"It was March 1949, BCG Campaign was just being born in India. My initiation into BCG vaccination work, also then took place. Training was given by experts of International Tuberculosis Campaign. I was not alone. There were others with me doctors, health visitors, clerks and peons. Some were declared unfit. After training, each doctor was made in charge of a team consisting of two health visitors, a clerk and a peon. We were allotted different areas for work. Our field of activity included schools, factories, police force etc. We had to visit each place of work thrice: first for the 1 TU tuberculin test, second exactly three days later for reading of 1 TU test and giving 10 TU test and third for vaccination etc. after another interval of 3 4 days. School Work3 : BCG work in the school was very slow and the coverages low the main reason consent from the parents. One year later an old head master (who had taught me) asked many a searching questions. He insisted on going through the literature. On our next meeting he asked me, 'Do you really want to vaccinate the children'? To an enthusiastic affirmative reply from me, he said 'Then, scrap the consent forms. They arouse unnecessary suspicion. I am convinced that the work you are engaged in is good'. I readily agreed and never used them again. Output of work improved. Soon the consent forms in my state were a thing of the past and gradually in other states too. Thanks to the venerable old head master-an unknown, unsung, hero of BCG Mass Campaign launched : In 1951 we were asked whether BCG vaccination could be extended to general population groups in rural and urban areas. The strength of a team was raised to six technicians. Maps and census books were obtained, vehicles and more vaccination equipment were procured, more cards were printed, the district and tehsil administrations were contacted, the programme was chalked out and the mass BCG campaign was launched. Changing Beliefs, Attitudes : In a group of villages no work was possible. We were at a loss to know the reason. At last we started to persuade a temperamental old woman in one of the villages. After some resistance she blurted out that a health worker had told them that some persons had become dumb and deaf after BCG vaccination. We contacted the person concerned. She had also heard about it from somebody. The information was not reliable. After discussions she was convinced. She went to all those villages; she made speeches in favour of BCG vaccination; convinced the people and informed us about it. Need for Publicity : We soon realised the need for more publicity. Public address equipment was hired, gramophone records were purchased. Later UNICEF provided the public address equipment, and cinema projectors were also supplied. The expenses were reduced. The publicity was thus built into the programme for the first time in a health programme in India. The output further improved. As the publicity for BCG increased, the publicity against it also increased. BCG was given the name of 'Birth Control Germs', and likewise many other names. Any intercurrent disease, or an accidental occurrence short of bone fractures, was attributed to BCG. Quiet perseverance and investigations into complaints by the workers, helped BCG to go on, to make strides. Hard Work : Entire teams were engaged from early hours of the day till late in the night. The duties were divided. Planning was rationalised. The first BCG manual was born. The organisational, operational and technical pattern of Mass BCG Campaign was established. The strain was less. Till 1952, two tuberculin tests before vaccination remained in vogue. After some trials by World Health Organisation, single tuberculin test was introduced. Absentees occurring at one stage, at least, were avoided. People were spared one prick. Vaccinations increased. BCG Conferences & Mass Campaign : Periodical conferences of all State BCG Officers were held. Exchange of experiences, difficulties encountered and methods to solve them were discussed. Mass Campaigns by combined effort of teams from few selected states were arranged in some large cities. Everybody put in his best. Success was tremendous. BCG workers fraternised into a close knit community. Some workers exchanged ideas by correspondence. All these efforts helped the Campaign.

