OPERATIONS RESEARCH <<Back
 
A : Problem Definition
 
083
PREVALENCE OF SYMPTOMS IN A SOUTH INDIAN RURAL COMMUNITY AND UTILIZATION OF AREA HEALTH CENTRE
DR Nagpaul, GVJ Baily, M Prakash & GE Rupert Samuel: Indian J Med Res 1977, 66, 635-47.

The broad relationship between the extent and pattern of sickness in a south Indian rural community, attendance at the Area Health Centre (AHC) and service rendered to the sick at the centre were studied by National Tuberculosis Institute (NTI), Bangalore. The objectives were to study (i) point prevalence of symptoms of all kinds and their pattern (ii) attendance at the AHC and the pattern of symptoms among them: and (iii) number of visits for each spell of sickness, by nature of symptom, laboratory tests offered, and referral to better equipped health institutions. A 30,000 population served by the Bettahalasur Primary Health Centre (PHC) which is 20 km. away from Bangalore city was chosen. The selection of villages was done by random sample so that about 1000 persons from each of 5 field health workers' area was available for symptoms questioning. The out patients at the PHC were questioned for symptoms by the PHC medical officer in a manner exactly similar to that for the community by the trained NTI para medical staff. The answers given by patients were recorded by NTI staff both at the centre and at the community. On revisits made for the same spell of sickness, the interval in days from the first visit, any laboratory tests done and reference to better equipped institutions were also recorded.

The point prevalence of sickness in the area was 9.5%; cough, pain and fever, in that order were the three cardinal symptoms that accounted for 68% of the total sickness in the community. Only 1.3% of the sick, at any point of time, had attended the AHC but the attendance by the sick persons residing in the village where the health centre is located was 9.2%. The composition of the out patients attendance was significantly different from that of the sick in the community in respect of age, sex and symptoms. Thus, women and the elderly persons who also constitute a major reservoir of tuberculosis, tended to disregard their symptoms while younger persons in the productive age group had availed the health centre facilities more freely. Among symptoms, cough was the most ignored. Of the total out patients, 71% had attended only once, 18% twice and 11% three times or more for any particular episode of sickness. Only 7 9% were offered laboratory examination and an insignificant number were referred to better equipped health institutions.

KEY WORDS: SYMPTOM PREVALENCE, RURAL COMMUNITY, RURAL HEALTH SERVICES.
 

  B : Programme Development  
 
093
CASES OF PULMONARY TUBERCULOSIS AMONG THE OUT-PATIENTS ATTENDING GENERAL HEALTH INSTITUTIONS IN AN INDIAN CITY
GD Gothi, D Savic, GVJ Baily & GE Rupert Samuel: Bull WHO 1970, 43, 35-40.

A study was undertaken in Bangalore city, Karnataka, to find out whether people with chest symptoms, including tuberculosis patients, attend General Health Institutions or report directly to tuberculosis clinics. The objective was to investigate the proportion of persons with chest symptoms (cough, fever, pain in chest and haemoptysis) among out patients attending the general city dispensaries, and the proportion of pulmonary tuberculosis cases among them. The findings of this study are based on examination of one day's attendance at each of the 19 general dispensaries of Bangalore city, consisting of 2,506 persons aged 10 years or more who had attended the dispensaries for the relief of any ailment. The investigation consisted of symptom questioning, examination of spot sputum sample and 70 mm chest photofluorogram. Sputum specimens were examined by direct smear and culture. Study intake period of 19 days was spread over three months.

The study showed that of the 2506 out patients, 1170 (47%) had visited dispensaries primarily for relief of chest symptoms. Of these, 31 (2%) had evidence of active or probably active pulmonary tuberculosis and 20 (0.8%) were sputum positive cases. It is concluded that even though there are special tuberculosis institutions in the city, a fair number of new and old tuberculosis patients contact general dispensaries. These dispensaries can therefore contribute considerably to tuberculosis case-finding in the city.

KEY WORDS: CASE-FINDING, URBAN HEALTH INSTITUTIONS, SELF REPORTING CHEST SYMPTOMS.

