The study was undertaken among 22,957 persons belonging to 55 randomly selected villages of Nelamangala taluk of Bangalore district in 1975, to find out precise estimates of prevalence of bacillary disease. Symptom screening was done by well experienced social investigators, according to a brief interview schedule. Sputum was collected from all above the age of 5 years reporting chest symptoms for seven or more number of days during the previous two months. Within two weeks after symptom questioning, all were tuberculin tested and all 5 years and above were X-rayed. Additional sputum collection was done for those asymptomatics who had abnormal shadows in their chest X-rays.

The overall prevalence rate of culture confirmed bacillary cases by symptom and/or X-ray screening was 0.32 percent. Same prevalence was seen with X-ray alone also. But the overall prevalence rate based on symptom screening alone was 0.21 percent which is significantly lower than that of symptom and/or X-ray screening, or X-ray screening alone. The prevalence rates by age and sex based on symptom screening were about two-thirds that of rate based on X-ray and/or symptom screening. Hence to obtain prevalence rate according to X-ray and/or symptom screening, a correction factor of 1.52 should be applied to the prevalence rates obtained by symptom screening alone. This correction factor is fairly good for most of the age groups. It was also estimated that the cost of surveying the population by symptom screening alone is about half that of surveying the population by X-ray screening.

A study was conducted in 55 randomly selected villages of Nelamangala taluk, Bangalore district in 1975 (1) to estimate the prevalence of symptoms in the general population during the two months prior to the epidemiological survey, (2) to study the nature of action taken by these symptomatics and, (3) to find out through sputum examination as to how many of them suffer from pulmonary tuberculosis. The entire population was interviewed and sputum was collected from those aged five years and above having symptoms continuously for seven days and more. A coverage of 98.8% was obtained. Symptomatics among the directly interviewed were almost double (32.3%) of those who had to be interviewed by proxy (16.8%). Proportion of symptomatics were higher in the age groups twenty years and above. 24.8% were symptomatic during the reference period of two months and 16.7% had symptoms on the day of interview. ll.1% were found to have chest symptoms. The prevalence rate of tuberculosis was found to be 21 per 1000, (for males 28 and females 14). Cough was the most prevalent and the symptom of longest duration.

The findings suggest that symptoms questioning should focus more on cough and its combination with other symptoms. Symptoms questioning as a tool to detect cases has less potential than X-ray, but data reveal that leading questions can elicit more information on symptoms and action taking. The manner of action taking was the same for chest symptoms as for other symptoms and the proportion taking action is also the same for males and females. Government health facilities are found to be the most important source of relief, indigenous medicine having some importance marked second and the private practitioners ranking only third.

Persons suffering from pulmonary tuberculosis generally experience symptoms such as cough, chest pain, fever and haemoptysis. It is possible to identify the symptomatics by interviewing them during community health surveys. The symptom survey was carried out in 62 villages and 4 town blocks of Tumkur district in Karnataka as a sequel to an epidemiological survey undertaken to estimate the prevalence of tuberculosis. The data was collected through structured schedule. The interviewers were given the identification details of individuals having X-ray shadows suggestive of tuberculosis and an equal number of matched controls within 4 weeks of the survey. A total of 1752 persons were taken into the study of whom 875 had x ray shadows and 877 were normals. Of the total persons under study 89.7% were satisfactorily interviewed. It was observed that 42.6% of the total symptomatics gave history of one symptom at the first general question, 13% responded having symptoms after being asked specific questions. In conclusion a 42.6% affirmative response to the initial question of 'How is your health' is noteworthy that an investigator is acceptable health agency as the interviewee is willing to confide in him regarding his health problems. Additional number of persons responded to direct specific questions.

It must be pointed out that interview is a generic term applied to a tool that may be used for obtaining information through verbal communication. As a tool in surveys for screening for tuberculosis it is amenable to divese techniques and has great potentialities of being applied to different situations and various categories of respondents. Hence, it is necessary to identify the nature of data to be obtained and to decide on the technique that would be most suitable. Proper training, skill and supervision of the interviewer can obviate any possible bias and subjectivity that could vitiate an interview. As compared to many of the tools of social science research, the interview is simple, easy and amenable to being used in live situations. It is also of prime importance among populations for whom vocalisation is the most important medium of communication. Hence, in a community survey for the estimation of the prevalence of chest symptomatics the interview can be a valuable tool. It also shows that the interview is adequate as a tool of community survey in tuberculosis.

