The Indian Journal of Tuberculosis - LRS Institute of Tuberculosis ...

Ind. J. Tub., 1993, 40, 107TheIndian Journal of TuberculosisVol. 40 New Delhi, July 1993 No. 3EditorialHOLISTIC HEALTH EDUCTIONIt is ironic to some extent that medical education and health education have come toacquire different connotations, practice and significance. Their relationship with healthpolicy, as a consequence, often appears confusing , to say the least.There are historic and other reasons for such a scenario. Taking India as an example,the Indian Medical Council was perhaps the first statutory body to be set up, as early as1933. Its main object was to guide the establishment of and regulate the teaching ofmedicine in this country. Following the practice in the West then, efforts were targetedon disease, in all its clinical aspects. The Council succeeded in their endeavours to a largeextent, till lately, when having got entangled in a web of political and social forces it hasbecome virtually ineffective in maintaining standards in teaching even disease orientedmedicine.The credit for placing the focus on health has mainly to be given to the World Health'Organisation. Health, of course, is not merely the absence of disease but a state ofcomplete physical and mental well being: a near perfect vision. One would haveimagined, then, that teaching of health, i.e. health education, would have been usheredwhich would have included the teaching about diseases. This holistic approach wouldhave widened the vision and techniques of our medical doctors, from merely treating thediseases in their patients to taking them towards the goal of health. This did not happen.The study published in these pages regarding the necessity of educating patients abouttheir individual illnesses, as a part of delivering better health care to them by theirdoctors, raises the question of holistic health education. The study has revealed that theaverage rural asthmatic patient in the Punjab (as perhaps anywhere) is highly ignorantabout his disease and its proper management, though perhaps reasonably well taken careof by the treating physician. One could safely presume that the findings, if correct, wouldapply not only to asthma but to all the diseases. And, the attitude of the average physicianto treat the disease but not necessarily the patient. Taking a logical step still further, thespecialist who is increasingly being sought out by patients wanting the best advice theycan get, would treat only the speciality disease and feel helpless enough to ignore theother, even ordinary, ailments of the patient. How far we are from the goal of the WorldHealth Organisation; what travesty of the profession?

TUBERCULOSIS OF BONES & JOINTS113gia is 10-30%. One half of all reported paraplegiasare due to tuberculosis of thoracic and thoracolumbarregions. If there are 30,000 to 90,000 casesof tuberculosis of the spine, patients with paraplegiawould be between 7,500 and 22,500, out of atotal of 15,000 to 45,000 paraplegics in the country.Nobody has studied this aspect in our countrytill today and the numbers given are pureguesstimates. It is important, therefore, thatsome body should take up the study of this importantproblem since the entire sequence ofdisease leading to complication is preventable.The vertebral regions commonly involved inparaplegia of tuberculosis origin are thoracic, thoraco-lumbar,cervical, lumbar and cauda equina,in that order.Griffiths, Seddon & Roaf 25 classified tuberculousparaplegia in two grades, Grade A andGrade B : Grade A with early onset, within 2 yearsafter onset of symptoms of tuberculosis, and gradeB with late onset, i.e. after more than 2 years.Grade B paraplegia might be due to recrudescenceof disease, mechanical pressure as a result ofsevere kyphosis, inadequate blood supply to thespinal cord as a result of slow exsanguinationresulting in a fibrous cord, and patchy meningitis.Grade B, in general, has a poor prognosis whichmust be explained to the patient. Grade A paraplegias(Pott's paraplegia) have also beendescribed 26 - 27 as:Grade I : The patient is not aware of the problem.On clinical examination, there are signs ofcompression, usually exhibited by long tract involvementsigns or segmental paresis. The patientis able to walk.Grade II: There is evident spasticity but the patientis able to walk, often with “jumpiness” inthe gait. Long tract involvement signs are significantlypresent.Grade III : The patient is bed-ridden and hasspastic paraplegia in extension with demonstrableneurological deficits, both sensory and motor.Grade IV : Paraplegia occurs with flexorspasm. There is bladder and bowel involvementand total sensory and motor loss. The prognosis ispoor.TreatmentAntituberculosis drug regimens : The MedicalResearch Council of the United Kingdom carriedout a series of trials in the late 60's and early 70'sto establish the antituberculosis regimens necessaryfor treatment of tuberculous lesions of bonesand joints. Though the emphasis in the trials wasprimarily on tuberculous spine, the recommendationsare for all types of musculo-skeletal lesions.Briefly, there is a four drug regimen for the firstthree months with dosages of the drugs based onage and body weight of the patient. The drugs ofchoice are Rifampicin, Isoniazid, Ethambutol andPyrazinamide, followed by three drugs, i.e. Rifampicin,Isoniazid and Ethambutol for 16 to 24months. If toxicity develops, the offending drug ischanged. Allergic reaction can occur to any drug;careful attention must be paid to toxicity. Thus,Streptomycin can effect the VIII nerve resulting indeafness or vestibular functional derangement. Rifampicincan produce hepatotoxicity and henceSCOT & SGPT levels must be monitored. Ethambutolcan produce depressed thyroid function.The major aim of treatment is to preventparaplegia. Most authors have adopted the use of4 anti-tuberculosis drugs for a period of threemonths initially followed by three drugs for 18 to24 months. The drugs used are Streptomycin,Rifampicin, Isoniazid, Ethambutol and Pyrazinamide.In children below the age of 12 years,both Streptomycin and Rifampicin are advocatedby paediatricians. The commonly followed treatmentmodality is the middle path, i.e. bed rest,drugs, periodic review of progress by X-ray andESR done every 4 weeks. A careful detailedneurological examination every 3 or 4 days ismandatory. If there is an increase in neurologicaldeficit, surgical intervention becomes desirable. Ipersonally advise surgery in all cases of tuberculousquadriplegia, paraplegia due to upperdorsal tuberculous lesion, when there is grade IVtype paralysis, and where investigations haveindicated extradural spread of the cold abscess orgranulation tissue. However, if there is improvement,on conservative treatment, it is continuedfor a minimum of 18 months.Auxiliary Treatment : Steroids are not recommendedto be given routinely. Short term steroidtherapy can be given in patients who are in a moribundstate, till anti-tuberculosis treatment startsacting or when patchy meningitis is present. Theaddition of steroid might prove crucial. Short termtherapy with anabolic steroids in debilitated malnourishedpatients enhances the protein intake but

114it should be avoided in women and children.I have always practised the following, as indicationsfor surgery, besides the above givencriteria:(1) Neurological complications which fail torespond to conservative care.(2) Paraplegia of the flexor spasm type, withbladder and bowel involvement and sensorydeficit.(3) Neurological status remaining static, or(4) Where the diagnosis remains doubtful.(5) Mechanical instability after healing.(6) Recurrence of the disease, and(7) Multiple vertebral involvement in childrenwith severe kyphosis.The various techniques of surgical treatmentare:(1) Costo-transversectomy, where there is alarge abscess in the thoracic region.(2) Antero-lateral decompression for a paravertebralmass, either an abscess or granulationtissue. The technique is primarily anextra-pleural exposure of the abscess/granulationtissue and the vertebral lesion, andpartial excision of the vertebral body so thatthe pressure on the cord is relieved.Normally, 2 or 3 ribs are removed for about2 to 3 inches at their vertebral end. The intercostalartery and nerve are identifiedand ligated. The cord with its coveringmembranes should be exposed anteriorlyand laterally so that pulsation of the cordcommences after the decompression. Thevertebrae are then fused with the resectedribs. This is the commonest procedure usedin this country.(3) Transthoracic anterior decompression, inwhich the rib is excised at the maximum diameterof the abscess below the 5thdorsal vertebra on the left side, and abovethe 5th dorsal vertebra on the right side.The intercostal artery is ligated beyond theorigin of retrograde spinal arterial branches,taking particular care to preserve the 9th leftintercostal artery. Pleura is then opened.The ribs are separated, after allowing thelung to collapse. The abscess is located intrapleurallyand confirmed first by aspirationof its content. The abscess cavity is thenopened by a cruciate incision, the abscessB. SANKARANevacuated, granulations tissue and vertebralbody excised till a pulsating cord isdemonstrated. The vertebral bodies arethen fused with the excised ribs.In the cervical spine, an abscess in the C,-C 2region is normally retropharyngeal and a transoralevacuation is necessary. Below the C 2 level,an abscess of the cervical spine is evacuatedthrough an approach centred on the posteriormargin of the sternomastoid muscle. Ligation ofthe branches of the external carotid artery maybe necessary. The trachea and oropharynx areidentified, retracted medially, the longus colli andanterior vertebral muscles identified after longitudinaldivision of the prevertebral layer of thedeep cervical fascia and the abscess evacuted.Diseased vertebral body is excised to normalbone; the pulsations of the cord are confirmed,and then fusion is done using an iliac graft.In the lumbar spine, evacuation of the lumbarabscess is done through Petit's triangle or bymeans of renal approach or through a retroperitonealsympathectomy approach. A psoas abscessis evacuated through the external abdominalmuscle parallel to the hypogastric or ilio-inguinalnerves.Laminectomy is indicated only if there is postelement disease with cord compression.Anterior spinal fusion is done in all caseswhere an anterio-lateral or a trans-thoracicdecompression has been done. Post spinal fusion,as recommended by Hibbs 28 , is done in children toprevent excessive kyphosis, ,and where there ismultiple segmental vertebral involvement. Noinstrumentation should be done in such cases.Post operative care in all the cases should be aprotective plaster jacket or a moulded orthoplastbrace for about 4 weeks. An adequate supportivebrace is necessary till bony fusion has occurred.(B). Tuberculosis of Sacro-iliac JointTuberculosis at this uncommon site isfrequently missed. Tenderness over the sacroiliacjoint and compression and distraction testsare painful. There could be either sacral or iliaclesion. The cold abscess can be either intra pelvicor under the gluteus maximus muscle. Diagnosisis established by aspiration of pus or a fine needleaspiration biopsy. Antituberculosis therapy andprotective bracing are the treatment of choice.Where .there is extensive obstruction, exposure of

TUBERCULOSIS OF BONES & JOINTS115the sacro-iliac joint, as advocated by SmithPatersen is done followed by fusion of the jointafter curettage of all infected bone and cartilage.(C). Tuberculosis of Hip JointInvolvement of the hip joint is the secondcommonest skeletal lesion, next to that of spine. Itcan occur in any age group but is more common inchildren.The clinical presentation is primarily a painfulhip limp. In early stages, when there is an effusionin the joint, the affected limb is flexed, abductedand externally rotated, with an apparent lengtheningof the extremity. In late stages, when destructionhas been progressive, the limb goes into flexion,abduction and internal rotation, with anapparent limb shortening. If a pathological dislocationoccurs, as a result of gross destruction ofthe femoral head or the superior acetabularmargin, the hip is dislocated posteriorly andsuperiorly with true shortening of the involvedlimb.The femoral triangle can be full and an abscessmay be palpable. Abscesses in the hip joint normallypresent themselves in the femoral triangle,but can present on the medial aspect of the thigh.Laterally, it can take the course of the femoralnerve, or posteriorly under the gluteus maximusmuscle. External iliac lymphadenopathy is normallypresent, sometime with caseating lymphnodes.The clinical stages of the disease can besynovitis, early and advanced tuberculous arthritiswith involvement of the articular cartilage andbone, and ultimate pathological dislocation.The anatomical sites of the lesions could be (a)the superior rim of the acetabulam, which isdrained by the communicating venous channels ofthe Batson's prevertebral venous plexus and (b)Babcock's triangle limited by the inferior neck offemur, medially by the epiphysial line or equivalentstress lines in adults and laterally by the stresstrabeculae of the neck of the femur which is intraarticularin location. Skeletal lesion can occur inthe head and neck of femur, in the greater trochanter.Rarely, the lesion could be purely synovial inlocation.Differential DiagnosisTuberculosis of hip has to be differentiatedfrom transient synovitis of the hip, Legg BerthesHalve disease, osteomyelitis of upper end of femur,acute infective arthritis of infancy and childhoodosteoid osteoma of the neck of the femurwith synovial involvement, rheumatoid arthritis,avascular necrosis of the head of the femur secondaryto coronary disease or cortisone inducedavascular necrosis. The diagnosis is best establishedby aspiration of the joint for a cold abscessor needle aspiration biopsy of synovial membrane.Rarely, a malignant synoviona of the hip joint canbe mistaken for tuberculosis of the hip.TreatmentTreament of hip joint comprises :(1) Rest in the acute phase, with skin traction toease the spasm in the initial stages followedby hip spica to prevent mobility of the joint.(2) Anti-tuberculosis treatment, as discussed. Ifthere is sequestration, or doubt in the diagnosis,open biopsy and sequestrectomy isdesirable. If there is marked synovial thickening,as evidenced by radiological finding,a synovectomy of the hip joints is of value.In India, because of the deformity that is frequentlypresent, the most useful method oftreatment is Mac Murray's defunctioning inter-trochantermedial displacement osteotomy.In selected cases, in men, a hip intraarticulararthrodesis with total excision ofthe focus and articular cartilage may be necessary.(D). Tuberculosis of Knee JointTuberculosis of knee joint can occur in any agegroup. The most common symptoms are : pain onmovement of the knee joint, synovial effusion,palpable synovial thickening and restriction ofmobility. Tenderness may be present in the medialor lateral joint line and patello-femoral segment ofthe joint. In advanced cases, there is triple dislocationof the knee : lateral, posterior, and superiordisplacement of tibia on femur.The lesion is quite frequently synovial in location,with villi formation. Purulent material canaccumulate in the joint space; destruction of articularcartilage secondary to the synovitis andmetaphysial and subarticular lesions can occur,both in femur and tibia.Diagnosis is established by radiological examinationwhich can show destructive lesions in the

116femoral or tibial condyles. Biopsy of the synovialmembrane and aspiration of the joint fluid followedby smear, culture and guinea pig inoculationcan confirm the diagnosis.Differential Diagnosis : Comprises internal derangementof the knee, pigmented or apigmentedvillio-nodular synovitis, haemophilic arthropathyof the knee, osteo-chondritis desicans of the articularsurface of femur, rheumatoid arthritis ofthe knee joint, osteo-arthritis of the knee joint andsynovial sarcoma.Treatment: Comprises anti-tuberculosis regimensas given for other tuberculous lesions of bones andjoints combined with postoperative immobilization.Synovectomy and joint debridement, if doneearly, give good results. When extensive articulardestruction is present, Charnley's 29 compressionarthrodesis of the knee is the treatment ofchoice. Though total knee replacements have beendone for tuberculosis of the knee, long termfollow ups have not been reported.(E). Tuberculosis of Ankle JointThe most common sites of lesions are tibia, fibulaand talus.Clinical symptoms are the same as for otherjoint lesions : swelling, synovial thickening andpain on movement. Osteochondritis desicans oftalus can simulate a tuberculous lesion of theankle.The treatment of choice is antituberculosisdrugs. Plaster of Paris immobilization, andarthrodesis at 95° planter flexion after debridementin adults are ideal.(F). Tuberculosis of FootThe foot bones can have isolated tuberculouslesions as in the os calcis or as diaphysial foci inmetatarsal bones (tuberculous dactylitis).A subchondral lesion in the os calcis leading totalocalcaneal arthritis and peroneal spastic flatfoot is a definite clinical entity. Talo-navicularand naviculo-cuneiform lesions and calcaneocuboidjoint involvement can also occur, particularlyin diabetes mellitus. The tarso metatarsal articulationat Lisfranc's level and the metatarso phalangealjoint of the great toe can be other foci ofinvolvement.Signs and symptoms are pain, swelling, rigidityof foot and swelling of the metatarsus. Rigid peronealspastic flat foot has to be excluded. FootB. SANKARANlesions very similar to tuberculous lesions can occurin Madurella madurella infection. Differentialdiagnosis should include a neuropathic change inthe foot, secondary to diabetes or leprosy.Treatment : Anti-tuberculosis regimens, as forthe other forms. Foot lesions are most amenable tocurettage and immobilization. A triple arthrodesisis the ideal procedure for lesions of the talo-navicular,calcaneo-cuboid or talo-calcaneal lesions.An isolated navicular lesion can be treated byexcision of the navicular bone. Post-operativeimmobilization, with foot in the plantigrade positionis essential in all cases. Tuberculous dactylitiscan be curetted out with adequate sequestrectomy.(G). Tuberculosis of Upper ExtremityThe shoulder involvement is rare, occuringmostly in adults. The classical sites could be headof humerus, glenoid, spine of the scapula, acromio-clavicularjoint, coracoid process and synoviallesion. It can also be iatrogenic : steroid injectiongiven for a stiff shoulder with the mistakendiagnosis of frozen shoulder, particularly in diabetics.The clinical presentation is with severe painfulrestriction of the shoulder movements, particularlyabduction and external rotation, and grosswasting of shoulder muscles.There is an atrophic type of tuberculosis of theshoulder, called caries sicca.Differential Diagnosis : Comprises peri-arthritisof the shoulder, rheumatoid arthritis and posttraumatic shoulder stiffness. Aspiration of theshoulder and fine nee,dle aspiration biopsy mightbe necessary to establish the diagnosis.The patient responds well to anti-tuberculosisregimens. A shoulder spica in the position of functionis necessary in the younger age groups.Shoulder arthrodesis is rarely necessary and if oneis done, it is restricted to the right shoulder only.(H). Tuberculosis of ElbowThe most frequent sites of involvement are medialand lateral condyles of the humerus, articularsurface of olecranon-intra articular (but occasionallyextra articular) and head of radius. Synovialthickening of the radio-humeral segment of the articulationcan be normally felt, particularly if thesynovium is involved. X-ray examination ishighly suggestive. A pathological dislocation ofelbow is very rare. The diagnosis can be con-