Experiences in Assessment Team

In 1955, I joined the All India BCG Assessment Team. I saw dedicated workers - busy for 18 hours a day. I came across instances of nervous breakdowns due to overwork and due to frustration. I have known one who slept 16 hours a day and divided the remaining eight hours, judiciously into bits of two hours each between dressing, getting ready for the day's work, sipping tea, meeting friends and taking well earned rest and food! I cannot forget the technician whose woolen suits served as mobile refrigerator for the vaccine; those who walked eight to ten miles a day to cover houses in hilly areas testing small two - digit figures; the silent workers and the boastful ones. The thought of the officer who dared the drivers to lubricate the piston rings daily in their vehicles amuses one besides another who would not sanction casual leave to the staff on basis of telegrams, because they did not bear stamp mark of the station of their origin! It is a pleasure to recall some of ever smiling radiant faces and I shudder at the thought of those who would not smile for any consideration. All types of people go to make the world and also the BCG Campaign! I had to travel a lot, had the opportunity to see the campaigns in different states. Visits to some states were a thrilling experience. Campaigns ran smoothly where they were organised in conformity with the manuals laid down by the Central BCG Organisation. It was a pleasure to see systematic coverage of areas, in some of the States. In a district 2 or 3 teams were posted. Teams divided the areas allotted to them into sectors and covered each sector starting from periphery. No area, no village was left. The testing and vaccination coverages were good. In a few other States I was disappointed to see teams transferred from one district to another, leaving vast areas uncovered. As if this was not enough, some easily accessible or less difficult areas were covered over and over again. Towering successes were followed by great falls where campaigns were built around personalities rather than on sound organisation. I learnt a lesson not to be carried away by such fleeting shows. The unfortunate countrywide press controversy on BCG, raging then, did not effect working of a well organised campaign. Impact of Administration on Work : It was seen that where reasonable powers for day to day administration were delegated to team leaders the work went on with clockwise regularity. I was impressed by success of campaign in states where staff was satisfied, where relationship between officers and staff was more on human than on dry official levels, where deserving staff could hope for promotions coming their way and where they were paid well. I saw campaigns where staff was drawn from other public health or medical sections transferred to BCG as a punishment for not doing well in their parent sections. They spread the contagion, spoiled the finer workers and made a mess of the campaign. Technique of Field Work, Supervision : Practice of making field staff work continuously for 24 days and compensating the Sundays and holidays by one free week in a month, in some states, facilitated the work and kept the staff satisfied. During the free week the vehicles were repaired, the supplies replenished, the payments were collected and the staff was enabled to look after the personal and family matters. Why should the work not be satisfactory? In other States for every holiday, the work was not possible for two days, the strain on vehicles was extensive, the breakdowns were frequent, supplies were not sent in time, the work was suspended, staff went on leave frequently, leave was naturally not granted easily and they felt frustrated; the results were obvious. I saw a few states where supervisors did not move out of their headquarters for months. Some of them were satisfied if supply lines were maintained. They did not realise that the field organisation had failed; timings of work were not kept and sterilisation was indifferent. They insisted on high outputs, quality of work being no consideration. But in States where supervision was frequent and regular and supervisors knew their job well, the standard of work was well maintained. The outputs were realistic. Problems of field work and difficulties of staff were understood and remedies found. The staff remained satisfied.

Supervision : to a few meant only checking the stock books, attendance registers and others. Some restricted it to inspecting the concurrent technical and publicity performance in the field. Only very few included examination of procedures of advance desk and field planning, cleanliness of equipment, sterilisation, preservation of biologicals both at camp and field, advance publicity, public relations work done by team leaders and technicians, the working of transport and public address equipment etc. Years rolled by. Many old faces were missed. In some states untrained and unbriefed supervisory staff led to overall deterioration of the campaign. Generalisations are dangerous as in some states matters improved with change of hands. The campaign were revitalised. Publicity Problem : While in my native state of Punjab, I used to look at the states having full fledged staff and organisation for publicity, with envy. But in some states it was a tragic situation. I felt that integrated publicity organisations in my state was a boon in disguise. In some of the have not states, every member of the team played the publicity game. Peons, drivers, technicians, clerks, team leaders and supervisors, all did their bit while in some states even with well provided publicity organisation such things did not happen. The work was the proof of desired effects of good publicity.

House-to-house Vaccination : In 1962, after the introduction of District Tuberculosis Programme (DTP), a house to house pattern of BCG Campaign was evolved. It offered new opportunities to revitalise the aging BCG Campaign. It promised comparatively stabler life to BCG Technicians. The intervention was timely as every one connected with BCG Campaign had realised its potential pitfalls. Human honesty and supervision did work for quite sometime. But, when the demand for the figures increased and the supervision decreased, fragile human honesty slowly gave way, with too obvious a result. In this short period I have seen that in states in which Mass BCG Campaign did not run well, the house-to-house campaign is also meeting similar fate. Sound organisation and supervision are hallmarks for success of the BCG work whatever be its pattern. I am hopeful that integration of BCG work with the DTP, may provide more efficient and frequent supervision. Prevention will then go hand in hand with cure."

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 coverages could be improved through adopting a house to house or door to door approach. The material from three different sources are examined. Firstly, the reports from the mass campaign showing the reported coverages in different age groups; secondly, the presence of BCG scars (as an evidence of vaccination) as seen in an epidemiological survey done shortly afterwards and finally the coverages as obtained in an operational study of door to door BCG vaccination.

