units.
This is the first time the health workers are being roped
in for serious TB work, the involvement earlier was just
in the policy not actualised. This programme will now
take the whole treatment outfit down to atleast subcenter
staff.
RNTCP also makes most of the sputum test by taking
three samples instead of one, and this is a sound
epidemiological strategy. Just one sample was not good
enough and two more of the same increase the sensitivity
of the test in-a big way.
3
Active case finding has been a penchant of all vertical
programmes so far, and there is not very great success
in any except the leprosy programme that is attributable
to this element. This active search also needs so much
time and energy which are hard to come by in the already
‘overburdened’ health workers. The RNTCP has rather
chosen to concentrate on doing a good job of case
management. This should win most of the caseload to the
programme in the long run.
4. Seeds of Failure
Despite good intentions and some well prepared plan, I
could see the cracks in the programme that were also
perceived by some others but there was an ?ur of non
chalance about it. Let us see the problems one by one.
1. The programme is well knit upto the sub district unit
level, as happens with so many vertical, programmes but
goes limp at the village level. This is because there is no
general village level health cadre that can take care of
such an ambitious and technically involved programme.
PHC Sub center (Swasthya Upkendra or Swasthya Ikai)
with its ANM and male health worker are the last people
to be doing it to the villagers. Obviously they operate at
the 5000 population cluster level and so cannot be called
as village level functionaries barring the village where
they happen to stay
2. 1 explicitly asked whether any other health personnel
like AWWs, Dais, erstwhile CHWs etc are to be involved
in the programme. After some hesitation though, there
was a clear ‘no’ from the gathering that discussed RNTCP
that day; may be somebody has different ideas up there
that we do not know of.
3. A part of the group underplayed the prevalence
problem and was inclined to estimate that for a 1000
population, there are only about 2-3 cases to be treated
by HWs. I wondered whether they were talking of sputum
positive cases alone. It turned out that they felt that all
said and done there are not many more cases than this
in actual practice and the estimates given by the official
documents were ‘theoretical’. I stated that should all TB
patients decide to come for treatment, there can be
around 15 cases (75 cases in 5000 population) seeking
treatment and this could distort their time calculations
in a big way.
4. For various reasons, some genuine and some not, half
4
of the subcenter staff is not staying at the headquarter
village. They make it to the subcenter by a morning bus
which reach at about 9-10 am and leave by bus at about
4-5 pm. This leaves the patients little choice outside their
working hours. In the social profile of TB patients,
sufferers are mainly the working men and women who
do most of the breadwinning for the family. This is
something that will keep them out of the DOT programme.
The Dot programme' is possible only where health staff
are staying in the villages.
5. The DOT programme insists on patients swallowing
medicines in their presence and keep a watch for some
time on the attendant risks. Every patient is going to turn
up every other day for 2-3 months and thereafter once
every week for 4 to 5 months. This means, that out of the
75 odd patients targeted in the RNTCP, about 10-15 must
be at the subcenter every other day. This, if it works as
originally designed, is a substantial involvement for the
health workers in terms of time and clinical responsibil
ity. In the existing job profile, FP, immunisations, ANC
etc are major priorities apart from other work that arises
from time to time, like malaria epidemics. TB is going to
occupy 4th or 5th position in the priorities list of HWs.
Does this match with the RNTCP requirements ? This is
an uneasy question.
6. The peripheral staff, HWs, are not supposed to collect
sputum samples in this programme; this is left to the
subdistrict units. So all the patients will have to queue
up before these units . Further, the requirement of three
samples (spot sample on visit, overnight sample the next
day and a spot sample on that day after a few hours) is
quite demanding. It requires overnight stay and expenses
for the patient and attendant plus the inconveniences.
This sounds unrealistic and may be compromised because
of obvious difficulties.
7 All anti TB drugs in this programme have both minor
and major side effects. Leaving the minor problems alone,
there are things like hepatitis/jaundice, respiratory
collapse syndrome, renal failure etc as adverse effects.
They are rare in a village size work over years, but cases
are bound to occur in every block and district given the
scale of operation. Health staff in the villages are already
at their wit’s end coping with a number of things like
meeting targets in FP and the like. The medical training
they get is not enough to tackle these problems. There are
neither immunities for such kind of work. People may not
mfc bulletin / July - August, 1996
express anguish or bum public property in retaliation for
mishaps, but will turn to private practitioners for TB
treatment. Already, many of them are with them. This
is an area (of adverse drug reactions) that needs much
more attention than is presently given.
8. The problem of coverage and access is going to remain
since it is going to be difficult (and uneconomic) for GO
TO per cent of the patients in the villages other than the
subcenter villages to make it so frequently and regularly
to the subcenter for collecting drugs . This involves travel
time and travel costs. This might prove to be the undoing
of an ambitious programme. If the RNTCP evolves some
mechanism to raise a treatment depot in every revenue
village this factor can be taken care of. But how does one
do it without raising a full scale TB cadre ? I feel this is
an impasse since we have already destroyed our Village
Health Worker programme.
9. At many places there are no subcenter buildings and
health workers conduct business at a rented room from
somebody’s house. This is where families are staying with
children. For a regular activity of some patients with
productive cough bringing out infective material in a
home kind of set up is unsound and unkind. This brings
us back to the infrastructure problem. Let us not sleep
over this problem since great care and safety is expected
even at microscopy centers. This fear of infection was also
brought up in the group by head of a TB hospital.
10. A large chunk of TB patients is with the private
practitioners, of all degrees and motives. The rigour
expected in the RNTCP is going to be missing from this
area. While RNTCP will be busy within its portion of the
statistics, half of the infectivity and morbidity will be at
the receiving end of weird and outdated regimens. The
RNTCP should take stock of this and build bridges to co
opt this sector in the rational treatment of TB. This
element is missing even from the documents.
11.1 gather an impression that even this new programme
is going to pay only lip service to the non sputum negative
patients since all calculations proceeded from 2-3 cases
per 1000 population. The group, at least part of it, was
uneasy at the prospect of having to treat the non sputum
negative case load. I wondered whether they were
attempting to telescope the new programme into the
frame of the bygone programme and only saw an
opportunity in the new funds for the programme?
*
mfc bulletin / July - August 1996
5
My dilemmas
Uptill now I was thick and snug about State’s responsibilty
of treating each and every case of TB, positive or
negative, young or old. In the group I met there was an
obvious thrust only on sputum positive cases being
converted to negative ones. This appears cynical on one
hand but also speaks of pragmatism of just stopping the
spread, treating any other cases that came their way on
humanitarian grounds. 1 cannot take a position on this
unless State’s role in health care is defined. Is the State
responsible for treating every TB case that is thrown up ?
What about other illnesses like peptic ulcers or middle
ear deafness ? Is TB important because it infects others
or because it imposes suffering on every individual it
strikes ? Further, in a society and nation that has failed
to solve its fundamental problems of development (which
are precisely the determinants of TB) is it possible, to
allocate funds on every morbidity that surfaces; and this
when there are so many of them ? Although there is a
scope for reallocation of State funds so that some of the
health needs are answered, it may not solve all the
problems that are there. New health challenges need
more funds and hence more foreign aid. We are willy nilly
designing programmes that are operated on direct and
indirect foreign aid. Whose health programme is this that
we are so fiercely dogmatic about ? India is a pauper
nation that is still fighting shy of world trade but foreign
aid is no matter and we lap up every programme thus
designed that comes our way. Are we solving the TB
problem or creating new survival pastures for the baburaj that has failed to deliver in the five decades ? We,
the poeple of India, do need the health care programme
but the Maibaap Sarkar may run out of steam if one goes
on inventing programmes on borrowed funds.
Salient Features of Treatment and Follow Up Schedules for Tuberculosis :
Revised National Tuberculosis Programme
Category of
Tuberculosis Illness
Short Course Chemotherapy
Total Treatment
Period
Follow Up
Intensive Ph^e
(IP)*
Continuation
Phase (CP)**
Category I : New
Sputum Positive
Cases and seriously
ill sputum negative
cases
2 months (RHZE)3
Add one months of
RHZE if sputum
tests positive at two
months and then
start CP
4 months (RH)3
6 months if sputum
becomes negative at
two months
Test sputum @ at
the end of 2, 4 & 6
months. If the first
test is still
positive, add one
month to IP
Category II :
Re-treatment of old
case
2 months (SHRZE)3
+ 1 month (RHZE)3
5 months (RHE)3
8 months
Test sputum at 3
months first, then
after 2 & then 3
months***
Category III
Non-serious sputum
negative cases and
extra pulmonary
cases
2 months (RHZ)3
4 months (RH)3
6 months
Sputum test after
2 and then 4
months****
* All treatment in IP Should be directly observed.
** Direct observation once a week/fortnight when patients report for drug collection
*** If sputum still tests positive for AFB in the final test, the case is treated further as a chronic case
«*** jf fina] Sputum shows bacteria, the patient is then treated as category II thereafter.
@ all sputum tests need three samples : spot-overnight-spot.
^ Figures after parentheses denote frequency of administration every week; thus 3 means three days in a week. y
____
____
P7
IJ
and
' r- j
8
nence pads, the hospital reduced waste output, and
reduced the load on the laundry by using less bed linen
(19)
’
'
Other writers have suggested that disposable surgical
drapes and gowns should be targeted for elimination,
because reusable fabrics have been improved by techno
logical advances to be equal to disposables in comfort,
liquid repellence, and infection rate.
Tieszen has suggested that eliminating disposable linens
and paper products can help reduce surgical waste by up
to 93 percent in mass (20).
Gilden et.al. made the following recommendations for
waste reduction indisposables usage:
* Eliminate the use of egg-crate mattresses. These are
generally used to prevent pressure ulcerations, but are
not sufficient protection against the sores at points of
bony protrusions. Pressure-reducing mattresses in the
wards where pressure .sores are a concern eliminate the
need for the egg-crate pads. Although most of these pads
go home with the patient, they wind up in the landfill
eventually.
* Hard plastic suction bottles are unnecessary. Fre
quently hard plastic suction bottles are used as a
disposable item by OR staff. The usage of a lightweight
plastic liner can substantially reduce the amount of
waste generated.
* Suture removal kits can be eliminated. A reusable
stainless steel hook “stitch cutter” makes the kits
obsolete.
Recycling
Much of the remaining solid wastes can be diverted from
the waste stream by recycling. Like disposables reduc
tion, recycling will not have a direct effect on PCDD and
PCDF emissions from an incinerator or only noninfectious waste is being recycled. However, the disci
pline required by a recycling program may help improve
the waste segregation process that has such an impor
tant, direct impact on the PCDD and PCDF output from
the incinerator.
The Tieszen study from JAMA has suggested that, along
with the reduction of disposables usage, an effective
recycling program can help reduce surgical waste by up
to 93 percent in mass. (21).
Recycling is the area, where the largest reductions of
mfc bulletin / July - August. 1996
waste’ volume can be achieved. Much hospital waste
consists of office paper, waste paper, apd cardboard.
Large amounts of this paper and cardboard can inadvert
ently find their way into the incinerator. By recycling
white paper, computer paper, and cardboard boxes, a
385-bed teaching hospital in Portland, Oregon, saved
$12,000 per year from its waste disposal costs. Addition
ally, recycling newspaper, glass, aluminium, and card
board can save another 100 per ton of waste generated
(22).
The recycling of plastics can pose a difficult problem.
Because there are so many different types of plastic, highquality plastic product that are made from recycled
plas’tic must come from material that has been meticu
lously sorted. High Density Polyethylene (HDPE) cannot
be mixed with styrene, and vice versa (23). One solution
to this problem would be to find new uses for plastic
items, so that they do not have to be re-manufactured into
a new item.
A hospital in Burlington, Vermont, began a program in
1992 called MedCycle that separates pre-op plastics (no
patient contact) into blue recycling bins. The pilot
program used volunteers to separate the plastics, and
discovered that the savings in disposal costs could pay for
the use of employee time (24).
A simpler program is offered by the Stericycle Corpora
tion, which offers an infectious waste treatment process
other than incineration. This program uses plastics
recovered from both infectious and non-infectious waste
to make recovery bins and sharps containers. The
recovery bins are used to collect the plastic, and the "
sharps containers are used to protect hospital workers
and waste handlers from needle-stick injuries. Addition
ally, the company, along with Baxter International, is
working on a way to manufacture medical products from
recycled plastics from infectious waste (25).
Waste Segregation
In August 1987, the Centres for Disease Control (CDC)
recommended the adoption of “Universal Precautions” to
protect health care Workers from infection by the HIV
virus and other blood-borne pathogens. In essence, the
universal precautions protocol states that all patients are
to be treated by health care workers as if they were
infectious. Consequently, hospital workers use many
more items designed for barrier protection, such as
examination gloves. Also, any instrument that has come
mfc bulletin / July - August 1996
into contact with a patient's blood or body fluid, such as
syringes or hypodermic needles, must not be used on
another patient. Other items, such as surgical instru
ments, must be sterilized before being re-used.
The assumption that a patient is infected has generated
a second assumption that all medical waste generated by
a patient is infectious. Based on this assumption many
hospitals treat almost everything as “infectious waste”.
This assumption is not valid. The Universal Precautions
principle and the OSHA blood-borne pathogens standard
are intended to protect hospital workers, and do not
address infectious waste.
Part of the problem is that there is no uniform definition
if “infectious waste”. The EPA has been reluctant to come
up with a definition, and so “infectious waste” is defined
by the states, sometimes in vague terms. In general, the
following is considered infectious waste: microbiology
laboratory waste, used sharps and needles, bulk blood,
pathological waste (body parts or tissue), and items
stained with blood (26). It has been estimated that a strict
adherence to that list, which has been recommended by
the CDC, can reduce the amount of infectious waste
generated by each patient by up to two pounds per day.
Another problem is that landfills may reject waste
because it looks “medical” and is therefore assumed to be
infectious. An incident where a landfill operator rejected
a load that contained tubing from the hospital pharmacy's
intravenous fluids lab, which was not “infectious waste”,
seems to be common (27). The entire load on noninfectious waste was incinerated, Another incident re
ported in the same article recounted a situation where a
hospital was slapped with a $10,000 fine when bloodcontaminated plastic was found in its regular trash. The
fine was dropped when the hospital showed that the
plastic had been used to wrap a side of beef. This obstacle
can best be overcome by keeping waste haulers well
informed of waste-segregation policy, and allowing them
to voice their concerns about these issues.
The single greatest problem in waste segregation is not
that staff may assume that too many things are infec
tious, but that they won't care. There is a very ingrained
mentality among health care workers that it does not
matter whether regular trash gets mixed with infectious
waste, as long as no infectious waste gets mixed with the
regular trash. Consequently, red bag containers, which
are supposed to be only for infectius waste, are used as
common trash barrels. Photographs taken at a major
9
Eastern teaching hospital graphically illustrate the
problem. The pictures shows an “infectious” soda glass,
“infectious” magazines, and “infectious” lunch wrappers.
This problem appears to be the unfortunate rule of
infectious waste segregation, rather than the exception.
Overcoming this problem can be very difficult. Health
care providers may feel that they have enough things to
worry about as it is. Once trash is placed in a red bag,
it must be considered infectious, and treated accordingly.
Usually, that means a trip to the incinerator, when it can
contribute to the toxic emissions associated with incin
eration. Hospitals have a very strong economic incentive
to prevent trash from being mixed with infectious waste.
Treatment and disposal of infectious waste can cost as
much as 20 times the cost of trash disposal, and so poor
waste segregation can cost even a very small hospital
tens of thousands of dollars per year.
Finding the opportunities for source reduction,
recycling, and improved segregation
An article that appeared in the November 1992 issue of
Hospital Material Management Quarterly outlines a
formalized approach to identifying opportunities for
source reduction or recycling. The article, “Total Quality
Management (TQM) and Statistical Quality Control:
Practical Applications to Waste Stream Management,”
urges hospital administrators to apply the principles of
TQM, made famous by Japanese manufacturing, to
hospitals (28).
TQM, in manufacturing, utlizes all personnel (manage
ment and labor) to find process solutions to eliminate
defects in the product. The opposite of TQM in manufac
turing is visual inspection and quality control, where
labor time is spent separating defective products, rather
than simply trying to identify the source of the problem,
and fixing it. In recent years, some corporations have
begun to view industrial wastes and emissions as a
“product defect”, and have used TQM to begin eliminat
ing that defect by designing it out of the production
process. This article urges hospital administrators to
view their product as “healthful community”, and the
generation of hospital wastes as a “product defect”, and
to apply the principles of TQM to reduce the source of the
defect.
A basic principle in TQM is that different sections of the
work force be able to communicate easily. TQM generally
relies on problem-solving “teams” made up of workers
from each sector of the operation. This allows the team
to benefit f rom all of the different perspectives of people
12
The elimination of the dioxin hazard due to the incinera
tion of medical waste depends on the elimination of
incineration and similar technologies as an available
option. Additionally, these programs will have a positive
impact on the solid waste production of the hospital, and
enable substantial financial savings in waste manage
ment budgets.
mfc bulletin / July - August. 1996
ume 11 : Properties, Sources, and Background
Exposures. External Review Draft. June 1994.
11. Cohen, Mark et. al. Determination and Character
ization of Sources of Dioxins, Furans, and
Hexachlorobenzene to the Great Lakes. Review
Draft. Center of the Biology of Natural Systems. Flush
ing, NY : Queens College CUNY January 1995.
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April 1995. p. 279-286.
15. Doebbeling, Bradley N. et. al. ‘The Direct Costs of
Universal Precutions in a teaching Hospital.” Journal of
the Amercian Medical Association. Volume 264,
Number 16. October 24, 1990. p. 2083-2087.
16. Little, Pam. “Cloth : Environmental Change at
Mineral Springs Hospital.” Journal of the Alberta
Association of Registered Nurses. Volume 47, Num
ber 4. April 1991. p. 41.
17. Napthine, Rober. “Challenging Consumption : Geelong
Hospital starts to quantihfy the cost.” Australian
Nurses’ Journal. Vol 19, Number 10. May 1990. p. 1314.
18. Reprinted from Gilden, Daniel J. et. al. “Disposable
Products in the Hospital Waste Stream.” The Western
Journal of Medicine. Volume 156, Number 3. March
1992. p. 269-272.
19. Kerley. Frank R. and Brent E. Nissly. “Total Quality
Management and statistical Quality control : Practical
Applications to Waste Stream management.” Hospital
Material Management Quarterly. Volume 14, Num
ber 2. November 1992. p. 40-59
20a. Garvin, Michael L. “Reducing Waste Volumes: 3
. mfc bulletin / Jul^ August 1996
13
f
Obstacles to Overcome.” Health Facilities Manage
ment June 1990. p. 32, 34-36, 38, 41-42
20b. Tieszen, Myles E, and James Gruenberg. “A Quan
titative, Qualitative, and Critical Assessment of Surgical
Waste: Surgeons Venture Through the trash Can.”
Journal of the American Medical Association.
Volume 267, Number 20, May 27, 1992. p. 2765-2768.
21. Tieszen. Myles E, and James Gruenberg. ‘A Quanti
tative, Qualitative, and Critical Assessment of Surgical
Waste : Surgeons Venture Through the Trash Can.”
Journal of the American Medical Association.
Volume 267, Number 20 May 27, 1992. p. 2765-2768.
22. Gilden Daniel J. et. al. “Disposable Products in the
Hospital Waste Stream.” The Western Journal of
Medicine. Volume 156, Number 3. March 1992. p. 269272
23. Gutin, JoAnn C. “Plastics : Can't Live With ‘Em. Can
we Live without Them ?” E Magazine. May- June 1994.
p. 28.
24. Barlow, Rick Dana. “Medical Waste Becomes Monster
in Cost-Cutting Fight.” Hospital Material Manage
ment. December 1991. p. 1, 10.
25 Brady, Lorraine. “Start-up establishing infectious
medical waste disposal system.” Health Industry To
day. August 1994. p. 1, 14.
26. Garvin, Michael L. “Reducing Waste Volumes : 3
Obstacles to Overcome.” Health Facilities Manage
ment. June 1990. p. 32, 34-36, 38, 41-42.
27. Garvin, Michael L. ‘Reducing Waste Volumes : 3 June
Obstacles to Overcome.” Health Facilities Manage
ment 1990. p. 32, 34-36, 38, 41-42.
28. Kerley, Frank R. and Brent E Nissly. ‘Total Quality
Management and Statistical Quality Control : practical
Applications to Waste Stream Management.” Hospital
Material Management Quarterly. Volume 14, Num
ber 2. November 1992. p. 40-59
Dear Friend,
The series—Clinical Re-appraisal, by Yogesh Jain and
colleagues, is quite good. The questions each of the
articles seek to answer are quite relevant, clinically and
epidemiologically. The answers are precise, backed up
with references. The second article (worm infestation
mfcb 228-9) however, is not as good as the first one on
upper respiratory tract infections in children.
I have a couple of questions to ask. But before that let
me make a couple of comments :
* Pinworm infestation (E vermicularis) has not been
included at all. Why ? It is a common worm infestation.
But does not have the lung-phase as in the case of other
worms, and hence does not cause allergic cough etc. Is
this the reason for its deletion in the article ? Heavy
infestation of pinworms must be treated and hence this
worm should have been included in this article.
* Safety status of use of anti-helminthics in pregnancy
should have been mentioned.
My queries are :
1. The authors state that a single dose of mebendazole
(500mg) is as effective as 100 mg twice a day for three
days. Will they give some more details of any study to
back up this statement ? Is it equally safe to give this
single does of 500 mg ? The recent recommendations of
“Medical Letter” reprinted in BODHI (Dec 95-Feb 96
issue) does not mention this single dose therapy with
mebendazole.
2. The authors state that piperazine is the drug of choice
in case of intestinal obstruction due to worms. Why?
3. Hookworm infestation is found only in certain pock
ets (at least in Maharashtra) whereas roundworms are
found everywhere. Why ?
Anant Phadke,
Pune.
* * *
29. Anonymous. ‘Solid Waste Survey; The Processing of
Plastics Poses a Pointed Problem.” Modern Hospital.
September, 1973. p. 91-93
We read the comments by Anant Phadke with interest,
The questions are relevant and we offer the following
answers :
30. Green, Alex E.S., ed. Medical Waste Incineration
and Pollution Prevention. New York : Van Nostrand
Reinhold, 1992.
* Pinworm infestation is common but other than
pruritis, has not been shown to be associated with
significant morbidity like malnutrition, anaemia or
contd. on page 15.
mfc bulletin / July - August, 1996
16
CONTENTS
Author
Page
• The Revised National Tuberculosis Programme
Sham Ashtekar
1
• The Incineration of Infectious Waste :
Philip F. Coppinger
6
A Threat to Public Health (Part-II)
• Dear Friend
13
• Some Reflections on Field Work
Mohan Rao
14
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is humane and which can meet the needs of the vast majority of the population in our country. About half of the MFC members
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108
medico friend
circle
bulletin
DECEMBER
1984
Discussing Tuberculosis Control - Why?
— Anant Phadke, Pune
(In the coming Xlth Annual Meet of the Medico
Friend Circle at Bangalore, we would be discussing
various issues concerning tuberculosis control in
India. The question is so vast that it is impossible
to have any useful discussion unless we define the
focus of the discussion. In my view, the purpose of
discussing any issue in mfc needs to be clearly
thought of and agreed upon. In this note, I would
argue what in my view would be the appropriate
purpose of the discussion at the mfc annual meet.
This note would inevitably involve a discussion on
the role of mfc.)
Role of discussion at the annual meet
Let me first quickly put forth a consensus that
we had reached about the general role of the dis
cussion at the annual1 meet. It was thought that
there is a definite section within medicos and non
medicos in India who already have a perspective
similar to that of mfc or who could come to mfc, if
there is adequate contact and dialogue. Different
individuals in this section are more interested in
specific aspects of the health system in India. If mfc
takes up various issues in different meetings, then
those individuals with
specific interests in these
subjects would come closer to mfc and may join us.
Secondly such discussions would help us, the mfc
members, to enrich our knowledge and perspective
of the health problems in India through well planned
discussions with the help of resource persons out
side mfc; and mfc in turn would hopefully make some
impact on the new participants during the course of
these discussions. Fine enought But all this does not
specify what specific kind of knowledge we want to
gain and generate through these discussions; whether
and in what way would the discussions be different
from the discussions in the academic or established
circles of community health.
in our anthology — HEALTH CARE WHICH WAY
TO GO? I would also like to remind readers of the
Centenary issue of the mfc bulletin No. 100-101
(May-June 1984) where the contributors had taken
a somewhat critical overview of what the mfc has
achieved, not achieved and what challenges we face
today. It is not possible to go through the history
of mfc in this note. I would only point out two specific
characteristics of mfc which are reflected in all these
writings. One, its concern for Social Revolution. At
least the core members of mfc have been very con
cerned about this and hence the articles in mfc bulle
tin have been quite critical about the existing health
system and the debate ‘mfc which way to go?” was
centered around how mfc could contribute to funda
mental socio-economic-political
(S-E-P as Abhay
Bang had put it then) change. The second characte
ristic has been the critical and questioning attitude
of mfc members:
critical of new ‘solutions’/strategies put for
ward by the establishment and the community
health enthusiasts (this critical outlook partly
reflects the grass root village level1 at which
many mfc members work)
critical (admittedly to a lesser extent) about
mfc’s achievement and
of late, critical about the existing prescrip
tions of community medicine.
INSIDE
The National Tuberculose Programme
4
The MARD strike — a view point
6
Dear Friend
7
Editorial Note
8
Specificity of mfc
To answer this question, let us go back to the
origins of mfc, the kind of discussions we have had so
far and the debate on ‘mfc'— which way to go’
carried through the pages of the bulletin and reprinted
False and genuine limitations
are genuine ones is something that needs to
be worked out concretely and is in a way a matter
of judgement also, but to be sure, there is such a
difference. Secondly the established value system
does not completely disappear in such project work
and the problem of poverty, social' and educational
backwardness, bureaucracy etc., etc., wquld continue
to affect health work in such a project, though in a
mitigated and different form. But the direction of
where we want to go would be clear.
My plea is, let us be more conscious about our
specific character and shape our discussions in the
coming annual meet accordingly. What does this
mean concretely? For example, let us look critically
at the argument that ‘since India is a poor country
Inj. streptomycin should be reserved only for sputum
positive cases and only the two drug regimen of
Isonex plus thiacetazone be given to sputrum nega
tive cases.’ We should question this argument and
ask ‘Is Indian economy so backward today that it
cannot really afford to give streptomycin to all the
cases of tuberculosis?’ Today, the existing system
squanders resources on useless activities and keeps
a smaller share than what is possible and necessary
for health work. Even within health, resource utilisa
tion is in favour of the medical establishment and the
well-to-do. In the case of drug production, for exam
ple, out of a total of about Rs. 1200 crores of drugs
used annually in India, it is estimated that only about
Rs. 350 crores of drugs are essential and rational.
The rest, though they yield higher profits for drug
companies, are useless and irrational. If these re
sources are utilised properly why can’t all those who
need antitubercular treatment get proper treatment?
Is Indian economy really so backward that radio
graphic facilities cannot be extended more to help the
diagnosis of tuberculosis and other conditions? Why
should mfc accept the false limitations imposed by
the existing system and try to work out solutions
within these false limitations?
A question may be posed: What is the point in
trying to create ideal islands of project work when
tney are going to remain islands, when the strategy
is not going to be generalized?’ Firstly I am not
talking about ‘ideal*’ situations which have no basis
in today’s reality. One is talking about rejecting only
false limitations. Now it is true that even this cannot
be generalised within this system (obviously!) and
our alternative can only flower in a different, better
social system. That is why mfc members should work
within the context of and with the cooperation of
social movements; forces which are really aiming at
a different and better society. This is how we as
medicos can help the social revolution which was the
original and is the specific inspiration of mfc. Instead
of working within the existing system and hence help
ing it, legitimising it, why not work outside or on the
system and help those social movements which are
aiming at changing the system itself?