TUBERCULOSIS OF BONES & JOINTS117finned by aspiration or biopsy of synovium fromthe lateral side.In differential diagnosis, I have seen a case ofosteochondritis desicans of the humeral condyleand an osteoid-osteoma of the lateral condyle ofthe humerus, intra-articular in location, being mistakenfor tuberculosis of the elbow joint.Treatment : Anti-tuberculosis regimes, as prescribedfor musculo-skeletal lesions and immobilizationin a functional position during early treatment.Synovectomy, joint debridement, excisionalarthroplasty of elbow with distraction of the excisedsurface using an external fixateur (Ognasian)has been advocated. Simple excision of theelbow gives satisfactory results though there islack of stability of the elbow.(I). Tuberculosis of WristThe anatomical sites of the lesions may be inthe radius or proximal row of carpal bonesscaphoid,lunate and capitate. Concomitant involvementof the sheaths of volar or dorsal tendonsmight occur. The differential diagnosis isrheumatoid arthritis of the wrist.Biopsy of the wrist can be easily done from thedorsal route. Anti-tuberculosis regimens alongwith plaster of Paris immobilization (a scaphoidtype of plaster) in position of function are recommendedtill the acute episode subsides. Anarthrodesis of the wrist in 10° dorsiflexion givesvery good result.(J). Tuberculosis of Short BonesTuberculosis of the metacarpus, metatarsus,and phalanges is common. They quite frequentlypresent as marked swelling on die dorsum of thehand and soft tissue abscess is normally a commonfeature. Chronic pyogenic osteomyelitis,leutic osteitis and mycotic lesions in the footbones have to be differentiated.Debridement and antituberculosis regimen resultin complete subsidence of the lesion.(K). Tuberculous OsteomyelitisTuberculous ostemomyelitis occurs in about3% of patients with bone and joint tuberculosis. In7% of them, the skeletal site of lesion is multiple.The most frequent sites are : manubrium sterni,sternum and isolated spinous processes. Tubercu-lous osteomyelitis can also occur in odontoidprocess, spine of the scapula, ischium and fibula,but the diagnosis is frequently missed. Disseminatedlesions may also present as bone cysts. Afirm diagnosis can only be established by biopsyof the lesion. Antituberculosis regimens with curettageof the lesion are the treatment of choice.(L). Tuberculosis of Tendon Sheaths & BursaeAny tendon sheath or bursa can be involved intuberculosis. The commonest sites are flexor tendonsheaths of hand, subacromial bursa,olecranon bursa and bursae under the medialhead of gastrocnemius. In the volar aspect of thewrist, the classical presentation is a dumb-bellshaped swelling giving cross fluctuation and crepitus.Antituberculosis regimes coupled withexcision of the synovial sheath and bursae are thetreatment of choice.The spread to these sites is normally from theneighbouring bone or joint but it could be due tohaematogenous spread. It can also occur fromgravitational spread of the disease from the diseasedarea. The most significant clinical feature iscrepitus due to melon seed bodies which are agglutinatedprotein nodules nurtured by the synovialfluid.AcknowledgementsThis oration would have been impossible togive without the help of Prof. B.K. Dhaon of theLok Nayak Jai Prakash Narain Hospital whogave me his invaluable time and material for makingthe entire package. To Dr Mathew Vargheseof St. Stephens Hospital, I owe a deep debt ofgratitude for providing me with clinical photographsand clinical slides for presentation.References1. Duraiswamy, P.K. and Tuli, S.M. : Five thousandyears of Orthopaedics in India. Clin.Orthop.; 1971, 75, 269.2. Editorial : Tuberculosis - retrospect and prospect.Clinician; 1968, 32, 1.3. Girdlestone, G.R. and Somerville, E.W.: Tuberculosisof Bones' & Joints. Modern Trends inOrthopaedics, Series I, 1950, Butterworth &Co., London.4. Grange, J.M. : The rapid diagnosis of pauciba-

118 B. SANKARANciliary tuberculosis. Tubercle; 1989, 70,1.5. Martin, T., Cheke, D and Natyashak, I. : Brothculture; the modern guinea pig for isolation ofmycobacteria. Tubercle; 1989, 70, 53.6. Dahl, H.K. : Examination of pH in tuberculouspus. Acta. Orthop. Scand.; 1951, 20,176.7. Tuli, S.M. : Tuberculosis of the Spine. AmerindPublishing Co. Pvt. Ltd. 1975.8. Lakhanpal, V.P., Tuli S.M., Singh, H. andSen, P.C. : The value of histology culture andguinea pig inoculation examination in osteo-articulartuberculosis. Acta. Ofthop. Scand.; 1974,45, 36.9. Dobson, J. : Tuberculosis of Spine. J. Bone JointSurg.; 1951, 33B, 517.10. Sanchez-Olmos, V. : Skeletal Tuberculosis,1948, Williams & Wilkins Co. Baltimore.11. Wilkinson, M.C. : Observations on the pathogenesisand treatment of skeletal tuberculosis.Ann. R. Coll. Surg. Engl.; 1949, 4, 168.12. Mukhopadhya, B. : Role of excisional surgery inbone and joint tuberculosis - Hunterian Lecture.Ann. R. Coll. Surg. Engl.; 1956,18, 288.13. Grewal, K.S. and' Singh, M. : Tuberculosis ofspine. Ind. J. Surg.; 1956, 18, 394.14. Sinha, B.N. : Osteo-articular tuberculosis. Ind. J.Tub.; 1958, 5, 134.15. Konstam, P.O. and Blesovsy, A. : The ambulanttreatment of spinal tuberculosis. Br. Jour. Surg.;1962, 50, 26.16. Tuli, S.M., Srivastava, T.P., Verma, B.P. andSinha, G.P. : Tuberculosis of spine. Acta.Orthop. Scand.; 1967, 38,445.17. Martini, M. : Ed: Tuberculosis of the Bones &Joints, 1988, Sprintger-Varlat, Heidelberg.18. Girdlestone, G.R. : Tuberculosis of Bone &Joint. 3rd Ed. (Revised by Somerville, E.V. &Wilkinson, M.C.), Oxford University Press,London, 1952.19. Freidman, B.: Chemotherapy of Tuberculosis ofthe Spine. Jour. Bone & Joint Surg.; 1973, 5.20. Tuli, S.M.: Tuberculosis of the Skeletal System.Jaypee Brothers Publishers, 1991.21. Tuli, S.M. : Tuberculosis of the Skeletal System.Jaypee Brothers Publishers, 1991.22. Hodgson, A.R. and Stock F.E. : Anterior spinalfusion. A preliminary communication on theradical treatment of Pott's disease and Pott'sparaplegia. Br. J. Surg.; 1956, 44, 266.23. Hodgson, A.R. and Stock F.E. Anteriorspinal fusion for the treatment of tuberculosis ofthe spine. J. Bone & Joint Surg.; 1960, 42A,295.24. Mukhopadhya, B. and Mishra, N.K. : Tuberculosisof the spine. Ind. Jl. Surg.; 1957, 19,59.25. Griffiths, D.L., Seddon, H.L. and Roaf, R. :Pott's paraplegia 1956, Oxford University, Press,London.26. Goel, M.K. : Treatment of Pott's paraplegia byoperation. J. Bone & Joint Surg.; 1967, 49B,674.27. Kumar, K. and Saxena, M.B.L. : Multiple Osteoarticulartuberculosis. Int. Ortho. (SICOT);1988,12, 135.28. Hibbs, R.A. and Risser, J.C. : Treatment of vertebraltuberculosis by the spine fusion operation.J. Bone & Joint Surg.; 1928; 10, 805.29. Charnley, J. : Compression arthrodesis, 1953, E& S Livingstone, London.

Original ArticleInd. J. Tub., 1993. 40, 119RESPONSE OF PATIENTS WITH INITIALLY DRUG-RESISTANTORGANISMS TO TREATMENT WITH SHORT-COURSE CHEMOTHERAPY*Rema Mathew, T. Santha, R. Parthasarathy, K. Rajaram, C.N. Paramasivan,B. Janardhanam, P.R. Somasundaram and R. PrabhakarSummary : The study reports on the responseof 763 patients with organisms initiallyresistant to Streptomycin, Isoniazid, andStreptomycin plus Isoniazid, to treatmentwith short-course regimens containing Streptomycinwith or without Rifampicin and oralregimens containing Rifampicin with or withoutEthambutol. Resistance to Streptomycinatone did not influence the outcome. For resistanceto Isoniazid, alone or in combinationwith Streptomycin, the response was significantlybetter when the regimens contained Rifampicineither daily for 2 or 3 months or intermittentlyfor 6 months. The oral regimensstudied were not effective in the presence ofresistance to Rifampicin plus Isoniazid orStreptomycin plus Rifampicin plus Isoniazid,even when they contained Ethambutol. Theimplications of these findings for the NationalTuberculosis Programme are discussed.IntroductionDrug resistance is a major problem amongpatients with pulmonary tuberculosis. At present,the level of initial resistance of Mycobacteriumtuberculosis to one or more drugs is of the order of25% among patients attending the TuberculosisResearch Centre (TRC), Madras, as well as underprogramme conditions.Controlled clinical trials conducted by the TRCand other centres have led to the evolution ofseveral short-course regimens, highly efficaciousin patients with drug-sensitive organisms 1 ” 5 . Mostof these regimens contain Rifampicin (R), inaddition to 2 or 3 other drugs, which includedIsoniazid (H) and Streptomycin (S). It wasexpected that with the presence of R, the regimenswould be effective against bacilli initially resistantto Isoniazid, alone (H) or in combination withStreptomycin (SH), unlike conventional regimens.We report here the response to treatment withshort-course regimens of patients with initiallydrug-resistant M. tuberculosis admitted to 4 majorchemotherapy trials conducted by the TRCbetween 1974 and 1990.Material and MethodsThe patients were residents of Madras,Tambaram, Madurai or Bangalore, who attendedout-patient chest clinics because of symptoms.They were aged 12 years or more, had at least 2positive sputum smears and were randomlyallocated to one of the study regimens. Theculture results and sensitivity pattern were knownonly later, by about the 3rd month of treatment,and those with negative cultures or only 1 positiveculture were excluded from analyses. Even if theorganisms were found to be resistant to one ormore drugs, the allocated regimen was continued,the patients being closely monitored. In additionto a clinical examination, 3 sputum specimens (2overnight collections and 1 clinic spot specimen)were examined by smear and culture every monthfor all patients. A chest radiograph (PA) was takenat the end of the 1st month, 2nd month and the endof treatment, and at other time points, if indicated.In the first 3 trials, in which S-containingregimens were studied, only patients who hadreceived either no previous specific treatment, orhad less than 2 weeks, 2 months or 6 months ofprevious chemotherapy were admitted to thestudy. In the 4th trial, in which fully oral regimenswere studied, patients were included irrespectiveof the duration of previous chemotherapy.A total of 4,792 patients were admitted to these* Paper presented at the 47th National Conference on Tuberculosis and Chest Diseases, Bombay : 26th to 28thNovember, 1992 and presented with Dr. R. Krishna Memorial Award.Correspondence: Director, Tuberculosis Research Centre, Chetput, Madras-600 031.

120trials. Of these, 763 patients with organismsinitially resistant to S, H, SH, RH or SRHconstitute the study population in this report.Sputum specimens were cultured by a modifiedPetroff’s method 6 . Positive cultures were screenedfor M. tuberculosis' and tested for sensitivity to Hand R by the minimal inhibitory concentrationmethod and to S by the resistance ratio method 8 .Definitions of drug resistanceStreptomycin : A resistance ratio of 8 or moreon 1 culture, or 4 followed by 8 or more on thesame culture, or 4 followed by 4 on two separatecultures.Isoniazid : Growth (20 colonies or more) on 1mg/L on one culture or growth on 0.2 mg/Lfollowed by the same result on a repeat test on thesame culture, or growth on 0.2 mg/L on twoseparate cultures.Rifampicin : Growth on 64 mg/L on twoseparate cultures.RegimensThe 19 short-course regimens studied in the 4trials are listed in Table 1. They can be broadlygrouped into (a) regimens containing S but no R,(b) regimens containing both S and R and (c) fullyoral regimens containing R with and withoutEthambutol (E).There were 2 S-containing without R regimens(one of 5 months' and the other of 7 months'REMA MATHEW ETALduration) containing 3 drugs namely, S, H andPyrazinamide (Z) given daily for 3 or 2 months inthe initial phase of treatment followed by the same3 drugs given twice-weekly, for 2 or 5 months, inthe continuation phase.Fourteen regimens containing both S and Rwere studied. Four of them had a daily initialintensive phase : one 3-month regimen, with 4drugs, R, S, H and Z given daily for 3 months withno continuation phase; two 5-month regimens,with the same 4 drugs given daily for either 2 or 3months in the initial phase followed by 3 drugs, S,H and Z twice-weekly for either 3 or 2 months;and a 7 month regimen with the same 4 drugsgiven daily for 2 months in the initial phasefollowed by S, H and Z given twice-weekly for 5months in the continuation phase.The other 10 regimens were fully intermittent,of 6 months' duration, and consisted of an initialphase of 2 months with 4 drugs R, S, H and Zgiven either thrice-weekly or twice-weekly,followed by a continuation phase of 4 months with(a) 3 drugs, S, R and H given twice-weekly oronce-weekly (b) 2 drugs, R and H given twiceweeklyor once-weekly, or (c) a non-Rifampicincontinuation phase of S and H given twiceweekly.The three fully oral regimens (without S)studied were : (1) a 6-month regimen without E, inwhich 3 drugs, R, H and Z were given twiceweeklyfor 2 months followed by R and H twice-Table 1 TRC short-course regimensDuration(months)Initial phaseContinuation phaseDrugs* Rhythm** Months Drugs Rhythm Months5/7 SHZ d 3/2 SHZ tw 2/53 RSHZ d 3 Nil5 RSHZ d 2/3 SHZ tw 3/27 RSHZ d 2 SHZ tw 56 RSHZ thr/tw 2 SRH tw/ow 4RH or twtw6 RHZ tw 2 RH tw 46 REHZ tw 2 REH tw 48 REHZ d 2 EH d 6***R = Rifampicin, S = Streptomycin, H = Isoniazid, Zd = daily, thr = t hrice-weeklv. tw = twice-weeklv,= Pyrazinamide, Eow= once-weeklv= Ethambutol.

DRUG RESISTANT PATIENTS AND SHORT-COURSE CHEMOTHERAPY121weekly for 4 months; (2) a 6-month regimensimilar to (1) except that it contained E twiceweeklyin addition, throughout the 6-month periodand (3) an 8-month daily regimen with 4 drugs R,E, H and Z given for 2 months followed by E andH for 6 months.Table 2 shows the dosages of the drugs used inthese trials.An unfavorable response to treatment wasdefined as (a) death due to tuberculosis, (b)clinical and/or radiographic deterioration orpersistent sputum positivity warranting a changeDrugTable! Dosages of drugsDaily0.75 g IntermittentStreptomycin0.75 gIsoniazid 300 or 400 mg 400-750 mgRifampicin 300-600 mg 300-600 mgPyrazinamide 0.75-2.0 g 1. 25-2.5 g(thr)1. 75-3.5 g(tw)Etbambutol 600 mg 1200 mg (tw)thr = thrice-weekly, tw = twice-weeklyof treatment, or (c) two or more positive culturesin the-last two months of treatment, including atleast one in the last month, with at least oneculture growing 20 colonies or more.ResultsOf the 763 patients with initially drug resistantbacilli, 498 were treated with the S-containingregimens described earlier. Of these, 123 patientshad organisms resistant to S alone, 175 to H aloneand 200 to both S and H. Table 3 shows theresponse of these patients as related to theduration and rhythm of R in the regimens.Of the 123 patients with organisms resistant toS alone, only 2 (0-4%) had an unfavourableresponse, irrespective of the duration and rhytliumof R. Thus, isolated S - resistance did not matter inthe management of patients with these regimens.Among patients who had organisms initiallyresistant to H alone, 40% of 30 who did notreceive R had an unfavourable response. Thisproportion was significantly lowered when R wasgiven daily for 2 or 3 months (8% of 52; p

122months of intermittent R, along with the otherdrugs.The response of 265 patients, with organismsintially resistant to H or SH and RH or SRH, asrelated to the duration and rhythm of E in the fullyoral regimens is shown in Table 4. Among thosepatients with organisms resistant to H or SH, 62%of 74 who did not receive E had an unfavourableresponse, even though they had received R twiceweeklyfor 6 months, as compared to only 20% of59 patients who received E in addition ( P

DRUG RESISTANT PATIENTS AND SHORT-COURSE CHEMOTHERAPY123resistance, the response to treatment wasunsatisfactory irrespective of the regimenprescribed even when they contained 4 or 5 drugsincluding E. This emphasises the need to evolveregimens effective against RH and SRH -resistantM. tuberculosis, considering the fact that R is nowwidely used in the treatment of both tuberculousand non-tuberculous disease.Fox 14 had concluded that sensitivity testing didnot contribute to the success of tuberculosisprogrammes using standard 12-month regimens.The observations made in the present reportwith regard to M. tuberculosis initially resistantto S, H and SH have important implications fortuberculosis control. Under the NationalTuberculosis Programme in India, and in otherdeveloping countries, treatment for pulmonarytuberculosis is usually started on the basis ofsputum smear examination, since culturefacilities are not readily available. Therefore,the culture and sensitivity pattern may never beknown in most cases. Under the circumstances,it is encouraging to note that nearly 80% ofpatients with H or SH-resistant organismsresponded favourably to treatment with shortcoursechemotherapy, provided the regimencontained R either daily for 2 or 3 months orintermittently for 6 months, and either S or Ein addition.References1. Tuberculosis Research Centre, Madras. Study ofchemotherapy regimens of 5 and 7 months' durationand the role of corticosteroids in the treatmentof sputum-positive patients with pulmonarytuberculosis in south India. Tubercle; 1983,64, 73.2. Tuberculosis Research Centre, Madras and NationalTuberculosis Institute, Bangalore. A controlledclinical trial of 3- and 5-month regimensin the treatment of sputum-positive pulmonarytuberculosis in south India. Am. Rev. Resp.Dis.; 1986,134, 27.3. Prabhakar, R. Fully intermittent six-month regimensfor pulmonary tuberculosis in south India.Tuberculosis and Respiratory Disease (Proceedingsof the XXVI World Conference of theInternational Union Against Tuberculosis, 4-7November, 1986, held at Singapore), ProfessionalPost Graduate Services International1987, 21.4. Wallace Fox. Whither short course chemotherapy?Brit. J. Dis. Chest; 1981, 75, 331.5. Wallace Fox. Short-course chemotherapy forpulmonary tuberculosis and some problems ofits programme application with particular referenceto India. Lung India; 1984,11,161.6. Tuberculosis Chemotherapy centre, Madras. Aconcurrent comparison of Isoniazid and PASwith 3 regimens of Isoniazid alone in the domiciliarytreatment of pulmonary tuberculosis insouth India. Bull. WHO; 1960, 23,535.7. Alien B., Baker F.J. Mycobacteria : isolation,identification and sensitivity testing. London :Butterworth, 1968.8. Canetti G., Fox W., Khomenko A., et al. Advancesin techniques of testing mycobacterialdrug sensitivity, and the use of sensitivity testsin tuberculosis control programmes. Bull. WHO;1969,31,21.9. Tripathy S.P., Menon N.K. Mitchison D.A.,Narayana A.S.L. and Somasundaram P.R. Responseto treatment with Isoniazid plus PAS oftuberculosis patients with primary Isoniazid resistance.Tubercle; 1969, 50,257.10. East African/British Medical Research Council.Influence of pre-treatment bacterial resistance toIsoniazid, Thioacetazone, or PAS on the responseto chemotherapy of African patients withpulmonary tuberculosis. Tubercle; 1963, 44,393.11. Tripathy S.P. Short-course chemotherapy of pulmonarytuberculosis. Ind. J. Tub., 1982, 29, 3.12. Mitchison D.A. Drug resistance in mycobacteria.British Medical Bulletin; 1984, 40,84.13. Mitchison D.A. and Nunn A.J. Influence of initialdrug resistance on the response to shortcoursechemotherapy of pulmonary tuberculosis.Am. Rev. Resp. Dis., 1986,133,423.14. Wallace Fox. General considerations in thechoice and management of regimens of chemotherapyfor pulmonary tuberculosis. Bull.I.U.A.T.; 1972, 47, 49.