094
COLLECTION AND CONSUMPTION OF SELF ADMINISTERED ANTI-TUBERCULOSIS DRUGS UNDER PROGRAMME CONDITION
GD Gothi, D Savic, GVJ Baily, K Padmanabha Rao, SS Nair & GE Rupert Samuel: Indian J TB 1971, 18, 107-13.

This investigation was to find out the drug consumption among tuberculosis patients put on domiciliary self administered chemotherapy, in terms of proportion of patients that make various levels of drug collections and proportion among them that consume drugs at different points of time during the course of treatment. In all, 816 tuberculosis patients aged 5 years and above residing in Bangalore city were admitted to the study. They were randomly divided into 6 groups at the time of inclusion into the study, for examination of urine samples for the presence of INH and PAS. One surprise urine sample was collected from each patient at the pre determined time after the drug collection. The samples of urine were collected from one group at first month, another at second month, third at fourth month, fourth at sixth month, fifth at ninth month and sixth at twelfth month of treatment. Urine samples were collected within 33 days of drug collection for the month because the drugs were supplied at a time for the said period. Urine specimens were examined for the presence of drugs or their metabolites. For INH, NM test & acetyl INH test and for PAS, ferriechloride and case test were performed. The drug collection was judged on the basis of treatment record and its consumption on the basis of results of urine examination.

Of the total patients included in the study, 54% made 10 or more drug collections over a period of 15 months. The initial radiological or bacteriological status or severity of disease did not influence the drug collection; however smaller proportion of old persons in both sexes collected the drugs for 10 months or more. Urine specimens of 71% of patients who had collected drugs were positive for INH on any one day. Bacteriological quiescence was obtained among the 82% INH sensitive patients who had made 10 or more collections. The above findings suggest that the patients who collect drugs also consume with fair amount of regularity and achieve a high degree of bacteriological quiescence.

KEY WORDS: SELF ADMINISTERED REGIMEN, DRUG COLLECTION LEVEL, DRUG CONSUMPTION, CONTROL PROGRAMME, COMPLIANCE.

095
A CONCURRENT COMPARISON OF AN UNSUPERVISED SELF-ADMINISTERED DAILY REGIMEN AND A FULLY SUPERVISED TWICE WEEKLY REGIMEN OF CHEMOTHERAPY IN A ROUTINE OUT-PATIENT TREATMENT PROGRAMME
GVJ Baily, GE Rupert Samuel & DR Nagpaul: Indian J TB 1974, 21, 152-67.

The relative merits of a fully supervised twice weekly regimen of Streptomycin and INH (SHtW) and an unsupervised daily regimen of INH and Thioacetazone (TH) in routine programme conditions in an urban area are compared in terms of acceptability and response to treatment at one year. Of the 474 newly diagnosed sputum positive cases at Lady Willingdon TB Demonstration & Training Centre, Bangalore during 1968-69, 134 were allocated to SHtW regimen and 189 to TH regimen. All others who were unwilling to take the allocated regimen or were excretors of bacilli resistant to INH and or SM were analysed as a subsidiary group.

About 25% of the patients allocated to SHtW regimen expressed unwillingness to start treatment on account of unsuitability of working hours and or distance. Refusal to TH regimen was negligible (5%). As regards drug acceptability after start of treatment, while the duration of treatment taken was similar for both the regimens, the level of drug intake achieved by the SHtW patients was lower compared with TH patients i.e., 31.3% of the SHtW patients and 56.1% of TH patients took more than 80% of treatment. If concealed irregularity among TH patients is taken into consideration, it is likely that the drug intake among TH patients would be similar to the drug intake among SHtW patients. The acceptability was therefore almost similar among SHtW and TH patients. Very low level (28%) of treatment completion was achieved by SHtW patients. With TH regimen, 46% had made 10 or more monthly collections during 12 months. Among the SHtW patients there was greater irregularity in the later months which was not apparent among TH patients. However, the favourable response among patients on SHtW and on TH regimen was 68% and 60% respectively. Deaths among SHtW patients were 4%, 13.5% among TH patients, the difference being statistically significant. The response was directly related to the level of drug collection or supervised consumption. The large proportion of the patients who stopped treatment prematurely, continued to remain positive with drug sensitive organisms, if initially they were so. In the subsidiary group there were 62 patients who were excretors of drug resistant organisms. They were treated with drugs to which their organisms were resistant and nearly 30% of these patients had negative culture at the end of one year.