There is a practical advantage in working with
such social movements. If a project work is under
taken in an area where such a broad movement to
wards fundamental social change is taking place,
people’s participation, one of the most important
requirements of good community health work (and
which is generally lacking in many projects run
mainly on the basis of funds) can become a reality
and the entire atmosphere is quite different from the
usual one of apathy, lack of faith, lack of commit
ment and too much bureaucracy. In such places, one
can concentrate on the real problems of health work
and also obtain people’s cooperation and participa
tion, required to solve them. I have deliberately used
the general terms social revolution and social move
ments, because concretely which are such movements
is something which individual members have to decide
on their own. Ideologically and politically mfc is not
very homogenous and different individuals have diffe
rent opinions. But one thing is certain, all of us want
a fundamental socio-economic change even if the exact
character of this change is a matter of debate.
My plea is that when we discuss the problem
of tuberculosis or any other problem, let us discuss
it with a view to the social revolution that alone would
be able to create conditions for a healthy society and
a healthy medical system.
We all know very well that India is both econo
mically and socially backward and even after a social
revolution resources are not going to develop at such
a rate as to make all desirable facilities available in
the immediate future. We would, therefore, have to
work out solutions within the constraints of limited
resources. But over and above these real constraints,
the existing system has imposed its own constraints
like — malutilisation of resources for the benefit of
a few; bureaucratic callousness of doctors and other
health personnel; curative oriented training; corrup
tion and commercialization in medical practice;
political interference by vested interests etc., etc. All
these together make it almost impossible for a scienti
fic strategy to be successfully implemented. In
these circumstances should we try to suggest methods
of improving the existing state of affairs a little more
by accepting all the false limitations of this system?
Towards a better medical and social system
Instead of falling into their trap under the name
of Practical difficulties’, and suggesting improve
ments to those who are neither particularly
willing nor capable of improving the existing state of
affairs (remember what happened to the reports of
numerous expert committees) why not expose them?
Why not concentrate on evolving a people oriented
scientific strategy in our own projects and other
activities? Such an approach would reject false limita
tions and try to work within genuine limitations.
Firstly which are false limitations and which
Tall talk?
It may be thought all this is high flown, tall talk'
there is no point in planning for a future society today
when we do not know when and whether it would
come about.’ Yes, in a way, it is tall talk. Was not
2
aiming at freedom from British rule tall talk in the
1930’s? Were not Mao and his comrades utopian
when they were aiming at a new society in the 1930’s?
The Freedom Movement in India was aiming at
total political independence on the one hand but at
the same time demanded certain reforms within the
system. Likewise we can and should ask for certain
changes in the existing medical! system to partly
alleviate the sufferings of the people. Our discussion
should also be geared to find out such points of
action. This is quite different from allowing our dis
cussions to be limited by the framework/problems
created by the existing system.
“We already possess all the necessary weapons
to wipe out TB. All we need to defeat the disease,
now and forever, are the financial resources and the
political will."
World Health — 1982
not won by full time political activists alone, it was
the product of the collective efforts of millions of
ordinary people contributing their individual, small
mite.
The coming annual meet
Concretely speaking, in the discussion on tuber
culosis during the coming annual meet, ipy sugges
tion is that we should concentrate on: (a) forging an
outline of a fundamental critique of \he existing state
of affairs in tuberculosis control in India; (b) identi
fying measures which should be demanded from the
governments to alleviate some acute problems; (c)
evolving an outline of an alternative strategy of
tuberculosis control. This would involve:
Innovations, ideas, created, practised by such
radical health work may alfco be used in a diluted,
distorted form by the existing system (for example,
the concept of community health worker). But it is
a different matter to aim at, limit oneself (consciously
or otherwise), to changes in the existing system. If
somebody says that you are evolving strategies which
cannot be generalised and hence your work is useless,
we should stand up boldly and say that yes, our work,
ideas are useless for the existing system but as the
movement for social revolution grows the success and
influence of our ideas would also grow.
There may be an objection that ‘all this tall talk
leaves no scope for those who cannot devote them
selves to such project work’. There is a misunder
standing involved in this argument about project
work. Project work does not necessarily mean village
level project work. Alternatives are to be planned
and tried out at all levels, wherever possible. A move
ment geared to analyse and expose the existing medi
cal system, alternative experiments in production and
distribution of rational, low cost drugs, in medical/
health education . . . etc., are all project work in this
sense. Concretely, in the case of tuberculosis control,
it is not necessary that everybody from the group has
to devote themselves to a rural project in order for the
group to analyse the existing strategy of the tuber
culosis control programme and to try to evolve an
alternative. There are a number of other small and
big tasks involved in this work: for example, gather
ing information, analysing it, disseminating informa
tion, organization . . . etc., in which different indi
viduals can contribute differently. Independence was
1.
Understanding the theoretical basis and the
evolution of the National Tuberculosis Pro
gramme. Finding out whether the strategy
has accepted and intema’Ased the false
limitations imposed by the system;
2.
Sharing our knowledge and experience of
how this programme works in the field and
why;
3.
Identifying and analysing the genuine tech
nical and social problems involved in the
control of tuberculosis in a backward coun
try like India;
Learning from the experiences of other
countries and formulating an outline of an
alternative and the role of mfc in it.
4.
(We are awaiting comments before we finalise
the session by session plan of the meet. These must
reach us by the 31st of December. The final plan will
appear is January 1985 issue — Editor/convenor) .
Under the Lens
— Health and Medicine
The third anthology of original! articles of mfc
bulletins (52 to 95) will be available for sale by the
end of January at a price of Rs. 15/-.
The first anthology (In search of a Diagnosis)
and the second anthology (Health Care which way
to go) are also being reprinted. The price will be
Rs. 12/- and Rs. 15/ respectively. The three
volume set will be available for Rs. 42/A pre-publication offer of the three volume set
for Rs. 35/- is available to all those who send the
order and amount by money order/demand draft
before 25th of January 1985 to the mfc office at
Bangalore.
Annual Meet 1985
Dates: 27-29 January 1985
Venue: Indian Social Institute, Benson Town,
Bangalore-560 046.
Theme*. TB and its control
Boarding and Lodging-. Rs. 15/- per day.
Registration: Rs. 20/Background papers: Rs. 10/- (Send in advance)
For further details, return bookings and other
queries write to MFC office at Bangalore.
3
The National Tuberculosis Programme
— What our experts say
sociological basis
village guide or the multi-purpose workers of a PHC
sub-centre or by the treatment organiser at the
health institution.
“Even with the present extremely limited and
inadequate facilities available for the diagnosis and
treatment of the disease, over half of the sputum
positive persons and over one third of the persons
with radiologically active disease have actually sought
assistance at government medical institutions moti
vated by their symptoms. The provision of elemen
tary diagnostic facilities, such as a district referral
x-ray unit and staining and microscopy facilities at
primary health centres, and the distribution on a
domiciliary/ambulatory basis, of suitable chemothe
rapeutic drugs would make it possible to treat a
sizeable number of cases. The cost and problems
of organising such a tuberculosis programme would
be almost negligible in comparison with those involved
in providing a system based on sanatorium treat
ment of similar magnitude or in combing the whole
country with hundreds and hundreds of mobile x-ray
units. ”
— Banerji and Anderson, 1963.
A district tuberculosis centre (DTC) supports
the tuberculosis work at health institutions by train
ing personnel at HIS, providing referral diagnostic
and treatment (including hospitalization) support,
by having a district wide information system and by
providing drugs and other supplies to HIS.
The Directorate General of Health Services and
the National Tuberculosis Institute, Bangalore are at
the apex, with facilities for a national information
system, training of key workers and monitoring,
evaluation and research. ”
— D. Banerji, 1984
evalution
“There are deficiencies in equipment, manpower
and there is human apathy. DGHS reports on diag
nosis and treatment activities are totally false.
epidemiological dimensions
Microscopes are there in many centred but these
are not used or are out of order. A large number of
cases are diagnosed without sputum examination.
Periodic examination of sputum of patients under
treatment is not carried out regularly with the result
the estimates of patients completing treatment or
sputum conversion rates of initially bacillary cases
are liable to be inexact...............
(i) Prevalence: This is about 40% in all age
groups rising from about 2 % in the youngest
age group to about 70% at age 35. There
after it remains almost constant.
(ii) Incidence of infection is highest in indivi
duals between the ages of 5 and 20 years.
(in) Risk of infection is about 2-4% per annum.
(ivt X-ray confirmed disease is about 2% among
total population aged 10 years and more
and of these about 20% are bacillary.
(v) Age/sex difference: The prevalence and
incidence are higher as age advances and
again higher among males than among
females, male to female ratio varying from
3:1 to 5:1.
(Vi) Time trends: The trend of tjuberculosis
appears to be almost constant over the
years except in some cities where better
services for diagnosis and treatment have
been available for some time.
(Vii) Distribution: Tuberculosis infection as well
as disease are more or less uniformly dis
tributed in utban, 'semi-urban and rural
areas. Thus the vast majority of pulmo
nary tuberculosis cases are to be found in
rural and semi urban areas, where more
than 80% of the country’s population lives.
— DVJ Baily, 1983
..... Reports are received on sputum exami
nation from centres where no smear is examined
.... In many States the staff sanctioned for DTC
is less than the minimum laid down under DTP ....
Full quota of NTI trained key personnel were in
position in only two of 10 districts visited ....
There is general lack of interest or even aware
ness ol responsibilitues by the doctors working in
peripheral health institutions (PHI) in connection
with TB work . . . PHI doctors do not send all
patients with suggestive symptoms to the laboratory
for collection and examination of sputum even if a
microscope is available and microscopist is in posi
tion ................ NTP manual meant for PHIs is not
available in any PHI.
Some cooperative patients go on taking the
treatment for over 2-3 years. In any case it seems
treatment is always stopped by the patient rather
than by the doctor whatever its duration................
The position regarding drugs were satisfactory.
No centre experienced shortage of drugs except
streptomycin and PAS.
Organizational plan
Tuberculosis diagnosis facilities are made
available in far flung rural health institutions (HIS).
Treatment of the diagnosed cases is organised by the
There is also a craze for using second line drugs
by the profession.
4
The condition about TB disease in children in
the country is apalling. There is ovetdiagnosis and
over treatment which needs attention
There are no arrangements for BCG vaccination in
any PHIs
Practically alP DTCs experienced
difficulty in procuring adequate quantities of minia
ture x-ray films, shortage in laboratory reagents,
printed cards
to “sink or sail” with the general health services,
neglect of the health services of the masses because
of pre-occupation with the high technology
health services of the classes, led to neglect of NTP.
There is thus an element of success in the failure of
NTP: by its failure, it has pointed out the failures
within the entire system of the health services of the
country. ”
— Review of NTP
ICMR Expert Committee, 1975
D. Bonerji, 1984
Anti—TB drugs
•
The ultimate solution
The production of First-line anti-TB drugs is
showing a downward trend inspite of the increase
in the number of TB patients.
•
Production of INH for tuberculosis is only one
third of the minimal requirement. On the other
hand tonics and vitamins are produced in wasteful
abundance.
•
Irrational combinations of streptomycin continue
to be produced, pushed and widely misused for
trivial problems inspite of the known dangers of
emerging primary resistance of TB bacilli to
streptomycin.
•
With government programmes unable to rearh
even half of the TB patients people suffering
from this disease are being forced to buy drugs
at costs which keep rising.
•
Environment is a Fundamental Factor in the
ecological triad of tuberculosis. Socio-economic con
ditions can alter the epidemiological situation power
fully, for good or bad, over a decade or two. Since
BCG vaccination has no influence on the naturally
infected population and chemotherapy merely elimi
nates some cases but cannot present cases from
occuring, a tuberculosis control programme has a low
potential for influencing the epidemic curve over a
short period. So far, no reported study has success
fully demonstrated the prime influence of anti
tuberculosis programmes in controlling the disease,
without a concomitant marked improvement in the
standard of living of ,(the people”.
—• D, R. Nagpaul, 1978
References :
Of the 52% of the infectious TB cases who seek
medical help for their symptoms of their own
accord, 90% of them come away with cough
syrups, tonics and even steroids with their diag
nosis missed and the problem untreated.
1.
D. Banerji & Stig Andersen (1963)
A sociological study of awareness of symptoms
among persons with pulmonary tuberculosis
Bull. wld. Hlth Org. 29 665-683
2.
ICMR (1975)
Review of National Tuberculosis Programme
Report of Expert Committee, ICMR.
3.
D. R. Nagpaul (1978)
Tuberculosis in India — A perspective
Journal of Ind. Med. Assoc. Vol. 71, No. 2.
4.
G. V. J. Baily (1983)
Tuberculosis control in India —
Current problems and possible solutions
The Ind. J. of Tub, Vol. XXX No. 2
political economy
5
“That India has taken the initiative to formulate
a felt need based NTP in 1962 and that it suffered
from grievous weaknesses in its implementation be
cause of diversion of efforts towards such high tech
nology areas as cancer and cardio-vascular diseases
to meet the needs of the privileged classes, reflects
the nature of interplay of social and economic forces
within the country. As NTP was specially designed
Mira Shiva (1983)
Rational TB care — a priority)
A hand out of VHAI.
6.
D. Banerji (1984)
Voluntary Agencies and India's National
Tuberculosis Programme
Background paper VHAI-GBM, April, 1984
•
There is great ignorance about drugs, dosages,
drug regimes, duration of treatment among quali
fied as well as unqualified medical1 personnel trea
ting TB cases. This is resulting in increasing
drug defaulting and drug resistance.
•
Uncontrollable sales and misuse of potent second
line drugs often in sub-therapeutic doses and in
irrational combinations by authorised and un
authorised agents is not merely an ethical' pro
blem but is turning the already difficult problem
of resistance into an insolvable one.
— Mira Shiva, VHAI, 1983
5
The 'MARD' Strike —A View Point
— Sanjay Nagral, Bombay
the government would revoke the decision (which
meant displeasing people with the clout and money)
in response to the protest of a small section of the
medical community they were hoping for too much.
The twenty-eight day long strike by resident
doctors, interns and medical students all over Maha
rashtra to protest against the opening of three capita
tion fee based medical colleges ended a few months
ago. The withdrawal of the strike on just a no-victimi
sation assurance was regarded by many as total sur
render. Two of the capitation fee medical colleges
have already opened since then and plans have been
announced for many more. In that sense the strike
was a failure. It was, however, unique in many
senses. For example, it was the first time that the
MARD (Maharashtra Association of Resident
Doctors) was going on an indefinite strike for an
issue other than pay rise. It is important to analyse
the various aspects of the strike not just because
there is a .lot of ground for criticism but more im
portantly to make us better equipped to react to
such struggles in the future. As the interns’ represen
tative on the central committee of MARD and on the
negotiating team, I had the opportunity to have a close
look at the events during the strike, and in this article,
I shall try to analyse some of them in the light of its
failure.
Political moves have to be fought politically and
by political forces. And with the present strength
of the ruling classes and their parties and their
total grip over the various state agencies,
^agitations many a times are likely to end
up wresting concessions of varying; degrees
rather than changing decisions. It was with this undesstanding that some of us from K.E.M. MARD
were proposing the idea of negotiating with the
government over the percentage of seats to be kept
on genuine open merit basis. In fact at one stage,
the government was ready to do so. What was dis
missed as a ‘compromise’ was in fact a tactical
move keeping the reality of the situation in mind.
A protest against capitation fees means a
protest against the right of the government to make
education a privilege of the rich and the moneyed.
But when a government is a puppet in the hands of
the capitalists, landlords and merchant class, it ulti
mately implies a clash with the strength of the rul
ing classes. This will necessarily have to involve
large sections of the masses, for whom even simple
medical education is a dream, for it to succeed. It
was these political realities that the MARD leader
ship failed to grasp. Although the strike did teach
quite a few lessons in cunning, ruling class poli
tics, by and large the attitude of the leadership re
mained immature and at times even opportunist.
And not in a few instances was this not due to inno
cence but a genuine desire for fast popularity and
personal gains.
First of all a few facts about the strike. On the
twenty second of June a one day token strike was
observed by resident doctors, interns and medical
students all over Maharashtra as a mark of protest
against the government’s decision to permit the
opening of three capitation based colleges at Karhad,
Satara and Pravaranagar in the State. A delegation of
the MARD was literally dismissed by the Chief
Minister who refused even to discuss the issue. A
decision was then taken to launch an indefinite strike
from the tenth of July, the call for which was given
by the MARD. The strike action by around 4500
residents was joined right from the start by around
1500 internees and later by around 8-000 medical
students. It lasted for 28 days and was withdrawn
on the 6th of August with just a no-victimisation
assurance from the government.
To begin with, was the total lack of prepara
tion and ground work for such a big struggle. Many
assumed that just residents striking work and
paralysing public hospitals would bring the govern
ment down to its knees. That in the past, the demand
was always a small pay rise, was totally forgotten.
Then, there was the total lack of effort (except by
some sections) to involve the medical fraternity as
well as otjier sections in the struggle. It was not
surprising that many senior doctors and their organi
sations although generously offering a lot of sympathy
refused to join the strike. Most of them are so well
entrenched in the profession and have so readily
accepted to be a part of a corrupt and wretched
medical system that to take such a step would be to
invite the wrath of the very government to whose
tune they dance. The classical example was of the
IMA many of whose office bearers although openly
supporting the strike refused to criticise the health
minister or take action against her as a president elect
The origin of many of the drawbacks of the
strike and of its eventual failure lay in the fact that the
leadership of the MARD never understood or analy
sed the politics behind the opening of capitation
colleges. The government’s arguments in favour are
too nonsensical and ridiculous to merit discussion.
The fact remains that this was and is a political
move by the government to satisfy the powerful sugar
barons (and their children), earn quick cash and
at the same time build a pseudo ‘pro-rural poor’
image. The desperate haste with which some of
these colleges were started, flouting all routine
norms, the panic on the government’s part after the
court case was filed, showed that the government
had a lot at stake in these institutions. The crude
effort to break the strike by offering persona] bri
bes and favours to some of the leaders, proved this
even more. And if the MARD leadership hoped that
(Continued on page 8)
6
^ear friend. , .
In the last few months we have often been
asked about mfc’s stand on the MARD strike. This
has been easy enough to answer, because as far as
we know mfc has no opinion on the issue. But this
has generated other questions which we would like
to verbalise here.
In the last year there have been at least three
long drawn out actions by doctors (West Bengal,
Orissa and Maharashtra). Their demands were not
only for better pay and working conditions but for
better health care, adequate facilities and drugs;
and in Maharashtra, specifically, against the opening
of capitation fee medical colleges. Why have these
actions never been discussed in the mfc?
Part of the reason is of course that those of us who
could have raised the issue, haven’t. But this reluc
tance itself tells a story. In fact, until the question
of mfc’s standpoint was persistently asked, we had
subconsciously thought of these issues as peripheral
to mfc’s main objectives and interests. But are
they?
mfc’s avowed concern is with the health care
system and the practice of medicine. As we read it,
mfc has always interpreted it as wholly discarding
the hospital-based established system of health care
and seeking alternatives in the delivery of such care.
Logically then, issues such as better working condi
tions of doctors, or better quality of health care
through the existing systems appear to fall outside
mfc concerns. What is here ignored is that the exis
ting system will not be replaced now or for some
time, and it is in fact being enlarged. So issues of
the hospital as workplace, and those concerning the
quality of health care become relevant, current and
even burning issues. And the MARD strike took up.
ironically enough, issues very much in the realm of
.mfc’s major concern — medical education. (For the
moment it is sufficient to consider only doctors’ agi
tations, mainly because mfc despite its statements to
the contrary, unfortunately tends to be very much
medico-oriented.)
We do not think it is a sufficient argument to
state that there was not enough information to
either discuss or assess the issue or even raise it in the
bulletin. The West Bengal strike had ended just
before the CINI Meet and the MARD strike has
received more press coverage than any other previous
strike, perhaps.
All this makes one wonder: Is mfc’s professed
role of ‘thought-current’ leading to a lot of fence
sitting? Are we perhaps so preoccupied with long
term change that we are missing opportunities of
making our considerable presence felt where it would
matter? Are we in fact, become so profoundly invol
ved with seeking limited alternatives that we are
opting out of mainstream issues?
Many friends from mfc have been involved with
providing workable and successful alternatives at the
local level in various ways. But isn’t it necessary
to make these activities of ‘model building’ at a local
area an integal part of all the struggles for better
health and for changes in the existing health care
system? Only such a perspective can make us more
sensitive to the struggles of people within the health
care system.
Secondly, the last few years have seen various
groups in the country take up health issues in their
own areas of work (eg., women’s movement, and to
a lesser extent, trade unions and the anti-nuclear
movement). What has been mfc’s involvement and
contribution to these movements? Is it not time
that we became more than a ‘thought-current’?
May we suggest that some of these issues as well
as the questions raised in Anant’s article (100-1) be
taken up at the GB Meet in January?
Yours sincerely.
Padma Prakash & Amar Jesani
Since I am more than aware of the deep concern
that mfc has for health issues, I would like to make a
few points here:
1. There is a dire need to pursue criticism of
existing medical education and suggest alter
natives. There needs to be more follow up of
another issue-that of RMPs and ayurvedic and
homeopathic practitioners using allopathic
drugs and vice versa. Both these issues are
inter-related.
2. The mfc members need to increasingly respond
to important issues like the resident doctors
strike in July-August 1984 and the mill work
ers strike in Bombay.
3. A group of young doctors tried to educate the
general public regarding the politics under
lying capitation fee medical colleges by way
of writing letters to capitalist press and also
directly addressing workers’ meetings.
The
same group of doctors had conducted free
medical OPD for striking mill workers and
made it a point to discuss politics and eco
nomics with workers. This was definitely an
eye opener in many ways for the young
doctors also. They could more than under
stand the problems of the working class and
realised the lack of relevance of present day
medical education to the social problems.
4
The same group of doctors also made several
visits to the blind school and made themselves
available for reading progressive literature,
story books, curricular books for the blind
students.
5
These doctors visited certain working class
localities in the suburbs of Bombay, conduc
ted free OPDs and also started circulating
libraries constituting progressive literature.
6. In conclusion, all the issues related to health
being our primary concern, we must keep live
contact with working class activities, schools,
colleges and various other institutions,
wherever we can work, mfc members should
(Continued on page 8)
7
mfc bulletin: DECEMBER 1984
RN. 27565/76
E<a]0[l©m0 □’DOftcg
In January we meet to explore the various
dimensions of the problem of Tuberculosis and TB
control within the context of Indian social reality.
Why are we discussing —
Tuberculosis and its
control? Binayaks paper in mfcb 105 highlighted
some problems and issues, Anant Phadke’s lead
paper in this issue goes into this question in greater
detail within the overall perspective of the medico
friend circle. Warning us of the false limitations that
the existing socio-political system thrusts on us, in
our attempts to evolve alternative and more peopleoriented strategies he outlines the various areas we
could/should discuss during the meet.
(Continued from page
of the IMA. There is no doubt, however, that if the
senior doctors had joined the strike, the impact
would have been much greater because of the total
paralysis of even the skeleton emergency services
that would have ensued.
Excessive faith and hope was placed by many
in the legal system to give a favourable decision.
The counsel for MARD bared it all very early when
he bluntly told us that the case against capitation
colleges was strong only as far as the ‘standard of
education’ part was concerned. That this legal system
does not consider ‘capitation’ as illegal and unconsti
tutional was apparent in the court’s verdict also. In
fact this ‘standard of education’ ploy was used time
and again by the government during the negotiations
to trap us into discussing something irrelevant. The
minister would go to extreme lengths to point out
how the standards were being maintained and some
of the MARD leaders would very obligingly deviate
from the issue of capitation.
Mention must be made here of the role of the
KEM unit of MARD, for here a definite attempt
was made to broaden the base of the struggle. The
mass contact programme, street plays, public meet
ings and parallel out patient departments, were all
efforts to take the issue to the public Meetings of
trade unions and student organisations were held to
chalk out a more broad plan of action. It would be
appropriate to mention that very few trade unions
responded to the invitation and those who attended
showed extreme lethargy to take any concrete action.
Thus, what was an excellent opportunity for the
working class movement to fight for a genuine issue
was lost. The gherao of an ENT Surgeon from
Bombay was deliberately planned to prove that mem-
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhmv mankad
editor :
ravi narayan
Regd. No. L/NP/KRNU/2Q2
Some excerpts from reports/papers by various
experts in the country gives additional background
to the situation, of Tuberculosis and its control in
the country. The readers are reminded of the reading
list and the check list questions in mfcb lOV-suppliement. Hope these will stimulate your preparation for
the meet?
The Annual Meet is also an opportunity to
critically evaluate mfc’s role and direction. Apart
from Anants paper, the report on MART) strike and
the dear friends letters raise many relevant issues
which could well be the starting point for such an
exercise in introspection.
bers of the profession who associated themselves with
these colleges should be exposed and attacked.
Two of the colleges have since then opened with
a lot of fan fare. Many more are being proposed.
These will -start sprouting up with regular fre
quency, closely competing with engineering institu
tions. The fight therefore will have to be a prolonged
one. Organizations like the MART) cannot and
should not fight such struggles alone. This is the
work of mass organisations, trade unions and working
class parties. Science movements and organisations
like the medico friend circle must take up such issues.
Always keeping in mind however that it is the symp
toms of a wretched and rotting economic structure
that are being manifest, time and again. It should
also be borne in mind that non-capitation ‘open merit’
education although apparently giving equality of
opportunity is heavily loaded in favour of. the rich
and the moneyed. This is especially true of higher
education. This is not very surprising since it is the
moneyed who rule. Capitation fees is just a more
vulgar and crude form of a degrading but crumbling
system. The only way to put a permanent stop to
such terrible obscenity is to strike at the roots of the
disease. Such struggles however have to be fought
and if fought with the right perspective can contri
bute a lot in this direction.
(Continued from page 7)
not remain away from any socio-political
struggle because it strengthens capitalists.
Atleast mfc members can act as conscience
keepers for existing political parties if mfc
cannot and is not able to function as a poli
tical party.
— Shriniwas Kashalikar,
Bombay
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
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Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan'at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan'»for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560034
II
medico friend
circle
bulletin
MARCH
1985
TB AND SOCIETY
Preamble
It is the first time in the last eleven years since
our inception that mfc has taken up a single dise
ase entity for discussion at the annual meet.
The disease selected—Tuberculosis'—was particu
larly relevant because of m'any reasons:
i. To begin with there is greater understanding
today of the multifactorial aetiology of the disease
where social factors more than biological are known
to have a significant impact on incidence, preva
lence, spread? diagnosis, management and control;
ii. Secondly unlike most of the national pro
grammes in India the NTP has developed on crucial
sociological perspectives derived from relevant
field studies;
iii. In its approach in terms of integration with
general health services, choice of appropriate investi
gative technology, alternatives in chemotherapy and
other aspects it has shown a greater people/patient
sensitivity than most other programmes and a signi
ficant shift from the dependence on the industrial
aspects of medical care;
iv. Inspite of these salient features the case
finding and case holding performance is far from
satisfactory and these have become a matter of great
concern for TB programme organisers and decision
makers,
v. The ICMR/ICSSR Report while analysing
the drug situation in the country has highlighted the
shocking state of availability of anti-tuberculosis
drugs ('one third of minimal requirement’) when
vitamins, tonics, health restoratives and digestives
are being produced in “wasteful abundance”;
vi. By its inclusion in the 20 point programme
the government has endorsed its relative importance
in the health scene of the country though whether
this step is part of a 'populist rhetoric’ or a nati
onal commitment towards control of the problem,
only time will tell.
It is in this context that the mfc decision to
relook at the whole situation of the TB problem and
its control in India as an exercise for 1984-85 is
significant.
Scope and Focus
The meet of over 110 friends from various
diverse backgrounds (ref mfeb 110 Feb 1985) with
its intensive small and large group discussions
highlighted that the subject was too large and too
important t0 be tackled in 16 hours of discussion
and that rather than expecting a meaningful criti
que of NTP to emerge from sq diverse a group —
what would, really be mlore realistic would be to
accept the annual meet discussions as the initiating
of a process of critical analysis. This would be
followed up by further study, small group work and
field evaluation through 1985 from which would
hopefully emerge an mfc perspective on the problem.