While the mass campaign reported that 35% of the total population was tuberculin tested (vaccination coverage reports were not available) the epidemiological survey showed that shortly after the mass campaign only about 19% of the children aged 0-9 years had BCG scars, while about 97% were tuberculin negative and eligible for vaccination. On the other hand in the house to house campaign 80% of the children aged 0-19 years could be vaccinated. The major disadvantage of a house to house programme is low output of work due to time taken up for registration of every household member. This can be improved by limiting registration to 0-19 years and by simplifying registration form.

In view of the variable and low levels of post-vaccination allergy elicited in the Indian Mass BCG Campaign vaccinated groups as observed by WHO and Indian BCG Assessment Teams, some studies were carried out to investigate some of the factors considered having influenced the levels of post-vaccination allergy. The reasons were potency and storage of vaccine, techniques, interval between vaccination and retesting and tuberculins used. Potency of the vaccine: Madras vaccine was compared with Danish vaccine. The retest done at 3 months with 1 TU RT 23 showed 11.8 mm induration with Danish and 11.9 mm with the Madras vaccine. Test done after one year with 20 TU induration was 18.3 mm for both the vaccines. It is reasonable to assume that the vaccine produced at Madras is as potent as Danish vaccine. Storage of vaccine: A comparison of post-vaccination allergy in respect of storage of vaccine by the ICMR Assessment Team and by Mass Campaign Teams was carried out in five groups of villages in the neighbourhood places where five BCG teams were working in Tamil Nadu. The non-reactors were vaccinated randomly by vaccines stored by either team and with the placebo III group as control. The retest done after 3 months showed that in all the five groups combined the mean size of indurations vaccinated with vaccine stored by Assessment Team were more in the vaccine stored by Mass Campaign Team. The loss of potency was 0.7 mm per week in vaccine stored by Assessment Team and 1.5 mm per week stored by Mass Campaign Team. Techniques: The above study was extended to five more groups vaccinated and tested by the Mass Campaign Team. Assessment Team also vaccinated separate groups with the same vaccine and tested on the same day. Mean size induration for groups combined was higher for assessment team but not significant. So, the techniques do not seem to make much difference. Interval between vaccination & retesting: Analysis of data collected on post-vaccination allergy in the groups vaccinated by the Mass Campaign Teams retesting according to intervals showed that the mean size induration decreased with the increase in interval between vaccination and retesting from 1-20 months. Thereafter, it rose again. These results indicate a tendency for the allergy after vaccination to wane with passage of time. The rise is presumably due to super infection or difference in batches of vaccine. In the third year (not included in this paper) greater proportion of people had bigger reactions. Besides, tuberculin used for retesting is also found to give differences in mean size induration. Tuberculin 5 TU RT 22 gave larger reactions than 1 TU RT 23 with tween, the differences were above 3 mm.

It can be concluded that at present Madras vaccine is satisfactorily potent, the post-vaccination allergy is influenced by storage of vaccine, by interval between vaccination and retesting and type of tuberculin used for eliciting the allergy. Technique of testing, reading and vaccination may not influence the results. Under Indian climatic conditions the liquid vaccine should not be used for more than 2 weeks. There is a need for Freeze-Dried vaccine.

During the 7th All India BCG Conference held at Ahmedabad in February 1965 various points regarding the technical aspects of BCG Campaign were put forward by the author of this article. The issues discussed were related to specific age group to be vaccinated; direct vaccination; vaccination of new-borns; techniques of testing, reading and vaccination; preservation of biologicals, Freeze-Dried vaccine; pilot and research studies; assessment and training.

Some of the suggestions given on the above aspects described briefly were: (1) Only 0-20 years might be taken up because that was the most vulnerable age group for infection from the natural sources. (2) Direct BCG vaccination in 0-20 years age group could be carried out in the first round followed by vaccination of population below 7 years of age (0-6 years) in the subsequent rounds. (3) Infant vaccination practiced at that time in some of the major cities only, would not contribute greatly to the control of tuberculosis unless it is extended to the rural areas also. (4) Results of vaccination should be exceedingly good provided vaccine was maintained properly, used within 2 weeks of manufacture, shaken well before opening, a drop ejected out before vaccination and proper dosage injected correctly. (5) The vaccine must be kept under refrigeration during storage, transport and use. (6) The personnel engaged in the use of Freeze-Dried vaccine had to be trained properly in its aseptic reconstitution. (7) Operational studies in respect of BCG work in cities; practicability and feasibility of setting up training centres in the states, assessment of programme by the states etc., were required to be undertaken. (8) Uniformity of techniques and procedures of BCG vaccination and proper assessment of Mass BCG Campaign by an independent agency would be required. The author in his article also stressed that no changes should be brought into operation without assessment.