A study on awareness of symptoms of pulmonary tuberculosis and action taking was repeated in the 62 villages and 4 town blocks of Tumkur district of Karnataka after an interval of 12 years. In the earlier study, 2106 persons formed the study population. In the present study, 1752 were intaken to obtain a comparison of these 1752 intaken persons who were eligible for interview, 875 were X-ray positive and 877 X-ray normal (matched control).

The study showed that 95% of patients having radiologically active tuberculosis by both X-ray readers, 70% by one reader, 49.5% inactive by both readers, were aware of symptoms. According to the bacteriological status 79.5% had symptoms among those who were sputum positive by both microscopy and culture, 62.2% among those positive by culture alone and 73.7% among patients sputum positive by any method. Regarding action taking it was observed that 49.5% of the bacteriologically positive patients took some action compared by 70% of those found to have radiologically active disease by both X-ray readers. Thus action taking was higher among the latter category in both the studies. It may be due to the fact that extent of lesions are less advanced among those bacteriologically positive than among those who were in radiologically positive stage.

The findings of the study are similar to the earlier awareness study carried out in 1963 in the same area (Tumkur). This also indicates that in spite of having advantage of DTP for a decade actual and total benefits have not reached the people.

A longitudinal epidemiologic survey was carried out in Nelamangala taluk of Bangalore district since 1961, to find out prevalence of infection and disease of tuberculosis. During V round of the survey 1977, after 16 years of the first round, it was planned to study the awareness of symptoms and action taking of persons in the community where repeated surveys consisting of tuberculin, X-ray and sputum examinations had been carried out since 1961 and facilities for diagnosis and treatment were available since 1974. Fifty one persons aged 20 years and above, referred as X-ray positives were interviewed by social investigators on a structured questionnaire to elicit the awareness of symptoms and details of action taken to seek relief.

Of the 51 satisfactorily interviewed, 41 (80.4%) had symptoms suggestive of tuberculosis, of the 20 bacteriologically positive cases 19 (95%) were aware of symptoms suggestive of tuberculosis, thus registering a higher percentage of awareness than the X-ray positives. Of those with symptoms, 58.8% sought relief, many of them at multiple agencies such as Govt. hospitals and private practitioners, and some at tuberculosis hospitals, on being referred there. Most had obtained services free of cost and appreciated the available intrinsic benefits. Prior personal or family associations were the main reasons for seeking the services of private practitioners. Only 23% had gone to the nearest health facilities. Lack of proper facilities for good treatment and preference to be treated at urban centres, were the main reasons for not availing of the services at the nearest health facilities.

Illness is mostly a subjective awareness of an individual, the relief of which may be sought within or outside medical or health facilities. Perception of illness vary from people to people depending upon cultural, ethnic and socio-economic differences. Perception of symptoms by persons suffering from tuberculosis is very high yet only half of them approach modern medical facility for alleviation of their suffering. A survey was carried out in rural area of Hoskote taluk, Bangalore district to determine perceived morbidity and accessible medical relief in 1433 households belonging to 18 villages; of them, 1393 (97%) were successfully interviewed. Selected households belonged to three types of villages i.e., those being within 3 kms of a i)PHC, ii)taluk headquarters hospital and non- Governmental health centre.

Of the 9286 individual belonging to 1393 households satisfactorily interviewed regarding health, 1201 (12.9%) were found to be ill at some point of time during the reference period of one month. No differences were observed in the perception of morbidity or in the health seeking behaviour in the three groups of villages. Persons with symptoms/disease accounted for 88.8% of the total sickness, 3.4% for injuries and 9.3% for disabilities, while action taking was 61.6%, 90% and 13.5% respectively. Age sex distribution showed no difference in illness occurrence. Sputum was collected from 147 chest symptomatics and seven were found to be sputum positive. Government health facilities were utilized by 37.6% of the sick persons, private doctors by 36.4%, nature medicine by 10.6% and home remedies by only 9.9%. In conclusion, the services at the government health facilities were acceptable and were utilized if accessible. Prompt and adequate relief for injuries and acute indispositions ensures confidence of the people and better utilization.