Original ArticleInd. J. Tub., 1993, 40, 125CHEMOPROPHYLAXIS IN HIGH RISK CHILDREN-ANALYSIS OF8 YEARS' FOLLOW UP : PRELIMINARY REPORT*D.K. Gupta 1 , R. Kumar 1 , N. Nath 2 and A.K. Kothari 2Summary ; During 1983, 215 male and 200female children, 5 to 15 years old, contacts oftuberculosis patients on treatment, who hadtuberculin test induration of 10 mm andabove were selected for chemoprophylaxis.The selected children were randomly allocatedto 5 groups : Group A - 85 children notgiven chemoprophylaxis; Group B - 82 childrengiven Isoniazid alone for 3 months;Group C - 83 children given Rifampicin plusIsoniazid for 1 month; Group D - 85 childrengiven Rifampicin plus Isoniazid for 3 monthsand Group E - 80 children given Isoniazid,Rifampicin and Pyrazinamide for 1 mouth.Follow up of the children was done on ambulatorybasis every 6 months.There were no significant differences inthe development of active disease in relationto age, sex and socio-economic conditions.In group A, 17 of 85 (20%) children developedactive disease while 10 of 82 (12.2%) inGroup B, 9 of 83 (10.8%) in Group C, 4 of 85(4.7%) in Group D and none of the Group Echildren developed active tuberculosis.IntroductionThere is no country free from tuberculosis :some have controlled it to a manageable limit,while in our country it is still a foremost killerdisease, even three decades after theimplementation of an “effective” NationalTuberculosis Control Programme. This couldindicate that the main tools of the controlprogramme are not sufficient to remove thisdisease as a major health problem and somethingmore needs to be done.Since we are armed with very potent antituberculosisdrugs that can destroy tuberclebacilli, both in their intra and extracellularhabitats, in acidic and alkaline environment, andin all the phases of their life cycle viz, activelymultiplying, slowly multiplying and dormant(persisters), it was planned to evaluate the efficacyof these drugs, in different combinations, inpreventing the development of active tuberculosisamong the high risk tuberculin positive children ofknown cases being treated in the department ofTB & Chest Diseases, L.L.R.M. Medical College,Meerut..Material and MethodsDuring the year 1983, children (in the agerange of 5-15 years) of the tuberculosis patientsbeing treated in our department were tuberculintested with 1 TU PPD RT 23 with Tween 80.Reading was taken after 72 hours and thosehaving an induration of 10 mm size and abovewere considered tuberculin positive and formedthe material of this study.There were 215 male and 200 female children;205 in the age range of 5-10 years and 210between 11-15 years old (Tables 1, 2). Childrenwith BCG scar, lymphadenopathy and prolongedrespiratory problems were excluded.The selected children were randomized intofive groups and given chemoprophylaxis asdetailed in Table 3.Group A : 85 children- They were not given anychemoprophylaxis in order to serve as“controls”.Group B: 82 children- They were prescribedIsoniazid alone in a daily single doseof 15 mg/kg body weight/day to amaximum of 300 mg daily, for aperiod of 3 months.Group C: 83 children- They were put onRifampicin 10 mg/kg body weight/day* Paper presented at the 47th National Conference on Tuberculosis and Chest Diseases, Bombay : 26th to 28thNovember, 19921. Associate Professor; 2. Assistant ProfessorDepartment of Tuberculosis & Chest Diseases, L.L.R.M. Medical College, Meerut-250 004Correspondence: Dr D.K. Gupta, Department of Tuberculosis and Chest Disease, L.L.R.M. Medical College,Meerut 250 004

126D.K.GUPTA ET ALTable 1 Age and sex distribution of total childrenAge(years)Male Percent Female Percent Total Percent5-10 105 25.5 100 24.0 205 49.511-15 110 26.5 100 24.0 210 50.5Total 215 52.00 200 48.00 415 100.00Table 2 Age and sex distribution of children in each groupAge(years)Group A(85)Group B(82)Group C(83)Group D(85)Group E(80)Total(415)M F M F M F M F M F5-10 22 20 20 20 22 19 20 22 22 18 20511-15 24 19 22 20 20 22 23 20 20 20 215Total 46 39 42 40 42 41 43 42 42 38 415plus Isoniazid as for Group B, bothgiven together in a single dose, for onemonth.Group D: 85 children- They received the samedrugs as Group C, but for 3 months.Group E : 80 children- They received Isoniazidand Rifampicin as Group C plusPyrazinamide 30 mg/kg body weight/day, all given in a single dose for onemonth.All the drugs were provided free from diehospital. The patients were advised to bring theirchildren every 6 months for a check up. However,there was considerable irregularity and defaults inTable 3 Chemoprophylaxis regimens given to childrenin different groupsGroup No. ofchildrenChemoprophylacticregimenA 85 NoneDurationB 82 H 3 monthsC 83 H + R 1 monthD 85 H + R 3 monthsE 80 H+ R + Z 1 monthH = Isoniazid; R = Rifampicin; Z = Pyrazinamidedrug intake. The results are analysed, after 8 yearsof follow up, with given irregularities in drugintake and follow up, presuming these affected thegroups equally.ResultsSince there are no significant differences in thedevelopment of active disease in relation to age,sex and socio-economic status of these children,the results have been analysed only in relation tothe efficacy of different chemoprophylacticregimes in preventing the emergence of activetuberculous disease.In Group A, which served as control, 17 of 85(20%) children developed active disease requiringTable 4 Development of active tuberculosis indifferent groupsGroup Total Children Percent p ValuedevelopingtuberculosisA 85 17 20.0 (Control)B 82 10 12.2 >0.05C 83 9 10.8 >0.05D 85 4 4.7

CHEMOPROPHYLAXIS IN HIGH RISK CHILDREN127Type of activeTable 5 Types of active tuberculosis according to different groups of childrenGroupstuberculosis A B C D ELymphadenopathy (LA)(alone or with matting)5 4 4 2 15Primary pulmonary complex (PPC) 6 2 3 2 13LA and PPC 3 2 1 6Progressive primary tuberculosis 2 1 - 3Pleural effusion 1 1 - 2Total(415)Miliary/meninigitis11Total 17 10treatment. In other groups receivingchemoprophylaxis, breakdown of infection intodisease was on the lower side, viz, 10 of 82(12.2%) children in Group B; 9 of 83 (10.8%)children in Group C and 4 of 85 (4.7%) children inGroup D. However, none of the Group E childrendeveloped any kind of tuberculosis during thisperiod (Table 4). Table 5 shows the type of activetuberculous disease encountered in the differentgroups. Lymphadenopathy (with matting ofcervical or axillary glands), primary pulmonarycomplex or a combination of the two were thecommonest modes of presentation. Progressiveprimary tuberculosis, pleural effusion or acutetuberculous conditions like miliary tuberculosisand tuberculous meningitis were observed rarely.DiscussionIt has been shown by Deshmukh et al that INHchemoprophylaxis,for a year, of asymptomatictuberculin positive children reduces the incidenceof active disease to about l/5th of what it would'have been otherwise.In our study, 17 of 85 (20%) children who werenot given chemoprophylaxis developed activedisease during a period of eight years, but among9 4 040those who received chemoprophylaxis, there hadbeen a relative decline in the incidence in relationto chemoprophylactic regimes used. Thisdifference, in the reduction of development ofactive disease in Group D children whoreceived INH and Rifampicin for 3 months isstatistically significant (p < 0.01) and in GroupE children who received INH + Rifampicin +PZA, it is highly significant (p < 0.001).ConclusionThe results of this study are veryencouraging. If authenticated by a large,multicentric study, employing differentchemoprophylactic regimes and durations, themost effective drug combination for theshortest duration of chemoproplylaxis can befound and incorporated into the NationalTuberculosis Control Programme.Reference1. Deshmukh, M.D., Master, T.B., Wagle, M.M.and Laxmi Krishnan : In Textbook ofTuberculosis, edit : K.N. Rao 2nd ed., 1981,Tuberculosis Association of India, New Delhi.

Original ArticleInd. J. Tub., 1993, 40, 129EVALUATION OF PERFORMANCE OF NATIONAL TUBERCULOSISPROGRAMME DURING VII PLAN*V.V. Krishna Murthy 1Summary : Performance of the NationalTuberculosis Programme (NTP) during theVII Five Year Plan was evaluated. Quarterlyand Annual reports for 10 years (1980-90) ofvarious States received at the National TuberculosisInstitute, Bangalore and some publicationsof the Ministry of Health & Family Welfarewere used for this evaluation. A budgetof Rs. 600 million was allocated to the NTPfor the VII Plan. The analysis revealed a substantialincrease in the number of sputum examinationsand new cases diagnosed comparedwith the VI Plan period; the number ofcases diagnosed, however, was not commensuratewith the number of exami nations performed;contribution of PHIs to case-findingactivity had increased; an improvement wasobserved in the pattern of drug collection bypatients on standard chemotherapy regimenand in programme efficiency; compared withquarterly reports the submission of annualreports was not satisfactory. Actual expenditureon NTP during the VII Plan was Rs. 1174million (excluding over-head costs). The estimatedcost of diagnosis of a sputum positivecase in Peripheral Health Institutions wasRs. 33.10 and at District Tuberculosis CentreRs. 90.00.IntroductionThe National Tuberculosis Programme (NTP)was launched in the year 1962 During 1975, onbehalf of the Ministry of Health & Family Welfare,an expert committee constituted by the IndianCouncil of Medical Research (ICMR) reviewedthe aims, objectives, implementation andperformance of the NTP through analysis of periodicreports and field visits. The committee foundthe conceptual and structural foundations of theprogramme to be basically sound and recom-mended a number of measures for improving itsoperational effectiveness.A team of experts of the Swedish InternationalDevelopment Agency (SIDA) evaluated the NTPduring 1979, and again followed it up in 1985.In the year 1988, the Institute of Communications,Operation Research & Community Involvement,Bangalore, an independent agency, conductedan in-depth evaluation of NTP and madeseveral recommendations.NTP was included in the 20 Point Programmeof the Government during the year 1983.Since the VII Five Year Plan has just concluded,a desk evaluation of the performance ofNTP for the said period is attempted. The performancein respect of implementation, case-finding,treatment, reporting, and the cost aspect ofthe programme activities has been evaluated and,wherever possible, compared will) the performanceduring the VI Plan.The NTP is about 30 years old and its conceptas well as outline of the activities have been documentedin considerable detail 1 . In brief, the operationalobjectives are to detect tuberculosiscases from the out-patients of the general healthinstitutions and treat them. Sputum and X-ray examinationsare the diagnostic tools and duration oftreatment is either 12-18 months (Standard Regimen- SR) or 6/8 months (Short Course Chemotherapy- SCC).The basic organisational unit of NTP is the DistrictTuberculosis Programme (DTP) which consistsof a District Tuberculosis Centre (DTC) usuallysituated at the district headquarters and PeripheralHealth Institutions (PHI), mostly PrimaryHealth Centres (PHC), located in rural areas. Tuberculosiscase-finding and treatment activitiesare integrated with General Health Services(GHS).* Paper presented at 47th National Conference on Tuberculosis and Chest Diseases, Bombay : 26th to 28thNovember, 19921. Statistical Assistant, National Tuberculosis Institute, BangaloreCorrespondence: Director, National Tuberculosis Institute, 8, Bellary Road, Bangalore-560 003

130V.V. KRISHNA MURTHYWorldTable 1 Government health expenditure in relation to total expenditure in different countries in 1985*IndustrializedcountriesDeveloping countriesAfrica Asia India Pakistan Sri Lanka10.38 12.28 7.93 3.14 2.16 1.00 3.77*Source : Health Information India - 1989MethodPeriodicity of reporting under NTP ismonthly, quarterly and. annually, of which thequarterly and annual reports are also received atthe National Tuberculosis Institute.The quarterly and annual reports of NTP receivedfrom various States, for the 10 years of theVI and VII Plans (1980-85) & (1985-1990), at theNational Tuberculosis Institute (NTI), Bangaloreand various publications of the Ministry of Health& Family Welfare, viz., Health Information India,Performance Budget etc., have been used in thisevaluation.Findings and InferencesBudget allocationsThe total financial outlay of the VII Five YearPlan (1985-90) was Rs. 1,800,000 million. The“health services” were allocated 3.7%(Rs. 67,000 million) of the plan outlay, as comparedto about 3% in the previous six five yearplans. The percentages of government health expenditureto total expenditure in different countriesin 1985 is given in Table 1. The percentageof health expenditure to total expenditure in India(2.16%) was one quarter of that in African countries(7.93%) and one sixth of that in industrializedcountries (12.28%).The budget allocated to health services in Indiawas shared almost equally by the Family Welfare(Rs. 33,000 million) programme, various nationalhealth programmes like National TB Programme,National Malaria Eradication Programme, NationalLeprosy Eradication Programme etc., andthe general health care services (Rs. 34,000 million).For the VII Five Year Plan, Rs. 600 millionwas allocated to NTP. A comparison of the proportionsof health budget allocated to the threecontemporary national health programmes and theper capita expenditure (under plan) on varioushealth services, is given in Table 2.It is seen from Table 2 that the allocation of1.7% of the health budget for tuberculosis programmewas the least of the three programmes.Programme ImplementationImplementation of NTP in various districts hasbeen a continuous process since 1962. The progressin tliis regard, over the VI and VII plan periods,is given in Table 3.Table 2 Budget allocation for various health schemes and per capita expenditure during VII PlanFamilywelfareHealthcareMalaria Leprosy Tuberculosis1 2 3 4 5 6Budget allocation (%)Per capita expenditure (Rs.)1985-861986-871.86.307.191.97.638.2212.61.121.012.40.180.181.70.150.15Total plan outlayBudget allocations: Rs. 1,800,000-million: Cols. 2 & 3 : % to plan outlayCols. 4 - 6 : % to Col. 3

EVALUATION OF PERFORMANCE OF NTP131Table 3 Implementation of DTPs during VI & VII Plan periodsYearNo. ofdistrictsNo. ofDTPsPercentNo. ofrural healthImplementedPHIsPercentinstitutions1980 420 320 76 22,333 10,240 461985 420 364 87 25,000 12,810 511990 438 378 86 28,300 15,270 54At the beginning of the VI Plan (1980), NTPhad been implemented in 76% of the districts and46% of the rural health institutions in the country.During the VI Plan, NTP was implemented in 44more districts and 2,570 rural health institutions(RHI) as compared to 14 districts and 2,460 RHIsin the VII Plan. At the end of the VII Plan, 86% ofthe urban community and 54% of the rural communitywere provided with the tuberculosis servicesunder NTP.During the VII Plan, SCC was introduced(1986-87), in a phased manner. At the end of VIIPlan, about 50% of the districts in the countrywere providing SCC, though not uniformly.ReportingThe NTP activities are reported monthly to theDistrict and State levels, quarterly and annually toState and National levels. Copies of quarterly andannual reports are received at the NTI for monitoringpurpose. During 1990, 76% of the expectedquarterly reports were received at NTI, a majorityof which were considered satisfactory for monitoringanalysis. Hence, the reporting efficiency was73%. However, only 27% of the expected numberof annual reports were received of which only2/3rds were worthy of further consideration, reducingthe reporting efficiency to 17%. It is to bementioned here that in the annual report, result ofcohort analysis is made available in addition to thecase-finding activity which occurs also in thequarterly report. The efficiency of the quarterlyreport being 73%, the low efficiency of the annualreport is due to the unsatisfactory reporting oftreatment activity which in turn depends on the receiptof treatment cards from PHIs and correctnessand legibility of the entries on treatment cards.The rectification of these weaknesses may improvethe efficiency of the annual report.Targets and Achievements During the VII FiveYear PlanSince inclusion of NTP in the 20 Point Programmeduring 1983, the Ministry of Health andFamily Welfare has been fixing annual targets forcase-finding and treatment activities of NTP. Thetargets fixed for the VII Five Year Plan period andrelated achievements are shown in Table 4.A target of 17 million sputum examinations tobe done in PHCs was fixed and 11.65 million sputumexaminations were performed, reaching 68%of the target. Similarly, a target of 1.4 million newcases was fixed for the first year of the VII Plan(1985-86) and gradually increased to 1.6 millionTable 4 Targets and achievements of NTP during VIIPlan periodActivityExamination of sputum(million)TargetAchievement(%)6817.0Detection of new tuberculosiscases (million) 7.45 102Percentage of cases detected 40 35-39to total estimated casesPercentage of disease arrested 65 Not availablecases out of those detectedSources : Performance Budget, Ministry of Health &F.W. and Health Information Indiafor the fifth year (1989-90) - amounting to an increaseof 14% corresponding to the budget increaseof 9% (not on Table). However, for the entireVII Plan, the target for the detection of newtuberculosis cases was 7.45 million against whicha total of 7.6 million cases was reached, attaining

132V.V. KRISHNA MURTHYActivity/InstitutionTable 5 Comparison of case-finding during VI & VII plan periodsVIDuring Plan(million)X-ray Examinations DTP 10.5 13.5 29VIIIncrease%Sputum Examinations DTP 11.0 20.8 89DTCPHI5.06.06.014.820147Sputum positive DTP 1.1 1.5 32cases DTCPHI0.60.50.70.71162Sputum negative cases 3.2 4.8 50Contribution of PHIs (%)Sputum examinations 54 71 31Sputum cases 41 50 22102% of the target.The target for the case-finding efficiency(% total estimated cases detected) was fixed at40% which was more or less achieved.Case-finding activityDiagnostic examinationsDuring the VII Plan, a total of 17 million X-rayexaminations and 24 million sputum examinationswere done (not shown on Table). Of these, 79% ofX-ray examinations and 87% of sputum examinationswere done for the new out-patients at theDTC and PHIs. In respect of new X-ray and sputumexaminations, done during VII Plan, an increaseof 29% and 89% respectively was observedover the VI Plan period (Table 5). The increaseobserved in the number of sputum examinationswas mostly contributed by the PHIs (147%).During the first year of the VI Plan (1980-81),PHIs had done 0-54 million new sputum examinationswhich increased by 307% (to 2.2 million)during the fifth year of the plan, compared to anincrease of 11% in DTCs (not shown on theTable). The increase in the output of PHIs may bedue to the inclusion of NTP in the 20 Point Programmein 1983. However, the corresponding increasesduring the VII Plan were 10% and 14% respectively.Sputum positive casesDuring the VII Plan period, 1.45 million spu-tum positive cases and 4.8 million sputum negativecases were diagnosed, showing an increase of32% and 50% respectively over the VI Plan period.PHIs had diagnosed 62% more sputum positivecases in the VII Plai> period over the VI Planas compared to 11% in DTCs, indicating that thecase-finding activity in DTCs might have almostreached the optimum efficiency.Contribution of PHIs in case-findingDuring the VI Plan period, 54% of total sputumexaminations and 41% of the total cases diagnosedwere contributed by PHIs as compared to71% and 50% respectively during the VII Planperiod (Table 5). Considering that PHIs are expectedto contribute around 80% to the case-findingactivity, 71% contribution in sputum examinationsand 50% in the total cases found is encouraging.The trend in the contribution of PHIs in yearlycase-finding activities in relation to the total performanceover the decade is shown in Fig. 1. Theincreased contribution from PHIs during the VIPlan period was conspicuous but marginal duringthe VII Plan period.Sputum positivity rate at different timesThe question whether the number of cases diagnosedremained commensurate with the sputumexaminations done is examined in Table 6 since itwould reflect the quality of sputum examination.

