OUTLINE OF A DISTRICT TUBERCULOSIS PROGRAMME
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- OUTLINE OF A DISTRICT TUBERCULOSIS PROGRAMME
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Reprinted from The Indian Journal of Tuberculosis June 1962
q
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OUTLINE OF A DISTRICT TUBERCULOSIS PROGRAMME*
M. A. Piot (JI7/O Medical Officer, NTI Bangalore)
% c^>^u 'r
Introduction
The present paper outlines the organization
of rural tuberculosis control within the framework of the National Tuberculosis Programme.
As such it does not deal only with the problem
of bringing relief to individual patients’
sufl'ering, but with an attempt at controlling
tuberculosis as a communicable disease in the
social context uf today's India. By tuberculosis control is meant the reduction, over a span
of years, of the problem of tuberculosis, as
expressed by the prevalence of the disease.
A reasonable target for control jjught be a
1 50 per cent reduction in prevalence of excrctors
I of tubercle bacilli over a period of 20 years.
How far the suggested programme may lead
to control in the above terms would have to be
assessed by use of epidemiological-mathe
matical methods.
In defining the organizational approach to
rural control one has to consider the medical
aspects of the programme against the back
ground of the socio-economic development of
the country, and to strike a balance between
what is technically desirable and what is oper
ationally (including financially) feasible. The
programme is conceived in successive develop
mental stages, each of them in harmony with
the other developmental activities under way
in the rural areas (under the Community
Development Scheme). Stress is laid on the
“organization, throughout the District, of drug
distribution and treatment follow-up agencies
as the first and forc.niq§L responsibility of the
programme ;^it
programme
;<
is argued pthat the awareness
Ljrf" TB as obscrv'Sd-fSdXy
obser'vfeiPtS’d^' in individuals and in
the community provides an adequate basis for
•
1
i•
i r
.•
case-finding, if all the rural medical facilities,
put
to
contribution.
hither-to unused, are
Immediate, general use of microscopy as a
diagnostic tool is emphasized; X-ray referral is
considered a subsequent development. The
important elements of the plan are thought to
be (a) the highest possible degree of integration
of the tuberculosis programme into the
1' general
_
’
public health services (especially the Primary
Health Units) and (b) the maximum participa- i
tion of the local Government (PsficKayats)
and
the Community Development Depart
ment. This implies a changed pattern in the
tuberculosis specialisms’ ^efd oLactiob from the
clinical level to essentially advisory, co-ordinat
ing and supervisory functions.
Facts and figures about the district
The present outline is drawn with an
average Indian district in mind. The pro
gramme defined below is dealing with a popu- 2.^4
lation of 12 lakhs, of which at least 10 lakhs
live in some 2000 villages.
The National Sample Survey has shown that
the prevalence of tuberculosis as defined by
the proportion of radiologically active on the
one hand, and of bacteriologically confirmed
on the other hand, average 1.8 per cent and 0.4
per cent respectively. This is the best estimate
of the prevalence of tuberculosis in any Indian
district. Based on these prevalence figures,
the caseload in a district maybe estimated to be
at least 20,000 radiologically active cases, of
whom nearly 5000 are confirmed bacteriologically at any point of time. Of these, over ‘
80 per cent are to be found in the district’s
villages, another 5-10 per cent in the district
headquarters town and the rest in taluk
headquarters.
a
The rate at which new cases occur is not/"1
known but the yearly incidence could be
estimated to be in the order of 1/5 of the total
existing at one point of time. This would mean
that over 4000 newxadiological cases occur every
year of whom nearly 1000 would be confirmed
bacteriologically.
The facilities available in the District
Most districts are in a fairly advanced stage
of development under the National Extension
Scheme: the figure of 8-10 blocks already
available in 1961 would be representative of
most districts. This number is to be increased
during the Third Five Year Plan, thus bringing
every district to full development stage within
* Paper used for discussion in the Panel discussion on TB Control in India at the 18th Conference of
TB and Chest Diseases Workers in Bangalore, January, 1962.
1
agencies which so far have not dealt with
tuberculosis, ~anci^one specialised agency viz., - ‘ V
the TB centre now being implemented, to
which TB beds, if any, and BCG teams will
be attached.
1965. It may be estimated therefore that at
present 10 Primary Health Units are available
and that this number will increase to the ulti
mate target of 16-18 within the forthcoming
years.
Prior to the National Extension.- Scheme,
health services had been developed on the basis
of taluks tehsils. The present day districts
riTn"dn an average 10 taluk/tehsils hospitals
and a District headquarters' hospital, frequently
with a limited number of TB beds attached.
Taking rural dispensaries into account there
are often 30 medical institutions with a M.O.
in attendance.
The tuberculosis centre envisaged under the
National Tuberculosis Programme is now
added to these facilities. Its buildings, staff
and equipment pattern have been defined in the
Second Five Year Plan as follows:
1
1
The Treatment of Tuberculosis
The number of persons to be catered for at
any point of time has to be judged from that
proportion of the existing caseload that are
known to seek medical relief at present plus
that proportion that would do so if facilities were
available. The sociological studies conducted
at the National Tuberculosis Institute indicate
that at present 1/3 of the radiologically active
cases (including one half of those confirmed
on smear) take action under the pressure of
symptoms: they receive mostly symptomatic
treatment;^.furthermore, another 1/3 of the
radiologically active (including an additional
quarter of the bacteriologically confirmed) are
sufficiently motivated by their symptoms to
seek advice, but do not come into contact with
medical facilities. In absolute figures this
means that in a district over 2500 bacteriologically active cases of TB can—and must—be
dealt with immediately. Another 1250 only
require information about the developing
facilities to seelT their services. This puts the
immediate yearly target of a district programme
at a caseloacfof 3750 symptomatic infections
patients. As the programme adequately deals
with these the yearly target will not change
substantially in size, but the composition of the
symptomatic group would gradually change
until it reflects closely the overall iatid of 1/5 |
b^twcuTbactcriological and radiological cases. /
Of course at all times some patients will seek
treatment outside Government agencies, and,
if given adequate therapy, will reduce the
target caseload.
•The size of the patients’ population to be
catered-forTTiakes if mandatory that treatment
of tuberculosis should be based on self
administration of drug. The two major
implications of such treatment are: (a) the
constant supply of drug by the Health Services
and (ft)-the regular intake of drug by the
patients.
(a) Since rural TB control is the objective
the supply of the drugs required is essentially
the government’s responsibility. 'Die dis
tribution of the drugs to the patients is the
responsibility of all existing health facilities;
Staff:
Coordinating Unit
1 Director, Senior Medical Officer
1 Senior Clerk
1 Statistical Clerk
Diagnostic Unit
1 Assistant Medical Officer
1 X-ray Technician
2 Laboratory Technicians
Treatment Unit
1 Supervisor of Treatment Organization
3 Home Visitors (Treatment Organizers)
1 Dispenser
1 Driver
Equipment
1 X-ray unit (transportable type but, at
present, without generator or vehicle)
1 Laboratory equipment (Microscopy only)
2 Tuberculin testing and BCG vaccination
kits
1 Motorized tricycle
1 Regular motorcycle
1 Public address unit
Finally, one BCG team consisting of 6
technicians and of one non-medical supervisor
with equipment and transport are now being
stationed in each district in connection with the
National Tuberculosis Programme.
The total facilities thus available today to
deal with the tuberculosis problem as defined
above are therefore some 30 non-specialised
2
I'
the allocation of drugs to the existing health
facilities (P.H.U.s and taluk hospitals) is the
responsibility of the Medical Officer of the
District Tuberculosis Centre.
(/>) The regular intake of drug by the patient,
comprising monthly drug collection and daily
drug consumption for one full year, is the most
important aspect of the whole programme.
Phis can only be achieved if the general health
and medical staff, guided by the district TB
centre, record and supervise the patients’
drug consumption and enlist the co-operation
of such non-medical agencies as Community
Development and Gram Panchayats for the
purpose of retrieving treatment defaulters.
-7,
The Drugs
It has been well established that in the treat
ment of tuberculosis, combined therapy is more
efficient in converting sputum and in reducing
the'risk of resistance. However, considering
that all patients coming forward must not be
denied treatment—in any year, their number
could be several thousands—the choice of the
drugs is to be made after due reference to the
cost and other operational factors.
Any treatment schedule should, in any
case, include INH. Of the 5,000 infectious
cases in a district, 2,500 being aware of the
disease, may come forward in the course of
(
a»V year: The cost of INH alone for these
patients would amount to Rs 20,000. A
further group of radiologically diagnosed cases
would presumably be given INH to the tune
of Rs 15,000 in addition, making Rs 35,000.
Combined Therapy: Addition of the, at
present, only drug available for self administration to all sputum positive (PAS) would
O
»>^increase this cost by 550 per cent to Rs 235,0Q0_
-"In order, therefore, to provide treatment only
to those who may come forward for it all the
money budgeted for anti-tuberculosis drugs
for each centre in the Third Five Year Plan
must be, of necessity, spent on INH. Funds
for an additional drug could be. soughTTFom
other sources -through reallocation of unspent
balances—or through an increase in budget,
but the cost of a programme based on combined
therapy, however desirable, remains today
prohilfitive, unless another cheap, effective
oral drug becomes available as a companion
drug. In this connection it is to be hoped that
rhe association INH-TSC (Thiosemicarbzone),
which has shown very promising results in a
3
B.M.R.C. trial in Africa and js now under
trial at the Madras Chemotherapy Centre,
will prove suitable under Indian conditions.
Such association would appear to achieve all
the advantages of PAS-INH over INH alone
in terms of sputum conversion (90 per cent_ys
60 per cent) and of emergence of resistant
strains (8 per cent vs 32 per cent)...At a cost. n
not exceeding one and a half times that of INH
alone. In order to prepare for this eventuality
an adequate treatment organisation capable of
ensuring in 2,000 villages a high proportion of
completed treatment has to be evolved—and
this cannot be done without at least the first
drug.
Diagnosis of Tuberculosis
The above philosophy of treatment has been
based on the knowledge that as much as 1/3 of
the existing patients are actually taking action
on their own initiative and that another 1/3 of
ihe existing caseload would do so as soon as
means of diagnosis are made available to them.
The implication of this knowledge with respect
to case finding is that the Health Services,
whether specialised or general, must be enabled
to cope with this load within the available
means. Obviously the classical TB clinic
approach cannot do it alone.
Diagnosis by General Health Services
Every primary health unit that qualifies
for international assistance receives, amongst
others, one microscope,
Taluk hospitals
commonly also possess one. The other health
facilities that are ffound capable of dealing with
1 ' ’be given
•
t a
the treatment of -tuberculosis could
micioscope within the framework of the present
Tuberculosis District Programme. This means
that in the district, the use of a microscope for
diagnosis of tuberculosis can rapidly be
expanded to cover the entire district area. Of
the above mentioned facilities, the primary
health unit is the most promising one, as it
has its own ramifications in the village in the
form of M.C.W. centres, weekly clinics, rural
dispensaries and so on. In these places sputum
can be collected for further processing at the
P.II.U. itself by regular primary health unit
staff~(specially trained.for the purpose by the.
TB centre personnel). When 10 taluk hospitals
andTO P H U s-with 'their 50 sub-centres of
any kinds—are all contributing to bacteriolo
gical diagnosis of tuberculosis, one may expect
that the entire portion of those cases who were
i
stated above to take action spontaneously would
be dealt with on a continuous basis. This would
be made possible merely by bringing the diag
nostic facility (sputum collection centre or
sputum examination centre) within a few miles
from any village.
As the pool of such cases gets diagnosed, an
increasing proportion of symptomatic persons
may Tmf' be found bacteriologically positive.
ThiT Justifies
: r
the introduction of•* referral'
procedures as the second development stage
of the diagnostic facilities in the district.
Where the only X-ray plant is situated at the
district centre, such referral must naturally be
made to the centie. Where other X-ray
facilities exist (such as screening plants in
taluk hospitals), those facilities would naturally
become of use for referring bacteriologically
inactive, symptomatic cases. In the eventuality
that a transportable X-ray unit is made available
instead of a static one, the organization of
referral can be based on all taluk hospitals
periodically (fortnightly) thus making the
development of the programme even in all its
area.
Where referral facilities at the taluk level
are not available and in the case of sputum
negative persons who are beyond doubt genuine
cases of tuberculosis from the clinical and
history data, diagnosis should be made on this
basis alone, especially in case of indigent
patients who cannot afford the bus fares
involved in referral to the District Centre.
patients to various types of treatment; in the
absence of a second drug, it would be justified
for the purpose of assessment of treatment
results.
With such diagnostic means available at
the district centre 50 per cent of the infectious
caseload in district headquarters town may
have been diagnosed within a few months fronf
'starting-of operations. In addition, asmaH
fraction of cases belonging to the periphery
would also be diagnosed there.
BCG Vaccination
The posting of the BCG team with the
district tuberculosis programme will achieve
the desirable objective of integrating the preventive and curative aspects of tuberculosis
control ft" also achieves a certain amount of
administrative integration. On the other hand
the policies prevailing in respect of the mass
BCG campaign conducted in the First and
Second Plans should remain basically unaltered.
The BCG teams would operate with a view to
cover systematically the entire district. Areas
should be taken up in the same sequence as in
the previous campaign(s). Work should be
confined to age-group 0-39. with a view to
achieve a maximum coverage. For this pur
pose some technical changes are needed: syste
matic house to house registration of individuals
is essential; otherwise tubercul.in„tcst is givelTi
as usual to all under 40 and BCG vaccination
to all reacting with 10 mm. and less.
Where the BCG campaign goes on, the
BCG team may provide a useful additional
function namely that of questioning adults for
the possible presence of symptoms and of
referring the symptomatics to the nearest
diagnostic facility (P.H.U. or taluk hospital).
Diagnosis of Tuberculosis at the District Centre
Whether patients report by themselves from
the district headquarters town or elsewhere,
or whether they are referred for further exami
nation by peripheral units, the diagnosis of
tuberculosis rests on the classical association
of the tuberculin test, the X-ray and sputum
examination, often qualified by clinical exa
mination. The tuberculin test serves the
purpose of pre-vaccination test for contacts in
addition to qualifying the type of radiological
picture in some cases. The miniature X-ray
picture defines the type of pathology and helps
forecasting the probability of its being active
tuberculosis. The sputum examination by
direct smear (for all cases with X-ray pathology
likely to be active tuberculosis and those others
in whom history and clinical investigation
cast a doubt on the radiological diagnosis)
would essentially serve the purpose of allocating
Co-ordination of the District
TB Programme
The co-ordination of the entire scheme
rests in the hands of the medical officer in
charge of the district centre with the assistance
of the district medical officer and district
health officer in their respective fields. At the
planning stage the medical officer in charge
of the district TB programme submits his
development plan through D M.O./D.H O. to
A D M S. (TB) for approval. At the implemen
tation stage the medical officer deploys the
technical staff under his supervision for training
the non-specialised personnel in P.H.U.s and
4
1
o
taluk hospitals in their respective techniques of the methods applied is given to all health
(microscopy, treatment organization). Together and development units. The Medical Officer
with the li.M.O. and D.H.O., he initiates and Health visitors prepare a priority scheme
the various stages in the selected block areas or for implementation of the expansion of services
taluks. This should always be presented as a on the basis of the best utilisation of the avail
normal responsibility of the general health able means (personnel and equipment) as
services, not as a specialised programme. For found in the survey.
ensuring mass support, especially in connection
The treatment organization section of the
with the treatment aspect, the medical officer district centre is then built up with a view to
of the Centre, together with the medical officer being able to conduct treatment operations
of the F.H.C.or
............
. ‘ ‘ always
‘
'
Taluk
Hospital
establish
(drug procurement, drug distribution and de
contact with the Panchayat Samitis and Block faulter follow-up system operating anywhere
Development Department with a view to using in the district) P.H.U.s or taluk hospitals are
Gram Sevaks and Panchayat Members as the encouraged to treat cases of TB coming to
essenti.il communication channels Between their knowledge. Treatment facilities (drug
th~gvncral public on the one hand and the and briefing of staff) are provided to such units
P.H.i',7rTfie"Taruii Hospitals
and theTB Centre
,
notifying cases. Treatment Organizers are
oh the
f other hand (for publicity as well as for deputed to brief their local counterparts and
treatment
follow-up).
’•rent .c.
’.c"initiate
initiate action.
action.
Proper co-ordination of the scheme implies
In the second phase, the case finding activithe c^mBllUDiis.as&c^meJlUif its achievement. ties arc started both at the periphery and in the
This is done by means of a district case register headquarters’ clinic.
maintained at the TB centre, in which all newfy
The district centres’ laboratory is built up
found cases from the beginning of operations and geared to process material from various
are entered. At regular intervals the case sources, and to train non-specialised personnel
register—which is based on the village as a in the peripheral unit. Such peripheral units
geographical unit—■will be used for establishing which satisfy to treatment requirements should
the proportion of the estimated caseload dealt be given first priority for sputum case finding:
with.
Lab technicians are deputed there to initiate
action and train their local counterparts.
Timing
The X-ray department of the district centre
The whole process of expanding anti is then established and geared to cater to
tuberculosis, facilities throughout the district peripheral patients as well as to local ones.
may take 1-2 years. The timing of the expan- The organization of referral to X-ray from the
sion essentially depends on what facilities are periphery, and the feed back of information
available at the onset of the programme and on to the periphery is expanded as peripheral
the pace of development of suitable new ones. units demonstrate their efficiency in sputum
The general principle implied in the above case finding. Simultaneously, with the com
of the X-ray
the district
chapters viz.,‘that it is not justified to diagnose pletion
.
. department,
.
cases before a proper organization exists that headquarters clinic is also ready to function,
Lastly,
is capable of ensuring the continuation of their
T
" as cases arc diagnosed and put under
treatment for one full year in the vast majority treatment, the system for notification from the
of cases’, should determine the general trend of peripheral units is developed and the district
:gist< is built up. The development of the
register
development.
In the first phase presumably lasting 2-3 register completes the building up of a District
months, the District Centre is established aiicT Tuberculosis Centre fit to deal with the
the District Programme planned; Treatment Tuberculosis problem in the District.
facilities are also established.
Assessment of the Programme
The Medical Officer and his staff conduct
a complete survey of existing health and develop
The achievement of an applied programme
ment facilities in the district, and draw com such as lhe one outlined above depends on the
prehensive maps of each area covered by such technicaL^fifficiency of its tools and on the
facilities. In the course of the survey, the operational efficiency of its methods, The
programme is explained and a detailed account technical efficiency of the tools (for instance
5
the sputum conversion achieved by domiciliary
chembthcrapy, or the protection achieved by
BCG_yaccination etc.) has been estimated in
clinical trials of the highest quality. It follows
therefore that not much effort need be spent
'^yzin the programme on technical assessment of
results ‘Th
jh individuals, because the mere
oEservation would not often lead to any feasible
corrective action. On the other hand the
operationa.LiacU>rs involved in the programme
are far less known but probably many times
more'Televaht to control work; health workers
are familiar with the critical coverage required
for making a vaccination campaign cpidemiologically successful; clinicians appreciate the
j
—jr --- --- of<• regularity
’ ■••
’
importance
and’ continuity
of<• drug
intake for the sterilization of infection. The
assessment of the programme must therefore
be concerned with measuring these operational
factors as often as these observations can lead
to some corrective action. The reporting
procedures, though simple must lay stress on
-output and coverage, the most important of
all being the proportion of 'cases completing
treatment. Outputs and coverages are com-
,L
pared, at every step in each area with the cstimated caseload, and this comparison indicates
the type of action required to improve the
achievement. The district register should not
merely record the cases found, their relapses
and deaths, but should accumulate operational
information in addition to social and epidemiological factors, as so to make long term adjust
ments of the programme possible.
As for the assessment of the ability of the
programme to achieve a problem reduction, it
is unfortunate that no direct observation
method is at present feasible to measure such
achievement. The present techniques of longi
tudinal suney cannot, within reasonable
running costs, demonstrate trends in prevalence
Cf disease. The only alternative is to calculate
reasonable estimates of the achievement of the
programme bv
by making use ol all the available
data: Given the initial prevalence of disease, the
coverage of the estimated caseload in terms of
completed treatment and the technical effici
ency of the drugs used, it is possible to estimate
fairly accurately the long term reduction in
number of cases achieved by the programme.
*
I
M-*?
5
Wesley Press, Mysore
.... ......... ..
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1C UBHAfjy
:*£3jjgggr;
SUM M ARI ES
9
OF \
/
NTI
-
ST UDIES
VOL. I
JULY
1976
AVALON
NATIONAL TB INSTITUTE
DIRECTORATE GENERAL OF HEALTH SERVICES
I
k '
' CGOVT. OF INDIA)
No. 8. BELL ARY ROAD
BANGALORE - 5 60 003
irnnu i j
>
I
CONTENTS
sq
No. j
4>
Subject
Page ’
No. ;
Reference
| EPIDEMIOLOGY
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2
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I
! 15*
i
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*
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?
logical inquiry
i
tuberculosis control programme In India |
I
!,
A socio-epldemlolog
lea
study ut
of OUTout- -r ■
I <.Q II aiuuy
-J" T
— —A. i • *
—1-
20
»
7
22*
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“ ”
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■
■
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\
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I
i 19*
I
I
indurations
I
II
*1
.......................... —
■
1970, Vol.XLIV,
I
i
i
i
i
I
1
Assessment of diagnosis of pulmonary
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- Gil)
I
I
2
3
■U
TREATI4ENT
°f tuberculous
7. patients in +rea+men+
rural areas
25
Intermittent treatment twith
* " stremptoIn rural
■ - ■ — I aroas
I
^ycln
mycln and isoniazid
I 26
Some observations on the drug ccmblU.t on of INH-thlacetazone u^de^he
conditions of district tuberculosis
! programme
I nd.Jour,Tuberc
Vol.12/2, P.62
1965,
23
Proceedings of TB & Chest
Diseases Workers’ Conferen'ce, Ahmedabad, 1965
P. 131
Ind.Jour.Tuberc.,
Vol.XIV/l, p.41
24
1966,
24
I
I
I
27*
under programme condition
Ind.Jour.Tuberc., 197?
Vol.XVIII/4, P.IQ7
25
Ind.Jour.Med.Res. , I960
.VoI.48, Po407
26
Ind,Jour.fuborc.
Vol.IX, P.15
26
B.C.G
28
29
30
31
32
33*
34
i
Assessment of BCG
vaccination In
India - 3rd Report
Allergy producing capacity of Madras
and Danish BCG vaccines as seen
among school children in Bangalore
1961,
Allergy after BCG vaccination
Proceedings of TB & Chest
Diseases Workers’ Conferoence. Bangalore, 1962,P.286
Door to door BCG
vaccination
simu Itaneous smallpox and bCG vacclnation
Assessment of post-vaccI nation allerov
vacr? ++?Se DCG vacc,na+ed Without pre-i
without
vaccination tuberculin test
Bui I.Dev.Prev.TB., 1962
P*,2> Procee^lngs of
io a Chest Diseases Workers’
Conference,Bangalore,1962
P.304
Ind.Jour,Tuberc., 1968
Vo I.XV/2, P.52-56
I nd.Jour.Tuberc.
Vol.17, P.|8
1970
27
28
29
i29
BCG without tuberculin test
Proceedings of TB & Chest
Diseases Workers’ Confere
nce, New Cel hl, 1964,P.138
30
- (Iv) 2
—
35*
3
A comparison of the Copenhagen and
Madras liquid BCG vaccine
I nd.Jour.Tubere.,
VoLXX/l, P.4
4
1973,
31
BACTERIOLOGY
36*
An Invltro study on sensitivity of
tubercle bad I into th I acetazone (TBl)
37
A comparative study of prevalence of
drug resistance to major anti-tuberculosls drugs
38*
I nd.Jour.Tuberc., 1966,
VolXHI, P. 147. Proc, of
TO & Chest Diseases Workers’
Conference,Calcutta, 1966
P.I32
A cold staining method for tubercle
bacilli us Ing Ch Ioreform .■
32
It
Proceedings of TB & Chest
Diseases Workers1 Conference
Hyderabad, 1967, P.52-62
33
I nd.Jour,Tuberc. , 1966
Vol.XIV/1, P.3
33
IndoJour.Tuberc., 1967,
Vol.XI V/4, P.186-198
34
Jour.of Inst.of Engineers,
1969, Vol.49/5, P.73-77
35
Ind.Jour.Tuberc., 1971,
Vol,XVI 11/4, P.131
36
i
GENERAL
39
40
4!
. District tuberculosis programme In
concept and outline
Problems of maintenance of hospital
, equipment
Assessment and monitoring of national
tuberculosis programme (NTP)
.
* Reprints of these publications
are available on request from the
NTI Library
I
PPZ
. ..yv -
<•
•d
-
I
EPIDEMI01 OQY
■
Bordia N.L.,
K „ IKM
At; Mclary
in youn£ chilie^nigh^"^^^^ iSex^f+h ^e. prevalence °f infection
population
Tuberculin testing was done in
(0-4 years) in Bangalore city^nd 2 589 of n!
reading was done in over 90% of the sSple.
r: -
tuberculosi3 problem in a
S °? Sa!npls of 2’883 children
? Plages. Tuberculin test
group^cXMt3^
infection in 0-4 years age
at 14® indurations®!
in th? ^ded^WZareHas-l-.lS
culosis infection was 2%,
tuberculosis infection
in t[le cit„ - Population the prevalence of tuberSocio
P^^l^orrelation between
' 'i
-0O0-
VIL“wLF°mw XSfosT °F
Raj Narain, Jambunathan M,V.
A study was undertaken with the
™KAL
& Subramanian M.
following objectives:
1)
To estimate the proportion
■
of population that
resurvey after 5’ years
would be available for
2)
To ascertain five years later the fate
3)
of persons with X-ray pathology,
To compare the prevalence
of tuberculosis in the villages at an
interval of 5 years.
Sputa were collected from
u-ne ^P^^ion was re^z-raved
such by either of the two readers
shadoWs interpretSTas
^AhVT °£ each othCT
wero e^ned toVamP+eS WSre Elected within
Analysis of the data showed that:
dire°t Smear .and b7 culture”
1)
2)
Nearly 70% were available for
examination after 5 years,
There was no significant
joints of time. ---- — difference inprevalenoe^ates
the two
i
: 1:
a
J,
T
- 2 -
3)
During the interval, 30$ of active cases had died and 20# were still active
at the end of 5 years
4)
There was almost a complete turn over of _the_bacillar£ cases during the
5 year interval.
-oOo-
LIMITATIONS'OF SINGLE PICTURE INTERPRETATION IN MASS RADIOGRAPHY
Raj Narain 3 Subyamanian
«
Surveys with MMR remains one of the most important methods available for measur
ing the size and extent of tuberculosis pi oblem in developing countries. Its
value in case-finding programmes is well recognised.. Nevertheless mass mini
ature radiography with a single picture of the chest has a fiarly wide margin of
error owing to the intra and inter-individual^differences in x-ray reading. A
study was undertaken to know the errors involved by repeating an x-ray picture
after an interval of 3 to U months and judging the first picture in the light
of a comparative reading of the two pictures. It is postulated that two
pictures, taken at an interval may afford bcttev_JudGement_regarding the assess
ment of a case than a single picture only. A total of 8,000 peroons were regi
stered, 5,300 of them were x-rayed and re-read, by two readers. Photofluorograms
were repeated after three and a half months after the first picture. At the time
of repeat x-ray, a spot sample of sputum was collected from persons with
abnormal shadows. Briefly the findings of the study were:
I)
About 20$ of baci 1 lary cases were unong •’•■hose with inactive or nontub_erculan_shadows on the basis of-a single x-ray filirio
2)
Inter-individual agreement for x-ray active cases was of the order of
50$.
3)
Intra-individual agreement for x-ray active cases was 52$ and 6o# for
the two readers.
Mass miniature radiography with a single film. Inspite of its inherent
limitations is the best
available method both for surveys as well as
for case-finding programmes due to its ability to find cases as well as
potential cases in a short time.
-oOo-
i
ASPECTS OF A - wbercueosis prevalence
IN A SOUTH
SURVEY
-■■i Indian district
f-a^ain, Cea: . r A,
^am.bunathan v. K ,
°bJeCtlVee^
objective
was tn
Z° eatablish tb.
radiological r :
.
cnee suggestiAre
active disease")
J Gna ^ctcrioic^i
sex groups.
Mlv
2:”"
‘wmo.
Tumkur District
x#
district headcuel yS°re
deluded fr®‘th
rS tOwn of
having G ponuln-f Survey- Random
1 -~anxL k town I,~,
VIth | TU RT 23 Wi+h% n hn reSi Stored population
“3 Population vere given^
6-1?11, A11 the
dnys after t^ teST6na+°- L°°8itudin£
' "T;J a ^-ntoux test
years and above were off At the tlDle of ■— diameter or -rindui-ation W3S ^ad
tubercmm test,'an
as abnormal ir.cludin
n 3inBle 70 .7Photofluorog^am. Persons _ag£d_£Q
"sJoCSX^a5q„Uatte
atura°3^erehth °VUberCU1'
For ea=h Picture
—ar pathology
°f jading the tubXuHn u
^^^dual'^ eXa” could not beand for each
-J repeated, a
concerned- was
°f Infection and di-A». / st* Various ■
collected at the time
studied.
1’6 r^°^- ^anT
“ °n of lnfection\nd disease ^re
COmnunlt
y
! Prevalence
sex distriologi^flly aftive^t
311 '
I had sputuJX^ve rrCUlar '
the total ,n. ltlve disease,
-Hmalna,
sense half were in n,,'! lrir«tiorrKM
Males,
^e group^ Io
”” -
™ <*5^;
-0Q0-
A COMPARISON OF THF
PICTURE TECHNIQUES RELATIVE VALUE C
IN TUBERCULOSIS
Raj Rarain,
bJair u,s,j ■5 Chandrasekhar P.
^imitations of*
the chest had been 11816 x.-pL°^Vor dlocatin,g “nd tnterpreting , ■
earlier,
"as suggested that studiedjXi
two r
J
*■
shadows in
picture of each nf Or tO reduce
: — these limitti
Picture was to b«
--tons, it
taken
after
■•aveXl
Pe
T
S
°
nbe
taken
about 1 to s
^^accrcentTofhxirayhtub:00^-
cms.
advantages
compared to a 311,816
PiCtu~ ^not been
mobile
x-ray units each with
an odelea
- 3 -
UP or down
• as
.’Ssi:s^s
camera were alternated
for the single
- 1* -
and double picture examinations. A‘ total
~ of about 2,000 persons were x—rayed
read independently by 3 readers.
;A spot sample of sputum was collec;
ted 3-^ days later
from
•_
-- ----- 1 Persons with abnormal x-ray shadows and was examined
by direct smear microscopy.
on.
id
Canparison of
the readings of the two sets of picture did not show a better
agreement between different (inter-individual) readers or between two different
readings of the same reader (intra-individual) when the two picture technique
was used. The x-ray cases detected by double picture only by ar....t reader were
any on€?
not confirmed, more often than those detected by single picture only. The~x-ray~
pictures of the bacillary cases were also, not interpreted more often as due to
double
<y th! tW° picture technique. It was concluded that the
Le^uluue ~ technique does not offer any advantage over the single picture
ie
-0O0-
PROBLEMS CONNECTED WITH THE ESTIM/TTION OF THE INCIDENCE OF
TUBERCULOSIS INFECTION
Raj Narain^ Nari. S,S.^ Chandrasekhar P. <S Ramanatha Rao G.
*
a.ccBBunlty is^eaposed. An accurate es'timitTon
iLv of^tubere.Hn5/3 °a =onsider?hle importance in understanding the epidemio-
been adonted
°rganlsln8 control measures. Various methods have
been adopted for the estimation of incidence of infection, indirectly from the
?TrG1?nCe+r^er °i4-^tion by Bogen (lQ5T)s Frimodt Moller
incidence rate of infection can also be
estimated directly by repeatingjtuberculin test at two points of tineThis
however, has the disadvantage that the reaction obtained
‘ ‘ ' at the s_econd test
tends to be hi^i, mainly du6 to the boosting effect of the earlier test.
The present study is based on a survey of a random sample of 13I1 villages No
previous testing or BCG vaccination had been carried out in the area but each
p™ ™s examined for BCG scars in Srder to exclude persons vaccinated probably
from other areas. After a complete census, a Mantoux test with I TU of PPD
RT 23 plus Tween 801 was given^on two occasions (Round I and II). Those with
reaction of 13 mm or less at Round I were offered a test with 20 TU with Tween
within a week of I TU test, The interval between the rounds was about 18
months. From the analysis of the data
— ----- i from the first 50 villages for which
complete information for both :rounds was available, it was seen that there was
a general increase in the size
of reactions-elicited in thfi__second_ro^d7 "
—
I
tetaeen'+h
vntlons.
al3° UHd t0 Etud5r varintlons in the technique of testing and
wa3 estimatea that on on average Inter and intro reader variations
The reading errors and an equal chance of being positive o^e^ti^.
- 5 except at the extreme ends of the district4™
-u
could only show an increase, and the vet/
^ere zero readings at Round I
of showing only a decrease at a subseauent
hRd a greater chance
problem of estimating the incidence of
8tUdy conc^rns the
' (Sli£^2tioiis__based on agc-srecific rrevni
culo'us infection in a ccmmunity.
7
r;i^3 °h
rates of t Acrc-Jin
^conclusions. For estimating th^^y^Kf^ct^d'^
^hJareliaU^eEid^lalogical
error
. suggested .based on the drawing r>r r 7 ’
ted» R new approach has been
|| in reaction sice C^nrro^d5^f^E^ibUtl°n °f dlff—ces
that if
Infection causes e. distinct
fn
°
irTs-osswncd
vity which is greater than the combined X lue tn
°f tubereulin sensitivariation, the distribution of dlffe^n. ria\due to enhancement and reader
the newly infected, and the method use tn
rOUndS Sb0Uld lndicnt«
been described in detail.
*identify the newly infected group has
With an increase in mean reaction size of S C°^ltute R h™°genous group
It rm. Accordingly, 98/ of the nowiv
™' and standard deviation or
' of I6_mm or more' There are
?,nfeated show an increase in reaction size
on a retest,'even i^hf
ases in allergy
-0O0-
ENHANCING OF TUBERCULIN ALLERGY BY PREVIOUS TUBERCULIN TESTS
Narairij, Nair S.S., Nananatha Rao G.s Chandraeekhar P. & Pyarelal
have
reported to elicit^ar^rreaction^
allergy in BCG vafcinaSd guin^
efn’be
(+T7) f0Und that
cf
dermal injection of PPD in e. dose of 5 m or Subst!ln*1®-11y enhanced by an intraof I TU. Kul Bhushan (1958-59) stulied^ T*
7 013 tubercu1^ in a dose
unvaccinatcd tuberculin positive and ™ it Phenomena among the vaccinated end
™ S undertaken where reactors of 13 m or less to I TU have been tested
previously untested^n^vaJcinatt^r^rno
11^! Study WaS
Carrled 0X11
reactions.
was earring
rwj+ j_n a
only about 2$^ of the roorulntinn '
populablon (Longitudinal r
where
about 605! nhoved 10
showed lU mm. or more to I TU and theSurvey)
:
e remaining
high prevalence of non-specific oiler™ i^the T TU' t2’”'’36 results c°n«™ the
tuberculin test does enhance the nlleX
a
T3 “ that "
enhancing effect is associated with th^inltltl
subsequent test. The
tuberculin, especially those elicited by a 20™ to 1 TO
confined to those with 10 mn and lanzp
71 ! !’ increase being almost
effect increases with in mse in ^e
??" tO 2°
7110 enhancing
increase in age especially among these with 10 mm or
Rjrrr • -r- w;.-'
A
- 6 •a
bigger reactions to 20 TU. It is possible that the enhancing effect is more in
comnuniti esjwit h high prevalenc e._of non^speci fl c allergy?
—----------- ——
-oOo21
DISTRIBUTION OF TUBERCULOUS INFECTION AND DISEASE AMONG
HOUSEHOLDS IN A RURAL COMMUNITY
X
W Naraina Nair S, S. a PcnTi(xna.th'ci Rao G* <S Chandrasel^ar P.
T distm“tlon of tuberculous infection and disease in households
have mostiy been restricted to the examination of contacts of known cases
t
read bv't™
S
* 7
Photofluorography.
All the x-ray pictures were
5S-l=°!
e ^a^P^tiono^ 21^1 was distributed over 5,266 h^fh^ds
baetPT-4 iC
clG3Blfied as bacillary case household with’ at least one*
lcgic51y°Ict?^ycLT"“e?itChSno ^^^S^o^ehold with at least one radioneither a bOMn
1 n° bac^llary cases and ’non-case household' with
Urtribu^d ii VtT nOrhatX_r:r Cnse- T0tal bacillary ~cases~were~Tr~5Ha were
had 3 bacillary^ase??6 ° S’
households had °‘>e case each and one household
The findings of the study have thrown considerAbIe dnuht On the useful
contact examination in tuhPreniA7T; control
Tr
'll -**
of infected
is—control. (IJ over^80/- of the total number
’ 1 6117 age 8r0Up’ ocourred in households without cases
of findi
f tU^T=illosis blurred mostly singly in households, and thelhar’ce
eitfS^all
^^-^.e-^t-exsination in the same householdTsh’Jf
CCmCn bellef has been that prevalence of infection in
this St?dv « 7
?p
a 800,3 3ndex of alsee®c in households; but if
children^ th^eLP°^
?L7f?0USeh°ldS Vith Casea of tuberculosis had no
only 12% Of Se eMlT^
ln.boUses
bacteriologically confirmed case
o-f buck
a
Uon
it 1^!??
7 ? *r:
nfection
ooula to that there is resistance to infecdo n7t become SeX Xsit^
vacclnation
positive* it is felt that a large number of children
a C.
l
rfLP^'1''
■<jV.aU.
I
'I <>
LJfe-A. fcveJ>.ixL-<v»
^kj2-
■
•'l “
to inhale tubercle
it develops, the <• Mcilii, but
children remain
SPrie children to get
infected,
- 7 primary conplex does
negative.
esis has been ma^^rth^^
not?’show
idenoe
made out that in’ W d° —■ eV
evidence
something known1 as
as n?Gsistance
??plain why under ccnSE~aEo_uo disease".
conditions <
f^evele^^^
OthcrE—*
^‘infect^15-^^ to
^^S'fXhf^
Possible
test
™yP
(Relbate to
Survey^.
„ -
stated that
> Survey).
Case. household is not
i the hypothesis
trXltS
will be confirmed.
nJ-
^onsehollsrinspite oftht10"
-0O0-
PROBL BIS. IN cil,
H/BERCULOSIS
DEF'TPSfK(™
Narain, NazrS.S.^
K
Chan^ekhar P
Ramanatha . Ptw'c.
* <s PyareZal
tuberculofi(S>-^a^h^ “neptahle definition .— • of^he tern "cese of pulraonary
SXTasd wU Vhere
8SZ^a“ent^
importance-both in
main purpose of th?5 in the ccnParison of dif-f2° hGrapeutic regimens are
defining a casn hl? pQper is to focus att^nt *erent GPitoniiologicai
The
and tuberculin test hVtS1S °f bacterlolo8icainexM>iinet?i:fflCU1^ies tota.
of
sample of I3h vill^eg ^th
two ^oessive prevalence0”’ X~ray eXf®ination
es in
prevalence i
tested with
—J cider
ES «.Vf K-g-""i "‘■■EE'.E'g.
watts’?