This sense of realism was forced on the group after
the first session on “Expectations of the Meet” in
which participants were asked to raise issues and
questions for discussion.
Expectations of the Meet
The exercise identified a phenomenal range of
problems far beyond the scope of the meet:
1. Need to understand the organisational
structure and implementation of NTP and the devi
ations from ideal in the actual field situations.
2. Need to identify issues on which we should
put pressure on policy makers.
3. Need to discuss the range of non-pulmonary
tuberculosis and how it is viewed by the NTP.
4. Need to discuss childhood TB and how it is
viewed by NTP.
5. Need t0 study how NTP actually operates
at the PHC level and what are the components of
the services actually available at the community
(village) level.
6. How do non-allopathic systems view TB as
a problem?
INSIDE
TB — SEP strategy
2
Towards a relevant
TB Control Programme
3
Subgroup reports on TB
5
AIDAN meeting report
7
2. The time period of each phase and the spac
ing of the drugs depend on factors such as — a.
accessibility to clinic and health centre;
b. infrastructure available; c. cost,' d. availabi
lity of drugs; e. stage of disease—serious and nonserious patients; and f. knowledge of patient com
pliance.
Many regimes taking these factors into account
are already recommended from which a selection can
be made.
3. While the regime is being dispensed it is
essential to ensure: a. psychological reassurance of
the patient; b. maintenance of a satisfactory doctor
patient relationship; and c. tactful information to
the patient to increase his ability to identify toxic
effects.
4. The use of supportive therapy such as cough
mixtures etc., should be done in a rational way
taking care not to overuse/misuse supplementary
medication.
1. Broadly speaking TB control programmes
should ensure the following three crucial features:
(a) A link with socio-economic and developmental
activity
(b) A stress on health education and awareness
building at all levels
(c) A commitment to community participation in the
decision making process and project evaluation.
It was felt that many of us who are working in
the field have already a sufficient rapport with the
community and the above could be integrated pri.marily by sensitising oursdlves to these issues.
Ensuring the above principles, certain specific
recommendations were made for practical imple
mentation during: A. Case Finding/Case Holding;
B. Drug Regimes; C. Training of Workers.
A. Case Finding/Case Holding
1. There is need to have a rough estimate of
how many TB patients ought to be in the area and
work towards identifying at least that number.
2. Involve health personnel at all levels in the
programme and also all the cadres of the govern
mental health service be they MPWs, CHWs and
Dais. Local indigenous practitioners and traditional
healers should als0 be involved.
3. School health check ups could be done as
an additional focus for case finding as in leprosy.
School teachers and high school students should be
involved in general awareness building.
4. People’s organisations like organisations of
the rural poor, workers, trade unions and other formal
and informal groups in the community should be
sensitised to the problem and involved.
5. Malnutrition surveys and m'antoux testing
could be adjuncts to case finding specially for
childhood. TB.
6. Patients who are on regular treatment or
have been cured should be actively involved.
7. The family of patients should be involved
in a positive way in the programe. Once they are
sensitised to the problem in a positive way (rather
than feeling a fear or social stigma) they can be
helpful in making the community aware and also
bringing patients from other neighbouring families
for treatment.
8. The socio economic difficulties of patients
should be assessed and transportation fare and other
small compensation for wage loss etc., should be
provided.
C. Training of Workers
1. First the present knowledge/myths/perceptions existing in the particular area should be
studied;
2. The people should be taken into confidence
about the programme envisaged by the team' and
their participation in decision making ensured.
3. Grass-root workers at village level to be
involved in the programme should be selected by
the community. The selection should be based
among other things on personal motivation and’
stamina.
4. The training of grass root workers or CHVs
should be undertaken in appropriate size of the
group (10-15).
5. The content of the training should include
cause of disease; symptomsi; case holding; side
effects of drugs and their management; and motiva
tion of patients.
6. The training should be theoretical along with
practical field training. The methodology should
include.
a. use of available aids, modifying them to make
them more relevant and meaningful to the local
area; b. involve the patient and get himJ to talk
about his symptoms/difficulties etc., c. reinforce
the learning by continous on-the-job training; d.
older CHVs to be involved in training newer ones;
c. use simple laymen language and avoid technical
jargon; f. concentrate on training to communicate
effectively with patients and the- community.
7. Periodic evaluations of the training pro
gramme should be undertaken eliciting feedback
from the CHVs.
8. Similarly an effective supportive supervision
plan and a system of continuing education in which
problems faced in the field are constantly identi
fied and discussed, should be included.
9. The CHVs should be trained to increase
community awareness of the existing NTP and the
availability of effective treatment as a right so that
B. Drug Regimes
There are several regimes which have been re
commended and are available in the existing litera
ture and also promoted by the NTI. Certain basic
principles to be followed before selecting the ap
propriate regimen are:
1. Technical — an intensive phase of two
bacteriocidal drugs and one bacteriostatic drug
followed by a maintenance phase of a bacteriocidal
and a bacteriostatic drug.
4
problem but as effective educators of their patients
in the preventive/promotive aspects of TB.
CHW training: There was a general feeling that
the existing governmental CHW training programmes
gave low priority and emphasis to TB control. The
lesson plans were limited and not integrated with
the rest of the training but given separately at DTCs
and PHCs.
From the experience of participants who were
involved in health projects in whiohf training of
CHWs was being undertaken there emerged the
need t0 include certain innovative methods of train
ing to make the CHWs more effective in the field:
These included:— (i) participation of senior CHWs
in training; (ii) learning through doings (iii) decent
ralised and localised training; (iv? participatory
methods; (v) use of locally developed or regionally
adapted AV aids and so on.
The group suggested that we in the mfc should
undertake to:
A. Review all available educational materials
and AV aids on Tuberculosis available from govern
mental and non-governmental sources and check
whether the points included in (1) above are present
and whether the social focus as identified in discus
sions exist.
(Anant Phadke agreed to study the TB Associ
ation Pamphlets for a start).
demands for more regular drug supply and more
effective government health centre services can be
generated. In the absence of such a commitment
the programme of NGOs will become ends by
themselves duplicating the efforts of government
and supporting their inefficiency. In the long run
since voluntary agencies cannot build up parallel
structures to government health services, the catalyst
nature and the 'awareness of rights’ generation
nature of non-governmental voluntary effort should
be promoted.
Mona Daswani, Bombay
Sub-group Report
Para-professional training and community
awareness in TB
1. The objectives of health education of the
community should be to promote an understanding of
the medico-technological aspects of TB, the socio
economic-political aspects, the rights and responsi
bilities of the patients and people, the common
beliefs and superstitions and demystification of all
aspects of the TB control programme.
2. The responsibility of providing this educa
tion and awareness is the joint responsibility of
government and non-governmental agencies. However,
it seems that one of the main reasons why health
education has not been given top priority in the
NTP is because of the field reality that the existing
services (even if they are geared up) cannot cope
with the increased demands of TB patients, if
awareness becomes widespread. There seems to be
no other reason why even after decades of NTP,
there is still no rationally formulated and researched
communication strategy. TB Associations have play
ed their role but their efforts seem to lack continuity,
technical competence or creativity and are predomi
nantly urban based.
3. Health education efforts should creatively
and competently involve all sections of the commu
nity not only as recipients of awareness building
efforts but also as promotors of further awareness.
While focussing on all sections particular interest
should be taken of policy makers, politicians and
community leaders including the functionaries of the
gram panchayat.
4. Improving the communication skills of all
categories of health workers from doctors all the
way to the community health workers should be an
important part of the strategy. At present this is one
of the most neglected areas in the existing curricula.
5. The science syllabus of schools does not
equip children with practical knowledge of common
diseases in India or for that matter for healthy
living. There is considerable scope for incorporating
knowledge about TB in the science teaching of
schools. Schools could also become a focus
of creative involvement of school teachers and
children in health promotion.
6. There are a sizeable section of private
practitioners, of non-allopathic systems who should
be involved in awareness building. They should be
involved not only in management of TB as a clinical
B. Review all available training manuals of
health workers (CHWs, MPWs, HAs) for the im
portance given, content, and focus of teaching of
tuberculosis.
(Marie D’Souza and Minaxi Shukla agreed to
undertake this exercise).
Based on the above two studies recommendations
can be made to policy makers, programme organi
sers and health educationists in the country.
Narendra Gupta,
. Prayas.
Sub-group Report
Tuberculosis in Medical Education
The group focussed upon the problem of produ
cing a socially useful doctor in connection
with
tuberculosis, and the hurdles in the present medi
cal education system that have to be overcome in
this direction. The group itself was a small one and
represented five medical colleges only.
Preamble
1. The basic structure of present day medical
colleges and medical curriculum, propagates a
certain value system, which is predominantly exploitatory in nature;
2. We believe that propagating the attitudes
currently plaguing the medical system is a general
process, which involves the attitudes and practices
of faculty members, the expectations of our families
and society, and the 'traditional’ role of a doctor
3. That medical education is incomplete in
itself, unless the social dimension of disease is stres5
system into the teaching that unless one’s clinical
judgement is backed up by labs, one is practising
'poor medicine’.
In fact, making a confident clinical diagnosis
with limited facilities available, is ‘good medicine’.
7. Emphasis is once again laid out on one
therapeutic regimien (ie., SM/INH/TA) for all TB
patients. The concept of suiting TB treatment to a
particular
patient's
background is
not even
touched upon, eg., A labourer
who can
at
tend a TB clinic twice a week may be offered a
different treatment regimen compared to another
who can attend daily for SM injections. It is sur
prising that in spite of the fact that much of the
research work on alternative regimens of chemo
therapy emanate from India most of these well ac
cepted findings hardly find a place in medical edu
cation in the country.
Limitations of the discussion
We in our group were not able to touch upon
the following topics as regards medical education in
tuberculosis.
1. Research in tuberculosis and research prio
rity identification. Whether research and intervention
of a purely technological nature as is currently
practised by the NTI should be pursued or other
issues regarding socio-economic-political factors be
raised as well. Lack of research in communication
and education strategies which is a major lacunae,
also could not be discussed.
2. Continuing education of doctors about tuber
culosis; whose responsibility it is; and the form of
the continuing education programme. The group sug
gest that in light of the discussion a comprehensive
integrated model of teaching of tuberculosis should
be drawn up which can be tried out within the exis
ting constraints of the medical curriculum in India.
As a preliminary process to this effort a much wider
feed back fromi members in or of different medical
colleges should be obtained on their own experiences
of TB training in their education. This exercise would
establish a continuing link with the annual meet
theme of 1984 and probably could also be
featured in the Anthology of medical education under
preparatibn.
(Ravi Narayan, Vineet Nayyar, and Srinivas Kashalikar agreed to follow up on this along withf other
♦members).
Vineet Nayyar,
Vellore
fsed upon. It is for this reason, that many of our
senior colleagues (even those from NTI) believe in
purely technical or medical intervention for TB
control.
4. Priority of medical education as it stands
today, is directed towards the question of where is
the lesion? or what is the lesion? rather than how
was it caused and why? Our medical education does
not stimulate an average student to ask and seek
answers to social questions.
5. That trying to produce primary care doctors
in tertiary care centres is a major drawback in
itself.
Specific issues
1. We felt that the topic of TB as a disease is
dealt with in a fragmented way, and is dealt with by
several departments in a medical college. It is for
this reason that the dynamic nature of TB as a
disease is ill understood, and problems in TB con
trol not even perceived. Some of us even passed
MBBS with the notion that TB meningitis is a dif
ferent disease from pulmonary TB and so on.
2. Specialised departments involved in TB
education cater to their own fields (perhaps a part
of the bigger problem of medical education in a
large set up). Attitudes of the faculty members are
built along the same plane. It is for this reason,
that physicians in the medicine departments absolve
themselves of the responsibility to teach about the
social aspects of TB.
3. Clinical medicine is glorified, while preven
tive aspects are looked down upon. Our system is
disease oriented and not health oriented. We look
at cavities and not at patients!
4. “Germ theory” of causation of disease is
propagated and medical intervention only is stressed
during undergraduate teaching. Even PSM depart
ments which undertake instructions in sociological
aspects of disease, have a narrow view of the dise
ase process. Most recommend medical interventions
as a solution quite like their own colleagues in clini
cal departments. Those that go a step further, preach
'better housing, more ventilation afid more food’
without understanding the deeper social aspect of TB.
Social action is almost never undertaken. Even
development projects which encourage income
generation schemes and other such social schemes
suppress a more basic question of unemployment in
society and so on.
5. Clinical teaching overemphasises
that
tuberculosis is a common problem and only classi
cal cases are shown to an undergraduate. This propa
gates the myth that being a common disease, it is
easy to diagnose and manage TB. Realities of TB con
trol are never dealt with or discussed so that an
average medical student at the end of his final year
[never Recognizes any problems concerning tuber
culosis.
6. There are dictums laid down by clinicians
who teach that investigations are essential to m'ake
a diagnosis. While this is largely true in places
where facilities are available, it introduces a value
An
Appeal
Thousands of innocent Tamils have been ren
dered homeless and jobless by the recent atrocities
and genocidal acts in Srilanka. Assistance is parti
cularly required in the fields of food supplies, medi
cal supplies, clothing and so on. A group called
MUST—Medical Unit for the Service of Tamils-—
been formed in January 1985. They have requested
us to put an appeal in the bulletin. AH contribu
tions and support may please be sent to MUST,
144 Choolaimedu High Road, Madras 600094,
India.
6
All India Drug Action Network
Report of The All-India Meeting on 30th & 31st Jan. 1985
• Tire Drug Action Forum, Andhra Pradesh
had held a convention on Rational Drug Therapy,
which was attended by about 100 delegates. A spe
cial “Drug Information and communication ce-H” is
being prepared in the 7th Five Year Plan of Andhra
Pradesh and District Drug Advisory Committees
are being set up to advise the authorities on the
Drugs-issue.
The AIDAN meeting was planned immediately
after the MFC meet. About a dozen groups from
different parts of the country had sent their repre
sentatives. First half of 30th January was spent in
reporting of what different groups have done during
last 6 months. It was nice to know that things are
moving forward on the Drug-Action front in differ
ent parts of the country. Special mention m'ust be
made of some of the activities:
Other groups in different areas have started
activities on the drug-front and building pressure
for implementing Government’s “Ban-Order” was
seen as an activity that would pick up
i _ in coming
days.
People in the Drug Action Movement
The Drug Action Forum of West-Bengal is
quite active. It had organized a protest-March to the
U. S. Consulate at Calcutta against the decision of
the American Congress to allow, under
certain
conditions, the export of those drugs which have
been banned in the U. S. The March was very well
attended. They have brought out a pamphlet in
Bengali with the title—“Are medicines meant for
the people or are people meant for medicines?” This
got a very good response. A calendar to spread this
message has also been prepared and is being sold.
A convention was organized in Calcutta on 20th
January and was attended by 400 delegates represen
ting various organizations working in the people’s
Science and Health movements. The convention
adopted demands like: removal of useless, un
scientific, harmful drugs; ban the banned drugs,
reduce drug-prices, abolish brand names...etc.
. Mira Shiva reported that one political partyCPI-ML (Santosh Rana Group) has taken this ban
order as an action-plan and they had approached
AIDAN for relevant background papers. They have
decided to launch in different cities in India, hunger
strike until death, to pressurize the Government to
implement its own ban-order. This news caused a
lot of flutter and all of us would be keenly interes
ted to know what happens to this action-plan; and
its impact.
Steering Committee Report
Dr. Mira Shiva, the co-ordinator, reported
amongst other things about the recommendations
of the Steering— Committee set up by the National
Drug Development Council. These recommendations
have recommended a smaller span of price-control
on the drugs than what exists today. Only 95 drugs
and their formulations will be under price-control
if these recommendations are accepted. The mark
up for the drugs from this priority list is also sought
to be increased.
The KSSP had organized a campaign on oral
rehydration and irrational anti-diarrhoeals in 600 rural
units of KSSP. The KSSP is planning a state-wide
and then a nation-wide seminar on the drug-industry
—“A decade after the Hathi Committee.”
This will lead to a rise in prices of all drugs—
both the price-controlled drugs and the decontrolled
drugs. This Steering Committee Report does not say
anything about irrational drug preparations in the
market. Coming a decade after the Hathi Committee
Report, this report is refrograde in character and
all of us must oppose it. It is likely to come before
the Parliament in the coming session.
The Arogya Dakshata Mandal has setup a few
“diarrhoea-centres”, in Pune city slums where slum
dwellers are taught the importance of oral rehydra
tion through demonstration. They are also publi
shing a two-volume book on Rational Drug Therapy.
The Catholic Hospital Association of India
(CHAI) held a two-day workshop op “towards a
people oriented drug policy” during its 41st Annual
National convention from 23rd to 26th November,
1984 at Bangalore. About 500 delegates from dif
ferent parts of the country listened to the different
paper-presentations about drug policy in India and
went back with idea of implerrJenting rational drug
policy at least in their own hospitals.
Mira Shiva had convened an emergency meeting
of the Co-ordination Committee of AIDAN in
Delhi on 26th. November to discuss this report and
to give our response to it in a meeting convened on
29th November by the Ministry of Chemicals and
Fertilizers to discuss the “New Drug Policy.” A
note containing our criticism of these recommenda
tions and our positive suggestions was prepared and
Mira Shiva conveyed this to the officials during the
meeting on 29th November.
The Lok Vidnyan Sanghatana is continuing its
campaign against irrational over-the-counter drugs.
The Bombay unit of LVS has m'ade available plain
aspirin, paracetamol, Chlorpheniramine maleate in
a plastic packet along with a proper label, as an
alternative to Aspro, Anacin, Coldarin etc.
Action-Plan:
1. Action-plan in the coming few months
would concentrate on forcing the Government to
7
RN.27565/76
mfc bulletin: MARCH 1985
implemtent its own order banning 18 categories of
drugs. Mira Shiva has prepared a list of brands be
longing to these 18 categories of drugs. This1 list
would be improved upon by rechecking it and ear
marking those brands which sell the largest. This
improved list would be printed in thousands and
made available to doctors and Chemists through
different voluntary organizations and they would be.
requested to stop using, selling these brands.
One specific form of action-plan was suggested
during the discussion—After making available, the
list of brands belonging to those 18 categories of
drugs banned by the Govt, the action-group would
go round the city in a Morcha and would request
doctors to throw away the samples of medicines
bearing these brands into a “Zoli.” Chemists would
also be requested to throw away some medicines as
a token and to return the rest of their stock to the
drug-companies. This “Zoli” containing these
‘'banned brands” would be publicly burnt at a pro
minent place in the city.
2. A short summary of A I D A N’s criticism
of the Steering Committee recommendations would
be published and different groups should give ade
quate publicity to this criticism in their respective
areas. These recommendations are quite likely to
be kept before the parliament in the coming session
in the form of a New Drug Policy. It is necessary to
raise our voice at that time and compel the Govern
ment to desist from taking this retrograde step. A
summary of the Steering Committee Recommenda
tions and our criticism of it would be available with
Mira Shiva, Co-ordinator, AIDAN, C-14; Com
munity Centre, S.D.A. New Delhi-110016.
3. Court cases:
a) E. P. Forte—
Delhi Science Forum has agreed to launch a
fresh case in the Supreme Court about E. P. forte.
b) Depo-Provera—
Dr. C. L. Zaveri, a gynaecologist from Bombay
has filed a case in Bombay-High Court against the
Drug-Controller of India for not allowing him to
import Inj. Depo Provera. Considering the importance
of this case, Women’s Centre of Bombay and
Medico-Friend-Circle, have with the help of the
Lawyer’s Collective in Bombay, applied in the Bom
bay High-Court to be allowed as co-petitioners on
the side of the Government of India. It may be re
called that the Board of Inquiry set up by F. D. A.,
U.S.A, has recently given its verdict ruling out
the use of Depo-Provera as a contraceptive in general
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
abhay bang
editor: ravi narayan
Regd. No. L/NP/KRNU/202
use. This notorious contraceptive is, however,
sought to be imported in India.
A broad-front of different women’s groups and
Science-groups is being formed to oppose the intro
duction of injectable contraceptives in India. Material
about the hazards of these drugs would be circulated
and a public-campaign would be launched against
its introduction.
Besides these co-ordinated efforts, there would
be local initiatives and its hoped that in 1985, the
Drug—Action—work would strike deeper, wider
roots and would create a much stronger public opi
nion against the irrationalities in the drug-situation
in India.
—An ant Phadke, Pune
URGENT
We need urgently contributions and donations
to support mfc’s studies/investigations in Bhopal and
publication of our team's reports for professional
and public awareness (cheques/DDs in favour of
'medico friend circle—Bhopal Fund’)
We are counting on you!
FORM IV
(See Rule 8)
: Bangalore 560034
1. Place of Publication
2. Periodicity of its
Monthly
publication
: Thelma Narayan
Printer’s Name
3. ______
(Whether citizen of India?) : Yes
Address
: 326, V Main I Block
Koramangala
Bangalore 560034
Thelma Narayan
4. Publisher’s name
Yes
(Whether citizen of India?)
: 326, V Main I Block
Address
Koramangala
Bangalore 560034
: Ravi Narayan
5. Editor’s Name
(Whether citizen of India?) : Yes
: 326, V Main I Block
Address
Koramangala
Bangalore 560 034
: Medico Friend Circle
6. Name and address of
50 LIC Quarters
individuals who own the
University Road
newspaper and partners
Pune 411 016
or share holders holding
more than one percent
of the total capital.
I, Thelma Narayan, hereby declare that the particulars
given above are true to the best of my knowledge and belief.
THELMA NARAYAN
Signature of Publisher
Dated : 10-2-1985.
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US $ 4 for all countries
Air Mail : Asia — US $ 6; Africa & Europe — US $ 9; Canada & USA — US $ 11
-
Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Pauline Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayan for medico friend circle, 326, Vth Main, 1st Block,
Koramangala, Bangalore-560 034
1
TB & WON EN
TB is the leading single infectious cause of female deaths in the
world. TB kills over one million women every year,
accounting for more than 2.700 women dying of TB each day. As
TB kills more women each year than all causes of maternal
mortality' combined, TB also desenes a place on the women's
health agenda.
1
j
Women in their reproductive years have a higher risk
of developing active TB than men of the same age. The hormonal and
nutritional stresses of pregnancy
might weaken a woman's immune
system, increasing her susceptibility
to developing TB in the post partuni
period. The majority of women
who become sick with TB do so
in their most productive years of
life, those in which they raise
children and perform other work: in
the labour force, in the household,
or in the fields.
ij
I
“ I
For example, Sarina, from Osh,
Kyrgyzstan, is a 45 year-old
single mother of three who has
TB. She wants to get help, to
cure herself and to protect her
children, but has run up
against the barrier of cost.
"Under the Soviet system,
health care was free." she says.
"Now we have so little money
and 1 cannot pay for these
medicines."
TB Is a Leading
Killer of Women
I
i I
1
often find it more difficult than men to access health care
services, because transport time and costs are greater for women
when viewed in light of their dual responsibilities at work and al
home. Also, some women have limited access to money, living in
households where men control the purse strings and women are
viewed as little more than property. Some women try to ignore
their TB symptoms because they fear rejection or stigmatization
from friends and family. Others simply lack basic information
about diseases and their bodies.
When this lethal disease takes
its toll on women, their family
members are also threatened by
TB germs coughed into the house
hold air. Because women have
such close contact with their
children, a mother sick with TB
poses a real threat to her kids. It is
common for mothers unwittingly
to infect their children with TB
before dying of the disease
themselves.
720,000
■I
428,000
92,000
AIDS
Maternal
Mortality
•.
TB
The HIV/TB co-epidemic is also
Mortality in Women and Girls Over Age 5. Source: WHO. "The global
assailing women worldwide. The
burden of disease in 1990" in Global Comparative Assessments in the
Health Sector. Geneva. 1994
rise of HIV infection among
women, especially in the deve
These impediments to treatment make clear the importance of
loping countries, has contributed to the development of many
curing women by using the DOTS strategy. DOTS allows women
more TB cases and deaths. For example, largely as a result of the
to be treated successfully and affordably near their homes, thus
AIDS epidemic, two New York City public hospitals reported
eliminating expensive, time-consuming trips which can make
seeing twice as many pregnant women with TB in 1991-1992 as
had been seen in the previous six years combined.
effective treatment impossible.
It is estimated that of the approximately six million women sick
with TB at any given lime, at least a third die because
they are undiagnosed or receiving poor treatment.
There are a number of reasons for this neglect, but money, time,
and transportation present the most significant barriers. Women
TB deaths among women have major implications for child
survival, economic productivity, and family welfare. Those who
care about empowering women and saving their lives must
recognize the enormous impact that TB is having on women
worldwide, and must ai I Io effect ( hauge.
-
L
h
I
I
...
-
-
■:
Laxmi, a woman who lives
near the Indian city of Patna,
faces other difficulties. It takes
her three hours to get to the
free clinic to pick up her
medicines, and another three
hours to return home again.
Some days, the clinic does not
have the correct medicines.
Time and time again, Laxmi's
Irciilment is interrupted. She
has been repeating this
common cycle for years, and
her illness is worsening.
151,000
Malaria
II
■
-
^,17
mfc bulletin 107
li. ■
COMMUNITY HEALTH C£LL
November 19Sf/l,(first Fioor)St. Marks n Supplement
£>AliG -lO3E • 360 001
Announcement — XI mfc annual meet 1985
Date
27-29 January 1985
Venue
Indian Social Institute, Benson Town
Bangalore 560046
Programme
The first two days will be devoted to a discus
sion on the theme ‘TB AND SOCIETY’. One day
will be reserved for the annual general body
meeting.
Preparation and background
1. A list of questions in this issue highlight the
iimportant areas which will be covered in the
discussion. Further questions are welcome.
2. The December 1984 issue of the bulletin
(mfcb 108) will be a special issue devoted to
TB.
3. Background papers on key areas are being
prepared (refer mfcb 106 — report on Sevagram meet). This will be sent out by mid
December. (All those who are interested please
send Rs. 10/- by MO).
Those who want to send any written comments
on any of the papers are welcome to do so. We shall
circulate such comments if received before 10th
January 1985.
(There will be no reading of papers at 'the meetonly small group and plenary discussions).
Boarding & Lodging
Room/dormitory type accommodation will be
available. Simple meals will be provided. Charges
will be kept to a minimum. Further details about
the arrangements will be sent out to the parti
cipants later. •
Travel arrangements and registration
Participants will have to pay for their own travel
as usual. For return reservation please inform
the mfc office at the earliest. Late informers may
not get return reservations.
Write to MFC OFFICE immediately regarding
participation, travel arrangements, suggestions for the
meeting and any other requests/queries regarding the
annual meet.
What you can do
Here is a check list of questions and issues to
stimulate your thinking as a preparation for the
annual meet in January 1985. Write to us if you have
more questions! The list is not exhaustive but covers
the important areas identified at the Wardha Meeting.
Understanding the situation
J. What is the extent/magnitude of the TB pro
blem in India?
2. What are the epidemiological, socio-economic,
political, cultural factors responsible for the
situation?
3. What is the situation of TB in the following
special regions in the world and why?
Developed countries;
ii. Socialist countries
4. What is the situation of TB in the States of
Kerala, Gujarat, Maharashtra, Karnataka,
others and why?
5. What is the situation of TB in the following
special groups and why?
a. tribal populations; b. hill populations;
c. refugee groups; d. factory workers;
e. socially disadvantaged groups; f. women;
g. children; and h. the aged
Assessing awareness
1. What is thQ awareness/knowledge/attitude to
TB among the following groups in society?
a. villagers;
b. slum dwellers;
c. tribals;
d. factory workers & unions;
e. teachers and students;
f. educated elite;
policy makers/administrators;
media people;
i. any others.
What is the awareness/knowledge/attitude to
TB among the following medical groups in
society?
a. medical profession;
b. nursing profession;
c. health workers;
d. general practitioners;
e. non-allopathic practitioners;
f. voluntary agencies.