EVALUATION OF PERFORMANCE OF NTP 133Fig. 1 Percent contribution of PHIs in case-finding (1980-1990)SP. Exam = Sputa examined, SP. Patients = Sputum positive patientsFor comparison, the case rates amongsputum examinations done in PHIs and DTCs atthe end of V, VI & VII Plan are shown. The caserates, in PHIs at the end of the VI Plan (5.2%) andVII Plan (5.1%) periods were one half of that atthe end of the V Plan period (11.1%). The abovevariation was marginal in DTCs (12.7% to11.4%).During 1980, the average number of sputumexaminations done in PHIs was 1700, and the caserate 11.1%. During 1985, the average number ofexaminations had increased fourfold (6900) andthe case rate reduced to one half (5.2%) and thesame trend, of decrease in the case rate with increasein the number of examinations, continuedduring 1985-90. May be, with the increase insputum examinations, the quality of selectionfor sputum examination got diluted to a greatextent. Consequently, the number of casesdiagnosed was not commensurate with the numberTable 6 Comparison of positivity rates according toinstitution doing sputum examination duringsuccessive Plan periodsInstitutionAt the end of PlanV VI VIIPHI 11.1 5.2 5.1DTC 12.7 12.3 11.4DTP 12.1 7.4 7.0of examinations done.Chest Symptomatics attending PHIs under-goingsputum examinationIn NTP, chest symptomatics (CS) attendingPHIs are eligible for sputum examination. It isexpected that consequent to the increase in sputumexaminations the proportion of CS attendingPHIs and sputum examined would increase. Thenumbers of CS in rural community and of them,those attending PHIs (11.1% and 24.1%respectively - Radha Narayan et al 2 ) were estimatedfor the years 1980, 1985 and 1990. Thenumber of CS attending PHIs and of them thosesputum examined are shown in Table 7.During 1980, 10% of the CS attending PHIswere examined by sputum; this proportion increasedto 47% during 1990. Despite this five foldTable 7 Proportion of chest symptomatics attendingPHIs who were sputum examinedYear CS attending Sputum PercentPHIs examined(estimated) in PHIs(millions)1980 5.4 0.5 101985 6.1 2.5 411990 6.8 3.2 47

134V.V. KRISHNA MURTHYTable 8 Pattern of drug Collection (standard regimen)Year Drug collection (%) Average no. of0* 1-3 4-7 8-11 12+ collections1985 5 41 19 13 26 71990 4 30 18 15 37 10*Initial defaultersincrease, nearly one half of the CS attending PHIswere not examined by sputum. An almost similarobservation has been made by Seetha et al 3 .Treatment activityThe annual report of NTP provides the patternof drug collection by a cohort of patients i.e. patientsdiagnosed during a specified period, eachone of them having an equal opportunity to completethe optimum period of 18 treatment months.On an average, about 50,000 patients could bethus observed for their treatment every year. Thepercentage of patients put on treatment making atleast 12 monthly collections in 18 months rangedfrom 26 in 1985 to 37 in 1990. The pattern of drugcollection by patients on SR, during the years1985 and 1990 is given in Table 8.A comparison of the pattern of drug collectionby patients starting treatment during 1985 and1990 reveals a shift to the right in drug collectionduring 1990, indicating improvement in drug collection.During 1985, 60% of the patients put ontreatment discontinued their treatment beforemaking their 8th collection, which got reduced to48% during 1990; during 1985, 26% of the patientsmade 12 collections or more compared to37% during 1990, showing a 42% increase. Theaverage number of drug collections per patientduring 1985 was 7 as compared to 10 during 1990,showing an increase of 43%.Material for carrying out a similar analysis oftreatment with SCC was insufficient.Efficiency of NTPCase-finding and treatment are the two mainactivities of NTP : the efficiency of the programmemainly depends on the efficiency of thesetwo activities.Case-finding efficiency is defined as the proportionof cases that could be diagnosed out of thepreviously undiagnosed sputum smear cases presentingthemselves for diagnosis.Treatment efficiency is defined as the proportionof cases converted to sputum negative statusat the end of the treatment period out of those puton treatment.Programme efficiency is, then, the proportionof cases estimated to become sputum negative outof the total diagnosable cases in the programme(product of case finding and treatment efficiencies).The above three parameters, at different pointsof time, are given in Table 9.YearTable 9 Case-finding, treatment and programmeefficiency of NTP at different timesEfficiencyCase-finding Treat-ment Programme1980 27 28 81985 36 26 91990 41 33 13Table 9 reveals that over a decade, about 50%increase in the case-finding efficiency & programmeefficiency, and a marginal increase in thetreatment efficiency have taken place.Estimated expenditure on diagnostic and treatmentactivities during the VII planDuring the VII Plan period, 41 million examinations(X-ray and sputum) were carried out and6.3 million tuberculosis cases were diagnosed.The financial requirement for the above two activitieshave been estimated to be Rs. 1174 million- 12% on diagnostic activity and 88% on treatment.

EVALUATION OF PERFORMANCE OF NTP135Table 10 Expenditure (estimated) on diagnostic and treatment activities in NTP during the VII PlanInstitutionX-rayExaminationsExpenditure (in million Rs.)*SmearExaminationsTotal Treatment GrandTotalDTC 79.1 8.0 87.1(60)PHI 41.3 15.7 57.0(40)DTP 120.4 23.7 144.1(100)(12)* Overhead cost not consideredPercentages within brackets525.3(51)504.7(49)1030.0(100)(88)612.4(52)561.7(48)1174.1(100)(100)Diagnostic activityDuring 1974, Naganathan et al 4 had estimatedthe cost of a smear examination to be Re. 0.54,and NTI had estimated the cost per X-ray examinationRs. 4.00 (not published). Considering thegeneral cost escalation, the cost of X-ray andsmear examinations now have been taken as Rs.7.00 and Re. 1.00 respectively. Based on the numberof X-ray and smear examinations done duringthe VII Plan period, an expenditure of Rs. 144.1million is estimated for diagnostic examinations(Table 10), 60% of which would be incurred atDTCs. This estimate is one and a half times thatincurred in PHIs, though the proportions of totaltuberculosis cases and sputum positive cases diagnosedin DTCs and PHIs were not different (Table5). Hence, the diagnosis of a case appears to costmore in DTC. Moreover, expenditure incurred onX-ray examinations, over the five year period, wasfive times that on sputum examinations.Treatment activityIn NTP, cases are treated either for 12-18months (SR) or for 6/8 months (SCC). SCC wasintroduced in a phased manner in about 200 of 378districts, by 1989-90. The expenditure to be incurredon treatment by SCC and SR was estimatedon the basis of the proportion of cases treated byeither regimen. The drug cost has been taken asRs. 125/- per patient on SR andRs. 7257- on SCC. It was estimated that an expenditureof Rs. 1030 million would be incurred fortreatment, shared equally by DTCs and PHIs; a totalexpenditure of Rs. 1174.1 million for the diag-HealthInstitutionExpenditure*(million)NewX-rayTable 11 Cost of diagnosing a case (during VII Plan)NewSputumCases diagnosed(million)SputumnegativeSputumpositiveCost of diagnosis(Rs.)SputumnegativeSputumpositiveDTC 58.8 6.0 2.6 0.7 24.92 90.00XC 35.7 5.2 2.2 0.4 18.59 92.95MC/RC 9.6 0.3 33.10NTP 94.5 20.8 4.8 1.4 24.02 79.52* Estimated cost of an examination : X-ray : Rs. 7.00, Sputum smear by microscopy : Re. 1.00. Overheadcosts not consideredXC = X-ray Centre; MC = Microscopy Centre; RC = Referring Centre

136nostic examinations done and treatment givenduring the VII Plan period. This estimate may beviewed against the budgetary allotment of Rs. 600million only for NTP during the said plan period.Cost of diagnosing a single caseUnder DTP, both X-ray and sputum examinationsare done for diagnosing cases (sputum positivesor negatives) in DTCs and X-ray Centres(XC), whereas in Microscopy Centres (MC) andReferring Centres (RC) only sputum examinationsare performed. Based on the number and types ofdiagnostic examinations done, the cost of diagnosinga case can be estimated. The estimated cost ofdiagnosing a sputum positive case and a sputumnegative case is presented in Table 11. 'It is observed that the cost of diagnosing a sputumpositive case in a DTC (Rs. 90.00) and XC(Rs. 92.95) is three times that incurred in a MC orRC (Rs. 33.10). The observation, that the cost ofdiagnosing a sputum negative case (X-ray case) isless than that of diagnosing a sputum positive caseshould not lead to the erroneous conclusion thatcase-finding by X-ray examination is cheaper. Itshould be borne in mind that cost estimates underprogramme conditions, wherein PHIs do manysputum examinations to find fewer cases andDTCs and XCs use both X-ray and sputum examinationand find more sputum negative cases, arebased on far more negative than sputum positivecases thereby reducing the cost of diagnosis of asputum negative case.Conclusions1. The targets for the VII Plan have been substantiallyachieved.2. There has been a substantial quantitativeincrease in sputum examinations doneand cases diagnosed, but the number diagnosedis not commensurate with the examinationsdone indicating that the qualityof selection for sputum examinationhad deteriorated. Nearly 50% of the chestsymptomatics attending PHIs were not referredfor sputum examination. Nevertheless,the contribution of PHIs to the casefindingactivity had increased, comingnearer to the expectations.3. Annual reporting was not satisfactory. AnV.V. KRISHNA MURTHYeffective and regular supervision and betterutilisation of trained personnel may improvedie quality of the annual reports.4. Though there has been an improvementin the pattern of drug collection, only37% of the patients put on SR made 12 ormore collections. Regular and adequatesupply of drugs to the PHIs may further improvethe drug collection pattern.5. There has been a substantial increase inthe programme efficiency.6. Nearly 80% of programme funds arespent on treatment after excluding establishmentcost.7. The cost of diagnosing a sputum positivecase in the programme was Rs. 79.52,calling for a more detailed analysis of costeffectiveness.AcknowledgementThe author is grateful to Dr B.T. Uke, Director,NTI, Dr A.K. Chakraborty, Addl. Director, Mr V.Murali Mohan Sr. Statistical Officer, Dr L. Suryanarayana,Chief Medical Officer, for their valuablesuggestions, colleagues of Statistical Sectionand Monitoring Section for statistical help, Mr C.Sathyanarayana & Mrs M.J. Jayalakshmi, StatisticalAssistants, Monitoring Section for informaldiscussion regarding functioning of NTP, Mr. B.R.Narayana Prasad for graphics, Mr P. Perumal andMiss T.J. Alamelu, for secretarial assistance.References1. Nagpaul, D.R. District Tuberculosis Control Programmein concept and outline : Ind. J. Tub.;1967,14, 186.2. Radha Narayan, Susy Thomas, Pramila KumariS, Prabhakar S, Ramprakash A.N., Suresh T &Srikantaramu N; Prevalence of chest symptomsand action taken by symptomatics in a rural community,Ind. J. Tub.; 1976 23, 160.3. Seetba M.A., Rupert Samuel G.E. and ParimalaN. Improvement in case-finding in district tuberculosisprogramme by examining additional sputumspecimens; Ind. J. Tub.; 1990, 37, 139.4. Naganathan N., Padmanabha Rao K, & RajalakshmiR.; The cost of operating and establishinga tuberculosis bacteriological laboratory; Ind. J.Tub.; 1974, 21, 181.

Original Article Ind. J. Tub., 1993, 40, 137WANING OF BCG SCAR AND ITS IMPLICATIONS*R. Channabasavaiah 1 , V. Murali Mohan 2 , H.V. Suryanarayana 3 , M.S. Krishna Murthy 4 ,and A.N. Shashidhara 5Summary : In all, 1095 children aged 0 to14 years were found with BCG scar in 119randomly selected villages of a south Indiandistrict during an epidemiological surveydone in 1961. Of the BCG scar* recorded atintake, 26.4% and 32.5% disappeared subsequentlyat three and a half and five year periodsrespectively. The disappearance of BCGscars was independent of the age of the childand the tuberculin sensitivity status at intake.Tuberculin sensitivity in children in whomscar had disappeared was the same as thatfound in children in whom scar had persisted,at intake and after five years. The misclussificationof children, in whom scars have disappeared,as unvaccinated leads to a difficultyin interpreting the results of tuberculin testdone for the purpose of computation of theAnnual Risk of Infection. Further, the extentof misclassiflcation increases in proportion tothe increase in BCG coverage of the population.This finding justifies the practice ofidentifying the demarcation level for classifyingthe infected persons in a population on thebasis of the distribution of tuberculin indurationsizes in each survey.IntroductionBCG vaccination is the only method of inducingspecific immunity against tuberculosis. Its extensiveuse in India began in early 1950's underthe mass BCG campaign. It was later included inthe Expanded Programme of Immunisation (EPI)and is currently restricted to infants, under theUniversal Immunisation Programme (UIP).The site of BCG vaccination is the shoulder(conventionally, left shoulder) of a person where atiny scar is formed 10 to 12 weeks after vaccination.Thus, if one wants to know whether a personhas been BCG vaccinated or not, the scar serves asa guide. Examination of both the shoulders forpresence of BCG scar or obtaining history of BCGvaccination is done for this purpose.Tuberculin test is done to get information aboutprevalence or incidence of tuberculosis infectionin a given population. The information is used toestimate the Annual Risk of Infection (ARI) forfinding the current epidemiological situation inthe community 1 . However, in most developingcountries covered extensively with BCG, the tuberculintest faces problems in identifying the infectedpersons from the uninfected. Therefore, resultsof tuberculin test in persons who do not showa BCG scar are usually relied upon. The NationalTuberculosis Institute (NTI) followed this procedurein its longitudinal study 2 ' 3 and in the two surveyscarried out in Tumkur district 4 ' 5 . It still hadproblems of interpretation of test results in separatingthe infected persons from the uninfectedfrom one survey to another. The problem wassought to be overcome by deciding to shift the demarcationline from survey to survey, based on thedistributions among “no scar” population 3 ' 5 .Recently, it has been postulated that BCG scardisappears in a good number of children 6 . Some ofthe scarless BCG vaccinated children may get includedin the non-vaccinated group, and cause difficultyin interpreting the results of tuberculin test.Thus, the error in interpretation, owing to the misclassificationof this nature, increases with the increasein the proportion of BCG vaccinated subjectsin a population, and justifies the use of demarcationlevels identified on the basis of distributionsof indurations from survey to survey 6 . Further,it is likely that the proportion of vaccinatedbut scarless children in a community is age dependent.This information is useful while selectingan appropriate age group for carrying out sur-* Paper presented at the 47th National Conference on Tuberculosis and Chest Diseases, Bombay: 26th to 28thNovember, 19921. Statistical Assistant; 2. Senior Statistical Officer; 3. TB Specialist; 4. Team Leader; 5. Investigator, NationalTuberculosis Institute, BangaloreCorrespondence: Director, National Tuberculosis Institute, 8, Bellary Road, Bangalore-560 003

138R. CHANNABASAVAIAH ETALveillance, through the study of ARI, since the latteris to be studied among unvaccinated children.The computation of ARI and interpretation of thetuberculosis situation would, consequently, dependon this information.This presentation analyses the information onBCG scar status in the younger population of a ruralcommunity in three taluks of Bangalore District.The following aspects were sought to bestudied:(a) Whether disappearance of BCG scar is dependenton(i) age of child,(ii) size of post vaccination tuberculin indurationat initial survey;(b) the tuberculin sensitivity status, at initial andlater survey, of children in whom BCG scarshad disappeared compared with children inwhom the scars had not disappeared.Area and PopulationThe data utilized in this report pertain to thechildren registered in 119 randomly selected villagesof three taluks in Bangalore district coveredby the longitudinal epidemiological study during1961 to 1968 2 . The information on presence or absenceof BCG scar was recorded on individualcards. The population under study was not beingcovered by the regular mass BCG campaign, fromJuly 1961 onwards, as it was got excluded by aspecial request to facilitate the longitudinal study.However, since population movement was notcontrolled, children from the study area could getvaccinated elsewhere. It is important to note thatpost BCG vaccination effects, such as scar formationand vaccine induced tuberculin sensitivitywere noted according to operational proceduresadopted by the state mass BCG teams.MethodsThe population was surveyed four times, from1961 to 1968 with an interval of one and a halfyears between I and II, II and III surveys, and twoyears between III and IV surveys.At survey I, a complete census of the populationin each village was taken by making houseto-housevisits. Data on each person were recordedon individual cards. At each subsequentsurvey, the persons registered earlier were identifiedand classified according to their present residentialstatus. New cards were prepared for thenewboms and immigrants. The procedure for registrationat each survey was the same except thatnew cards were prepared at survey IV, giving onlyidentification particulars of the persons registeredbefore the IV survey.All the registered persons were examined ineach survey, at a place centrally located in eachvillage. Both the shoulders were examined by thetuberculin tester for presence (definite or doubtful)or absence of BCG scar.MaterialThe following two groups of children aged 0-14 years are studied in this paper.(a) 796 children who had BCG scar at I surveyTable 1 Children with BCG scar at I survey and their scar status at IV surveyNumber atScar- status at IV surveyAgeI survey withamong children in col. 2(years) BCG scar*PresentDoubtfulAbsent(1)(2)(3) (4)(5)0-4 101 (100) 41 (40.6) 12 (11-9) 48 (47.5)5-9 376 (100) 218 (58.0) 40 (10.6) 118 (31.4)10-14 319 (100) 178 (55.8) 48 (15.0) 93 (29.2)0-14 796 (100) 437 (54.9) 100 (12.6) 259 (32.5)Figures in brackets are percentages* Only those followed up at IV survey are included