It is concluded that (i) SHtW regimen was superior to TH as it prevented deaths and showed better bacteriological conversion among patients with level 3 & 4 of treatment and (ii) treatment organization is the most important factor in obtaining better results in routine chemotherapy with available drug regimens.

KEY WORDS: TH REGIMEN, DAILY REGIMEN, SUPERVISED INTERMITTENT REGIMEN, ACCEPTABILITY, EFFICACY, CONTROL PROGRAMME.

096
A STUDY OF SOME OPERATIONAL ASPECTS OF TREATMENT CARDS IN A DISTRICT TUBERCULOSIS PROGRAMME
MA Seetha, GE Rupert Samuel & VB Naidu: Indian J TB 1976, 23, 90-97.

The paper presents some aspects of domiciliary management of tuberculosis patients in a District Tuberculosis Programme (DTP) viz., the interval between diagnosis and initiation of treatment, regularity in collection of drugs, role of motivation of patients for collection of drugs and pattern of defaulter retrieval actions by health institutions. The treatment cards of 3089 patients of pulmonary tuberculosis belonging to Bangalore DTP diagnosed during 1964 were analysed. The cohort of 2479 patients was divided into 3 groups according to the place of treatment, viz., (i) those treated at District Tuberculosis Centre (DTC) where better trained staff motivated tuberculosis patients & took defaulter actions (ii) the Urban Peripheral Health Institutions (UPHIs) where motivation and defaulter actions were taken by specialised staff and (iii) rural PHIs where non- specialised general health workers along with general duties did motivation and took defaulter actions.

The study has shown that in the entire district about 94% of patients were put on treatment within 10 days of diagnosis. In rural PHIs, among 14.5% of patients the treatment was started after 10 days of diagnosis. For the 149 initial defaulter patients, actions were taken only for 39% of the patients, lowest being in rural PHIs (10.8%). The defaulter actions for 69% were taken in time, more promptly by DTC staff for DTC & UPHI i.e. 71.5%, whereas rural PHIs were poor in this respect and only 37.5% of the actions were taken on time. Sputum positive cases collected drugs more often than sputum negative and also more patients collected drugs on due dates at DTC in comparison with PHIs. Both the differences were statistically significant.

About one third of the lost patients came from those who made the first default. About 55-63% and 75-82% of this group defaulted by the second and third collections respectively. Defaulter actions were not taken by rural PHIs for 66.7 to 72.5% defaults, while DTC staff had not taken defaulter action for about 20% of defaulters and 67.8% of such actions were prompt in DTC, whereas it was only 19.3% in rural PHIs.

KEY WORDS: COHORT ANALYSIS, COMPLIANCE, CONTROL PROGRAMME, OPERATIONAL FACTORS.

098
CONTROLLED STUDY OF THE EFFECT OF SPECIFIC TREATMENT ON BACTERIOLOGICAL STATUS OF "SUSPECT CASES"
Aneja KS, Gothi GD and GE Rupert Samuel: Indian J TB 1979, 26, 50-61.

The effect of specific anti TB drugs on patients having smear negative radiologically positive pulmonary tuberculosis (suspect cases), was studied in Lady Willingdon Tuberculosis Demonstration & Training Centre (LWTDTC), Bangalore during 1975 & 1976. The main objective was to know the proportion of suspect cases treated under the programme requiring the specific treatment with anti TB drugs. A total of 457 suspect cases were randomly allocated to one of the two regimens; 228 patients were treated with INH + Thioacetazone (TH) and 229 with calcium gluconate (Placebo) regimens, for one year. The placebo group allowed a concurrent comparison of status of suspect cases without any specific treatment. After the intake, sputum examination by direct smear, culture for M.tuberculosis and sensitivity for drugs as well as X-ray examinations were carried out at 0, 2nd, 4th, 6th, 9th and 12th month of treatment.