Understanding Technicalities
1. Understanding the methods of investigation
and case finding and management and follow
up from
i. NTP’s point of view
ii. patient’s point of view;
iii. cost factor—to health service and to patient
2. Understanding the regimes of treatment — by
rationale, socio-cultural acceptance, efficacy,
toxicity, patient compliance, relapse rate,
resistance, cost.
3. Understanding the problem of childhood
tuberculosis and extra pulmonary TB. How
important? What magnitude? How usually
tackled?
4. What is the status/effectiveness of BCG
immunization?
Discovering bottlenecks
1. What is the dynamics of anti-tuberculosis drugs
in India? Production; distribution; medical
advertising; cost factor; availability; usage;
professional acceptance; patient compliance.
2. What is the status of TB in medical/nursing/
paramedical education?
2.
kN. 27565/76
’• 3.
th:
mfc bulletin: NOVEMBER 1984
how is subject covered in present curricula?
approach, emphasis and course content,
what are the lacunae, wrong emphasis?
what are the suggestions for change?
What are the existing educational/awareness
building efforts in govemment/non-govemment
and voluntary tuberculosis programmes? How
effective?
Understanding the health system
1 . How does the NTP function at the state/
regional/taluk/phc level?
what is the local experience?
what are the problems —conceptual/technical/
at field level?
2. What is the role of —
i. general practitioners
ii. private health system — hospitals and nur
sing homes
iii. voluntary agencies
iv. non-allopathic systems
Regd. No. L/NP/KRNU/201
Discovering new approaches
1. What new/altemative approaches can be used
for tackling TB problem?
2. How can people’s movements/trade unions/
consumer groups/media be harnessed in TB
Programme?
3. How can non-allopathic systems be involved?
4. What are the relevant areas of research in TB?
technical; field practice; communication;
1.
Reflect on these questions in the light of
your own field experience.
2
. .
Apply some of these questions to your own
area/project/taluk/city and discover the field
reality of the TB programme.
3. Interview some PHC staff, DTP staff, general
practitioners, health teams of voluntary
agencies in your area and get important/
relevant feed back
Selected Reading
I. From the National Tuberculosis Institute, No.
8 Bellary Road Bangalore-560003.
1. Banerji, D: Public Health Perspectives in the
formulation of the National Tuberculosis Pro
gramme of India, 18, 50, 1983.
2\ Chandrasekhar P and Kurthkoti, AG: Tubercu
losis Situation in India—Epidemiological features
3. Seetha, MA: Epidemiological Data of Tuber
culosis
4. Gothi,.GD: Evolution of the National Tuber
culosis Programme, 18,. 22, 1981.
5. Baily GVJ: The Efficacy of BCG Vaccination —
A brief Report of the Chinglepet BCG Trial,
17, 108, 1980.
6. Aneja KS: Chemotherapy in National Tubercu
losis Programme, 19, 58, 1982.
7. Aneja, KS: Short Course Chemotherapy — Ret
rospect and Prospect,
8. Some Practicable short course drug regimens for
chemotherapy of tubercuosis.
II. From 'the Voluntary Health Association of India,
C-14 Community Center, Opp. ITT Main Gate,
SDA, New Delhi 110016.
1. Mira Shiva: Towards Rational TB care — A
continued commitment.
2. Mira Shiva: The BCG Story
3. Banerji, D: Voluntary Agencies and India’s
National Tuberculosis Programme
4. Health for the Millions, Vol X No. 2, April 1984
Tuberculosis Special Issue.
We mourn the death of our Prime Minister Smt.
Indira Gandhi and the hundreds of innocent lives
that have been lost in the spate of violence that
erupted in the past few weeks.
III. Other Sources: Indian Journal of Tuberculosis
1. Baily GVJ: Tuberculosis Control in India —
Current problems and possible solutions, Vol.
XXX, No. 2, April 1983, Pp. 45-56
2. National Tuberculosis Institute: An operational
study of alternative methods of case finding for
tuberculosis control, Vol. XXVI, No. 1, January'
1979, Pp. 26-34
3. Nagpaul, DR: District Tuberculosis Control
Programme in Concept and Outline, Vol. XIV,
No. 4, Pp. 186-198
4. Baily GVJ: Present Status of Immunization
againsit Tuberculosis
(Review Article), Vol.
XXVIII, No. 3, July 1981, Pp. 117-125.
Other Indian Journals
1 . Nagpaul, DR: Tuberculosis in India — A Pers
pective, Vol. 71, J Ind Med Assoc., No. 2, July
16, 1978, Pp. 44-48.
2. Srikantaramu et al: An Operational Model of
the District Tuberculosis Programme, Ind. J
Pub. Health, Vol. XX, No. 1, Pp. 3-8
WHO Sources
1 . Banerji, D & Stig Anderson: A Sociological Study
of Awareness of Symptoms among Persons with
Pulmonary Tuberculosis, Bull. Wld Hl th Org.,
29, 1963, Pp. 665-683
2. Stig Anderson & Banerji, D: A Sociological in
quiry into an urban tuberculosis control pro
gramme in India, Bull. Wld Hlth Org. 29, 1963,
Pp. 685-700
3. National Tuberculosis Institute, Bangalore:
Tuberculosis in a rural population of South
India: a five year epidemiological study, Bull.
Wld Hlth Org, 51, 1974, Pp. 473-488.
Papers mentioned in TH. Other Sources' are available
in most of the medical college libraries. They can also
be obtained from the National Tuberculosis Institute,
No. 8 Bellary Road, Bangalore 560003 on request.
COMMUNITY HCALTH CELL
47/1. (First Floo.-JSt. Marks aoad
BANGAtOaE-BiidOOl
108
9
1
medico friend
circle
bulletin
DECEMBER
1984
Discussing Tuberculosis Control-Why?
— Anant Phadke, Pune
(In the coming XIth Annual Meet of the Medico
Friend Circle at Bangalore, we would be discussing
various issues concerning tuberculosis control in
India. The question is so vast that it is impossible
to have any useful discussion unless we define the
focus of the discussion. In my view, the purpose of
discussing any issue in mfc needs to be clearly
thought of and agreed upon. In this note, I would
argue what in my view . would be the appropriate
purpose of the discussion at the mfc annual meet.
This note would inevitably involve a discussion on
the role of mfc.)
Role of discussion at the annual meet
Let me first quickly put forth a consensus that
we had reached about the general role of the dis
cussion at the annual1 meet. It was thought that
there is a definite section within medicos and non
medicos in India who already have a perspective
similar to that of mfc or who could come to mfc, if
there is adequate contact and dialogue. Different
individuals in this section are more interested in
specific aspects of the health system in India. If mfc
takes up various issues in different meetings, then
those individuals with
specific interests in these
subjects would come closer to mfc and may join us.
Secondly such discussions would help us, the mfc
members, to enrich our knowledge and perspective
of the health problems in India through well planned
discussions with the help of resource persons out
side mfc; and mfc in turn would hopefully make some
impact on the new participants during the course of
these discussions. Fine enought But all this does not
specify what specific kind of knowledge we want to
gain and generate through these discussions; whether
and in what way would the discussions be different
from the discussions in the academic or established
. circles of community health.
Specificity of mfc
To answer this question, let us go back to the
origins of mfc, the kind of discussions we have had so
far and the debate on ‘mfc — which way to go’
carried through the pages of the bulletin and reprinted
in our anthology — HEALTH CARE WHICH WAY
TO GO? I would also like to remind readers of the
Centenary issue of the mfc bulletin No. 100-101
(May-June 1984) where the contributors had taken
a somewhat critical overview of what the mfc has
achieved, not achieved and what challenges we face
today. It is not possible to go through the history
of mfc in this note. I would only point out two specific
characteristics of mfc which are reflected in all these
writings. One, its concern for Social Revolution. At
least the core members of mfc have been very con
cerned about this and hence the articles in mfc bulle
tin have been quite critical about the existing health
system and the debate ‘mfc which way to go?” was
centered around how mfc could contribute to funda
mental socio-economic-political
(S-E-P as Abhay
Bang had put it then) change. The second characte
ristic has been the critical and questioning attitude
of mfc members:
critical of new ‘solutions’/strategies put for
ward by the establishment and the community
health enthusiasts (this critical outlook partly
reflects the grass root village level1 at which
many mfc members work)
critical (admittedly to a lesser extent) about
mfc’s achievement and
of late, critical about the existing prescrip
tions of community medicine.
INSIDE
The National Tuberculose Programme
4
The MARD strike — a view point
6
Dear Friend
7
Editorial Note
8
The 'MARD' Strike-A View Point
— Sanjay Nagral, Bombay
the government would revoke the decision (which
meant displeasing people with the clout and money)
in response to the protest of a small section of the
medical community they were hoping for too much.
The twenty-eight day long strike by resident
doctors, interns and medical students all over Maha
rashtra to protest against the opening of three capita
tion fee based medical colleges ended a few months
ago. The withdrawal of the strike on just a no-victimi
sation assurance was regarded by many as total sur
render. Two of the capitation fee medical colleges
have already opened since then and plans have been
announced for many more. In that sense the strike
was a failure. It was, however, unique in many
senses. For example, it was the first time that the
MARD (Maharashtra Association of Resident
Doctors) was going on an indefinite strike for an
issue other than pay rise. It is important to analyse
the various aspects of the strike. not just because
there is a .lot of ground for criticism but more im
portantly to make us better equipped to react to
such struggles in the future. As the interns’ represen
tative on the central committee of MARD and on the
negotiating team, I had the opportunity to have a close
look at the events during the strike, and in this article,
I shall try to analyse some of them in the light of its
failure.
Political moves have to be fought politically and
’■’l the present strength
by political forces. And with
their
of the ruling classes and X1
' parties and their
total grip over the various state agencies,
^agitations many a times are likely to end
up wresting concessions of varying degrees
rather than changing decisions. It was with this undesstanding that some of us from K.E.M. MARD
were proposing the idea of negotiating with the
government over the percentage of seats to be kept
on genuine open merit basis. In fact at one stage,
the government was ready to do so. What was dis
missed as a ‘compromise’ was in fact a tactical
move keeping the reality of the situation in mind.
A protest against capitation fees means a
protest against the right of the government to make
education a privilege of the rich and the moneyed.
But when a government is a puppet in the hands of
the capitalists, landlords and merchant class, it ulti
mately implies a clash with the strength of the rul
ing classes. This will necessarily have to involve
large sections of the masses, for whom even simple
medical education is a dream, for it to succeed. It
was these political realities that the MARD leader
ship failed to grasp. Although the strike did teach
quite a few lessons in cunning, ruling class poli
tics, by and large the attitude of the leadership re
mained immature and at times even opportunist.
And not in a few instances was this not due to inno
cence but a genuine desire for fast popularity and
personal gains.
First of all a few facts about the strike. On the
twenty second of June a one day token strike was
observed by resident doctors, interns and medical
students all over Maharashtra as a mark of protest
against the government’s decision to permit the
opening of three capitation based colleges at Karhad,
Satara and Pravaianagar in the State. A delegation of
the MARD was literally dismissed by the Chief
Minister who refused even to discuss the issue. A
decision was then taken to launch an indefinite strike
from the tenth of July, the call for which was given
by the MARD. The strike action by around 4500
residents was joined right from the start by around
1500 internees and later by around 8000 medical
students. It lasted for 28 days and was withdrawn
on the 6th of August with just a no-victimisation
assurance from the government.
To begin with, was the total lack of prepara
tion and ground work for such a big struggle. Many
assumed that just residents striking work and
paralysing public hospitals would bring the govern
ment down to its knees. That in the past, the demand
was always a small pay rise, was totally forgotten.
Then, there was the total lack of effort (except by
some’ sections) to involve the medical fraternity as
well as other sections in the struggle. It was not
surprising that many senior doctors and their organi
sations although generously offering a lot of sympathy
refused to join the strike. Most of them are so well
entrenched in the profession and have so readily
accepted to be a part of a corrupt and wretched
medical system that to take such a step would be to
invite the wrath of the very government to whose
tune they dance. The classical example was of the
IMA many of whose office bearers although openly
supporting the strike refused to criticise the health
minister or take action against her as a president elect
The origin of many of the drawbacks of the
strike and of its eventual failure lay in the fact that the
leadership of the MARD never understood or analy
sed the politics behind the opening of capitation
colleges. The government’s arguments in favour are
too nonsensical and ridiculous to merit discussion.
The fact remains that this was and is a political
move by the government to satisfy the powerful sugar
barons (and their children), earn quick cash and
at the same time build a pseudo ‘pro-rural poor'
image. The desperate haste with which some of
these colleges were started, flouting all routine
norms, the panic on the government’s part after the
court case was filed, showed that the government
had a lot at stake in these institutions. The crude
effort to break the strike by offering personal bri
bes and favours to some of the leaders, proved this
even more. And if the MARD leadership hoped that
(Continued on page 8)
6
^4
^Dear friend. . .
In the last few months we have often been
asked about mfc’s stand on the MARD strike. This
has been easy enough to answer, because as far as
we know mfc has no opinion on the issue. But this
has generated other questions which we would like
to verbalise here.
In the last year there have been at least three
long drawn out actions by doctors (West Bengal,
Orissa and Maharashtra). Their demands were not
only for better pay and working conditions but for
better health care, adequate facilities and drugs;
and in Maharashtra, specifically, against the opening
of capitation fee medical colleges. Why have these
actions never been discussed in the mfc?
Part of the reason is of course that those of us who
could have raised the issue, haven’t. But this reluc
tance itself tells a story. In fact, until the question
of mfc’s standpoint was persistently asked, we had
subconsciously thought of these issues as peripheral
to mfc’s main objectives and interests. But are
they?
mfc’s avowed concern is with the health care
system and the practice of medicine. As we read it,
mfc has always interpreted it as wholly discarding
the hospital-based established system of health care
and seeking afternatives in the delivery of such care.
Logically then, issues such as better working condi
tions of doctors, or better quality of health care
through the existing systems appear to fall outside
mfc concerns. What is here ignored is that the exis
ting system will not be replaced now or for some
time, and it is in fact being enlarged. So issues of
the hospital as workplace, and those concerning the
quality of health care become relevant, current and
even burning issues. And the MARD strike took up.
ironically enough, issues very much in the realm of
mfc’s major concern — medical education. (For the
moment it is sufficient to consider only doctors’ agi
tations, mainly because mfc despite its statements to
the contrary, unfortunately tends to be very much
medico-oriented.)
We do not think it is a sufficient argument to
state that there was not enough information to
either discuss or assess the issue or even raise it in the
bulletin. The West Bengal strike had ended just
before the CINI Meet and the MARD strike has
received more press coverage than any other previous
strike, perhaps.
All this makes one wonder: Is mfc’s professed
role of ‘thought-current’ leading to a lot of fence
sitting? Are we perhaps so preoccupied with long
term change that we are missing opportunities of
making our considerable presence felt where it would
matter? Are we in fact, become so profoundly invol
ved with seeking limited alternatives that we are
opting out of mainstream issues?
Many friends from mfc have been involved with
providing workable and successful alternatives at the
local level in various ways. But isn’t it necessary
to make these activities of ‘model building’ at a local
area an integal part of all the struggles for better
health and for changes in the existing health care
system? Only such a perspective can make us more
sensitive to the struggles of people within the health
care system.
Secondly, the last few years have seen various
groups in the country take up health issues in their
own areas of work (eg., women’s movement, and to
a lesser extent, trade unions and the anti-nuclear
movement). What has been mfc’s involvement and
contribution to these movements? Is it not time
that we became more than a ‘thought-current’?
May we suggest that some of these issues as well
as the questions raised in Anant’s article (100-1) be
taken up at the GB Meet in January?
Yours sincerely,
Padma Prakash & Amar Jesani
Since I am more than aware of the deep concern
that mfc has for health issues, I would like to make a
few points here:
1. There is a dire need to pursue criticism of
existing medical education and suggest alter
natives. There needs to be more follow up of
another issue-that of RMPs and ayurvedic and
homeopathic practitioners using allopathic
drugs and vice versa. Both these issues are
' inter-related.
2. The mfc members need to increasingly respond
to important issues like the resident doctors
strike in July-August 1984 and the mill work
ers strike in Bombay.
3. A group of young doctors tried to educate the
general public regarding the politics under
lying capitation fee medical colleges by way
of writing letters to capitalist press and also
directly addressing workers’ meetings.
The
same group of doctors had conducted free
medical OPD for striking mill workers and
made it a point to discuss politics and eco
nomics with workers. This was definitely an
eye opener in many ways for the young
doctors also. They could more than under
stand the problems of the working class and
realised the lack of relevance of present day
medical education to the social problems.
4
The same group of doctors also made several
visits to the blind school and made themselves
available for reading progressive literature,
story books, curricular books for the blind
students.
5
These doctors visited certain working class
localities in the suburbs of Bombay, conduc
ted free OPDs and also started circulating
libraries constituting progressive literature.
6. In conclusion, all the issues related to health
being our primary concern, we must keep live
contact with working class activities, schools,
colleges and various other institutions,
wherever we can work, mfc members should
(Continued on page 8)
7
mfc bulletin: DECEMBER 1984
RN. 27565/76
E(g]Dfl@mD DWflg
In January we meet to explore the various
dimensions of the problem of Tuberculosis and TB
control within the context of Indian social reality.
Why are we discussing Tuberculosis and its
control? Binayaks paper in mfcb 105 highlighted
some problems and issues, Anant Phadke’s lead
paper in this issue goes into this question in greater
detail within the overall perspective of the medico
friend circle. Warning us of the false limitations that
the existing socio-political system thrusts on us, in
our attempts to evolve alternative and more peopleoriented strategies he outlines the various areas we
could/should discuss during the meet.
(Continued from page 6)
of the IMA. There is no doubt, however, that if the
senior doctors had joined the strike, the impact
would have been much greater because of the total
paralysis of even the skeleton emergency services
that would have ensued.
Excessive faith and hope was placed by many
in the legal system to give a favourable decision.
The counsel for MARD bared it all very early when
he bluntly told us that the case against capitation
colleges was strong only as far as the ‘standard of
education’ part was concerned. That this legal system
does not consider ‘capitation’ as illegal and unconsti
tutional was apparent in the court’s verdict also. In
fact this ‘standard of education’ ploy was used time
and again by the government during the negotiations
to trap us into discussing something irrelevant. The
minister would go to extreme lengths to point out
how the standards were being maintained and some
of the MARD leaders would very obligingly deviate
from the issue of capitation.
Mention must be made here of the role of the
KEM unit of MARD, for here a definite attempt
was made to broaden the base of the struggle. The
mass contact programme, street plays, public meet
ings and parallel out patient departments, were all
efforts to take the issue to the public Meetings of
trade unions and student organisations were held to
chalk out a more broad plan of action. It would be
appropriate to mention that very few trade unions
responded to the invitation and those who attended
showed extreme lethargy to take any concrete action.
Thus, what was an excellent opportunity for the
working class movement to fight for a genuine issue
was lost. The gherao of an ENT Surgeon from
Bombay was deliberately planned to prove that mem-
Editorial Committee :
kamala jayarao
anant phadke
padma prakash
ulhas jaju
dhruv mankad
editor:
ravi narayan
Regd. No. L/NP/KRNU/2Q2
Some excerpts from reports/papers by various
experts in the country gives additional background
to the situation of Tuberculosis and its control in
the country. The readers are reminded of the reading
list and the check list questions in mfcb 107-suppliement. Hope these will stimulate your preparation for
the meet?
The Annual Meet is also an opportunity to
critically evaluate mfc’s role and direction. Apart
from Anants paper, the report on MARD strike and
the dear friends letters raise many relevant issues
which could well be the starting point for such an
exercise in introspection.
bers of the profession who associated themselves with
these colleges should be exposed and attacked.
Two of the colleges have since then opened with
a lot of fan fare. Many more are being proposed.
These will start sprouting up with regular fre
quency, closely competing with engineering institu
tions. The fight therefore will have to be a prolonged
one. Organizations like the MARD cannot and
should not fight such struggles alone. This is the
work of mass organisations, trade unions and working
class parties. Science movements and organisations
like the medico friend circle must take up such issues.
Always keeping in mind however that it is the symp
toms of a wretched and rotting economic structure
that are being manifest, time and again. It should
also be borne in mind that non-capitation ‘open merit’
education although apparently giving equality of
opportunity is heavily loaded in favour of the rich
and the moneyed. This is especialfy true of higher
education. This is not very surprising since it is the
moneyed who rule. Capitation fees is just a more
vulgar and crude form of a degrading but crumbling
system. The only way to put a permanent stop to
such terrible obscenity is to strike at the roots of the
disease. Such struggles however have to be fought
and if fought with the right perspective can contri
bute a lot in this direction.
(Continued from page 7)
not remain away from any socio-political
struggle because it strengthens capitalists.
Atleast mfc members can act as conscience
keepers for existing political parties if mfc
cannot and is not able to function as a poli
tical party.
— Shriniwas Kashalikar,
Bombay
Views and opinions expressed in the bulletin are those of the authors and not necessarily
of the organisation.
Annual subscription — Inland Rs. 15-00
Foreign ; Sea Mail — US$4 for all countries
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Edited by Ravi Narayan, 326, Vth Main, 1st Block, Koramangala, Bangalore-560034
Printed by Thelma Narayan at Paulijfe Printing Press, 44, Ulsoor Road, Bangalore-560042
Published by Thelma Narayanifor medico friend circle, 326, Vth Main, 1st. Block,
Koramangala, Bangalore-560034
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Combating TB
The World Health Organisation’s announcement of a break
through in the treatment of tuberculosis is of particular significance to
India, which has 15 million or a third of the world’s TB patients. The
new treatment will prevent at least 10 million deaths from the disease
over the next decade. For years now, warning bells have been sounded
on the growing incidence of TB in fatal conjunction with AIDS. With
four lakh people dying of TB every year and three million HIV posi
tive cases reported, the government has responded by seeking to im’’’ ment a number of unviable strategies. One of these is the proposal
lonitor the progress of individual TB patients undergoing treat
ment, overlooking the fact that there is a severe shortage of health
workers. TB in India cannot be tackled solely as a health problem but
must be treated as a symptom of a socio-economic malady. Overpopu
lation and unsanitary conditions are the main causes for the spread of
the disease, to which the urban poor are particularly vulnerable living
as they do in congested tenements lacking in basic civic amenities.
The situation can only get worse in the years to come with the urban
population density increasing; the past three decades have seen a phe
nomenal growth rate of 360 per cent. To make matters worse, there is
a growing incidence of multi-drug resistant TB. The health authorities
are still in the dark as to the best combination of drugs to counter this
new killer strain of the disease. The theory that patients put them
selves at risk by not completing the full course of treatment is valid.
But in many cases, victims of the disease have no access whatsoever
to any form of treatment because of the prohibitive cost coupled with
a non-existent public health care system.
No magical remedies or new strategies are required to halt the
onslaught of the virulent strains of communicable diseases that are
killing or incapacitating people today. What has to be overcome is the
unconscionable apathy of the health authorities who act only in reac
tion after a full blown epidemic has broken out. The national disease
surveillance and response system set up with much fanfare has failed
break the vicious cycle of morbidity and mortality. No new prexptions are needed; we already know the answers; shift the accent
from curative to preventive health care and make efforts to create a
cleaner environment in which disease cannot thrive. This cannot be
done unless civic amenities are strengthened and a great deal more
than the current niggardly six per cent of the GDP is allocated to
health. Photo opportunistic politicians taking to the streets with
brooms every now and again or administering polio drops to babies
make a mockery of the grievous health threats that the country faces.
The ‘health for all by 2000’ slogan so casually tossed about has be
come totally meaningless today. The primary health centres which are
meant to be at the vanguard of the initiative are so ill-equipped or so
inaccessible that they have ceased to matter. In such a situation, it may
be a while before the WHO breakthrough has an impact here.
[
I
THE NATION ON THE MOVE
d., Jaipur. An ISO 9001 Company.
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Rotary Gears.
Take you from the 4th
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manoeuvrable,
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ASP-NBC-111/97
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boqk review
for travel expenses; and to OXFAM and the Leeds Philosophical and
Literary Society for grants.
REFERENCES
1 Raina BL. Official history of the Indian Armed Forces in the Second Work!
War 1939—45. Medical services. Preventitive medicine (Nutrition, malaria
control and prevention of diseases.) Combined Inter-services historical
section. India and Pakistan, 1961.
2 Report on the health of the Armed Forces (annual April to April;
MDGAFMS) Civil Lines, DelhkController of Publications.
3 Narasimhan NS. Acute anterior poliomyelitis in the Madras Presidency.
Indian J Surg 1942;4:22-8.
4 Vora DD. Some observauons on the 1949 epidemic of poliomyelitis in
Bombay. Indian Physician 1949;8:337-442.
5 AthavaleVB. Acute anterior poliomyelitis. Indian J Pediair 1960;27:309-27.
6 Singh S, Meherhomji KM, Gharpure PV. Poliomyelitis in Udaipur. A small
outbreak in 1963 and the use of Sabin vaccine. J Indian Med Assoc 1964;
43:153-9.
7 Diesh P, Pattanayak S. Sehgal PN, Rao CK. Mathur PS, Dave KH, et aL
Poliomyelitis in Delhi. J Common Dis 1972;4:65-73.
8 Gujral W, Dhamija, Sethi SK. Gangrade S. A threat of polio epidemic in
Delhi and areas around. J Common Dis 19713:31-8.
9 Arora RR. Choudhury DS. Gujral W, Ray SN, Das A, Sharma D, et al.
Epidemiology of poliomyelitis in Delhi. Indian J Med Res 1978;67:11-18.
10 Bose C, Chandorkar RK, Tiwari SC, Naik G. A study of incidence of paralytic
poliomyelitis in Bhopal agglomaration from 1972-78. Indian J Public Health
198105:20-3.
11 Mahadevan S, Ananthakrishnan S, Srinivasan S, Nalini P, Puri RK. Badrinath
S, et al. Poliomyelitis: 20 years—the Pondicherry experience. J Trap Med
Hyg 1989;92:416-21
12 Paul JR. A history ofpoliomyelitis.
ale University Press, 1971:346-56.
13 McAlpine D. Acute poliomyelitis. Medical Directorate, India, Technical
instruction no. 46. Public Record Officer, Kew, England. 1945, WO/177/30.
14 Brown D. Report on poliomyelitis in 1945. India Command. Public Record
Office. Kew, England, WO/177/31.
15 Anonymous. Notes on neurological cases—acute anterior poliomyelitis.
Documents by Major, RAMC, 199 Indian General Hospital (British Troops).
16 Kaul S. Poliomyelitis (some recent developments). J Indian Army Med Corps
19493:24-8.
17 Findlay GM, Anderson JR, Haggle MHK. Poliomyelitis in West Africa.
J Roy Army Med Corps 1946;86:20-5.
18 Samuel R, Balraj V, John TJ. Persisting poliomyelitis after high coverage
with oral polio vaccine. Lancet 1993341:903.
19 Khare S, Kumari S, Nagpal IS. Shanna D, VergheseT. Oral polio vaccination
in infants: Beneficial effect of additional dose at birth. Indian J Pediatr
1993.60:275-81.
20 Wyatt HV. Mahadevan S, Srinivasan S. Unnecessary injections and paralytic
poliomyelitis in India. Trans Roy Soc Trop Med Hyg 1992;86:546-9.
It
Book Review
A Family Guide to HIV and AIDS in India. Clive Wing.
Shankar Chowdhury. Popular Prakashan, Bombay, 1994.
81 pp, Rs 35.
This small but excellent book provides straightforward and
comprehensive information, using a question and answer
format, on HIV/AIDS and its prevention, with a special
emphasis on India.
The book is organized into seven chapters covering the
various clinical and social aspects of HIV/AIDS. It also
provides guidance on prevention and suggestions for care
and support of those already infected. The history as well
as the current situation of the HIV/AIDS epidemic
worldwide and in India has been presented and common
misconceptions explained. The guide personalizes the infor
mation for families in India, presenting suggestions on talking
to children about HIV/AIDS and for realistic assessment of
one’s own risk of infection.