SdCbDenS Were ex^ined*byd-iu either °f the tw° inde^ndent°
Se' with My abnorthose
nnd by culture.
J ilu°nSscence microscopy and Z1Zm
nders- Both the
—- .^
readers.
„ ,
Ziehl Nelsen technique
-Anfilysig of clo/ta 1
* ’ ** *
shown that
—^-i^lcjinil
of P^onaxy-.tuberculosis"
considerably in thelr tufefiFMlti^t^ °? SeTCral
and sputum
experience. The
The status
o? n 5 reliability of their
results of x-ray
status
cbnnges with time
and = f cases found at initial nr,^^0312 and mortality
and such
various types time,
of eases
It v
Show considerable
SUrVGys ^owed
Qf cases, it
considerabl
^single
defiTitioHTE^^6 tO
situations. One has to i.2.1
adequate
- finding a single bacillus
------ osis, it
-s was shown that finding of
SU-rt*.
BS*
- 8 less) was
It
if
shat
poths
artifacts and should not be the
■iivi
case of tuberculosis, U indices have been suggested.
-tlon
•e
I)
Cases defintely positive by direct sm- '-ar.
2)
Cases definitely positive by culture
3)
All cases by culture (including less jlhan twenty colonies)
Sputum positive cases which are radio.-ogically active.
Each therehseens0SdbpennSea+r°r ai+ff+erE;,t situitions. However, it was concluded
that,
J®
? te.ng_option but „tp. use more, than one-definition for assessing the_prevalence and incidence of disease
-oOo-i
A’oj
Chandrasekhar
Satyanarayanachar P.A, <§ Pyarelal
! f !je fiE* of infection and disease in man from drug resistant
strains of mycobacterium tuberculosis is
not clear.
is not
clear,. An increase in the preva
lence of primary resistance indicates the extent of such a risk while an increase
oi secondary or acquired resistance could be considered as a problL o? the
individual patient and may reflect limitations of his treatment.
de??yibes the prevalence of strains with acquired or primary
resistance or of sensitive strains found in 3 successive surveys in a sizeable
ease^AT
+Vi\1,1SeS in 3 S°Uth InalRn strict. Changes' in the status of
+trains
one-survey to another and their infectivity among
household contacts arc also described.
. e prevalen^Q pf tuberculosis infection among household contacts of enseg w-tt.h
acquired resistance dtp i sonia 7.5 d^zas_ significancly higher than thnga vjth
grmaraxresistance.ojivltb sensitive culturen This.was probably due to the
of^iLnosis
Euf
P°Eitivity of isoniazid resistant strains at the tine
tS coXaet! infectivity as Judged by the incidence of nev infection awng
household contacts was generally less for cases with acquired or primary resistance
not ^tati'vS::iwth/e?^tiV: CUltUreS’ thOUeh the Terence Ob™7 w"
"Sv those with ®i?niflcant: A larS= "r
o^ture positive cases especi- 1J those with primary resistance had no radiological evidence of active
- 9 pulmonary tuberculosis. The prevalence of , ’
primary resistance
was high in certaii
andethor r °VaSeS
the differences bet^eT
■
----1 cases
with primary resistance
this coSd^e due’to th reSjStance
and
large.
It was suggested that
t^tma^despite^ppsitivitViPtheslsta1?- cultures_being.—of* atypical myco■?J
iLivity m the niacin test. 1There was n qignlfickht^ihcrpRr
in the number of cpror
—x—a---------------------owirr tn -i
n
f
th ^.cpuired resistfin^Ft'o> isoniazid
_
at the thirdsuHFEy;
resistance at thriirlouK^^SS^_U_ The prevalence of primary J
-oOoEXAMINATION OF MULTIPLE
Chandrasekhar P,,
SPUTUM SPECIMENS IN A TUBERCULOSIS SURVEY
S.S., Ftao K.P., Ramanatha Rao G. g Pyarelal
Prevalence ^^.re"
r-----S'
eStteatin6
tuberculosis problem
different countries.
tuberculin gst,.
mass miniature x
limitation of sputum examination
the.44-u h haS lts •own limitations. A
community cannot b~ diagnosed when
2^ SPU^ P°siti^ cases in the
each eligible person. Barton (iQSfl) rmnrt
sputunl ls examined from
ex^mtion_iifL_E_E£cc^^ec‘^
fp jt^L-additlgn_o£_igg_poSitiveS through
attending Tuberculosis Chemtoerapygentre M^s^it0163 r"’"1’ °f patlents
sample added about LS to the culture n^+<’
“ WaS found that a second
(^nd?evs and Radhnkrishna (1950)
Multiple
detected by the first specimen
possible under field
condition'ef
exanlllati™ are jot often
-naitloiLef .suryejrs_covering the whole comunityV
It would be worthwhile to have sone idea of the extent of nndPr-diemn^n ln
sputum examination,
specimens of sputum
each person with an abnoraal chest
India* jiach specimen
technique and culture„
whom all the four
average 21 (62^) >
of prevalence obtained
X’eKX"
no to e.t th;T;iXr,V:„2?s xm
Similarly,
S
n„Iy. lh= t^^tooio,
..
from all four specimens ™A?^-lp™ed fron;T frc^th^^rAT^ZZLto j8
only a marginal increase from I^to^I?63 p°nflrned by culture method showed
this disadvantage. More than So^nf th
1®roscence nicroscopy did not have
could be found from
Positives Ronfi^ed by culture)
sp^SnTby nuorcscence^LX detXTS ofc .^-inatlon of two
.j
becuea about Q5% of cases demonstrable by
t
I!
C
- 10 » certaij
ance
that
al myco*
increas
survey
•imary
this method. But with the Ziehl Neelsen technique additional specimens may add
more ”false positives”. Multiple specimens are most rewarding~fof~aetecTIng'‘~|j
cases found positive~on culture only.
-0O0-
SOME EPIDEMIOLOGICAL ASPECTS OF TUBERCULOUS DISEASE AND INFECTION
IN THE PAEDIATRIC AGE GROUP IN A RURAL COMMUNITY
Gothi G,D.t Nair SrS.
ffetest,
A
le
>ugh 1
nd
•a
& Pyare lai
The prevalence and Incidence rates of tuberculous infection and
disease in the
community are known in the age group 10 years and above from several surveys
carried out so far. The present paper provides various parameters of tubercu
losis in the paediatric age group in particular.
A random sample of 119 villages in 3 taluks of Bangalore district were surveyed
L times from May, 1961 to July 1968 at intervals of 18 months, 3 years and 5
years of the initial survey. Tuberculin test was done for the entire available
population with I TU PPD RT 23 with Tween 80 and 70 mm x-ray was done for all
available persons aged 5 years and above. Two samples of sputa were obtained
from the x-ray abnormals, and examined by smear and culture.
It was found that prevalence of infection increased with age from 2.1% at 0-U
year age group to 16.5% at 10-lL year age group compared to ^7% at 15 and above
age group. Prevalence of disease in 5-1^ year age group was considerably lower
than in age 15 years or more. Tuberculosis morbidity increased with the size
of tube_rculin reaction_and it was high among children with reaction 20'm~of '
more. "
■
~
?
'■r
e
d
Incidence of infection increased with ag? from 0.9% per year in age group 0-h
to 2.8$ per year among that of 15 years and above., Incidence of disease also
showed the same phenomena, rising from
n5% year
in age group 5-lTto
__ __Qper
among 15 years and above. The fate on follow-up of cases of tuberculosis in
this age was not serious.
The survey had no means of examining miliary and meningeal tuberculosis
The paper further presents the crude mortality rates in relation to tuberculin
reaction size and thereafter discusses the role of National Tuberculosis Programme
in relation totuberculosis in the paediatric age group.
-0O0-
distribution of CLUSTERS o
-T ^XlXSolds0 D,SEASE |N
^anatha nao G.
^ndrasekhar po
Pata from 62
part■ of U SrewlSS*jS—®8 in * ^strict , - formed pprevalence
Institute, BQngalore
. ^rlng I960-6l3rfesedb°dt
the Nntionnl -Indl->.' which
29,813 persons
—
in
Tuberculosis
yhle eithe^ in “
households, mher^ . Gn nade use of. The —survey covered
1Prepared by ^rvey^taf^'^r °nd 3°° aspect
,’acnii
'
— demonstrhousehold as
village
map
R?cleus and adjacent household
c„
nucleus hoXhold^n^ith*
Gp-ch case
household
-o of about
— - in
closest to the
household
neighbourhood and those
another case household x.^OU^ nelShbourhood
together was called nnd so on. The .
was
If
-1 neighbourhood °f thea fcluster.
irst oase the
neighbourhood of the 1_
new case also
dusters and clusters with
■■-“XT
“ ?J^nelehbo“-ho^
-»•«»«.. .4T :.XT:,zr
Similarly,
aspect case clustn^e
aspect clusters
^roup, non-case
households that
^re not
--1 only one
differentiated as
simple
Further, to> serve as
ra control
a systematic
sample of 105
suspect case clusters.
I
no fviaenc»
case CofShi^ .P””4”’ ‘
°nly 7 had multiple
of
01 high
high concentration
cases
-—1 of disease in case showing that there
clusters.
contacts
(0-l4
.
clusters (nC1^e&rnS/25.W),
years) infected
there was
was <considerably
— •
“-h differen^
clusters (9.8^).° Simii^?06 betveen
sample and composite clusters. ~ arly» there wassuspect
not
Infection r-01710ng child c •
"Uighbourh^di:
was higher in
To get rprevalence
clusters
- to avoid °5 ^nfcc^i°n was
no influence of
of influent
—ice of
also ’ noted that f- case may extend
suspect cnses andthere was
non-cases.
Case cl^
cluster:■s in which
(evident
the nucleus
-- on X.•ray reading)
! case had shown activity of i
°r had <c°ugh showed si^nifim
among child
“ ~Ung leslon
did not show contacts. Clusters QrOlUld cas^ P=Sltlve on bX!Zher *nfec«on
higher infection than those
(This may be due
to sputum
around cases positive^
and culture
Xeerth:nxencr+of C?Ud
I
examination °f single specimen oS)OT CUltUre
-II-
-12Out of the total infected persons in the community only 2^ were in case house
holds and 1% in suspect case households, over 9^- being in non-case households.
The zone of influence of a case extending at least upto the 10th neighbourhood
and the overlapping of such zones of influence of cases, present and past,
seems to be the most probable explanation for the wide scatter of infection in
the ccmmunity.
;red
-trP
e
out
lose
le
■he
Prevalence of infection among child contacts was definitely higher in case
clusters. But, the significance of this could be understood only from a study
of the incidence of disease during subsequent years in different types of
clusters. It is significant that only 10^ of the- total infected persons in the
community were found in case clusters.
The case yield in general population, cluster contacts, household contacts and
symptomatics attending general health institutions have been compared, The case
yield in the last group(lO^) is much higher than the case yeild from both types
of contacts (0.7^ iand 0.6^) which were only slightly higher than the case yield
from the general population
-0O0-
. ->1
A COMPARISON BETWEEN LONGITUDINAL AND TRANSVERSE DIAMETERS
OF TUBERCULIN TEST INDURATIONS
Kul Bhushan^ Mukherjee M.N., Chattopadhija S.P, & Ganapathy K.T.
ir
. 2
In the epidemiological surveys carried out by the National Tuberculosis Institute
(NTI), Bangalore, instead of reading the tuberculin reactions (indurations)
by measuring their transverse diameters as is done conventionally, the longi
tudinal diameters were read. Later on, as the longitudinal diameters were
observed to be larger than the transferve diameters., an investigation was
carried out to study whether this difference would affect the estimation of
infection ra^es.
Out of 1,21+0 tuberculin tested persons, for I,l8Q both transverse and longitudi
nal diameters were read by each of two readers, one accustomed to read the
longitudinal diameter and the other, the transverse diameter, AU care was taken
to avoid bias on the part of the readers.
All four readings were available for 1,075 persons. It was found that longi
tudinal diameters were larger than the transverse diameters for all ranges (of
sizes) of reactions when either diameter for each reader was taken as standard.
The prevalence of infection, considering 10 mm+ reactions as the minimum level
for those infected, were almost the same for both the diameters and for both
the readers. Analysis according to age and sex gave similar results. Variations
between the readers are known to be of much higher magnitude than those
observed between the diameters in this study.
- 13 -
the basis of longitudinal
nlle+T calcu1^
Suters8
’
’
1 be larger than those for transverse diameters.
4
wherein loneitudin^ ^SU“S’ th!
of the NTI epidemiological survey
- rem longitudinal diameters of tuberculin reactions are read, will not onlv
othAr orenni' +1
°ther ®tudles c°naucted by NTI but also with studies done by
other organisations - national or international.
y
-0O0-
SOCIOLOGY
A STUDY OF MIGRATION IN FOUR TALUKS OF BANGALORE DISTRICT
Andersen S, & Banerji D.
The
purpose
'
----seiehTon
ofof the study T
rate °f
in a random
with a view to forecast the likely^loss
of
population in
a rollow-up study on BCG vaccination in
-- the
-he area, r
The
study
was
carried
out in
tne total population 35 villages of ~
of Channapatna, Devanahalli, Magadi and Nelaznango.la taluks of Bangalore district. ]
Demographic characteristics such as birth
ana death rates, immigration rates and proportion
.
1 of persons temporarily absent.
;r?re also studied.
The head of the household or if absent »
any other responsible adult was inter
viewed on a house-to-house basis, :regarding the conposition of the ftunily
™ctir
„„ „„ „a
._,_i was to
the population of
; year. Each
rrl„,nt TOOtB
household neraber was listed as under :
Persons now in the household who also belonged
B.
Persons born during the past year.
C.
Persons who
D„
Persons dead during the past year.
E.
Persons emigrated during the past year,
*
to it one year ago.
inmigrated during the past year.
The registration was as follows :
Total registered Population
Category A
ti
Bn
C
n
D
n
E
Temporarily absent
13,338
13,183
1+70
230
200
307
770
a
III It was estimated that no more than 5% of the population would be lost by emi=
gration over a period of two years. About 1/3.of the emigration is withiiTthe
)
same taluk•" Only a smallTportion of the emigrants are above 30 years of age.
/
It is also found thau a good proportion of women’s migration is due to marriage. /
y
-0O0-
A SOCIOLOGICAL STUDY OF AWARENESS OF SWPTOMS /WONG PERSONS
WITH PULMONARY TUBERCULOSIS
\
Banerji D. & Andersen S,
?
This study was undertaken in JU villages and.U_tQwnJhlocks where a few weeks '
earlier an epidemiological survey was carried out. All persons above 20 years r
whose photofluorograms wore read as inactiveprobably active or active'bjT’at
least one reader were, age-sex matched with an equal number of x-ray normals to
form the experimental and control groups respectively. Thus a total of 2,106
were eligible for social investigation.
~
----
Interview sheets, with particulars of the none and location of village, house
hold number, and individual number and the identifiable data of the interviewees
were made available to .the social investigators at randan for contacting and
interviewing them at their hemes. The interviews were non-suggestive in nature
and
the details of symptoms experienced by the respondent, which
were fully recorded.
79$ of the experimental group and 83$ of the control group were satisfactorily
, interviewed, which constituted the data further analysed. Of the numerous
symptoms recorded, only such that were associated with pulmonary, tuberculosis
considered, of which cough occurring for one month or more, fe^r~occurring
for^AJloPlfe-OXlinore, pein in the chest, haemoptysis and all ccmbination of these
four symptoms were analysed statistically'
~~
Cough was found to be the most important single symptom. It was not only the
most frequent symptom alone or in combination in the^e5q)erimental group
•up but
b' was
less frequent in the control group in that 69$ of sputum positive andI k6% of—n
radiological positive had cough while _only_9$ of the control~group hacTitT __//
Considerably fewer people had fever and pain in the chest. Pain in the chest
appears to be non-specific, giving a ratio 6Tonly 2 : 1 along the experimental
and control groups while fever was in the ratio of 6 : 1 and haemoptysi r was
11 : 1. It was seen that 69$ of the sputum positive cases, 52% of the x-ray
active or probably active, 29% of the inactive and 15% of the noimals (control
group) had at least one of the above mentioned symptoms. In all the groups, the
proportion of symptoms were higher among the males than among the jfgnRjps. in
both males and females the prevalence of symptons was higher in the middle age
groups than among the younger or older groups. This age variation wasInore
marked in the females.
The findings of the study were analysed further along with the data obtained
1
- 15 which formed the total of^tbe*villas sS^Ct^
rest Of the 28 Ullages
out further that 95/ of tacter^^^C^: ^^^ogieally. This br^ht
further
“OOo-
A SOCIOLOGICAL INQUIRY
INTO ™i^X?BERCUL0SIS C0NTR0L
■M
I INU I H
Andersen S. a Banerjz D.
has proved su^m
necessary to studv
»je treatnent period.
^1&1S
+
». 'Featment of cases of tuberculo^?
P
chenotherapy
mr, v
behaviour towards the programme during
1
Study Population
otudy-population consisted’Of 7fih
i
^^osed at
to 5.5.1961. As per the clinic procedure all
Traini?S Centre between 13.3.1961
submitted to a tuberculin test and eyainin'itS-.P^r80n^attendlns the clinic v«re
who were x-ray
positive
’
..........
~l?T5ere
given
.TL^hoteflunjsgram. Those
of sputa by both smear and' culture on thliexamination of a g^t sample
AlTfa^^^their
second^
on their second
visit scheduled
Tuberculosi^B^rtmiOT
XS^iologically positive
the 7LadyWiiiinga^
‘ ~~
jp1?®15 were
PUt on a treatment
o
period of png year. During the
I' <cases were given 10 (333 of PAS in addition.
study population was interviewed i
initially at the clinic imediately after
------within four weeks
their defaulting;
W. ss» „a K,
°r ------- j period; the ofcoverage
being
“XS; aS“tOT “ “A A;.*. - - -
Findings
I
The following Table swnnarlSOB the findings :
>
*aii
u-
- 16 lages
rought
toms.
Summary of Distribution of 78b Patients by their Administrative Status
and their Initial Sputum Status
Total
&
Initial Sputum Status
Sp.
Sp.
Sp.
not
not
Sp,
Neg. Prod E^cami- Pos.
uced
ned
Persons who did not return to learn
the result,of their diagnosis
8U
11
o
o
an
0
Patients whose houses could not be
found
,<
h6
6
22
5
1
18
Patients resisiding outside the city
138
17
9
5
77
Patients who emigrated during the
treatment period
1+8
6
17
6
0
25
173
22
. 61
11
5
96
139
18
70
28
1
1+0
156
20
53
35
6
62
781+
ioo
270
9U
102
318
Administrative Status
-•rapy
* ever
Patients who took all or^art of their
treatment outside the cHnlc's control
at
*1961
re
ose
le
rd
Patients not completing the full 12 months r treatment
-----Regular patients
Total
No# attempt
was made
to taking
follow-ur
the
(1
ally.
Accurate
address
viU
befill
heS
in
ve
ag;
,
^faultea
vell as the 6? of those whose houses could not be found duri^ followup*’ “t
a^dST XLSreaS V0Uld haTC ^ve^XtnX^ty1'
_
the c-*tv limit
Th^v
diJgnosed and put on treatment were residing outside
tee n“es^ ^f SX
Un+V° be lrre^r
treatment which points to
aa!.,b^^S -^^SPgtie and treatment centres nearer to their homes
22% is seen to aare taken treatment from other health facilities also Thin’
ara^vailable
“ ws^
^e_^er^ndLjgaElety^ health facilitig_n
tf! !Ttipat
1 P
essectially a^rabl^of co-ordination to ensure tj^t
traa^ent.
clblelMh^iS^S^
00 aNivation at the cli^c.-7DeTauIt-l8-a
W<il
ween default ar;
a?d this study did not bring out any correlation bet
Wit^E^s teMa ™^5eo,Je> BOGia!^, educational or other status -f the pati ent.
♦
oOo-
A CITY TUBERCULOSIS
IN A TUBERCULOSIS
CONTROL PROGRAMME
«•
Vi Donath M.Ka
The objectives of
*•+■»,a
- —.
inquire into
attending a l
reason for attendance ;
see whether there
services for alleviation
any differences
eviGt^n
w
2: ^encnstration
district TubercuTne-t
Sss,“°X' 8K-S*—« “s
fis-g-i £55X: 5.SS?
* •««- « «. W ™ ‘
centre. Bangalore, which
^bereulo-
. Si™
uslns a questionnaire teeXn
interviewed by
■u’- l hence eliminated fr^^he^ +t^enders of vil™ 9% were below 5 years
■' toth^d1!^(S4^ttif°T *° ^-•^0Sei°D,ra8 ”®dee^
- ^:d S
•
-te
nearly 80!? of out-patients in +h
k
“ore symptoms suggestivTo/n,1
“ and -■““i
rural groups were aware of one or
suggestive
of
cases were found
ImongThm
tuberc^oels
—
1
among
them.
■ syhptras presumahlTlf
Most of the
cterlstic o? tte ^Rteoau8e °f ae^y in
of the disease.
and rural patients
patients -In
in th«
the There is no >
the urban
4 c-f the urban
naf-fo
+
revale
ace of Wtofflg at the timebetween
of“ reporting. 61%
urban patients and PksK
Of the
°fThe
attended
. ~~~—within three months of the
^Wptans. The higher
were found in the
yisld in bShT:-;_
urban and rural patients
-J 8rouPa with symptomCGSe
duration
---1 Of 1-3 monthe0
Distance was a fifnificant
i
factor. Upto' h.S km the
barge but the case yield Tnumber of jnew
— pat 1 Guts was
patients decreased but thews poor, while beyond that distance the
_1
—» e
mmber
of outinfluenced by distance. ■e .case yield was more, suggesting a selective
-- j process'
Xt was also found thn-b
' their own initLt^W
“d^ XXse^1-\
1™ECG VOrkers
“ttendere showed that o^h
— -d
on
- 17 -
t
J
I
IS
IS
ocioor the
oue
asking
incetl
•s.
CUlo^
. rban
lers
by
An analysis of the total attenders showed that 20% of the out-natients had
contacted the centre directly on their own initiative without Sy prior contact
with any other source of treatment
n-p
u
n 7 , , prior contact
of their own accord had had nrevious contact ^with <M-h ° £
to have come
regarding their chest symptoms. 31% o?
F^ho”adehad°r t^lr Syffiptom3’
enalysis^Xd^of^the Pre‘
t^on: of generalSS “ Ta^Td? instltutl°ns 8W — at instiBPeeialised tuberculosis institutions and 2% We^ SlTt'o ro^^Vexact
Out of the 1,985 urban patients, 7% failed to return on the third day for
ascertaining their sputum result and commencing of treatment if needed
(initial default). 82$ of those
-Zff6 ■<?cntacted at home when reasons of failure
to return were elicited,
Same of them were as travel inconveniences”, ’’forgot"
was "out of station”, etc.
“e
e
is3.
©.
- 18 -
:lr fyTSi^oVX^r a: a SP:°lallZea
centre
such specialised
TXo do
°f the knowlea*e that
people prefer speciaH^d
X”* It^l^s^tT
and rural patients behave in almost the sfeme way in that their fir^ ™ 7
sy^toms restive of tuberculosis, is initially at the SeXl
or
W)
-0O0-
CASE-FINDING
ts
SOME OPERATIONAL FACTORS INFLUENCING THE RELATIVE UTILITY OF
CULTURE METHOD OF DIAGNOS IS OF PULM3NATO TOBERcXII
K.P., flair S.S., Cobbold N. a Haganathan N.
1
is ^6ed on the Pre^nCe of
t^ercle
ra».
6
the laboratory techniquea enmloyed and ite
f effichcy depends on
ouch as epidemiological suX
different practical situations
diagnostic service Sd ZSon of L^ZTorganisation of
control programmes.
th™etXn<T
treatment iE tuberculosis
countries musthe .tnZ,
tl cat,ilitT of culture method in developing
data
X investigation^des^ned\P£Pr
Wlth Q sy8tCT-3«a stud£ of
operational factors on the utility^ the eu^t^etmeSod^flUeDCe °f Certaln
villages in the three sub-diXSn^fTaSkfUif B^alore^irtrict11
»!
sis is based on the material from the fi-st round
t aistr\ct- P1® “by
spot and overnight were coUected at intervals of’slf-UB
°f sruta’
x—
- 19 the
^ory at the r National Tuberculosis
in the laboratory was 1-7 days60 A^e^100 °f sp6clEens in the f
-s stained and examined first
X^r,QtS6eoceopy
thenT^/^l^.
E”hS'-"
Neelsen method. Each specimen
ensen medium. All positi^Xs
growth at room temperature,
^n,i exposure to
light, catalase
and PAS.
j sensitivity to INH,
Study ii; relates to a mss case,
two
specimens (spot and overnicht) vZren^e^~
end over with sympt^s rswestive
- :' '
of pulmonary tubercS^Kd^20
uberculin reactors below'PQ
voluntarily
f
Positive
specimens were then treated-Jinyears
the same w as in^t^i
Wons. The
Meelsen
waeBsaent
of , ‘
performed by the auxiliary
“hStV^c^
0^ USlns ZlehlRnn-’"1- -- '..I... a X>t ^h< 1 ff °f FeriPherai health
at each health ?L11 •
Speo:imen ~
“
examined by Zlehl-Neelsen
were XS-E”
:!e
~ '^amination
1 and
—i-HSSSa” -
vere identified ras in Study I.
smear.
these centres' and
the procedures andX^nterLT °Ot tran3P^ed in
the interval are same as in previous
riet7tubercLL>i^en^a Wlth qperntIon^ and technical r
assessment
of the distment. A sample was taSTL®
Si strict one year
after its
cccunenceperiod 'nut <51'1 not collert tbeiZ
Started treatment during a
in the field, stored with™+\„
fl helr dn?--s- Spot specimens —
thereafter the same procedure fX^Xto SiX* t0 were collected
-1 laboratory,
IngLheXt^e^ethod0^!?4^63 ’>rou^lt 0,rt
certain operational factors affect?he reGults showed that
an interval of 7 eays
aM lts processing in the laboratory
positlve cultures,
the sP*ci°®B vere^
condltlonS.
ZLiugher proportion of ■
than
br P^du^^^tS?
^^t
yas depndent upon
“t£
116'na8nifr>r sputum examination. (3)
UP°n the Px'ccedwe of L__
Id service programes ^strieted^rpe^o^”0'13
(3) In
with symptoms who attpna /?<«
rvioe programmes restricted tn
diagnostic
icc^ed view L t00 S5all to
between collection of
did not affect the
stored and transrnXT
I^sitive cases X^eteS
s*~S£ ."•zs:
-0O0-
SMumMna
i
cassia
POTENTIAL yield OF PULMONARY TUBERCULOSIS I-- —
CASES BY
DIRECT MICROSCOPY
OF SPUTLM IN A DISTRICT OF SOUTH
INDIA
Jis
ulture.
G.V.J.t Savic D., Gothi G.D.
Naidu 7.5. & Nair S.S.
The objectiveso of the study were to undergo
n
?es
ure,
m^t1?
perlPher^ health'inst^utions fP^^^T^r1 SBPeCtB °f Case-
(1) Mat is the frequency of -Gersons shnwinT o
' in an integrated programme,
tuberculosis among the nonnal'out-patient
pulmonary
can be found by direct microscopy of sputum of
h°v many cases
be the workload of TB case-finding at a Pm an.thoa® ^t^ics, (3) what will
will be willing td and will actually attend the’mhat Proportion of symptomatics
referred there for'X-ray examination.
District TB Centre (DTC) when
INil,
ro
The study was conducted in a diRtr^+
-> x.
and 55 PHIs. 15 PHIs were seated -on Kn .
3
At each PHI an NTI investigator worked for a
random sampling,
patients were questioned for avmrf™
;period of one month. All new outpatient with defined symptoms (thinly
and suggestive) and any
to a sputum examinatioXd
tha“ one
™s subjected
and also referred for
-------- x-ray examination at the DTC.
It was found that 3.5£ of the total r~ ^
-S^t-patients aged 10 years or more ,
lained of cough for more than Fweeks
and
eompCj
cases, of pulmonary tuberculosis. When the
symDtomQtics, '11% were new —":
When the symptomatics were referred forVmv
examination, only 66#
to
referred) actually vent for x-ray
^ch'S
hadT Whil: Only 1655 (°f the
each PHI had to examine only one or two .
sputa per working day.
r
■•d
>
Inllllon> ^ng one IXPC
As the study was conductpri -fn a —A
duration of time, the material perait^thresti^r16 °f
f°r Q representative
of cases in a DTP during a nerlod r>f <-< he,estimatlO“ of the potential yield
ofthe total estimated^prevalenc^of
“ VaS estinSed that
nos^d _in a DTP during a period o/one year
“^rict can be diagthe programme recommendations. The workload L ? .
according to
ie smal* and can be managed with the exint?tul)arc’ilQsia_caBe-finding
JH-Ej.lays a very modest role in c^e rinding
°f a PHIa
examination of sputum at the PHI has to
* dlreOt “
-oOoB
BACTERIOLOGICAL DIAGNOSIS
OF PULMONARY TUBERCULOSIS -
SPUTUM MICROSCOPY
K.»P, tS NagpauL DtR,
diagnosis of puUom^y tuberculosisr^acterioloric^di^10 ?ethods for the
- P^^ses
of bacteriological diagnoale. is a varlable^ce^al^^e^^
20 -
i
I
- 21 -
trebly influence the sensitivity and tS
viability of bacteria consivary under different diagnosti^lflclty;
^ese in turn
would
variations could be the different crtteria'admt
reasons for the observed
might be due to the observed ran«re
aa'3Pted for examination; another
logical survey at the one extreme to tS^es
S“uatlons fr®> an epidemioively .backward community with poor tuberculosirSnostic^mces!
^^rti^\tat1^eC“^a^XjvCMR
“ haS
^at culture
patients attending rural general health^rwtitirt-tC
whereass among
of the infectious cases foundry catu^e^nuia^^^^L diagnosis, about 8?%°^
SpOt ^ecimens fRao et aTlOgg)
hy “icroscopy
Tublrculosia Centre, could X 67? oe „
ikand (19fi5) frcra E,ew Delhi
'
Mitchison (1967) fOund Sat '35? Jere
micr0BC0Py. ^ereaa
reDortinB for the first time
In th i*ivc' “5cng the sputum positive •
Study in the Banaalore area rt w»«
J
longitudinal Epidemiological
direct smear and'the
" W
"v
these variations could be the different 7XL
°ne of 0,0 reaEOns
ie the etSning^nXe^dopS^rXrthe1’^1"?1^ °f SpUt™1 "^wsePPy
clan. It has been fou2d thetoX^Xsis
°f the drained tXithe general health institutions (1 S)
auxiliary staff (trained) in
diagnosis (1.3/) hy experienced techMM^ v favourably with the overfactors like the quality of snutum
1 f.8 Besides these aspects, other
*
1 deciding the suita™Z
bah;i^
various of
countries
and in different diagnos^i^Xiio^s:
pulmonary tuberculosis in
-odo-
CASES OF PULMONARY ------out-patients attends
general health’iNin^oiJs
- - J IN AN INDIAN .CITY
Gothi G.D., Savic D.,
G'V'J, & Samuel S,
The Study was undertaken to investigate the
nnzi
r^ortion of persons with chest
rttenMm rt’1® ’ feVer* Paln in chest and
haemoptysis) among out-patients
attending the general city dispensaries
J» and the proportion of pulmonary tuberculosis cases among 'them.
Us
If
- 22 Siould
srved
XXhX‘:T7hc
)-
tion of spot sputum sample and 70 mm chest^hotof??ptom ‘I11®8*toning, examina^direct smear and culture. ■ Study duration was wT^-sp^TeTth^"^
was
■a-
ure |
j
X
w
The study showed that about b7% of the out-natlPn+=
4* 4. 4.4
primarily for relief' of chest symptoms. Of^hese
^nsaries
probably active pulmonary tuberculosis and 0 fl? ™
h * evlaence of active or
is concluded that even Siowh S are sneci’^ XT
P°Bitive
It
city, a fair number of new and old
4
terculosis institutions in the
ries. These dispansaries can thereforeTi+T J8*161118 contact general dispensacase-finding in the city.
P
contribute considerably to tuberculosis
*>y
-0O0-
ASSKZ)H^lnI^W tuberculosis by sputlm
MlOTOSCOPY IN A DISTRICT TUBERCULOSIS PROGRAMME
i-
Kao K.P., thir S.S., Saganathm N. & Pajalakshni R.
. microscopes
S=ro'coS!%^it7S
“eL.th°fSJr)TT
Jhethdiagn
°SiS 1S M3ed On 8Put“
fbr this p^rpos^
Ttrict are PTWldea
gramme activities haveTTbe carried out bv
TT instltutions the pro
training given by OTC personnel on th?^not
“ Sh°rt perloa of
PHIS is likely to be carried out bv anvT™ J? < mlc£-O3eolV workjjijthe
by a qualified laboratory technini^n^TF’^^T^T—-^^B^SZngSggsarU-y
the standard of microscopy carried out bv
f Lne?essaiy to
whether
short training will be 1^0 ^e mark^
P^edical personnel after a
'."ES'aSL.xxsx’:" x •—
4
, a study
various
of the
Under the DTP a spot specimen of sputum is collected from
attending the he&ihtitStions and a ^eS is made
every chest symptomatic
examined for tubercle
bacilli and all positive cases are put under treatment.
eXam4lned in the8e
Centre3 were b
clan. Duplicat7rael^ tcTXiXT eXaml“ea^ en experienced laboratory t^hniresults canpared with Results ofrJTTT T” th6Se sPecimens and their
specimens were cultured b^swab meth™, TT" fma 8entr®’s examination. All
to sensitivity and ^i?icTion terts
CUltUreS Were SUbJected
I
4
- 23 -
Analysis of the renni*
x
on culture showed that barri
thriai=V‘^^
: - Sxs. S-™
variation and d
^fer diagnosis
“
The
examination that
-- -ng«
” 2K XT-^‘2 =SS.‘-‘
■
•“OOo—
treatment
PROBLEMS of
treatment of tuberculous
^othi G.D. &
>
.1
PATIENTS in rural areas
G.V.^
The paper ls
rural areas, a discussion ron the problems < “ As suggested therein*
allzed anti -tuberculosis
tuberculosis in the
- .
J an integrated
service
is
vast rural areas.
^^ice9 ie the
specie
-J only suitable method to
reach India’s
The problem
and
listed Qa technical,
considered, ^TXr0Xlti’microhials should
1,216 ch°ice of &Mt‘ organisational
the patient.
Qntl-raicrobials was
Streptcmycin
-3 acceptable to
deliver to
,------*aee
suitable,
patients in rural
^
^ces to
for the health r~
Paper
the probabilitv
the wide P^7/
aiT
r was
Probabiiitv’nr^^ . Station
llmltation of
This hasnnot beXLT
iCat
*On
of
been conslKl
trea^SV’
re8iorw* treatment
considered
t° the vast ma.lSlt^rT^Sl^^hgh
'
coXiVlXegiT
1:
i-
I
StsriT*" -
drus coliection^thei0^608 listed ve
re: (i) irr
were:
and remedial action (4^ntification, (ii) def^^V °f
Intake and
®ent and folloW_UT)
* Eain'tenance of record^ ’ ,at,druS collection, intake
regular collection could
whlle on treat
C0U15 ,CCra;rleticn of treatment''’ Th'Z Check
cation of initial an<l^ubsea,talrfn 53 “ index of’re^ia?6?®1, 8,uP'?ests that
- subsequent
actions could retr<Z
sul,se<iuent defaults had to
tr, be'^
f
intake. Identic
yell as fX^
3
°*
°
f
the
inters
6
•■'-up after treatmX®Jeters. <^ck
patients due tn
r_treavment were
4.- V.^?.cK_up_during treatment
to «
a number of reasons.
fOUnd to be
acceptable to~lSe~
^52^ -
iDS °f 8taff to
render services was also
problems and ita remedial
measures discussed. higiilighted as one of the major
-oOo-.
K?’
1
tn-’-'®'
it
’her©
INTERMITTENT TREATMENT WITH STREPTOMYCIN AND ISONIAZID IN RURAL AREA
and
Govindaswamy V. & Savic D,
B-
i
?r
This paper studied the acceptability and applicability of the drug regimen strep—
tomycine 1 gm and INH 650 mgm once a week in a rural area as well as the regula
rity with which the rural folk took this treatment. Association between the
observed regularity and factors like age, sex , etc., was also to be studied.
107 rural patients'of tuberculosis, diagnosed at 5 taluk hospitals in Ananthaz
pur district of Andhra Pradesh on the basis of sputum examination by direct
smear and/or x-ray examination with the help of mobile x-rays, consented to
treatment with intermittent regimen mentioned above. About half of them were
new patients and the rest were old patients who were mostly regular on an
earlier oral regimen. 94 of the above were available for analysis.
T
1
The regimen was found quite practicable in the sense that at no centre was the
study interrupted or discontinued because of the inability of the health centre
staff to give injection. However, its initial acceptability to the patient and
subsequent regularity of those acceptingthe regimen were quite~I6w. There was
very steep fall in regularity during the first 10 weeks^bf^treatment, nearly a
half of the total cases became irregular during the first 6 weeks. Beyond L
months of treatment, patients who continued to attend centres regularly for"
treatment became negligible, thus pointing, that injection was not a key varia
ble in the treatment regularity of tuberculosis.
-0O0-
SOME OBSERVATIONS ON THE DRUG COMBINATION OF INH+THIACETAZONE
UNDER THE CONDITIONS OF DISTRICT TUBERCULOSIS PROGRAMME
Gothl G.D,9 0rRourke J.O, & Bally G.V.J.
The study reported, the applicability of INH-Thiacetazone combination with ref
erence to acceptability and toxicity.
150 patients from Tumkur town and some nearby villages were discovered during a
mass case-finding programme, of whom 127 Including 43 sputum positives were
given chemotherapy with 300 mgm INH'and 150 mgm thiacetazone (TH), in a single
tablet to be taken once a day. All but one of them had the treatment on an
ambulatory basis. Results of treatment in respect of 103 patients are presented
in the paper.
The overall death rate was of the order of 15$. About twice the number of
deaths occurred among the sputum positive patients than among the negative ones.
About 4o$ of death occurred during the first quarter. In all, 23 patients
developed side effects, in 18 of whom thiacetazone had to be withdrawn.
Serious side effects occured among 5 (about L$) patients. These patients did
not report to the treatment centre and could not have been detected, if not
- 2L I
I
- 25 home visits were
^ade, -thus /living ar
with th.
erroneous impression about Bide
^^sputum conversion
effects
.
-at the
survivors
•Among
eBfi
yeQr
Was
the
c
■
_th0se v.a ^rsion ^te.^E63i;
Of SOX
all
sensitive arH
- - Favourable
radiological
rfcXSE1
^d
Thus, •••
v one year, con' caI response w?s
■though cheap
seen in 7k%.
and <dinicali-----found to
■
to produce
-X ef fecf ive
ttt •?
seriousJ and sigm^
■LV^> ih in ctreatment centres
combinatio;
,n with IWH vas
txiis region o
were *hou/?h to ant 31 do ei’fects
e ^oessajy vhen Hence givigiiance ty
the patients
—5 are on
-oO o-
Qollect/om and ^ONS(j^pj*|Q{\j
5
‘ DRUGS UNDER
G.D,
I *
Savzc D.a
anti-tuberculosis
Rao K
*
This ‘
— e™irtl0n vas to find
ea*s put
•• - J Qn dailiciliary r - 3 °ut the
Nazr s.s.