WANING OF BCG SCARS AND ITS IMPLICATIONS139Table 2 Children without BCG scar at I survey found with BCG scar at II survey and their scar status at IV surveyAge (years)Number with BCGscar at II surveybut not at I surveyScar status at IV surveyamong children in col 2Present Doubtful Absent(1) (2) (3) (4) (5)0-4 32 (100) 19 (59.4) 5 (15.6) 8 (25.0)5-9 162 (100) 105 (64.8) 14 (8.6) 43 (26.5)10-14 105 (100) 63 (60.0) 14 (13.3) 28 (26.7)0-14 299 (100) 187 (62.5) 33 (11.0) 79 (26.4)Figures in brackets are percentages* Only those followed up at IVth survey are included(time of vaccination not known) and whoseBCG scar status was available at IV survey,(b) 299 children who showed no BCG scar at Isurvey but were found with BCG scar at IIsurvey and whose BCG scar status was availableat IV survey.Findings and Inference(a) Disappearance of BCG scar related to age ofchildOnly a small proportion (4.8% not on Table) ofdie examined children in 0-14 years age groupwere found with BCG scar at I survey because NationalTuberculosis Programme was not implemented,by then, in the study area. From Tables 1and 2, the extent of disappearance of BCG scar atIV survey in those found with scar at I (Table 1)and II (Table 2) surveys is shown in column 5.Considering both the Tables, in the age group 0-14 years, 32.5% scars disappeared during a 5 yearperiod (Table 1) and 26.4% during three and halfyear period (Table 2). There is no significant differencein the disappearance of BCG scars betweenthe 5-9 and 10-14 years old children (Table1) perhaps because the time elapsed after BCG administrationis the same for both these age groups.However, the rate of disappearance of BCG scarin both these age groups differed from that in the0-4 years old children (Table 1) but there is no differenceamong the three age groups (Table 2) insuggesting that the time elapsed since BCG waslast administered had become the same, that is, anaverage of 9 months for all the three age groups.A study of the children in all the three agegroups in Table 2 would suggest that disappearanceof BCG scar in a good number of childrenwas independent of their age. In Appendix Tables1 and 2 this aspect was studied. Here, childrenwithout BCG scar at I survey were analysed accordingto their age at I survey, allowing same averageperiod elapsed since BCG was last administered,that is 9 months for children in AppendixTable 1 and 18 months for children in AppendixTable 2. Those children with BCG scar found at IIsurvey (Appendix Table 1) and at III survey (AppendixTable 2) were examined for scar at IV survey.In both the Tables, the disappearance of BCGscars (column 5) in a good number of children isindependent of age. It could, therefore be inferredthat the disappearance of BCG scar is independentof age of children.(b) Disappearance of BCG scar in relation topost vaccination sensitivityTable 3 gives the distribution of tuberculin indurationsto the standard tuberculin test (1TU RT23 with Tween 80) given to children with BCGscar at I survey with respect to the disappearanceof the BCG scar at IV survey, under each agegroup.In each age group, disappearance of BCG scaris independent of tuberculin induration size (x 2test results show no significance).(c) Tuberculin sensitivity at initial and later surveyof children with disappeared scar and inwhom scar persistedTable 4 gives tuberculin test results for twogroups of children at two points of time, namely I

140R. CHANNABASAVAIAH ETALFig. 1A Distribution of differences in the size of tuberculin reactions between I and IV surveys (3 point movingaverages) (age : 0-4 years at I survey)Fig. 1C Distribution of differences in the size of tuberculin reactions between I and IV surveys (3 point movingaverages) (age : 10-14 years at I survey)

WANING OF BCG SCARS AND ITS IMPLICATIONS141Table 3 Children with BCG scar at I survey by age groups and post vaccination induration to 1 TU with their scarstatus at TV surveyPostvaccinationinduration atI survey(mms)Age at I survey (in years)0-4 5-9 10-14Present(definiteor doubtful)BCG scar status at IV surveyAbsent Present Absent(definiteor doubtful)Present(definite(or doubtful)0-1 21 15 47 26 27 132-3 7 9 60 33 32 124-5 12 9 61 24 32 166-7 3 7 30 15 28 148-9 2 1 19 3 28 810-11 2 2 6 6 19 712-13 - - 6 2 17 314-15 2 2 9 2 9 616-17 2 - 5 - 9 218-19 1 - 4 3 1 420+ - 1 73 15 7Total 52 46 254 117 217 92and IV surveys. Group 1 comprises children withBCG scar at I and IV surveys and group 2 thosewho had BCG scar at I survey but whose scar haddisappeared at IV survey.At I survey, for each age group, there is no significantdifference in the mean size of reactionsbetween the two groups. Similar is the observationat IV survey. Again at I survey, the percentages ofreactors to the tuberculin test at levels 10 +, 14+and 18+ mm of induration, in each age group, betweenthe two groups of children are not differentand similar is the observation at IV survey.From this, it is inferred that response to the tuberculintest is the same in children in whom theBCG scar disappeared compared with children inwhom BCG scar did not disappear.Again, from figures 1A, IB, and 1C, it can beobserved that there is no significant difference betweenthe distribution of differences in the size oftuberculin induration of IV survey minus I surveyamong the two groups of children.DiscussionFor the surveillance of tuberculosis in a popula-Absenttion through the study of ARI, the result of tuberculintests done in, unvaccinated population areconsidered necessary. Where records of vaccinationare not maintained/available, the vaccinatedsubjects are identified by the presence of the postvaccinial scar. Disappearance of BCG scars makesit difficult to correctly identify the unvaccinatedpersons.The Tuberculosis Prevention Trial showed thatabout 2% of the persons vaccinated with a strongdose and 13% with a weak dose of the vaccinewere without scar at the end of two and a halfyears'. However, in that BCG trial, the BCG vaccinationprocedures were strictly controlled unlikein the study from which the present material isderived. Other studies 8 ' 9 - 10 based on records onlyhad shown the following proportions of disappearanceof BCG scar: among Asian children residingin UK, scars in 25% of those vaccinated at birthhad disappeared at 22 months; among northernCanadian Indians aged 1 to 15 years, in 17% followingBCG vaccination at birth and in Finland,among vaccinated children aged 11 to 13 years, in15.4%. Data from northern Malawi indicate that

142R. CHANNABASAVAIAH ET.ALTable 4 Mean size of reaction and reactors (%) at different levels at I and IV surveys for two groups of children byage at I surveyAgeat IsurveyChildren with BCG scar at I surveyIV survey - scar foundIV survey - scar disappearedGroup 1 Group 2Number Mean Number of Mean Number ofsize reators Number size reactorsof reaction (%) at levels of reaction (%) at levels(S.D.) 10+ 14+ 18+ (S.D.) 10+ 14+ 18+1 2 3 4 5 6 7 8 9 10 11I survey I0-4TU reacti40ions4.15(4.50)5(12.5)3(7.5)- 47 4.15(4.89)5(10.6)5-9 205 5.28 28 18 8 116 4.74 16 8 610-14 155 (5.21) (13.7) (8.8) (3.9) 85 (4.98) (13.8) (6.9) (5.2)7.44 47 20 98.13 27 18 110-14 400 (5.99) (30.3) (12.9) (5.8) 248 (7.01) (31.8) (21.2) (12.9)6.04 80 41 175.79 48 29 18(5.65) (20.0) (10.2) (4.2)(5.97) (19.4) (11.7) (7.3)IV survey I TU reai ctions0-4 40 4.55 44 3474.45 6 4 3(5.92) (10.0) (10.0) (7-5) (5.73) (12.8) (8.5) (6.4)5-9 205 5.94 39 32 18 116 6.31 24 17 15(6.30) (19-0) (15.6) (8.8) (7.61) (20.7) (14.7) (12.9)10-14 155 8.25 53 33 16 85 9.20 31 20 15(6.65) (34.2) (21.3) (10.3) (7.55) (36.5) (23.5) (17.6)0-14 400 6.70 96 69 37 248 6.95 61 41 33(6.52) (24.0) (17.2) (9.2) (7.46) (24.6) (16.5) (13.3)among children vaccinated any time during 0 to14 months after birth, 46% of scars had disappearedat 25+ months after vaccination” from anearlier high level of 95% between 7 and 12months.It becomes logical, therefore, to infer that followingBCG vaccination scar formation may nottake place at all in a proportion of children and,even if it does, the scar may disappear with timein some, due to multiplicity of factors. Due to thefact that accurate vaccination records may not bereadily available, field workers may still have todepend on examination of shoulders for scar fromBCG vaccination given at a prior date.The present study deals with BCG scars observedin a longitudinal epidemiological study in arural population in south India. A proportion ofscars vanished resulting in the classification of3(6.4)1(2.1)some BCG vaccinated persons without scaramong the unvaccinated. This proportion was relatedto the proportion of BCG vaccinated childrenin the community (BCG coverage). This reportexamines whether the disappearance of scarwas age related and in what specific age groupwere scars more stable, if at all, because thesecould be tuberculin tested for the computation ofARI. A sizeable proportion of BCG scars werefound to have disappeared in all the age groupsstudied, without a trend with the rise in age. Noparticular age group could be identified inwhich scars were relatively stable. Post-vaccinationtuberculin sensitivity was also not relatedto the disappearance of scars. In fact,tuberculin sensitivity in BCG vaccinated childrenwithout scars was similar to that found in childrenin whom BCG scars persisted. Therefore, the

WANING OF BCG SCARS AND ITS IMPLICATIONS143inclusion of BCG vaccinated children without scaramong the unvaccinated amounts to includingsome children with scar among the unvaccinatedwhen investigating tuberculin sensitivity in apopulation.It is essential to meticulously separate outthe unvaccinated from the vaccinated children(with or without scars) when tuberculin tetingfor computation of the ARI. Since age of thesubjects does not help, the objective could bestbe achieved either from cards maintained byUIP or by meticulous history taking, whichcould be operationally difficult to achieve.Hence it would be desirable to keep an openmind on the question of the induration size toidentify the infected subjects after tuberculintest. Under the circumstances, the answerseems to lie in arriving at the demarcation linebetween the infected and uninfected subjectsfrom the distribution of tuberculin reactionsonly, separately at each survey.AcknowledgementThe authors are very grateful to Dr. B.T. Uke,Director, NTI, for his whole hearted support andDr. A.K. Chakraborty, Additional Director, NTI,for his guidance. We thank members of the TechnicalCo-ordination Committee for their valuablecomments, specially to Dr. (Mrs) Sophia Vijayand Dr. L. Suryanarayana. We also thankMr. Mether. M. Islam for statistical assistance;Mr. B.R. Narayana Prasad for drawings; Mr. T.C.Manjunath for secretarial assistance.Appendix Table 1 Children without BCG scar at I survey found with BCG scar at II survey with their scar statusat IV surveyAge atI survey(years)Numberwith BCG scarat II survey*BCG scar status at IV survey amongchildren in col 2Present Doubtful Absent1 2 3 4 50-4 84 (100) 49 (58.3) 11 (13.1) 24 (28.6)5-9 150 (100) 104 (69.3) 11 (7.1) 35 (23.3)10-14 84 (100) 46 (54.8) 13 (15.5) 25 (29.8)0-14 318 (100) 199 (62.6) 35 (11.0) 84 (26.4)Figures in brackets are percentages.* Only those followed up at IV survey are includedAppendix Table 2 Children without BCG scar at I survey found with BCG scar at III survey with their scar statusat IV surveyAge atI survey(years)1Numberwith BCG scarat III survey*BCG scar status at IV survey amongchildren in col 22 Present Doubtful3 4Absent50-4 95 (100) 58 (61.0) 15 (15.8) 22 (23.2)5-9 167 (100) 110 (65.9) 10 (6.0) 47 (28.1)10-14 100 (100) 55 (55.0) 12 (12.0) 33 (33.0)0-14 362 (100) 223 (61.6) 37 (10.2) 102 (28.2)Figures in brackets are percentages* Only those followed up at IV survey are included

144R. CHANNABASAVAIAH ETALReferences1. Chakraborty A.K., Chaudhrui K., SrinivasT.R., Krishna Murthy M.S., Shashidhara A.N.and Channabasavaiab R. : Tuberculosis infectionin a rural population of south India :23-year trend, Tubercle and Lung Disease; 1992,73,213.2. National Tuberculosis Institute, Bangalore: Tuberculosisin a rural population of south India : Afive year epidemiological study, Bull. Wld. Hlth.Org.; 1974, 51,473.3. Chakraborty A.K., Singh H., Srikantan K., RangaswamyK.R., Krishna Murthy M.S. andSteaphen J.A.: Tuberculosis in a rural populationof south India: Report on five surveys, Ind. J. Tuber.;1982, 29,153.4. Raj Narain, Geser A., Jambunathan M.V. andSubramanian M: Tuberculosis prevalence surveyin a south Indian district, Ind. J. Tuber.; 1963, 9,85.5. Gothi G.D., Chakraborty A.K., Nair S.S., GanapathyK.T. and Banerjee G.C. : Prevalence of tuberculosisin a south Indian district - twelveyears after initial survey, Ind. J. Tuber.; 1979, 26,121.6. National Tuberculosis Institute, Bangalore : Tuberculintesting in a partly vaccinated population.Ind. J. Tub.; 1992, 39,149.7. Raj Narain and Vallishayee R.S. : Some errors intuberculosis surveys, Ind. J. Med. Res.; 1980, 72,825.8. Grindulus. H., Baynham M.I.D., Seott P.H. et al.Tuberculin response 2 years after BCG vaccinationat birth, Arch. Dis. Child.; 19&4, 59, 614.9. Young T.K. and Mirdad S. : Determinants of tuberculinsensitivity in a child population coveredby mass BCG vaccination, Tubercle and LungDisease; 1992, 73,94.10. Tala-Heikkila M., Nurmela T., Misljenovic O.,Bleiker M.A. and Tala E. : Sensitivity to PPD tuberculinand M. scrofulaceum sensitin in schoolchildren BCG vaccinated at birth, Tubercle andLung Disease-,1992, 73,87.11. Fine P.E.M., Pannighaus J.M. and Maine N.: Thedistribution and implications of “BCG scars” inNorthern Malawi, Bull. Wld. Hlth. Org.; 1989,67, 35.

Original ArticleInd. J. Tub., 1993, 40, 145IMPORTANCE OF THYMUS DERIVED ROSETTE FORMING CELLS INPULMONARY TUBERCULOSIS*N. Nath, S. Bansal, R. K. Garg, D. K. Gupta and A. K. KothariSummary : Significantly lower levels of activeand total thymus derived rosette formingcells compared with the normal controls havebeen found in cases of pulmonary tuberculosis.After the start of treatment, no changewas observed during the first 3 months but arise in both the levels was seen at 6, 9 and 12months of treatment. Cases in whom the levelsdid not improve had far advanced disease.Besides, patients who could not achieve anear normal level of active rosettes, even after2 months of treatment, had far advanced disease.IntroductionT-cells are derived from and processed or influencedby the thymus in animals and humanbeings'. An important surface property of the humanT-lymphocytes is the presence of receptorsfor Uie sheep erythrocytes. Binding of three ormore sheep erythrocytes to the surface of a lymphocyteis termed as 'rosette'. Rosette formingcells are decreased in patients with diseases thatinvolve defects in cell mediated immunity. In thepresent study, rosette forming cells were evaluatedin patients of pulmonary tuberculosis in orderto see their status before and after treatment and toobserve whether there is any relationship betweenactive and/or total rosette forming cells andthe severity of the disease.Material and MethodsIn the present study, 1,135 patients of pulmonarytuberculosis were examined while 225healthy normal individuals served as controls. Allthe patients included in this study were AFB positive.Active rosette forming cells were evaluatedby the method of West et al 2 whereas total rosetteforming cells were evaluated by the method ofJondal et al 3 . Patients were followed up for a periodof one year.ResultsTable 1 shows that before treatment the meanpercentage of active rosettes (16.11 ± 5.02) in patientswas significantly lower (p < 0.001) than thatof controls (25.72 ±2.16).Three months after starting treatment, the meanlevel was 20.07 ± 6.43 (range 10-36%), at sixmonths, 21.94 ± 3.71 (range 15-39%), at ninemonths 22.31 ± 4.62 (range 16-45%) and at 12months, 23.94 ± 3.17% (range 19-45%).Mean percentage of active rosette forming cellsin pulmonary tuberculosis patients remained significantlylower than that of the controls till 9months of treatment, whereas after 12 months thedifference in the mean levels was not significant.Table 2 shows that in pulmonary tuberculosispatients the mean percentage of total rosette formingcells (45.72 ± 10.26) before treatment was significantlylower as compared to controls (68.2 ±3.31).After 3 months of treatment, the mean level oftotal rosette forming cells rose to 56.78 ± 9.79with a range of 23-68%, after 6 months, 59.38 ±7.54 (range 23-69%), after 9 months, 64.62 ± 5.28(range 24-71%) and after 12 months of treatment,66.63 ± 5.67 with a range of 26-71%.During follow up, it was found that the meanlevel of total rosette forming cells in pulmonarytuberculosis patients remained significantly lower(p < 0.001) in comparison with controls till 6months. No significant difference in the meanpercentage of total rosette forming cells wasfound between pulmonary tuberculosis patientsand controls after 9 months and 12 months oftreatment.* Paper presented at 47th National Conference on Tuberculosis and Chest Diseases, Bombay: 26th to 28th,November 1992Department of Tuberculosis & Chest Diseases, L.L.R.M. Medical College, MeerutCorrespondence: Dr. N. Nath, Dept. of TB & Chest Diseases, L.L.R.M. Medical College, Meerut-250 004