Among the 228 patients on TH, 103 (45.2%) were real suspect cases, 83 (36.4%) sputum positive and remaining 42 non- tubercular. Similarly, out of the 229 patients on placebo regimen, 110 (48%) were real suspect cases, 61 (26.5%) sputum positive and 58 non- tubercular. The effect of treatment was measured by observing the incidence of bacteriologically positive or radiologically active disease from among the real suspect cases of the two groups. At the end of the treatment period, 12.6% of TH group and 29.7% of placebo group were broken down, the difference being statistically significant. Further, an element of self healing was also observed, as about 40% of patients in placebo group showed either clearance of lesions or continuing regression which could be due to self healing or the lesion being non- tubercular in nature. About 30% of the 457 patients at the start of the study were real cases of tuberculosis who under the programme were missed and 20% broke down with bacteriological positive or progress to radiologically active disease when treatment was not offered. Thus, nearly 50% of the suspect cases diagnosed in the programme required anti TB treatment and for those requiring treatment, perhaps TH is not sufficient, as 12.6% broke down in spite of treatment. It would be appropriate to treat suspect cases both from the clinical and epidemiological point of view after taking due precautions to remove non- tubercular cases by doing repeat sputum examination.

KEY WORDS: CONTROL STUDY, SUSPECT CASE, TH REGIMEN, EFFICACY.

104
ORGANIZATIONAL EFFORT IN A CLINICAL TRIAL AND ITS RELEVANCE TO APPLICABILITY OF SHORT-COURSE CHEMOTHERAPY IN NATIONAL TUBERCULOSIS PROGRAMME
KS Aneja & GE Rupert Samuel: Indian J TB 1982, 29, 19-28.

The high rate of treatment completion and the regularity of drug intake achieved in clinical trials of Short Course Chemotherapy (SCC), could possibly be attributed to efficient organizational set-up, careful selection of cases and all-out effort to control defaulters. The organizational effort put forth to achieve the regularity is relevant to the applicability of SCC in the existing set-up of District Tuberculosis Centres (DTCs) under National Tuberculosis Programme (NTP). First 300 patients admitted to SCC trial to assess the efficacy of three drug regimens of 3/5 months duration under fully supervised conditions, carried out jointly by National Tuberculosis Research Centre, Madras and National Tuberculosis Institute (NTI), Bangalore, have been analysed for the purpose.

To keep up the regularity, 1/3rd of the patients required home visits-some of them repeatedly. If the actions of the same intensity of defaulter retrieval in the form of home visiting are envisaged to be taken in a DTC with the normal working pattern catering to 500 patients, 250 to 300 home visits will have to be made in a month. This may not be feasible in the existing set-up of NTP. A new strategy of defaulter retrieval actions for programme conditions may have to be devised. Further, selection of drug regimen which has the maximum potential of being given on self-administered basis may reduce the work-load to a considerable extent. Drug toxicity, side effects and the cost of drugs may not be major handicaps. However, the only way to understand various operational problems is to undertake scientific operational studies in actual working conditions of NTP.

KEY WORDS: SCC, APPLICABILITY, CLINICAL TRIAL, COMPLIANCE, CONTROL PROGRAMME.

106
ACTIVE CASE-FINDING IN TUBERCULOSIS AS A COMPONENT OF PRIMARY HEALTH CARE
KS Aneja, P Chandrasekhar, MA Seetha, VC Shanmuganandan & GE Rupert Samuel: Indian J TB 1984, 31, 65-73.

Feasibility of introducing limited active case-finding in tuberculosis involving Multi-purpose Health Workers (HWs) to supplement the existing methodology of detecting the cases through chest symptomatics attending Peripheral Health Institutions (PHIs) on their own, was studied earlier with encouraging results. The present study was undertaken to understand the existing working system of HWs and within that the priority areas of input which may lead to better case yield.