Samue l R,
X Patients that
nake v«-ious le^£;
M-^-ug collections i?1”3 Of pXion
"
different
^ or time
U’ 'L
■'• I w
M
city vere
the time
inelusion
surprise
tine
Croup
««t aoX X,
sixth
Urine
becau= 3 tt?e LVei‘e
were c
.e?*^
Judged °n the ba3is or
°f results
xb’fifth
f urine exami^tion.
'
G/^ed 5 v°ar
galore
stw! r0;- ^.^ination ar^iJnto~^o^
at
ssriPies/n5ne
w.e SEK1, ooch patient at i-t1
series of urine were con'PPprnlRed
’.third at fourt?-6^
one
J1Z Qt twelveth month fourfcth at
“ drug coliLf •
treatfflent9 .
• the ^id peri^D fnLthe “'’"th
their
at recorff and" metabolites. The dXSreC1”ens
CplfiWtion on t^ ba°s^seCtlOn
™
Of the
over^ ^X^ients in0iuaea
in the ctudv
d or severity -0 fd.i c o^°nthS
[I P£22ortion
■
,
.
for
h Ion
t’^6^^
for IN
inh
-2riIfH se^itive
•
^otwiolo^ie’V8 Who had collectea ^clra^Sthg~oF
«»s;
“•«»w
Quiesence,
I
sWest that +>>
ections.
- —
th e
^o eoli^ '
achieve
le’e a hlgfc
of
aiso consume
t’acterioiogicai
"•c Do
.4
r
B.C.G
ASSESSMENT OF BCG VACCINATION IN INDIA - 3RD REPORT
Kul Bhushan
In the period 1955 to 1958 the All India BCG Assessment Team carried out an
appraisal of post-vaccination tuberculin sensitivity in mass campaign BCG
vaccinated 262 schools in 159 different localities with 91 different batches of
vaccine produced in Madras, The interval between vaccination and retest varied
frcsn Is to h2 months. Tuberculin test was given with 5 TU RT 22.
1
The mean size of reactions varied from 8.3 to 16.6 with overall mean of 12.5 mm.
Less than 10% of the mean values were under 10 mm and less than 10% over 15 nnn.
Analysis also showed that BCG vaccination was responsible for an increase of 6-7
mm in the mean size of reaction over the pre-vaccination level of the non
infected. or 6-7 mm less than that of £he naturally infected children.
1/3 of the groups had their sensitivity increased upto 6irm and 2/3 by 7-11 mm.
Comparing with the highest attainable degree of tuberculin sensitivity in the
infected 1/3 of the vaccinated group fell short of it by 5-9 mm whereas 2/3 were
within h mm of this level
Increase in allergising capacity of the BCG vaccine after introduction of modi
fications in the production procedures in 1955 and again in 1956 in the Madras
Laboratory were seen. Waning of allergy upto 20 months after vaccination and
boosting thereafter probably dueto supeinfection was also observed.
In view of the variable and low levels of allergy in many groups switching over
to production and use of Freeze Dried BCG was suggested.
-cOo-
ALLERGY PRODUCING CAPACITY CF MADRAS AND DANISH BCG VACCINES
AS SEEN .AMONG SCHOOL CHILDREN IN BANGALORE
Bag Barai/i^ Xul Bhuehan & S'^bramanvan M.
A
In all, 1,259 students aged 11-19 years from three boys High School of Bangalore,
formed the study group. They were tuberculin tested with 1 TU RT 23 containing
Tween 80. Boys with a reaction of 13 mm or less to tuberculin test and.willing
for BCG vaccination were allocated in 3 groups: (i) to be vaccinated with
Madras vaccine (211), (ii) to be vaccinated with Danish Vaccine (236), (iii) co
ntrol (no vaccination) saline injection (231). Strength of Madras and Danish
vaccines used was same, 0.75 mg per ’dose. After 3 months of vaccination,
second tuberculin test with 1 TU RT 23 with Tween 80 was given to 575 boys
included in both the vaccinated groups and in the control group. A follow-up
at one year after vaccination was done among 328 boys, who were again tuberculin
tested.
The analysis of data shows that the mean size of rost-vaccination tuberculin
- 26 -
- 27 -
BCG vaccinatetTgroup3 ^draB ECG vaccinated group w>3
g
m respectively
was 11.9 cn> the
devdntL
DaniEh
not rtatisti™^, , ? Ve differences between
o
vere 3-8 “d 4.5
2 BCG vaccinated3^ E Knificant" Similarly, the post
va°clnated groups were
more to 1 TU RT 2? t.h+/£ ” rre“VGCcir^tion tuberculin inX
nation
Tveen* did not increase bv^
9 mm, had an ineXK SsF pre7vaccination tubercSin
concluded that the pi - * J ~st“vacciration allerrv o^* a
1X3st’vaccination
was 9 m er
»»««y .?£ s‘asu:
~
tX ? Wns hel-w
over 8
-o0O'-
ALLERGY AFTER BCG VACCINATION
KuZ Bhushan
Tn view of the <--- •
the Indian Mass BCG
Teams, some studies
S fnflUeDCed the
Of
In the ]
* •-_
neighbouring
un-vaecinated QreaB
on allew.
They are described
„
^-xasKsS1£S^°' ’“1M” “
Sr.s.»«:„e;i.a „
-f»y “SSBESfg-p--»
nated by aE8eB^^^a“°“
mass
months later.
was higher in aU t:
the five groups vacciWith vaccine stored bv the
aCcine st°red by them than
n in those vaccinated
groups vaccinated in the firsT CS?I’alpn teamE>- « '
vaccinated in the subsequent veS^
level was further seen that the
of allergy than those
!
i
I
assessment t^w^nd ^^^0^^
W gr0UrS (°Ut cf
vaccinated by
was similar for both the teX
the Mass Campaign TeaM.
In one group
it
w- higher in the case of^;^ ““ B1groups ccmbined,
however
2fSrss
and vaccination with
technicians each were
at random from four
testing,
rending
the mass c ~
it was found that
efficiency of
xicantly from
and rreading
'*
differed sipii-.
however, were noticed in regard to the assessment
team personnel. No differencgg*
post.
.
-vaccination allergy.
- rmisn-:-;
r
' -------- - -
I —.......
- ‘28 -
Slin de^°
m
whereln a lar*e rr™r' of BCG vaccinated children was randomly
SmaJ'1 ;rr'up5’ to RVOi/?
boosting due to the repeat tuber-
The resets show that the mean of reactions at 1 year and 2 years were
In Jhose re-tested after 2 years, however, one-third of persons had
be the XTn?3’
Onrt^lrd had ve;ry biS reactions. While the former could
thS latter Vas ^rhaPs
natX^StinSL0"
to a
•In the third year (not included in the paper) greater proportion of people had
bigger reactions and the level of post*vaccination allergy was higher,
^5! XS
!
r
n
red properly, (3) that tuberculin testing and reading
ninS rn,3!^ ^QSS ca21paign personnel though inferior, their vaccination techRlve+camParahle Post-vaccination allergy-,and (M that post-vacciClergy not only craned with time, but also perhaps was influnced by
1 syPGr-iDfe^ion with time making it necessary to elicit post-vaccibnt-po* aoX^rgy f£°n ^tGr ^ccinatlon and at more or loss a fixed time eop„
between 3-6 months after vaccination.
-oOcDOOR TO DOOR BCG VACCINATION
Bail'j G.VoJa
The objectives of the presentation were to understand the operational efficiency
of the centre type of BCG mass campaign in India and how the efficiency especially the BCG vaccination co
coverages could be improved through adopting a houseto-hov.se (or door to door)
"*) approach.
‘’
wars ssgis» jss s ss:
Presence of BCG scards (as an evidence of vaccination) as seen in
syrrey done shortly afterwards and finally the coverages as
obtained m an operational study of door to door BCG vaccination.,
nn
^paign sported that 35$ of the total population was tuberculin
(,vacc^nay°n coverage reports were not available) the epidemiological
. ur-v-ey snowed that shortly after the mass campaign only about 10$ of the total
popvlat on had BCG scars, while 60$ were tuberculin negative and eligible for
vaccination. On the other hand in the house-to-house campaign 80$ of the eligi^les could be vaccinated. The presentation also highlights the dis advant ng e6f
carnSgn
USe prOgramne i’e’» that U is slovor than ^e centre type of'£ss
-oOo-
SIMULTANEOUS smallpox and BCG VACCINATION
Kul Bhushan, Bally G.V.J. & Naidu
70 B9
stered/stomMOTUsly witOrimar^^i^3' WheD BCG vaccination is admini-
below
•s^25^^y
e^d'^^tXio thf5tu"7-
yere TOcci-
«-?k: yssas ts‘“ r*3®ss&»asT
5esltW° rC31n®®tw^"”™^e^^^it«S01?8ical InterfereBce between
i 3-'
J
lesion of smallpox vaccination
1-e,” the
of
similar to the develojsnent of the -maii smultaneous1y vaccinated rrrnUp was
smallpox vaccinated group and, theleSi°n
the
__
..
_■ vaccinated
group was similar to the^o^6^7 f"® tO 3CG aDlonF the
siraultaneously
'~_
among the only BCG vaccinated grour.
^-vaccination allergy
were very few and similar’
_
'_
ng the simultaneously vaccinated^s^0111^1^5
other respective group.
Thamo
e ac
I
ceptability of ^maneor^^S^^iX!
The above study J
has demonstrated that BCG and mniiy.
administered^simultaneousl^.'
2^2£inaticns can be
!
-oOo-
.{
assessment of post-vaccinat;^ allergy among those
w ITHOUT PRE-VACCI NAT I L ' tUsXl™
BCG VACCINATED
TEST
AwZ BhiLshcm, Nair S.S, <3 Ganapcrthy K.T..
1
Assessment of BCG vaccination is Lnort^
this studymportant.
l!
TI
“ 29 -
.. ...•
S nethOd °f Teehnical
Following methods were tried in
I
4,' I
'i ! ' '
- 30 1.
Four groups of directly BCG vaccinated persons aged 0-19 years were divided
into infected and non-infected by a tuberculin test done within 2b hours of
the vaccination. 12 weeks later post-vaccination allergy was elicited only
in the non-infected. Varying levels of allergy were seen for the four
groups. This constituted the reference method against which technical and
operational efficiency of other methods was compared.
2.
0-L years age group being predominently.non-infected when tested after 12
weeks of direct vaccination showed differences from reference test. Thus,
not technically suitable. Moreover, fcr sufficient children to give valid
results, coverages-of very large population was needed.
3.
Having found a positive correlation between tuberculin non-reactor (0-9 m
tuberculin induration) with 0-13 mm local vaccination reactions on the Lthday, when the latter were tuberculin tested after 12 weeks they showed
compptrstive levels of post-vaccination allergy with the reference method.
Operationally however, this method only gave a marginal advantage since 3
instead of 4 visits were required.
. I
u.
Induration size at the site of vaccination after 21 days were not found
comp ararable with the post-vaccination allergy' in the reference methodo
Operationallyi this method would have been most useful, as it involved only
one visit to the group.
c
Difference between mean size of post-vaccination tuberculin reaction among
directly BCG vaccinated and in the reactors in the neighbouring unvaccinated
areas as index of adequate post-vaccination allergy in the former group, was
found to be reasonable method. Though it needed lesser number of visits
(two only) to the area but involved greater amount of work. Further investi
gations on this are necessary.
6.
Tuberculin testing of all directly BCG vaccinated persons including the
natural reactors about 12 weeks after vaccination compared favourably, with
the reference method, as the tuberculin reactors contributed less than 1 ram
over (and above) the allergy in the vaccinated non-reactors. _ This method
wftuld be useful when rate of tuberculin reactors is less 20$ in 0-19 years
age group and their mean size is less than 20 mm. Operationally, it is a
simpler method next only to No.h above. Further investigations are considered
necessary for final selection of.this or any of other method.
(
-oOoBCG WITHOUT TUBERCULIN TEST
Gothi G,D,9 Yut B/iushanj Nair S.S. S Baiby G.V9J.
Considering that in the BCG Mass Campaign low outruta end coverages of BCG
vaccination, done after tuberculin test were due to slowness of the campaign
because of two visits to an area, the fear of two pricks and tuberculin tested
^b&enting themselves from reading of the test it was thought that if ECG
T
fl
-r—
T-
« 31 vaccination could be given without
coverages^ppr^'iabS^otr
- .
earned out ;
I
prior
test without cnusir.r c-th' °tuberculin
U^ut?
any
+1,4
I----- J
more than dr.uoled
-1 and
.-or
or this, the following three studies were
- O^QtLd®«a
B “F—"
™B
-raJ^^^X
reaction
oggur^Ttoea^t^
?
. | complex) in the fonn of new .'diseased
i?
Up Of do^Lf0c^Pr^ry
tuherculinOtested<3LdU?<Of1*’52° ropulatlon from 4 villages
S s^V?ne ^rd°t^: FFreafrtioas.
™ned nor
\
\
reartiOB8*
------1,186 TOre both
aay confimea-t^nd^^ "
«
this etudy axillae were not
^atl°n
tors^lt
study because of lft|ye- ■
ocaj7, reactions ..in the Wit!
tes its acceptability S^the r^M4 .l----vaccination~waiF?^^^
investigated,
; -a- Pof tMst direct BCG^
in
t
SX“r? reactions
''“*‘“-o0o~ 1
w « OP^e, « MADRAS LW,0 „ vm,K
A
« «»»<„, Mr s.s„
t
Indian BCG vaccine* uVi-i al*
its potency was adi,^ 5 WaS lnltlaHy weak was
t^Vfh^^
and stability on storage?
8^eqUently 80 improved that
was canpared^l^^n
°n’ obserStraln8’ productlon-efticiencyTth^SoX^6
On a predetermined date in each
t0DanlEh
« -wr
t
- 32 -
i
ti™ strains^nd oSy ^sh^i 01d/^
TOCcineB
their reapaalaboratoryTvaccinations £re
°f ftrainS bo^a from the other
consecutive weeks randomly, to 2^9 taberc^i™^1^8
n°nth’ in two
allergy was elicited lOw^ks later when siS of KG nT?0”’ P°st-TOCcination
Viable counts on all vaccines were done^
nOted’
further ana^rir^fo^d^LrMad^s BCG^trai^111'117-'1^8 °f allersy’ on
i
i
o^"^^
tetter
induced the highest.le^el of allergy? The^tebllit^of" ^T88 Laboratory
'
Madras strain was found to be unsatisikrtn^
f vacclnes Produced from’ / .
lesion size more or less confiTrn^a
x r^* ^esu^^B according to vaccination
corroborated in terms of SrXnts.
filldln«3- They, however, were not
over time/seedlrtR of?suitabl^^stP yadraa
strain.wgs^due^^tojutetion
from Madras Laboratory.
BCG atrain wo,31a ensure uniformly potent vaccine
-oOo-
'I
BACTERIOLOGY
AN INVITRO STUDY ON SENSITIVITY OF TUBERCLE BACILLI TO TH IACETAZONE
Rao K.P,t Nair
i
I ■
i
(TDD /
■ ^aganathan N, <S Rtmanatha Rao G»
on the study of 735 cultures < * °f patlents te
°mi
Sputum.specimenswere
attradi^g
Tuberculosis Demonstration and TraiMn»collected
p1 fted from patients
attending the
?
’
ainln
8
Centre
>
Bangalore,
and
from
th!mass
case-finding studies in
CeD^’ Ban«31ore.
from the
rnycln,
IsoXi^X
^s.
Drug
sensitivity
tests
for
^n’ ;®n*a21d> PAs’and ThiXtazone'rfth1’^1-8-—t’Vlty testa for StreptoStrepto- '
different size of inocX^d for2°“
aiffereOt drUe e°"=entrations7
or inoculum
-------- 1 and for various length of incubation were carried out.
was observed in the duration of Bw»Ui oerween sensitive and
hS
8”"“ b«"“ •™‘«»
sub-cultures on drug^Tlones JSJT®1106, °? rri”ary ala«n^tic cultures or
primary cultureslXXj■ s'Xta tit63 "“o
SUBpe"aa°n. The
appear on
drug free
media. Large se^itlveT^JT8 2 WeSkS f°r the srowth to
appear
on drug
free media,
concentration of thiacetazone to inhiblt^h.?
populatlon required higher
of
inoculum
size
for
sensitivifv
11
^
e
1
erowth
»
suggesting
standardization
of inoculum size for l
slopes
showed
profound
influ^ce
on
th'
1
Pro
n
l
oD
S
ea
.
i
“
^bation
period
on drug
slopes showed profound’SH^e
-thiacetazon^
with
t
p^^
r
X1“* — *
sensitive culture r.:^
of this observation
in the inhibition < “ ~
presumed to be due togrow™
either or sensitive organisms on drug media with time is
by the mi^rgaSX!
ln the media or aue
to radaptation
' ‘
-
i
I
- 33 -
Because of the inhibition of growth
even sensitive organisms may be class!fl
for
senanivity Ia prol^:aC^«
It is suggested that a standard inoculum sLe
—a period should be adopted ftr Sng “t
Cultures classified r* “•*
'the three first " ‘
or more, shaved no different inthe
°r resistant to 6ne
-J pattern of sensitivity to TB1’
-oOo-
'
s™ s.s-x?: Es”— to
to K.P.
(^°^E Pat:ientS Varies ln £Serert
S “
reBlstance ““’“S tuber.
(1) Sasatcria (ii) Urb Tuberculosis Clinicns;,
^tuatlons considered are:
pensaries, (iv) the mass casef1?1’
^nerai Health
(v) survey of Fenem ror-ulnt.ioa 1PR
“^cted group.0f populatioirand
highest (^alX^Er^ong^aUents^de^^t^r^rn4 PAS) 18 f0UDd to be
S
c£°”® nevirdiXBedSu^00®
institutions and selected c£eX^ tuberculosis clinic, rural general health
IHH resistant organisms were 262. -wj, and* pyoportion of patients with
^generally hipest in
resistant rates
rates were not sigifficantly different---- The nXS 5 sltuations, case-wise
resistance among patients found in snecla?™,
e! °f I1,H’ Streptomycin
gramme, were significantly lower than anon/^H“^-finding tuberculosis proculosis services or general health institutions!61148 attendlnB sPe°ial tuber-
^ttend^jJJJXsis^er^es4^
U^Lofthe^eva^nce^f' drug resist in the c!Xty!°na 18
B trUC
-oOoA COLD STAINING METHOD
for tubercle bacilli using chloroform
Rao K.P., Naganathan N. & Hair S.S.
The difficulty In staining
complex surface structure tubercle bacilli is believed to he related to the
staining technique which > containing a large amount
—.—j cof unsaponiflable wax. Any
to give bX^XX^
■ fore be expected
<— ■ *
rnho 1
°f this wax could thereThe_ standard method in vogue is by
the applicationi of heat which renders the bacilli
- permeable to aqueous dyes.
4
• - 3H Several attempts have been made to develop a cold staining method for tubercle
bacilli as for other organisms. Since this wax is soluble in chloroform, a cold
8taining_methQd using carbol fuchsin containing chloroform was developed and the
results of staining by this new method have been compared with the conventional
ZN method in the present study.
Triplicate smears were made fran 186 specimens and smears of each were stained
by ZN, CS end FM methods. The results of examination of duplicate smears by ZN
and CS methods show a higher degree of correlation with 75/showing identical
grading and only 8$ were positive by one and negative by the other method. The
reliability of these methods was 'judged on the basis of culture results and
agreement among themselves. The cold staining method was found to be as effi
cient as ZN method in detecting different gradings of culture positives. False
positives with this method were significantly, lower than by ZN or FM microscopy.
Some possible explanations for the relatively less number of false positives
under CS method have been discussed in the paper.
-oOo-
GENERAL
DISTRICT TUBERCULOSIS CONTROL PROGRAMME IN CONCEPT AND OUTLINE
Nagpaul D,R.
This is a conceptual account of the District Tuberculosis Control Programme.
The district Tuberculosis Programme was formulated by the National Tuberculosis
Institute in 1962 to form the basis of a community-wide programme to deal with
the challenge of a large, predominantly rural tuberculosis problem in this country,
bjjilted resources in the form of, funds, trained personnel and, equipment,
made it necessary that the programme be simple, easy to anvly and. widely
acceptable.
The DTP includes provision for tuberculosis case-finding, treatment andrrevention_throughout the district from the health institutions in an integrated
manner. Case-finding is carried out among the symptomatics attending the
health institutions primarily by sputum_ examination and treatment is offered on
ambulatory dctaiciliary basis.
District Tuberculpsis Centre CDTC) represents the pivot around which, the inte
grated DTP revolves. DTC takes up all the responsibilities in respect of the
programme on behalf of,the District Health Authority. It undertakes planning,
implementation, coordination and supervision of theDTP in the entire district
besides offering the usual diagnosis anTtreatmeht service to the population,
under its direct care. Health institutions other than DTC which participate
in the DTP are called "Periperal Centres”. These are categorised into
’Microscopy Centres" and "Referring Centres" depending upon possession of
microscope or otherwise. Both categories are full-fledged "Treatment Centres”.
Sputum examination is offered to all symptomatics reporting at ’’Peripheral
Microscopic Centres" and if found positive for AFB the patient is motivated and
put on treatment iiraediately. DTC maintains the important "District. TB Case
»
- 35 ::-J referred^The
"° the SPUtW1 Enear
symptomatica
referred by the "ReferS^entr"
"p^_e?U“1?atlon ?°
•
there
is^T^
^^2
“ ---- •>-.Va®®i-tion Tea.
also works under BTC
—
TB clinics become Just ’’Sub-Centres" u£der on^DT^*
already existing
Laboratory T^hnio^toJ^an’x^^w^ir’ ^reatment Organiser (TO), a
stical Assistant is required“o
&M * Sta«’
the prograsmo of caso-finding and irXonF^n
and to or^n^e
tho district from all aTOilablo instnuXs^^^^^
-0O0-
PROBLEMS OF MAINTENANCE
i
OF HOSPITAL EQUIPMENT
Menon V,A9
W.H.O.Vmy
?f IndlS’ Hp Bro-
in
found that botwoonj^p^ and 50g x.-mi
roasons and Buggers a ^edy ISF’
are to the commlty. lt'e^^+fe+J!S4arLf?8tltufcion ftor delireturns on thp J^v^stmeut^of^resQurces
fair
not put to us^hen r^dred
avBilable to such
an institution are
i
This paper also• suggests a method of evalu^tion^f th*
C»unlty loses—h reasons for s^TJoss?
* 1086 lncurred
community and deals\ith
One of the jnain
—
fg^gns./pr non-utilisatJon < - aVaUable faCillties
the un- '
—-ion and p^uc^ The main cause for
s^te o'
is poor distrihutlm
reasons make fservicing of equipment very
^s® tw°
under which the :institution delivering health’~caw\ ^^slratiy^onatraints
-r^ee
inaccessible to them or creates cons^rahde
♦
preceding period,^th^Zvera^f co^per^? ““Penance in NTI during the
out. By comparing it with^ost of Lsimilar sX?
re?alr servlceislB worked
institution it is shown that to eff,#v»+-r i
rvice available to an average
a Cheap service organization which has mits^X-ih’r^’*10118 °TCr a wlde area»
country is required.
Its dlstributed very widtely in the
SSn^^ cheVse^ce001”1111^7 aUe tO ldle e<luiP^nt , ’
and cost of creating
service organisation is prom^e^Ftfe/ci™ '’iF11 that investment in such a
Rs 71 milllont can be brou> do^ to U
1038 °f
7 TBttllSHT-TJhus; a conr-mityTC ^
only
W oFTietter fnrintip.
F- X? 1 to
extent of 53 million every year bv
^uSirelT^STcc^- for^eS3: “
'
I
personnel and 0.8 million for running iF sFFf rlT1*” fOr '“i’^nance
Power required for running a c^wi^; oSiLt^”
the
-oOo-
'lit,
I* .* •
assessment and monitoring of
national tuberculosis
PROGRAMME (NTP)
S.S.
extent to_T&jCh its - ‘
—•
/br?13
In Particular to
- • t0 be done
within what period of tine','
However, assessment of effSrnn 4
Prograde is felt oniy afUr a <• <
L‘ impact of a
as the
fairly 10^
of
Tuberculosis
of P^lem reduction will^Zi^f0 influencp
—«J_other
ana Win posSbi7Sar“
be a very’costly attempt at Any early assessment
Hence, a different proving the obvious
methodology of
Measurement of the
the
the programme are
Such assessment r
of Clonal Tuberculosi
L
-^ent has £ LeXe^Strat1-.
*1
—B Prograde.
°1Utlon t^thTVroblem ofrf^
For this purpose,
o, certain stages
(expectations) should
of the programme with
be ifonnulated
in dlfferent
and i
qua_ntlfiaMe objectives
stages should2 be considered assessment of efficient
----- y of programmes
separately.
Use of monitoring or r—
assessment based on
stressed that r
reports has been illustrated, it is
programme provided:
useful information
—J about the working of the
i) the <
district level
health :*institutions to the
improved.
improved, and
and Central levels
—> is
ii) such (----assessment is done
separately for districts under different
of development
stages
takenTAssess^nt eho^d 2*^“*
*h*’ r'“
''
corrective actions indicated
ilndingB should be accepted or at6n0Uph to insPlre c
are not
’ confidence and its
the actual “
—• persons incharge of
assessment should
Proper climate for
sers and corrective actions
organ!completion
-
—
brthe
the
-Oijr-
PP/
a/
" 1 INDIAN JOURNAL OF PUBLIC HEALTH
I
Igl
Ivfol
y*/
Volume VII
Official Quarterly Publication of the Indian Public Health Association
OCTOBER 1963
Number 4
OPERATIONS RESEARCH IN PUBLIC HEALTH
By
Stig Andersen*
1.
Introduction
The spectacular progress of public health in
certain parts of the world during the last cen
tury, and notably in the last half century, was
a result of a cumulative interaction between a
large number of .factors, chief among which
are two broad groups 'of factors: economic
progress and the development of science. The
gradually richer society could afford to buy
more and more Public Health Services,
improved public health in its turn accelerated
economic progress, but also—and this is the
crux in the present context—the technical
means of the Public Health Services became
invented and developed more or less at the
time when the increasingly prosperous society
could afford to apply them. The research that
was needed during this process was mainly
inventive and experimental.
The situation in the under-developed coun
tries by mid-twentieth, century corresponds in
some respects to the situation a hundred years
earlier in the rich countries; economies that
cannot afford to buy an adequate Public Health
Service and a state of national health which
hampers economic progress. However, the
decisive difference is that a very large part of
the inventions and experience in techniques are
now available to apply in logical systems as
and when the economic position permits—and
forces—the authorities to develop the public
health service. This relative preponderance of
technical knowledge over ec-cnomic capacity is
the social fact which necessitates a new type
of research. The research which is foremostly
needed in the poor countries of the world is
not inventive and experimental research; the \
demand of these societies is no longer for new j
techniques and new inventions to improve ;
their human material to a level they can now
afford; their demand is for systems composed!
of largely known techniques which give the^
optimal utilisation of scarce economic re-/
sources. Research’ that satisfies this demand
can be called application research or, borrow
ing an expression from certain other fields:
Operations Research
2.
Operations Research
The techniques of Operations Research have
mamly~been developed, after a start in~~the
"military field during and after_ihe__Second_
•CTorTfiCTarTTn the tidOiJaHiStnIi.I_ii-ui.nagc“ment. There is little likelihood that opera-p
"lions research in public health can reach a i
stage, for many years to come, where it can /
utilise directly many of the mathematical pro-\
giamming techniques which have been deve- ?
loped for military and industrial purposes.J
However the basic concept of research into total
systems which, in principle, can be translated
into mathematical models, can and should be
adapted to the needs of public health services
research. The name operations research im
plies that it involves research- into some or all
aspects of conducting or operating a system,
a business, a service, and treating the system
as a living organism in its proper environ
ment; thus it distinguishes itself from laboratory
research.
The following are the major phases in opera
tions research, adapted by the author from
* Sociologist and Senior WHO Officer. National Tuberculosis Institute, Bangalore, India.
14!
IND. JOUR. PUB. HLTH, VIJ. 4, OCTOBER '63
Churchman, Ackoff and Arnoff (1957) and
Hoidden (1962):
1. Formulating the problem, including defi
nition of the objectives.
2. Collection of data relevant to the prob
lem.
3. Analysis of data to produce a hypothesis and a mathematical model’ to
represent the system under study.
4. Deriving solutions from the model.
5. Choosing the optimal solution and fore
casting results.
6. Testing out the optimal combination of
interventions, with controls in-built in
the system to keep continuous check on
the hypotheses
7. Recommending implementation of the
solution, including the control system.
'fhe concept of an operations research team
is an important aspect of operations research.
No one single person possesses all the neces
sary skills and experience to conduct worth
while operations research. Usually a team in
industry comprises scientists in the fields of
mathematics, statistics, economics and engi
neering, in addition to experts in the special
field under study. Sometimes the team also
includes a professional logician or a. specialist
in the science of scientific methods.
research to one system within India’s Public
Health Service is being made by India’s
National Tuberculosis Institute in respect of
the developing National Tuberculosis Pro
gramme. The Institute is only at the begin
ning of its efforts, and only a few aspects
have been dealt with in published papers.
Andersen & Plot (1962) gives a summary of
the operations research approach of the NTI.
Raj Narcdn (1962) summarizes the extent of the
problem to be. dealt with, Waaler, Geser &
Andersen (1962) attempt a first formulation
of an epidcmetric model, and Panerji & Ander
sen (1963) and Andersen (1962) deal with
certain sociological and economic aspects. A
provisional “optimal combination of interven
tions” is suggested in Plot (1962). The present
paper suggests that operations research be
applied to the whole system of a Public Health
Service and attempts to foresee some of the
types of problems which an operations research
team would be faced with, divided into the
seven major phases of operations research
listed above. In principle the problems out
lined would be common to a good number
of countries in Asia, Africa and Latin America,
but here and liiere if may be apparent that
India’s Public Health Service has been con
sciously or unconsciously in the author’s mind.
3.
3.1 T he Phases of Operations Research
3.1.1 Formulation of the problem
Operations Research Applied to Public
Health Services
The need for applying an operations
research approach to public health problems
has during the last few years been recognized
by a few foresighted public'health administra
tors particularly in the United States and in
the United Kingdom, see e.g. • Committee of .
Enquiry (1956) and Bailey (1962). One of
the problems that has particularly had the
attention of operations researchers in these
countries is hospital planning, see Bailey
(1957).
There is no doubt that many public health
administrators in the poof nations of the world
are solving problems in ways implicitly akin
to operations research. However, it is the
contention of this paper that a more explicit
adoption of an operations research approach
would be of the greatest benefit to the Public
Health Services of- these nations. Moreover,
operations ‘resehrch should be applied not only ■
for* solution* of detailed problems within the
services, but, more * importantly, ’ to larger
systems within them, as well as to the entire
system of the Public Health Service in the
nation. A modest attempt to apply operations
142
The first and perhaps one of the most
formidable challenges to the operations research
team is the precise and explicit formulation of
the problem. What is the system under studv?
Does it comprise the entire health field of the
nation? Or can the team at least confine
itself to that part which is under direct public
control? How does the team define the boun
daries of its field'towards other public under
takings the expenditure on which can be
considered alternative to expenditure on public
health? Can it evaluate public health out
puts without comparisons with results of alter
native investments? It is not unlikely that it
may be found necessary to confine the first
stages of a systems analysis to one or .a few
local areas, and. perhaps even, to begin with,
to a given total budget so as to reduce the
total number of variables.
Even if, by this and other means, the system
under study is brought down to manageable
proportions, the team is left with an equally
arduous task: 'he definition of objectives. At
first glance it may appear puzzling that this
should be part of the researchers’ function. It
ii ii c-eiiia
OPERATIONS RESEARCH
service1 which “re ditomi^d by^h?'tlecutive
i;
a
I
;
9
<1
■•i
I
s
I
the course of the data collection process Fhe
demands in these respects will become clearer,
when the data collection and model construe’ tion are dealt with, below.
arid ultimately by the people and its eke; cd
assemblies. However, m modern complex
sSes the popular will and even the execu.
3.1.2 Collection of data
live’s objectives are not necessarily very trans
narent and they are usually difficult to translate
The collection, of data, is inextricably related
into scientific terms. Conceivably, the admini
to the formulation of objectives above, and
strative and political heads of the Public Heakh
the formulation of the hypothesis, below.
Service could be assumed to want the maxi
Data collection, no doubt, is bound to ,be
mum utilization of the given resources towards,
einensiveTbufit must also be strictly economrthe promotion of health among the peop ,
••cal, and strictly relevant to theyobjectives and
but tiie operations research team would require
the hypothesis. It can perhaps be Said that
far more specific objectives than that -A
'
dafa collection', in present day public health
major obligation of the team in the first stages
services research, is relatively over-developed
ofX work is to guide the executive toward
A wealth of material, no end of oflicial
■ very specific definitions of objectives (I* the
reports, quite a bit of scientific data, become
team never achieved anything else this would
available every year, but this material is rarely,
in fact be an extraordinarily valuable conbi
tf ever related to clearly formulated objectives,
bution).
and hypotheses, and it is therefore of far Uoo
The team must stimulate the executive to
little value for decision making. For th s very
define the objectives by putting to mm tie
reason the operations research team wi 1 have,
logical alternative: what is meant >y
to supplement existing data considerably; .but
resources”? Cannot the resources planned to
it should only collect data that are strictly
be expended on public health services be nnecessary for its other functions andjt should
creased or reduced, if the expenditure can be
not be hesitant about making
informed
shown td be more oh less profitable i-ian
guesses” when it finds that data collection on
assumed? What is meant by Prom°‘l°n
a particular subject is out of proportion in
health”? One might P^icu a ly w sh m
cost to the importance the data will have in
emphasise one of the two entirely different
the total system. .Naturally, the team wll. rel^
aspects- 1) the state of health itself, m a
extensively on sampling techniques Th s s
certain distribution in the population, which
particularly true for a large part of the output
asain might be viewed under a) , absence of
functions,
where a good deal of the
ill-health and b) presenceiof positive
tion
is
to
be collected among the general
or tn existence, in reasonable proximity ot the
population.
On the input side, cost of services,
distributed population of a confidenceraining of personnel, medical stores, handling,
inspiring health service. Again, ‘tmo-.g - ■
people” must be far imore sharpy de.med, z administrative and technical, operations, data
collection will largely be total .. s'n.cv '■
assuming that equality is a guiding pnnei^e
number of units to be observed will often be
are qualifications to the general equality
too small for sampling. The major part o
principle to be considered permissible, e.g,
the data to be collected under this phase will
Imrh-isis on highly productive groups, or
be on the system as it now and, the
results that arc now obtained. But under
difficult problems are those of the dyna nncs
many circumstances it will probably be form
nf the objectives: Should tnere be date
necessary to supplement these data with a
tat Jpsetting? Or should the formulations be
fimited amount, of data of a more.expenmen al
mobe dynamic and relate to. the development
type. Such public health, exPer'm£ntsT have
X a period? If so, which period? and
■ for example been found useful by India s
should they be related to the concomitant
National Tuberculosis Institute whichi is con
economic, demographic and other social deveducting a series of comparisons of organiza
lopment?
tionat approaches to tuberculosis control m
Already at this stage the team will have
number of primary health unit Mocks iri South
to start considering the terms of ‘he solutions
India. The detailed protocols rot these so
particularly on the output side. When tac
called operational investigations ^avadabk
team—and the executive—have agreed on a
(National Tuberculosis Institute (1961).
of general objectives, they have to be
14
IND. JOUR. PUB. HLTH, VII, 4, OCTOBER ’63
For its data c"’lection functions the opera
tions research tea ... will have to- employ special
investigators. D ending on the fields in
which data are particularly lacking, they may
need medical officers, various kinds of para
medical technicians, accountants, social investi
gators, demographic investigators. Most of
these categories must be given special courses
in interviewing techniques.
One phenomenon must be mentioned in this
context: the effect of observation on that
which is observed. . That is a difficult factor
to deal with in all scientific enquiry, but it is
particularly disturbing in operations research
where “experimental conditions” cannot, in
fact shall not, he established. This observer
effect must be kept constantly in view, partly
in the data collection and the test runs (see
below) themselves, where all devices must' be
employed to mirlmise its. influence, partly in
the analysis where the effect which nevertheless
remains must be accounted for..
adopting operations research techniques in
public health. Firstly, for quite some time,
invaluable contributions can be made by the
other phases of the research: the careful
formulation of the problem and the objectives,
the purposeful, economical collection of data,
the precisely formulated and carefully evaluated
test runs (see below).
Secondly, while it may not be possible to
formulate the model or the hypotheses wholly
mathematically to begin with, the operations
research team can very well, and will, think
mathematically, i.e. logically, in making the
formulations under this phase; they will think
in terms of hypotheses, assumptions, para
meters and prognoses precisely expressed and
systematized—committing themselves so that
they expose themselves to the test of verifica
tion.
The model is a simplified explicit descrip
tion of the existing Public Health Services, the
elements and factors of which it consists and
relationships between them. It comprises the
3.1.3 Analysis nd hypothesis formulation
input of resources, in terms of money, mate
rial, personnel training, in terms of preventive,
curative and educational services, in terms of
The formulation of the hypothesis or the
administrative, decision-making and evaluating
construction of the model to represent the
machinery, in terms of geographical and func
system under study may be considered the
tional distribution of resources. It comprises
pivotal procedure of operations research in the
output partly in terms of operational achieve
fields where it is now relatively highly deve
ment,
’ public participation in services, numbers
loped. By far the largest part of existing
of
relevant
health personnel actions, again
literature on operations research deals with the
geographically
and functionally distributed,
mathematical and statistical problems involved
partly
in
terms
of
fulfilment of declared objec
in this phase of operations research (an ex
tives,
including
disease
contrpl, health promo
ception is the very useful book by Eddison,
tion,
demographic
change,
consumer satisfac
Pennyctdck and Rivett (1.962), which, gives an
tion and economic effects. The construction
overall review of operations research in indus
of
such a model, even if vastly simplified, is
trial management in largely non-mathematical
in itself a complex affair. However, the
terms). There is also no doubt that the
pioneers in operations research in public health v operations research team cannot be satisfied
before it has at least broadly outlined the rela
must rive, within a few years, to reach the
tionships
of this model to the whole social
stage where at least simple models depicting
system,
i.e.
the interactions of the public health
a public health service can be constructed.
system
with,
th. rest of the system and the
Such models will probably be input-output^
partly
supplementary,
partly competitive rela
models of the type which are particularly '
tionships
between
investments
in public health
employed in econometric research. However,
and
alternative
investments.
with a system as complex as a whole national
health service, with inputs that can only with
The operations research team will, certainly
the greatest difficulty be translated into com
in the first phases of its work, severely limit
mon terms and, particularly, with outputs the
the scope of their model in order to keep it
units of which vary from, say, average nutri
within a reasonable degree of simplicity. Firstly
tional status of a population to, say, average
and forcmostly, it would no doubt find itself
health, service consumer satisfaction, it must
forced to disregard other sectors in the social
be considered unlikely that comprehensive and
system to begin with.. As already mentioned,
useful models strictly mathemetically formu
under definition of objectives^ above, the team
lated, will result from the first few years of
would perhaps also start with the assumption
the operations research team’s efforts. This
that present resource allocation to the total
does not by any meafis defeat the purpose of
public health service is an unchangeable para-
144
OPERATIONS research
■
1
i;
;TiI
meter. Furthermore, it would restrict; the
inclusion 'of objective fulfilment in the model
simple indices. Finally, but not
to a very few
1
least, the team would attempt to construct the
whole sysem in terms of a manageable number
of key variables.