146N. NATH ETALTable 1 Active Rosette fanning cells before and after treatment in pulmonary tuberculosis patientsActive Rosette Forming CellsNo. of cases Range (%) Mean ± S.D.Controls 225 21-48 25.75 ±2. 16Before treatment 1135 9-33 16.11 ±5.02***3 months after treatment 1113 10 - 36 20.07 ± 6.43***6 months after treatment 946 (278) 15-39 21.94 ±3.71***9 months after treatment 868 (345) 16-45 22.31 ±4.62**12 months after treatment 827 (397) 19-45 23.94 ±3.17*p - significance : control vs treatment *** < 0.001, ** < 0.01, * < 0.05Figures in parenthesis indicate the number of patients who attained normal level of active rosette forming cellsafter treatment.Table 2 Total Rosette fanning cells before and after treatment in pulmonary tuberculosis patientsTotal rosette forming cellsNo. of cases Range Mean ± S.D.Controls 225 55-76 68.20 ±3.1Before treatment 1135 22-62 45.72 ±10.26***3 months after treatment 1113(115) 23 - 68 56.78 ± 9.79***6 months after treatment 946 (281) 23 - 69 59.38 ± 7.54***9 months after treatment 868 (362) 24-71 64.62 ±5.28*12 months after treatment 827 (415) -26-71 66.63 ±5.67*controls vs treatment: p*** < 0.001, * > 0.05Figures in parenthesis indicate the number of patients having normal level of active rosette forming cells.DiscussionIn the present study, significantly decreasedlevel (p < 0.001) of active rosette forming cellswas observed in pulmonary tuberculosis cases incomparison with controls before treatment. Asimilar observation has been made by Prabhu andReddy 4 .To make our study more meaningful, we followedthe patients for one year. During follow up,it was found that, after 3 months of treatment,none of the cases had normal level (percentageequivalent to controls) of active rosettes but after6 months, out of 946 patients who turned up forfollow up, 278 cases had normal level of active ro-settes. Similarly, after 9 months and 12 months oftreatment, 345 out of 868 and 397 out of 827 patientshad normal percentage of active rosettes.Patients who were not having normal percentageof active rosettes even after 12 months of treatmentwere having far advanced disease. Thus, thepercentage of active rosette forming cells wasclosely related to the severity of disease. 4 ' 5Like active rosettes, the total rosette formingcells were also found to be significantly decreasedin pulmonary tuberculosis patients in comparisonto controls. Our results agree with those of Bhatnagaret al, 6 and Katz et al. 7 Paranjape et al 8 foundno difference in percentage of total rosette formingcells between pulmonary tuberculosis and

THYMUS DERIVED ROSETTE FORMING CELLS147nontuberculous cases.After 3 months of treatment, 115 of 1,113 (outof 1,135) cases who turned up for follow up werefound to have a normal level (values within therange of controls) of total rosette forming cells.Similarly, after six months, 281 of 946 cases, after9 months, 362 of 868 cases, and after 12 months415 of 827 cases were found to have a normal percentageof total rosette forming cells. Like activerosettes, total rosette forming cells were also relatedto the severity of disease. 4Serial estimations of active rosette formingcells and total rosette forming cells during followup could be a useful tool for assessing the progressof the disease.References1. Wybran, K. and Fudenberg, H.H. : Thymus derivedrosette forming cells. Tlie New Eng. J.Med.; 1973,288,1072.2. West, W.H., Bryanbooger, R. and Herberman,R.B. : Low affinity E-rosette formation by thehuman K-cells. J. Immunol.; 1978, 120, 90.3. Jondal, M., Holm, G. and Wigzel, G.H. : Surfacemarkers on human T & B lymphocytes. I. Largepopulation of lymphocytes forming non-immunerosette with sheep red blood cells. J. Exp. Med.;1972,136, 207.4. Prabhu, T. and Reddy, M.V.: Active and total E-rosette forming cells in pulmonary tuberculosis.Ind. J. Med. Res. ; 1983, 77, 308.5. Wybran, K. and Fundenbery, H.H. : Thymus derivedrosette forming cells. The New Eng. J.Med.; 1914, 80, 765.6. Bhatnagar, R., Malviya, A.N., Narayan, S.,Rajgopalan, P., Kumar, R. and Bhardwaj, O.P. :Spectrum of immune response abnormalities indifferent clinical forms of tuberculosis. Am. Rev.Res.; 1911, 115, 207.7. Katz, P., Goldstein, R.A. and Fauci, A.S. : Immunoregulationin infection caused by Mycobacteriumtuberculosis. The presence of suppressormonocytes and alteration of subpopulationof T-lymphocytes. J. Infect. Dis.; 1979, 40,12.8. Paranjape, R.S., Ravoof, A., Acharyulu, G.S.,Krishnamurthy, P.V., Tripathy, S.P., Prabhakar,R. and Narayanan, P.R. : Cell mediated immuneresponse in south Indian pulmonary tuberculosispatients. Ind. J. Tub.; 1988, 35, 163.

Original ArticleInd. J. Tub, 1993, 40, 149ALTERNARIA SPORES AND BRONCHIAL ASTHMA*A.K. Kothari, Sushma Kothari and Vandana TyagiSummary : Fungal spores are importantbio-particles in the airspace. The source ofairborne fungal spores is the substrate at theground level. Spores of Alternaria are presentthroughout the year because it grows on awide variety of substrata in different climaticconditions. As such, Alternaria is a potentialsource of allergic disorders in human beings.There is a close correlation between the peakconcentration of spores in the atmosphereand aggravation of symptoms in sensitizedindividuals.IntroductionAeromycology is concerned with thedistribution of fungal spores and other fungalcomponents in the air. Interest in this fieldheightened when it was established that fungalspores play a major role in allergic disorders inhuman beings e.g. bronchial asthma, hay fever,allergic pneumonitis, allergic rhinitis, etc. Anunderstanding of the periodicity and quantity offungal spores in the air gives an idea of thediseases occurring and likely to occur in the area.Alternaria is a common plant pathogen. Its sporesare encountered in aerobiological surveys 1,2 andare known to cause allergies in man 3 . Anaerobiological survey was carried out by us tostudy the prevalence of air borne pollen grains andfungal spores. The daily periodicity of Alternariaspores in relation to climatic factors was observedfor one year. Simultaneously, cases of bronchialasthma were subjected to intradermal sensitivitytests. A correlation was observed between theconcentration of these spores in the atmosphereand symptoms in these individuals.Material and MethodsMicroscope slides coated with a thin film ofglycerine jelly were exposed, every 24 hours, inthe “aeroscope” located at a height of about 10metres on the terrace of the Botany Department,Meerut University. The exposed slides weremounted in glycerine jelly and the total number ofAlternaria spores present on the slide werecounted in an area of 12.5 cm 2 . The monthly datawere expressed as the number of spores per cm 2by dividing the obtained spore count by 12.5 toobtain the frequency.Simultaneously, proved cases of bronchialasthma were subjected to intradermal skin test.The results of spore counts and skin tests werecorrelated.ResultsThe monthly frequency of Alternaria spores inthe atmosphere is shown in Table 1. TheTable 1. Monthly frequency of Alternaria spores inatmosphereMonth Actual count Frequency/per 12.5 cm 2 cm 2December 137 11January 209 17February 489 39March 875 70April 1175 94May 2808 224June 634 51July 510 41August 204 16September 323 26October 427 34November 321 26* Paper presented at 47th National Conference on Tuberculosis and Chest Diseases, Bombay: 26th to 28thNovember, 1992Department of Tuberculosis and Chest Diseases, L.L.R.M. Medical College, Meerut and Department ofBotany, Meerut University, MeerutCorrespondence: Dr A.K. Kothari, Department of Tuberculosis and Chest Diseases, L.L.R.M. Medical College,Meerut (U.P.)

150KOTHARIETALFig. 1 Frequency of Altenaria spores in relation to weather conditionsminimum spore count was observed in the monthof December; a steady increase in the frequencyof spores was observed from February onwardsreaching the maximum in the month of May. Thehigh spore frequency was followed by varyingcounts till November.The frequency of spores in the atmosphere alsovaried with weather conditions (Fig. 1) The occurrencesof spores throughout the year, however,could be due to the ability of Alternaria to growand sporulate in different substrates. For example,from February to May, the steady increase inspore concentration could be due to high windvelocity and air temperature and various hostplants available in the area to serve as substrata.Very high temperature and high relative humiditythen lowered the frequency of spores in themonths of June and July. A very low sporefrequency was observed in August, probablybecause of the cleansing effect of rainfall. FromSeptember to November, spore frequency pickedup again coinciding with the period of variouswinter crops like tomato, potato, brinjal etc. Thesubsequent decrease occurred in December andJanuary due to the low air temperature and windvelocity.After a clinical diagonsis of bronchial asthmawas established, patients were subjected tointradermal skin test with various antigens. A totalof 2,080 skin tests were performed. There were 37positive reactions to Alternaria antigen. Details ofthe positive results are given in Fig. 2. Thenumber of cases in April and May (15 cases) andOctober and November (9 cases) is more andcorresponds with the high atmospheric sporecount; cases in July and August are very low (1case) as is the spore count.Similarly, the symptoms of these cases showclose correlation with spore counts (Fig. 3): Therewas worsening of symptoms as the spore countrose in May and June.DiscussionThe year round analysis done at Meerutindicates that there are two Alternaria sporeseasons. The first season, from August to January,is characterized by low spore frequencies with themaximum seasonal spore count in October. In thesecond season, the maximum spore count isobserved in April-May. A combination of variousclimatic conditions e.g. moderately high airtemperature, high wind velocity, moderately lowrelative humidity and availability of substrata(host plant) is related to these two annual cycles of

ALTERNARIA SPORES AND BRONCHIAL ASTHMA 151Altemaria spores in atmosphere. These spores areusually relatively large and occur in chains.Sometimes, these are light due to their lowcellular content affecting easier dispersal.The seasonal variation of Alternaria sporesobserved in Meerut City is similar to that reportedby other workers 2,4,5 . The variation is because ofmultiple factors affecting spore production :availability of substrata, rainfall, humidity,temperature and wind velocity.Workers from India and abroad haveestablished beyond doubt that fungal spores are animportant source of allergic disorders in humanbeings 6,7 as shown in the present study by Uieresults of skin tests and occurrence of symptoms.A continuous determination of atmospheric fungalspores can help the clinician in managing thesecases such as starting of appropriate prophylactic

152treatment, planning of journeys, holidays or socialgatherings.References1. Bhati, H.S. and Gaur, R.D. Studies onaeriobiology atmospheric fungal spores. NewPhytol.; 1979, 32, 519.2. Agarwal, M.K., Shivpuri, D.N., Mukerjee, K.G.Studies on the allergenic fungal spores of Delhimetropolitan area. The Journal of Allergy, 1969,44, 193.3. Crofton and Douglas's Respiratory Diseasesedited by Anthony Seaton, Douglas Seaton & A.Gordon Leitch, Oxford University Press, 4thedition, 1989, 679 & 725.KOTHARI ETAL.4. Sandhu, K.D., Shivpuri, D.N. and Sandhu, R.S.Studies on airborne fungal spores in Delhi.Annals of Allergy, 1964, 22, 374.5. Tilak, S.T. Fungal Spore and Allergy, CurrentPerspective in Palynological Research, SilverJubilee commemorative volume of the Journalof Palynology, 1990-91. 369-386.6. Feinberg, S.M. and Durban, O.C., Allergy inPractice. Chicago, 1944, Year Book MedicalPublishers, Inc., 216.7. Agarwal, M.K. Mukerjee, K.G. and Shivpuri,D.N. Studies in the allergenic fungal spores inDelhi atmosphere in Aspects of Allergy andApplied Immunology, Delhi 1968, New HeightPublishers, 91.

Original ArticleInd. J. Tub., 1993, 40, 153KNOWLEDGE ABOUT ASTHMA AND ITS MANAGEMENT IN ASTHMATICSOF RURAL PUNJAB*Rajinder Singh BediSummary; In all, 160 asthmatics of ruralPunjab were interviewed to determine howwell-informed they were about their ailment.A number of wrong concepts were foundprevalent about aetiology, desensitizationtherapy and the prognosis of asthma. Only18% were prepared to try inhaler therapy,even after motivation; as many as 84% werenot even aware of the drugs prescribed forthem. The importance of the findings indelivering better service to an averageasthmatic is discussed.IntroductionDespite numerous advances in the managementof asthma, the morbidity and mortality due toasthma are increasing the world over.' Factorsinvolving physicians, health care services andpatients can be responsible for this paradoxicalsituation. Unless a patient possesses basicknowledge about his ailment and its management,he is not likely to make the best use of theavailable facilities. 2,3We have hardly any data from our country,especially its rural areas, as to how knowledgeableare the rural asthmatics about this ailment. Thepresent study was planned with an idea to collectsuch information.Material and MethodsIn all, 160 consecutive asthmatics, 15 years andmore of age, hailing from neighbouring ruralareas, who had been suffering from asthma for atleast three years and had attended our clinic forthe first time constituted the material for thepresent study. Their personal data as well asinformation provided by them about the differentaspects of asthma, like its aetiology, managementand prognosis, etc. were recorded on a speciallyprepared proforma. Every effort was made toavoid asking leading questions.Observations and ResultsPersonal dataTable 1 gives the age and sex distribution ofthe study group. As regards other particulars, 126patients (79%) were either illiterate or had studiedupto 5th standard. Duration of ailment varied from3 to 30 years. Males were mainly farmers (92%)and females, housewives (94%).Knowledge about aetiologySeventy seven cases (48%) showed ignoranceabout the aetiology of asthma; 23 cases (14.5%)considered heredity as the cause; for theremaining 60 cases (37.5%), asthma was either an“infectious” disease (32 cases) or due to faultyeating habits (10 cases) or the “curse” of somegoddess (8 cases).As regards precipitating factors, a majority ofpatients blamed faulty eating habits or suddenchange of temperature as reasons for the episodeswhile only 23 cases (14%) thought that variousaero-allergens could precipitate an attack ofasthma (Table 2).Knowledge about managementAs many as 83 cases (52%) were aware ofallergy tests and immunotherapy and when toldabout limitations, 60 their were still keen to trythis form of therapy.Taking of tablets, capsules or syrups for routineuse and injections during “attacks” were thepreferred modes of drug administration. As manyas 135 cases (84%) were not even aware of themedicines that had been prescribed for them. Only* Paper presented at 47th National Conference on Tuberculosis and Chest Diseases, Bombay: 26th to 28thNovember, 1992Correspondence: Dr. Rajinder Singh Bedi, Bedi Nursing Home, Sher-E-Punjab Market, Patiala 147 001

154RAJINDER SINGH BEDITable 1 Age and sex distribution of rural asthmaticsMale Female TotalAge (Yrs) No. % No. % No. %15-24 19 20.6 12 17.6 31 19.323-34 28 30.4 22 32.3 50 31.235-45 22 23.9 14 20.6 36 22.5Over 4523 25.020 29.443 26.9Total92 . 100.068 100.0160 100.0Table 2 Awarencess about precipitating factors*Precipitating FactorsNo. (*)* Faulty foods/eating habits 54 (33.7)* Sudden change of temperature 54 (33.7)* URC/chest infections 50 (31.3)* Exposure to cold air 40 (25.0)* Smoke/Smoking 23 (14.4)* Aero Allergens/dust 22 (14.0)* Alcohol 20 (12.5)* Pungent odours 12 (7.5)* Exertion/Exercise 10 (6.3)* Psychological factors 10 (6.3)* Gastro-oesophageal reflux/vomiting 2 (1-2)*Many gave more than one reason10 cases (6%) were aware that unsupervised oralsteroids, when given for prolonged periods, canlead to serious adverse effects. Only 18% (29cases) knew about inhaler therapy and only 2%had used inhalers for brief periods. Whenmotivated about the advantages of inhaler overoral therapy, only 29 cases (18%) were preparedto try this mode of treatment. The reasons givenby patients for not preferring inhaler therapy aregiven in Table 3.None of the patients in the present study knewabout peak flow meter or lung function tests astools for monitoring their disease.PrognosisAs regards fate of their disease, 96 cases(60%) considered asthma as a “curable” diseaseand that cure could be achieved with drugs (40cases), immunotherapy (36 cases), alteration indiet (4 cases) and alternative systems of medicine(16 cases). Of the remaining, 38 cases (23.8%) didnot know about the fate of their disease whereas26 (16.2%) thought their disease could becontrolled but not cured with drugs.DiscussionThe present study reveals that an average ruralasthmatic of Punjab is generally ignorant about bisailment and has misconceptions which need to berectified. Considering asthma as an “infectious”disease or a “curse” or due to “faulty foods”reflects the extent of ignorance, as does the fact of84% not knowing what medicines are being

KNOWLEDGE ABOUT ASTHMA155Table 3 Inhaler therapy - reasons for refusal*Reasons No. (%)Difficult to use 66 (50.4)Difficult to carry 64 (48.6)“Habit - forming” 55 (41.9)“Last - resort” 50 (38.2)Social stigma 48 (36.6)Matrimonial reasons 10 (7.6)Fear of in-laws 10 (7.6)Not effective 10 (7.6)High cost 8 (6.1)Oropharyngeal side effects 3 (2.3)* Many gave more than one reasons.administered to them. This may also indirectlypoint to the extent a quack or even a registeredmedical practitioner may exploit these patientsbecause under the cover of “secrecy ofprescription” some of these patients are beingadministered oral steroids without telling them.Even though inhaler therapy has, by and large,been accepted as the first line treatment indeveloped countries, 4 a vast majority of ourpatients either do not know its benefits or arereluctant to use inhalers (Table 3). At first glancea high degree of awareness about desensitizationtherapy (52%) may appear surprising, but tin'sperhaps reflects how strongly these patients hadbeen motivated to undergo allergy tests. 5A large number (60$>) of patients still considerasthma to be a “curable” disease and in search of“cure” they often fall in the hands of quacks andmay become victims of oral steroid toxicity.Sincere and sustained efforts are required toeducate an average Indian asthmatic. Therefore,it is necessary that we first ascertainwhether our general practitioners/family physi-cians are fully aware about the recent advancesin asthma management, and if they are ready tomotivate the masses to accept these newermeans.References1 Editorial, Asthma's changing prevalence,B.M.J.; 1992, 304, 857.2. Bailey, W.C. Richards, J.M., Brooks, C.M.,Soong, S., Windsor, R.A. and Manzelle, B.A : Arandomised trial to improve self-managementpractices of adults with asthma. Arch Int. Med;1990, 150, 1164.3. Beasley, R., Cushley, M., Holgate, S.T. : A selfmanagementplan in the treatment of adultasthma. Thorax; 1989, 44, 200.4. Partridge, M.R. Problems with asthma caredelivery : Respiratory Medicine No. 5. Ed.Mitchell, D.M. Churchill Livingstone, London,1991; pp 61-77.5. Ohman, J.L. Allergen immunotherapy inasthma : Evidence for efficacy. J. Allergy Clin.Immunol; 1989, 84, 133.

