The study was carried out at Lady Willingdon Tuberculosis Demonstration & Training Centre, Bangalore to inquire into the epidemiological and sociological characteristics of patients attending a city TB clinic for the first time, to ascertain the reason for attendance and the nature of previous treatment if any. It was also to see whether there was a preference for seeking specialists and specialised services for alleviation of the symptoms experienced and whether there were any differences amongst the urban and rural attenders. A fifty per cent random sample of 2,658 out patients during 6l working days, formed the study population. They were interviewed by using a questionnaire based on the above mentioned objectives. 247 were not eligible due to incomplete record and below 5 years of age.

Majority of the out patients were in 20 30 years of age and were wage earners. Nearly 80% were aware of their symptoms and contained 95% of the tuberculosis cases detected at the clinic. Most of them were having 2 3 symptoms. No difference in time of reporting was observed among urban or rural patients; 61% of the urban and 42% of the rural patients attended the clinic within 3 months from the onset of their symptoms. Distance is a major obstacle. Upto 4.8 km the number of new outpatients was large but the case yield was poor. As the distance increased the out patients decreased but the case yield was more, suggesting a selective process influenced by distance. It was also found that 20% of the out patients came of their own without any prior contact with any other source of treatment, 32% had previous contact with other health institutions, 31% were actually referred by them and 17% were advised by BCG workers. Further analysis that of the 1,642 patients who had previous contact with health institutions, 84% were at general health institutions, 10% at specialised TB clinics and 6% were others. Of the remaining eligible 2,403 patients, 83% were from urban and 17% from rural areas. Sputum was collected from 2,308 patients. Of them, 179 (7.8%) were found to be positive by direct microscopy or culture or both and 169 were positive by culture (91% confirmation by culture). 131 (80%) were sensitive to isoniazid and 32 were isoniazid resistant.

The data obtained suggests that attendance at a specialized tuberculosis centre is not necessarily a function of awareness of symptoms and of the knowledge that such specialised services exist. It also does not support the theory that people prefer specialized institutions in cities. It is also seen than urban and rural patients behave in almost the same way in that their first contact for symptoms suggestive of tuberculosis, is initially at the general medical services and they should be strengthened with adequate means for diagnosis and treatment of tuberculosis.

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.

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.

This is a conceptual account of the District Tuberculosis Control Programme. The District Tuberculosis Programme (DTP) 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 the country. The limited resources in the form of funds, trained personnel and equipment, made it necessary that the programme be simple, easy to apply and widely acceptable.

The DTP includes provision for tuberculosis Case-finding, treatment and prevention 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 domiciliary basis. District Tuberculosis Centre (DTC) represents the pivot around which the integrated 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 the DTP in the entire district besides offering the usual diagnosis and treatment service to the population, under its direct care. Health institutions other than DTC which participate in the DTP are called "Peripheral Health Institutions" (PHIs). 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 chest symptomatics reporting at "Microscopy Centres" and if found positive for AFB the patient is motivated and put on treatment immediately. DTC maintains the important "District TB Case Index" and offers "referral" X-ray examination to the sputum smear negative symptomatics referred by the "Referring Centres". One BCG Vaccination Team also works under DTC. There is one DTC in a district and the already existing TB clinics become just one of the PHIs under one DTC. Key staff consisting of a District Tuberculosis Officer (DTO), a Treatment Organiser (TO), a Laboratory Technician (LT), an X-ray Technician (XT), BCG Team Leader and a Statistical Assistant (SA) are required to provide service from the DTC and to organise the programme of Case-finding and treatment in an integrated manner throughout the district from all available institutions of General Health Services.

Of all the available methods for the diagnosis of pulmonary tuberculosis, bacteriological examination is the most reliable. Diagnosis of pulmonary tuberculosis is chiefly done by sputum microscopy and culture. This paper discusses sputum microscopy from various points of view. Sputum, which forms the basis of bacteriological diagnosis, is a variable source material. Type of specimen, its quality, quantity, bacterial content and viability of organism considerably influence the sensitivity and the specificity of the methods; and these in turn would vary under different diagnostic situations. One of the reasons for the observed variations could be the different criteria adopted for examination; another might be due to the observed range of diagnostic situations varying from an epidemiological survey situation at the one extreme to the other where cases seek treatment in a comparatively backward community with poor tuberculosis diagnostic services.