One of the central functions of the team is
the selection of what is to be considered, at
least provisionally, 'the key variables of the
system In such a complex system as a health
service, no model or hypothesis can ever be
expected to comprise all the innumerable inter
dependent variables of which the system. consists Among them, the team must choose the
kev variables, i.e. the variables the changes of
which bring about the largest effect in the total
system. Though observation plays its considerable role when this choice is made, thcrcan be no doubt that insight and more or less
intuitive understanding of the system will b
' S decisive importance. This is the situation
where all team members, with wisdom and
mtknee even humility, must sort out what is
me insight from what is mere prejudice.
T s n the formulation of these hypotheses
th-1 the tewl
is put to its acid test.
There can be no strict delimitations of the
functions of each team member; everyone must
contribute his insight,
expenen e-and
his tolerance and patience. -The log sties ana
and methodology may well be largely cont buted by the mathematician and the stat st
cian and the material knowledge by tne pub.ic
health administrator, the epidemiotogist the
economist and the sociologist but unless tney
praduallv all eet a considerable grasp oi eac
Shts’ subjects they will be unable to make
3.1.4
Deriving solutions from the model
The solving of the model consists in a long
continuous series of theoretical ^Put
in the model and calculation of the probable
output changes. Input changes range
for example, replacement of female health
visitors with male -or simplification ot proce
dure for indenting supplies, to, for example,
major shift of emphasis from curative to pre
ventive services or radical, reforms in the
organizational machinery or in the traming o
health personnel. The solutions theoretical!}
carried cut—on paper and in digital computers
_ will have the form of combinations of mter- ventions in the existing system. The number
of possible combinations of interventions,
naturally, is virtually infinite
However, two factors will contribute -0
restricting the number of combinations to be
deemed worthy of study. Firstly the team s
choice of key variables in the system (which
may, admittedly, be revised. in the course ot
the process of deriving solutions) will limit the
number of even theoretically possible solu
tions. Secondly, the economist will constantly
keep the team in check in respect of what is
economically feasible; the public health ad
ministrator will have a similar function on
administrative subjects; the epidemiologist
will restrain enthusiasm, for examp e concern
ing the possibilities of “eradication of specific
diseases; the sociologist will no doubt often
have to remind the team of what is soma y
psychologically and politically acceptable, a d
the statistician and the mathemat.ctan wd .
among other tasks, certainty see: that the ma
• gination of the team does not transgress
reasonable limits of calculabihty. Fma.ly a <
their full contribution.
most importantly, the common sense of all lean
Examples of factors and relationships which
members will restrict the field of theoretical
would beyond doubt be part -of the model are
study to sufficiently few combinations to make
it possible to derive solutions before the
Input- the total health budget, its
Ind functional breakdown inflow and outflow
administrators become too impatient a.ou
of personnel, quantity and quality of training
th(When Ulis is said, however one should no;
inflow storage and consumption of durable
and non-durable goods, distribution of all typos
forget that it is exactly in the play of m
Of. health services and institutions, o^tputo
creative imagination of the team togUhonerational achievements seen from the side
with its scientific rcstraint-^atnftlll’W^sten.
of the services, including for example, partici- .
of considerable improvement of the systen
nation and attendance, vaccinations performed
under study. Within reasonable hnmts o
number of child births assisted, wells conrealism and practicability, the team shoul*
' structed drugs distributed; otherwise tb^S’utz_play a very free game with the multiple factor
nut part of ^the model can probably afford to
and relationships involved, combine and c
be rather sketchy and give four or live mdic. s
combine until theoretically optimal c0^b^‘
as mentioned above e.g.-demographre: crude
tions are approached. This game will co
or age-specific death-rates and birth-rates
sist cf an iterative process of varying the valu
epidemiological: prevalence of two or tmee
of a small number of variables while keepm
major diseases, educational: at least one index
the remaining variables constant. In t
of health educational status.
IND. JOUR. FUB. HLTH, VII. 4, OCTOBER ’63
process, a nn -.her of, at least ap, arently,
virtually equal.'.; good intervention combina
tions will be pi ’sued, until the team ends up
with, perhaps, five or ten combinations the
output results of which appear to be of com
parable magnitude.
3.1.5 Choosing the optimal solution and
forecasting results :
With a limited number of intervention com
binations thus arrived at. the team faces the
choice of one of these solutions to be put to
a test (under some circumstances the team may
find it desirable and possible to put more than
one solution to a test).
Before making this choice the team should
consult the executive. The various interven
tion combination are likely to differ from each
other particularly in two major respects:
firstly, there will be a variation in regard to
the degree of departure from the existing
system, secondly, the solutions will differ in
respect of the degree to which they are cal
culated to fulfil each of the three, four or five
major objectives.
The team is now in a position to present the
executive with .. set of specified proposals for
interventions with details of changes needed
in the system and consequences of these,
changes. The choice should be a collective
choice of the executive and the team, but no
doubt with a f.i.al veto-power vested with the
executive.
Once the choice is made (and this could be
of two or three combinations of interventions,
as mentioned above), the team proceeds to
working out th details of implementation of,
input changes and details of the prognosis of
results, Operational as well as in terms of ful
filment of objectives.
These details should in the first instance be
worked out only for the test run area; and
they should 'specify not least the exact time
table of - implementation. One would hazard
to guess that a good deal of the intervention
would lay major emphasis on training changes
and, again a gums, would comprise a scries of
manuals laying uown the functions, in greatest
possible detail, of all personnel engaged in the
public health services in the area.
A crucial part of the solution is the prog
nosis. This prognosis will partly forecast the
change in operational achievements, partly the
change in results (mostly in indices) in terms
of. the declared objectives. In this prognosis
the team is to prove its worth. Their task is,
at least in principle, relatively simple as far as
operational achievements are concerned: for
146
I
example, this and that change in attendance to
out-patients departments, this change in turn
over of such, and such drugs in the medical
stores depot, so many new closed and chlori
nated wells in so many villages thus distributed
over the area; though even in these forecasts
their skill, not least in judging human frailly,
will come to a severe test. But more difficult
by far, both principally and practically, is the ■
team’s task of forecasting the results proper in
terms of the objectives, so much more so as
they cannot afford to omit any of the major
aspects of health and disease in their forecast.
For example, while incidence of small-pox may
not necessarily be comprised in the model
describing the existing situation, the forecast,
should probably include an opinion on the
likelihood of small-pox outbreaks in three and
live years’ time.
Cne of the most important obstacles for the ,
output forecast relates to the relative slowness
with which health status, health consciousness,
health action, health habits, etc. develop. Even
rather radical changes in several aspects are
not observable in less than five or ten years'
time, because the variation within the material
is so huge. The team will therefore probably
have to select a range of indices with varying
reliability and varying sensitivity, so that
changes in at least some of them arc observ
able after a rather short time, say, two years,
and if these indices are then, as one would
expect, relatively unreliable, one must await
their gradual confirmation by more reliable,
but less sensitive, indices during the following
years.
The form of the prognosis will largely be
statistical and conditional, where the results,
for example, are expressed in terms of 19 in
20 chances of this or that value being within
sqch and such, limits, provided the operational
achievement atttains such value, and within
such other limits if the operational achieve
ment attains su.h other value.
3.1.6
The test run and the control system
The test run is not a central part of opera• tions research in industrial management, but
it is likely that it should play a key role in the
application of operations research to public
health services. The first operations re
search teams will not only have no experience,
at least in this particular field, but they will
also, on the whole, have far less operational
knowledge and less epidemiological, socio
logical and psychological data, compared
with the knowledge and data available to
OPERATIONS RESEARCH
their colleagues in industry. Their system
will not be vastly more complex than the
systems in industry, and it will be rather less
complex than econometric systems, but >n
comparison with industrial, researchers the
team will be confronted with a lai ger numbci
of factors which would not be within their
ambit of control (though the demand for
health services is probably just as foreseeable
as the demand for, say. nylon stockings).
Under these circumstances it would seem
advisable to give rather heavy emphasis to
the test run. Operations research in public
health has, in the practicability of test runs,
a considerable advantage over econometrics,
where test runs are 1virtually out of the question. •
The most importantj characteristic of .the
testt run
run is
is th,at,'while limited geographically,
it is
is true
... to life in every possible aspect. It
is true that the. observer-effect mentioned
above will play a role; it is also inevitable
personnel executing the test will
that the
t.
"e in a special
know that they participate
and
’
'that
this'
will
influence
their
prosramme
—
.
behaviour. These factors must be rigorously
controlled, and in the evaluation of the test
run they must, as far as possible, be taken
Risking to state the
into consideration,
obvious, it may perhaps ’bej mentioned that
the test run is in no way spectacular, a show
piece: the test run operators are, with as
little fuss as possible, quietly told to follow
such and such new instructions which, in
many cases, may not be strikingly different
from existing ones, though probably often
more explicit. The test run area should be
of manageable size, but it should be suffi
ciently large to provide observations for
proper statistical inference. Thus, it would
seem necessary to have no less than 60-100
basic health units (centres, dispensaries) .in
the test run area, so that their operational
achievements can be analysed as proper distri
butions.
The major difference between the test run
and the final national implementation is that
the former has a more intensive control
system. Even the final implementation will
have, of course, a carefully planned control
system but for the operations research team
to derive full benefit of the test run they
require a particularly good apparatus through
which information on all aspects of the
operations and their results are fed back Vo
them. This feed-back information will con
tinuously be analysed and compared with the
proenosis and whenever key variables attain
values outside the pre-determined limits of
variation these new values must be fed into
the
the model and the hypotheses and the model
solved anew. The question will soon arise as to
what extent to allow change to be made in
the test run programmes, if and when they
turn out to run wide of the mark. In prin
ciple, the test run should no doubt be allowed
to run itself out without modification, anu
new test runs in new areas implemented if
need be, but the team may have to find com
promises between this principle and practical
necessities.
Although the control system should largely
be in-built, i.e. the operators and operations
report themselves on their performance, the
test run will need additional investigations
staff to conduct sample investigations of the
results (mainly interviews of population) and
even local statistical assistance to cope with
the very large material which the team will
require.
3.1.7
Recommon ding implementation
The last link in the chain of operations
research is implementation .of the solution in
the whole system, and establishment of a total
control system, i.e. an evaluation machinery
with an apparatus for new decision making
when the key variables change beyond pre
determined limits. In industry (and in the
military field) such, implementation follows
more or less automatically after the final solu
tion has been arrived at and tested, though
even here the stock-holders may insist on
having their last say. In a public service
there may well be considerable obstacles
before the rational solution is put to work.
This rationality may in the first place be
questioned by the executive and by the public,
and even when the rationality is recognized
the solution may be deemed politically un
acceptable to special groups or certain political
parties including the party, in power. How
ever, in principle even such factors should
already have been taken into consideration
by the research team—this is one of several
justifications for the inclusion of a sociologist
—and in the case of failure to have the
scheme implemented it can rightly be blamed
on the team that it did not appreciate the
political climate in which it worked. For
example, it is of little use if the team arrives
at a major conclusion that the whole health
service, including general practitioners, should
be nationalised, if the feelings and power of
the medical profession and/or the public are
147
IND. JOUR. PUB. HLTH, VII, 4, OCTOBER ’63
such that this part of their solution is not
feasible.
The recommendation for national imple
mentation would probably’ in many cases, not
withstanding a successful test run, be in the
form of a recommendation for gradual exten
sion, with a large pilot area to begin with,
where the realism of the test-run-modified
solution is put to a final test.
3.2
Minor Uses of Operations Research
Techniques in Public Health Services
Operations research is wholistic, it treats a
system as a whole. However, whole systems
usually consist of many '• nailer ones. A
national public health service is itself a sector
only of a whole economic-social system, and
the public health service in its turn comprises
a large number of smaller and bigger sectors
and units within many of which one can well
visualize good use being made of operations
research techniques. Such work has, it would
seem, far lower priority than the efforts
described in the preceding paragraphs, but a
team working in a country on such a major
effort might find it worthwhile to’ gain
experience from solving such smaller systems
problems. One example of a sub-system
which would no doubt be fertile ground in
many countries is the medical stores system.
Considerable loss in operational efficiency is
sustained in some countries because the
Medical Stores take months, even years, to
expedite indents; and this often occurs at
the same time as the Stores have to dispose
of, occasionally destroy, items which have
become obsolete because of technical develop
ments.
The team might also try to solve part
problems within the main system before, or
as part of, the solution of the overall systems
problem. Examples of such part-problems
are: optimal size of area and population to
be covered by midwife, smallpox vaccinator,
basic health " unit; ideal vehicle for local
health, workers; administrative management
solutions leaving maximum time for technical
personnel to utilize their skills; architectural
design of hospitals and health centres; queue
ing problems in out-patients departments and
hospital waiting- lists; solutions to integration
problems where specialized services have
developed on emergency basis outside the
general health services. For the methodology
of some of the above problems the team
could rely heavily on techpiques developed
in industry, the parallel often being quite
obvious with industrial management problems.
3.3
The Operations Research Team
Operations research can be a more or less
continuous process, or it can be a valuable one
time effort. Once a team has gone through
the full seven-phased procedure, described
above, the service will presumably have been
considerably improved, and the task of the
team can be considered accomplished. For a
smaller national service such a procedure or
perhaps gradually a more simplified one, could
be repeated with intervals of, for example,
10 years. For a large country, for example
the three or four largest in Asia, it would
seem justified to make operations research a
permanent feature of the national health
service. The team would here be employed,
perhaps equally much, in the overall systems
research and in work on part-systems and
specific local and functional problems. With
such a variation in the requirements it is diffi
cult to suggest general rules for the size and
composition of the operations research team.
However, some features would be more or less
common to all such teams:
The minimum composition is probably a
public health administrator, an epidemiologist,
a mathematician, a statistician and a social
scientist. Larger teams should probably also
comprise an engineer (sanitary), an education
ist, and the general social 'scientist should be
replaced by an economist and a sociologist.
To this must be added, because the team must
have its own data collection apparatus and
test run evaluation system, a number of investi
gators of various categories, perhaps 10 or 20
more, and a group of junior statisticians and
statistical clerks, numbering perhaps equally
many. Finally, if they cannot rely on outside
assistance in computer programming, they must
have their own personnel for this purpose.
They must have full-time disposal of statistical
processing machinery, for example of the IBM
101 type, and part-time disposal of a digital
computer, e.g., of the type IBM 1620. Men
tion has already been made above of the
extraordinarily strict discipline and dedicated
loyalty that must govern the behaviour of the
team. Such a team spirit can only be ex
pected, if each individual member is very care
fully selected, but-another condition is no
doubt that the team is headed by a man of
outstanding competence. He must partly
command complete respect and loyalty among
his team members, partly possess all the diplo-
V
OPERATIONS RESEARCH
latic skill which is required to secure the
ecessary cordial relationships with the scores
f top men operating the system which the
iam reviews—and sets about io change.
.4
A note to two kinds of sceptics
S.4.1
“This is just common sense—with a
superstructure of line new words
Operations research, is very little but comnon sense. This is perhaps even more true
,vhen it is admitted that in the first stages of'
applying operations research m public health
services mathematical models may be of rather
limited relevance. The essence of operations
research is that logical thought, combined with
careful observation and methodological ana
lysis should form the basis for decision
makinc. Adoption of such a principle may
not appear very revolutionary, but _ in an
irrational world the public health service that
carries it out to it its full logical consequence,
abiding by its sometimes exacting commands,
would be likely to find itself a vastly better
service The methodological study of alterna
tive courses of action can of course be given
many names; much the same kind of activity
has variously been called Work Study, Cyber
netics, Systems Engineering, or simply Uannjng—anci probably most operations resear
chers would be quite proud to have their
science known as the Science of Common
Sense.
3.4.2
“Operations Research can never replace
experience"
Human experience is a more or less un
conscious collection of data and analysis qt
data by an individual or a group of indivi
duals. But experience is often unreliable is
often narrow-based and tends to be biased m
the selection of data. Scientific methods can
remove the bias and ensure that data are pro
perly systematized to give a truer picture ot
the past and a more reliable forecast of the
future including the probable outcome ot
intended executive action; and they can give a
measure of the so-called imponderables by
calculating probabilities of occurrences. How
ever the operations researcher still needs the
“experienced’’ man who helps in the selection
of key variables and in estimating their value
if they cannot be directly assessed, and in these
processes intuition and inspired guesswork arc
indispensable.
But intuition and guesswork
will play only their planned part and should
not be allowed to govern the whole or the
larger part in the decision making.
4. Proposal for a Project to Study the
Methodology of Public Health Services
Research
It will be obvious from the above that there
exists a great, need for the development of
methodology of public health services research,
with special reference to the poor countries.
Some ways to tackle the methodology prob
lems have been suggested, but they are all very
tentative. It would appear that, the stage
reached is one where a project is requirec,
which could attempt simultaneously to con
duct methodology research and action research,
a project which is foremostly aimed at deve
loping methodology of public health services
research, but which, for this purpose, goes
through the motions of doing this research,
thus conceivably achieving material results for
the country in which it works.
The difficulties in implementing such a pro
ject are momentous. But the possible divi
dends of carrying it out with an acceptable
decree of success would seem to justify a
' risk of failure—provided one takes
certain
cognizance of the difficulties in formulating the
plans for the project.
4.1 Location
If even moderately successful, this project
may be considered the first in a series to be
planned and implemented in many countries
in all regions of the world. It is therefore
important that it should be located in a
country which can provide an example tor the
situation which may become reasonably typical
of other countries in some years.’ time, this
condition points towards India in Asia and
the comparatively developed countries in
Africa, for example, Nigeria and Ghana.
India has an advantage in its very size;. India s
huge area and population would provide the
necessary testing ground both for data collec
tion, test runs and pilot application, and t ie
variation in conditions from one part of India
to the other would constitute a smaller prob
lem than the variation between, for example,
the various sovereign states of Africa.
major disadvantage is probably the federal
structure of its government and health service
National plans arc formulated, but in the nnai
analysis the individual state has complete auto
nomy in health matters.. In fact, however,
there is considerable and increasing uniformity
in structure between state health services.
149
gr-IND . JOUR. PUB. HLTH, VII, 4, OCTOBER ’63
In favour of India speaks also tne avail
ability of personnel. This is true both ior
senior personnel—India’s fine traditions in
statistics are well-known—and for the indis
pensable medium-level personnel. It is not
fortuitous that India has also pioneered in
applying an operations research approach to
problems of national economic planning; see
Malialanobis (1955).
4.2
Plan of. Action
It is to a degree a self-contradiction to pro
pose any details of the project’s plan of action,
since it should be clearly understood as one
of the basic principles ot the project, that the
team should have complete freedom to choose
and develop its own methods. Even the frame
■outlined in the above seven phased programme
should in no way be binding on the team.
However, it is of course necessary ior plan
ning and budgetting the project to have a
vision of the probable physical set-up. Below,
therefore, is an outline of this set-up, which
would have to be reviewed by the team as
and when they begin to decide on their
methodology. The team proper should, com
prise the following specialists: a >public health
administrator, an epidemiologist, a . mathenratician, a statistician, a social scientist (sociolo
gist), an engineer (sanitary) an educationist, an
economist. This team is headed by a team
leader who can be either one of the above n
one is suited or a ninth person who could then
devote himself entirely to the coordination ot
the work and the external relationships.
In addition to its foremost duty, namely
thinking, the team will have certain executive •
functions, managing (I) data collection which
will probably mainly be under two heads (1.1)
epidemiological and related data and (l.J
social, economic, organizational' arid related
data, (2) test runs, and (3) statistical process
ing, including computor programming.
Data Collection
4.2.1
The data collection activity will, to begin
with, mainly be related to the model construc
tion ’ or hypothesis formulation. In _ later
phases data will have to be collected in the
test run areas to supplement the information
fed back through the in-built control system.
It is possible that the team will iind it neces
sary to carry o'ut a limited amount ol experi
mentation in small scale operations. , If this is
*
the case a third unit should probably be added
to the two suggested below.
4.2.1.1
Epidemiological Unit
The epidemiologist should head a unit collectina data of epidemiological and related
nature. It is difficult to foresee the need ol
personnel in such a unit. Some data are co lected from existing reports and other liteiature; for this probably two or more research
assistants are necessary. Some data are col
lected in the field, and it is only when starting
his work'that the epidemiologist can begin de
ciding the kind and amount of stall he needs.
One may guess that he will need at least one
or two medical officers, one or moic labora
tory technicians, quite a number of inter
viewers, who might be medical social workcis.
He would probably also need a statistician in
his own unit to do the sampling in the held
and to check and control records from the
field investigators.
4.2.1.2
Social Science Unit
The social scientist should head a unit col
lecting data of social and related nature. 'Ihi.<
unit again would need several research assis
tants to sift existing recorded data, amom.
whom probably a professional accountant o
budget analyst. Field data collection will alst
be. considerable, and certainly half a dozen
perhaps a dozen social investigators will b<
needed.
4.2.2
Test Rims
It is visualized that the test runs will pla
a very dominant role at least in this fir
project, if the project is located in Indi,
the team might conduct as much as two. thri
or four test runs, each probably covering
full district, the average population of vvhu
is 1 3 million, with an average number <
health institutions of 40 to 60. For managn
each test run the team should probably ha;
a special team on the spot, consisting I'
example of a medical officer, a public heal
nurse and a statistician. Each such lea
should have clerical assistance to the tune
one stenographer and tour statistical cleri;
Since it is envisaged that one of the mai
proposals from the operations research, soltion will be improved and extended pi=
service and in-service training of health pt
sonnel, the test run sub-team could probat
---- —
OPERATIONS RESEARCH
undertake training functions in addition to
their main function as local evaluation unit,
though there may be a danger in combining
an executive function and evaluation m the
same persons. The head of the unit directing
and coordinating the two, later perhaps t tee
or four teams would presumably be the public
health administrator of the operations research
team.
4.2.3
Statistical Processing
The
The statistician
statistician of • the team will head a
rather large statistical unit. The unit
----- should
.
two
additonal
statisticians
probably comprise
and about a dozen statistical assistants and
clerks. To this must be added the operators
required for the computer and other statistical
machinery. With the exception of a good
deal of transport, virtually the -only type of
equipment needed for this project is the statisti
cal machinery. It is likely that part-time
service of a machine of the 1MB 16_0 type
would be required in addition to
processing machines, but it is essenHal 11at the
statistician and the mathematician of the ea
should make this important decision them
I
selves.
Internal Administration Unit
4.2.4
In order that the team should have minimal
problems of internal administration aT a^
quate administrative and accounts unit should
be established, headed by a high-powered ad
ministrative officer. In summary, the Opera
tions Research Team, itself numbering 8 or 9
nersons might need the assistance of as many
as 75 to 100 professional and semi-professional
-!
j
people.
4.3
Recruitment of Personnel
It is not an exaggeration to say that the
personnel for such a project dff not exist, it
must be created, or it must gradually create
itself A group of, probably relatively young,
scientists must be collected who arc prepared
to dedicate themselves for a good deal of their
life-time to what amounts t0 peat,n8 a
branch of research. It would no doubt be
an advantage if one or more of the group had
exrerienco ^n operations research m industry,
fading which one or more should have experi
ence "in programming techniques in national
If the project is' partly financed from
international sources, a number of the members
of the team might be internationally recruited,
to the extent that naional staff is not available.
Finance
4.4
A project as the one outlined above might
cost between 10 and 20 lakhs rupees per year.
Though it is likely that the project would soon
be able to effect savings of a considerably
higher order than this, it is also true that the
project’s purpose of developing methods could
be hampered if loo early material results were
expected from the team. Under these circum
stances. it would seem natural if a good deal
of the financial burden were to rest with inter
national agencies.
References :
Andersen, S. (1962) Ind. Journ. Tub., Vol. IX.
p. 176.
Andersen. S. & PIOT, M. (1962) The Operations
Research Approach, in Souvenir of the l«tn
Tuberculosis Workers’ Conference, Bangalore,
1962.
3. Bailey, N. T. J. (1'957), Operat. Res. Quart., A’,p. 149.
\
B
ailey
,
N.
T.
.1.
(1962),
Operational Research
4.
Chapter 7 in, Society. Problems and Methods ot
Study edited by A. T. Welforo M Argyle.
D. V. Glass. J. N. Morris. London 1962.
5. Baner.ii. D. & Andersen. S. (1963). Bull. Wld.
Hlth. Org., Vol. 29, No. 1.
C
hurchman, C. W.. Ackoff, R. L. Arnoff.
6.
E. L. (1957). Introduction to Operations RcKe
search, New York 1957.
7. Report of the Commitfee of Enquiry (Gudlcbaud Committee) into the Cost of ihe Na
tional Health Service
(1956), London.
H.M.S.O. 1956. .
& Rivett.
8. Eddison, R. T., Pennycuick. K.. Research
' B. H. P. (1962), Operational Research in
m
Management. London 1962.
9. Houlden, B. T. (Ed.) (1962). Some Techniques
of Operational Research. London 196_.
10. Mahalanobls, P. C. (1955). Sankhya. Vol. 16.
P- 3.
ational Tuberculosis Institute ^961) Pro
II. N
tocols for Operational Investigations, Mimeo
1.
graphed. Bangalore 1961.
JX.
12. PIOT. M. (1962). Ind. Journ. Tub., Vol.
p. 151.
(1962), Ind. Journ. Tub.. Vol. IX.
13. Raj Nara in
p. 147.
. A. & Andersen. S.
14 Waaler. H. T.. GeserPubl.
Hlth., Vol. 32.
(1962). Amer. Journ. 1
p. 1002.
economic planning.
151
4
I
PROCEEDINGS -
I
f
OF THE TWENTYSIXTH
NATIONAL CONFERENCE ON
TUBERCULOSIS
i
AND CHESJ
DISEASES
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HELD IN
IV
/cQ CdacQ
•
. .\ T r
t
BANGALORE
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JANUARY 1971
4
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4
UNDER THE AUSPICES OF
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12
penetrate down to the rural areas. Their mission should oervade
Fnr^h-6011011 °f thie community and permeate every strata of society
purP?se lhe.y should have a net-work of efficient district and
taluk associations with programmes to involve the community in
their working I am afraid our Associations have not yet reached
fnrm^?86’
the State Associations no doubt stimulate the
formation and working of District Associations and some of them
p^oarammes d‘The SerV1CeS l° deraonslrate the benefits of official
£rarr|mes- The mass contact programme organised bv the
^rffi^nnd'-r^50013110/1 an/ lateIy by KeraIa and Andhra are note
"°™b}a nd if extensively adopted can bean effective programme to
stimulate and supplement Government work.
IndiJ.5; Iam,h:1PPy 10 sa-'’ that the Tuberculosis Association of
India is considered as one of the best voluntary Associations. It
has a regular programme of which organising the National Conference yearly ,s only one. Through its highpower Technical Comml
roT wornke“nV0lUnrdita0 "fh'6
°P<™ndi for tuberculosis comrof work in India. The publication of the Blue-Print revision of
Classification, compilation of the Text-Book, publication of the
ournal and the Hand Book on Tuberculosis are some of i?s out
standing contributions. It has recently established a Research
Committee with distinguished workers as members. Its outstanding
^ntribution in the international sphere relates to the imtiXn o?
the formation of the Eastern wing of the International Union which
today ’s said to be the most active Regional Body of the Union
Crecht for reaching this stage of excellence is entirely due to Shri
B.M Cariappa, the Secretary-General, the Executive and Tech
nical Committees with the cooperation of all of you. We all recog
mse Shri Canappa’s dedicated services and great contributions fn
appreciation of his personal qualities and spirit of dedication the
Executn e Commutee have awarded a prize of Rs. 5,000 - to him on
behalf of the Association. The Tuberculosis Association has "reat
opportunities to be the harbinger of the health development of the
people by showing that tuberculosis control is a community effort
and with the cooperation of the government, the profession and the
voluntary organisations the disease can be controlled with the parti
cipation of the people. It has been my privilege to have been
closely associated with the Tuberculosis Association of India for
over two decades now. J take this opportunitv to record m hi°h
appreciation of its work and wish it and its affiliates all success ° I
thank you for the honour given to me.
Shri B.M, Cariappa then read out the citation On
Dr. A.K. Sil before the Governor presented the “T.A.I.
cash prize” of Rs. 500/- to Dr. Sil whose article on “Status
of the Disease compared in urban and rural areas in the
newly diagnosed pulmonary TB cases” was adjudged best
tor the prize. The citation read as follows :
13
DR. A.K. SIL
I
ta
£raduating from the R.G. Kar Medical College Calcutta
Dr. A.K. Sil passed his M.B.B.S. in 1954 from the Calcutta Univer
sity and T.D.D ml 958 from the same University. He has been
admitted to Ph. D. (Medicine) of the Calcutta University in 1970
and is now working as a Medical Officer in charce. TB Unit Urban
Health Centre, Chetla and Rural Health Centre, Singur under the
^961 He ha^heM
and PubliC Heallh' Calc”tta. since
1961. He has held other positions since 1955. He has published
several medical and scientific papers and educative handbooks
t
E
.
Dr. K. Somayya, President of the Conference, in
his address said :
Introduction
.^UraUy therefore the presidential addresses would have been
from different angles and appropriate emphasis made on
Itwffi be^hpttV1 HUS StrageS °f
develoPmenl in this specialised field
muh.W
add t0
I
However, most of the suggestions common t
to these addresses
u°imP[emenJed to this day. Let us therefore get to the
—- grassroots, rather than adoptivory tower platitudes.
Time is both an asset as well as a challenge. Wc have been in
ie anti-biotic era for quarter of a century now and the Five Year
lan pciiod for well over two decades. Formerly wc had no anti TB
drugs and no national programme. We have both these now Bm
cFtf3111110 tO IiniPlemcnt the nat.ioiiaJ_programmc throws addiiion-.T~
^Henges and creates fresh problems. We ^t earch^
and^
HowevSit
oS '
lives ^ntsU vimi^^
•mercifully’ sparing then f
Ka 1S ■ lt^,V1.ctI™s f°r a few more years. The ‘wonder-drugs’ seem to
be losing
°n the bacillus due to the imperfect and mTom° V
Fhe dnet
Hnt g,Ven t0 the patient- Treatment can be inipe PecUfnrnd f?r-pd°ues
keeP ^east of the developments Ht can be
in thTP Cte lf lhe sufferer does no1 fuI|y cooperate. Both will result
n
bacilli which offer dangerous pro
th« n^^ar?ernb 6 Se.1 back and reversion to the pre-drug status of
the patient viz., prolonged suffering. These are unwelcome devplnn-
-'^1
r^ensc^oT deydk7tldablte W!ih tHe r'’01’21’ educat!°.n and infusion of
^ETselves ?ca^c-
“d -he —
0
14
15
A war is on, ever since the discovery’ and application of modern
drugs—a glorious war on this age-long enemy : but we are not yet
waging a TOTAL WAR, a determined war though the situation
demands it and several other countries have done so. Hence, we
have to heed the warning signal and gird our loins to fall in’line
with them.
Men, Munition, and Money are the three essential requisites to
wage a war. The fight against TB also requires these. When the
specialist has given place to the generalist, the professional tends to
become an unwilling worker, a half willing organiser and less res
ponsible crusader. Hence, our cadres have become depleted and
dispirited. Drugs are our munition. We hear they are in plenty and
yet it is comnion to hear of shortage. At least there seems to be
no shortage of the 2nd item—Money—on paper. How much of it is
actual!) allotted and spent is not known. As funds were being thus
diyerted in thejast minutgjby the State Governments the centre has
taken up this responsibility and TB control has become a centrally
sponsored programme. But the release of funds by the centre in
volves a lengthy procedure and waste of time. Assistance from
International Organisations is said to be progressively declining. The
picture therefore does not look to be rosy. It is against such a
background that workers in the field of TB and Chest Diseases arc
meeting annually.
Before I proceed with my stray thoughts on various aspects of
the problem. I wish to thank the Chairman and Secretary-General
.of the Tuberculosis Association of India and Members of Standing
Technical Committee for nominating me as Chairman of the Com"
mittee and President of this Conference—I consider this as an
honour to my profession-public_health of whom I had been a solitary
represeniatpe. I am also aware that in choosing me. you are re
cognising the contribution made by the Andhra Pradesh State Tuber
culosis Association which I have the privilege to serve as its Official
Secretary almost since its inception.
I began jny_carecr as ^Medical Officer in the arinv-durin" the
Second World War, Later 1 was selected for the State Health
Scrvjce. I was assigned the charge of BCG Vaccination Campaign
when jt was facing great opposition. AFfhelame time I was also
given the opportunity to form the Andhra Pradesh TB Association
and step up its activities including the Seal Sale Campaign for fundraising as well as Health Education. Thanks to the French Govern
ment, I had the opportunity to study'thT’well organised Anti-TB
services in Europe and the role played by their ^excellent Social
Security System, which greatly enhanced the value of the control
measure. Nly association with the Technical Committee of the
Tuberculosis /Association of India for vears enabled me to study tha
growth and development of the National TB Control Programme?
With the integration of Preventive and Curative services in^Andhra
Pradesh I had first-hand knowledge of the implementation of this
programme in my State. I shall naturally be leaning on the ex
periences and knowledge gained by me therefrom. I "request you
therefore, to share my thoughts. My address may not take you
into the visionary heights of research of Dr. Viswanathan. Professor
and Emeritus Scientist, nor be comprehensive as that of Dr. K.N.
Rao, former Director General and noted TB Specialist. It will not
be a marathon effort like that of Dr. Bordia, who fully justified his
Advisorship, nor can it be so sweet and appealing as that of the
.v. indefatigable worker Dr. Deshmukh who is creating history with his
. "
Anti-TB Shibirs. It can be only a simple address"like that of my
immediate predecessor, late Dr. Umesha Rao. May God bless his
C1 C.lA’soul ! But being an administrator and essentially a health worker,
I also see the ‘failing side of the wave’ and be critical of the values
‘ z
^..attributed to our programme. If my remarks are depressing at
tinics 1 recluest You to please bear with me, as my intention is onlv
yjvto alert the audience, wake up the Associations and request the
organisers of National Programme to come to grips with the
problems.
1 have to submit that these are my personal views and do not
represent those of my government.
i
The Problem
As you know the problem is vast and is spread out evenly
among the six lakhs villages and 3,000 cities and towns with about
seven million active cases of which nearly two million arc infectious.
With the increase in the population every year, more number of
cases seem to be added than being controlled under the programme.
Therefore it is likely that the gains made are neutralised, or even the
provisions currenly available become inadequate. As several health
problems are to be tackled simultaneously, an integrated approach
has been adopted. Happily today there arc 95,000 "doctors working
in more than 12,000 institutions all over the country in 5.200~community development blocks covering about 75.000 ’ population each
but all of them arc not involved in tuberculosis work. As against
a general bed-strength of 2.5 lakhs, about 35.000 beds arc devoied to
TB in 92 Hospitals and 68 Sanatoria and some of these becls arc
lying vacant for want of finances which formerly were used by the
paying patients. Today patients claim the privilege of getting free
treatment and brought down the cost. However", since" the "direct
and indirect costs of treatment of TB cases are estimated at 2.000
crores of rupees, no effort should be spared to reduce this colossal
waste of funds on illness and premature death, and to increase
economic production and ensure better health to our people (Dr
K.N. Rao).
‘
In several countries TB was fairly well controlled even before
the advent of drugs with the traditional concepts of prolonged rest,
fresh air and good food, backed by excellent social security measures.
In the post-war Europe, especially the East European countries —
Bulgaria, Hungary. Poland and Czechoslovakia—put up an all-out
1
16
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V
>
'cXt—
effort ana
and brought the problem under control within a decade,
enon
making use of the modern drugs, mass Miniature X-ray and mass
preventive campaign with BCG. Therefore, we can now control the
problem even with the known drugs and BCG without waiting for the
discovery of better drugs provided we make an all out effort.
National TB Programme
• At the very outset let me pay my warm tribute—one of
admiration —to the great men who started the NATIONAL TB
INSTITUTE and worked with a missionary zeal to find out ways
and means to control this most difficult and multi-facetted problem.
I had the privilege of being in the first-batch of Senior TB workers.
I was one of those who were completely convinced of the new
philosophy.
A comprehensive programme based on the experience sained
in the projects and test runs conducted around Bansalore has shown
the way for the developing countries in Asia and Africa. Based on
the successful demonstration by the Madras Chemotherapy Centre of
the value of domiciliary treatment as against institutional, and social
approach based on the ’felt-need’ of TB patients, it has the advantage
oi being within the means and resources of the country. Our control
units if established in all the districts and function effectively can
make a deep dent on the problem. They should all be staffed properly
and provided with drugs. At present there are 20ffj£amsL fuuciioning
in districts after getting 12 weeks training in the NTI. Peripheral
centres are organised in about 8000 rural clinics, where microscopic
examination is undertaken. Reliance is placed on sputum smears
as ’culture’ facilities are available only at a few places in the country’
The previous emphasis on X-ray has shifted to.the microscope as
there are many fleeting shadows due to viral and other inf^ct’ions
which cause confusion. As even the symptomatic patients visitin'’
the existing facilities do not get diagnosed properly, the case for
mass case-finding except in pilot projects has been given up. BuF
this has robbed the educative value for the campaign and its tempo
has come down very much. ‘’Implementation at '’Grass-root’ level
has not been very satisfactory and as it is being implemented to-day
it cannot be expected to achieve the control of TB in the nearfuture”. (Dr. Bordia)
Consequent upon the change in the strategy, fresh problems are
cropping up viz., widely spread out services, maintainance of conti
nuous supphes of drugs etc. and apparent shortages due to procedural.
dmtculties and other bottle-necks—creating headaches to the
Administrator. There seems also to be a certain dampenin’’ of the
earlier enthusiasm both among the workers and administrators which
is^really to be guarded against. VNew programmes have been stealing
Vaccffiatio 1 ep0''ecl clur'ng l^e Mass Campaign phase of BCG
The present steady but not very spectacular progress made by
(he National TB programme raises several doubts. Have wc reached
a blind end, where the incidence offresh disease is”equal to those
temporarily cured, maintaining or even increasing the backlog of
cases with each year ? Have we gained during the'ten-vear interval
epidemiologically, to have the assurance that we are proceeding on
right lines and that victory is in sight ? Are we sure how long' the
valuable drugs will continue to be so, in view of the resistance to
drugs which may nullify its value like DDT in malaria control ?