Ind J. Tub., 1993, 40, 157SUMMARIES OF PAPERS PRESENTED AT THE 47TH NATIONAL CONFER-ENCE ON TUBERCULOSIS AND CHEST DISEASES, BOMBAY : 26TH TO28th NOVEMBER, 1992RESPONSE OF PATIENTS WITH INITIALLY DRUG-RESISTANT ORGANISMS TO TREAT-MENT WITH SHORT COURSE CHEMOTHERAPYRema Mathew, T. Santha, R. Parthasarathy, K. Rajaram, C.N. Paramasivan, B. Janardhanam,P.R. Somasundaram and R. Prabhakar(Paper is being published in full)RADIOLOGICAL REGRESSION OF TUBERCULOUS PULMONARY LESIONS AND FATEAFTER CESSATION OF THERAPYFive hundred sputum positive pulmonarytuberculosis cases from amongst serving militarypersonel were randomly allocated to one of four 6months regimens :(A) 2 SHRZ + 4HR, (B) 2SHRZ + 4H2R2 (C)2EHRZ + 4 H2R2 and (D) 2S3H3R3Z3 +4S2H2R2.Cavity closure was seen in 68%, 71% 79% and51% cases in A,B,C, & D regimens respectively at8 weeks and 95%, 99%, 98% and 91% at 16weeks. Persistence of cavity (Open negativesyndrome) was seen in 2 cases in A, 1 each in Band C and 3 in D at 24 weeks.Residual lesions at the end of therapy inS.C. Tewari and R. Jayaswaldifferent groups did not differ significantly.Advanced residual lesions (opacities extendingover 3 segments) were observed in 8%, 5%, 7%and 10% of cases respectively in A,B,C, and Dgroups; minimal to moderate residual lesions wereseen in 28% in A, 31% in B, 25% in C and 38% inD.The follow up of residual lesions for 2 yearsafter cessation of therapy, at 6 months intervals,,revealed that further clearance occurred mostly inminimal and moderately advanced lesions. Theoverall clearance was 34% in A, 31% in B, 25% inC and 22% in D group. In most of the casesfurther regression occurred in the first 6 monthsafter cessation of therapy.SHORT COURSE CHEMOTHERAPY IN DOMICILIARY TREATMENT OF PULMONARYTUBERCULOSISS.N. Tripathy G.N. Sahu, R.N. Mania and J. PatnaikNine hundred eighty nine sputum positivepreviously untreated patients were prescribedshort course chemotherapy (Regimen B of D.T.P.manual i.e. 2 SHRZ or 2 EHRZ plus 6 TH or6EH). Seven hundred forty-nine (75.7%)completed 2-month intensive phase while only472 (47.7%) went on to complete the treatment.Sputum was converted in 86% at the end of 1stmonth and in 92% at end of 2 months. Two casesfailed to convert even after 8 months, bothproving resistant to INH and Rifampicin. Twocases relapsed during one year follow up.

158SUMMARIES OF PAPERSVALUE OF SPUTUM EXAMINATION IN PREDICTING PROGNOSIS DURING SHORTCOURSE CHEMOTHERAPYSujatha Chandrasekaran, R. Rajalakshmi and P. Jagota.Culture examination of sputum is the best toolfor assessing the prognosis in patients of pulmonarytuberculosis. Controlled clinical trials withshort course chemotherapy (SCC) have shown thatculture examination of sputum at the end of twomonths gave a high degree of conversion. However,it is not possible to provide culture facilitiesin the District Tuberculosis Programme (DTP).Since smear examination facilities are widelyavailable under the DTP, it is important whetherresults obtained with it could be comparable withculture in patients on SCC . It is also examinedwhether evaluation of the treatment results in patientson SCC by smear examination at twomonths has any role under operational conditions.Data from two operational studies on SCC areutilised for this purpose. Of a total of 256 patients,62 were smear positive at the end of two months,but 41 (16%) of them were excreting non-viablebacilli. Nevertheless, it is observed that as far aspredicting the final outcome of chemotherapy isconcerned, there was no significant difference betweensmear and culture examinations performedat the end of two months.EFFICACY OF CIPROFLOXACIN IN SHORT TERM CHEMOTHERAPY OF SMEARPOSITIVE PULMONARY TUBERCULOSISK.C. Mohanty and T.M. DhamgayeA double blind study was undertaken in 60patients with newly diagnosed bacteriologicallypositive pulmonary tuberculosis to evaluate thepossible contribution of Ciprofloxacin (C). Thepatients were randomly allocated to either2SHRZ/4HR or 2 SHZC/4HC.All patients in 2SHRZ/4HR regimen and all butone of the 28 patients in 2 SHZC/4HC regimenattained a favourable bacteriological response atthe end of 2 months. Ciprofloxacin was welltolerated. After completion of chemotherapy,1 (5.9%) of 17 2SHRZ/4HR patients followed for6 months and 3 (16.6%) of 18 2SHZC/4HCpatients had relapsed bacteriologically.SERIAL CT SCAN FOLLOW UP OF BRAIN TUBERCULOMA TREATED WITH SHORTCOURSE CHEMOTHERAPYTB Research Centre, Madras(Updated summary not received)SHORT COURSE CHEMOTHERAPY IN TUBERCULAR LYMPHADENITISG.N, Sahu, S.N. Tripathy, R.N. Mania and Jyoti PatnaikFrom 1985 to 1992, 61 cases of tuberculouslymphadenitis at a single or multiple sites werediagnosed, 53 of them on histopathologicalevidence or by FNAC (2 having radiologicalevidence as well).All the 53 patients were treated with 2 SI1RZ/7HR on domiciliary basis. Of them, 45 cases(84.9%) completed treatment satisfactorily and 8were lost. Two cases had further enlargement oflymphnodes while on treatment and one case wenton to a cold abscess formation. Eventually, all the'treatment completed' cases gave a satisfactoryresult but one case relapsed during the second yearof a 5 year follow-up.

SUMMARIES OF PAPERS159EVALUATION OF PERFORMANCE OF NATIONAL TUBERCULOSIS PROG-RAMMEDURING VII PLANV.V. Krishna Murthy(Paper is being published in full)INTEGRATED RURAL HEALTH PROJECT - FOR TB AND LEPROSYE.V. Savitha SriA rural TB and Leprosy Project was started inPavagada (Karnataka) by the Swami VivekanandaRural TB Centre to augment the services alreadyavailable from governmental institutions in theTaluk comprising 146 villages and 2 towns. Priorto the start of the Project in January 1992, the 5PHCs in the area had detected 54 sputum positivecases, in a population of 186,000. Besides offeringadditional services from the S.V. Rural TBCentre, weekly general health camps were held,using a mobile unit, undertaking case-detection,treatment and health education. A team of tenmedical and para-medical personnel ran thesegeneral health camps, in three planned circuits,ensuring that each village was visited once amonth for case-holding of TB/Leprosy cases.In about a year's time, the number of detectedcases has risen to 376 (all kinds) and 180 smearpositives compared with 54 cases at the start. Ofthe 180, 2 died, 18 migrated, 58 have completedtheir treatment and 102 are still receiving shortcourse chemotherapy.FUNCTIONAL INTEGRATION OF TUBERCULOSIS SERVICES WITH GENERAL HEALTHSERVICES UNDER DISTT. TB PROGRAMME - A FIELD STUDYR.C. SharmaA field study of the functional integration oftuberculosis services into general health servicesin a district of U.P. has revealed that diagnosis isdone mainly on chest X-ray examination;treatment regimens are “self styled” and case-holding is inadequate. Only 33% of the peripheralhealth institutions are participating as PHIs. Thesupply of consumables from the DTC even to thefew implemented, PHIs, was insufficient onaccount of meagre budget.TREND OF TB CASE-FINDING AND CASE-HOLDING IN A MAJOR PHI IN TAMIL NADUM. KannanSince monthly reports had shown that Talukhospitals had been functioning as major PHIs,perhaps because of their X-ray facilities, the trendof tuberculosis case-finding and case-holding wasstudied at Sriperumbudur in Tamil Nadu over a 3year period (1990-1992).While the OPD attendance (new) remainedsteady, sputum examinations done climbedfrom 40% in 1990 to 50% in 1991 and 54% in1992; sputum positivity rate among thoseexamined went up from 2% to 3% and 5%respectively.Around 100 cases were put on standardchemotherapy (SR) and 25 on short courseregimens (SCC), every year. Of those on SR, 28%completed treatment, 50% were lost and 22%remained on regular or irregular treatment. Nodefaulter action had been taken. All those on SCCcompleted treatment.Of the 56 cases who completed treatment fromthe cohort put on treatment between July 1989 andJune 1990, sputum at the end of treatment hadbeen examined only for 27 cases and all hadconverted.

160SUMMARIES OF PAPERSDEFAULTER PROBLEM IN PRIVATE PRACTICE IN THE MANAGEMENT OFPULMONARY TUBERCULOSISS. Brahamananda RaoThis is a retrospective study involving 113sputum positive adult patients. Majority of (liepatients were put on short course chemotherapy.All were given consultative advice periodically.The patients could be divided into three groups :(1) Regulars : Who completed their 6 months SCCor 1 year standard therapy satisfactorily - 60(53%); (2) Early defaulters : Patients who did notcome for review at the end of 2 months - 24(21%); (3) Late defaulters : Those who came for areview at the end of 2 months but did not attendsubsequently - 24 (26%). Only 11 of the 53defaulters could be contacted subsequently. Eightof these patients were still symptomatic (4 of thembeing sputum positive), 3 patients wereasymptomatic and sputum negative.EVIMUNOTHERAPY IN MANAGEMENT OF PULMONARY TUBERCULOSISM.S. Agnihotri, R.P. Saxena and Surya KantA study was planned to examine thesimultaneous use of chemotherapy and Ayurvedic“Rasayan” in patients of tuberculosis.In 25 patients (study group) modern chemotherapywas given along with Rasayan whereasto 25 cases in control group only chemotherapywas given. It was observed that patientsin the study group became afebrile in a periodof 6 weeks compared to 8 weeks in controlgroup. Similarly, the study group showed higherincrease in weight gain as compared to the controlgroup (mean weight gain by 8 weeks was 5.16pounds in study group and 2.84 pounds incontrolgroup). The study group showed earlysymptomatic improvement as compared to controlgroup and increase in the T lymphocytes count of12.90% as compared to 7.30% in the controlgroup.WANING OF BCG SCAR AND ITS IMPLICATIONSR. Channabasaviah, V. Murali Molian, H.V. Suryanarayana, M.S. Krishna Murthyand A.N. Shashidhara(Paper is being published in full)IMPORTANCE OF THYMUS DERIVED ROSETTE FORMING CELLS IN PULMONARYTUBERCULOSISN. Nath, S. Bansal, R.K. Garg, D.K. Gupta and A.K. Kothari(Paper is being pubished in full)APPLICATION OF RESTRICTION FRAGMENT LENGTH POLYMORPHISM ANALYSIS TOTHE ORIGINS OF RELAPSE AND ISOLATED POSITIVE CULTURES FROMTUBERCULOSIS PATIENTS IN HONG KONGSulochana D. Das, B.W. Alien, D.B. Lowrie and D.A. MitchisonRestriction Fragment Length Polymorphism from tuberculosis patients in a MRC-Hongkong(RFLP) technique was used to establish the origins Govt. short course chemotherapy study done inof relapse and isolated positive cultures obtained 1972-73.

Insertion sequence IS 986/IS 6110 was used asa probe to analyse totally 265 cultures. GenomicDNA was isolated from the mycobacterialcultures, cut with restriction enzyme PVU, thensubjected to electrophoresis, Southern transfer andprobing with chemiluminiscence detection system(ECL-Amersham).The complete study was done on codedsamples. A high degree of polymorhpism wasobserved and almost every patient was infectedwith a different strain (pattern of RFLP bands).There was a good agreement (87%) betweenrelapse cultures and pretreatment cultures in eachpatient which gives strong evidence that theSUMMARIES OF PAPERS161relapse cultures are mainly endogenous andderived from the original organisms. Isolatedpositive cultures mostly differed from those whichoriginally infected the patients (only 12%agreement), which suggests that they might haveoriginated from new infection or due tocontamination of the bronchial tree from otherpatients or laboratory contamination.A comparison of these RFLP results withthose obtained by phage typing on the sameisolates (at CDC Atlanta) showed that RFLP wasgreatly superior to and more reliable than phagetyping. It was found to be an useful epidemiologicaltool.PLASMA CORTISOL LEVELS IN ACTIVE PULMONARY TUBERCULOSISBaldev Raj, A.S. Sanini and Dilbagh SinghThe study was undertaken to find out whetherplasma cortisol levels were correlated with extentand severity of pulmonary tuberculosis. The studygroup comprised 80 sputum and culture positivecases of both sexes in age group 15-55 yearsmatched with 20 healthy controls. The mean valuein patients was 19.79 ± 8.94 as compared to 12.7± 2.51 ug% in the controls. It was observed that (i)shorten the duration of illness, higher the meancortisol level; (ii) higher the rise in bodytemperature and E.S.R., higher the cortisol levels,(iii) greater the radiological extent of the diseaseor the number of cavities, higher the cortisollevels.RAPID DIAGNOSIS OF TUBERCULOSIS BY IMMUNOLOGICAL TECHNIQUESK.V. Laxmi and G.G. BhaveFor rapid and accurate diagnosis oftuberculosis, especially in cases where thediagnosis was in doubt on the basis of the usuallyavailable tests, the use of presence ofmycobacterial antigen in the serum by ELISA,Reverse Passive Haemagglutination (RPHA) andCoagglutination (COAG) tests was attempted.Of 96 sputum specimens (41 positive by smearand 54 by culture), 81 (84%) were positive byELISA, 32 (33%) by RPHA and 10 (10%) byCOAG. Of 38 CSF specimens (10 positive bysmear plus 2 by culture), 32 (84%) were positiveby ELISA, 21 (55%) by RPHA and none byCOAG. Of 91 plural fluids (15 positive by smear),64 were positive by ELISA (70%), 38 (42%) byRPHA and 30 (33%) by COAG. Of 41 asciticfluids (all negative by smear and culture), 25(61%) were positive by ELISA, 13 (32%) byRPHA and 7 (17%) by COAG. Among 14 lymphnode aspirates (2 positive by smear and 1 byculture), 7 (50%) were positive by ELISA 3 (21%)by RPHA and 2 (14%) by COAG.ENDOSCOPICALLY VISIBLE BRONCHIAL CARCINOMA WITH FIBEROPTICBRONCHOSCOPYRajendra Prasad, M.K. Goel, B.K. Khanna and A.N. SrivastavaFlexible fiberoptic bronchoscopy wasperformed in 60 patients of lung cancer. Tumourwas endoscopically visible in 38 (63.3%).Tumours involved main bronchus in 21 (55.3%),

162lobar bronchus in 14 (36.8%) and segmentalbronchus in 3 (7.9%) patients. Histopathologicalexamination of bronchial biopsiesyielded positive diagnosis in 31 (81.6%) patients.A combination of bronchial biopsy, bronchialSUMMARIES OF PAPERSaspirate cytology and postbronchoscopic sputumsmear examination yielded diagnosis of lungcancer in 35 (92.1%) patients. Squamous cellcarcinoma was found in 60.0% and small cellcarcinoma in 28.6%).ALTERNARIA SPORES AND BRONCHIAL ASTHMAA.K. Kothari, Sushma Kothari and Vandana Tyagi(Paper is being published in full)IMPORTANCE OF PREBRONCHOSCOPIC SPUTUM BRONCHIAL ASPIRATE &POSTBRONCHOSCOPIC SPUTUM EXAMINATION IN DIAGNOSIS OF LUNG TUMOURSM.K. Goel, B.K. Khanna, Rajendra Prasad and A.N. SrivastavaThe diagnostic value of prebronchoscopic sputum,bronchial aspirate and postbronchoscopicsputum cytology has been assessed in a total of 60cases of proved lung tumour. The prebronchoscopicsputum examination for malignant cellsyielded an overall positivity in 16.7%, bronchialaspirate cytology in 38.3% and postbronchoscopicsputum examination in 23.3% cases. Two caseswere diagnosed solely by prebronchoscopic spu-tum examination, 8 solely by bronchial aspiratecytology and 3 solely by postbronchoscopic sputumexamination. In 2 patients, both bronchial aspiratecytology and postbronchoscopic sputumwere positive when prebronchoscopic sputum andforceps biopsy had yielded negative results. Thus,though these examinations, considered separately,give a low diagnostic yield, they greatly enhancethe diagnostic yield when considered together.PREVALENCE OF BRONCHOGENIC CARCINOMA IN PATIENTS WITH NON-TUBERCULOUS UPPER LOBE PULMONARY LESIONSS. Rajasekaran, T.G. Manickam, C.S. Jayachandran, R. Subbarman,P.J. Vasanthan S. Kumar and A. ManimaranIn India, where pulmonary tuberculosis is oneof the commonest disorders, it is common to comeacross instances of mismanagement of nontuberculousupper lobe pulmonary lesions with dieuse of anti-tuberculosis drug regimens. A studywas undertaken to assess the prevalence ofbronchogenic carcinoma among patients withnon-tuberculous upper lobe lesions. In all, 43.3%of 150 patients, studied over a period of two years(1990-1992), were found to have primarymalignant tumours of the bronchus; 42 (67.7%)had squamous cell carcinoma; 91.9% of lungcancers were detected in > 40 age group and 57%patients with smoking index > 200 were found tohave upper lobe carcinoma. Therefore, routinescreening for malignancy in high risk patientswith non-tuberculous upper lobe lesions ismandatory.BRONCHOGENIC CARCINOMA IN A RELATIVELY NON-SMOKING POPULATIONBalbir Malhotra and B.M. KalianTwo hundred patients of histopathologicallyproved bronchogenic carcinomas were studied. Asmany as 54.5% of the patients were smokers; themean age in smokers and non-smokers was 54.6

years and 53.8 years, respectively; malespredominated; epidermoid carcinoma wasencountered in 65.5% of patients (72.5% insmokers and 57.5% in non-smokers), anaplasticSUMMARIES OF PAPERS163carcinoma in 12.5% (14.7% in smokers and 9.8%in non-smokers), adenocarcinoma in 3.5% (5.5%in smokers and 1.1% in non-smokers) andcarcinoms of other types in the remaining.KNOWLEDGE ABOUT ASTHMA AND ITS MANAGEMENT IN ASTHMATICS OF RURALPUNJABRajinder Singh Bedi(Paper is being published in full)OBJECTIVE EVALUATION OF CHEST SKIAGRAMSP.V.P. Rau, Gajanana Gaude, Subhakar K. Sukhesh Rao and M.V.V.S. Murthy.In the absence of objective criteria forassessing radiological extent of tuberculosislesions, chest X-Ray reading is always open tointer-individual and intra-individual variation.The study was designed to attempt an objectiveassessment of chest X-rays by graphic evaluation.A total of 100 chest skiagrams with pulmonarytuberculosis lesions were evaluated. All Uie X-rays were read by four chest physicians,independently, by graphic evaluation.A graph was plotted on the X-ray view boxwith each square measuring 1cm. x 1cm. Thechest X-ray was superimposed on it and the extentof the lesion was read according to the number ofsquares involved. Less than ¥2 square involvementand pleural based opacities were excluded fromthe analysis. The progression or regression of thelesion was objectively graded in 3 groups (Gr I, GrII, Gr III) by all the readers. The inter-individualvariation ranged from only 4.2% in Grade III to8.3% in Grade I. Using Koppa's Test for statisticalanalysis, the level of statistical significance for theobjective evaluation was found to be highlysignificant (z = 3.915). It is concluded that thismethod of objective evaluation of chest skiagramscan be used to assess radiological lesionsSOCIO-BEHAVIORAL STUDY OF HIV & TUBERCULOSISA.D. Nageswari, R. Parmasivam, Chellammal and J. KesolonIn the Government Hospital of ThoracicMedicine, Tambaram, 400 sputum direct smearpositive patients admitted during March toSpetember, 1991 were screened for HIV infection.Four of them (2 male and 2 female) were foundELISA positive and were confirmed HIV-I by theWestern Blot test.Information regarding sexual behaviour,condom usage and awareness about AIDS wasobtained from these 200 male and 200 female,randomly selected patients, all in the 16-60 yearsage group, during a 20 minute inteview by atrained social investigator using a standardisedquestionnaire. One half of the patients were rural,one third from the city of Madras and the restfrom other towns.Among males, the mean age of onset of sexualactivity was 19.6 years; 80% had premarital sex;of the married, 38% were having extra-maritalrelations; 46% were contacting commercial sexworkers; only 10% used condom while 26% wereignorant of their use; 61% had not heard of AIDSwhile 38% knew that it was incurable.Of the female patients, the mean age of theonset of sexual activity was 17.3 years; 5% hadpremarital sex; of the married, 3% were havingextra-marital relations; 3% used condoms and