The book avoids the use of euphemisms so commonly
employed when discussing sensitive subjects. It provides
clear, accurate and practical information on commonly asked
questions and those that are not even asked. This will help
readers to protect themselves and others from HIV infection.
A list of names and addresses of sources for additional
information is also provided. However, the names and
addresses of several important Indian organizations such as
the Voluntary Health Association of India which produces
HIV/AIDS information material in a variety of formats and
languages, and the National AIDS Control Organization
are missing from the list.*
An additional small, but important fact which could be
included in the section on condoms and their use is that
unadulterated glycerine (with no additives such as colour or
scent) is a safe and cheap water-based lubricant. It is available
with most chemists and can be used instead of the much
higher priced, and frequently unavailable, K-Y jelly.
Reasonably priced at Rs 35, the book should prove an
excellent reference for its target readers comprising parents,
youth, AIDS awareness and prevention groups, and profes
sionals such as teachers, doctors, nurses and social workers.
The only criticism of this book is that it is written in a
professional language which may be a barrier for many
potential readers also in need of this important information.
NANCY JAMIESON
Calcutta
* The addresses of these organizations are: Voluntary Health
Association of India (VHAI), 40 Institutional Area, New Delhi
110016 and National AIDS Control Organization (NACO), ReJ
— .
Cross Building, 1 Red Cross Road, New Delhi 110001.
"
. r c i
• —Editor '
. -.0 r
(
■
r\
144
THE NATIONAL MEDICAL JOURNAL OF INDIA
Table. I. Composition of some of the anti-tubercular
‘kits’ available in the Indian market
Brand name
AKT-4
Isorifazin
Isorifazin S
Isorifazin forte
Composition
1 capsule of rifampicin 450 mg
1 tablet of ethambutol (800 mg)
and isoniazid (300 mg)
2 tablets of pyrazinamide 750 mg
Each capsule contains:
Rifampicin 225 mg
Isoniazid 150 mg
Pyrazinamide 500 mg
Each tablet contains:
Rifampicin 450 mg
Isoniazid 300 mg
Pyrazinamide 1000 mg
Each tablet contains:
Rifampicin 300 mg
Isoniazid 200 mg
Pyrazinamide 750 mg
Macox-ZH
Each capsule contains:
Rifampicin 225 mg
Isoniazid 150 mg
Pyrazinamide 750 mg
Montorip
Tricox
Each capsule contains:
Rifampicin 150 mg
Isoniazid
100 mg
Pyrazinamide 500 mg
Rimactazid-Z
1 tablet of rifampicin (450 mg)
and isoniazid (300 mg)
2 tablets of pyrazinamide 750 mg
Rifacom-EZ
2 tablets of pyrazinamide 750 mg
I tablet of ethambutol 800 mg
Zucox kit
I tablet of rifampicin 450 mg
1 tablet of isoniazid 300 mg
2 tableu of pyrazinamide 750 mg
Zucox E
I tablet of rifampicin (450 mg)
and isoniazid (300 mg)
possible for anyone to remember the variable
composition of these ‘kits’. Further, the combina
tions of tablets/capsules in these ‘kits’ also vary,
vith some containing rifampicin and isoniazid
and others containing isoniazid and ethambutol.
Therefore, the prescribing physician may not be
sure whether the patient is taking the correct drugs
in optimal doses. It may be argued that every
physician must familiarize himself with the ‘kits’
he is prescribing. However, a study conducted in
India has clearly shown the multitude of regimens
(many of them inadequate or inappropriate) used
by physicians in the treatment of tuberculosis.4
Further, the patient may consult another physi
cian, who may not be familiar with the composi
tion of the ‘kit’ being taken. There is a good
chance that with these ‘kits’ the patient is not
being optimally treated and, therefore, may not
respond to therapy due to the development of
resistant strains, which defeats their very purpose.
In view of the above facts, we strongly feel that
the Drug Controller of India should regulate the
composition of the ‘kits’ (which could be used
according to the weight of the patient). These
could be as follows:
1. For patients weighing <35 kg: 300 mg
rifampicin, 200 mg isoniazid. 1000 mg
pyrazinamide and 800 mg ethambutol.
2. For patients weighing 36-50 kg: 450 mg of
rifampicin. 300 mg of isoniazid, 1500 mg of
pyrazinamide and 1000 mg of ethambutol.
3. For patients weighing 50-60 kg: 600 mg rifam
picin, 300 mg isoniazid, 2000mg pyrazinamide
and 1200 mg ethambutol.
5 April 1996
Praveen Aggarwal
R. Handa
J. P. Wali
Department of Medicine
All India Institute of Medical Sciences
New Delhi
REFERENCES
1 American Thoracic Society. Treatment of tuberculosis
and tuberculosis infection in adults and children. Am J
Resp Crit Care Med 1994;149:1359-74.
2 Horne NW. Drugs used in chemotherapy. In: Modem
drug treatment of tuberculosis. New Delhi.Oxford
University Press. 1992:1-27.
3 Davidson PT, Quoc Le H. Drug treatment of tuberculosis—1992. Drugs 1992;42:651-73.
4 Uplekar MW, Rangan S. Private doctors and tuberculosis
control in India. Tuber Lung Dis I993;74: 332-7.
VOL. 9, NO. 3, 1996
when it is documented, it would be vital to
determine the exact aetiology and presentation
of these non-polio cases, e.g. the differences in
clinical pattern of the disease compared with
polio. If after declaration of eradication of
poliomyelitis, non-polio cases continue to
occur, the problem will remain unsolved.
5 April 1996
Amar Jeet Singh
Department of Community Medicine
Postgraduate Institute of Medical Education
and Research
Chandigarh
REFERENCES
1 Basu RN. Magnitude of problem of poliomyelitis in
India. Indian Paediatr 1981.18:507-11.
2 Ministry of Health and Family Welfare. National child
survival and safe motherhood programme. New
Delhi:Maternal and Child Health Division. Department
of Family Welfare. Ministry of Health and Family
Welfare. 1994
7
3 Sokhey J. Progress of poliomyelitis control—Selected
States and Union Territories. Indian J Communitx
Medicine 1992; 17:140—50.
I
Polio eradication programme in India
The weekly epidemiological records of the World
Health Organization (WHO) and the Central Bu
reau of Health Intelligence of India (CBHI) were
reporting an annual incidence of 10 000-32 000
cases of poliomyelitis during 1974-90. The CBHI
The HIV-tobacco theorem
^h,C H,y-lobacco theorem states that ‘in terms of
risk of death, being a smoker is equal to getting
s
data were based on information received from
yourself deliberately pocked with an HIV-infected
selected hospitals. On the understanding that these
needle, thrice every year.’
data were not representative of the actual number,
The proof:
Basu' estimated that less than I in 15 cases were
reported and that the actual incidence was about 2
1. The seroconversion rate following a needle?
Ctir'ir intumr
Ifiir
lakhs per year.
stick injury from an
HIV-positive person is
The total number of cases in India is quoted to
0.47%.' If one were to have 3 such injuries
’
be in the range of 3000—5000 per year.2 A seventy
every year, one would face a 1.5% risk of HIV
per cent reduction in the number of cases is being
infection yearly, or a 45% risk over 30 years.
j
claimed, i.e. a decline from 26 000 to 5000 cases.
Since HIV infection is usually fatal within 10Nobody is quoting the 200 000 figure anymore.
12 years, this would mean a 45% risk of death
Thus, while progress in polio eradication in India
over 40-42 years. Thus, thrice-yearly HIVis commendable, in view of the ‘pulse polio’
infected needle-pricks would kill 45% of
mfected
3
campaign now being undertaken in the country
recipients over 42 years.
there are some questions that require clarification:
2. Tobacco kills 50% of its regular users within
.
1. Are these 3000-5000 reported cases only those
40 years.2
which have laboratory confirmation? Sokhey
Therefore, smoking is at least as dangerous as
in 1992 has stated that laboratory confirmation
getting yourself deliberately pricked with an HIV- g
is not yet widely practised.'
infected needle, thrice every year.
2. Are these cases based on the CBHI report
It is time we stop the proliferation of something
alone? Is the extrapolation as done by Basu in
as dangerous as HIV—the tobacco plant.
1981 still applicable?
3. Was the extrapolation by Basu wrong? If so. it
25 April 1996
Jayant Sharad Vaidya
would imply that the figures were unnecessarily
Department of Surgery
inflated to 200 000 in the 1980s and that the
Royal Marsden Hospital
problem of poliomyelitis was not as serious as
London
it was made out to be.
United Kingdom
4. Is it possible that because emphasis is now on
confirmed polio cases, the other cases of
REFERENCES
paralysis are being labelled as those of non
1 Marcus R. Surveillance of health care workers exposed
polio origin? It is likely that earlier even these
to blood from patients infected with human
non-polio cases were being included in the list
immunodeficiency virus. N Engl J Med 1988;319:
of polio cases.
1118-23.
5. What is the present number of cases of paralyses
2 PetoR, Lopez Alan D, Boreham J, Thun M, Heath C Jr.
from causes other than polio? This information
Introduction. In: Mortality from smoking in developed
is important, since after eradication of
countries 1950-2000 New York:Oxford Medical
laboratory-confirmed poliomyelitis, as and
Publications. 1994:A-10
I
THE NATIONAL MEDICAL JOURNAL OF INDIA
VOL. 8, NO. 3, 1995
>5 4 ■ I?
133
Medicine and Society
Poliomyelitis in Indian adults
4
H. V. WYATT
introduction
Acute poliomyelitis has been a major problem in India with
at ennon focused mamly on children. However, from several
rather limned stud.es, more than 300 adult cases have been
described which suggest that many cases are unreported
How is it possible that when the median age of paralysis is
about 12 months, individuals can reach their teens without
^equate .mmunoiogical protection? This paper examines
possible reasons for the occurrence of polio in adults in areas
where polio virus is ubiquitous.
ADULT POLIO
1
Table I. Acute poliomyelitis among servicemen, India
Command 1942-61
Year
1942
1943
1944
1945
1946
_____ British*
Officers Other ranks
18(1.1)
18(0.8)
36(1.2)
64(1.8)
38(1.6)
Total 174
Other Indian cases
oases in teenagers and adults have been
reported
( able II), the oldest being 38 years, although I have met
an Indian scientist who was paralysed in middle age. Almost
a 1 the older cases were reported before 1960, a period when
infant mortality was high and probably few children with
paralysis reached hospital or survived. In these reports, 1.8%
o the cases were more than 9 years of age. After 1958 there
was probably only one case over 14 years of age. I have
found no cases in the literature since 1978, but it was at this
time that the Extended Programme of Immunization (EPI)
paediatnc^ °" Ch'ldren’ with 11,051 PaPers coming from
paediatric departments and reported in paediatric journals
Many papers report lameness surveys, which do not include
adults. Present reports concentrate on the under-fives only.
Dependants of Indian servicemen
Jhe hospitals of the Indian Armed Forces treating the
(T^r mu' Servicemen have recorded cases of polio
e II). However, all sick dependants will not necessarily
H^V
32 Hyde TerTaCe’
9LN- UK
• V. WYATT Department of Clinical Medicine
Correspondence to 1, Hollyshaw Terrace, Leeds LS15 7BG, UK
© The National Medical Journal of India 1995
: ■ og;
Mortality (%)
British*
Indian
21 (0.33)
17(0.14)
45(0.36)
70 (0.49)
47(0.54)
3(0.01)
7(0.01)
15(0.02)
52(0.06)
19(0.03)
31
29
30
28
18
43
13
10
5
200
96
26.5
11
World War 11
In World War II, polio was a serious medical problem among
British and American servicemen in the Middle and Far
ast. t was more common among officers, particularly officer
cadets, compared to other ranks.' There were more than 96
cases among Indians, an incidence which drew no comment
even from the Indian doctors who wrote the official medical
’stones as it was so much lower than among the British
( able I). Unfortunately, we do not know if there have been
cases in the Indian forces since World War II as the annual
Report on the Health of the Armed Forces does not include
polio as a separate section for servicemen.2
Indian
includes Indian officers
use the military hospitals. Wives in villages or those far from
the nearest military hospital would go to a local doctor. The
absence of any deaths among wives may suggest that the
most severe cases do not reach hospital and that those who
do come after the acute stage has subsided. Small children,
on the other hand, may be carried to a hospital when ill’
The mortality of nearly 1.7% is close to that for children
with polio attending outpatients in large sentinel hospitals.11
No compansons are possible as the total numbers of children
and wives are not known. The annual report2 also mentions
a few cases attending Family Welfare Centres, but these
may duplicate the hospital admissions.
diagnosis
Arr ^^U,tS misdiagnosed or are these red cases of
n A0/ a0. 1943’the consultant neurologist in India, Brigadier
. McAlpine, reported on the epidemic of polio in Malta
where more than 400 children and 57 British servicemen
suffered from paralysis. Polio virus had been isolated from
post-mortem material injected into primates in Egypt and
at the Rockefeller Institute, New York* (also post mortem
reports in possession of the author and replies from doctors
nurses and polio victims). In India, cases were seen at militant
. °Sflta!ST^y BntIsh and Indian doctors but on evacuation
to the UK, patients were seen by a board of specialists.
Specific notes were distributed for differential diagnosis,
including acute toxic polyneuritis and infective neuritis and
their occurrence in both British and Indian servicemen. *44
Many other neurological diagnoses including acute encephalitis
lethargica and arsenic poisoning were considered:
Similarly, dependants of Indian Armed Forces officers
and men were treated and examined by service neurologists
and avilian specialists. After World War 11, several impor
tant papers on polio among civilians in India were published
by Indian Army medical officers.16
THE NATIONAL MEDICAL JOURNAL OF INDIA
134
VOL. 8, NO. 3, 1995
Table II. Cases of paralytic poliomyelitis in Indians aged 10 or more reported in the literature
I
Year
City
Total cases
Age (years)
n
Comments
1937-4P
Madras
279
10-14
24
Age of onset, surgical patients,
probably includes Europeans
15- 24
25-38
10
6
Both females, 1 pregnant, age 23
all males
1949*
Bombay
82*
16- 24
25-30
2
3
1945-585
Bombay
1310
10-14
15-19
>19
17
7
25
19636
Udaipur
75
13
1 girl, died
1969-717
New Delhi
2316
10
19 boys, 10 girls
eldest case
1971*
New Delhi
390
11
1974-759
New Delhi
2045
>10
6 boys, 6 girls
1972-78l"
Bhopal
489+
25
1 male
128 (1.8%)
6986
Total
• these cases may have been included in the totals quoted by Athavale’ for the Polio Research Centre (PRU), Bombay shown here
Hospital. Bairagarh
+ cases admitted to the Paediatric Department of Kasturba Hospital, Bhopal and the Military Hospital,
Table III. Number of admissions for poliomyelitis and polio
encephalitis among dependants of officers and other ranks of
the Indian Army (1967-91)2
Years
Officers
_______ Wives_______
Children________
Officers
Other ranks
Other ranks
1967
1972-78
1979-80
1985-89
1990-91
7(1)
22(2)
3(0)
16(0)
1(0)
78(2)
850(8)
171(2)
516(12)
105(2)
0
0
0
2
2
0
0
20
51
12
Total
49(3)
1720(26)
4
83
There were no entries for the year 1968-71 and 1981-84
Figures in parentheses are the number of deaths
DISCUSSION
Indian soldiers were not alone in being attacked by polio;
7 cases occurred among 150000 West African soldiers serving
in Sierra Leone, Nigeria and the Gold Coast from 1940-45.
Among West African soldiers invalided from India and
Burma one had polio.17 These soldiers, like the Indian soldiers,
came from countries with childhood polio. In adult Africans,
however, the disease would seem to be very rare.
Did all these youngsters and adults lack immunity to one
type of polio virus, or was their immunity temporarily lowered
or overwhelmed? There has been no analysis of social,
temporal or other factors which might affect susceptibility
in a country where there is constant exposure to the polio
virus. Cases of paralysis in children with full immunization
have been reported from Vellore,18 might polio in adults
provide clues?
In India where almost all cases of polio occur in children
under 5 years and the polio virus is ever present, we might
expect that adults would be constantly challenged and have
high antibody titres. Fifty-five babies were tested at 6 weeks,
when they should have maternal antibodies and be protected.19
Two-thirds of these babies had no detectable antibody to
any of the three types of polio virus. Of 87 babies, the cord
bloods of 29% were triple negative. Therefore, in spite of
constant exposure mothers have very low titres. One possi
bility is that constant exposure to infection with polio viruses
induces very effective gut immunity and no stimulation of
humoral immunity. If this were so, a very heavy infection
with a virulent strain might overwhelm the gut immunity,
invade the blood stream and establish an infection before
enough antibody had been synthesized.
Indian servicemen in World War II had a case-fatality
rate of only 11% (Table I), less than half that of the British.
Although there will have been some older British officers,
most of the servicemen both British and Indian will have
been 18-30 years old. The low case-fatality suggests that
Indian servicemen might have had some protection against
paralysis. There were no deaths among 87 wives of servicemen
(Table III) suggesting that these were not acute cases but
patients coming for physiotherapy or examination. The reports
give a mean stay in hospital for each group, but no other
details.
If the immunization programme reduces the passage of
the wild polio virus, adults might be left with decreasing gut
immunity and any exposure to the wild virus might then
lead to paralysis.
All cases of paralytic poliomyelitis in persons over 10
years should be investigated by attempting virus isolation
and antibody determination.
We need to know the age, gender, social class, history of
injections, of exercise20 and whether the pattern of muscle
paralysis is typical of polio.
I would be pleased to hear from doctors who have experi
ence of cases of polio in adult residents in India.
ACKNOWLEDGEMENTS
I am very grateful to the Director General of the Indian Armed Forces
Medical Services and Colonel Ashok Chaturvedi for their kind help,
to Save the Children Fund and the Society for General Microbiology
5
Indian J Med Res 103, January 1996, pp 19-25
Tuberculosis - the continuing scourge of India
r. Prabhakar
Tuberculosis Research Centre (ICMR), Madras
Accepted December 22. 1995
Epidemiological picture of tuberculosis in India is complex with wide variation in the annual risk of
infection and prevalence of disease. The concentration of the disease among younger age groups makes
tuberculosis a major socio-economic burden in India. The disability adjusted life years (DALVS) is
estimated to be around 63 and 46 lakhs of years of life lost in men and nomen respectively. The burden
is likely to increase with HIV epidemic with an increase of cases with dual infection, increase in
morbidity and mortality due to tuberculosis. Management of drug resistant tuberculosis is a major
hurdle in tuberculosis control and is a major step in cutting the chain of transmission to those with
HIV infection, AIDS and immunodeficiency. Development of new therapeutic modalities to address
this problem arc also urgently required. Poor patient compliance has been the reason for failure of
many control programmes. Operational research studies conducted by the 1 RC have resulted in
elucidation of socio-bchavioural aspects of patients which need further investigation lor remedial
measures. Studies to improve drug delivery and to measure the impact of health education and mass
media on compliance arc areas which need to be concentrated. Newer techniques such as DN'A
fingerprinting need to employed to improve knowledge of the patterns of transmission in communities.
The impact of HIV infection on tuberculosis and the role of chemoprophylaxis in HIV infected
individuals in high risk populations, children in close contact with newh diagnosed patients and HIV
infected individuals need to be urgently explored. Improved methods for diagnosis of Mvcobactenum
tuberculosis infection must await considerable advance in the understanding of basic immunology,
mycobacterial antigenic structure and host-parasitic interaction.
Key words AIDS - BCG - case holding - case finding - controlled clinical trials - DN’A finger printing - HIV - multi-drug resistance operational research - tuberculosis
in the last two decades. However, there has been a
global resurgence of interest in tuberculosis due to
the HIV/AIDS epidemic and the WHO and other
agencies have launched a massive research
programme to combat the disease.
Tuberculosis has been identified globally as an
important health problem and enormous research has
been carried out all over the world on the operational, applied and basic aspects of tuberculosis con
trol with special emphasis on epidemiology, with
primary objective of monitoring the trend of the
disease by effective surveillance and to find effective
preventive strategies in the form of chemoprophylaxis
and immunoprophylaxis1. Several aspects of tuberculosis such as the epidemiology, immunology and
Pathogenesis Still remain unclear while there have
een no new drugs for the management of the disease
Prevalence of infection
The tools to measure both infection and disease
have remained relatively unchanged for decades. Our
current knowledge about infection is based on the
tuberculin test which requires well trained personnel
and is affected by cross-reactions with other myco19
20
INDIAN J MED RES. JANUARY 1996
bacterial infections and BCG vaccination. Multiple
risk factors that are associated with the development
of the disease have been identified although the natu
ral history of the disease is poorly understood.
Chingleput district, Tamilnadu, have not shown de*
creasing trends in annual risk of infection and esti
mates have been 1.7 percent in 1969, 1.93 percent
in 1979 and 1.73 per cent in 1984K.
The epidemiological situation in India does not
appear to have changed significantly over the years
since the First National Sample Survey of 1955-58
(ICMR-Tuberculosis in India. A sample survey spe
cial reprint series No. 34. Delhi, ICMR, 1 -21). A few
small scale studies of district population conducted
in the rural and peri-urban areas around Bangalore
and a longitudinal study with 6 rounds conducted
from 1961 to 1981 in 22 villages around Bangalore
provide good data on small populations1. Similar
information is available from the BCG trial popula
tion in Chingleput district of Tamilnadu2.
Prevalence of disease
The National Sample Survey did not include tu
berculin skin tests and the annual risk of infection
could not be measured directly at that point in time.
The prevalence of infection based on tuberculin test
ing has been shown to be age dependent in the earlier
studies carried out by Ukil and Benjamin3 4 who also
showed that, contrary to popular belief tuberculosis
was common in rural areas. Frimodt-Mollcr5 found
that the infection rates in Madanapalle to be 10. 21
and 31 per cent at the ages of 10, 20 and 30 yr
respectively. Similar observations have been made in
skin test surveys conducted in Dharmapuri district,
Tamilnadu and Anantapur district, Andhra Pradesh6.
These surveys done between 1983 and 1984 showed
that the prevalence of infection in children 0-9 yr was
10.1 and 10.4 percent respectively. In the Chingleput
BCG study area, the overall prevalence among all
age groups was 50 per cent (54% in males and 46%
in females)2.
Incidence of infection
In the Chingleput study the incidence of infection
which was measured in the placebo treated grouj
was 1.75, 2.4 and 4.03 per cent in the 1-4, 5-9 and
10-14 yr age groups respectively at the end of 4 yr
of the study2. A longitudinal survey conducted by the
National Institute of Tuberculosis, Bangalore7, has
provided information on the annual risk of infection
of 3.2 per cent. In contrast the three surveys over a
15 yr period, using tuberculin testing conducted in
Passive case finding is the mainstay of case find
ing in most developing countries. This relies heavily
on sputum examination by smear and culture, chest
radiography and tuberculin skin testing. The preva
lence of disease in the BCG trial area as seen by
culture positivity with one sputum sample was 404/
100,000 (598 for males and 205 for females)2. Stud
ies of prevalence of disease conducted over several
rounds of the longitudinal study of the National
Tuberculosis Institute (NTI), Bangalore, in the sur
rounding areas have shown that the overall preva
lence of smear and culture positive tuberculosis has
apparently remained constant9. But there has been a
marked decline in smear positive tuberculosis and
this is attributable to different screening methods
used in the 1984-86 survey than in the previous
rounds. This could have resulted in the increase in
the number of smear negative culture positive cases
detected.
In surveys I to IV conducted by NTI. the entire
population over 5 yr of age was X-rayed and those
with suspicious X-ray had sputum bacteriology done.
However, in the 1984-86 survey, the population (1044 yr of age) had skin tests and those with positive
reaction 10 mm with PPD had sputum bacteriology
done while the entire population over 45 yr of age
had sputum bacteriology done. Thus, sputum bacte
riology was performed on a much larger population
in this recent survey. The decline in smear positive
prevalence closely parallels the decline in annual risk
of infection measured in the same population lending
support to the hypothesis that in the area around
Bangalore tuberculosis has been declining6. Contrary
to the finding of NTI surveys in Bangalore area, the
Tuberculosis Research Centre (TRC) surveys on
small scale in the districts of North Arcot in
Tamilnadu and Raichur in Karnataka States have
shown total bacteriological prevalence of 430 and
1090 per 100,000 respectively10. The sputum exami'
nation in these surveys was conducted using Ziehl
Neelsen stain and fluorescence microscopy on two
PRABHAKAR : TUBERCULOSIS - CONTINUING SCOURGE OF INDIA
samples of sputum, and culture examination. These
small scale studies illustrate the wide range of preva
lence rates within India with potential for the occur
rence of extremely high annual risk of infection in
some areas such as Raichur district.
Thus, epidemiological picture of tuberculosis in
India is of a complex nature whh wide variation in
the annual risk of infection and prevalence of dis
ease. Hence it is felt essential that the level of risk
of infection state-wise be determined in order to
understand the epidemiology of tuberculosis in the
Indian context and to monitor the control programme
by well designed surveillance studies. The National
Sample Survey and the Tuberculosis Research Cenjurveys have clearly brought out the age distribu
tion of the disease and its concentration among the
younger age groups which are considered as the most
productive segment ol the population similar to the
situation in most developing countries. I he unique
age-distribution of tuberculosis makes it as a major
socio-economic burden in India.
Tuberculosis and women
It would be wrong to assume that tuberculosis is
only a major health problem for men oxer 30 yr of
age rather than for women although epidemiological
studies show higher rates of this disease in men . The
National Sample Survey of 1955-58 and the
longitudinal survey around Bangalore and more
recent district surveys have shown that the problem
tuberculosis in women is considerable in their
productive age of 15-44 yr. There are an estimated
70,000 deaths each from tuberculosis in the age group
15-44 yr6.
Mortality
I
I
-5
The mortality rates in tuberculosis as made out
from published evidence of the first 4 surveys for
1961-68 have been between 69.2 and 95.4 per
100,000 and in subsequent V and VI surveys in 1977
and 1981 was estimated to be 41 per 100,000. The
estimate made by sample registration system 1988 is
around 400,000 deaths per year from tuberculosis
and shows an increasing trend with age11. These may
be crude numbers; probably underestimates of the
real mortality rate.
21
Burden of illness
The socio-economic impact of the disease in the
community in India needs to be looked into since the
disability adjusted life years (DALYS) is estimated
to be in the order 62.8 and 45.6 lakhs man-years of
life lost in men and women respectively12.
The burden of illness due to tuberculosis has hardly
shown any decline and it is likely that it will be
increased by the HIV epidemic with an alarming rate
of increase of cases with dual infection to be fol
lowed by an increase in morbidity and mortality due
to tuberculosis. To add to this complex situation,
irregular and inadequate chemotherapy as a result of
poor drug compliance by patients, difficulties in
management of multidrug resistance tuberculosis and
relapse of the disease coupled with a low efficiency
of the control programme could add to the existing
problem. It may be worthwhile mentioning that ra
tionalization of prescription practice of anti-tubercu
losis drugs by practitioners of medicine is essentia!
for the efficient management of tuberculosis.
Tuberculosis in industries
As in other countries tuberculosis has been seen in
areas with rapid industrialization and urbanization in
India. There have been several surveys of tuberculo
sis among workers engaged in dusty occupations. An
increased occurrence of tuberculosis was seen in the
pottery and ceramic industries. However, there was
no increase among those working in the coal and
steel industries. Higher rates of occurrence were seen
among bidi workers and cotton mill workers13.
Drug resistance
Management of drug resistant cases of tuberculo
sis is a major problem for the practitioners of medi
cine and programme managers in tuberculosis con
trol. It has been estimated that the initial drug resis
tance (primary and acquired) to INH in patients seek
ing treatment is as high as 30 per cent in North Arcot
district in Tamilnadu and Delhi; and in those who
remain bacteriologically positive after chemotherapy,
it is estimated to be around 78 per cent in North
Arcot district, Tamilnadu14. Added to the problem of
INH resistance is the appearance of rifampicin resis
tance which is of the order 2-4 per cent in newly
22
INDIAN J MED RES. JANUARY 1996
diagnosed cases and up to 16-30 per cent among
treatment failures14. An estimate of drug resistance is
of utmost importance in the epidemiology and con
trol of the disease since the treatment programme
needs to be modified for effective management of the
disease. More importantly, this will also help to cut
the chain of transmission of drug resistance tubercu
losis to the vulnerable individuals especially those
with HIV infection and AIDS and others with immu
nodeficiency.