Having been wedded to the general principle of integrated approach,
has the programme been accepted by the general practitioners fully
as to drive the specialist away from the field ? How do the patients
and public react to this changed picture in Tuberculosis Control 9
As already mentioned, our commitment to an ideal—the integration
of TB control programme with Generaj Health Services—has,'to mv
mind, led to several disadvantages,' The lustre of a specialised
programme is fading and the campaign approach of the hay davs of
BCG Vaccination more or less halted. This was quickly 'followed
by an anonymous existence, leaving the front stage to other prestigi
ous programmes.^
°
*<=*■—I
The District Medical and Health Officer—a busy person—is
pressunsca td^aftend to crash programmes and usually forgets the •
<
existence of this programme. Similarly the Director at State level
is hard pressed for timc.CIvcn the TB Adx iser, who is the programme ; C ^3
executive, is not a master of his show. A decade ago he had a
complete control oxer the closely knit anti-TB services? He is now
drawn into a wider organisation without freedom to act dccisivcl'. in
the interests of the programme. Have we shown the white flag of
surrender or can we co-exist honourably with other major health
programmes ’ jl\\hen funds could be found for so many other
programmes and infra-structure created at Block level, how is it
mat a major health problem with its still considerable death toll and
vast sutlcring has been relegated to the background ?
None could be held responsible for these unwelcome changes
c^eptt he doctrinaire flair for integration, which was taken by the
° -2" 1?1eal?IPro"rhninics as surrender. As this must have demor
alised he TB services, the immediate task Po be undertaken in res
ponsible quarters is to restore the individuality of this immense
Programme. We should now gEt our due Fv miffing the other Iicalt'lF
programmes serve the TB cases and the TB patients. VWc Juivc to
ua.m our share m the funds allotted for several campaigns and get
Nt-TXarmark^’ as wc arc a,Iotlcd a mere subsistence 'dole onlv.
the poor victim of TB, the programme should not also suffer.
to camjin15 "Ji31 Dr’N L’ Bordia said in his address: “I would like
cnthuyAr ran<? ,sound a aote of warning to those who are over
nthusiatm.for integration of tuberculosis services with the general
ealth services with the aim of control of disease. Our experienced
enco'uS10". °.f ‘“berculosis work so far has not be^n very i
eratP
§>u
limes inteSratl°n is taken so far as to disinte
grate even what has been achieved. No major communicable disease J
(I
F
I
18
19
in this country has been successfully controlled entirely by the
integrated approach. Efforts in measures like case-finding and
treatment will be diluted to such a great extent that control of disease
will never be achieved. 'The policy on integrated tuberculosis
services therefore needs careful thinking before inteeration can be
effecteckat any level. It can be tried only at the periphery, at the
block level but even there specialised para-medical personnel will
have to be provided at the Primary Health Centre or taluk hospitals
etc. for tuberculosis work, as have been provided for maternity and
child welfare, family planning, small pox, malaria etc. To-day
Tuberculosis is nobody’s child and has therefore remained neglected.
This is an important reason why casefinding and treatment supervision has not satisfactorily developed at the"periphery.”
How much more population and with this growth to what extent
will the TB problem increase ? By the time the country is fully
covered the programme as at present worked may become inadequate.
It is certainly not clear, whether we are gaining control of the ’head
end’ of the problem or drifting towards its ‘tail end’. We can onlyguess in the absence of uptodate facts. Complacency in our own
minds based on a decade old data, will be unjustified and the
programme needs to be evaluated thoroughly.
Probably sociological approach with its ‘felt need’ thcorv has
contributed unwittingly to this grim situation. Earlier TB' com
manded the sympathy of the community as a great social problem
and on account of the economic and human suffering caused thereby.
However, the felt-need approach, which was meant to stream-line
the services and deliver the goods effectively, narrowed down the
concept of the problem. Measured" against such'Tolossal needs ol
protected water supply and environmental sanitation, which arc
impractical with our financial resources for a tfng time to come, TB
problem has become only one of the ‘felt-needs’ of the country and
cut down artificially. It is said that a casual dailv TB case at the
Health Centre does not merit the services of a specialist. But what
of the vast number of persons who need immunisation against TB ?
Thus while due to the decline in the mortality the problem
of TB has lost its 7horror\ the ‘felt-needi sociological, approach has
&Fed complacency in the attitude of1 the administrator Tliere 7s
therefore an urgent need to restore the real image of the problem.
Dr. Deshmukh has repeatedly pleaded “let us make it clear to the
authorities that this is not a measure for cutting down expenses ;
that wc need adequately equipped and staffed TB clinics and
sufficient drugs to give adequate treatment to all the active cases
Now that we have a detailed National Plan for Control of Tubercu
losis. let us not be .satisfied with just a 'service programme' but press
on 'case finding programme’ as well' and again l'Lct us put this fight
on a real war-footitfg. Surely, the Commander in-Chief must he in
constant touch with his various Generals in the field in every phase of
the battle ; then only correctives can be applied when things seem to
go wffmg”. He compared the Adviser in TB to Commander-in-Chief
and the State TB Officers to his Generals.
But we are trying to develop it on the excellent lines of
Madanapalle or Madras Project studies, although there is a great
disparity and lack of uniformity of programmes in different parts of
the country. Therefore a common planned approach, though
essential, will not be adequate. At the rate of upgrading one
District TB Clinic per State, when will the programme be completed ?
I
Meanwhile I wish to appeal that the programme should be
given the necessary acceleration and a forward direction. The nine
fold intensification of the programme spelt out by Dr. Bordia in his
address viz.. Intensive Health Education. Intensification of case
detection drive, increasing BCG teams, more intensive supervision in
the field, financial support to patients for checkup visits as well as
social assistance, organisation of voluntary efforts, incentives to
District TB Centre staff and a better understanding and improved
patient doctor relationship—are worthy of implementation. Let us
remove the cobwebs of complacency that “all is well with the
programme” and satisfy ourselves that ail is really going well.
Community Programme—Lack of a Proper Climate
_ In a sense, the defects noted above in the implementation of
National TB programme are largely inherent in the communitv
approach, and the lack_of a proper climate for the development of
community Health Programme. Till the Social Welfare Services are
well developed. Health check-ups. surveys and the communilx
programme have no prestige value either in the minds of the profes
sion or the public. An epidemiologist does as grand a job as a
pathologist in a General Hospital. But in practice the work turned
out is difierent.
Similarly the para-medical worker who forms the backbone of
the community pragramme, is not given the importance or the real
encouragement he or she deserves. He is often made to sit at the
desk or the compounding table. His work is noL_superviscd and
when looked into, lacks the enquiry that is needed. This is due to
the lack of interest by his immediate oflicer who is not oriented. He
has no conception of team work and is unaware that his presence in
the tie d will add immense prestige to the drab work ofTIic para
medical worker He has absolutely no concept of field research and
not even the elementary ideas of planning and evaluation. Hence
therms no direction given to the field work, which therefore strays
away with the whims and fancies of the field workers like “the
driverless carf’H
Health Education
h.,»mLaCr of' Hea,th Education is also glaring. There may be
d. | of Posters, some journals and odd press features or some illapted audio-visual material. These do not constitute real Health
I
!
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20
21
Education, which should lead to health action by the community.
The workers arc mostly tongue-tied. Hence lack of communication
is the basic defect in extention services and knowledge gets bottled
up. It Is sad to note that the volume and tempo of Health Education
carried out during early phase of Mass BCG Vaccination Campaign
has come down almost to a-stand-still. The equipment and vehicles
are either under repair or idle. I consider personal communication
to be of the utmost value in field work and reluctance or resistance
is generally overcome by proper motivation. There will be far less
defaulting by patients if the treatment organiser adopts a friendly
approach, ably supported by the medical ’ officer through initial
motivation.
of the campaign. It is not uncommon that the UNICEF donated
BCG vehicles are used in other programmes or lie in workshops
unattended for, especially -alter the -special-transport organisation
merged forming the nucleus of general Health Transport. At the
present rate and tempo of the programme, only a very small percent
age of the population will be covered. “By door-to-door work,
hardly 2H-% of the population can be vaccinated every year which
is almost the yearly population growth. We have not vaccinated
even one fourth of the population in 20 years” as commented by
Dr. Bordia in his presidential address.
Everyone will admit that public institutions differ from private
hospitals—specially in one essential viz., the lack of doctor-patient
relationship. Pleasing the patient is of utmost importance and here
lies the art of private practice. Even a quack is able to command
the confidence of his patient by this personal behaviour and com
munication. But that is entirely absent in the Government-run
clinics and hospitals. When will it be realised that Hospitality is the
basic equipment of a hospital ? It is quite common for the patient
who has taken all the trouble to get examined, to disappear after
taking one or two instalments of drugs. Therefore the doctor-patient
relationship has to be developed in the community programme as the
community programme needs this factor in even much larger a dose
than the curative piactice. When the para-medical worker"knows his
patient, the programme will be successful.
BCG Vaccination Programme
Due to the above mentioned factors, great damage has been
done to the preventive limb of the National Programme and
Prevention is one of the three main pillars of the control programme.
According to W H O. schedule and even otherwise, BCG is the first
immunisation a new-born child deserves. But the small team of six
BCG technicians cannot be present everywhere to protect these
babies ! Due to the lack of emphasis on the programme, a BCG
Vaccinator was not provided during the IVth Plan for everv Primaiy
Health Centre which would have filled the void of in fra-structure for
TB Services. Il should be noted that BCG is both a general
immunisation programme as also a part TB control programme. But
without adequate preparation, the mass campaign was terminated
and the teams were attached to the District TB Clinics, which arc
yet to develop. No wonder the campaign reached a new low !
About 50% of the mass campaign output remains fairly constant
although the staff remained the same or even increased slightly. Even
the indiscriminate vaccination—-though it created bottle-necks in the
vaccine production and supply due to the large quantity of vaccine
required to vaccinate even Mantoux positives—has not ‘covered' the
population with BCG. as it was expected to. Besides, the verv slow
pace of the campaign, many other insurmountable difficulties like
the immobilized transport etc, have also contributed to the neglect
Therefore the programme has to be extended as a general
immunisation measure and all the knowledge gained in recent years
in the field applied to spread out the Campaign wherever there is
necessity. We have still io make use of the simultaneous BCG
Vaccination programme with small-pox. Doubts linger in the minds
of the Health Administrators whether such a procedure is effective.
The N.S.E.P. staff have been increased recently. It is quite easy for
the inclusion of simultaneous BCG programmes also al least in
Child Welfare Centres and Hospitals. We have not made it
obligatory for the Local Bodies to carry out this preventive measure.
Supply of portable kits with equipment poses problem. It is also
necessary to fill the felt-need of the preventive measures. Several
General Practitioners wijl be willing to carry out this work, along
with triple antigen, in their paediatric practice. Unless all such
steps are taken to popularise the programme, the preventive pillar
, will not be strengthened. In Andhra Eiadesh BCG vaccination is
carried out by 19 Local Bodies since a long time covering a sizeable
number of the newborn in those municipalities. But these programmmes have not been expanded or taken up in all States. There
is need to bring out a legislation or issue a directive at least to the
local bodies.
Drugs—Uninterrupted Supply
There are other difficulties facing the programme. Our
Munition—Drugs—are in shon supply. Even though we produce
standard ahli-tuberculosis drugs-jate are not yet self-siffikieiil.' Rawmaterials_are_sLiLL±eing imported. According to Dr. K.N. Rao. we
consume at present about 100 tons of Isoniazid. 30 tons of Strepto
mycin. 425 tons of PAS an'd 5 tons of Thiacetazonc., Second line
drugs like Ethionamide have been introduced, but Pyraxinamide and
Cycloserine have not been allowed to be imported freelx due to high
cost and shortage of foreign exchange— Ethambutol has just been
introduced in the country. Without an adequate supply of second
line drugs it is not possible to take up surgery and treat drug-resistant
cases. Even the National drug bill for treating 1.5 million infectious
cases with PAS. INH and Thiacctazonc in a year would be about
Rs. 250 million. The total quantity of drugs available in the country
will be adequate enough to treat only 8,00,000 to one million cases,
bul due jo misuse of drugs and organisational difficuliies, a larger
section of infectious cases are not getting the needed drugs.
ft—'
■>
22
23
Further, it is unfortunate that there are too many defaulters
inspite of the various methods used to motivate them by personal
_ contacts and through correspondence/4 The success of the programme
will depend entirely upon the availability of adequate number of
trained personnel and of anti-tuberculosis drugs in sufficient quanti
ties. More than anything else, proper machinery is to be evolved to
see that the drugs are taken by patients consistently and continu
ously. That constitutes the whole crux of the problem” (Blue Print).
It is here that TB Associations have to step in. They should have
well meaning volunteers to supervise regular drug taking by patients
and prevent default.
community programme if such aspirations continue to divert their
attention ? These attitudes are revealed in connection with the train
ing in the National Tuberculosis Institute as a deputation for the
purpose tQj<ri.is resisted from the day the orders arc issued. A
timehas come when every one has Io seriously think of the damage
done to the programme by taking in unwilling or indifTcrent workers.
I have sufficient evidence of such damage. Better remuneration and
early prospects for promotions are some of the measures to overcome
this lack of attraction. Thereby the waning prestige of the diploma
holder will be restored. As it is, very few candidates arc joining the
diploma course for the above reasons and majority of the vacancies
are filled by general doctors. Dr. Deshmukh has rightly pointed this
in his address “General Medicine practice and other specialities
appear to keep our young medical men away from Tuberculosis.
Even for those who are willing to go in for full time service, there are
other attractive and better paid set-ups. Flourishing pharmaceutical
concerns appear to spirit away our laboratory technicians by means
of their ability to pay higher wages. It is high time we give sufficient
thought to this problem and make the salaries and aliowances at
various levels attractive enough to attract and retain our staff”.
Dr. Bordia has also pleaded for better incentives to those toiling hard
] in anti-TB services. It is time that the senior District TB Officer is
eiven the rank of a Civil Surgeon and a junior selection grade, be
cause he has to inspect the work of Medical Officers of Primary
Health Centres, which cannot be done by an equal grade Officer.
i
Cadres of Willing Workers
A few words about the men that man our programme ! During
the last two decades revolutionary change have taken place in the
control of TB, but our specialists have not realised the full significan
ce and impact on their careers as many look helpless and are unable
to find their place in this rapidly moving picture of TB control.
What is his role today ? Has he been sufficiently equipped and finan
ced to hospitalise only those cases which need admission and render
surgical aid or second-line drug therapy'? Or, for want of facilities
has he been simply competing with the Domiciliary Services and
treating out-patients as in-patients ? How is his line of speciality
ensured of its continuity and are sufficient number of young doctors
enthused to take up this branch of the profession, as it was the case
in the pre-chemotherapy era ?
What is the standing of a diploma holder before the full-fledged
Post-Graduates possessing a Doctorate in General Medicine? How
does he compete with Chest Surgeon who developed a speciality with
a wider field ? Is theJTDD, who formed the back-bone of the TB
services, a specialist or an organiser ? As a specialist what is his
place in a Teaching Institution ? For an organiser there has been no
significant change in the TDD curriculum. Except for the longer
duration of the course and probably some community orientation,
the emphasis still remains mainly clinical. In some States a general
duty doctor is usually the District TB Officer. How will the com
plexion of the serxices change, when at the district lex el also a gene
ral duty doctor replaces the TB Specialist ? Sometimes the Medical
Officer in charge of the TB Ward deals with advanced cases, while
the TDD specialist is organising the programme in the villages; he
is prohibited from ward work. Thus the poor diploma holder is
squeezed from both the sides—from the generalist at the periphery
and the full fledged post-graduate at the District level. In fact several
general M.Ds feel quite insulted to refer their cases to the Diploma
holder.
The programme has also resulted in a separation of tiie TB
clinics. It is not uncommon for the District TB Officer to cast long
ing eyes for a job in the TB hospital/sanatorium and wait for the
earliest opportunity to get posted there. What is the fate of the
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D.T.C.D—Community Orientation
It is often said that the training in TB (DTCD) should be orien
ted to community approach. His attention however still largely
remains clinical and there is practically no participation by him in
the work of his para-medical staff. Whether it is due to a deficiency
in training or the contents of the syllabus needs examination. It is
well-known that the Professor of Social and Preventive Medicine is
not much involved in the training programme and although a large
content of SPM might have been taken into DTCD, there is no evi
dence, of such orientation. It is probably due to such a difficiency,
the NTI started orientation courses for the medical officers and staff.
A properly integrated syllabus and course will prepare the DTCD
much better for shouldering the tasks of National TB Programme.
It may also be rcmembe'red that not all DTCDs will be engaged in
the NTP and receive NTI orientation. Hence this aspect needs to
be urgently looked into and the Professor of Social and Preventive
Medicine involved in the undergraduate and post-graduate training.
I would suggest that the Technical Committee should examine this
question.
Institutions
I have already mentioned that about 35,000 beds are distributed
in 82 hospitals and 68 sanatoria for indoor treatment of TB. They
z form even today an important segment for scientific management of
?
.18
24
25
District Officer mixes ®-ith the fellov. officers in a spirit of sen ice am!
draws the attention of his ‘boss’ m his programme.
General Practitioner :
atten.lmh?ha^ ^net deservtehatT0Ur in.stilulio"? "iH soon receive the
IHEWsasig
HillaBliits
short periods according to
Our army of workers will not be complete without th^ p ■ t
Practitioner and the voluntary aeency comin i t^
big way. Whether we like it or no the ee era nmc kin ’7 m "
major role in the control of TB-probably not so mnrh VT aS.
^^dicTp?asi::dztxhe-tihv^t,ts
possible and irregular use nf tbo i
‘.P(.C'’ ^ecdlise of the
not supply dru's \o him " T m hv 7S/ ' n°l- shoi,ld
we have not followed an acthe policy "oi^-T18u 'acci,lalionDrugs cannot be misused probably -s it’is bein< V’ begeIS 1 rusI"be done at the moment. There U iherel^e e T' °r rCP°rled l°
general practitioner and the services and th « \ ° camPs~ll,e
be most unfortunate. Due to this thou*^ands nf n"? tWeCn ll’Cni wil1
and Vaids and languish at their m/rcv ‘ Un P
11 F° 10 H;ik,ms
like Amritsar about 40° of the nt ’ i
l,ndcrstand mat in a place
Role of other Health Agencies
household but he may not stop a TB patient
Ho^simnle1^^ ^£5'
nonal expenditure to be proxided in d nH.c
\d f°r lne add|-
--■-^.icmersJhebgh.—
pamc.pat.on in .heir programme is ttry much needed Thus .here
is a great scope to co-ordinate TB and Family Planning activities
Government may encourage such activities' so as lo reach all he
HUTBlnd
^”P«-
these facilities. The entire picture can be changed, provided the
Voluntary Effort
K ’Si
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26
27
in his district. It is time that all the major Associations in the
country make a note of this and start activities to enthuse officials,
patients, general practitioners and the public.
merely confined to undergraduate and post-graduate education but
embrace the wider public and para-medical staff.
TB Association of India
But there is dangerous aspect of ‘make-belief’. The official
circles give the impression that they are an isolated group and that
other’s^co-cperation is needed. They are also confident that the
duties prescribed for them are carried out by the staff scrupulously
and may not even care to supervise them adequately. This is the
typical ‘touch me not’ attitude of the bureaucracy, which is
detrimental to the success of a community programme TTke the
Natio.ial TB Programme. As years roll by, there is a back-log of
cases? which cannot be followed up by the programme staff. In a
district with ten-year old programme only 2,000 of 20,000 cases
—just 10 percent are attending the service programme. In Tumkur
district the volunteers have done a good job and the TB Association
of India is trying to prepare a feature film of this project. Such
dovetailing of voluntary and official organisation in the field is very
necessary as their activities are essentially complementary in nature.
State branches may come forward and take up this activity, as this
is True Health Education—which should lead to community action.
Mere follow-up activity by the volunteers will not improve the
programme, unless the defaulters are not. only motivated^ But
retrieved. All these require the co-operation of voluntary bodies
and their appreciation by the official sector. Hence their doors
should be thrown open to volunteer activity.
After much thought and deliberations, the Association has
released a “Blue Print' for TB control in our country. This should
become a bible for action by the voluntary agencies. Unless the
voluntary sector covers the entire area, programme will not make
an impact. It is the duty of one and all of us lo see that the
contents of the Blue-Print are digested by the official and voluntary
agencies.
There is another useful field of activity for the TB Association
to play. Maharashtra has set a fine example of conducting ‘Shibirs’
or camps to stimulate public enthusiasm and fill a gap where
necessary. Such mobile camps are quite essential in India and
should be recognised for giving medical relief while the community
is no doubt systematically being covered by the regular health
services. It will be a great help and the programme gets accelerated
by such camps.
Seminars have been initiated by the Association, but the
co-operation of the Teaching Institution is necessary and a joint
partnership has to be built between them. In this, the role of State
TB Centres’ is very great indeed. At present the State TB Centres
have not developed the activity to any appreciable extent—although
their earlier name clearly emphasised these activities e.g. TB
Training and Demonstration Centres. These activities should not be
As with my predecessors. I am bound to say a few words
about the parent Association of voluntary TB effort. We are all
aware of the monumental work turned out by our All India body
started just before the 2nd World War. She soon spread her Ions
arms not only throughout the country but even abroad. Thanks to
Sri B.M. Cariapppa, our Secretary-General and Dr. P.V. Benjamin,
the first TB Adviser, due to whose partnership there was a harmo
nious blending of non-official and official effort, the Association
could become a model for developing nations and their scrxiccs are
recognised' Il is this recognition which prompted the International
tlnion in 1956 to entrust Dr. Benjamin and Sri Cariappa with the
task of organising the Eastern Regional Wing of the Union. Both
ofthemdida remarkable job and this Regional Wing has now
become the most active one among the regional bodies. The Associ
ation has become a model for other voluntary bodies for organisinu
conferences, seminars etc. There are other stalwarts like Drs. Sen~
Viswanathan, K.N. Rao. Sikand. Frimodt Moller and Bordia who
added lustre by their services in the various committees and achiexed
the international distinction. The yqunger guards have stepped in
with Drs. Pamra. Menon, Nagpaul. Dingley. Singh etc. who are no
less enthusiastic.
k.
f i
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Times have changed. So also our fighting strategy. The need
is now for developing mass organisation. "Unfortunately our
affiliated bodies are suffering from limited membership, probabh
due to a policy of isolation. The Association should enlist even
citizen as members. Health propaganda must be carried on from
every platform, besides the medical forum. Thev must enlist the
cooperation of the film world, cultural field, educational institutions,
temples, churches, mosques, synogogues and every conceivable
forum.
As we are getting funds through the Seal Sale Campaigns, it
seems lo
to work as disincentive for raising more membership/ T.
’.v
Tiie
Health Education aspect of Seal Sale Campaign has to be accele
rated to compensate for the small element of voluntarx coercion
inherent in the Seals Sale Organisation. But the campaign has been
generating tremendous enthusiasm among the public and the
organisers, wherever it has been handled properly. Let me pay my
compliments, as one who knows something about the difficulties
involved in building up this campaign, on'’the brilliant efforts put
up by our Tamil Nadu Association for winning the All-India Shield
successfully. I. take pride, though I do not '’claim to know their
secret yet,.that Andhra part of the Association was once part of the
parent body—the Madras TB Association.
As suggested by Dr. Umesha Rao, we may also encourage the
.i
28
institutional treatment of middle class patients by subsidising a few
vacant beds in the private TB sanatoria and see that the bed
strength is effectively utilised. Refresher courses arc very usefulnTCTw
that General Practitioner is becoming aware of his responsibilities
for treating tuberculosis in a big way. The co-operation of State
TB Centres is very necessary and direction may be given to that
effect by State Goxernments and Government of India to provide
facilities and incentives to the Association, as given to the College
of General Practitioners. It is not always possible to arrange the
subject of TB in their curriculum and unless experts are invited, the
interest of General Practitioners is not maintained, which involves
additional expenditure. Further, the College of General Practitioners
pays daily allowance and travel expenses to the refresher course
trainees. Hence the need for subsidy to TB Associations.
The celebration of aimual ‘TB WeeJC is a ‘must’ for the
organisation, now that several such weeks and fortnights arc being
run in the country. Success lies in the extensive campaigns conducted
all over the State by the district branches. During this week exce
llent contact with public and co-operation with the services should
be aimed at.
National Conferences
I have been attending almost regularly several conferences and
since my first attendance as a BCG Worker, I was pestered by one
thought—How far do these help to create favourable climate in the
battle against this fell disease; besides its _social__ancLeducatiye
aspects, and how many of the workers are seized with the pro
gramme that is being developed and how closely the efforts of the
voluntary and official sectors integrated? I leave these questions to
be answered by you. But the successful conduct of these confe
rences—comparable to the ‘Yagna’ of the olden days-requires no
mean effort. As one who knows, let me thank the' Mysore State
Association for the wonderful organisation made by them. Our
veteran Secretary-General carries on with his indefatigable energy
using all the devices that he can employ in getting the maximum
turn-over of effort from the Association playing the host. Naturally
these conferences are bound to generate a tremendous amount of
enthusiasm among the delegates and camaraderie besides its educa
tive value. But the full use of the conference will be in evidence
when we can forge a fighting front against the enemy—the myco
bacterium Tuberculosis!
Before concluding my address there are a few more items—
some of which bear repetition and thanks-giving.
29
the effect has not been effected yet. This may be urgently consi
dered.
Insurance
The difficulties of patients are well realised in developed
countries. In France the Social Security Scheme permits financial
relief by giving 3 years leave on full pay and 2 more years on half
average pay. It is difficult to expect that every patient can support
himself and his family while undergoing the prolonged treatment.
As in France, the disease should be considered as a disease of long
duration and leave given. Insurance companies should be prevailed
upon to cover TB risk, as pointed out by my predecessor late
Dr. Umesh Rao.
I
■
There arc some ‘protected’ groups of people who receive free
medical services in India. Government employees and industrial
workers who come under compulsory health ’ insurance scheme.
Railway employees, and Posts and Telegraphs employees arc some
of these fortunate persons. The vast majority of TB patients are
found among the general poorer public, agriculturists, farm
labourers, workers in smaller establishments and- who do not have
the benefit of free medical attention except those available in the
Government institutions. Most of these establishments are found in
urban areas where TB services arc fairly available. Tuberculosis
being an infectious disease it is of paramount importance for its
prevention and control that as many unknown cases as possible
should be detected as quickly as possible. (Dr. S. Chandrasekhar).
Research
We arc grateful to the excellent research work beine done in
the country and in particular in the Madras Chemotherapy Centre
Madanapalle Tuberculosis Research Centre and the U.S. Public
Health Service. A number of co-operative studies also arc under
taken. You will be very happy to know that the Tuberculosis
Association of India has just established its Research Committee
,s trying to build up a strong Research fund. Their attempts
I believe, will be to find out if and how the period of irc.aiijL'UJA _of
the tuberculous can be shortened. We might also expect as a
result oi world-wide studies that arc being made, better drues which
will treat the disease in a shorter pcriod'and also find out the secret
thediseasy
3
5111311 perCent °r lhc infected Persons develop
Legislation
International Organisation
Notification of TB is very necessary and has been emphasised
by almost all the Presidents in their addresses. But a legislation to
I will be failing in my duty if I do not express my thanks as
we11 as the gratitude for the large hearted and unfailing assistance
ti^en to the national programme by the WHO, UNICEF and other
I
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II
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31
international agencies right from , the beginning. As already men
tioned any sudden switching off the assistance will tell upon the
programme adversely. It can only be tapered off when the pro
gramme in every respect can be carried through. We should be
particularly grateful and happy for recognising our programme as
the mode! for all developing countries.
of the individual by improvement of housing conditions, sanitation,
water supply, drainage and nutrition. They arc as important for the
prevention of tuberculosis as they are for the prevention of other
communicable diseases in general—a no mean gain !
Conclusion
Unless these long term measures are carried through no real
conquest of TB.is possible.
,. ye are yet a long way from achievement. The desired
objectives of reducing the pool of infection one percent prevalence
natural reactors to Tuberculin among children below 14 years of
age, has eluded even the developed countries with their every
advanced control programmes. With the present infection rate of
about 50 0, it will take a long time and so long Tuberculosis “will
be permanently with us and the control measures hence should be
made permanent". As we might have crossed the crest of epidemic
wave its decline may be uneventful, though slow. After the control
of malaria. Tuberculosis has become a major public health menace
and its conquest imperative. In view of the individual focus given
to the disease over several decades, community approach recently
developed has to catch the imagination of one and all. Education
of the public as well as the Administrators is very essential on these
aspects. It has not been possible to make ideal treatment available
to all patients due to shortage of drugs, lack of facilities for injec
tions. treatment, treatment over a prolonsed period, high rate of
default in regular drug intake and lack of "facilities for drug resis
tance test.
Ilr
als° been c!earI>' pointed by my predecessors that only
50/o of the cases at best that are detected could really be treated
while the rest are likely to remain infectious to the community.
Further, the capacity of all our clinics, hospitals, sanatoria put
together can at best tackle a million patients. What about tEF
remaining million of estimated infectious cases, who are at larce
without treatment ? These are disturbing thoughts and something
has to be done. Again we have a paradox of scarcity of medical
man-power in our country side. Only 20% of the doctors work in
villages where 82°; of population lives, while 80% of the doctors
arc ini uroan area where only 18% live ! How is this problem to be
solved . Again poverty breeds Tuberculosis and Tuberculosis in
turn breeds poverty. So let us wage a war on poverty as advised bv
our esteemed President of the Republic and remove pockets of
infection as well as vulnerable areas of infection.
Modern Tuberculosis control work is mainly organisational,
administrative and financial. Though the disease is caused by a
specific micro-organism, its development and spread arc related to
social and economic conditions. Efforts therefore oueht to be made
to improve these conditions in order to minimise" the effect of
environmental circumstances in the spread of the disease in the
community. It is also necessary to improve the general resistance
Lastly we should not hesitate to evaluate the programme in its
entirety. If our drugs are not delivering the goods let us say so. if
integration has retarded our pace let us say so and find a solution.
If our services have become demoralised or filled with unwilling
persons—square pegs in round holes or vice versa—let us weed them
out and create attraction for real talent. If our hospitals arc merely
competing with Domiciliary Services and not playing their role
effectively let us say so and find funds and staff to reorganise them.
If the Campaign has lost its edge due to integration and consequently
Health Education has suffered, let it be corrected. But let us not
fight shy or shirk our duty.
It should be recognised that objective truth is the goal of
operational research and field practice will become largely" unpro
ductive without such research. 1 have noted that essential elements
like Planning and Evaluation—which are the beginning and the end
of any activity—are lacking in the daily activities "of countless
number of field workers. I once again make a plea that the baseline
data gathered 15 years ago can be misleading and upto dateclata
be gathered making use of the 1971 census data as well as fresh
studies conducted.
Let me conclude with well known invocation from the RIG
VEDA
“May He protect us both
“Sabana vauathu
May He nourish us both
Sahanau bhuuaktu
May wc both work together with
Sa/iaviryam Kara \avahai
great energy
Tcjaswina vadithaniastu
May our study be thorough and
Mavidvishavahai"
fruitful”
Om, Peace, Peace. Peace
Om Santhi, Sant hi, Santhi
Let us work together to gather the fruits of collective endeavour in a learn spirit.
' . Let us be rid of hatred.
I wish my fellow workers a happy and useful conference and
hundred percent success in their great efforts to root out this
problem. 1 also thank you all for the patient hearing given to me.
OM TAT SAT
35
state director, health services and the TB Association of India for
giving me this opportunity of evaluating the work of a district in
M.P. The choice of the district to be evaluated was left at the
pleasure of the Director, Health Services. Casuallv without anv
special reasons the choice fell on a district which was almost an
average district of M.P. State.
SUNDAY, 3rd January, 1971
MORNING SESSION
I
The conference re-assembled in the Auditorium of
the Government Medical College, Fort, Bangalore with
Dr. K. Somayya, President of the Conference, in the
Chair. Dr. Somayya announced that the mornina
sessions will begin _ with a session on “Progress and
Evaluation of National Tuberculosis Control Pro
gramme” under the moderatorship of Dr. K.N. Rao.
ItDr' Rao t0 take his seat on the dias.
Dr. N.M. Smha acted as the rapporteur for the session.
Dr. Rao then requested the participants to come
to the dias. The following persons participated in the
session :
Dr. N.L. Bordia
Dr. M.D. Deshmukh
Dr. Raj Narain
Shri S.S. Nair
Dr. Jaswant Singh
Dr. T. Srinivasulu
Sri K.S. Sundareswara
Dr. G.D. Gothi
Dr. Rao requested Dr. Bordia to present his
paper.
A BRIEF ASSESSMENT REPORT ON THE TWORK OF A
DISTRICT TUBERCULOSIS PROGRAMME
By
i«n
0
H.P , ° •
Dr. N.L. Bordia, m.d.,
Indore (M.P.)
reporter to look into tne working of a district Tuberculosis pro
gramme (National Tuberculosis Programme). I am grateful to the
In 1962 the Government of India had made certain recom
mendations to the State Governments as to how tuberculosis service
should be organised in each district. The National Tuberculosis Insti
tute have trained numerous teams in these years to implement these
recommendations and the UNICEF had assisted these district centres
with the necessary equipment including transport. So far State
Governments have established nearly 200 such district centres
throughout the country. The development of the district tuberculosis
programme envisages establishment of a close net work of diagnostic
and treatment services at the permanent health centres of diiferent
denominations in the entire country in an integrated manner so that
the medical and paramedical personnel work there as multipurpose
workers for all health services. The long term aim of the proeramme
is to develop the service to the extent that it can have some impact
on the problem of tuberculosis, and gradual reduction in prevalence
could be expected in the future.
To achieve the objectives of control of disease which is a lone
term aim it was visualised that development can take place only
slowly. In the first stage of development the teams would set trained
and equipped. Then it will take two to three years for the proeramme
to expand to the entire district. When the proeramme would be in
good speed from the third year it could be expected that almost all
symptomatic sputum positive patients would take action and report
^noz Va^°iS PeJriPheraI heahh centres. Of these patients about
40 ,0 could be defected by careful microscopy at the peripheral
centres and the district centres. A few patients would be taken care
ot by the general medical practitioners as well. Once the major
proportion of sputum patients are detected and treated then the
yearly detected cases would approximately be equivalent to the
annual attack rates. It was then presumed that a quarter of the
total cases were developing disease every year Comma to the
treatment service it was presumed that if 80%’ will be the efficacx of
chemotherapy and 80% patients will take drugs in their own homes
on a domiciliary basis without supervision, then 65 to TO1',;, will be
rendered non-infectious. The fourth five year plan was therefore
planned as early as 1963 on the above presumptions. Provi ion was
made to cover every one of the districts out of tne 335 districts
existing then. 200 new integrated district TB centres were to be
^veloped during the plan period. 15 to 20 lakhs of patients were to
nboPr?kdeidLWIth antl'TB druSs every year from the 12.000 pe.'ii ain centres’ dispensaries and other institutions under the
cIrarfv?LT,s ,pr°Sra™“c- While planning the Government was
mpnt r ldiha aatl'TB drugs must be freely supplied by the Governt ot India and that there can be no economy on this item of the
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36
37
w.llbe ■ toymaTnt™C Ion"™ Teltmenl"6 m°St di®CU,t prObIem
feared
that theone
paramedical
It ‘was
also
and
therefore
“ aPT" Z con muity.
su®ci“
.™'=rest
Tuberculosis work at everv E ?IJ,7ployment spec,all2 for
country. However this
7 hfalth ,centre ,n the entire
later stage. Finally; the fourth five"™^ n'fan fw® the P'7’ a‘ 3
centrally sponsored scheme A^insr'rhL n i
accepted as a
TB programmes which have formed the h ba5kground the district
Tuberculosis Programme are developing forX laTeight ykrn3™”31
r°^ °‘h-
eomm^iSo^TuiVX'-d
Area 1727 sq. miles, density of population 346 per sq. mile.
District Administration: Two Senior Officers rn rvc • .
Health Officer : controls PHCs, dispensaries Public Mp’niti
Djstr,ct
Family Planning. (2) Civil SurgedContro^Hosni a
dispensaries and Tuberculosis Clinics.
P als’A>ur'edlc
a
State Health Administration'. (1) Director of Public Health
Family Planning etc. is responsible for all PHCq „ w• i C , , lh’
family planning, (2) Direct HeSth sX^ntfols^t
Ayurvedic Institutions. Tuberculosis clinics
r HosPI.ta,s’
and medical college hospitals
’ (3) DeanS for teachinS
Much of the
time ^pem^^
r
l
V-
13 grades dispensaries
Tuberculosis Services
rate of Health ServiSs.T ^StatUS
ntf
information could have been collee-PH r L7
pent morc
specially to studv how tb d.aPno.Hc
. rep°rier had In ™nd
functioning in the distrim and
!IeatmFnl service was
de\ elopment of the programme 3t th- lhc dAcuities were in the
health centres like PHCS and ‘d.spensarieTof’va'Xu'i; dXmmhons.
52 be^uCgmde^
Assistant Director in the Directed
in 1954 "'ith
analyst S^e^ct^ia^mZ
1965 for District TB pro~e
,UNICEF ass,s,ancc
vaccination team integrated with District TB ^en^'fJhT'' ECG
in position. The district TB team hus 7 „
Centre, full team was
more neighbouring district where !here is no DTC pr°8ranime ,n one
Basic data of the district evaluated :
NTI tramedlllfre^tealth™
Population of State of M.P
total districts 43.
organisers), one statistical clerk \!ra.lr!ed as treatment
technician (no laboratory assistance,’no A ro'ornSan^^'0^
estimated to be over 30 million.
plain. BeighnsoOfVe^abo^
mil.
M.P., partly hilly, partly
Population 490,COO aproximateiy (1961)
now estimated 0.6
2 medic5I officers
drugs.®UdSet iD 1969 Rs' 56’000/- (this does not include anti-TB
System of working-, according to standard NTI manuals.
Minor deviations
District Headquarters is a town of 100,000 (estimated 1970).
There are four Tehsils (Talukas) only.
75°,
75% population is rural, 25% urban.
0) Case register maintained separately in addition
to case
index and cross index cards.
addition
(ii) Sputum examinations
mostly by collection of over night
sample.
VNIC^iiS^StamGove0;.^^r°USh G”ent of Jndia,
1
F
|
38
s
39
Evaluation of Treatment cards of all diagnosed patients in the
the calendar year 1969 has been undertaken that is from
1.1.1969 to 31.12.1969.
Post Treatment Evaluation of 1969 Patients
Sputum status of 652 patients
i:
Technical Evaluation for 1969
District
work ^ersons x-rayed 2,756 including case finding amongst factory
Suspected tuberculosis 652-:—minimal 58, moderate 151, advanced 390 and others 53.
Whole district
Total 454
I Local
I District
| Migratory
234
220
198
(120 males 114 females)
(140 males 80 females)
(138 males 60 females)
(Outside District cases)
Sputum Positive Cases
Whole district
151
Local 65 (35 males. 30 females)—65% of attack
•
rate
Rural 86 (61 males. 25 females)—20% of attack
rate
Migratory 85 (60 males, 25 females)
Total sputum positive 236 (out of 652 radiological suspects)
Not a single sputum positive detected at any PHC in the whole vear
under report
cent.
Sputum positivity rate in treated pulmonary cases—36 per
Treatment given to 652 (DTC 577, PHC 75) (5 migratory
transferred)
Regimens
Sputum positive to negative
Sputum positive to positive
Sputum negative to negative
Sputum negative to positive
Sputum result not available
INH, SM, TZN
INH, TZN
INH alone
Other
79
283
161
71
58
Regular means.