This study based on an individualistic model examines the significance of factors such as symptom awareness, knowledge about the disease, recall of clinic instructions, economic problems and social interaction in the treatment regularity of patients with pulmonary tuberculosis through a multi dimensional comparison of regular patients, irregular patients and their households. There was no difference in the symptom awareness of the two groups of patients. Thus frequency of medical visits is to adopt the sick role than of stress. In NTP patients are denied the sick role has “rest” and “special diet” the vital elements of traditional treatment are not recommended as part of treatment. Yet, three of the four cardinal symptoms of pulmonary tuberculosis, cough fever and haemoptysis being of a nature observable by others, have been observed by the households to the extent similar to patients awareness. Most of the patients who take treatment from non- paying centres such as the LWTDTC live in overcrowded areas where there is generally a high degree of neighbourhood interaction not only social but in sharing common utilities such as courtyard, water tap, bath room, toilet etc. It is therefore not surprising that nearly half of the patients and households said that the neighbours knew about the patient's illness.

Seeking multiple sources of treatment is a common behaviour pattern of patients. Yet, it is disconcerting to find that tuberculosis patients who can ill afford to pay and who need to be under treatment for a long period should 'shop around' for treatment. It is the irregular patients who have sought treatment at other agencies more often. The study shows that patients showing regular drug collection have had help from household members in collecting the drugs. They have also had help from household members in remembering to consume the drugs. More of the households of the regulars mentioned LWTDTC as the place of treatment while in the in case of the households of the irregulars mentioned several places of treatment.

No significant differences were seen between the regular and irregular patients in their social interactions within the households or in the behaviour of households towards the patients. To the household, economic difficulties were the most important, perhaps for the reason that the patients were men in the working age group. Though economic difficulties were important to patients also the predominant aspect was pain and discomfort the physical dimensions of suffering. A treatment agency that can pay adequate attention to the relief of physical suffering and non- relapse of symptoms can perhaps help to improve treatment regularity of tuberculosis patients appreciably.

National tuberculosis programme reaches people through PHCs and sub centres. A study was conducted to find out the perception of illness and utilisation of health facilities by the community. This study was conducted in a random sample of 48 villages selected according to Probability Proportioned to Size within 5 Kms of the selected PHIs in Kolar District using a Multi stage sampling technique. Information on socio economic status, availability of health services and their utilisation was collected. 13,323 individuals were interviewed. 706 were ill in a period of two months prior to survey. 71.3% had taken allopathic system of treatment. 69.1% had approached government hospital or PHC. 34 patients reported to have TB. All had attended either DTC or PHC.

The study indicated that morbidity was perceived much early and also followed by an action. Data indicates a high percentage of preferring allopathic system in general and from peripheral health centres and other Government hospitals in particular. Data indicates that in spite of overall backwardness of the study area and very limited economic resources people have utilised the PHC to the maximum. The reason could be either high acceptance of PHC or inevitability. But, there is an evidence of higher utilisation of family welfare and MCH services. The data shows all tuberculosis patients have had exposure to standard regimens, all of them have approached either PHC or DTC for treatment. This confirms the felt need oriented concept of National Tuberculosis Programme. Also high level morbidity among children below 4 years of age and action taken indicate an enhanced level of demand for health services.

Case-finding and treatment activities in the National Tuberculosis Programme (NTP) are mainly dependent on self reporting chest symptomatics. It was of main interest to find out that patients who report to the health institutions due to suffering remain symptom free later on or there is a recurrence of symptoms among sputum positive patients during 14 intervening years i.e., from 1961-1974. The follow up was carried out in 1974, in spite of such a long interval, information from 20.3% of the patients including dead was collected.

At the time of diagnosis in 1961 at LWC, 91.6% of patients had symptoms. During the total period from 1961 to the time of interview 7-16% had recurrence during each of the intervening years. Recall was possible because majority of them have taken action. But at the time of interview 29.7% reported to be having symptoms, of them nearly half had symptoms for more than 6 months. It is likely that during preceding years also there might have been a higher percentage of symptoms but the recall was poor. Considering the total duration of symptoms, 52% had experienced symptoms for more than 6 months.