The National TB control programme and its impact
Management of pulmonary tuberculosis was
revolutionised in the mid fifties by the advent of
domiciliary chemotherapy established by the Tuber
culosis Chemotherapy Centre (TCC, Madras) now
known as Tuberculosis Research Centre (TRC), with
proven efficacy. This was the need ot the hour when
there were approximately 1.25 million infective pul
monary tuberculosis cases prevalent in the country
with only about 30.000 beds in the sanatoria. The
Government of India having been convinced with
reliable results obtained by the well planned and
executed controlled clinical trials by the Centre,
considered integration of the National Tuberculosis
Programme in the primary health care system to
tackle the problem of pulmonary tuberculosis which
was equally distributed in the urban and rural set
tings. The Programme was drawn up with excellent
user-friendly protocols and manuals for health work
ers. The regimens of treatment which were investi
gated at the Centre and elsewhere in the world using
streptomycin, PAS or thiacetazone and isoniazid
initially for 2 months followed by 10 months of
double drug combination of PAS or thiacetazone and
isoniazid proved nearly 80 per cent efficacious under
the clinical trial conditions15. However, there were
failures of the regimen to the extent of approximately
20 per cent due to initial drug resistance and relapses.
Earlier attempts at prevention of poor drug compli
ance by patients led to the evolution of supervised
administration of streptomycin and isoniazid on a
twice weekly basis for 12 months which was again
a signal contribution of the TRC. Madras. This was
found as efficacious as the daily unsupervised regi
mens (self-administered) of treatment. However the
major setback for these regimens of treatment for a
period of a year has been poor treatment adherence
by patients with an unacceptable rate of 25-30 per
cent of patients completing treatment under the
programme conditions16.
Extensive experimental studies with highly bacte
ricidal and sterilizing drugs such as rifampicin and
pyrazinamide revolutionised the treatment of tuber
culosis in the early 1970s. Applying the principles of
chemotherapy based bn sound scientific foundation
regimens of treatment of shorter duration ranging
from 5-8 months containing highly bactericidal drugs
such as streptomycin, isoniazid, rifampicin and
pyrazinamide were evolved by well designed and
conducted studies at the TRC. Madras and elsewhere
in the world by the British Medical Research Council
(BMRC)17'19. These short course chemotherapy regi
mens were highly efficacious with very low relapse
rates ranging from 1 -5 per cent and were also found
to be very useful in successfully treating patients
with initial drug resistance to streptomycin and
isoniazid.
The treatment regimens of 12 month duration and
short course regimens of 6-8 months duration have
been accepted for application under the NTP by the
Government of India based on the proven efficacy of
these regimens under controlled trial conditions.
The regimens of treatment with shorter duration of
6-8 months when applied under the existing condi
tions in the District TB Programme in India on a
pilot scale in 18 districts were shown to improve the
treatment adherence; 50-60 per cent of patients com
pleting treatment compared to about 30 per cent with
conventional 12 month regimens. However, this is
not a panacea for tackling the major problem of
treatment defaulters. Operations research studies
conducted by the TRC and elsewhere have resulted
in identifying sociological and behavioural problems
in patients which need to be investigated to find out
remedial measures and evolve suitable strategies.
One such strategy could be the involvement of the
community in the programme with its effective part
nership in tackling this major health problem by
establishing a link between the providers and benefi
ciaries of health in respect of tuberculosis. There is
also need for health education of the community to
create awareness of the disease and sensitisation to
demand health care from the providers. A good
programme needs good health services management
PRABHAKAR : TL BERC ULOSIS - COXTINUNG SCOURGE OF INDIA
d the providers.of health care either the Govern
mental or the non-Governmental Organisations
1 hould be efficient programme managers and as such
training of health personnel at various levels should
Iso be ensured. Basic orientation of health workers
at the management and grass-root levels should also
be considered by instituting continuing education
programmes by experts at the state and district lev
els.
Although the NTP has been in operation for the
past three or four decades there has been little impact
on the epidemiology of the disease which could be
attributed partly to the laxity in the management of
the Programme, financial constraints and probably
due to lower priority given to the Programme as
ccAared to others. With the advent of HIV infectionand AIDS and the projected heavy burden of the
deadly disease in the population, the problem of
tuberculosis in India could escalate many folds with
50 per cent of the population already infected with
tuberculosis as evidenced by tuberculin positivity
and an ARI (annual risk of infection) of 1.2 to 1.5 per
cent among children below 5 yr6.
It is therefore obvious that in spite of the fact that
effective tools to tackle this major health problem arc
available, the disease has perpetuated for decades
since the tools have not been put to proper use. Thus
( all efforts should be made to augment the efficiency
of the programme in order to contain and control the
disease. The revised tuberculosis control strategy that
has been planned emphasises good treatment adherei^of patients, with micro level planning and an
I aflmpt to decentralise at the district level to improve
I the efficiency at the peripheries in order to meet the
I requirements of health services at the primary health
care level.
i
e
I
It is worth mentioning here that no programme
would be worse than a badly managed programme
since a badly managed programme would result in
Perpetuating the malady not to mention the financial
drain on the national exchequer. Further, a badly
managed programme could result in serious conse
quences such as increase of drug resistance tubercu
losis especially the multidrug resistant forms (MDRTB) which will incur a phenomenal amount of money
lor management of such patients; a burden that is felt
even by the technically advanced countries with af-
23
fluence.
Recommendations for research in tuberculosis in
India
Research in the area of epidemiology should be
focussed on the establishment of surveillance sys
tems to monitor the change in transmission risk in
selected communities and the risk factors for tuber
culosis disease should be identified so that control
measures may be modified or focussed. Newer tech
niques such as DNA ‘fingerprinting’ need to be
employed to improve knowledge of the patterns of
transmission in communities. The impact of HI\
infection on tuberculosis and the role of
chemoprophylaxis in HIV infected individuals also
need to be urgently explored.
Diagnosis (ccise-findiiig): Passive case finding is the
mainstay of case finding in most developing coun
tries. This relies heavily on sputum examination by
smear and culture, chest radiography and tuberculin
skin testing. Improvement of case-finding
programmes will require development of methods
for estimating the coverage and efficacy of case de
tection in the community and to determine the prin
cipal factors influencing the coverage of case-detec
tion. such as health education, training of health
personnel. Attention should be given especially to
technological improvements in existing diagnostic
procedures for use during the period preceding the
introduction of new technologies. The objectives are
to increase sensitivity, specificity and technical sim
plicity without compromising cost-effectiveness and
to adapt present technology for the increasing prob
lem of diagnosing sputum smear-negative tuberculo
sis in HIV-positive individuals. Improved methods
for diagnosis of Mycobacterium tuberculosis infec
tion must await considerable advance in the under
standing of basic immunology, mycobacterial anti
genic structure, and hostparasite interactions. The
objective is the development of a better (z.e.. simple,
rapid, sensitive, specific, inexpensive) method for
identifying persons harbouring viable tubercle ba
cilli, especially those most likely to develop clini
cally active disease.
Treatment and case-holding '. Although efficacious
regimens have bee,n developed for the treatment of
tuberculosis, poor patient compliance has been the
24
INDIAN J MED RES. JANUARY 19%
reason for the failure of many control programmes.
Studies of options to the delivery of the intensive
phase of therapy by evaluating the feasibility of di
rectly observed therapy (DOT) in the initial intensive
phase of short-course chemotherapy need to be ex
plored. Studies to improve the patient compliance by
use of calender packs, identifying patients who need
to have supervised therapy, and the effect on compli
ance of personal health education and mass media are
other areas which need to be explored. Studies to
determine how, and quantify the extent to which,
private physicians can be induced to participatean a
National Tuberculosis Control programme through
accurate diagnosis, appropriate regimen selection,
and extended patient follow up as well as studies of
the surveillance of primary resistance to isoniazid,
streptomycin, rifampicin and ethambutol worldwide
also need to be carried out. Development of new
therapeutic modalities (i.e., new drugs, drug delivery
systems, and immunotherapy) to address the prob
lem of increasing drug resistance and further shorten
current therapy are also urgently required.
Prevention : BCG vaccination and preventive che
motherapy are currently used as preventive agents in
tuberculosis. The role of BCG has been critically
examined in several trials but the results al best have
been equivocal. Efficacy and operational studies,
including analysis of cost-effectiveness to define the
role of preventive chemotherapy in high-risk popu
lations, especially children living in close contact
w ith newly diagnosed patients and persons infected
with HIV need to be carried out. In addition, studies
of revaccination with BCG vaccine to assess this
frequently perfonned but unproven intervention need
to be explored.
Development of new forms of preventive therapy,
e.g., new drugs, depot preparations, and immuno
therapeutics need to be explored along with efforts to
develop and test new tuberculosis vaccines, includ
ing basic studies of the immunology and microbiol
ogy of the tubercle bacillus. These studies should
also include efficacy studies of neonatal vaccination,
ci.
studies of additives of BCG (e.g., killed M. vaccae),
and continued studies of the safety of BCG vaccine
in HIV infection.
Economic, social and operational research : The
WHO has identified major socio-economic challenges
and operational problems confronting national tuber
culosis programmes20. These include studies of th
economic and social impact of tuberculosis at the
household, community and national levels, including
analysis of differential impacts on socio-economic,
ethnic and age groups. The development of a tuber
culosis transmission model to illustrate the potential
benefits of proposed tuberculosis control programmes
at the national level will greatly help in planning
control strategies. It is mandatory that surveys of
tuberculosis should include estimation of prevalence
of drug resistance also as a major component in order
to monitor the control programme. The outcome of
such studies could be the evidence of drug complj.
ance by patients and prescription practices.
Accurate epidemiological information is needed
through well planned and designed studies which are
properly executed to yield reliable results. These
studies need to be conducted by group of experts
from various disciplines with a common protocol
using reliable tools and application of proper meth
odology for collating and analysing the data col
lected. There is also a need to establish methodolo
gies for surveillance which should be standardized
and made user-friendly to be applicable throughout
the country by any agency. These are considered
important steps in epidemiology as it may be ob
served from the foregoing paragraphs of this paper
that the epidemiology of tuberculosis presents a var
ied picture in different parts of the country attributed
to the geographic location, socio-cultural milieu and
economic strata.
Acknowledgment
I wish to gratefully acknowledge the contribution rendered by
Dr V. Kumaraswami and Shri P. V. Krishnamoorty in the preparation>
of this report and to Shri V.R. Venkata Ramanan for secretarial|
assistance.
References
>
I.
Technical Series, Pulmonary tuberculosis. Journal
Association of Physicians India publication, 1995.
2.
Tuberculosis Prevention Trial, Madras, Trial of BCG vaccin^^
in South India for Tuberculosis prevention. Iridian J Med
1980; 72 Suppl - 1-74.
3.
Ukil and Benjamin. Indian J Med Res 1930; 17 : 2066.
4.
Benjamin PV. Indian Med Gazette 1938; 73 : 540.
5.
Frimodt-Moller 1. A community-wide tuberculosis study in*
PRABHAKAR : TUBERCULOSIS - CONTINUING SCOURGE OF INDIA
South Indian rural population 1950-1955. Bull WHO I960;
6.
7.
s
8.
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I
■8
22: 61-170.
Murray CJL. Draft Trip Report. Geneva. WHO CDS 1992.
National Tuberculosis Institute. Tubercle Lung Dis 1992; 73
: 213-18.
Mayumath S, Vallishayec RS. Radhamm MP. Prabhakar R.
Prevalence study of tuberculosis infection over fifteen years
in a rural population in Chinglcput district (South India).
Tuberculosis Research Centre, Madras. Indian J Med Res
10.
1991; 93: 74-80.
National Tuberculosis Institute. Bangalore. Tuberculosis in a
rural population of South India, a five year epidemiological
study. Bull WHO 1974; 51 : 473-94.
Tuberculosis Research Centre. Report on Research Activities,
12.
Chakraborty AK. Gothi GD. D^arakanath, S, Singh H.
Tuberculosis mortality rate in a South Indian rural population.
Indian J Tuberc 1978; 25 181-86
World Development Report. Invc^ung in llcalih Oxford,
9.
1989-1991.
NY : Oxford University Press. 1993
■
13. Gothi GD. Epidemiology of tuberculosis in India Indian J
Tuberc 1982; 29: 134-48
14. Parmasivan CN, Chandrasekaran \ . Santha T. Sundarsanam
25
NM. Prabhakar R. Bacteriological investigations for short
course chemotherapy under the Tuberculosis programme in
two districts of India. Tubercle Lung Dis 1993; 74 : 23-7.
15. Tuberculosis Chemotherapy Centre, Madras. Isoniazid plus
thioacetazone compared with two regimens of isoniazid plus
PAS in the domiciliary treatment of pulmonary tuberculosis in
South Indian patients. Bull WHO 1966; 34 : 483-515.
16. National Tuberculosis Institute. News letter 1984; 20 : 47-50.
17. Tuberculosis Research Centre, ChetpuU Madras, Study of
chemotherapy regimens of five and seven months duration
and the role of conicosteroids in the treatment of sputum
positive patients with pulmonary tuberculosis in South India.
Tubercle 1983; 64 : 73-91.
18. Tuberculosis Research Centre. MadrasA National Tuberculosis
Institute. Bangalore. A controlled clinical trial of 3- and 5month regimens in the treatment of sputum-positive patients
with pulmonary tuberculosis in South India. Am Rev Resp Dis
1986; 134 : 27-33
19. Balasubramanian R Fully intermittent six-month regimens
for pulmonary tuberculosis in South India. Indian J luberc
1991; 3A : 51-3.
20. WHOTB'91.160. Tuberculosis Research and Development,
WHO. Geneva, 1991
Reprint requests : Dr R. Prabhakar. 14. East Main Road. Shenoy Nagar. Madras 600030
3)15 4 •
SpeciatArticle
National Tuberculosis Control Programme
•W
G R Khatri *
Tuberculosis is major public health problem. It prima
rily .affects people in their most productive years of life.
PROBLEM :
World
The annual incidence of new cases of all forms of
tuberculosis (TB) world-wide is estimated to be approxi
mately 8 million of whom 95% occur in developing
countries. The total number of TB cases at a given time
world wide is 16-20 million of whom 8-10 million are
smear positive and highly infectious.
Three million people died from TB in 1995 surpassing
the worst years of 1990's when 2.1 million died annually.
India
In India about 50% of the total population are infected
with the bacillus of tuberculosis. Fourteen million people
arc estimated to be suffering from active TB of which 33.5 million are highly infectious sputum positive cases.
About 0.5 million die of the disease every year.
Around 1.5 million TB cases arc detected every year of
which about 20-25% arc positive for sputum and rest arc
radiologically active sputum negative patients. It is esti
mated that almost an equal number of TB cases arc
detected and treated by non-government organisations
including private practitioners. The number of new TB
cases detected and put on treatment during the last 5 year
is shown in Table 1.
Table 1 — Show ing Number (ff New TB Cases
1991- 92
TB cases detected and put on treatment
(in lakhs)
12.79
1992- 93
15.39
|993-94
13.59
1994- 95
. 12.49
1995- 96
13.89
Year
TB AND HIV CO-INFECTION :
Most people are unaware of the enormous and deadly
role TB is playing in the AIDS epidemic. More HIVinfected individuals die from TB than from any other
cause. In one out of every 3 people who dies of AIDS, it is
TB that actually kills them.
F .
The experts opine that the epidemiological situation
with regard to TB will deteriorate further with the spread
of HIV as it has happened in other countries. Around 60%
of the AIDS cases reported in India have evidence of active
TB. Patients suffering from HIV are 25 times more likely
to develop TB disease as compared to persons infected
with tubercle bacilli alone. When an HIV positive person
is infected with TB it is very likely that he/she will get
seriously sick with TB. TB is the only major opportunistic
infection which can spread through the air to HIV negative
people. Therefore as HIV/TB dual infections continue to
rise, TB will spread more quickly to otherwise healthy,
populations. Furthermore TB in an HIV positive case
hastens the process of development into an AIDS case.
National TB Control Programme (NTCP)
To combat the problem of TB the Government of India
launched the National Tuberculosis Control Programme in
1962 with the following objectives:
(i) To detect as many TB cases as possible.
(ii) To effectively treat all patients so‘as to render
infectious cases as non-infectious, and prevent non-infec-.
live active cases from becoming infectious.
(iii) To established district TB centre (DTC) in every
district of the country.
(i v) To extend short course chemotherapy (SCC) in all
district.
(v) To strengthen existing State TB training and dem.
onstration centres.
strategy :
'•
(i) Early detection and regular treatment.
(ii) Free domiciliary treatment through PHC.
(iii) Conversion of infectious cases into non-infectio |
and preventing non infectious cases from becoming m
tious with treatment.
.
(iv) Establishing DTC in every district.
, " >
At the time of launching the programme, treatmen^
tuberculosis patients was done with standard regin^11 .
12-18 months. Subsequently short course chemot er^
(SCC) drugs were introduced on a pilot basis during
84 in 18 districts and later extended to another 101
by 1987-88 and further to 75 districts during 198
present 292 districts in the country are providing .
drugs for treatment of TB cases.
* Deputy Director General (TB), Ministry of Health and Family Welfare.
Government of India. New Delhi 110 011
372
I UBEKCULOS1S CON'i ROL PROGRAMME — KHATR1 373
current STATUS OF THE NTCI’ :
> At present DTCs have been established in 454 of the
496 districts in the country. DTCs concerned with the
inanagerial responsibility of the programme like plan’ ning* implementation, co-ordination and supervision of
I tuberculosis case finding and treatment. It also provides
I referral service for TB patients from peripheral institu1 lions. Each DTC has trained personnel, diagnostic
3 equipment (x-ray and microscope) and transport.
I
In addition there are about 330 TB clinics functioning
1
Table 2 — Showin}’ Standard Re^imen/Conventional Rej’imen
Regimen code
Regimen with
drugs
Duration
(month)
Rl
2STH/10TH*
12
R2
I2TH
12
RA
2EHRZ/6TH
8
RB
2SHRZ/4S.H.R,
6
J
s:
in the country and arc mostly located in the big towns and
1 cities and arc equipped with laboratory and x-ray unit.
There are 47600 beds available for treatment of TB cases.
TP training and demonstration centre :
At present 16 TB training and demonstration centres
are functioning in different States of the country. Apart
' from raining, these centres are providing guidance, supervi. i, co-ordination and technical assessment to the
programme in the respective Slates.
I
voluntary organisation under nti’ :
The country has a large number of voluntary organisations (NGOs) active in the field of health. For TB control
programme voluntary organisations are assisted in terms
of free supply of drugs for conventional therapy only.
Presently, 57 such NGOs arc registered with the NTP.
CASE FINDING :
Case finding undertaken in DTP is passive one. These
include the chest symptomatics with cough for more than
3 weeks or those with haemoptysis of variable duration
reporting on their own al DTC as well as PHIs.
Method of case diagnosis arc by direct sputum
microscopy and x-ray examination.
| treatment policy :
(
nothcrapy policy for NTP is laid down, taking
| mto consideration the efficacy and operational aspect of
j NTP. The salient feature of the chemotherapy policy arc:
3
TB patients under NTP arc treated either with (1)
| standard regime (SR) for a period of 12 months or (2) SCC
■ br6-8 months.
Drugs are issued free of cost including administration
| °fstreptomycin injection.
Treatment is offered on domiciliary basis as self ad! ^nistration chemotherapy giving medicines for 30 days
II'.
SLl*me.
Sputum positive patients have been accorded priority
°Versputum negative patients in order to cut the chain of
’tansmission effectively. Sputum positive patients are
I ^vitfed with SCC in the SCC districts only.
9
i
™ENT regimen :
.-TB patients diagnosed under NTP are treated either
Jh SR for a period of 12 months or with SCC for 6 or 8
| ?nth
; The categorisation of patient and drug regimen
a.
| forlreatmcnt arc shown in Table 2.
SCC:
Category of patient
New smear positive cases
where SCC is not avail
able
Seriously ill smear nega
tive cases
Extra pulmonary patients
in general
Smear negative cases with
x-ray positive
Lost patients, smear
negative on reporting
back
Highly irregular patients
New smear positive cases
Serious form oi extra pul
monary
Failure cases
Relapse cases______
* E to replace S and vice \ersa. depending on availability and E to
replace T wherever not tolerated.
Dose : S = Injection streptomycin 0.750g. T = thiacetazonc 150 mg.
H - INI! 300 mg. E = ethambutol SOO mg. R = rifampicin 450 mg. Z =
pyrazinamide 1500 mg.
DRUG PROCUREMENT AND SUPPLY :
The programme is based on 50:50 sharing basis be
tween Centre and State. The amount of drugs needed by
each State is determined annually by the Central TB division
from the number of patients reported in the previous year,
the population and the request received from the districts.
These requests arc initially scrutinised at the State level.
The Medical Store Organisation under DGHS procures
anti-TB drugs. The drugs are routed through 6 medical store
depots for distribution to various DTCs of the Stale directly
by rail or road transport on the release orders issued by TB
division of the DGHS.
CASE HOLDING .*
Motivation—Case holding is an essential part of the TB
control programme. Presently the case holding is very poor
resulting in low treatment completion rate. This can be
achieved by educating and motivating the patient and his
family and maintaining regularity in drug supply and case
management.
Defaulter action—Under the programme, provisions
are made for the retrieval of the defaulters fordrug collection
specially the smear positive patients. First action is taken if
the patient does not report for drug collection on due date
by posting a letter next morning. Second action is taken by
home visit, if patient does not report on 4th day from due
date. The defaulter action taken and date and dosages of
drug collection are recorded on the treatment card. But
there is no provision for reporting the action taken for
defaulter retrieval.
*
» ' i. \
. h l; i >
1 Obi .k. 1 '‘A)
Supervision—According to NTP policy, the DTO
and his team of laboratory technician and treatment organ
iser are responsible for the supervision of all personnel
within their district involved in tuberculosis activities. The
team is expected to visit each of their PHIs on a quarterly
basis. They are to evaluate diagnostics and treatment
procedure, validate laboratory result, monitor the drug
supplies and support equipment. Supervisory checklists
have been provided by the NTP to guide the supervision
of DTCs and PHIs. At PHI level, medical officers have
been made responsible for the supervision of laboratory
technician and multipurpose health worker.
Training—National Tuberculosis Institute (NTI),
Bangalore is responsible for training the DTP key person
nel through an in service training in the implementation
and management of the programme. The NTI is conduct
ing annually two courses each of 10 weeks duration. The
State TB training and demonstration centres train other
medical and paramedical staff involved in the programme
Jivery.
Achievement—With the inclusion of TB programme
in the 20 point programme, a thrust has been given for the
expansion of the essential activities under the programme.
Targets for detections of new TB cases arc being increased
every year.
As the programme is integrated with general health
services, attempts arc also being made for distributing
anli-TB drugs through sub-centres so that the treatment
facilities arc available closer to the patient.
Short course chemotherapy (SCC) drug regimens con
taining highly potent drugs have been introduced in the
programme since 1983. So far 292 districts of the country
have been brought under the ambit of SCC and it is
proposed to introduce these regimes in all the districts in
a phased manner.
The mortality rate has decreased from 80/100,000
nopulation in 1970 to 53/100,000 population in 1993.
irther the severer forms of childhood tuberculosis is on
the decline and extensive exudative lesions are less fre
quently seen.
Rerevised Strategy
On the basis of the findings of the review and recom *
mendation made, a revised strategy has been evolved with
technical assistance from WHO. The revised strate?
strengthens the identified weakness of the programme and
stresses the effective utilisation of the available infrastruc
lure. The objectives of the revised strategy are:
(i) To achieve 85% cure rate by administering super
vised SCC.
(ii) To detect 70% of the estimated cases after achiev
ing desired cure rate.
To achieve the above objective the following strategy
has been adopted :
■-^=
(a) Use sputum testing as the primary method of diag
nosis among self reporting case.
(b) Standardise treatment regimen.
(c) Ensuring a regular, uninterrupted supply of drugs
up to the most peripheral level.
(d) Increase budgetary outlay.
(c) Augmentation of the peripheral level supervision
through creation of a sub-district supervisory unit.
(f) Emphasise on training, 1EC and operational research.
SPUTUM EXAMINATION - DIAGNOSTIC TOOL :
Chest symptomatic and other persons with symptoms
compatible with tuberculosis consult medical staff and
general health facilities. These may be government
organisation. NGOs or private. Government facilities offer
systematic sputum examination - free of charge -to sympto
matic who have productive cough of over 3 weeks duration.
The medical officer al the health facility screens the
patients and sends those who can be tuberculosis suspects
for smear examination (three samples in two days, two spot
and one early morning). The patient receives sputum con
tainers and instructions, and provides the sputa, which is
examined in the laboratory. In case sputum microscopy is
not available at the health facility then the patient's sputum
or smears arc sent to the nearest microscopy centre or the
patient himself may be referred to these centres if these are
nearer. Two spot specimens and one early morning collec
tion are recommended for sputum examination. How the
chest symptomatics arc diagnosed is shown in Fig 1-
REVIEW OFTHETUBERCULOSIS CONTROL PROGRAMME
Though the programme has been in operation for last
30 years nothing much of epidemiological impact was
achieved. The programme was reviewed by ajoint team of
Government of India, WHO and SIDA in 1992. Their
salient findings were
(i) Inadequate budgetary outlay and shortage of
drugs.
(ii) Too much emphasis is given on clinical and
radiological diagnosis.
(iii) Sputum microscopy facilities are not sufficiently
utilised.
(iv) Poor quality of sputum microscopy.
(v) Emphasis on case detection rather than cure.
(vi) Lack of consensus among practitioners regarding
treatment regimen.
Chest symptomatic
■
______________ 3 Sputum smears
I
I
I
2 +ve
I +ve
3 -ve
'
-
-
Antibiotics
(1 -2 weeks)
I
X-ray
r
I
+ ve
-ve
Symptoms
persist
I
X-ray
T'e
JL
Non-TB Sputum-ve fB -ASputum+ve
TB
_______________________
AmpWj^PL. |
Anti-TB therapy
Fig 1—Showing the Diagnosis and Management of Chest symp101113- ^
ltipo
S . \ I I V '. s .
•fe- ■
3
4
.
Pilot Project
pilot phase - I :
A; With SIDA assistance the revised strategy was tested
25pilot project from last quarter of 1993 in 5 project areas
jn Delhi, Bombay, Calcutta, Mehsana in Gujarat and
Bangalore covering a population of 2.35 million.
Categorisation of Patients and Treatment—Patients
-i yyere categorised as I, II and III according to the status of
’ sputum finding and the treatment regimen followed for
different categories are as listed in Table 3.
Table 3 — Showing Caiei’orisalion of Patients and Treatment
Category Type of patient
Intensive
phase
Continuation
phase
I
Sputum +vc and
seriously ill
sputum -ve
EHRZ thrice
a week for
2 months
HR thrice a
week for 4
month?,
II
Sputum +vc
relapse,
failure and
others
EHRZS thrice
a week for 2
months, then
EHRZ thrice a
week lor
I month
EHR thrice
a week for
5 months
Sputum -vc
pulmonary and
extra pulmonary
HRZ thrice
a week tor 2
months
HR l hr ice a
week lor 4
months
ill
Dose : E - I2(X) mg. H - 600 mg. R - 456 mg. Z
I.500 mg. S 750 mg
Drugs under the pilot study were supplied in multidrug
blister packs for one day. During intensive phase drugs
were taken by the patients under direct observation ol the
health staff ie. direct observed therapy (DOT). During
continuation phase a blister pack tor one week (3 doses)
was given to the patient and al least the 1st dose was
directly observed al the time of collection. On the next
collection the patient should return the empty blisters.