Regular 12 per cent
Partly irregular 20 per cent
Very irregular 42 per cent
Initial defaulters 26 per cent
(80% or more regularity)
50 to 80% drug collection
Less than 50% collection
Collected once or not at all.
652
454
198
102
( 92
10)
55 ( 33
119 ( 86
12 ( 3
8 ( 3
22)
33)
9)
5)
296
79
r1 •
I-
I
Defaulter action on district patients as recorded in Treatment
Cards,
Post cards sent
Home visited
Message sent
No action on remaining defaulters
Retrieved
Il
ir
30
50
14
18
52 beds (plus two private rooms)
Total admissions
Patients admitted
District:
Migratory:
Regularity in 4 4 district patients
26)
10)
14)
1)
147)
Results not available for the rest (356) 237 district cases and
119 migratory.
Hospitalisation
SM+INH
87 ( 61
29 ( 19
65 ( 51
7 ( 6
464 (317
X-ray Evaluation
Miniature x-ray same as before
Clearance of disease by less
than 50%
Clearance more than 50%
Complete clearance
Worsening
L
Migratory
707
258
%
84 males 54 females
86 males 34 females
Many patients admitted twice or thrice or more time in the
same year.
Work at sub-centres
Participating Centres : PHCs 6, Dispensaries 3, general hospi
tal 1. No programme at any other centres^
.’BJ
I
40
41
Diagnostic activity in 1969 only at Civil Hospital, 23 cases
detected sputum positive.
workers, even then the programme did not expand. The major
responsibility is therefore mainly on the district team. Following
reasons are responsible for failure of expansion of the programme: °
Treatment cards 75 in all sub_centres.
There is not much of difference in
'
in sputum positivity,
treatment
regularit}' in district patients and migratory ones.. Patients auuimcu
admitted
to inpatients wards had very high defaulter rate in drug taking after
discharge from wards.
Extra Pulmonary Tuberculosis
Main Findings :
Glandular disease
Abdominal
Bones & Joints
Pleurisy
Others
162
(males
38
( „
26
( „
17 ' ( „
19
( „
70
9
6
7
9
262
104
females
92)
29)
20)
10)
10)
I. The district TB Centre team had not toured the district
PHCs and other centres as much as necessary. The vehicle h->d
covered 152,60 kilometers in all but 8307 k.m. was for tuberculosis
programme and the rest for other purposes.
;
Thereis comFieteapathy and lack of interest in most of
the officers of PHCs and dispensaries m undertaking tuberculosis
work both microscopy and treatment service. Paramedical workers
are still worse. Medical Officers are unable to get work done As
that are no microscopists or laboratory technicians/assistan'ts in
Pnmary Health Centres and even tn small civil hpspitals, no member
of the staff is W11 mg to do necroscopy. Deterioration in discipline
has gone to the stage that para-medicals concoct false record fear
lessly. The dtstnct TB team felt disgusted with the lack of response
and made no further attempts to establish microscopy cent?es at
X Jllx-zO.
158
Average age in males 1-15 years
Average age in females 1-44 years
Diagnosis of Extra Pulmonary Tuberculosis ’was questionable
•
as they were mostly referred cases from main hospitals.
predominated in aSe group 15 to 44 and males pre
dominated in age group 0 to 15.
1
General Observations and Recommendations
I,n
.,'a
riv-i J11’ T^er.e
Iack °f supervision from all levels the DHO
T fh Su^eon' Assistant Director of Tuberculosis and the regional
a
i
th-'1 “.sr3t,if>’in8 *° observe that the system of record keeping
« ^ °:1 tuberculosis programme is efficient, meaningful at
eond metb ’ I rnn e and “r7 10 maintain- The system provides a
fetion Thel0Zf° nWUP o,f Pat,ents and provision for defaulter
due mainbl , 51
r n” the teSt lnSpite of sh°rtfallS which are
oue mainly to human failure.
me is enforced, no programme can succeed.
XfF ‘ti iP kr^ T?ey had a the retluired facilities of adequate
nroo^
orders for implementation of the
p ocramn.e, other equipment for peripheral centres and anti-TB
renmpH
H mUSt bu stre5Sed that the district team was well
reputed and known to be well trained and consisted of willing
<■
P
are necessa^Tt afl DT&mJ’h J601™0*311 and Laboratory Assistant
™XCS
aDd ---n,?hatPSc7osCcZ0dervterop",Cr^;
43
42
VI. Vehicles must be used exclusively for the purpose they
are provided for. In this district in 1969 nearly _45% mileage vva$
done by the DTC vehicle for purposes other than tuberculosis work.
The DTO was unable to keep the vehicle in good condition. Even
for repair of a punctured wheel, quotations have to be called and
approved by the Civil Surgeon’s office. Powers of the district officers
for major repairs should be enhanced.
VII. Stress on other health programmes specially family
planning need not deter personnel from undertaking tuberculosis
work, as they were not over worked. Incentives provided by family
planning programme has acted as deterrant to tuberculosis work.
VIII. Deafulter rate in drug taking is very high. This can
create serious problem in the years to come. It will result in higher
resistance rate and chronic infectious invalidism. All procedures
laid down to prevent defaulters and retrieve them should be
enforced throughout the district. Activities of the district TB
Association should be developed to educate patients and the commu
nity.
IX. The DTC team should be more careful in completing all
entries on the respective cards and forms so that some type of
evaluation of the work is possible. I understood from DTO that
more work had really been done than observed from cards as
entries were not made in many cases.
X. The salary scale of the entire tuberculosis service is low.
This deserves to be looked into. With the rising prices, families
cannot sustain interest in work with present emoluments. They have
to look other sources of income at the expense of work.
XI. There is need to develop human discipline in bolh
patients and the services. Unless steps are taken to improve them,
programme will not succeed.
XII. There is need to do more serious thinking on how tuber
culosis will be controlled. Trends indicated by this evaluation are
that problem of drug resistance and chronic invalidism may develop
following high irregularity in drug taking and by ineffective chemotherapv? Every step should, therefore, be taken to ensure that
detected patients take prolonged continuous effective anti-TB drugs
therapy.
Dr. Rao : Thank you. I would now request Dr.
Deshmukh to present his paper.
DISTRICT TUBERCULOSIS PROGRAMME
IN MAHARASHTRA
' i’
By
Dr. M.D. Deshmukh
I must congratulate Dr. Bordia for his excellent report on the
working of the District Tuberculosis Programme in Madhaya
Pradesh. I was also asked to carry out similar work in my State
but I have not yet been able to do it. The authorities in my State
have not been as prompt in responding to my request as in M.P.
My observations are based mostly on the official report 1 received
late in December, 1970.
l1
Progress of District Tuberculosis Programmes in Maharashtra
Figures from year to year are not available. It seems that
since 1963 District Tuberculosis Programme has been established
only in 11 out of 26 districts of Maharashtra viz. Thana. Dhulia.
Nasik, Jalgaon. Aurangabad, Parabhani, Nanded. Latur (Dist.
Osmanabad). Chandrapur, Wardha and Nagpur. Il seems Poona
had everything ready except the UNICEF vehicle for many years
Now that the vehicle has arrived, the new medical officer has to bt
sent to National Tuberculosis Institute for training, for the prexious
N.T.I. trained medical officers have been posted to Jalgaon.
Akola, Sholapur and Sangli ha\e all the necessary require
ments except the UNICEF equipment release of which is expected
soon.
Satara and Ahmednagar TB Clinic buildings are stated to b?
nearing completion.
Plans for TB Clinic buildings are yet to be submitted by Civil
Surgeon of Ratnagiri. Alibag, Bihar and Bhandara. The informa
tion about the remaining districts is not at hand.
The total number of TB clinics in the state is 27 but 3 of these
are not for the Districts ( J.J. Hospital, G.T. Hospital and Kalyan
Camp) which means 2 districts (Kolhapur and Buldhana) are still
without a TB Clinic.
n.
Rise of District Tuberculosis Programmes as compared with rise
in number of trained teams
The information given under this heading is rather confusing.
It seems that the practice of sending a team as a whole to N.T.I. is
J
^2
I
•4V
'I
I
44
45
long abandoned. Odd persons in different categories are sent from
do.erent p.aces and it is hoped that some teams would be made
out of them.
It is stated that in the 21 courses conducted at N.T.I. from
August 1962 to May 1970, the following were trained for our State :
Medical Officers
Treatment Organisers
X-Ray technicians
Lab. Technicians
B.C.G. Team leaders
Statistical Assistants
24
36
28
22
16
23
Rise in District Tuberculosis Programmes has not been consis
tent with training of personnel. Out of 24 medical officers trained
so far, 9 are oosted to District Tuberculosis Programme 5 to TB
Clinic awaiting upgrading to District Tuberculosis programme. 1
resigned, 2 promoted as Class I officer, I died. I to TB Hospital. 5 on
general side. Of the paramedical personnel, most are staled to be
working m District Tuberculosis Programmes or TB Clinics except
a few especially statistical clerks who are working on general side
because oi promotion as senior clerks.
HI. Corelation of District Tuberculosis Programme with rise if anv,
in case finding, case holding, and B.C G. coverage.
In 11 District Tuberculosis Programmes, 225 Peripheral
centres have been so far established—104 Primary Health Centres
69 Zilla Parishad dispensaries, 35 Municipal dispensaries and 16
other health agencies. A total of 6,391 patients are stated to be
under treatment.
It is not stated how many are sputum positives, It is also not
ciear if this figure represents the total number under treatment in 11
District Tuberculosis Programmes or if the patients at District
Headquarter^ are excluded. The average per peripheral centre
works out al just over 28.
at the peripheral centres it is 40 to 50%.
prove or disprove this.
B C.G.
Out of the total of 15 teams (1 team leader and 6 technicians)
one is working in the city of Bombay and 14 in the districts.
Their performance is admittedly poor. We have details only
for the months of August and September 1970.
Taking the better performance in September 1970 we find that
only 80 technicians out of the available 98 (14x7) appeared to have
worked for 20 days in that month. Out of just over 4 lac regis
trations they have vaccinated only 94.505, an average of 58-59 per
technician per day (direct vaccination). At this rate just to cover
the susceptibles in one district alone all 14 teams will have to work
for nearly 12 months.
Bombay team is said to be averaging 98.7 vaccinations per
each technician per day but in the programme of primary school
vaccination in the month of August they could do only 1,140 total
vaccinations in the whole month. In our camps, in one day. we
can get 1.500 to 2.000 vaccinations done with 2 technicians. Train
ing by B.C.G. Department appears to be at a very slow rate. From
January to November 1970 only 31 candidates could be trained—an
average of less than 3 per month.
Evaluation
I have no reliable information on these points but I venture
my suggestions :
We propose to have a team to assess the programme in
Maharashtra very soon.
I believe that the concept of evaluating efficiency by matching
achievement against expectation is quite sound under our existing
conditions.
AV hen we consider the load which the District Tuberculosis
Programmes with its peripheral centre should carry, the figure seems
P'ti-bly low For the average of expected TB cases per district
should be 20.000 (5,000 sputum positives). 11 District Tuberculosis
Programmes here are covering only 6,391 patients which work out as
j ,'v cf iota, cases. Even if we consider peripheral centres as res
ponsible only for 80% of the total it is hardly one or two per cent
higher.
r
Proportion of sputum povitives
Case Holding
Respective role of city centres etc.
It is stated that cases holding at district clinics is 60-70% but
There are no figures to
Even in the best run programme in our State (Nagpur) the
contribution of Peripheral Centres by way of sputum positives in
total number under treatment appears to be less than 10% whereas
the percentage of sputum positives is given as 10%. In many
places the microscopes are not working and supervision on the
work where it is done appears to be poor.
No figures are available. It appears that most of the cases are
at present diagnosed at city centres.
■*-
•
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District Tuberculosis Control Programme
TB Control & Training Centre, Nagpur
Ycarwise analysis of centres cases in rural area
Year
No. of
Centres
Micros
copic
No. of I’os. Diag
nosed
sputum
exam
Total
under
treatment
April 1966
4
4
I 12
12
212
1967
9
7
500
56
509
1968
15
8
1226
55
613
1969
26
10
1742
89
879
1970
Up to
end of
Nov. 70
34
12
2493
138
1 197
Referral
centics
Sp
exam
Diagnosed
Total
under
treatment
Total
eases
under
treat incut
212
123
632
7
3z2
935
16
549
1428
W/.C7. * 4 v’l
kM'
ri
D
Q
E
o’
s
M
3
CX
c
era
(JQ
rt>
V)
o*
I
The Maharashtra State Anti-Tuberculosis Association
Total work done in fifteen Tuberculosis Camps in ihe year 1969 & 1970
Place of camp
No. of
persons
examined
No. of
persons
screened
No. of
X-Ray
positive
No. of
sputum
examined
No. of
sputum
positive
No. of
BCG
vaccina
tions
Oral
polio
321
350
490
404
194
304
426
321
276
113
J 25
154
202
132
69
37
31
17
37
67
32
30
37
56
25
75
45
32
12
5
16
8
3
12
7
1291
1035
237
214
349
1138
1387
226
220
350
96
174
742
762
143
96
50
250
109
24
35
9
22
10
14
24
8
22
9
4
7
3
5
5
1729
253
1400
1449
1437
324
1124
213
171
171
67
86
41
8
28
41
8
12
13
3
525
454
115
1. Roha—Dist. Kolaba
2. Mtn iid-.laniira—Dist. Kolaba
3. Gargoli-Dist. Kolhapur
4. Chinchani—Dist. Thana
5. Khopoli—Dist. Kolaba
6. Mahad-Dist. Kolaba
7. Ashta- Dist. Sangli
8. Ahbag, Nagao. Rcvdanda—
o
Dist. Kolaba
9. Virar—Dist. Thana
10. Khcd—Dist. Poona
11. Ambarnath - Dist Thana
12. Takli-Kazi —Dist. Ahmedabad
13. Gorcgaon Mangaon Dist. Kolaba
14. Khcd—Dist. Ratnaniri
15. Parichgani- Dist. Satara
Total
ObfO.
eE 0 a-3 p z.
6265
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51
nation for those with definite or doubtful
doubtful X-ray
X-ray shadows
shadows were
carried out. Interval between successive surveys was 18 months.
The number of deaths shown in Table 2 is regardless of its
Though all Fhe P131 children in'lte-groL^CO-^^yeLsh^
Risk associated with infection among Children :
Table 1 shows the prevalence of 15 mm or bigger tuberculin
reactions at Survey I among children in 3 age groups. 15 mm or
bigger tuberculin reactions, at least for children below 15 vears,
max De regarded as strong evidence of infection with Mvco. tuber
culosis 18 o of the children in age group (0-4) vears, 7% for
age group (5-9) years, 12.6% for age group (10-14) years had 15 mm
or bigger reactions.
TABLE 1
bigger reactions, only 8.4% died over a period of 3 vears (1).
CXtrary- 'i0 3 Pres.ent belief, this mortality rate for infected
children is low and the rate,for those that developed infectious
nfrnUL0S’S t1S !°^er StiIL Even if il is assumcd that all
the 8 4/0 died of tuberculosis, as only 1.8% were infected, deaths
due to tuberculosis for children below 5 years would appear to be
of the order of -——2L1-8 cr iess than one sixth
of totaj
population. It must be emphasised that these low rates are in the
absence of any treatment worth the name. Possible interpretations
of this low risk of infection could be :
1
I
Prevalence of infection at I survey
Age
group
Total test
read
0—4
5-9
10-14
Those with 15 mm or bigger reactions
7976
7454
7242
Number
Percent
148
520
915
1.8
7.0
12.6
had p^tty WgL^t^nce^hist
°f
Several reports, Tuberculosis Chemotherapy Centre
"a-ras
Bh^ tw1°l,erI1(3)’ Ba,bir Singh (4> and last and most ‘ comhLrUb
i
er et al (5)’ shovv that a lar§e proportion of the
bac^.lli^
from patients had very low viruterTcc "often ’'s lov' a1-
Tabic
shows that during the next 3 years i.e., by the time
laoie 2 snows
Survey Ill was done, of the children below 5 years of ace, 11 or
8.4% had died. 105 were X-rayed at Surveys II 'or III and none
had developed bacteriologically confirmed pulmonary tuberculosis.
For this report only sputum culture positive cases are regarded as
cases of pulmonary tuberculosis. Such a definition has its weak
nesses especially for children, but number of cases showing only
X-ray evidence of cisease is not at the moment available. Similarly
of me 477 infected children of age (5-9) years, 9 or 1.9% had died';
of the 4j0 X-rayed at Surveys II or III only one had developed
pulmonary tuberculosis. In age-group (10-14) years 1.4% had died
and out ol 740 or 0.5% had developed pulmonary tuberculosis.
t at o BCG,.
That infection is very_slow aejing and the three-vear
follow-up was too short to bring out the full risk associated with i*
us assumption itself would be against the generally held belief that
the greatest danger is soon after infection.
5
i
("7* I
h
Whatever the cause of this low mortality be it should he
^lueedforhe °Vr the riSk associated with infection, the greater is hs
nossihll° PrOdUCinS-™nity aSainst tuberculosis.
Also the
possible low proportion of deaths due to tuberculosis amono
mnHien W°U d suggest that tuberculosis mav not b* as serious a
problem as is generally made out.
TABLE 2
Risk associated with new infection
Mortality and morbidity over a period of 3 years for children
with 15 mm or bigger reactions at I survey
This low risk associated with large reactions was also s-r
Age
group
Number
followed till
Survey HI
Number
dead
0-4
131
11
8.4
105
0
5-9
477
9
1.9
430
1
10—14
741
10
1.4
740
4
Number
x-rayed at
Survey II or III
No.
culture
positive
been tak?nS^ 5
F Vhe S1Ze of mduration at Survev I has
of aee m
* evidence of new infection. At Survey II 85 children
Dur?no die nyelTtl\/ne1anrfr-ed x
Were found new,y infected.
died :"he cause if deat
by Survey IH, only 2 of them had
be X-raved
H u
?1 known- None of those who could
X-rayed
- rayed at Survey II or Survey III (only those who had attained
c
I
52
i
TABLE 3
Mortality and morbidity over a period of 18 months for newly infected children
Age
group
0-4
*
5-14
Number found
newly infected*
at survey II
85
229
53
villages resulting in great irregularity in treatment and consequently
in the great and rapid increase in resistant cultures at Survey III.
TABLE 4
Number that
died by
survey III
2
%
2.4
Number who had
pulmonary
tuberculosis at
survey II or III
Proportion of resistant cultures at the three surveys
Survey
0
Total
number
4
* An increase of at least 16 mm
mm in size of tuberculin reaction from
Survey I to Survey II among those with
... 9J mm or smaller reactions at Survey I.
•.he age of 5 years were eligible for X-ray examination) were found
o have bactenologically confirmed pulmonary tuberculosis. In ageSj5L14 ■ yeaJS’ °f lhe 259 newIy infected at Round II. not one
had died during the next 18 months and only 4 had developed
pulmonary tuberculosis.
Thus the risk that new infection carries is also low in the
area, confirming that tuberculosis infection in our context is not
t tat angerous as is generally made out. These findings suggest :
(i) Tuberculosis itself may not be as serious a problem as is
usually made out.
In) 2Llhe_n5k. associated with infection is low, BCG in our
C°d Tn ihT 6rPt?sh0BCGaTmUlCh protection a£ainst tuberculosis as it
Development of drug resistance
The second factor relevant to National Tuberculosis Pro
gramme is shown in Table IV. Cases found at each of the 3
surveys have been divided into 2 categories—those that were
positive both on Culture and Microscopy and others that were
positive on Culture but negative on Microscopy. For the 2 cate
gories number and percentage of those with cultures resistant to
Isoniazid either alone or in combination with other drucs, is shown
m the table. At each of the 3 surveys the proportion of cases with
resistant cultures was more for the group which was Microscopv
Positive. Also at III Survey a marked, statistically significant,
increase in the number of cases with resistant culture's for the
Microscopv Positive cases only is noteworthy. At Survey I the
cases found could not be offered treatment. They depended'on the
very few facilities for treatment that existed in the area. After
Survey H most cases were offered treatment with isoniazid alone.
1 ms oher was not fully utilised by the patients from these far fluns
Culture + Microscopy cases
With cultures resistant
to isoniazid+
No.
%
CultureH- Microscopy cases
Total
number
With cultures resistant
to isoniazid +
No.
%
I
68
12
17.6
111
8
» 7.2
II
61
15
24.6
105
12
11.3
III
61
27
44.3
95
13
13.7
Thus the Microscopy Positive case which is the king pin in our
control programmes appears much more likely to develop resistant
cultures than the case positive on culture only. The latter type of
case at the moment is beyond the reach of our National Program
mes. Thus development of cases with resistant cultures is a risk
which could result from our control programmes. The risk is there
in any programme as shown bv me study by Frimodt-Moller
extending over 17 years in which seven Mass Miniature Radio
graphic surveys of the population of Madanapalle Town and sur
rounding villages were carried out. Facilities for treatment provided
for admission of each case in a hospital and drug supoly was more
plentiful and regular than in the National Tuberculous Programme.
Yet, at the end of 17 years, the total pool of infection remained
almost the same while the proportion of cases with cultures resistant
to INH increased significantly (8). The risk of developing resistant
cultures would appear to be much more in the National TubcrcuFjsiT
Programme.
I
i
I1:
To sum up. :
(i) The risk of infection with Myco. tuberculosis is much
lower in India than the described in text books of tuberculosis by
European authors.
(ii) Risk of increasing the number of patients with resistant
cultures with our present Control Programme is real.
Both factors point to the great necessity for assessing our
Control Programmes. The eminently feasible National Control
Programme forms only a beginning. Only by constant and realistic
assessment can we improve the programme and also judge whether
<
■ i
hI
54
it can lead us to our objective—namely—the Control of Tuber
culosis in the country or to the degree to which it can do so.
REFERENCES
1.
2.
3.
Raj Narain
Naganna, K., Chandrasekhar, P., and
Pyarelal. Crude Mortality by Size of Tuberculin Reaction,
Amer. Rev. Resp. Dis., 1970. 101. 897.
Bhatia, A.L., Csillag, A., Mitchison, D.A., Selkon J B
Somasundaram, P.R., and Subbia, T.V. : The virulence in
the guinea pig of tubercle bacilli isolated before treatment
trom South Indian patients with pulmonary tuberculosis •
2. Comparison with virulence of tubercle bacilli from
British patients, Bull. Wld. Hlth. Org.. 1961, 25 313
Frimodt-Moller, J. : Inquiry into the virulence to guinea
pigs and mice of tubercle bacilli isolated from tuberculous
patients prior to, during and after treatment with
streptomycin, PAS and Isoniazid, Indian Council of
Medical Research Scientific Advisory Board, Technical
Report, New Delhi, 1957, p. 153.
H.
Singh, B. : Guinea pig virulence of Indian tubercle bacilli,
Amer. Rev. Resp. Dis., 1964, 89, 1.
1.
Wijsmuller, G., Merle Selin and Mary Long.: The virulence
of tubercle bacilli for guinea pigs and the susceptibility of
?oU7neir?lgS
tUbcrcle baci,li’ Amer‘ Rev- ResP,
1970, 102, p. 221.
55
Dr. Rao : Thank you. I would now request Mr.
Nair to present his paper.
ASSESSMENT AND MONITORING OF NATIONAL
TUBERCULOSIS PROGRAMME (NTP)
By
S.S. Nair
The Approach
Assessment of a programme is the measurement of the extent
to which its objectives have been fulfilled. Assessment may also
include a study of factors that may influence the achievement. It is
clear that the objectives have to be defined in quantifiable terms so
that the extent of achievement can be measured.
In the past, control of tuberculosis defined as a systematic
reduction of the problem of tuberculosis to an extent that it ceases
to be a major public health problem had been accepted as the goal
of the National Tuberculosis Programme. The difficulties arising
from such a definition of the goal are :
*
(.
7.
American Thoracic Society : Preventive Treatment in
Tuberculosis; A statement by the Committee on Therapy
Amer. Rev. Resp. Dis., 1965, 91, 297.
Raj Narain, Nair, S.S., Chandrasekhar, P., and
Ramanatha Rao G. : Problems connected with estimating
the incidence of tuberculosis infection. Bull. Wld Hlth
Drg., 1966, j4, 605.
Frimodt-Moller, J.. Report to the Expert Committee on
Tuberculosis of the ICMR of the Madanapalle Tuberculosis Research Unit, Oct., 1970.
I
j
s
1
1.
What is a major public health problem ?
2.-
In what quantifiable terms—social and epidemiological—
should the tuberculosis problem be defined ?
3.
To what extent should the problem thus defined be reduced
for it to be a major public health problem no longer, and
4.
What should be a reasonable period of time required for
achieving this reduction ?
IJ
A number of attempts have already been made to quantify
the problem. But, more thinking and research has to be done before
these and^ related considerations can form the basis of assessment.
A clear definition of the goal in quantifiable terms has vet to be
adopted.
..
Another serious difficulty for assessment arises from a lack of
precise information on the period between infection and disease.
If, as is commonly believed, most of the cases* occur among the
already infected, then prevention, case-finding and treatment can
have only a marginal effect, during the initial period of the pro
gramme. Thus, a sizeable reduction in the number of cases may not
occur within a period of 10-15 years, or even more, unless the disease
is already on the decline. Any early assessment of reduction in the
* Cases are those patients confirmed bacteriologioally; the rest are
suspects.
t
I
J
■I
56
57
number of cases will only be a very costly attempt at proving the
obvious and will possibly lead to frustration. Nevertheless, it is
necessary to know the gains from tuberculosis control measures
involving sizeable amount of public funds. For this, a different
methodology of assessment has to be adopted since it is almost
impossible to provide a direct answer in terms of reduction of the
problem.
»
specified time will itself indicate the progress achieved. One advantage
of this method is that after assessment, attention can be concentrated
on the corrective actions required for fulfilling the expectations for
that stage.
It is true that based on the trend of the disease, before intro
duction of the programme, epidemetric models can be used to
predict the size of the tuberculosis problem at future points of time.
Comparing this with the actual size of the problem after the pro
gramme has been working for sometime, can provide a measure of
the problem reduction cue to the programme. But, even for this,
the programme has to be on for a sufficiently long period so that a
demonstrable reduction could be expected.
Assessment of efficiency
4
Measurement of the extent to which the objectives of the
Programme as a whole have been achieved may be called assessment
oj cjjicacy. Measurement of the extent to which the expectations
for various activities under the programme arc being fulfilled is
referred to as assessment of efficiency. It is generally true that
improving the efficiency of each activity under a programme will
result in improvement in its efficacy, provided the improvements in
one activity do not place restrictions on other activities. On the
oasis of this rationale, assessment of efficiency seems to be a
practicable solution to the problem of assessment of a tuberculosis
control programme.
Realistic expectations for outputs and coverages under different
activities can be set up on the basis of potentiality studies on the one
hand and programmes working with reasonable efficiency on the
other. The former provides information on what could be achieved
with a given staffing pattern and method of work. The latter on
what normally is achieved in the environment in which the activity
is performed. Achievements of the programme could then be
matched against these expectations.
Need to define stages
One important consideration is that the programme can only
be implemented in a few districts at a time and administrative and
operational conditions may vary among those districts. Thus
ciiierent districts will have the programmes developed to different
levels. Any overall assessment of such a heterogeneous programme
situation may give a confusing picture. One way to avoid this is to
aenne some stages eff of development of the programme, with graded
expectations, and to assess each district at suitable intervals m judoe
whether it qualifies to cross from one stage to the other. The number
ot districts which qualify to go from one stage to another at a
I F
i
Monitoring
A detailed stage-by-stage assessment could be supplemented by
monitoring i.e., a continuous ...watch on some key indices of the
programme calculated from periodic reports. This requires~~a
reasonably efficient reporting machinery. At present about 30 '0 of
the district programmes do not report on time. Within the reporting
programmes more than 50% of the peripheral health institutions
doing tuberculosis work do not report on time. Under these circum
stances, monitoring or any assessment-based on reports will under
estimate the achievements and cannot be considered reliable. It
would be better for assessment based on reports to be separate for
programmes under different stages, as the expectations against which
achievements are to be matched differ with the stages.
4
n
I
I
Comparison of performance against expectation
Some results of monitoring are given below mainly for illustrat
ing the methodology and the type of conclusions that can be drawn
An average peripheral health institution in which tubercuiosi.-,
programme is implemented could be expected to examine sputu
from 75 “symptomatics” per quarter and diagnose about 7.5 cjs-s"
The achievements of the programme in the Southern Region gencraliv
^no/0 r 16 Or^er
expectation for examinations and
40 /0 for cases diagnosed. On the average about 60% of the cas^s
are exPected t0 collect their drugs do so i.e.. about
o3/0 of a fairly high target of 95% of patients on hand taking
treatment at any time. For BCG vaccination, the all India average
monthly performance per team is about 55% of the expectation of
o.UUU vaccinations. Thus, comparatively, case-finding activity needs
greater attention and improvement at present. Then comes ECG
and lastly treatment.
ij
II
Contribution from peripheral health institutions
Three indices help in assessing the contribution made by PHP
the programme (Table 1).
(1) Only about 28% of the total cases diagnosed by aan average
DTP are found by peripheral institutions (aboutt SO^-o in
the Southern Region).
(2) Only about 23% of the total cases and suspects in an
average DTP are diagnosed by peripheral health institu
tions, suspect cases diagnosed at DTC on referral bein^
credited to the referring institutions.
s
I
■ I
I
58
59
TABLE 1
Indices showing contribution of peripheral health institutions (PHIs)
(January 1967—March 1970)
Percentage of total
Range
Mean
diagnosed every year in an average district i.e., about 70% of the
rate at which new cases occur.
Range in performance of an average DTP
v.
The quarterly reports prepared by the Directorate Genera] of
Health Services show an interesting feature. The average perform
ance of a district tuberculosis programme has been fairly stable over
the last four years with respect to the number of X-ray and sputum
examinations, new cases diagnosed and cases under treatment (Table
2). It could be that these programmes have reached a particular
i*-
Diagnosed by PHIs
TABLE 2
(a) Cases
23.8—34.1
28.1
(b) Cases and suspects
18.4—27.9
22.9
(c) Treated by PHIs
9.1—34.9
26.2
N.B. :
Figures are underestimates because of non-receipt of
reports from peripheral health institutions.
(j>) Only about 26% of the patients on treatment are treated
by peripheral institutions (about 50% in the Southern
Region).
ri ! Afler making allowances for non-receipt of some renorts. it is
like y that the combined performance ofa large’number of peripheral
health institutions falls much short of that of the district tuberculosis
centre. This can be improved if the case-finding efficiency of the
peripheral health institutions can be increased, so that more and
•mTireatSThere5^
fr°m these institutions could be diagnosed
Comparison with case load in the community
An average district is expected to have about 5,000 cases - at
any point of time and an annual incidence of about 1.500 cases.
The present rate of diagnosis in an average district programme is
about 158 per quarter or 632 per year and is only about 40% of the
rate at which new cases occur. This figure again mav be an under
estimate and is an average for districts under different staees of
development. It is likely that this percentage will be quite high in
some districts and a more correct picture could only be obtained by
separately considering districts under different levels of development
However it ^significant that the diagnosis of only one more case
per peripheral health institution per month will increase the number
diagnosed by an average district with 30 peripheral institutions by
360 per year. And, this will result in more than 1.000 cases being
i
Average quarterly output per district programme
(April 1966—March 1970)
Range
Mean
X-ray examinations
1559—2353
2085
Sputum examinations
1162—1512
1356
Cases diagnosed
143—190
158
Cases and suspects diagnosed
458—627
532
Cases and suspects under treatment
2092—2641
2366
N.B. :
I
Figures are under estimates because of non-receipt of
reports from peripheral health institutions.
level of performance within such a short time and that furtbAr
improvements are not easily achieved. One possible reason fo
t^s may be that the situation is a true reflection of the overall
efficiency of the general health services. In other words the effic enev
Conran, Ipat,Onl.Of PeriPheral health institutions in tubercS
control may not be much different from the achievements for other
act.vtt.es of these institutions and the problem cannot be considered
effortsPwm h r t0 the tubercu,osis programme alone. If so, concerted
enorts will be necessary to increase the all round effirienev nfiS
ServiCeS' ™s is a"
more importam fi .Tt y becaus
'“lable resources do not permit many parallel vertical heahh
P 8.r:*Inmes and secondly because the performances under such
special programmes viz., BCG, NSEP, Family Planning etc have
services.
Sh°Wn a much h,8her efficiency than the graerai’health
<
1
I
I
1
1
I
1
60
Comparison of DTPs with Tuberculosis Clinics
Monitoring could also be used to compare the contributions
from different components of NTP vis-a-vis the resources which have
been spent on them. For instance, the case-finding output of an
average DTP is about 260% that of District TB Clinics where the
integrated programme has not yet been introduced (Table 3). This
comparative performance may even be better (may be more than 3
iimei) if allowance is made for non-receipt of reports from some
TABLE 3
Average cases and suspects found by district programmes and
district clinics (April 1966—March 1970*)
61
programmes. Assessement findings are generally acceptable when
the assessment team has been authorised by the administrative
authority concerned and has the necessary technical capacity and
status. When assessment of a district programme is done without a
favourable attitude on the part of the persons responsible for the
actual working of the programme and/or that of the State Govern
ment concerned, the findings may not always be acceptable and may
not be followed by effective corrective action. Developing a proper
climate for assessment and authorising a suitable and competent
agency to carry out assessment are extremely important if resources
spent on assessment should not be wasted. This aspect has not so
far been given the attention it deserves and may be one of the
reasons for assessment being equated with fault finding and thereby
inhibiting the progress of assessment activities which are essential
for the healthy development of programmes and better utilization
of resources.
Cases and suspects
found per quarter
per district
Range
Mean
District programmes
458**—627**
532**
District clinics (without inte
grated programme)
149
—305
drl
In conclusion, the following points may be re-emphasised :
(1) Attempts should be made to define the goal of the
programme in quantifiable terms—both epidemiological
and social.
(2) It is almost impossible at present to calculate the extent
of reduction of the tuberculosis problem. Assessment of
efficiency is a practicable solution to this problem of
assessment.
203
(3) Certain stages of the programme with quantifiable objec
tives should be formulated and assessment of programmes
in different stages should be considered separately.
Based on the quarterly reports of the Directorate General
of Health Services.
(4) Monitoring or assessment based on reports could give
useful information about the working of the programme
provided (i) the efficiency of reporting from peripheral
health institutions to the district level and from districts
to state and central levels is improved and (ii) such
assessment is done separately for districts under different
stages of development.
** These figures may be underestimates because non-rece:pt
of reports from peripheral health institutions.
peripheral health institutions. TLL
___ % indicate that establishThis would
ment of district tuberculosis programmes could probably give better
results than district clinics. On the other hand, the expenditure on
a district programme will be more than that of a TB clinic and it
has to be studied whether even this three fold increase in case-findine
is commensurate with the additional expenditure involved. Similarh;
data on treatment for these two components of the programme
cou’d also be compared.
(5) A proper climate for assessment should be created so that
assessment is welcomed by programme organisers at state,
district and periperal levels and correctixe actions are
taken soon after completion of assessment, This very
important aspect is not given the attention it deserves.
Need for a proper climate for assessment
Assessment becomes a mere exercise if the indicated corrective
actions are not taken. Assessment should be objective enou°h to
inspire confidence and its findings should be accepted or af least
appreciated by the persons in charge of the actual functioning of the
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Dr. Rao : Thank you. May I now
Dr. Jaswant Singh to present his paper ?
request
Slide No. 1
Dr. Jaswant Singh
ks'im^leme
Tn thepS District
As regards the establishment of diagnostic and
X
PXa^, &
was brought around to co-operate.
1 conccrned
. .d. sEi'sss is“'x,E‘s ', lnyE'■,
Out of these 38, 10
centres 1
and Tm^nFcVn^’a^bS'dTsT3: trSged0^ocato?X0dStra,i°n
training of TB Health Visitors was also c>mT,Ty.,'rSCS
extend the benefit of this programme to the whTle state.'11 °
t0
been ®
c^ntr^LS3"1.?6’
*for persuading The staTT/d “tTalu rliouT “f d°"th
laboratory sundries, forms and cards etc Theresas heen^ ( drUgS’
of drugs and laboratory sundries in the orevfn?
shortage
the forms and cards had to be managed on Psomp yearS alth?uSh
certain other funds.
uianagea on some occasions from
diasoosed oasMhaa bwn^dertaken byMeVa'rhXlidn
This slide shows the numb.r of sputum examinations done at
the periphral institutions in the years 1965. 66 and 67 respectively.
The vertical limb shows the number of sputa whereas the horizontal
limb shows the years and the quaters. In 1965, in the 1st quarter
the number of sputa examined was 56 and in the 2nd quarter when
according to the syllabus curriculum of TB Health Visitors, the
batch under training at that time was sent to the Primary Health
Centres; the number of sputa examined sprang to 431. After their
coming back, the number again dropped to 244 and 190 in the
subsequent quarters.
»-
A few dfspenslries0^^? d^ 1S
partiejpating in this programme.
collection of sputa and its handling while staining has been another
setback and remarked as a "Hazardous Task” with no incentive
and extra allowance for this risk.
During the training of TB Health Visitors Course, the field
training was also included in the curriculum.
By
Punjab StatTJn “’l
1
‘he
was undue pressures from Sthe admmstrnive authorities^11
ing the targets of some other pubi c health
f°r attainNMEP and FP. The fear complexPaX^
Again in the year 1966, in the 1st quarter, the number of sputa
examined was 188 and in the subsequent quarters, due to the pre
sence of under training health visitors, the number rose to 488 and
545 respectively, and alter their withdraw! the number of sputa
exammed dropped to 107. The same thing happened in the vear
1967. In its 1st quarter the number of sputa examined was 159 and
when the health visitors were sent there it jumped to 397 but a-ain
dropped to 106 on their withdrawal. This constant experience of
three years gave us the impression that the diagnostic activity of
tne peripheral health centres was boosted only when a special’ norrShpnentVaS depurted, there t0 heIP
staff in this programme In
ine interest of this programme the matter was discussed with the
administrative authorities and the State Directorate agreed in princiwa.
f°ne !Xtra workerat each primary health centre as it
a 2 g nOneJOr °fher CUrr£nt °ubHc hea,th programmes. Such
nrh?S b£en de3!=nated as a “Multipurpose Worker” and the
training of these workers has been entrusted to this centre This
training was commenced in the year ls69.
Slide No. 2
at 7 1“
“lumn sums up the total number of sputa examined
u iti per‘Phral diagnostic centres for the quarter endinu on 3] r 69
f r "
C pre3ence°fan ext™ personnel for this activity’ >he
and th Stlkg-» °f niult,PurPose workers was done in February, 1970
and though Hvyas at a few centres to start with, the number of
theOnd Xami.n-d rro.se from !55 ir the Preceding quarter to 423. In
“°d cluarter of th>s year another batch was trained and posted at
exZm^m/'nin8 1prim.aJy1 health cenlres and the number of sputa
- ’P'Hed jumped to 1018 nnci simdnrly in the 3rd quarter to 977
a wortfrTT," °f lhe 3Idr <’uarlerit is very ciear|y evident that when
orker was transferred from one primary health centre the number
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65
of sputa examined in the whole quarter came down from 161 to 9.