The study revealed that the population available at any beat schedule of HWs was about 42% of the eligible population of age 20 years and above. Only 60-75% of the field days were utilized for routine multi-purpose duties. Of the total area, 25% to 40% remained uncovered. The effective tuberculosis work was done only on 5% of the beat schedule days and the work was not uniformly spread throughout the month. Even so, the contribution by HWs was twice the number of cases diagnosed at PHIs under study in one year. Had the HWs covered the entire area of their beat schedule, 80 against 26 cases would have been diagnosed. Moreover, there is possibility of detecting more cases among the elderly patients who normally do not attend their area health centres. However, the success depends upon meticulous supervision and regular flow of supplies.

KEY WORDS: HEALTH WORKER, PRIMARY HEALTH CARE, CONTROL PROGRAMME, CASE-FINDING, RURAL COMMUNITY.

112
IMPROVEMENT IN CASE-FINDING IN DISTRICT TUBERCULOSIS PROGRAMME BY EXAMINING ADDITIONAL SPUTUM SPECIMENS
MA Seetha GE Rupert Samuel & N Parimala: Indian J TB 1990, 37, 139-44.

A study was conducted to augment Case-finding in the programme by increasing case yield through repeated sputum examinations by collecting 2-3 samples on the same day. The study was conducted in nine Peripheral Health Institutions (PHIs) of Bangalore district. They were all Microscopy Centres and were drawn on the basis of random allocation. A Health Visitor (HV), Laboratory Technician and Laboratory Attendants of National TB Institute (NTI) were posted at the PHIs during the entire study period. After collection of first sputum sample from the eligible chest symptomatics, 2nd, 3rd or 4th samples were collected at an interval of half an hour from those whose first specimen was negative. Separate smears were prepared from all the specimens for examination at NTI. The duration of the study was nine months.

From among 4233 total new outpatients, 458 chest symptomatics were identified. Of them, 451 gave the first specimen, 416 the second specimen and 379 and 332 the 3rd and 4th specimen respectively. There were a total of 25 smear positive cases; 18 were detected by the first specimen, 3 were added by second and the remaining 4 by the 4th specimen. Of the 451 chest symptomatics, 185 were selected by the PHI Medical Officers (MOs) and 266 were picked up by the NTI HVs from the remaining outpatients. Of the 25 cases detected, 10 came from the chest symptomatics selected by the MOs and 15 came from those selected by the NTI HV. The study has shown the feasibility of collecting multiple specimens of sputum from each symptomatic on the same day. A loss of 60% cases was due to casual symptom questioning by the MOs. It was further observed that the intensity of the physical suffering has influenced the behaviour of patients towards action taking. The sputum positivity rate was 5.5%

KEY WORDS: CASE-FINDING, CONTROL PROGRAMME, SPUTUM EXAMINATION.
 

 
  BCG  
 
 
131
INTEGRATION OF BCG VACCINATION IN GENERAL HEALTH SERVICES IN RURAL AREAS
Baily GVJ, Kul Bhushan, GE Rupert Samuel & BK Keshav Murthy : Indian J TB 1973, 20, 155-60.