Results—The initial results are very encouraging. In
the voject areas the ratio of pulmonary smear positive
to Smear negative ranges from 1 : 1.1 in Delhi to 1 : 1.4 in
Calcutta, as compared to the national figures of 1 : 4 to 1
• 5. This reflects the improvement in quality of diagnosis
brought about in project areas by emphasis on good
Quality sputum microscopy and better supervision.
It is also observed that the sputum conversion al 2-3
months was over 90%. The cure rate for the first cohort
from 3 project areas ie, Delhi, Gujarat and Bombay shows
acure rate of 96.8%, 81% and 75% respectively. Due to
ftason of migratory population, Bombay achieved a less
‘ cure rate. It can be observed that the cure rate achieved
i Very closely match the sputum conversion result at 2-3
1 Months.
•1 ^L0T PHASE ’11:
■' Encouraged by the results of the pilot phase - I the
J Government of India decided to extend the revised stralto 17 project sites covering a total population of 15.83 '
.3 Jillion. World Bank assistance of US $ 1.996 million has
JS Peen made available as project preparation facility
'■ ^vance.
1
l LOM.N I.
i KUl
Ail: —
It is envisaged to extend the revised NTCP in phases
throughout the country. To ensure a systematic and speedy
introduction of revised NTCP without sacrificing quality
control a series of interventions will be introduced which
will modify the functioning of the entire NTCP. The
following interventions are being proposed
(a) Strengthening of the TB cells at the central and
Slate levels.
(b) Strengthening of the Training Institutions forTB at
the Central and State level.
(c) Gradual implementation of the revised strategy for
TB control in 102 districts covering a population of 271
million.
(d) Strengthening of the National Tuberculosis Con
trol Programme in remaining 203 SCC districts as transi
tional step to adopt the rexised NTCP.
(c) Providing for an uninterrupted supply of anti-TB
drugs (both SCC and conventional) throughout the country
The Government of India is seeking World Bank assist
ance for the above interventions.
I\TERN/\TIONAL ASSISTANCE :
The International Agencies like UNICEF, WHO. ODA.
DAN IDA and SID.A have pro\ ided necessary support and
assistance to the National TB Programme in the form of
supplying x-ray equipment, x-ray rolls, laboratory equip
ment, vehicles, SCC drugs and operational research. Japan
Grant Funds arc also available for conducting workshops
and training programmes.
WORLD BANK ASSISTANCI - RI V ISED NTCP :
Gross inadequacy of funds to support various compo
nents of the programme has been primarily singled out for
the poor achievements of results under NTCP. Considering
the vast magnitude of the problem of TB existing in the
country and expert's concern of possible worsening of the
situation with the advent of HIV spread in the country,
renewed emphasis is being given to the revised NTCP and
ODA assistance has been sought to obtain adequate funds
to support various components of the programme.
The Government of India has requested the World Bank
to provide funds for implementing the revised strategy of
NTCP in the country. To start with, this revised strategy is
to be implemented in 15 States covering a population of
271.21 million and the rest of the district are to be prepared
for revised NTCP. World Bank assistance of around US S
150 million is being sought.
The various components of the revised strategy have
been prc-tcslcd in 16 project sites of the above mentioned
cities and States covering a population of 13.85 million
with budget estimate of about Rs 8 crores. The World Bank
has provided Project Preparation Facility (PPF) for imple
mentation of the revised strategy in this Pilot Phase.
ODA support:
The British ODA has shown its interest in supporting
TB control in its programme of support for health develop
ment in India. They have been participants in the World
Bank. WHO Missions visiting India from lime to lime. The
ODA has reached an agreement between the Government
(Coniiniied un pctge 384)
384
--O
J INDIAN MED ASSOC, VOL 94, NO 10, OCTOBER, 1996
DRUG DOSAGE :
Drug
Isoniazid
Rifampicin
Streptomycin
Pyrazinamide
Ethambutol
Thiacetazone
RECOMMENDATIONS TO GOVERNMENTS :
Daily dosage
mg/kg
Intermjtent dosage
mg/kg
5
10
15-20
35
25 for 2 months
then 15
4
15
15
15-20
50
30
Despite the availability of highly effective treatment
regimens for tuberculosis, cure rates remain low in most
developing countries. The main reason for this is that
patients do not take the prescribed medicines regularly
for the recommended period, ie, poor patient compliance.
Daily regimen, as short as 6 months, of therapy is
more effective than intermittent regimens because minor
irregularities in taking drugs do not affect the effective
ness of the therapy. On the other hand, intermittent
regimens may be less effective in the face of such ir
regularities, because many poor and uneducated patients
start taking medicines weekly or twice weekly whenever
they remember.
‘WHO—Treatment of Tuberculosis, Guidelines for National Program
mes, Geneva : WHO, 1993.
‘’American Thoracic Society —Treatment of tuberculosis and tuber
culosis infection in adults and children. 4m Rev Respir Dis 1986:
134 : 355-63.
The 17th Eastern Regional Conference on-rWI7
lce on 1
culosis and Respiratory Diseases ^comniended^W
member associations in the region should en
governments to :
.
(i) Identify tuberculosis as a priorky, in national
and budgets and international collaboration actiyitjO
(ii) Ensure that national tuberculosis progranS
comply with the new global tuberculosis central strat W
developed by the International Union against Tu®
culosis and Lung Disease and adopted by the WW
through the introduction of short course chemotherW
as a prime objective of all tuberculosis control progrO
mes.
(iii) Implement this strategy, taking into consider^®’
the sustaining health service system. Once 85% cure
is achieved, the programme should start to exnanMB
case finding activities for detection and treatment of
cases.
:
(iv) Continue BCG vaccination of the newborn,’Wf
less the infants have AIDS - related symptoms, -lit
■ Ai
Seth V — Chemotherapy for tulierculosis. Indian Pediatr 1996,
146-7.
Iseman MD — Treatment of multidrug-resistant tuberculosis. NR
J Med, 1993, 329 : 784-91.
< .J
i
(Continued from page 375)
of India for support to the NTCP to the extent of
£900.600.00. The areas of support include strengthening
of Central TB division, training activities and implemen
tation of the revised NTCP in Medak district of Andhra
Pradesh and Moti Nagar and Nehru Nagar district of
Delhi.
DANIDA assistance has been sought to implement the
revised strategy of NTCP in the State of Orissa where the
emphasis would be focused on tribal areas.
Conduct operational research in problem areas^
programme implementation including logistics and ser L
ice delivery.
.
It is also proposed to revitalise NTP in non-proje®;
areas by expanding DTP in the remaining distric§||
extending SCC in all the districts, strengthening Sta«|
TB demonstration and training centre, improving
ity of sputum microscopy, improving the system
procurement and supply of drugs and augmenting heal^^,^
,
...
"
education activities.
r>
FUTURE PLAN .*
EXPECTED OUTCOME I
Twenty-five per cent population (271.21 million) cov
erage under revised NTCP initially.
Preparation and extension of revised NTCP strategy to
the remaining 203 SCC districts in a phased manner.
Extension of revised NTCP to all the non-SCC districts
once implementation of strategy in SCC districts in a final
stage.
Government of India would maintain the trend of
increasing the budgetary allocation; 10 crores (1989-90)
to 46 crores (1994-95).
Strengthen the State TB training and demonstration
centres.
With the successful implementation of the .reyi^^H
strategy it is expected to achieve.
.
(i) A cure rate of atleast 85%.
(ii) Case-detection of atleast 70%.
(iii) Rate of reduction in the annual risk of
from the current 2-2.5% to 8-10%.
(iv) Reduction in mortality to about 20/100’^M
DAN1DA SUPPORT :
4
,
P°Pulationfr«
(v) Reduction in relapse rate to less than j (o
current rate of 15%.
(vi) Reduction in drug resistant/failure cases o
than 5% from current figure of 20%.
.ri-.^'d
p-'t'.-tvl
r
iS
'7 ^ < ;
’*NWJf tiiSkE'?^
•S *
s
0
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LA
£2
TUBERCULOSIS
Persistent killer
TB is a social and environmental disease to control which technical packages
alone are insufficient, says Thelma Narayan.
Bap UBERCULOSIS (TB), an ancient infectious
ious strains of the organism with differing virulence.
|g
disease, was known as the dreaded “white
The south Indian strain, for instance, is less virulent
H
plague," “pthisis" or “consumption" in the
than the British strain.
English terminology of the last century and as
Animals harbour different species of mycobacte
ria. From the human disease point of view, cattle arc
"Rajyaro^r (king of diseases) in India.
Fifty- years after Independence it is still Indias
the most important. In Europe. Mycobacterium Bovis
biggest public health problem, claiming an estimat
was a fairly important source of infection. It spreads
ed 500,000 lives every year and causing disease in
from Cjittle to people through drinking raw, unpas
about 17 million. Affecting adults in the prime of
teurised or unboiled milk. /\ major control pro
their lives, it causes much suffering and economic
gramme. involving the detection and slaughter of
loss for patients, their families and the nation. It
infected tuberculin positive animals, was successful
results in 26 per cent of preventable adult deaths and
is one of the most important causes of death among
ly conducted.
Studies in Calcutta and Bombay in the TTiirrits
women of child-bearing age. What is tragic is that
and Forties found that M. Bovis was not a cause of
the disease is curable.
human TB in those areas and was relatively uncom
mon in cattle. Studies in Madras around the same
Causative agent
period indicated the presence of TB infection among
Though its infectious nature was recognised ear
lier. it was the German scientist Robert Koch, who
cattle herds.
More recently in 1995. at a meeting in Madras,
Mycobacterium
veterinary- scientists and TB specialists expressed
Tuberculosis as the causative agent of tuberculosis.
concern about the occurrence ofTB in cattle. Cattle
in
IS82
isolated
the
bacteria
The work of several researchers suggests that the
primarily suffer from pulmonary- TB (affecting rhe
tubercle bacillus has co-existed with human beings
lungs) with infection almost invariably progressing
since early times. Like other organisms in the process
to disease. It spreads through the air borne route.
of evolution it has developed a complex ecological
The primary human disease due to M. Bovis is usu
relationship. This is indicated by the presence of var-
ally non-pulmonary.
to
Bl
II
§s3s
v-J
i
______
Childirn at a TB hospital in Chmnai
TH( HINDU SUtVtr OF TH! (NVItONMfNt
•7
n
1—
I
There arc a wide range of species of saprophytic
anpical environmental mycobacteria. While not
usually associated with human disease, more recent
ly. infections caused by zV. Aiiuin hitraceilularc have
occurred in patients with AIDS.
substantially in West Europe and the U.S. This was
unrelated to medical intervention and before the dis
cover}’ of anti-TB drugs, which occurred from the
late Forties onwards.
It has been suggested that population increase
and
European migration, colonialism and war initi
Reasons for the spread
ated “epidemic waves” in different regions of the
Tuberculosis was probably only a disease striking world in the last century. In India, people faced
animals many years ago. Two important periods in heavier taxes, landlrssness increased and textile and
the epidemic spread of the disease among major cottage industries were affected. The process of
human population groups appear to have been:
impoverishment set the scene for repeated famine,
(a) The period of transition to agriculture and an increase in TB and other epidemics.
cattle domestication followed by population increas
During the First World War (1914-1918). death
es during the sixth and seventh millennia BC in the rates due to TB increased in all countries at war. The
eastern Mediterranean region and Europe. Some of decline of TB in the U.K.
... — ----- was halted for 10 years
'
the earliest written records and ancient Indian med from the start of the Second World War in 1939.
ical treatises are said to describe the disease in early
Recent studies show high er rates of TB during war.
India. Tuberculosis probably existed among people conflict and among refugees.
at low levels of endemiciry. Most often, that is, small
India had a big problem of TB among the post
proportions of the population suffered from the dis Partition refugees in 1947. Disrupted social condi
ease at any time.
tions, undernutrition, poor housing and physical
(b) The period of industralisation starting in and emotional stress arc pre-disposing factors.
Fhc Association of socio-economic factors with TB was forgotten
forgotten in
in the
the
“scientific optimism” generated by the discover)' of chemotherapeutic drugs.
f <
England and Europe in the 16th century. This Tibetan resettlements in India also report a high
resulted in a process of urbanisation with over prevalence of TB.
crowded, unhygienic living conditions for the work
The disease thus seems closely linked to the
ing class in the new industrial and mining towns.
social history of humankind mediated through its
People were paid low wages and had long hours of effect on the environment and on living standards.
hard working in appalling conditions. Research
The association of socio-economic and environ
indicated that this process was repeated in the U.S.
mental factors with TB has been highlighted inter
and Africa and that industrial and urban growth
nationally by researchers. It was explicitly recognised
were correlated with TB. There has been the obser in India at policy making levels by the Bhore
vation that TB was “perhaps the first penalty that Committee (1946) and the Mudaliar Commince
capitalistic society had to pay for the ruthless
(1961). It later was forgotten in the “scientific opti
exploitation of labour.” The environmental condi mism generated by the discovery of effective
tions during that time were <closely
‘
associated with chemotherapeutic drugs. These discoveries did accel
the poverty of people though the elites were reaping erate the tailend of the decline of the disease in
the benefits of empire and industry.
countries that could afford and organise good
Observations in different countries, during the nation-wide health services.
past 150 years, have shown these conditions to form
the essential substrate in which TB and other infec Physical environment
tious diseases thrive.
a) Hotulng: Tuberculosis primarily affects the
With improved housing, working conditions and lung_ bi>ut can also spread within the body affecting
nutrition of large proportions of their populations, several other organs. It is an air-borne disease, trans
disease and death rates from TB starred declining mitted to others by coughing, spitting and talking.
J2
THE HINDU SURVtY OF THt ENVIKONMENt ’f?
i
i
Onlv patients whose phlegm or sputum contain bac
in India in 1993 co give greater importance to urban
teria (termed sputum positive) are sources of infec
areas in the programme. The urban population has
tion for other people.
increased over three decades from 20 per cent to 26
I hc bacteria disperse in the atmosphere through
per cent in 1991. with some inter-State variations.
small droplets which survive for long periods in
Before the l ifties. I B was considered to be largely an
dark, unvcntilatcd conditions. .Sunshine, present
urban problem, as it was in Europe. I he National
abundantly in India, cflcctivclv kills the bacteria.
Sample Survey findings, however, showed that it was
Small tenements and houses with insuflicient or
equally prevalent in urban and rural areas. Since 80
no ventilation provide the right environment lor the
per cent of the population was then rural, the prob
survival and spread of (he organism. Poor, congested
lem was understood as being predominantly rural.
I hc National Tuberculosis Programme was the
housing, a result and indicator of poverty, is an
first health programme to emphasise the need to
important clement in disease transmission.
Phc National Sample Survey, a large multi-Statc
develop general health sejvices in rural areas with
cross-sectional Indian study conducted in 1955-58.
which TB services were to be integrated. Health ser
found that people living in kutcha houses had a
vices and health personnel uere then predominantly
higher prevalence of TB. Twenty to twenty five per
urban based. ThirnTivc years later. 74 per cent of the
cent of patients with TB give a history of someone in
population is still rural. Though some gains have
the family also having had TB. Government and
been made, there continue to be urban-rural differ
development groups w'orking on housing schemes
entials in health budgets and health care senices.
and activist groups campaigning towards housing
Vulnerable groups
rights thus inditcctly contribute to TB control.
Smoky cbuHnis or cooking fires are shown by
The urban poor living in slums, jhuggi colonics
studies and experience in India to increase the risk of
and shanty towns comprise about 60 per cent of the
respiratory problems. They could aggravate the dis
urban population. The most deprived arc homeless
ease and make the life of a TB patient more difficult
migrants, rag pickers and street children. These vul
and perhaps be a risk factor in the spread of TB.
nerable groups arc at greater risk of TB and need
Similarlv patients with TB are advised not to smoke
specific intervention, protection and social securin'.
to present further lung damage. Promotion of
smokeless chuih.u by development agencies, could
the years with basic infrastructure unable to cope
The urban habitat has deteriorated greatly over
also be part of the ami-1 B package.
b) t'rb.inisjuon: There were attempts in the
with the growing demands tor housing, water, sani
Revised National Iuberculosis Control Programme
small unregulated lactorics close to domestic sites or
:h(
hinou
tation. roads and transport. The grow ing presence of
sur. (» Of int
in.
JOMMtnt
73
J
b
the growth of slums next to large factories add to the
problem. The all-pervasive corruption prevents and
slows the development of basic sendees.
c) industralisation and work environment'. The
work place provides an important environment
which could predispose to or facilitate the develop
ment of TB. Miners and quarry’ workers exposed to
various kinds of dust are likely to develop silicosis,
and arc at greater risk of developing TB. In crowded
industrial sheds and factories, with poor ventilation,
inadequate sunshine and fresh air, if one or some
workers have untreated sputum positiveTB there are
definite chances of spread of infection.
Rapid industralisation, driven by the present eco
nomic imperative, most often sacrifices safety proce
dures (dust control) and cfBucnt treatment (air pol
lutants) which decrease profit margins. This is par
ticularly so when regulatory mechanisms are poorly
implemented and the workforce is inadequately
informed and poorly organised.
There arc several indicators that air pollution lev
els arc growing alarmingly in urban areas. Any addi
tional assault dr damage to the respirator}’ system
(like smoking) could aggravate TB. The potential
occupational hazards faced by health personnel
working in close contact with TB patients has
received scant attention.
d) General causer. In the early parts of the centu
ry there ware anti-spitting drives in several countries
i
I
I
such as the U.K. Australia and South Africa among 1
others as a preventive measure against tuberculosis,
besides providing for better general environmental
hygiene and cleanliness. Given the rampant practice
of spitting in India, this would cenainly be a chaiImpact of political and economic policies
Moving beyond the physical environment to the
broader political and economic enviromments, it is
important to understand global changes that arc
occurring and their impact on nations and on peoplej especially the poor. Studies to understand the
immediate and short-term impact of structural
adjustment on poverty, unemployment and the environment are important for several reasons.
These programmes also have a direct relationship
with TB. Several countries across the world, for
instance in Africa and the Phillipines. have documented the ill-effects of these programmes on the
health of the poor, including high TB rates.
The impact of explicit pro-privatisation policies
in State-run health services also needs careful study.
These services arc used most often by the jKXir to
whom private care is inaccessible for long-term seri
ous illnesses like TB.
Nationally, an important issue is the low priority
given to health in terms of Central and State
Government budgets. Equally important is the lack
;
*
•
i
I
•
*
’J
*
I
SMIi
tHt HINDU SUIVtt O» IHf INVIIONMINT
77
r
'7
I
<
I
4
i
of commitment to develop and maintain quality of
care and service in public sector institutions.
Political interference, mismanagement and rampant
corruption have reached unacceptably high levels in
n viul tfica al li.% i li ig die hrah li and well I »<• 11 ig of i II
izens. This is an area for concern and social action.
Expectations belied
There were great ex pectations that the National
Tuberculosis Programme (NTP), articulated in 1962
after indigenous research, would be able to relieve
human suffering caused by TB and later reduce disease transmission so that it no longer was a public
health problem.
Evduation studies in 1975 and 1988 and the
monitoring system of the NTP consistendy report
gaps between expected performance and actual out
come. One study has indicated that only 8 to 16 per
cent of expected cases of TB get complete treatment
from the public health services.
The past decade has seen a major change in the
tions. These events created a panic, raising the scep
tre of a new epidemic in which available tools of
treatment would not be effective. Newer diagnostics
and drugs were not available as basic research in TB
had iinpprd lliicfi dn adri ag«». The new cvenii
brought to mind the long period, from the late 18 th
to the early 20th centuries when TB was the leading
cause of death in Europe and America, decimating
about 20 per cent of the population.
With international travel, global trade and inter
national capital being involved and potentially
affected, the sense iof urgency appeared great. This
resulted in a new global policy environment in
which TB war once again high on the international
public health agenda.
The World Health Organisation (WHO)
declared TB a global emergency in 1993. There was
increased intervention by the WHO, World Bank
and bilateral agencies in the control of TB in “low
and middle-income" countries.
I
*
I
Revised programme
t
Poor and congested housing, a
result and indicator of poverty, is an
important environmental element
in disease transmission.
TB situation globally. In the mid-Eighties there was
a reversal of decline in the incidence of TB in the
U.S. This was followed between 1986-91 by an
increased number of cases up to 33 per cent.
Increased TB rates occurred in several West
European countries too. Reasons cited for the
increase in TB are association or co-infection with
HIV/AIDS, neglect of TB control programmes by
governments for over two decades and the development of Multi Drug Resistant (MDR) TB (bacteria
that are resistant or non-respohsive to two to three
anti-TB drugs). A number of cases occur
basic: antiTB
among the inner ci:y homeless, among drug users,
and among migrants and indigenous people.
Twentyfivc per cent of cases in the U.S. were among
die “foreign born,’* similar to West Europe.
MDR TB arises because of inadequate and
incomplete treatment for which the health services
and patients have been blamed, out of context to the
under-resourced and difficult ‘circumstances in
which they function and live respectively. The treat
ment of MDR
is extremely expensive and often
has a unsuccessful outcome under the best condl-
IL
A revised National TB Control Programme
(RNTCP) has been introduced in India. A $150
million soft loan from the World Bank has been
negotiated. This is conditional to using the WHO
package prescription. A key element in this is the
Direct Observation Treatment, Short CourseChemotherapy (DOTS) in which health workers
have to watch patients swallowing their pills three
times a week, for at least two months, out of a six
month treatment.
There are doubts about the feasibility, sustainability and ethics of such an approach. Being entirely technical it does not consider the social and environment roots of the disease. Hence it ignores social
and community dimensions within which any tech
nical package needs to be embedded. This would
include personal, social support to affected people
and their families. It would also recognise development organisations and activists as partners. Most
importandy, it would address the question of social
and economic inqeuality and injustice. It also
assumes that the health system will “deliver’ the
RNTCP and does not try to understand the reasons
why the NTP did not fulfil expectations.
! • H — ;
Thelma Narayan is member-in-charge of research and
evaluation at the Society for Community Health, Awareness,
Research and Action, Bangalore.
*
THE HINDU SURVEY OF THE ENVIRONMENT *»7
I
j)/5 4 '22
Cotild Tuberculosis be a Psycho-somatic digease^-an alternative view
^T^odified version of thej article,
article, "Can
"Can stress
stress cause disease?
Revisiting the tuberculosis research of Thomas^
Thomas Holmes;,
Huhnes
1949-1961.
'• >3
Barron
Internal
Barron H
H Lerner.
Lerner. Annals
Annals of
of -----— Medicine 1996;124.673 680.
Robert Koch’s discovery of M. tuberculosis in 1882 proved that
tuberculosis was an infectious disease. However the introduction of
skin testing in 1908 showed that many more persons were infected wit
the bacillus than acutally had the disease.
In. 3
^th ?B
surveys show that one-third of all people are infected with TB
(primary tuberculosis), Only a small proportion of people reactivate
the disease in adulthood (secondary tuberculosis). The factors that
have been identified that lead to the spread and occurrence of disease
are urbanisation, overcrowding, poor housing, unhealthy working
conditions, specific occupational exposures, immunosuppression and
undernutrition.
Many, of these factors are thought to act by
increasing the risks of air borne transmission. However if_m°st of the
adult tuberculosis is due to endogenous reactivation, how do the above
factors facilitate this reactivation process.
.
A large amount of TB research today is focussed on the immune
response; why do only a few people develop tuberculosis why do ^ople
respond differently to treatment. An, area of research which is ignore
in current literature is 'psycho-somatic research in tuberculosis.
Rene Dubos, and other early TB researchers discussed that the issue of
stress was closely related to theconcept of resistance to
tuberculosis. But with the focus on the germ and therapeutics, these
ideas have not been pursued.
■ "
Thomas Holmes was a pioneer in psychosomatic research credited
for showing the relationship between stressful life events and disease
in general, and his work became the cornerstone of modern mind-body
research
He started his work on psycho-somatic research, as a
physician in a United States TB sanatorium ;in 1949 exploring the
relationship between stress and tuberculosis. Although he lacked the
sophistication of modern epidemiological techniques, several of his
studies showed that persons who had experienced stressful situations
such as divorce, death of spouse, a loss of a job were more likely to
develop tuberculosis and less likely to recover from it. He devised
numeric scales that quantified stressful events and did prospective
studies with control groups (some of his work is summarised below).
Although Holme's work was rudimentary, and open to scientific
criticism his basic contention may have been correct.Holmes was
well regarded among his colleagues qnd his work received governmental
funding. His scientific findings however were not necessarily
accepted. This may have been because the focus at that time jjjas on the
'germ' and TB treatment was believed to be causing a major decline in
the disease prevalence.
He left TB research in 1962 and his
subsequent work was published in psychosomatic journals.
Holmes also emphasized the need to understand each patient
The following is a discussion of a 29 year old black
holistically.
woman at a case presentation:
. . .2
2
At this point in her life, the man she later married returned
from war service to the small town in Louisiana, and after a month of
superficial acquaintanceship they were married,
The marital
adjustment was always poor .... She spoke of herself as "not a
hotblooded woman" who preferred church activities.
Her husband
preferred sports and parties. She resented the fact that he was not
a good provider and stated, "My father built a good home for my
mother.
Here we are packed in; I need my own home".
The husband
chose Seattle as a place to live, and in 1946 they moved here. . . . The
patient always resented the separation from her family and stated, "I
always keep the far home available".
Holmes then explained why this .particular woman had become
tuberculous : "It was in the setting of unfulfilled dependency needs,
and an increasingly strained marital adjustment in a new and
unsympathetic environment, that the patient developed pulmonary
tuberculosis " .
This analysis recalled the holistic approach to
psychosomatics that placed disease in the context of a patient’s
personal history.
The contention of this article is not that Holme’s work proved
the link between stress and tuberculosis,, but that the body of his
research has been completedly ignored in contemporary tuberculosis
literature.
His research and his presentations sought to challenge
the standard model of the disease as a straightforward infection.
"Although infection with the bacillus was necessary, tuberculosis
could not be understood without recognition of the etiologic role
played by underlying personalities and stressful situations".
The
research agenda that he initiated, has remained unworked on since that
time.
While Holmes developed a sophisticated model of tuberculosis as
a psycho-somatic disease1, he had little say about its prevention and
treatment. Of course one way to alleviate stress among poorer people
would have been to provide them with better jobs, housing and
nutrition. However like most contemporary medical people he advocated
educating people how to anticipate stressful events and thus adjust to
them better.
The fate of Holmersswork is not unusual, Although we know that
tuberculosis is a disease with social and environment roots, our
technical solutions ignore this.
Could the various factors that we
are discussing, urbanisation, overcrowding, poverty mediate some of
their
influences through stress ?
Is there a different way of
looking at the same problem ?
Summary of Thomas Holmes work of tuberculosis
* In a study of 109 sanatorium residents Holmes found that patients
who had localised resolving tuberculosis, were anxious and had normal
or high urinary ketosteroid levels, whereas those with
. . .3
3
advanced and deteriorating TB were depressed and had low urinary
ketosteroid level.
* In a study of Seattle residents* he found that the disease
predominated in areas where there were poorer and non-white people.
* To understand the effect of emotional stress and difficult social
relations, he interviewed 100 patients admitted to the Seattle
sanatorium. He found that 71 % had experienced financial hardship, 52
% job dissatisfaction,
31 % met criteria for alcoholism and that
these factors clustered in the 2 years preceding the admission.
* He did the same study using a control group and a interview schedule
which he devised to measure the previous occurence of psychosocial
stress (Schedule of Recent Experience).
He compared 20 matched
sanatorium employees who developed TB and those who did not and found
disturbing occurences more frequently in the preceding two years of
tuberculous employees alone.
He also assessed
their "emotional
integration" by a different scale and found that the TB employees were
more frequently "pathologically disturbed".
* In the next study he used a partially prospective design, comparing
patients who redeveloped sputum positivity on treatment after 3 months
of sputum negativity (21 patients), to patients who remained sputum
negative (24 patients) .