Ihis is an infantile pei iod of the posting of multipurpose workers,
but the increase in the number of sputa examined is manifold and
very significant. The boosting effect of these multipurpose workers
on this programme is quite obvious.
6.
There should be no dual administrative control of BCG
teams in the districts.
7.
Under the pressure of other priorty programmes, the
activity of this programme should not suffer."
It should also be mentioned at this juncture, that the organisa
tion and pursuation tactics were handled by my epidemiologist, a
senior collegue of mine, who studied the problems for about" four
months with personal visits to the diagnostic centres. A few
diagnostic centres even after the posting of multipurpose workers
the average sputum examination was less than one sputum a day and
when the medical officer and the other ancillary staff was tackled
by him then, their attitude of mind was changed.
8.
A very common observation is regarding the vehicle which
is supposed to be allotted to the DTO. In almost all
the district the CMO always requisits the vehicle on one
pretext or the other. This results in the neglect of the
control programme.
9.
To maintain the records in the proper order the forms
should be supplied by one agency may it be TAI or DGHS.
10.
The personnel trained should not to be disturbed bv the
Government.
To sum up in brief the following points, devices need proper
attention.
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Dr. Rao : Thank you. I would now request
Dr. Srinivasulu to present his paper.
V
Functional uniformity must be there.
2.
Orientations for change of attitude of medical and para
medical members engaged in general health services in
such a way that this programme is accepted and not
repulsed.
OBSERVATIONS ON THE NATIONAL TUBEERCULOSIS
PROGRAMME OF KURNOOL DISTRICT, ANDHRA PRADESH
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From the administrative side :
(a) The attention of state level authorities for this prog
ramme should go in parallel to the other top priortv
programmes.
(b) As being none for other programmes, targets should
be fixed, and incentives offered as for family plannina etc
Extra facilities should be allowed and annual confidential
reports scrutinised.
(c) Periodic check of district TB Centres L,
by admmistrative heads and the difficulties and problems to be solved
at spot.
(d) There should be a decentralisation of administrative
powers to overcome difficulties at the spot.
4.
From the point of organisation there should be adequate
arrangements of stocks, forms, drugs and laboratory
sundries etc and the supply should be regular and with
out any pitfall and break.
5.
District level monthly meetings should be L.
held to have
open discussions on this programme with the
-e same enthusiasm as for NMEP and FP. ~
Dr. T. Srinivasulu
Kurnool
I had the privilege of working in National T.B. Programme for
a period of two years after my training in N.T.I., Bangalore.
The National Programme was started in Kurnool District in
1966 _and the programme is in existence for 5 years. In this district,
ie_PTP is functioning according to the recommendations of the
pj-1- .The whole itam is trained ar N. i.l. The District Tuberculosis
Officer ts the drawing Officer and the District Medical and Health
Omcer is the controlling and coordinating officer between District
Tuberculosis Officer (DTC) and the Peripheral Health Institutions
(PHIs).
The BCG team is integrated with D.T.C. since 1967 and doing
mass BCG Vaccination door to door type without mantoux
among the eligibles i.e., 0-19 years age group " There is a vehicle for
the team but often the vehicle is being diverted for other program
mes, which is interfering with the cox erage of BCG. New"born
vaccinations and vaccinations in Municipal towns by BCG vaccina
tors, the output and coverage is not unto the mark. Tiie team is
not working with full complement due to frequent transfers of BCG
technician5 to other national programmes and the posts arc not
n.led up for a very long time in sufficient numbers. Since the liquid
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67
BCG vaccine is supplied only a few days before the date of expiry
it is resulting in a lot of waste. In 1970, 6655 cc vaccine was
supplied to Kurnool out of which 3275 cc was wasted. The wastage
can be minimised if freeze-dried vaccine is supplied in laree quantity
In 1968, the team registered 1,24,000 cases and vaccinated 42.000
cases and the performance is 50% of the expected.
Diagnostic activity by the DTC
From 1966 to 1970, the DTC has indexed round about 3 000
cases every year. By the end of 1970, the total cases indexed’are
13,000. There is a steady rise in the participation of PHIs in
D.T.P. In 1966, there were 10 peripheral health institutions partici
pating in the programme. By the end of 1970. fifty PHIs are parti
cipating in the programme.
. .
suPPly : There was free supply of sufficient quantity of
Anti-TB drugs by the DGHS all these years. Of late, there is a
shortage in supply.
'lX"-Pay : X-Ray machine has gone out of order very frequently causing setback in case-finding.
L^r^,0’y,
On an aYerage, 3 thousand sputa were examined
by the D1C, Laboratory, and on an average one thousand sputa
were found positive every year.
General approach towards evaluation and why assessment of
epidemiological impact has to be kept aside for the time-being
The distribution of Tuberculosis cases in rural as well as urban
areas is equal among the general population as revealed bv the
surveys. Hence assessment of epidemiological impact of tuber
culosis has to be kept aside for the time being for the following
reasons. The problem of tuberculosis will be much reduced onlv
when s.'stemahc case-finding and intense treatment is carried out for
all T.B. patients through DTPs. Since Tuberculosis is a chronic
cisease the assessment of epidemiological impact cannot throw much
light in a short period of time of existence of NTP. Further bv our
approach to the problem through NTP, we are tackling the problem
uniformly throughout the country. A reasonable target will be 50%
reduction in 20 years. Now the programme is in existence only for
5 years. This period is too short to assess the epidemiological impact
in a chronic disease. Hence it has to be kept aside for the time
.-being.
Concept of evaluation efficiency by matching achievements
against evaluations
In a big district of Kurnool with a population of 20 lacs the
expected case load at 1.5% of the population will be 30 thousand
and sputum positives at 0.4% will be 8,000. In a period of 5 years
10 thousand cases were indexed within the district and four thousand
sputa were found to be positive. As the programme gains momen
tum due to the increasing awareness of the public and frequent
visits by the DTC statf to the peripheral health institutions with
regular supply of drugs nearest to the place of residence, increase in
hospital beds and more trained team manning the programme and by
enlisting the co-operation of the PHIs' staff, we can expect 3 to 4
thousand cases to be diagnosed every year by DTP. At this rate, in
another 5 years 20 thousand (5x4 thousand) cases can be detected,
provided the case load is constant, i.e.. an equal number of cured
cases are added to the ‘'Pool” every year. While evaluating the
efficiency we have to take into account new population added to the
existing population minus total patients cured and died. Since births
are more than deaths, we can expect total increase in population and
also in the case load.
If the remaining 20 thousand cases are not diagnosed in five
years from now, we have to conclude that either there is a recession
in tempo of the programme or a substantial increase to the total
‘pool’ of cases than the number of cases cured and dead.
•i!'
Therefore atlcast 10 years period is required to evaluate the
efficiency by matching achievements against expectations. A reason
able target will be 50% reduction in a period of 20 years Even if
we are net able to achieve this end, the programme need not be
considered a failure, since larger number of tuberculosis patients are
receiving anti-TB treatment through DTP.
i
Proportion of sputum positives in the total casefinding yield and
factors which determine its variability
The National T.B. survey has shown that about 1.8% of the
general population are suffering from disease and |th of them are
excreting bacilli (sputum positives). 50'% of them are approaching
tor modern medical help. If these could be discovered forthwith
as smear positive cases by a network of microscope centres by ofiering sputum examination, the PHIs car. contribute a good proportion
of sputum positives to the total case finding yield. Low yield of
sputum positives is due to failure to use microscore by large number
of microscope centres. Another cause of variability is that the
annual incidence of the sputum positives of the district is likely to
be 1,000 and therefore any gain in annual casefinding over and
above thousand is likely to pay dividends towards TB control as it
would lead to quicker draining of the pool of infectious cases lead
ing to a receding risk of infection in the community.
'■
Selection of patients for sputum examination among the
symptomatics yields a high percentage of sputum positives when
compared to the general population. A good microscope, fresh
stains,, a trained technician go a long way in detecting more positive
cases. Examination of overnight collections, overspot collection
yields better results in detecting positive cases. Above all, PHI
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69
medica1 officers examining sputum of all symptomatics yields best
results in detecting positive cases. In service training to all car
gones of Para-medical persons and reasonably good standards in
microscopy after such a training can be expected. This aoes a lon<>
way in delecting sputum positive cases.
nc
^herX^i;0?p^Xeen‘re (DTQ and rUra' Cen,reS ™
PHls Thin
Vg hl°? . for the success of NTP are lhe
is In 1969 the DTC, Kurnool alone has diagnosed 9 600 cases
onlvCV60 rthe 50
(°Ut °f which 2 are T B- Clinics) ’diagnosed
onlj . 60 cases working upto an average of 7 cases per PHI per year
or one case in two months. If the two T.B Clinics
P - y-are excluded
«kcasef,nd,ns activi,y of seneral hea,th
like t£rTYrrhlS We Cian (?Ikc,ude that on,y specialised T.B. Clinics
fwdino DrTC am6 otherT-B- Clinics in the district are doing case-
a second thSt03000’ In lhe light °f these figures- we have'to give
a second thought on integrating NTP with general health services^ or
out other methods to enlist cooperation of PHI medical officers
PHI Inso tUen;CfXasmn?tlOnS f°r 311 thC somatics that aUend
inn themJd- .of
stains a"d slides from DTC and requestng the medical officers to cooperate for the success of programme
the response is very poor. What is the remedy for this ? °c’ramme
What factors determine (he treatment regularity
as shown by assessment
and desening. sympathetic attitude even towards chronic' defauhen;
”oack o'fariSTn the?r'tre^enl “
t^atment. Solving
to tne drug collecting centre (PHI) or the PHT
; Jesia.ence
ThraUiiudeTt^
^»Sesafo(a clSaHei0perio°df
regularity.
°
miporiance in
treatment
Influence of changed BCG policy on BCG outputs and coverage
i
By the changed BCG policy, simultaneous coverage of the
whole country through DTCs instead of some parts of each state as
before, doubling the speed of work, cutting the cost proportionately
and improving coverages by saving losses due to absenteeism and
refusal at the time of second prick are achieved. Freeze-dried
vaccine can be used for 6 months with a longer date of expiry and
increase the coverage and output. There is a minimum wastage of
vaccine. Changed BCG policy is definitely advantageous if carried
out strictly as per the NTl manual.
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Dr. Rao: Thank you. I would now request Mr.
Sundareshwara to present his paper.
COMMUNITY LEADERSHIP IN NATIONAL TB CONTROL
PROGRAMME-A CRITICAL STUDY OF TUMKUR
PILOT PROJECT
By
Mr. K.S. Sundareswara. M.A. (Socio)
Joint Secretary, Mysore Stale Tuberculosis Association, Bangalore.
!
The Author is glad to have this opportunity to participate in
this Symposium under the leadership of Dr. K.N. Rao. whose name
and fame in the medical field in general and tuberculosis work in
particular, is well known all over the world. The observations that
follow are based on his personal experience durina the past 6 years
haying been closely associated with the non-officiaT Pilot Project, the
object of which is to bring out clearly and impersonally the merits
and demerits of the National Tuberculosis Programme, both ofnciai
and non-official.
The dynamics of society presupposes certain conditions which
as a process itself divulges an analytical understanding abou; i's
sttuctural relationships. It is essential always to make
attempt lo
study each social aspect in its entirety in relation to the functioniim
oi the whole phenomena. This functional approach often tends to
aenvation of certain uniformities with the help of which one can
build up meaningful course of social change; or accelerate the social
planning on the direction envisaged. Therefore it would not be
inappropriate if we subject the programme of National TB Control
1 rogramme, its implications to an explanation in relation to the
existing and changing social order.
First of all, the National Tuberculosis Programme. emer°irn as
a social concept, formulated into a fullfledged Health Programme
taking into consideration its limitations as far as its scope in the
light of the social, economic and other major health problems
especially in a developing country. The series of sociological and
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other scientific investigations conducted by N.T.I. and Madras
Chemotherapy Centre blended National Tuberculosis Programme
into a hormonious social planning. The formulation ot National
Tuberculosis Programme through an operational research has vividly
characterised the quality of the participation of the community in
the programme.
The understanding of the functional relationship between the
programme and the community is a vast field of study for the social
scientist and it has opened a new prospective particularly to the
social ecologist whose scope of study can comparatively be enlarged
with newer concepts of societal behaviour. These findings may help
those who attempt to evaluate N.T.P. in its larger scope but do not
at all by itself determine the indecies for evaluation or set standards
for its progress.
It is essential to know what constituted the idea of implemen
tation of a community participation programme like Tumkur Pilot
Project hereinafter called as Voluntary Project. It was a modest and
a scientific understanding that a felt-need oriented programme
(National Tuberculosis Programme) necessitates “sustained effort
over many decades and the effective application of new tools requires
a very high level of community understanding and co-operation.
Experience gained oxer the last few years in all parts of the world
has clearly demonstrated the conflict between the ’ basic efficiency of
the control tools on one hand and human lethargy on the other.
The assault on the human lethargy factor was expected to be
launched effectively by the voluntary agencies’’. Whatever such
other technical reasons prevailed, it was a measure of necessity to
rind out how a community can be mobilised as a strong social force
to accelerate the achievements of N.T.P. in the alleviation of phvsical
and mental suffering of TB patientsand whether this objective can
be effectively implemented through voluntary agencies, if so; how?.
In biief, the primary objective cf the voluntary project imple
mented about six years ago in Tumkur district was to test the
validity of the concept of supplementary assistance to N.T.P. in
improving the communication between the patients and the existing
TB Health facility where amongst the community, there is already a
fair level of awareness of the pathological symptoms on the part’of
n.e patients. The defective communication between patients and the
Health facilities was one of the main causes for the higher rate of
defaul.ing or irregular treatment of the TB patients in the control
programme. (The regularity of treatment was found to be in less
than 50% of the patients).
With the help of these analyses a course of action was
prepared and followed in the name of voluntary project in Tumkur
The examination of factors which the project implied cannot
be arbitrarily summarised to any conclusions and correlated to the
• ns of the National Tuberculosis Programme without a proper
fUn<hod of inquiry. This needs veritably an exhaustive study and
^.ta'ed investigations. But one thing can be pointed out that this
reIluntary project by itself formed a hypothesis for a field operational
and the whole programme can be treated as a study.
Method of present inquiry
In order that a critical review is arrived, the entire functioning
of the project since 1964 has been subjected to an investigation based
on case studies recorded by the author as and when they were
noticed. Hence it is admitted that while interpreting these case
studies, there can be some amount of subjectivity being crept into
the explanation of the facts. In a sociological study, like this, the
treatment of the subject will be invariably both objective as well as
subjective.
The case studies which are intrepreted here have not been
described elaborately for want of space and time; only an analytical
discussion on them has been stated. The analysis of these studies
reveal themselves around two major subjects, firstly, the community
represented bv a volunteer and a patient and secondly the commu
nity welfare ' programme i.e. N.T.P. The inter communication
between these two subjects forms the base on which the community
behaviour is studied or understood in relation to a newer social
situation, i.e. National Tuberculosis Programme.
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Volunteer in N.T.P.
The definition of a volunteer calls for a close study of the
social situation in which he functions. Here a volunteer is defined
outside the general attributes of the formal leadership. This means a
volunteer need'not always be an existing leader but at the same time
he may be projecting the qualities of leadership conducive to me
promotion of knowledge about a particular programme in the com
munity (National Tuberculosis Programme). In short, the leadership
of a volunteer in a given situation (in a gixen community pro
gramme) is determined by the existing social values (of leadership)
permeating to community itself; in order to invoke or locate such
leadership in the community, it is imperative to study the community
behaviour at its close quarters continuously over a long period oi
lime. This is a time consuming process; but one cannot help oneself
without doing that. This is the main realisation that the project
achieved in "its process of recruitment of volunteers to assist the
National Tuberculosis Programme. Even without a project such
informal leaders supporting the programme may exist, but the
project acted as a special social agent in a district to find such
volunteers to assist the N.T.P. The influence of these congenial
volunteers on the progress of N.T.P. is also not only natural but
also indiscernible in character. The measurement or an assessment of
such a social function cannot be gauged objectively; that is why it is
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indicated that even tthis
’ i aspect
t
may be taken up for a detailed socio,
logical studies by the interested
rr.’.cr-tcd agencies.
(d) The other class of volunteers are those who are unwilling
to take up the work, but due to certain pressures they accept the
job. The High School Teachers, Government Officials, including the
community village level workers and leaders with political ambitions
fall into the category.
\ aiues determining the leadership in the programme
From the above discussion it is clear that all existing leadership
may not be helpful for a given programme or situation. Then it
becomes a task to locate the leadership or create such leadership in
a village. This has led to the belief that is always unproductive to
depend on the existing leadership in the village community for any
kind oi programme without properly recognising the attitude of such
persons towards a particular programme or action.
The studies of the volunteer structure in the voluntary project
indicate certain social difierentiation on the character of volunteers
in relation to their role they are playing in the programme. It is true
that many other social factors also play to make a person a volun
teer in the programme, like his sympathy towards a sick person, his
personal interest in a patient who might be a close blood relative, or
a sense ot appreciation or an understanding of the Programme, but
what was prominently observed was the interplay of social attitudes
and values, resulting in the acceptance of a function bv a person in
the education of a patient.
How values differentiate volunteers
(a)There are volunteers who have accepted the role of leadership
in tne progiamme because of an urge to gain their social status over
o^ers or to confirm their existing social status in the community.
About 12-.'4 group leaders out of 59 or 60 can be giouped in this
category; among the rest of 700 and odd volunteers 20°,may belona
to this group. The volunteers of this class normally exhibit their keen
interest in the programme, since such a kind of participation will
proMde them with opportunity to come in closer contact with the
officials oi a Hea!lh c
e or D T C ? lhat wjll enable hjm to
confirm his hold on the community. In short, his alreadv existing
■socia. status is further recognised with confirmed actions' done bv
him m the programme.
i ’
The volunteers can be also grouped under another class of
leadership who manifest a negative approach. For fear of Iosina the
existing social status, they accept the responsibilities in theft
gramme. Taey accept the job because the community may not let
them down m prestige. Generally, they constitute an older a<>e
group and the traditional leaders like village patels, castes heads
C iC.
(c) Some volunteers in the voluntary project feel that these
programmes give them an opportunity to become important persons
X itC°TUn'l-V-Jn l‘?iS kind falls Petty shop keepers, primary
school teachers, students back at their villages.
'P
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Volunteers and the programme
The volunteers are generally trained by the project staff at their
respective villages on the general aspects of the Control Pro
gramme; the process of training continues as long as the volunteer
remains in the project. Therefore, it is hoped that he would pick up
his work after he gets sufficient experience to deal with his patients
over a sufficient long time. The main emphasis is given to create a
situation wherein the volunteers conducts •‘Home Visits” to patients
on cordial terms, constantly. This has resulted in establishing a
regular process of social interaction between the patient and the
volunteer inter linked with the purpose of the programme, i.e. the
regular collection and intake of TB drugs by the patients.
The personal efficiency of a volunteer largely depends upon his
attitudes towards ms work. However it is also true that the exterior
factors also qualify the work of a volunteer. As far as the volun
teer’s efficiency in his own area of function is concerned, it could be
raied high to low from (a) to (d> as classified earlier. Generally the
volunteers who have an urge to improve or to retain the social
status in the community life form an active group of workers in the
village. Such groups are intelligible to the training that is imparted
to them. It should be noted here that formal and didactic Education
of Volunteers through training sessions will not be effective since
such measures cannot be sustained throughout the Programme. The
personal interaction between the volunteers and the educator
especially in the presence of a patient in a village is the dependable
mean of education.
Interfering forces
There are specific areas in the programme where the volunteer
cannot directly act in order to achieve his purpose. The attitude of
Medical Officers and other health stafl. towards the Control Pro
gramme, the administrative aspects of distribution of TB drugs, and
the frequent transfers of the Health Centre Staff are some such
factors that may influence the performance of volunteers in either
ways, they may increase the performance of volunteers in right
direction if they are conducive, or may precipitate a slakemng or
disturb the entire voluntary structure in a given place. But. there are
instances to show that even during such conflicting situations,
volunteers have been able to achieve conditions favourable to them.
Such instances are very less. In the process of social interaction on
a realm of common enterprise, it is always possible to find out
uniformities on which a fair level of co-operation can be achieved.
Even within the organisation of the cntrol programme, and voluntary
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TB Association, the experience of the project indicated that it would
be a persuasive task to achieve a cohesive commitment with the
purpose and implementation of the voluntary project. This feed
back education, though not realised in full, is a by-product of
the project.
Health education, its widened prospects
In the final analysis, the entire functioning of the project can
be treated as a programme of Health Education. The important
contribution of this project has been able to give us is that a com
munity can be effectively dealt with in aspects of a programme
education or social education, through an organised leadership of
the community—while other means of education being kept as
supplementary or secondary. This interact method of Health
Eoucation can be co-ordinated effectively since it is formulated on
the basis of study of interaction of various social aspects in relation
to the functioning of a society as a whole.
The fact that the patients are found to be generally mixing
freely with the other persons of the village, either gossiping in a
country coffee shop or in the agricultural farm, poses a different
problem for Health Education. Neither the patients nor the other
villagers seen to have little concern over the possibility of infection.
The so-called social stigma usually attached to a TB patient in a
village is almost seem to be non-existing. The voluntary project had
to meet this situation from a different angle. Any efforts through
general propaganda like showing film^on Tuberculosis and distribu
tion of literature or conducting lectures had little impact on the
community. Constant and persuasive talk with the villagers registered
good success as probably the range of personal participation of a
volunteer in such conversations with the villagers established
necessary rapport.
The other important factor observed in the voluntary project
was that the volunteers’ influence has been of little effect on patients
who become defaulters or irregular, because of their attitude of
indifference towards their treatment owing to the presence of other
economic problems, like, food, employment, etc. But the volunteers
have successfully prevailed upon patients who default because of
ignorance about the efficacy of the domiciliary TB treatment. The
initial defaulters who discontinue the treatment within a few' months
after diagnosis do not set much difficulties to a volunteer. A doctor
is always a deciding deity to a patient who looks to him with all
hope and faith. A dialogue between them is so personal that any
other force is almost feable desect it. If a volunteer as per the
programme try to convince his patient friend that INH and PAS
which are issued to him, (since injections are not made available in
the hospital) are effective; and that he could get relief, his efforts may
be futile, because the patient has already been told that injections
are the ‘must’ drugs for his relief. Therefore, the Health Education
should start on a
implemented.
plane of common understanding of the programme
I
Evaluation
The Question of assessing the contribution of the voluntary
rniec to the overall progress of the Control Programme has been
engaging the minds of the members of the project committee.
There have been some attempts to evaluate, to know whetner the
Lme visits to TB patients have led to more icgularity of drug
Smion by patients. This is yet to be assessed, since no nropedenominator is visible in the programme for the time being. However it can be said, as stated by Dr M D Deshmukh that th.
effectiveness of voluntary efforts would be. when the combine.,
efforts of both the Government and the voluntary resu.t in
progressive control of TB. But again, it is very difficult to know in
what
what degree
degree and
and in
in what aspect each agency contributed to h.
pro^ress'of the control programme, since each social force do_> not
act Independently.
Independently. Therefore
Therefore it
it is
is modestly suggested taat in sud
situation two areas (DTPs).
\ one with the project and the other
without it, can be subjected to a comparative study.
:F
f i-
I
a
s
Summary
la) It is not impossible to locale leadership in the community
to mobilise support in favour of a given community
Welfare Programme.
Health Education will be more effective if processed through
social interaction between the volunteer-patients-and the
National Tuberculosis Programme, the other mooes oi
education being kept as supplementary.
(b)
(c) The assessment of such voluntary programme in relation
to a Nation wide Programme cannot objective y be
achieved, but such programme in general can help the
major programme to achieve its purpose with more
understanding of the community behaviour.
(d) The success of voluntary projects depends largely on the
quality of guidance and leadership provided by the
voluntary agencies. Commitment of faith m such pro
grammes on the part of members of the vouintary
agencies and Governmental agencies is an essential factor
for the smooth implementation of such vo umary
programmes. This may be noted by other Voluntary
Agencies who are eager to implement such projects.
■
IW’-
if
I HI
i
/'J.
o
I
(e) It is suggested that some of observations made here in
respect of leadership, and Health Education may be taken
up aaain for a detailed sociological study to obtain a
better" and authentic understanding; hence it is reasonable
i
b
1
to
*
76
to hope for abetter recognition of social scientists in
N.T.P and other connected programmes.
T! e author is greatly indebted to various authors whose work
have .be- n referred and specially to Dr. H. Shivalingappa. Dr. R
Susai Mary, Dr Nagpaul, Dr. Raj Narin and Sri B.M. Cariappa,
with whom the author nad the privilege to discuss this paper. The
author expresses His thanks to Dr. K.N. Rao. once again for giving
an opp rtunity to present these observations in the symposium.
REFERENCES
I
Five reports of Tumkur Pilot Project-by Dr. P.V. Benja
min. Chairman, Fumkur Pilot Project.
The problem of Social Planning in a Development
Country-by Dr D. Banerji—Medicare, Vol. 3, No. 3, July
September, 1965.
Awareness of Symptoms among persons with pulmonary
TB—by D. Bancrji and Stic Anderson, World Health
1963. 23. 665-683.
4.
How Realistic & Effective is the concept of voluntary
support ol Government Tuberculosis Programme, by Dr.
. l.D. Deshmukh, Maharashtra State Anti-TB Association,
Bombay.
5.
A review of the Tumkur Pilot Project, by Guilda M.
Albert, IUAT Representative, National TB & Respiratory
Diseases Association, U.S.A.
6.
Outline of Tumkur Project.
Dr. Rao: Thank you. May I now request Dr. Gothi
to present his paper?
(Paper not receivedfor publication)
77
Dr. Somayya, President of the conference, anounced
that the next item of the programme will be a
n
session on ‘‘CHEMOTHERAPY” which has been
separated into two parts, the first session consisting of
the first seven papers mentioned in the printed pro
gramme to be under the Chairmanship of Dr. M. D.
Deshmukh and the other four papers under the Chair
manship of Dr. R. Viswanathan in the afternoon. He
then requested Dr. Deshmukh to take his chair on the
dais. Dr. M.L. Mehrotra acted as the Rapporteur for
the sessions. Dr. Deshmukh called upon the repre
sentative of the New Delhi TB Centre to present his
paper.
CAUSES OF TREATMENT FAILURE
BY
S.P. Pamra, G. Prasad and G.P. Mathur
(New Delhi Tuberculosis Centre)
Chemotherapy makes it possible to achieve cent per cens
conversion of sputum under ideal conditions. In routine practice,
however, the conditions are seldom ideal and, therefore, the results
usually fall short of the possible cent per cent. This shortfall is
often associated with several factors which are supposed to be the
cause of treatment failure. An attempt has been made in this paper
to study these factors and to quantify their contribution to treatment
failure. The paper is based on a retrospective analysis of 525 new
pulmonary tuberculosis patients with positive sputum diagnosed in
the New Delhi TB Centre in 1966 from the domiciliary service area
of the Centre and treated on a domiciliary basis. Seventy four other
patients who did not attend even for a single day after diagnosis and
therefore took no treatment are excluded. Majority of these were
not bonafide residents of the domiciliary service area.
A list of thirteen possible factors, some of which are present at
the start of treatment and others appear during the course of treat
ment, was drawn up and the results of treatment were analysed in
respect of these factors. For convenience of analysis, factors of
similar nature present initially and likely to influence the results
of treatment in an identical manner have been grouped together as
follows
Group A—Disease involving 5 or 6 zones, large bilateral cavities and
extremely poor general condition.
Group B—Tuberculosis or non-tuberculosis complications.
il
: h
i<
213
212
tomy is undoubtedly the superior treatment where appli
cable. Of the collapse operation Crew’s technique was
found to be valuable.
Table IV showing the results as compared with that
of
Andrew’s series.
TABLE IV
Operation
Andrew’s series
% cure
% death
(4) Nine cases required two major operations.
Drainage
10.7
7
6.2
6.7
Thoracoplasty
43.5
8.2
86.8
2.7
Resection
54.1
8.1
58.3
8.3
Decortication
63.6
9
96.4
Nil
Total
152 cases
(5) Only three cases were fit for primary decortication.
Present series
% cure
% death
(6) There was an overall mortality of 8.9%.
(7) In 6 patients empyema could not be cured though there
was persistent improvement in their health and disease.
I
<
1.
212 cases
Table V shows the overall mortality as compared with other
authors.
TABLE V
Overall mortality
Gordon et al
(1968)
Samson et al
(1958)
5%
2.9%
Andrew Present
(1965)
12.5%
hough amount of d.scharge is much less and their general condh
tion is much improved.
(3) Different surgical procedures were adopted and their
results analysed. Decortication or decortication and lobec-
Barrett, N.R. (1954) Ann of Royal College of Surg. Eng.
15, 25.
3.
Gordon. L. Snider & Suhayl, S. Salen (1968) Dis. Chest
54, 410,
4.
Grow, LB. (1946) Dis. Chest 12, 26.
5.
Le Roux, B.T. (1964) Jour. R.C. Surg. Edin. 9, 215.
6.
Samson, P.C.. Merrill, D.L., Dugan, D.J., Shabart, E.J.,
Y'ee, J. & Barber, L.M. (1968) J. Th. Surg. 36, 431.
7.
Yeh, T.J., Hall, D.P. & Ellison, R.G. (1963) Am. Rev.
Resp. Dis. 88, 785.
BCG PROGRAMME IN INDIA—PRESENT POLICY
AND FUTURE PLANS
Summary
(2) Out of these 187 cases (88.2%) have been cured.
2.
Dr. Somayya, President of the conference,.announ
ced that the next item of the programme will be a series
of papers on ‘B.C.G.’ under the Chairmanship of
Dr. S.P. Pamra. He requested Dr. Pamra to take his
chair on the dias and conduct the proceedings. Dr. P A.
Deshmukh acted as the Rapporteur. Dr. Pamra reques
ted Dr. Barua to present his paper.
8.9%
(1) 212 cases of empyema treated in a surgical unit have been
analysed.
REFERENCES
Andrews, N.C. (1965) Dis. Chest 47, 533.
/
By
Dr. B.N.M. Barua
BCG vaccination was first introduced in India in 1948 and
the mass BCG campaign was started in 1951. The target was to
coyer the entire susceptible population in a reasonable period of
time, say 10 to 15 years. It was estimated at that time that 170
214
million persons were available in the young age group which need to
be covered by the mass campaign and that 350 to 400 teams should
be able to cover this population, as also addition because of new
births, in about 10 to 15 years. By 1962, though a total of 178
million persons were tuberculin tested as against the 170 million
estimated to be available in the younger age group in 1951, in fact
the achievement was no where near the target. An analysis of the
performance of the mass campaign in 13 years from 1951-62 showed—x
that of the 178 million persons tested, only 112.7 million belonged
to the 0 to 20 years age group and not more than 50 million.of
them were actually vaccinated, because 1) this population was
covered over a period of 13 years with inadequate number of teams,
2) this population also included repeat coverages specially in urban
and semi-urban areas, 3) during these 13 years large number of
children were transferred to the next higher age group and 4) the
vaccination coverage in the younger age groups was further diluted
by addition of new births. The back-log of population to be covered
at that point of time was estimated to be more than 90% in the 0
to 6 years age group, 50% in the 7 to 14 years age group and 38%
in the 15 to 24 years age group.
------ -
215
Xn/the period from 1965 to 1968, we had two distinct program-
n£s A larcc number of the teams were integrated with district TB
clinics and these teams were doing mostly direct vaccination from
house to house. Their increased out-put because of direct vaccination
- was offset by very poor out-put in house to house vaccination. The
other teams' about a third of the total teams, were doing centre-wise
tuberculin testing and vaccination, as a result of which the out-pu
continued to be poor.
Therefore, in 1969. it was decided to give precedence to school
vaccinatian over house to house vaccination because in the meantime
more than 70% children in the 5 to 11 years age group were known
S be revered in schools and in any case even m the house to hou^
programme and before that in the orthodox mass BCG campaign a
Parge proportion of the figures reported were those of work done in
>/ schools.
Cj
y The presenLpolicy of the BCG campaign is, therefore the sum
total ofthesechanees, namely concentration in only to 0 to 20 years
aoe group, only direct vaccination, precedence to school vaccination
overhouse to house vaccination and integration of BCG teams vv (th
District TB Programmes, aiming at speedy and thorough coverage of
the susceptible population. The procedure to be adopted by the
mass campaign in Pespect of BCG vaccination in the_ country is that
BCG vaccination will be restricted only to the Oto .0 years a c
group. Unlike the mass campaign 0 to 1 year age group vvill al^tx
covered. The entire population will be covered by <i'rec BCG
vaccination without anv tuberculin test. It in the age group of 10
to 20 years the infection rate is known to be high iromprevmbs
experience, this aae group will also be ignored rather than Kin
PXPd with tuberculin testing and BCG vaccination. As. most of
the children in lhe school going age group are now available in the
schcols, precedence should be given to vaccination in schools over
house to house vaccination.
It was realised that the figures in millions that we quote as the x
performance of the Campaign are not really that important unless
a thorough and very speedy coverage of a given population can be
ensured and maintained at a high level.
To ensure through coverage and proper record keeping, house
to house vaccination was introduced in 1962. At the same time,
endeavour was made to integrate BCG teams with the district TB
Control Programme. Contrary to our expectations though house to
house vaccination improved the coverage to a very small extent, the
output per technician came down so sharply, that on an average not
more than 30 to 40 persons were vaccinated by a technician per day.
It was then realised that with the limited number of mass BCG
campaign units the country, unless very speedy coverage of the
population can be ensured, it will never be possible to achieve the
target. As direct vaccination was by then found to be useful, this
was introduced in lhe mass campaign at first in the 0 to 6 years age
group and thereafter it was extended to the entire 0 to 20 years age
group in 1965.
♦z •
A further analysis was again done in 1968. Till then 112
million BCG vaccinations were performed from the inception of the
campaign. It was established that about 84 million of these belonged
to the age group 0 to 14. By working out the point coverage i.e. how
many persons living in the age group 0 to 14 as on July, 1, 1968
have been vaccinated, it was estimated that of the total persons
vaccinated, only 36.08 million survived and were in the age group 0
to 14 as on July 1, 1968, the others having died or crossed the age
of 14 years. This gave a percentage coverage of only 16.53 of the;n
totalpqpulation in the 0 to 14 years age group estimated to be* /
available at that point of time. This was because at this stage i.e-r-7 1
•
0'
x
■
I
yAll these changes do not seem to have still improved the
performance to any large extent though the number of vaccina ions
has none up slightly high, being 1OA53q mil non in 969 and I I
million (estimated) in 1970 against 8o.49 million in. 1968. AH the
teams have not fallen in line with our recommendation oi precedence
to school vaccination yet, but the present indications are that school
vaccination has improved the performance to some extent, being
117 vaccinations per technician day as against 42 vaccinations per
technician day by the teams that are still working from house to
house. In the meantime new born vaccination through maternity
and other institutions is being further expanded and other agencies
are being encouraged to offer BCG vaccinations.
BCG teams has been in
The mass BCG campaign wiith special
,
existence for more than 19 years now and more than one round of
BCG operation has been conducted in almost all the areas, but it is
doubtful whether in the initial mass campaign phase we have been
216
able to achieve a high population coverage because a huge propor
tion of the susceptible population still remains uncovered. At the
present rate of coverage, the limited number of personnel available
for BCG operation
at
present, will
never
be able
to attain a satisfactory level of coverage. There are 237 sanctioned
BCG teams now and by the end of the 4th plan, itTiFexpected to
rise to 330, giving one BCG team per district as part of District TB
programme. It is not possible to expand the mass BCG campaign
any further, nor is it possible to continue with the mass campaign
for very long, as the ultimate aim of the BCG programme, and in
fact of all other vertical programmes of- today, is to integrate with
the general health services. The strategy has, therefore, got to be a
little different.
^For ensuring effective coverage in BCG operation, the scope
of activity of the programme has to be expanded further through all
avenues possible, keeping in view the strategy that/BCG should be
offered atl?ast in three stages i e. new borns, school entrants and
school leavers, and at the same time the feasibility of integrating
BCG services with other general health services has to be explored.
The three main services through which BCG prngramme can be
expanded further and with which BCG can also perhaps be integra
ted are the basic health service of the Primary Health centres, the
School Health Service and the Maternity and Child Welfare service,
which is now a part of the Family Planning programme.
So far as the basic health service in Primary Health Centres is
concerned, this exists in qnly_T.hose Primary Health Centres that have
entered into the Malaria maintenance phase. Of 5,044 Primary
Health Centres at present, 2,462 (approximately 50%) are in
Malaria Maintenance phase. In these areas, there is one basic health
worker for a population of 10,000. The main duties of these basic
health workers are, 1) Vigilance for Malaria, 2) vaccination
for small-pox (mainly re-vaccination), 3) Health intelligence in
respect of detection of communicable diseases,/5) recording of
birihs, deaths and vital statistics, 0) information in respect of
family planning. However, in practice they are doing only
Malaria and family planning work and to a very small extent, small
pox vaccination. They are expected to visit every house once in a
month, which means that there being about 2.000 houses in a
population of 10,000, he is to visit about 100 houses per working
day,—vigilance for Malaria being his main responsibility. As per
norm fixed, for 2,462 PHC’s, there should be 20,000 basic health
workers, but in 1969, there were only 14,000. However, the picture
is likely to improve considerably, by the end of the 4th Plan when
about 4,000 Primary Health Centres i.e. 75% of the total blocks are
likely to go into Malaria Maintenance and thus there should be
about 40,000 basic health workers.
Under Family Planning programme, the Primary Health
Centres have been further strengthened due to re-organisation of
family planning to public health approach. At the sub-centre level,
1
217
additional staff has been provided so as to have one Auxiliary
one health assistant
nurse mide-wife for each 10,000 population and
_
fnr 20 000 population. They are primarily meant for family planning
□nd maternity services. These additional staff for family planning
have been provided in almost all the Primary Health Centres and at
present there are about 19,000 A N.M.s and 10,000 dias in the subj centres.
9 ’
It thus appears that para-medical personnel are now available
at the sub-centre level. However, they are meant for limited- PurP%je
at the present stage. Whether these workers will be made available
for BCG vaccination, and, if available, whether they can be utilised
for BCG vaccination of the new borns, infants and children in their
areas aiming at thorough and periodical coverage, need to be studied.
J Already there is a feeling that though para-medical personnel
exist at the lowest level, at present they are mostly single purpose—
which is not in tune with the concept of basic health serv‘ce’ and
therefore, a proposal to see if it is possible to pool all the para
medical personnel at the sub-centre level and utilise them as multi
purpose workers is under consideration
In that case Par‘
medical personnel are likely to be available for a much smaller
Donulation than 10,000 as basic health workers to whom it may be
possible to
to entrust
entrust the responsibility of BCG vaccination in due
course.
'S So far as school health service is concerned, this is at different
stases of development in different States. However, the P1’65'^1
recommendation of the National School Health Counci is that
School health services should be recognised as an integral part of
the Communitv Health service organisation. Tnerefore, the aim is
integrate school health service at the primary health centre levd fo
which cither an additional public health nurse or atleast an A.N.M.
is to be provided. In absence of any special organisation for school
health service, if BCG is to be integrated with school health sen’ce,
the responsibilitv will have to be taken over by the additional pub lie
health nurse or A.N.M. provided for school health service at the
Primarv Health Centre level. How far this single school health nurse
will be'able to ensure thorough coverage of the entire sci c
population in a Primary Health Centre area where about 100 to 1
Har^ Schools are expected to be available, also requires to be
studied.