BCG vaccination is being conducted as a mass campaign. It is difficult to maintain a high coverage of the population at risk i.e., new borns. This can best be done by integrating the BCG vaccination services with the general health services. The present investigation was planned to study the feasibility of routine BCG vaccination of the new borns by the Primary Health Centre personnel using the normal records maintained by them. In a rural population of 33,128 persons (1971 census), served by PHC Bettahalasur of Bangalore district, BCG vaccination was administered to 0-15 months old children by 2 Block Health Workers (BHWs) and 3 Auxiliary Nurse Midwives (ANMs) after training them for about 3 weeks. They used a compact specially designed BCG kit and employed a conventional intradermal technique for BCG vaccination. Routine work was not to be disturbed in any way. Each worker prepared a list of children eligible for BCG vaccination from the register of unprotected children and updated the list for those not found registered. National Tuberculosis Institute (NTI) field staff registered a sample population, allotted to each worker for estimation of eligibles. Three months later they also examined BCG vaccination lesions in a sample of children. BHWS and ANMS were interviewed by a medical officer from NTI regarding their opinion on integrated work.
The findings showed that the ANMS and BHWS had already registered nearly 50% of the new borns in their records with variation in registration from 21 to 80% by the field workers; ANMS understandably having registered lesser numbers. All of them were, however, able to update the registrations to a level of 82%. They could pick up the BCG vaccination technique easily. Of the total eligibles, ANMS and BHWS could contact 86.4% and vaccinate 77%; remaining 23% either refused or were excluded from vaccination. In the total eligibles registered, however, the vaccination coverage was 66.6%. Of the children reported vaccinated, 96% had evidence of BCG vaccination indicating a high degree of reliability of reporting. The opinion of all the 5 field workers on integration was favourable. All the ANMS and BHWS workers, on interview, stated that they had done BCG work without detriment to their other duties and would be easily able to do so in future. The field workers can accumulate the new borns for a year and vaccinate them during a month. This has mainly operational advantages including less vaccine wastage. For urban areas a different operational design with the same principles may become necessary.

KEY WORDS: INTEGRATION, BCG VACCINATION, HEALTH SERVICES, RURAL POPULATION.

132
BCG VACCINATION INDURATION SIZE AS AN INDICATOR OF INFECTION WITH MYCOBACTERIUM TUBERCULOSIS
GD Gothi, SS Nair, Kul Bhushan, GVJ Baily & GE Rupert Samuel: Indian J TB 1974, 21, 145-51.

After the introduction of direct BCG vaccination, assessment of post-vaccination allergy and information about prevalence of infection could not be obtained. Few methods were tested i.e., i) retesting of persons with 0-13 mm reaction at site of vaccination on 4th day of vaccination, ii) retesting of all vaccinated persons of age 0-10 years. It is not only necessary to find out the size of BCG lesion that could separate them but also the day after vaccination on which the tuberculin reaction size best correlates with the BCG vaccination size. With this in view, two studies with regard to direct BCG vaccination done in India have been examined further. In Study I, 816 eligible persons were tested with 1 TU RT 23 read on 3rd day and vaccinated with either Indian or Danish vaccine. The vaccination lesions were examined on the 3rd, 6th and 90th day of vaccination. On the 90th day post-vaccination tuberculin test was done and read on 3rd day. In Study II, a total of 691 who had no previous BCG scar were simultaneously tuberculin tested with 1 TU RT 23 and vaccinated with either Indian or Danish vaccine. The BCG lesions were examined every day and on 39th and 90th day.

The correlation of pre-vaccination tuberculin test and BCG lesion size showe d that sixth day in first study and fifth day in second study was the highest. Tuberculin reaction size of 10 mm or more correlated well with 14 mm or more induration size of BCG in classifying the persons as infected and non-infected. Correlation between the size of BCG scar at 3 months and size of pre-vaccination tuberculin reaction was poor. Considering the two studies together vaccination induration of 14 mm or more on 5th or 6th day appears to be the best criterion for demarcating the infected from non-infected. Some other choices are 12 or 14 mm levels on 2nd day, 10 and 12 mm levels on 5th day and 10 mm levels on 8th day seems to be nearly as good and operationally useful.

A BCG Vaccination induration size of 14 mm and above between 5th and 6th day of vaccination, for all practical purposes may be considered satisfactory for demarcating persons infected with M.tuberculosis from those non-infected. It can be concluded that estimation of prevalence of infection, when BCG vaccination is given to all without prior tuberculin testing, can be made on the basis of BCG vaccination induration size of 14 mm or more.

KEY WORDS: BCG VACCINATION, M.TUBERCULOSIS, INFECTION, TUBERCULIN INDURATION, RURAL POPULATION.
 
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