In epidemiological community survey (ICMR 1968), it has been found that culture positives that were also smear positives varied from 73% to 87%, whereas among patients attending rural general health institutions for diagnosis, about 82% of the infectious cases found by culture could also be discovered by microscopy of single spot specimens (Rao, 1966). Sikand (1965) from New Delhi Tuberculosis Centre, could get 67% of culture positives by microscopy, whereas Mitchison (1967) found that 35% were smear positive among the sputum positive patients reporting for the first time. In the longitudinal epidemiological study carried out in the Bangalore rural area, it was found that about 40%-48% were positive by both direct smear and culture and the rest by culture only. Reasons for these variations could be (i) different criteria adopted for examination (ii) different situations from where the sputum specimens were collected (iii) sensitivity and specificity of sputum microscopy technique adopted and (iv)the experience of the trained technician. It was observed that over diagnosis by the trained auxiliary staff in the general health institutions (1.9%) compares favourably with the over diagnosis of 1.3% by experienced technicians indicating simplicity of smear examination. Besides these aspects, other factors like the quality of sputum smear, time spent on examination, type of sputum specimen, the use of multiple smears, etc., also influence the results. The cost of bacteriological examination have also been studied, and the cost ratio between microscopy and culture have been worked out to be 1:6.6. Cost can become an important factor in deciding the suitability of bacteriological methods for diagnosis of pulmonary tuberculosis in various countries and in different diagnostic situations.

The findings of two studies, (i) one on comparison of Ziehl-Neelsen method of staining of acid fast bacilli with and without alcohol decolourisation and use of Gabbet's Methylene blue (in place of decolourisation and counter staining) and (ii) comparison of two different types of Basic Fuchsin dye used in the preparation of Carbol Fuchsin, have been presented. The first study has shown that omission of alcohol decolourisation or the use of Gabbet's Methylene Blue has not influenced the detection of positives, though the latter has more often produced a non- satisfactory background. The second study has brought out the fact that two types of Basic Fuchsin are similar in every respect. However, the findings does not rule out the possibility of a bad dye giving rise to poor results. Need for conducting studies for simplifying the staining procedure has been stressed.

There is no generally acceptable definition for developing countries. On account of multiple demands of varying urgency on small resources, public health often receives lower priority than it deserves. To change the equilibrium between man and bacilli in the direction of positive health it would be necessary to invest resources on many key factors. Control of tuberculosis can only be a part of the effort to achieve the positive health. It is also now known that undue importance to quick conversion of sputum or early return of patients to work, need not be given. But the objective of TB programme for developing countries should be i) not to neglect service to actual sufferers and ii) to apply specific control measures in harmony with measures aiming at the overall improvement of socio economic conditions.

For developing countries domiciliary chemotherapy is the treatment of choice. Applying chemotherapy on a long term basis poses many problems, the main being the fall out of patients from treatment. The key factors are: a practical and economically feasible Case-finding and treatment programme, an adequate supply of anti TB drugs and effective executive cum supervisory organization. The District Tuberculosis Programme for a population of 1-1.5 million in each district, comprises one specialised district TB Centre which makes use of the area general health services for tuberculosis Case-finding and treatment. Several stages of development are envisaged and a start can be made from any stage, according to the facilities already available. The emphasis is on providing treatment for the patients nearest to their homes, along with effective supervision exercised by general health services staff under the guidance of the district centre. The choice of a drug regimen in the programme will depend upon efficacy of the regimen, availability of drugs, average cost of treatment, suitability for self administration and acceptability by patients/organisation. INH+PAS daily or supervised streptomycin containing intermittent regimen for smear positive cases, INH alone daily for sputum negative appear to be the regimens of choice for developing countries. It is unfortunate that a powerful regimen like S + H + PAS is very expensive and less acceptable. Thus a planned and systematic approach is needed to deal with the problem of TB. For running an organised and coordinated tuberculosis control programme, the national character of the Campaign should be recognised right at the start and maintained till the objective has been achieved.

Health has been defined as the state of perfect physical, social and mental wellbeing which is somewhat an abstract definition. In this paper economics of health is measured through economics of sickness. Because sickness is experienced, it can be measured and it inflicts physical social and economic sufferings. In a community, economic prosperity is directly dependent on quantum of sickness and its prevention by health services. A sociological enquiry into part played by disease in the socio economic development of society was made by carrying out a study in two village population groups. The social investigators of NTI made deep probing questions to elicit presence of symptoms, action taken by them, money spent on treatment and the loss of wages. In first study observation participation technique was also adopted. The investigators lived in the village for four months. In the other study 20% households of those 22 villages which participated earlier in an epidemiological survey conducted by NTI, were interviewed.

Findings of two studies are combined and presented. Illnesses were classified into major and minor on the basis of clinical severity and the duration of symptoms. In both the studies 60% of all persons were asymptomatic during 2 months prior to the interview. About 18% had one minor illness, 13% had major illness and only 3% had one major and one minor illness. The quantum of multiple disease (3 or more) occurring in one person was less than 2%. Only 20% of living man days were spent as sick man days. The average annual loss on account of health reasons per family has been estimated to be Rs.90 and Rs.15/ per capita. The overall economic loss due to sickness, direct and indirect amounted to 3% of the per capita income in the poorer groups of villages and 6% in the economically more favourable placed villages. The material available here strongly suggests that the sizes of households will not have much influence over the sickness in the community. Another significant feature of this study was the phenomenon- of substitution within the family whenever the wage earner could not go to work. The evidence examined in this paper suggests that the actual economic loss is only 1/3 of the calculated loss. It also suggests that the overall cost of sickness to the individuals and family is far less than what is normally calculated and is influenced by the money available in the household.