He found that those who had "thrown a
positive" faced emotional problems during hospitalisation and had long
histories of unstable lifes, lack of social,economic and family
supports. Based on this data, he devised a new instrument to measure
the level of emotional disturbance which predisposed to "throwing a
positive". He re-analysed the baseline psychological difficulties of
10 controls using his instrument. On this basis he predicted that two
of the controls on followup would "throw a positive’ and his
prediction actually came true.
* His final major study titled "Experimental study of prognosis’ used
the Berle Index, an instrument that identified psychological and
social factors characteristic of recovering patients. A high Berle
score predicted recovery from the illness. He prospectively studied 41
randomly selected newly detected tuberculosis patients. After five
years followup, among the 26 who had achieved a normal or high Berle
score, there were no treatment failures.
However five treatment
failures occurred among fifteen patients who had low Berle scores.
Could Tuberculosis be a Psycho-somatic disease : an alternative view
point
( A modified version of the article, ’’Can stress cause disease?
Revisiting the tuberculosis research of Thomas Holmes, 1949-1961.
Barron H Lerner. Annals of Internal Medicine 1996;124:673-680."
Robert Koch’s discovery of M.tuberculosis in 1882 proved that
tuberculosis was an infectious disease. However the introduction of >
skin testing in 1908 showed that many more persons were infected with
the bacillus than acutally had the disease.
In India skin test
surveys show that one-third of all people are infected with TB
(primary tuberculosis). Only a small proportion of people "reactivate1
the disease in adulthood (secondary tuberculosis). The factors that
have been identified that lead to the spread and occurrence of disease
are urbanisation, overcrowding, poor housing, unhealthy working
conditions, specific occupational exposures, immunosuppression and
undernutrition.
Many of these factors are thought to act by
increasing the risks of air borne transmission. However if most of the
adult tuberculosis is due to endogenous reactivation, how do the above
factors facilitate this reactivation process.
A large amount of TB research today is focussed on the immune
response; why do only a few people develop tuberculosis, why do people
respond differently to treatment. An area of research which is ignored
in current literature is "psycho-somatic research’ in tuberculosis.
Rene Dubos, and other early TB researchers discussed that the issue of
stress was closely related to the concept of resistance to
tuberculosis. But with the focus on the germ and therapeutics, these
ideas have not been pursued.
Thomas Holmes was a pioneer in psychosomatic research credited
for showing the relationship between stressful life events and disease
in general, and his work became the cornerstone of modern "mind-body1
research.
He started his work on psycho-somatic research as a
physician in a United States TB sanatorium in 1949 exploring the
relationship between stress and tuberculosis. Although he lacked the
sophistication of modem epidemiological techniques, several of his
studies showed that persons who had experienced stressful situations
such as divorce, death of spouse, a loss of a job were more likely to
develop tuberculosis and less likely to recover from it. He devised
numeric scales that quantified stressful events and did prospective
studies with control groups (some of his work is- summarised below) .
Although Holme’s work was rudimentary, and open to scientific
criticism, his basic contention may have been correct,
Holmes was
well regarded among his colleagues and his work received governmental
funding. His scientific findings however were not necessarily
accepted. This may have been because the focus at that time was on the
"germ1 and TB treatment was believed to be causing a major decline in
the disease prevalence.
He left TB research in 1962 and his
subsequent work was published in psychosomatic journals.
Holmes also emphasized the need to understand each patient
holistically. The following is a discussion of a 29 year old black
woman at a case presentation:
. . .2
2
At this point in her life. the man she later married returned
from war service to the small town in Louisiana, and after a month of
superficial acquaintanceship they were married.
The marital
adjustment was always poor .... She spoke of herself as "not a
hotblooded woman" who preferred church activities.
Her husband
She
resented
the
fact
that
he was not
preferred sports and parties.
good
home
for my
a good provider and stated, "My father built a
mother.
Here we are packed in; I need my own home".
The husband
chose Seattle as a place to live, and in 1946 they moved here. . . . The
patient always resented the separation from her family and stated, "I
always keep the far home available".
Holmes then explained why this particular woman had become
tuberculous : "It was in the setting of unfulfilled dependency needs,
and an increasingly strained marital adjustment in a new and
unsympathetic environment, that the patient developed pulmonary
tuberculosis " .
This analysis recalled the holistic approach to
psychosomatics that placed disease in the context of a patient1s
personal history.
The contention of this article is not that Holme’s work proved
the link between stress and tuberculosis, but that the body of his
research has been completedly ignored in contemporary tuberculosis
literature. His research and his presentations sought to challenge
the standard model of the disease as a straightforward infection.
"Although infection with the bacillus was necessary, tuberculosis
could not be understood without recognition of the etiologic role
played by underlying personalities and stressful situations".
The
research agenda that he initiated, has remained unworked on since that
time.
While Holmes developed a sophisticated model of tuberculosis as
a 'psycho-somatic disease’, he had little say about its prevention and
treatment. Of course one way to alleviate stress among poorer people
would have been to provide them with better jobs, housing and
nutrition. However like most contemporary medical people he advocated
educating people how to anticipate stressful events and thus adjust to
them better.
The fate of Holme'sswork is not unusual. Although we know that
tuberculosis is a disease with social and environment roots, our
technical solutions ignore this.
Could the various factors that we
are discussing, urbanisation, overcrowding, poverty mediate some of
their
influences through stress ?
Is there a different way of
looking at the same problem ?
Summary of Thomas Holmes work of tuberculosis
* In a study of 109 sanatorium residents Holmes found that patients
who had localised resolving tuberculosis, were anxious and had normal
or high urinary ketosteroid levels, whereas those with
. . .3
3
advanced and deteriorating TB were depressed and had low urinary
ketosteroid level.
* In a study of Seattle residents* he found that the disease
predominated in areas where there were poorer and non-white people.
*
To understand the effect of emotional stress and difficult social
relations, he interviewed 100 patients admitted to the Seattle
sanatorium. He found that 71 % had experienced financial hardship, 52
% job dissatisfaction,
31 % met criteria for alcoholism and that
these factors clustered in the 2 years preceding the admission.
* He did the same study using a control group and a interview schedule
which he devised to measure the previous occurence of psychosocial
stress (Schedule of Recent Experience).
He compared 20 matched
sanatorium employees who developed TB and those who did not and found
disturbing occurences more frequently in the preceding two years of
tuberculous employees alone.
He also assessed
their "emotional
integration" by a different scale and found that the TB employees were
more frequently 'pathologically disturbed".
* In the next study he used a partially prospective design, comparing
patients who redeveloped sputum positivity on treatment after 3 months
of sputum negativity (21 patients), to patients who remained sputum
negative (24 patients).
He found that those who had "thrown a
positive" faced emotional problems during hospitalisation and had long
histories of unstable lifes, lack of social,economic and family
supports. Based on this data, he devised a new instrument to measure
the level of emotional disturbance which predisposed to "throwing a
positive". He re-analysed the baseline psychological difficulties of
10 controls using his instrument. On this basis he predicted that two
of the controls on followup would 'throw a positive’ and his
prediction actually came true.
* His final major study titled 'Experimental study of prognosis’ used
the Berle Index, an instrument that identified psychological and
social factors characteristic of recovering patients. A high Berle
score predicted recovery from the illness. He prospectively studied 41
randomly selected newly detected tuberculosis patients. After five
years followup, among the 26 who had achieved a normal or high Berle
score, there were no treatment failures.
However five treatment
failures occurred among fifteen patients who had low Berle scores.
ZPis A :
q^ekicaN Journal ok Ei*ii>hmioi.o<;v
It’Copyright © 1975 by The Johns Hopkins University
Vol. 102. No. 2
Printed in U.S.A.
TUBERCULIN SENSITIVITY I'IN u,?IGH’riSK canine
POPULATION
w. R. SNtDER,. D. COHEN. J. S. REIF. s. c. STEIN?
&
Snider, W. R., D. Cohen, J S R f (q
Pennsylvania, Philadelphia, PA 19174)
Vetennary Medicine, U. of
sensitivity in a high.risk canine
-J’
TUb—1975.—An epidemiologic study of tuberculost in d
' 102:1S5-1S0.
with recently reported tuberculosis was undertak
9SD<’xpos<*d “> humans '
July 1966 and June 1968. A total of 29 doos m t ln phdadelphia between
in the high-risk population were studied b history"^‘ .Cr,.,eria ,or inclusion
tradermal tuberculin tests and radin
h,storY^ physical examination, in-
tture
.„
»dog,,bj:dx,
(USDA) standard
7.‘x.“£r**
second strength PPD
USDA mammalian i
«. Bb,si„L
evidence of tuberculosis
In a comparison group of 70
two positive responses .. vsoa .bb.reubn
PPD.
‘
,.dus,.pb*c’;r'“"“"d,“ “
'°z
““
dog diseases; epidemiology; tuberculin tost; tuberculosis; zoonoses
•!
Despite intensive
intensive efforts
enorts aimed
aimed at con
trol and eradication, tuberculosis continues to represent an important disease of
Dogs and cats living in close association
man m the United States, especially in
urban areas. In the United States approxi with active cases of human tuberculosis
extraordinary exposure to this dismately 37,000 new active cases were re
ported in 1970 (l),In Philadelphia, Penn- ease and represent a population of animals
sjlvama, a large, urban community, ap- at high risk. In an investigation of appar
pfOi“mately 900 new active cases are re- ently healthy canine and feline contacts of
tuberculous patients by Hawthorne and
r^fXeMa"hPl(M975>n MarCh ‘2’ 19741 and in Lauder in 1962 (3). Mycobacterium tuberculosis was recovered from seven of 48
exposed
dogs and cats examined by cultur
I tuberCulin; ppD purified
pr«ein derivative; TU. tubercull^t’
---------ing rectal and pharyngeal swabs. Twenty.. .
---------3, School
tional1 canine tand feline contacts
Studies.
Schooi two addi-------University of Pennsylvania, of tuberculous patients werp i
mests tz>
Hr Reif'at.thai
D„.r
..
were (examined by
•ddres.)4' <Reprint ^quests
to Dr.
BCG intradermal testi
. ----- :s and 11 (50 per cent)
A“ Brant from Pennsylvania were ound positive. Ten of these 70 animal
9S Department
the U-S-A-P-H.I.S.,
tWV6 °btained for aut°Psy and one
H«hh SeX Tr/ Agr,aulturei “nd by US Public h°d
0^0^
h r°S1C f‘ndingS °f tuberCdlosis.
•Formertv- TP "L"* Gr,ant 11 GM 975Anient o aLVuI. ’’a giSt' A P H I-S-- US De- Other investigators have documented simiin August 1973! e'
n' Texas' Dr- Snider
ar instances of canine and feline tubercu
I ,h7aXaelAddreSS: University of ‘he Negev. Beer- losis; aetjutred from human patients (4-6)
The role of the dog and cat as potential
’fetment1
ity °f Phjladelphia.
(
reservoirs of bovi
• me tuberculosis on PennHealth, State of Pennsylvania.
sylvania farms
was recently described (7).
■
r
14-.
(*
185
ii;:-
I
J
Birr
fflll
186
|
Is
Ill?"f1
,1*1 I'I
1
irii
111
fl I 41
w
i
11
II I
rj’.
■
ii
!
ui
’I
i
j
Vi'’
I- ! |
fe
ns! '
Two or three types of tuberculin wereSKi
administered simultaneously using 0.1
of each antigen at separate sites. Unite4^^^^
States Department of Agriculture (USDA)^<||
standard mammalian tuberculin (aPPmxi-|L7|
mately 15,000 TU) and second testjdj*
strength purified protein derivative (PPD)S#r
in dogs.
(Parke Davis and Co.) (250 TU) were
Materials and methods
ployed routinely. Old tuberculin (0T)g||
Dogs from Philadelphia households in
Davis and Co.) (250 TU), was^Oi
which patients with active tuberculosis (Parke
employed as the third antigen in 12 cases.^^|^
had recently been discovered were chosen Animals with induration of 5 mm or greater||lj
for study. The animals were identified by
at 48 hours were considered positive.
?
the Tuberculosis Control Section of the
3) Radiographic studies: Chest radioPhiladelphia Department of Public Health
’ > were made of each animal in theBlW
Upon finding a dog in the home of a newly grap
dorsoventral and left recumbent positions.
reported case of human tuberculosis, the
4) Bacteriologic studies: Swabs of theW^U
public health nurse referred the animal,s caudal pharynx (or larynx) and rectum^B
owner to the investigators. The owner s were taken for culture and placed in sterileW®
cooperation was solicited by telephone call
tubes containing 0.5 cc saline. At necropsy,
or personal interview. A comparison group selected tissues from lung and lymph nodes^g
consisted of dogs without known exposure
admitted to (mesenteric, sub pharyngeal, and bron«|
to tuberculosis which were a-------;
collected for Ziehl-Neelsen|
the University of Pennsylvania Veterinary chial) were
staining and mycobacterial culture.
Hospital. The comparison group consisted
Samples were processed according to|
of routine hospital admissions. Animals recommendations of the National Tuber-f^1
which were critically ill or appeared to be
Associa-.
culosis and Respiratory Disease Associa^®;
in the terminal stages of diseases were not tion (9). Cultures were kept under observa-Mjp
tion (9). <
tion for eight weeks. Mycobacterial growl,h§B;
tested.
The following diagnostic procedures was identified
identified and
and classified
classified by
by biochemil
biochemlgB
were performed on all dogs:
cal tests and growth characteristics^
|g gcharacteristics.
1) History and physical examination: A
During the period of this study (July 1^^,,
history of each' animal was taken and Wee^to June 30, 1968) the number of^
2 OU, lauo; bixc
-recorded. Special attention was given to
active cases of human tuberculosis in
the type, degree and duration of known adelphia was reported to be approximated
exposure to tuberculosis. To evaluate this 950 annually (10).
.
i
exposure, histories of associated human
Sixty patients with tuberculosis Kom
patients were also recorded. Information Philadelphia or their families were inter|
concerning human patients was provided viewed to request permission for exal^M
by weekly morbidity listings of newly dis tion of their dogs. Forty ownersJ6/n!$
covered cases of human tuberculosis in cent) cooperated. Ten dogs brough
Philadelphia (8). The listings included re clinic were excluded because of insutnci
ports on the patient’s bacterial status and
incoi
exposure to active tuberculosis or
disease activity.
plete examination.
2) Intradermal tuberculin test: IntraderroforroH hy fl veterinary
Concurrently, urban dogs exposed to hu
mans with active tuberculosis were exam
ined. An evaluation was made of various
diagnostic procedures, particularly skin
tests, as case finding tools for tuberculosis
11
'll
-1
SNIDER, COHEN, REIF, STEIN AND FRIER
i
ilI
i
(jl 11M11XMX*
---------
u
i-
I
I®'
itt "■
I
l'
TUBERCULIN SENSITIVITY IN A CANINE POPULATION
®st organisms in pulmonary and medias- tuberculin with induration and erythema
'tinal lesions of metastatic squamous cell ranging from 10 to 30 mm. Five of these 10
Carcinoma and has been described else positive responses were supported by si
multaneous reactions to PPD. In the other
where (11)Twenty-four of the household pets were five, doubtful or negative responses to PPD
l^^exposed to patients with active pulmonary occurred. Two of three dogs in this group
j^B'Hisease in which tubercle bacilli had been tested with OT responded with induration
’“’'. ^ isolated from sputum samples sometime and erythema of 10-17 mm. Both of the OT
during their illness. In the other five dogs positive animals reacted simultaneously to
(T 602, 604, 606, 620, 622) exposure was USDA and PPD tuberculin. The 19 dogs
either to individuals with active disease in that were negative to USDA tuberculin
areas of the body other than the lung or to were also negative to PPD and 10 of these
Inpatients with quiescent pulmonary disease 19 tested with OT were similarly negative,
^in which acid-fast bacilli were not re- Erythema without induration was occart^’?)vere^’
sionally noted in response to one or more
I f^The dog’s contact with the patient also antigens and was considered to represent a
^^ivaried. In some cases intimate association negative reaction.
$®was reported in which dog and patient
Table 1
/.•$: shared the same room and were constant
• companions. In one case (T 647) the dog Comparison of intradermal tuberculin test results iiin
had frequently ingested his tuberculous 29 dogs exposed to human tuberculosis (Uniuersity of
Pennsyluania. July 1966-June 1968)
owner’s sputum. In another instance the
Tuberculin test results
contact between pet and patient was de
scribed as casual and infrequent.
Animal
USDA
No.
Results
I
I
187
No signs of clinical illness were detected
in any of the 29 dogs examined. Radio
graphic examination revealed no evidence
< of pulmonary tuberculosis. Attempts to
isolate Mycobacteria by culture of rectal
and pharyngeal swabs were also unsuccess
ful. In one tuberculin reactor which was
;; ^euthanized and necropsied no gross or
histologic evidence of tuberculosis was
found.
|
Comparison of intradermal tuberculin
resu^ts *n d°*s exposed to human
is Presented in table 1. The
ra^es f°r tuberculin sensitivity in
d°£S tested were 34.5 per cent for
Rppn tuberculin and 17-2 Per cent for
fewith* n.tbe 24 dogs exPosed to patients
active pulmonary disease the rates
Offlere. 41.7
fBuL
602
603
604
605
606
607
614
615A
615B
615C
616
619
620
622
624A
624 B
628
633
639
640
641
647
648
649
651
652
656
658
660
mammalian
PPD
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Pos. (15 mm)t Neg.*
Neg.
Neg.
Pos. (20 mm)t Pos. (8 mmlt
Pos. (25 mm)t Neg.t
Pos. (30 mm)t Neg.i
Neg.
Neg.
Neg.
Neg.
Pos. (20 mm)t Pos. (10 mm)t
Neg.
Neg.
Neg.*
Neg.
Neg.
Neg.
Pos. (20 mm)t Pos. (15 mm)t
Pos. (10 mm)t Neg.
Neg.*
Neg.*
Neg.
Neg.
Neg.
Neg.
Neg.
Neg.
Pos. (20 mmlt Pos. (10 mm)t
Pos. (15 mmlt Pos. (10 mm)t
Neg.
Neg.
Neg.
Neg.
Neg.*
Neg.
Neg.*
Neg.
Pos. (10 mmlt Neg.*
Neg.*
Neg.*
Now
Nee.*
*
5
r
L
i.
i!
(
OT
Neg.
Neg.
Neg.
Pos. (15 mm)+
Pos. (17 rjim)+
Neg.
Neg.
Neg.
Neg.
Neg.*
Neg.*
!
I
188
I?!
-
L
jrl
1 -
I
I
I
|
(
SNIDER. COHEN. REIF. STEIN AND PRIER
fl
source population of approximately 19^
new active tuberculosis cases for the
year period of this study were solicited
present their dogs for examinations. Con-Wg
servative estimates of the dog PopulaticQ^g
in Philadelphia indicate the 60 owners®
interviewed represent ^approximately 14W
per cent of the patients with active tuber'.'®- .
culosis who owned dogs. These figures arefl
based on data presented by Cohen et al.® .
(13) in which the licensed dog to human]
ratio in densely populated metropolitan ]
areas adjacent to New York and Philadel-1
phia was reported to be approximately^
1:15. Assuming that each new active case i
of tuberculosis in Philadelphia was from a I
different household and the average f i;
Discussion
We know of no efforts in the United household contains 3.5 persons (US Census 1
States, prior to this investigation, to sys figures), the total human population in the W
tematically examine canine contacts of household of 1900 new active cases of >
human patients with active tuberculosis. tuberculosis would be approximately 6650 B ’
The only records available concerning the persons. A dog to human ratio of 1:15 |
’ - in
‘
would suggest that during the two years of *
prevalence of mammalian tuberculosis
Pennsylvania dogs were those at the Uni- this study approximately 443 canine conversiity of Pennsylvania Veterinary Hospi- tacts of active human tuberculosis existed .
tai, Philadelphia. During the two-year pe in 1900 Philadelphia households of which |
riod of this study one case of tuberculosis 60 or 13.5 per cent came to the attention of t
this study. Of the 60 owners, 20 were |
was recorded in a dog, unrelated to the
>,
investigation. Only three cases, all in dogs, uncooperative and 11 additional pets were /
have been found during the last 15 years att excluded from the study because they did
this hospital among approximately 75,000 not meet selection criteria of this high-risk |
population. In the final analysis, 29 dogs
patients.
owned
by 29 patients were studied. The
The incidence of tuberculosis in man
dogs
examined
thus represent approxicontinued to decline in Philadelphia dur
mately
7
per
cent
of all dogs
- estimated . to ■
ing the period of this study, but at a i------ - <- .1
1 --------------------------- m Dkila.
decreasing rate when compared to figures be owned by tubercuious PaUef^s;
stable delphia during the two years of this study. J
for previous years. The increasingly
i
Tuberculosis was not demonstrated in
tuberculosis rate in Philadelphia was evi
these
29 dogs. No evidence of tuberculosis r
dent in yearly reports of new active tuber
was detected either clinically or radio-jj
culosis cases.
graphically. Attempts to isolate Mycobac-1
In successive years of 1966 and 1967
teria by culture of rectal and pharyngeal |
approximately 950 new active tuberculosis
reported annually (10). This swabs from the 29 dogs were unsuccessful-1
cases were J .
figure represents a rate of 46/100,000 popu In an earlier study of dogs.and cats exposea |
_____
to patients with active tuberculosis, direct
lation. Among cities in the United States,
incidence
of
Philadelphia ranked 14th in L.--------- — culture of rectal and pharyngeal swabs on |
either Lowenstein or Dorset egg media J
tiihp.rciilosis in 1966 (12).
Comparison group. Two tuberculin posi
tive dogs were found in 70 hospitalized
animals tested. The positive responses
were to USDA tuberculin only. Simultane
ous tests with PPD and OT were negative
in the two reactors. No evidence of tuber
culosis was observed either in the two
reactors or in the other 68 hospital dogs on
routine clinical examination. When results
of tuberculin tests in this group were com
pared to results of the test in the urban
dogs owned by patients with active tuber
culosis, a significant number of high risk
'
positive to intradermal
dogs
wereJ found
1
tuberculin tests (x2 = 15.521, p < .001).
K
i'f
i■
TUBERCULIN SENSITIVITY IN A CANINE POPULATION
189
f^^lent human tubercle bacilli from 48 dogs. In general, there was agreement in
^posed dogs and cats (3). In the present the results obtained with these tuberculins,
'Study, swab specimens were treated with 4 as demonstrated by simultaneous testing
Recent sodium hydroxide solution before of the same animal.
f •’ ’
on Lowenstein’s media. This
inoculation
Because of the high concentration of
Eeatment was employed to reduce the USDA tuberculin, approximately 15,000
-KO^number of saprophytic bacteria, but may TU/0.1 cc, an atypical inflammatory reac
W^^also have been toxic to mycobacteria if tion was occasionally observed. This reac
3^7^'they were present in the specimen.
tion, however, was distinguishable from
Tuberculin tests on canine contacts of the induration and erythema of a true
' tuberculous patients in this study indicate positive response. Atypical inflammatory
;T ■* that the reactor rate in this group is signifi- reactions to PPD and OT were observed
Scantly higher than reactor rates in dogs less frequently than to USDA tuberculin. A
W; >from a general population. One-third of the true positive response to PPD and OT was
V "dogs in the high-risk population were posi- also accompanied by induration and ery
live to tuberculin. This rate is less than thema. The diameter of the true positive
T■"■'***that found in Glasgow dogs and cats with response was greatest for USDA tuber
& ■'•‘similar exposure in which 50 per cent were culin, intermediate for OT and smallest for
positive to BCG (3). Since BCG was not PPD.
employed here, a comparison of reactor
Although precise determination of the
rates in the two studies is not possible. sensitivity and specificity of each of the
However, a comparison group of dogs with tuberculins employed is not possible, it
out known exposure to tuberculosis was would appear that USDA mammalian tu
tuberculin tested as well as dogs from the berculin may have higher sensitivity
high-risk environment. The reactor rate of and/or lower specificity than PPD or OT at
34 per cent in the high-risk group was the concentrations employed.
found to be significantly different from the
The findings in this study and a similar
3 per cent reactor rate found in the compar one conducted in Scotland (3) have pro
ison group.
vided evidence that- canine contacts of
A higher reactor rate was found in con human tuberculosis are influenced biologi
tacts of patients with active pulmonary cally by their exposure. In the Glasgow
tuberculosis than in contacts of patients
investigation both the increase in reactor
with extra-pulmonary or quiescent disease.
rates to BCG and the recovery of virulent
Though limited by small numbers the
human tubercle bacilli from pharyngeal
difference supports a hypothesis that infecand
rectal swabs indicated that the dog
lion
-i was transmitted by droplet nuclei or and cat may be involved in the epidemiol
in,‘gestion of sputum.
ogy of human tuberculosis. Although ac
No standardized irecommendations
’ •
for tive disease or viable tubercle bacilli were
tuberculin 1testing exist for a dog. Systemnot recovered from canine tuberculosis
atic studies
'3 to compare the sensitivity contacts in the present study, the reactor
and rspecificity
—-r'
- various tuberculins
ofn the
rates to tuberculin in dogs approximated
^ployed in field studies’ hTve*
perform^ mu " /------- nOt been the findings of the Glasgow study. These
^iiurmea. lherefore several
r
’ antigens
/ __ disclosures
” ‘
should furnish sufficient evi
Were emPloyed in this population at the
dence that dogs living in contact with
concentration normally available for field
persons with active tuberculosis must be
e- USDA tuberculin and concentrated
considered as alternate hosts and potential
•; . .^ngths ofPPD and OT were found tn
raeorvmrc for Unwins
1-------- : 11:
. b-!i...
i
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!
SNIDER, COHEN, REIE. STEIN AND PR1ER
190
I
lie Health, City of Philadelphia, 1970
be examined and dealt with utilizing the 3. Hawthorne
VM, Lauder IM: Tuberculosi^^^^^
same principles which apply to other mem
man, dog and cat. Am. Rev Respir Dis
bers of the patient’s family.
1962
We recommend that clinically affected 4. Stableforth AW: A bacteriological investigatiou^®
cases of tuberculosis in 5 cats, 15 dogs, a parro^Wl
dogs be euthanized because of their public
and a wallaby. Journal of Comparative Patholo„';?M
health risk. However, we are faced with a
and Therapeutics 42:163, 1929
much more difficult problem in determin 5. Hjarre A, Herlitz CW: Danger to man of tuber^^B
losis in dogs and cats as sources of tuberculosishfiOs
ing what to do with exposed, sensitized,
man. Acta Tuberc Scand 13:103, 1939
but clinically normal pets. These animals
should be kept under surveillance to evalu 6. Lovell R, White EG: Tuberculosis in dogs. I. Hr
Tuberc 34:117, 1940
ate their public health significance. In view 7. Snider WR, Cohen D, Reif JS, et al: Tuberculos^gl
of the rarity of tuberculosis sensitivity^ .
in canine and feline populations. Study of highfS®
risk populations in Pa. 1966-1968. Am Rev Respir^f
the total canine population it would per
Dis 104:855, 1971
haps be worthwhile to consider drug ther
apy (e.g. isoniazid) in tuberculin-positive 8. Division of Statistics And Research, Philadelphi^^^
Department of Public Health
contacts. This could be justified on the 9. Diagnostic Standards and Classification of Tu.W
basis that, since we do not know the time of
berculosis. New York, National Tuberculosis
tuberculin conversion in the case of the pet
sociation. 1961
animal, each tuberculin-positive animal 10. Annual Tuberculosis Report. Department of Pub^B
lie Health, City of Philadelphia. 1967
should be considered as a recent converter
11. Reif JS, Snider WR, Kelly DP, et al: Caviiauai|g
and treatment instituted to abort the de
pulmonary metastases in a dog: A case report.
velopment of progressive disease.
Am Vet Radiol Society 10:12, 1969
References
1. Morbidity and Mortality. Annual Summary 1970.
Center for Disease Control, Atlanta, GA
2. Annual Tuberculosis Report. Department of Pub-
12. Reported Tuberculosis Morbidity (1966), Publi-Ml
cation No 638, 1968
13. Cohen D, Booth S, Susman 0: An epidemiologi-W
cal study of canine lymphoma and its public^
health significance. Am J Vet Res 20:1026,1959 yj
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