During last two decades, the health care delivery system has undergone several changes. The implementation of the concept of Primary Health Care and of the Multi Purpose Health Workers (MPWs) Scheme can be utilised to improve both Case-finding and case holding activities of the District Tuberculosis Programme. A study was undertaken by National Tuberculosis Institute (NTI) to obtain a profile of work of MPWs, observe their work on time and motion analogy and to ascertain output of tuberculosis services and other works. The study was carried out in a contiguous area of 6 PHCs of a district. The work of 16 MPWs was observed by a Social Investigator of NTI who accompanied them during a day's work; one month period was selected as reference period. 160 MPWs were asked to give details of their activities through self administered questionnaire and records of the six PHCs were studied in terms of output of the services.

On an average a MPW travelled 15 kms, spent 4 hours in the village, visited 70 homes; Of them, 25% were locked. The time spent on different activities during home visits were 34% for minor ailments, 26% on malaria, 12% on family welfare and 11% on tuberculosis. Profile of activities carried out on a randomised day were, 77.5% did not perform any anti tuberculosis activities. Those who did anti tuberculosis work identified 4 symptomatics, prepared two smears and followed up 13 patients. The highest performance was with regard to Family Welfare (68%) and treatment of ailments (64%). As per the opinion of MPWs tuberculosis was 7th, 8th and 9th rank, malaria was lst and 3rd and family welfare was 1st and 2nd. As per the actual output of work from the PHC records, anti malaria (70%) and minor treatment had the maximum performance and family welfare averaged, as only 35 of the eligible couples were registered. Findings suggest that tuberculosis was given lower priority in terms of all the three points i.e., actual performance, profile of work of MPW, actual day's work of MPW and diverse health activities among rural population. Integration of tuberculosis at periphery needs more important considerations.

One of the hypothesis put forth for the failure of BCG vaccine to show protection against bacillary pulmonary tuberculosis in Chingleput trial was the interference from non-tuberculous mycobacteria that were prevalent in the trial area. In order to test this, a study was conducted with the following objectives: to investigate (1) Protection given by BCG and M.avium intracellulare (MAI) which is the most prevalent species, against the challenge with high and low virulent strains of M.tuberculosis in sensitised guineapigs. (2) Whether M.avium Intracellulare (MAI) interferes with the protective effect of BCG against challenge with both high and low virulent strains of M.tuberculosis. Sensitization was done with MAI in guineapigs using both oral and intradermal routes. Groups of species were immunized with BCG/Placebo and later challenged with high/low virulent strains of M.tuberculosis. Colony counts of M.tuberculosis bacilli from spleens of the animals were done to measure the protective effect.

The findings were: (1) BCG showed protection against both high and low virulent challenges. (2) MAI in both oral and intradermal routes had no effect against low virulent challenge. (3) There was no significant interaction between BCG and MAI against low virulent challenge. (4) MAI when given orally, showed a significant protection against high virulent challenge. The same was not seen with intradermal route. (5) MAI orally, interfered with the protective effect of BCG against high virulent strains of M.tuberculosis.

This paper describes the need for Health Education Component in the National Tuberculosis Programme (NTP). The potential achievement of the programme activities viz., prevention, Case-finding and treatment has been established by studies conducted by the National Tuberculosis Institute. Corrective measures to achieve the potential would no doubt have to tackle all the three constituents of the programme viz., objectives, activities and resources. However, incorporation of a health education component in the crucial activities of the programme would help, where under achievement is due to the lack of knowledge and proper attitude both on the part of the patient and the health worker. In order to evolve an effective methodology, the goals of the health education component should be synchronised with those of the programme. While the health education aspects in the Case-finding and treatment activities can be incorporated at health institutions and on an individual or group basis, education for the preventive activities has to be on a mass or community basis. While the nucleus of the community education should be on BCG vaccination, the mass media could be utilised for the overall tuberculosis education in the general population. Thus, there is scope for employing a variety of material, methods and media of health education in the NTP.