On the whole, in the existing circumstances integration of BCG
to certain extent appears possible with either■ c> the .gene a eal h
cervices discussed above, more so because freeze dried vaccine in
ncr as n2 quantity will be available, but this has to be exannned
further by operational studies, specially to ascertain the best
procedure’ for field work, changes that may be necessary 1
working schedule of the different para-medical personnel, ^asibi
of combining BCG with small pox vaccination, the arrangement for
supply, supervision, record keeping etc.
r
^TechnicaJ an_d operational investigations to study the feasibility
of integrating BCG work with the General Health Services through
the Basic Health Workers are in progress at the NTI. Similar
studiies for integration of BCG work with other services would be
' needed.
It, however, appears that unless the basic health services are
further strengthened and many more basic health workers than at
present are available and they are made multipurpose, any integra
tion of BCG with these services cannot perhaps be in substitution of
the existing BCG vaccination programme, but can only be as an
expansion of the present services.
Dr. Pamra : Thank you. I would now request
Miss Vasantha to present her paper.
FREEZE DRIED BCC VACCINATION
(PRODUCTION, PROPERTIES AND USE)
BY
Dr. J.C. Suri, Shri A.V. Oommen, K. SudhX and V. Vasantha
{BCG Vaccine Laboratory, Madras)
Till the end of the year 1967, the BCG Laboratory at Guindy.
Madras, was supplying only Liquid BCG Vaccine for use in the
“BCG Vaccination Campaign’’. However, the use of Liquid BCG
Vaccine in such Campaigns has great limitations because of certain
inherent drawbacks in the vaccine such as :—
1.
Liquid BCG Vaccine has a “short-life” of two weeks from
the date of manufacture. Because of this, the vaccine has
to be released for use, before completing many of the
prescribed control tests.
Also the Laboratory has to prepare a fresh batch of
vaccine every week. Impairment in the production due
to factors like scarcity of water, contamination, etc. has
often resulted in short-supply of vaccine to many BCG
Teams.
2.
219
218
Liquid BCG Vaccine deteriorates rapidly even at room
temperature and also on exposure to daylight. Therefore
extreme care has to be taken at all stages' of its production,
storage and use.
Since BCG Vaccine in the lyophilized state is a more stable
product, the use of Freeze Dried Vaccine in the Campaign was
expected to give more satisfactory results. However, from the large
number of enquiries received from the various BCG Teamsit appears
3
that the superiority of the dry vaccine over the Liquid Vaccine has
not been clearly appreciated.
The questions often asked have been :—
1.
What is the ‘life’ of the dry vaccine and should it be
protected from light and higher temperatures ?
2.
What is the period upto which reconstituted freeze dried
vaccine can be used, and should the vaccine be kept on
ice during this period ?
3.
In the field, when facilities for refrigeration arc not avail
able, within how many days should the vaccine be used ?
During the past two years, the Laboratory has done several
experiments to assess the properties of the dry vaccine and thereby
provide rational answers to these questions. In the process certain
modifications were introduced in the production methods.
Materials and methods
Production o f Freeze Dried BCG Vaccine
Freeze Dried BCG Vaccine is prepared from Liquid BCG
Suspension. The BCG Strain used for vaccine production at the
Madras Laboratory is the Danish strain (1331).
Surface cultures of BCG. after eight days' growth on Liquid
Sauton medium, arc harvested, using the Birkhaug’s filter. A known
quantity (8 to 9 gms) of the semi-dry BCG Cake, thus obtained, is
ground into a homogenous mass andsusp.mded in Sodium-glutamate
solution, to a final concentration of 10 mg ml.
About 0.5 ml of the concentrated suspension (5 mg of BCG) is
filled in each ampoule and freeze-dried. The dry vaccine in one
ampoule is reconstituted with 5 ml of the diluent to obtain a final
concentration of 1 mg;ml.
Since BCG is a ‘live’ vaccine, its potency depends on 11.c
number of viable units contained in it. Therefore, in the experiments
reported below, the “Viable Units Count” test has been used to
estimate the loss in potency of the dry vaccine, under different
experimental conditions.
Technique of the “Viable Units Count" test
Serial dilutions of the samples of vaccine are made in diluted
Sauton (one part of Sauton medium diluted with three parts of
distilled water). The last three dilutions are adjusted to obtain, for
the middle dilution, an estimated optimum count of 50 colonics per
bottle of medium, the first dilution 100 colonies and the third
dilution, 25 colonics.
236
237
TABLE 3
Comparison of F.D. vaccine lots dried from the same suspension
Dr. Pamra: Thank you. May I now request Dr.
Somayyato present Dr. Umapathi Rao’s paper since he
has not come here?
Viable Count of
F.D. Vaccine lots
Suspension
B C.G. AFTER INTEGRATION WITH TUBERCULOSIS
SERVICES
A comparison with Mass and modified mass campaign phases
r
I
A
I
I
r
i
B
i
i
10.0
18.0
10.0
14.0
9.5
15.5
12.2
12.8
18.5
9.7
14.5
11.0
16.0
C
TABLE 4
Results of testing of F D. vaccines—strain 1331—from
Madras and Copenhagen
Average of the results from the three Laboratories
F D. vaccine
from Madras
F.D. vaccine
from Copenhagen
0.37
0.43
6.9
6.3
Oxygen uptake
Microlitres/
Milligram hour
0.566
0.616
Germination
Rate—72 hours
50-75
60—90
Tests
Optical density
Viable units
Millions mg.
}
I
By
Dr. D Umapathay Rao
Introduction
The problem of Tuberculosis is of immense magnitude
million
affecting nearly 10 million population of which a quarter
.
are infectious and spreading the disease to the non-infected
individuals. The control of Tuberculosis requires not only detection
and treatment of the cases but also protection of the susceptible
individuals by BCG Vaccination.
Objective
To make a retrospective study of the progress of BCG after
integration with District Tuberculosis Programme and compare with
the earlier Mass phase of the campaign. Factors for lack oi progress
will be identified though not studied in depth to asses the value of
each fact.
The old set-up (Campaign approach)
B.C.G Vaccination was introduced in the erstwhile Hyderabad
state in 1948 and it is one of the few states to take up the programme
quite early. B.C.G. Campaign was under the charge of the
Assistant Director of Public Health (BCG) and there were five Units
under the campaign—Warangal, Visakhapatnam, Guntur, Ananthapur and Hyderabad. The Warangal Unit consisted of Warangal.
Adilabad, Khammam and Karimnagar Districts. The Visakhapatnam
Unit consisted of Visakhapatnam, Srikakulam and East Godavari
Districts. The Guntur Unit consisted of Guntur, Krishna and
West Godavari and Nellore Districts. The Ananthapur Unit
consisted of Ananthpur, Chittoor, Kurnool and Guddapah districts
and the Hyderabad Unit consisted of Hyderabad Districts and
City, Nizamabad, Medak, Mahaboobnagar and Nalgonda
Districts. Each Unit consisted of one Team leader and Health
Inspectors, driver and peon etc. Each Team had to cover
a population of a District (10-20 lakhs), testing 3,000 and vaccina
tions 1000 a month. The reports were received and consolidated in the
238
office of the Asst. Director of Public Health and sent to the Director
General of Health Services. The individuals were mantoux tested
and Mx-negative people were offered BCG vaccination. In the
year 1962 direct BCG Vaccination was introduced and in 1965 new
born vaccination was taken up all over the state.
The present Set-up (Integrated approach)
The BCG campaign is now integrated with tuberculosis
services through the District TB Programme as envisaged by the
Government of India. In Andhra Pradesh 14 Districts were upgrated
in this pattern and the teams are also integrated with tuberculosis
services. In the remaining districts the TB Clinics were upgraded
and BCG Teams are being supervised technically by District TB
officers under the administrative control of the District Medical &
Health Officer in each District. There are 31 BCG teams working
in Andhra Pradesh one in each District and one in Hyderabad city
(in the newly formed Ongole district separate tuberculosis services
including BCG Teams are not functioning but are catered to by the
neighbouring districts). In July 1967 with the integration of
Medical and Health Services a separate post of Asst. Director of
Medical & Health Services (BCG & TB) was created and he is also
the state TB Control Officer. Under him there are two Supervisory
Medical Officers exclusively for BCG Work. State TB Control
Officers supervises the District TB Programme including the BCG.
District TB Programme provides for registration of the population
visited and direct vaccination in the BCG Campaign for all the
susceptible population in the age groups of 0-19 years which forms
49.2% of the entire population.
/4cAw!ft7ge5:Unified command for the curative and preventive
parts of National TB Control Programme both at the State and
District levels.
As-atfra/zrages.-Unmanageable district and directorate offices.
Consequent delays and inadequate provision of TA etc. , . District
TB Officer’s supervision is part time and superficial while that of
the District Medical & Health Officer nominal.
Results
There were 3 phases of the campaign—Mass campaign upto
1962, modified mass campaign with direct vaccination of age-group
0-6 years, and the present phase of door-to-door vaccination
campaign with registration and direct vaccination only upto 20
years of age. The figures shown are for 3 years periods during
these phases.
I
239
Year Phase of the campaign
Tested
Read
(in lakhs)
Vaccinations
1954
1955
195.6
Mass Campaign.
14.15
30.02
25.25
11.98
22.88
19 05
4.89
10.38
8 47
1963
Mass Campaign/Dvs
(DTD.)
18.49/2 92*
10.98
10 23
19.16/4.99*
21.20/6.44*
(♦Direct Vaccinations)
na
n.a
12.38
1441
1964
1965
D.V.S. Alone (DTD)
1.06/14.80** not done
(**Regd. population)
*41.862 (*thousands)/,,
1969
23.46.
7752/27.09
1970 (incomplete
for Dec.)
1968
5.55
7.83
7.59
As can be seen from the table, from the year 1964 onwards,
the vaccinations figures doubled or trebled as compared to the
previous years. This has been due to the introduction of direct
vaccination due to which all those who were tested previously,
were instead vaccinated in the earlier age-group.
During 1968
and 1969 the figures are comparatively low because the BCG
Teams were deputed on other duties like “Pushkcram” work
at Rajahmundry and Vijayawada and suspended due to the
Telangana agitation. Added to that most of the districts in Andhra
and Telangana also suffered from inclemant weather such as
Cyclone and floods etc.
The complete figures for 1970 are
also not available.
The following points are interesting to note :—
(i) During successive years the size of the positive induration
was raised from 5 mm to 10 mm. Hence in 22.8 lakhs read in 1955.
there should have been more negative than 10.38, as induration
above 5 mm, were left out as positive and not vaccinated.
(ii) The number of Teams operating in Mass campaign phase
were only 11,
while they are 21 during the present direct
vaccination period.
(iii) Vaccinations were given only on 12 days in a month
in Mass Campaign. Now PVs can be given all the 24 days in the
month, but there has been no increase in this respect. The out
I
1
241
240
put of technician was about 1000 vaccinations during mass
campaign while it averages around 500 vaccinations at present.
Discussion
The administrative and technical difficulties were got over
by the integration of BCG with TB Services and the creation of a
single post of District TB Officer at District level and State TB
Control Officer at State level. However progress depended primarily
upon Technician output and technician days, All other factors
like vehicles, ice, petrol, TA & DA etc., are woven around these
two factors-.
Technician output :
Technique Oi”
campaign—TA (Prompt
payment) —Kit condition and other
equipment—Supervision—public coope
ration and Health Education.
Technician Days :
i.
No. of Teams and Technicians sanc
tioned.
No. in possession.
No. working.
ii.
Diversion, disturbances, deputations—
leave—transport
iii.
Vaccine—availability - date of expiry—
wastage—size of ampoule—difficulties
in production (Some of these diffi
culties may be solved by the supply
of Freeze dried vaccine).
iv.
Vehiclee—age—on road and in garage—
other duties.
v.
Petrol—Ice—Budget for TA & DA.
These factors operated during the three phases.
For example the Technician days put up are as follows:Year.
Tech. Days.
Year.
Tech. Days.
Year.
Tech. Days.
1962
1149
1965
1594
1968
939
1963
1274
1966
1473
1969
1145
1964
1152
1967
1216
1970
Howevr during 64, 1152 Technician days gave
12f8°Srs ^tio£
the output was only 7.83 lakhs.
The mass campaign phase had certain disadvantages and soon
deteriorated during the period 57-61. The modified mass campaign
phase had certain advantages and revived the campaign, soon
becoming one of the best organised in the country
New project
like new-born vaccination, door-to-door approach with direct
vaccination and simulteneous BCG and smallpox, were taken UP the State Organisation.
The present policy envisages school
vaccination—DTD, w'hich is like modified campaign approach.
This chance in policy should be reflected in NTI J^hing a so.
Only then the policv formulated by the All India BCG Officers \ ill
be implemented by’the District TB Officer and their Team Leaders.
Conclusion
tx to.
don has come down to what it was in 1956. The number of the
then Tuberculin tested have been covered by the Direct vaccination
and the intensive coverage which was expected after the change over
to form the mass campaign to door-to-door campaign die no
materialise.
The paper does not refute the value of door-to-door vaccina
tion, but that it should be limited in its application to carher agceroup onlv and also recommends retention of some of the aspects
of N'iass BCG Campaien, like publicity ajid_J]ea!th..,.education fo
some time more in our couW“m view ^Flhe
Lcia]
education etc. From the past experience, a nucleus of spec al
organisation is necessary to take care of the campaign from th
the District to the National level, as very little supervision is
exercised a/ the District level, as at present.
J^Svhile there are about 260 million individuals today who
require vaccination in 0-20 age-group, with the present set-up and
the number of teams we are not able to touch even the frm e of 11 e
copulation. No. of teams have to be obviously ra^ed f
;
in view of the door-to door vaccination policy. Sufficient budget
should be made available for TA & DA for the personnel as also
the timely supply of vaccine in adequate quantities and roadworthy
vehicles.
If the freeze dried vaccine is made available as a routine
supply, some of the operational difficulties can be solved.
243
•242
Dr. Pamra : Thank you. Now I would request
Dr. Bordia to present his paper.
ion throughout the study.
civelv for the same preparation throng '
coloured similar bottles were filled with
PPD-RT-23 with tween 80 in the strength of 1 TU in each
(a)
HEAT KILLED BCG VACCINE AS A “TUBERCULIN TEST”
COMPARED WITH PPD-RT-23 WITH TWEEN 80 AND
OLD TUBERCULIN
(b)
BY
(c)
Dr. N.L. Bordia, M.D.
Emeritus Professor of Tuberculosis M.G.M. Medical College,
Indore and Advisor in Tuberculosis M.P. State Government
Four amber
0.1 ml.
O.T. 1/1000.
Freeze-dried BCG. dissolved by solvent as done commonly
(d)
in BCG programme and
For dummy vaccination
was used.
carbolised normal saline solution
Introduction
<•;
Tuberculin test is an import'ml tool for the diagnosis of infec
tion with the Mycobacterium tuberculosis especially in children.
Various tuberculins have been used. At present 1 TU of PPD RT23 with Tween 80 is in common use. However in many instances
it gives negative or weak reactions even among bacteriologically
confirmed cases of Pulmonarv tuberculosis (1). Stronger strengths
of the tuberculin (PPD-RT-23 with Tween 80) are not commonly
available in India. Supply of Old Tuberculin is irregular. Even
PPD-RT-23 1 TU with tween is available only to specialised
agencies.
Can heat killed BCG Vaccine be used in place of 1 TU PPDRT-23 or Old Tuberculin ? Comparative response to Old Tubercu
lin and PPD-RT-23 with tween has been reported (2) but not in
India. Similarly heat killed BCG Vaccine has not been used as a
tuberculin in India though it has been reported elsewhere (3, 4, 5).
Using heat killed BCG Vaccine in different dilution, Frappier and
Guy (3) reported that it was more specific than the tuberculins in
common use. In these studies (3, 4, 5) reaction to ‘BCG Vaccina
tion’ was measured but BCG was not used for a Mantoux test. The
present study was undertaken to see if BCG could be used as (an
antigen for) a Mantoux test for detection of infection. If so. unused
vaccine which is not thrown away, could become available for
general use or for use to those who are unable to get any of the
standard preparations of tuberculin.
Objective of the Studv was to study the comparative sensitive
ness of 1 TU of PPD-RT-23 with tween 80, 0.1 cc of Old Tuberculin
(O.T.) 1/1000 and 0.1 cc of heat killed BCG vaccine (freeze-dried).
Methods and Material
Two consistent BCG technicians for testing and reading of the
Mantoux tests were selected and were used for the entire study).
New syringes and needles were colour coded and used exclu-
sis
different antigens.
AS far as possible, only fresh
r" ■80^TU
and freeze dried BCG vacc‘"eWelcome' only fresh dilutions in carwas procured from
dried BCG diluted to Stanbolised normal saline were us<d.
15 minutes. To
dard strength vaccine, and boiLd nadded tQ the
”e±red
to S tube. The boiled contents were empt.ed
required level
into the amber coloured bottle.
Bacteriological testing of the v^a^11‘y
biological? nor on
not done, nor were the stenl.zation tests on tne^o
- umo(J that
carbolized saline for
C ""15 minutes killed all the living
boiling the reconstituted vaccine ioi
BCG organisms.
28.7.1970 to 14.8.1970 in
The study was conducted between
Indore City, M.P.
Four intradermal tests were ^^^"/‘^“p^oved ptonts'of
left and two on the ngh
investications in the Tuberculosis
^aTor'ium; for 161 patients test results are available.
271 patients of both sexes in a general hospital were also given
four tests. 236 tests results are available.
School children were given only' two_tests each•
PPD.RT-23-1 TU or heat k,l ed BCG m O.T
ettor
^toaner^cludi^g all those with previous BCG vaccinat.on scar.
T9L
292
13.
Smith, D.T:, Use of steroids in conjunction with chemo
therapy in selected cases of active tuberculosis, Trans, of
16th VA conference on chemotherapy of tuberculosis,
140, 1957.
•;
J;
14.
Tuberculosis Society of Scotland, Research Committee :
Prednisolone in the treatment of pulmonary tuberculosis :
A controlled trial : Brit. Med. J., 2, 1751, 1960.
MONDAY. 4th January, 1971
Weinstein, H.J- and Koklar, J.J.-, Adrenocorteroids in the
treatment of tuberculosis. New. Eng. J. Med. 260, 412,
' The conference reassembled in the auditorium of
the Government Medical College, Bangalore at 2-30
p.m. with Dr. K. Somayya, President of the conference,
in the chair. He announced that the afternoon sessions
wiU begin with a session on “Social aspects of tubercu
losis” under the chairmanship of Dr. Mohandas K. Pai.
He requested Dr. Pai to take his chair on the dias.
Dr. M.M. Singh acted as the rapporteur for the session.
Dr. Pai called upon. Dr. S.P. Pamra to present his
paper.
15.
1959.
■
• ’ /
T?
11
4il
AFTERNOON SESSION
’
s i. '•ImrZ r! ...........
r
1 I
£
I
V: I
Treatment taken prior to reporting at specialized Tuberculosis
Institutions.
A MEDICAL-SOCIAL INVESTIGATION
*
By
s
S.P. Pamra,1 S.H. Pathak2 & G.P. Mathur3
The basic principle of tuberculosis control is to reduce the
transmission of infection in the community. Many patients however
do transmit infection for varying periods before they are diagnosed
and rendered safe for the community by appropriate treatment.
There could be many reasons for this time-lag. The patients may go
on ignoring symptoms and take remedial action quite late. There
may^be no conveniently located health facility where they could go
and seek relief. The facility they go to may not have the wherewithal
of diagnosis. Lastly, tuberculosis may not be suspected at the
facility where they report, thus delaying the diagnosis.
I
1
With a view to study this problem and to get an idea of the
factors involved in late diagnosis, new patients attending the New
Delhi Tuberculosis Centre were interrogated in respect of the
duration of symptoms and remedial action taken by them before
reporting at the Centre. Data thus collected were then correlated
1. Director, New Delhi Tuberculosis Centre, New Delhi.
2. Director of Field Work, Delhi School Work, Delhi.
3. Statistician, New Delhi Tuberculosis Centre, New Delhi,
i
S-
295
294
with the clinical and bacteriological status of the patients with a view
to ascertain the consequences of late diagnosis for the patient.
The investigation was entrusted to 4 students of the Delhi
School of Social Work. The New Delhi Tuberculosis Centre, referred
■ to as Centre hereafter, draws its patients from three different
territorial entities viz domiciliary service area (DA), areas of Delhi
served by other regional clinics (OA) and patients coming from
outside Delhi (OS). DA, OA and OS cases are usually in the
proportion of 2 : 1 : 1. The social workers interrogated . 00, 100 and
100 consecutive patients of the three categories respectively before
they were examined clinically and entered the data according to a
previously drawn out questionnaire. Patients discovered through
contact examination and case-finding programmes, those referred for
opinion or fitness for service or visa and those already diagnosed and
treated for tuberculosis previously were excluded. The study started
on May 18, 1970 and the requisite number of patients was completed
on June, 6 1970.
Table 1 shows, category-wise, the distribution of pulmonary
and non-pulmonary tuberculosis patients.
The proportion of
pulmorary tuberculosis patients is more or less the same in each
category and furthermore, is similar to the percentage that is
usually obtained in the Centre year by year. Two hundred and forty
one of these patients were males and 159 females. Except for males,
especially those above the age of 30 years, being somewhat more
preponderant in OA and OS categories, there was no other appreci
able difference in the age and sex composition of the three categories
of patients. Amongst patients from outside Delhi, females are
invariably fewer than males.
TABLE 1
Analysis was also made of the three categories of patients in
respect of their presenting symptoms, especially cough. No d’ffeicnces
were however found in the three categories. Nor was frequency of
cough different in tuberculous and non-tubcrculous patients.
Table 2 shows the number of remedial actions that the
tuberculosis patients had taken prior to reporting at the Centre in
each category separately. Nearly 15% of the DA patients came
straight to the Centre without attending elsewhere. The percentage
of similar patients in the OS category was, as expected, less. It is
worth noting that even amongst DA patients, nearly 120/o had
attended at three or more places before attending at the Centre.
Most of them had sought assistance from the general practitioners
(GP) and general health institutions (GHI); nearly one fifth tried
indigenous treatment. (Table 3). Amongst the OS patients, however,
a much larger percentage of patients took ind genous treatment
and this is understandable since general practitioners and GHIs are
less easily available in the rural areas from which most of these
patients came.
—
--tablet';;
Number of ‘actions’ taken by TB patients prior to reporting at a TB clinic
1
No. of actions before
reporting at a TB clinic
b a.
O A.
None
16
14.5%
5
10.9%
4
8-2%
One
39
35 4%
34
73.9%
20
40.8%
Two
42
38.2%
7
15-2%
21
42.8%
Three ore more
13
H-8%
0
0.0%
4
8.2%
110
100%
46
100%
49
100%
OS
Distribution of patients Included in the study*
Pul.
Tbc.
Non-Pul.
Tbc.
Non TB
Total patients
I
D A.
97
13
90
O.A.
42
4
54
:00
200
Total
OS-
I
44
5
51
100
Total
I
183
22
195
400
•D.A. Patients from dcinfciliary treatment area
O.A. Patients from ot.ier areas of Delhi
O S. Outsiders (patients not belonging to Delhi
Table 4 is important and shows that, contrary to the usual
belief, nearly 80% of the patients in each category took remedial
action within one month of the appearance of the symptoms, most of
them within about 10 days. Somewhat larger percentage of patients
waited for over three monihs before taking action in OS category as
compared to the DA. Table 5 shows the average duration oT treat
ment under each ‘action’ taken by the patients prior to reporting at
297
296
TABLE 5 V
TABLE 3
Average time lost per ‘action’by TB patients
Nature of first action taken by TB patients
Nature of 1st Action
TB clinics
General Health
institutions
D.A.
C.A.
O.S.
Total
16
5
4
25 (12.2%)
39
General practitioners
Indigenous trearment
Total
35
20
110
19
I
46
O S
Total
<1 month
62
20
22
104 (50.7%)
1—3 months
18
6
- 3—6 months
7
4
6
17 (8.3%)
>6 months
7
11
6
24 (11.7%)
Not applicable
16
5
4
25 (12.2%)
110
46
49
105 (100 0%)
2>3 months
I
Total
Interval between symptoms & 1st action related to patients’educational level
D.A.
O.A
O.S
Total
92
83.7%
35
76 1%
38
77.6%
165
80.5%
9
82%
5
10.9%
2
16
7-8%
9
8.2%
110
100%
6
13 0%
46
100%,
35 (17 1%)
TABLE 6
/interval between symptoms & 1st action (TB patients)
1—3 months
I
205 (I00%t
49
TABLE 4
I
11
42 (20.5%)
19
Total
<1 month
I
66 (32.2%)
12
3
C.A
72 (-5 1%)
14
19
D.A.
, 4° % . j
c I 1
9
18 4%
49
k0%
24
H-7%
205
100%
the Centre. Patients in OA and OS categories preserved with the
ineffective treatment, on the average, longer than the DA cases. To a
certain extent it may be due to lack of adequate facilities for the
OS cases but why there should be difference between DA and OA
cases is not clear: since facilities for diagnosis and treatment of
tuberculosis are available more or less to .-.he same extent to OA
patients as to the DA in Delhi.
Tabic 6 shows that the action was less prompt by the less
educated patients. This was but expected^ Only in 2 of the 22 with
high school or higher education, the prior action/actions lasted for
Uneducated
Belov. High
School
High school
or mere
Total
<1 month
101
78-3%
44
81.5'%
20
90.9%.
165
80.5%
1 - 3 months
9
7.0%
5
9.2%
9 1%
<3 months
19
14 7%
5
9 -%
0 6%
24
H.7%
Total
129
100%
54
100%
100%
205
100%
I
16
7.8'’
I
more than one month before coming to the Centre. Table 7 shows
the approximate expenditure incurred by these patients on treatment
elsewhere before reporting at the centre. Patients with lower income
spent proportionately larger amounts of money on the previous
ineffective treatment. This is in keeping with the earlier observation
in relation to the educational status of the patients.
Table 8 shows the reason or reasons which ultimately promp
ted these patients to come to the Centre. It would be seen that a
I
TA Bl E 7
Money spent by TB patients prior to reporting at a TB dinicfall catcnories combined)
Rs.
I 50
7
38 9%
9
100
29
33.0%
31
9
9
101- 150
19
32.2%
21
5
8
151—200
6
35.3%
7
1
2
201-300
4
44.4%
2
2
Over
300
7
50.0%
4
Total
72
35.1%,
74
36.1%
0—50
Rs
201-300
Rs
101—2i 0
Rs.
51 100
None
51
Average*
expenditure
Mono spent on eat Her trealinent
Patient’s
family
income per
month
Rs.
< )vcr
Rs. 300
Total
Rs.
I
18
100.0%
66
4
88
100.0%
97
4
59
100 0%
10)
17
100.0%
73
9
110
1
6
1
I
I
to
so
co
100.0%
I
79
14
I
100.0%
22
10.7%
17
8 3%
93
205
100.0%
10
10
4.9%
4-9%
•Patients who did not spend any money have been excluded for purposes ol this calculation.
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TABLE 9
with G.Ps or GHIs the proportion of sputum positives to sputum
neeatives in each category was more or less the same.
Extent of disease among pulmonary tuberculosis patients who took no,
one, or more actions prior to reporting at the Tuberculosis Centre
Conclusions
Minimal
Moderately
advanced
Far advanced
Total
No action
8
34.8%
9
39.1%
6
26 1%
23
100.%
One action
17
22.7%
25
30-5%
40
48 8%
78
100.0%
Two or more
action
12
15.4%
22
28.2%
44
56.4%
78
100.0%
37
56
90
Total
183
TABLE 10
Sputum positivity among PT patients who took no, one or more action/s
prior to reporting at the Tuberculosis Centre
I
D.A
Sp
Pos
Sp. , Total Sp.
Neg |
Pos
12 -i
4
One action
17
El
Two or more
actions
31
Total
60
No action
I
O.A.
I
I
O.S.
Sp.
Total Sp.
Sp.
Neg. |
Pos. | Neg.
I
16 I
I
■I
2
■I
32
12
19
31
7
i
Total
3
3
8
11
I 19
11
II
22
acknowledgements
25
44
The authors are grateful to Miss Aruna Kumari. Miss I. Rama
Rao Miss U. Mathu? and Miss A. Mchra. students of the Delhi
School of Social Work for their painstaking work in the collection
and compilation of data presented in this paper.
I
18
49
4
3
37
97
18.-
24
42
|
Before drawing conclusions from this study it may be men
tioned these patients represent in a way a selected group. For every
patient who did not get relief from the facility tried first, and, there
fore, shifted elsewhere and finally to the TB clinic, there must have
been many who would have been relieved of their symptoms and
hence, even if tuberculous, felt no necessity to attend anywhere else.
Further the conclusions that can be drawn from a material like this,
based entirely on patients’ version, which may not always be entirely
correct can only be general, indicating trends rather than precise
quantitative differences. The study has shown that, contrary to the
usual impression, patients by and large do not delay remedial action
once the symptoms have appeared. However, a large majority of
them do not suspect that the symptoms could be due to tuberculosis
and hence their first action is not attendance at a tuberculosis clinic,
even if it is within easy reach, but elsewhere, be it a GP or GHI or
indiaenous treatment. They take this treatment for a longer or
shorter duration depending upon the available facilities, their
educational and financial status and ultimately a large majority come
to the specialised clinic when they are referred by tne previous person
wno was treating them. It is obvious that if the person to whom
thev reported first had suspected the disease and taken steps to arrive
at a diagnosis, or if that was not possible, had referred them to a
clinic much of this lost time could have been saved and many more
could'have been put on proper treatment at an earlier stage of
disease. This would not only have improved the patients' prognosis
but also reduced the transmission of infection m the community.
Though there may be some justification for the earlier remedial
actions being elsewhere in OS patients, (for want of a specialized
clinic) that this can happen within a walking distance ot a specialised
clinic calls for more concerted effort to motivate not only the general
public but more than that, the GPs and GHIs to suspect early and
to take requisite steps for diagnosis or to refer early if the tentative
remedial action is not successful.
19
-
sputum
cases
, positive
. . among
- them. This
/ ma.v appear to be anoma
lous but actually it is not so. Many geheral practitioners and GHIs
prescribe anti tuberculous treatment without labelling the patient as
tuberculous. Inspite of proportionately more advanced disease the
lower percentage of sputum positives among those who had had
treatment elsewhere before attending the Centre is probably due to
some anti-tuberculous treatment they may have had earlier It was
also found that whether the previous treatment was indigenous or
313
312
References
1.
Gothi G.D., O(Rourke), J.O. and Bailley. G.V.J. 1966 Ind.
J. of Tub., 14, 41.
2.
Pamra S.P. (1964) Proceedings of 19th TB & Chest
Diseases Workers’ Conference, Delhi.
Anderson, S and Banerji, D (1963) Bull.
685.
Wld. Hlth. Org. 28,
Sen, P.K. (1962) Proceedings of 18th TB &. Chest Diseases
Worker’s Conference, Bangalore.
3.
Januarv-February, 1968, indicates the existence of 1.2% to 3.6%
radiologically active cases out of which 25% to 30% are bacillary
positive. This great variation is probably due to the seperate
colonies built for the Officers. Upper subordinates and other cate
gories of staff and the wide difference of social conditions prevailing
in the relevant colonies.
Incidence of morbidity
1. Age and Sex-wise incidence : No age or sex is found to be
exempted. Incidence in males is noticed to be highest between ages
of 31—45 years (Fig. 1) whereas in females it is seen to be maximum
FIG. 1
Graph showing comparative incidence of P. T. Age and
Sexwise during years 1965-1969
Dr. Pai : Thank you. I would now request
Dr. S.U. Khan to present his paper.
THE RAILWAY AND THE SOCIAL ASPECTS OF
TUBERCULOSIS
By
Dr. S. U. Khan
S'. E. Railway Chest Clinic, Adra, (VTest Bengal)
Foreword
It is true that the disease “Tuberculosis" can never develop
without the specific infection caused by the organism “Mycobac
terium Tuberculosis", but at the same time it is also equally true that
the social factors and economic stigmas existing in the community <
play a vital role in the pathogenesis and progress of disease. More
over the close and constant impact of such decapacitating diseases
in due course of time, particularly in cases of big industrial esta
blishments, besides acting as a definite social evil in aggravating
human sufferings, also bears a direct concern with the efficiency of
work and output of production.
I
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between 26—35 years of ages. Analysis of datas reveal that the
males have 2.5 times greater preponderance oxer the females. The
reason for this increased incidence in males is perhaps the inevitable
free, frank and frequent contacts during the daily affairs of social
and official engagements, and the cause of the above high incidence
in females seems to be related to the physiological wear and tear
phenomenon of the child-bearing period.
2. Incidence amongst employee and family : Further analysis
of dates show.'*that the incidence amongst employee (Fig. 2) is
FIG. 2
Graph showing yearly incidence of P. T. amongst employee
and family from yeaas 1965-1969
i/e
Hi
Object of study
*8
With the above view point, the present study based upon the
careful observations of the “Epidemiological trends of tuberculosis”
as noticed amongst the railwaymen from years 1965 to 1969, is a
sincere effort to find out the co-existing social factors of better
called “Sociological Tuberculogenic Factors" that are really respon
sible for the development and spread of disease in the population.
Prevalence of disease
A sample survey of a few of our railway colonies done in
8^
7T
ci.
■O
e
I c
7|7
>965
'966
t
/96 7
|
I '
/ 96 Q
'96 9
315
314
TABLE 1
nearly four times higher than the family. The cause behind this
enormous increase again, appears to be the close and constant
association with unknown cases and the bearance of far more social
familial and professional stress and strain that the employees, as
active earning members, have to share and shoulder at almost all
step of the usual work of life.
Shoeing average yearly Incidence of P.T. according to the nature of workihg
1969
conditions as detected during year 1965—1909
Nature of work
Strength
of Staff
Average
cases per
year
Incidence
of disease
Percentage
in the
category
Sedentary light works
1 4000 (App)
17
0.42%
28
Incidence of mortality
In this connection our study also shows that the incidence of
mortality in the railways too is fairly low on the same grounds as
attributed to the general mass of population.
Medium physical labour
7000
33
0.48%
Hard physical labour
9650
62
0.64%
Other co-relative factors
1. Socio-economic conditions : The study in regards to the
trends and behaviour of disease in different socio-economic groups of
railwaymen arbitrarily classed in accordance to their monthly incomes
and the relevant standards of living (Fig. 3) discloses ' that the
incidence of tuberculosis is more rampant amongst the low-paid
categories and is inversely related to the groups of income.
T
32%
40%
10-12% in group 3 (Hard labour) in comparison to the sedentary
aroup is not the pure outcome of the nature of work entirely but .is
considerably co-influenced by the associated food and dietetic
conditions also.
3 Living conditions : In this reference the graph (Fig 4) is
self evident tha°t the incidence is maximum in single-room quarters
FIG. 3
Graph showing comparative incidence of P T. amongst
different Socio-economic groups during 1965-1969
FIG. 4
Graph showing yearly incidence of P. T. according to living
conditions from years 1965-1969
"1
5
<01
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2o</-
1
if
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n
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2 | >2
2. Working conditions ; In this context it is observed (Table )
that the incidence of tuberculosis amongst sedentary workers,
workers doing medium physical labour and workers encaged in hard
manual labour is 0.42%, 0.48% and 0.64% respectively. Further
analysis of the total incidence of occurence shows that the percent
age of distribution in the above three groups respectively, is as 28%,
32% and 40% approximately. This apparently indicate that the
incidence increases with the increase of physical actinties. But
further careful social history of the patients gives a definite clue that
the above difference of 4-5% in group 2 (Medium labour) and
'965
5
JI
2
/966
?-2
H I IM
|2
/?6 7
I M
/96ft
JL
2 f2
~'969
t
and proportionately declines with the increase in the space of
residential accommodations. Here the long house-hold or neigh
bourly contacts, the presence of reservoir of infection in the vicinity
and the hygienic conditions existing in the locality appear to be the
positive contributory factors.
4.
Food and Nutrition : The lack of proper food and nutrition
317
316
resulting into poor health and general debility in all sphere of human
life and work appears to be one of the important co-existing factors
in the precipitation of disease.
5. Habits : Personal unclean habits and certain social evils
like heavy smoking particularly “Ganja” and excessive drinking
specially without proper diet and performing hard physical work,
have a definite reactivating effect in enhancing the incidence of
disease.
Tuberculogens” existing in a society, have a strong hand in the
contribution and multiplication of disease :
1.
2.
(i) Proximity to infectious cases.
(ii) Reservoir of infection in the vicinity.
(iii) Hygienic conditions of the locality.
Changes in pattern of disease
3.
Our clinic records from the year 1965-1969 (Fig. 5) reveal that
the majority of cases reporting for treatments are registered in
4.
FIG. 5
Showing incidence of P. T. according to the nature of direase,
Bacillary status and drug resistance during years 1965-1969
I
5.
6.
ll
6r
1
1.
JIJL.
• «
6?
n
54
I
r
iy ■
<i
2%
I Uli 1
1966
!
z?
’5
6
Visuo-auditory education regarding contact and spread of
infection.
3.
Efforts to find out hidden cases :
2
/? 61
1 '
n
?
F £i
/ 9 6F
(a) Periodical department-wise screening surveys.
(b) Screening of the families of infected members.
1
61
4.
advanced stages and 35% to 40% out of them are detected to be
bacillary positive by direct smears only. The number of ''Drug
Resistant" cases also arc seen to be rising each year. The convincing
reason for all these seems to be revolving round the false phobia of
financial distress by employees, in case if detained for long under
railway treatments, without any real realization about the social and
familial damages, the therapeutic complications and the public
health problems that usually creep in as a wanton social menace, due
to the act of such deliberate hiding and haphazard irregular treat
ments of the disease.
Conclusion
2.
!•
ll
o
'915
Attention towards correction of :
(a) Socio-economic and (b) living conditions.
i
I
*
Lack of proper food and nutrition specially with bad habits
and hard physical labour.
Habits of excessive drinking and smoking particularly
“Ganja” without proper diet.
Ignorance about contact and spread of infection.
Hidden cases and haphazard irregular treatment.
Suggestions
es
1 ■
Depressed socio-economic conditions.
Living conditions :
5'
The conclusive outcome of this study amongst railwaymen,
which in all respects is a miniature form of the general stream of
population, suggests that the following social factors or “Sociological
Some arrangement for the attendance and free medical
treatment of non-railway population residing within the
railway premises.
ACKNOWLEDGEMENTS
1. My sincere gratitudes to Dr. S. L. Malhotra. Chief
Medical Officer, South Eastern Railway, for permission to report
the study.
2. My respectful thanks to Dr. M. Kumar, Divisional
Medical Officer, S. E. Railway, Adra, for his help in conducting the
study.
3. Last but not the least, my heartfelt thanks to the Members
of Technical Committee, Tuberculosis Association af India for
giving me the opportunity to present my paper at the 26ih National
Conference on Tuberculosis and Chest Diseases-Bangalore, on the
4th of January, 1971.
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