164SUMMARIES OF PAPERS54% were ignorant of their use; 85% had no homosexual but 31% of males and 12% femalesknowledge of AIDS.gave history suggestive of STD and 7% of malesNone of the patients was a drug addict or had had a blood transfusion.INCIDENCE OF HIV INFECTION IN TUBERCULOSIS : CLINICAL MANIFES-TATIONS,COURSE, INVESTIGATIONS AND MANAGEMENTK.C. Mohanty and R.B. PasiAll 3,257 patients (2,429 male and 828 female)admitted to the respiratory ward of JJ. Hospital,Bombay during four successive years (1989-1992)were screened for HIV infection by ELISA testtwice, confirmed where necessary by WesternBlot Test. The rate of HIV positivity during thefour years was, successively, 2.32%, 2.27%,3.43% and 7.90%. History taking revealed that outof a total of 134 HIV positive patients,heterosexual contact accounted for 128 (95.5%)blood and blood products 5 (3.7%) and use ofcontaminated instruments 1 (0.7%). Nearly 80%of the patients were in the age group 11-40 years.Of the 134 HIV positive patients, 126 hadtuberculosis (including 64 who were AFBpositive) and 8 non-TB chest diseases. Of the 126TB patients, 103 (82%) responded to anti-TBtreatment (3 HRZE/6HR) and the drugs werewell-tolerated. All 8 non-TB patients tooresponded well to antibiotics and symptomatictreatment. All the 23 TB patients who did notimprove died.CLINICAL FEATURES OF HIV POSITIVE AND HIV NEGATIVE PATIENTS OFPULMONARY TUBERCULOSISV. Sivaraman, V. Udayaraj, Balu, Flora, Vasudevaiyah, Umashankar,Govindarajan and IrudayarajClinical features of cases of pulmonarytuberculosis admitted in TB Sanatorium,Pondicherry between January 1990 and May 1992were compared according to their HIV positivitystatus. Along willi routine investigations, ELISAtest was done twice in each case and, if positive,confirmed by Western Blot. Cultures were doneonly in selected cases.In all, 520 patients were admitted, of whom 22(one HIV positive) were found to be non-tuberculous,leaving 498 cases for analysis. Of the 498,11 (2.2%) were HIV seropositive; 7 out of 389(1.8%) males and 4 out of 109 (3.7%) females.Sputum of 8 (1.6%) cases could not beexamined because they died or absconded. Nine(82%) of the sero-positive and 287 (60%) of theseronegative cases were smear positive. Amongthe limited cultures, 3 were of unclassifiedmycobacteria; most of the tubercle bacilli grownon culture were sensitive to all drugs.Co-existing opportunistic infections were metwith in 2 (18%) of the seropositives and 6 (1.2%)of seronegatives and extrapulmonary disease wasassociated in 27% and 2.7% respectively.Response to chemotherapy could not beassessed properly on account of the large numberof 'lost' cases. Four out of 8 (50%) seropositivecases follow up had died compared with 23 outof 92 (25%) of seronegative patients, themean interval between diagnosis and death being330 (SD 326) and 808 (S.D. 1411) daysrespectively.STUDY OF ASSOCIATION OF HIV AND TUBERCULOSISG.G. Bhave and V.G. AdvaniTwo hundred and fifty cases of clinically andradiologically diagnosed cases of tuberculosiswere examined by culture of sputum, ELISA andWestern Blot. Of the 250 cases, 11 were HIV

positive and 110 were culture positive (103 amongELISA negatives). Of the 103 cultures fromELISA negatives, 12 turned out to be atypicalSUMMARIES OF PAPERS165myco-bacteria. Of the 7 cultures from ELISApositives, 7 were of M. tuberculosis and 1 ofMAC.SOCIOLOGICAL ISSUES IN HEALTH CARE DELIVERY WITH PARTICULAR REFERENCETO TUBERCULOSIS CONTROL PROGRAMMEM.A. SeethaA systems approach is necessary for understandingihe health care delivery system (HCDS).Some of the variables that go into the system are :health policy, centre-state relationship, otherhealth care agencies in the field, training of medicaland para medical personnel, private practiceallowed to doctors, selection of people orientedtechnology, other systems of medicine and thenumbers offering those services, the health cultureand practices of the community and the role ofinternational and multilateral agencies.Very few sociological studies have been doneto understand the HCDS on which success of NTPdepends.ROLE OF HEALTH EDUCATION IN INFLUENCING BEHAVIOUR OF CHESTSYMPTOMATICS FOR DETECTION AND CONTROL OF TUBERCULOSISS.A. RajagopalanThis study was undertaken to judge the influenceof health education on case-finding and caseholdingamong chest symptomatics in two comparableareas. Services of local bodies and voluntaryassociations were utilized for health education.Intensive education methods were used. No conclusiveevidence could be found, perhaps, becauseother variables were not controlled.BEHAVIOUR AND ATTITUDE OF SOCIETY TOWARDS TUBERCULOSIS PATIENTSS.N. Tripathy and S.N. TripathyTo study the changes in behaviour/attitude ofsociety towards a patient diagnosed to be sufferingfrom tuberculosis, a questionnaire was prepared.Changes in behaviour, companionship andhabitation (sitting and eating together) were notedon a six point scale of 'no change', 'markedchanged' and “remarkable (hatred) change'categories, the last two constituting “badbehaviour”.Bad behaviour was least (17%) by the parents,followed by 25-32% by spouse/children andemployer/colleagues and 43% by relatives to atotal of 250 patients (179 male and 71 female).Hatred was shown most towards female patients.Bad behaviour did not depend on the kind offamily, the family income or profession of thepatient but was somewhat more frequent inrespect of rural patients and less towards educatedpatients.Society was more unkind towards the sputumpositive patients which could be due to what thedoctor told the family members.TUBERCULOSIS AND PREGNANCYS.N. Tripathy and S.N. TripathyIn a prospective study, from 1981 to 1991, 51sputum positive female patients who were foundto be pregnant at the time of diagnosis werematched with an equal number of pregnant

166females who had no tuberculosis. The matchingwas done for age, parity and socio-economicstatus. Into this 'control group' was added anothercomponent comprising age, socio-economic andsputum status matched non-pregnant females. Thestudy group and the controls were followed upduring the course of pregnancy, delivery andneonatal outcome, perinatal morbidity andmortality as well as stabilisation of the disease,sputum conversion and relapses.Only one patient who had drug resistant diseaseunderwent MTP at 8 weeks of pregnancy. Therewas no difference between the study group andcontrols with regard to toxaemia, ante-partumhaemorrhage and pre-tenn labour. The course oflabour and delivery were also similar. Duringpuerperium, one “study” case had post partumSUMMARIES OF PAPERShaemorrhage, one had retained placenta and twohad puerperal pyrexia of which one died on the10th day due to pulmonary embolism. Theneonatal outcome too was similar (no congenitalabnormalities were met with even though somehad received anti-tuberculosis drugs during thefirst trimester), nor had pregnancy exercised anyeffect on the course of the disease while ontreatment. The cases were followed up for 2-5years for relapse but none occurred even thoughfive patients delivered another baby during thefollow up. A majority of the patients did adequatebreast feeding.It was concluded that given proper andadequate chemotherapy, pregnancy and itsaftermath posed no problem for tuberculousfemales.A CASE CONTROL STUDY OF RELAPSES IN PULMONARY TUBERCULOSISA.B. Amle, B.R. Maldhure, M.C. Pathak and L.R KulkarniThe study cases were taken from 669tuberculosis patients completing chemotherapyduring the period March 1984-December 1989. Inall, 82 subjects were included in this study : 41relapse cases and 41 controls. The informationregarding the various risk factors was collectedfrom the medical records of these patients.It was found that pretreatment extent ofradiological lesion and extent of residual lesionhad a strong association with relapse (p < 0.001).Other risk factors such as presence of initialcavitation, irregularity of treatment, time ofdefault and 'no weight gain during treatment'definitely influenced the relapse in pulmonarytuberculosis (p < 0.05).Factors like age, sex, treatment regimensduration of default also influenced risk of relapse,but were not statistically significant. The factorswhich did not have any effect on the occurrence ofrelapse in pulmonary tuberculosis were side oflesion, concurrent disease, time of sputumconversion, intermittent sputum positivity,hospitalization of patient and initial drugresistance.INTRATHORACIC LYMPHNODE TUBERCULOSIS IN ADULTS - CHANGING SCENARIOB.N. Panda, R.S. Pahwa, R.K. Jetley, R. Jayaswal, K. Sahoo, P.B. Rao and M. LuthraIntrathoracic tuberculous lymphadenopathy(ITTL) in adults is not a common presentation.In a retrospective study, we have comparedITTL met with in 1,000 consecutive casesadmitted to Armed Forces Chest DiseaseHospitals in 1986-87 with a similar number ofpatients in 1991-92. During 1986-87, theproportion of ITTL was 0.9% compared to 2.8%in 1991-92 in two distinct peak ages, namelyaround 20 years and after 50 years respectively.There was one case associated with HIVseropositivity. All the 37 patients (nine in 1986-87and 28 in 1991-92) showed good response to shortterm chemotherapy.

SUMMARIES OF PAPERS167CHEMOPROPHYLAXIS IN HIGH RISK CHILDREN - ANALYSIS OF 8 YEARS'FOLLOW UP : PRELIMINARY REPORTO.K. Gupta, R. Kumar, N. Nath and A.K. Kothari(Paper is being published in full)PREVALENCE OF PULMONARY TUBER-CULOSIS AMONG BUS TRANSPORTCORPORATION EMPLOYEES IN MADRAS CITYK. Jagannath, D. Ashok Kumar and S. RajasekaranAn epidemiological survey to assess theprevalence of pulmonary tuberculosis amongMadras City Bus Transport employees wasundertaken. 8,581 (47.2%) of the total 18,185employees were screened by Mass MiniatureRadiography. Of the 288 X-ray suspects (3.4%),121 workers (1.4%) had active or probably activepulmonary tuberculosis. Of the 288 suspects, 130had already received adequate treatment forpulmonary tuberculosis, 37 did not know detailsof their past treatment, 18 were still on treatmentand 103 (36%) were freshly diagnosed.Prevalence of bacillary cases in this mixed groupwas found to be 0.12% only. There was nosignificant difference in the prevalence of sputumpositive cases among various categories ofworkers. The lower prevalence rates in transportemployees compared with the general populationwould suggest that working and living conditionsof bus drivers and conductors do not make themmore prone to tuberculosis than the travellingpublic.ORGANISATIONAL VERSUS TECHNICAL ASPECTS OF SHORT TERM CHEMOTHERAPYAMONG TB PATIENTS OF A PRIVATE PRACTITIONERK.C. MathurThe retrospective study deals with drug defaultand results of treatment with SCC among patientsof a private medical practitioner from January1986 to September 1989, with a follow up donetill June 1990. The patients had to pay forconsultations, investigations and medicines andwere previously untreated. They were expected tovisit the doctor of his own choice every month anddefaulter action was taken if they did not do so.In all, 131 patients were treated with 2 RHZE/4RHJ5/3RH. DTP procedures were adopted forfollow-up. In all, 107 (81.7%) completed theirtreatment.Regularity of treatment was assessed in termsof the monthly visit or die actual period of drugintake as stated by the patient and was 66%and 82% respectively i.e. those who made 7 ormore visits or completed 7 or more months oftreatment.Of the 131 patients, 34% did not default, andamong the rest, 67% responded to the defaulterletter. While the need for defaulter action wasgreater for patients in the same district comparedwith outside district, there was no differenceaccording to urban/rural residence but ruralpatients responded to the defaulter letters moreoften.At the end of treatment, of the 107 patientswho had completed their treatment as prescribed,43 (40%) had become sputum negative, 54 (50%)were still sputum positive and for 10 the sputumcould not be examined.

168SUMMARIES OF PAPERSBEHAVOUR OF A SOUTH INDIAN VARIANT OF M. TUBERCULOSIS DURING EIGHTYEARS OF ANIMAL PASSAGEVijay K. Challu, Sujatha Chandrasekaran, B. Mahadev, B. Jones and R. Rajalakshmi(Paper is being published in full)NONTUBERCULOUS MYCOBACTERIA ISOLATED FROM AN EPIDEMIOLOGICALSURVEY IN RURAL POPULATION OF BANGALORE DISTRICTM.M. Chauhan(Paper is being published in full)ROLE OF SALINE NEBUHSATION IN BACTERIOLOGICAL DIAGNOSIS OF SPUTUMNEGATIVE PULMONARY TUBERCULOSIS PATIENTSR.S. Pahwa, B.N. Panda, K.E. Rajan, A.K. Basu, S.P. Rai, J. Jena and S.M. Bhale RaoDefinitive diagnosis of tuberculosis can only beobtained by demonstration of M. tuberculosis. Tomake bacteriological diagnosis in suspectedsputum negative cases with minimal or negligiblesputum production, we have used salinenebulisation to induce sputum production. Out of45 patients, including one case of Macleod'sSyndrome, one case of COPD and one caseof chronic cough, we obtained smear positives in16 and subsequent culture positives in 3 more.The use of nebuliser is considered a safe,inexpensive and effective procedure which can beused for inducing sputum production beforesubjecting a patient to bronchoscopy or FNAC formaking a bacteriological diagnosis oftuberculosis.DRUG DEFAULT IN PULMONARY TUBERCULOSIS WITH SPECIAL REFERENCETO PSYCHIATRIC FACTORSSudhir Chaudhri, S.K. Katiyar, R.P. Singh, S.S. Agnihotri, K.P. Singh and S.N. SharmaIn all, 153 cases of pulmonary tuberculosis whohad been defaulting in their treatment patients and91 freshly diagnosed (to serve as controls) wereadministered the Hindi version of Cornell MedicalIndex (CMI) to monitor psychiatric illness andEysenk's Personality Inventory (EPI) forpersonality evaluation. Of these, 17 defaulters and5 controls were excluded because their “liescore” was above the cut off point.Follow up on treatment revealed that asignificantly higher proportion of defaulters hadabnormal CMI scores. Depression followed byanxiety neurosis were the commonest of thepsychiatric disorders. In EPI, the defaulters hadmore of neurotic personality compared withcontrols, while the extrovert traits were aboutequal.The study suggested that identification of thepatients at the start of treatment could help inreducing default because depression and anxietyneurosis could be treated along with tuberculosis.

Contemporary IssuesNON-TUBERCULOUSMYCOBACTERIAL INFECTIONNon-tuberculous mycobacteria (NTM) areknown to be highly prevalent in tropicalenvironments. Infection with NTM produces skinsensitization which cross reacts with that causedby infection with M. tuberculosis, thus interferingwith the proper interpretation of the Mantouxtest 1 . Besides, it confers a degree of protectionagainst tuberculosis which has been implicated inseveral trials carried out to measure the protectiveeffect of BCG vaccination 2 - 3 . It is, therefore,important to study the level and extent ofsensitization caused by the different strains ofNTM in our population in order to find out if itcould explain the insufficient effectiveness ofBCG in the latest trial carried out in India 4 .While there are several reports of infectionwith NTM from other parts of India 5 ' 6 ' 7 , no suchstudy has been done in and around Hyderabadcity. We carried out a pilot study in 170 schoolgirls in the 12-16 years age group who had residedin Hyderabad since childhood^ after obtainingtheir informed consent. Sixteen kinds of NIMtuberculins were gifted to us for the purpose byDr. J.L. Stanford, London, U.K. Separate syringes(sterilized separately) were used for NTM testing;the indurations were read after 72 hours, and aninduration of >2 mm was regarded as positive, asreported by Dr. Stanford. The antigens had beenderived both from slow and fast growing NTMspecies (M. gilvwn, M. vaccae, M. diernoferi, M.flavescense, M. duvalii, M. fortuitum, M. nonchromogenicum, M. marinum, M. avium-B, M.xenopi, M. scrofulaceum, M. kansasii, M.gordonae, M. fortuitum-1, M. malmoense and M.intracellulare.The mean percentage of the pooled positivereaction was 53.0% (± 17.5%). All the ninechildren tested with antigen Kansasii; 8 out of 11tested with Scrofulin and 7 out of 11 tested eachwith vaccin and intracellulin gave a positivereaction. The proportions reacting to rest of theNTM antigens were comparatively less but in noInd. J. Tub., 1993, 40,169group was the response completely negative. Ahigher proportion of children with BCG scar wasnegative to NTM antigens (pooled data) comparedwith children having no BCG scar.In conclusion, the study has shown that levelsof sensitization to non-tuberculous mycobacteriais high in this region. More of BCG vaccinatedchildren were negative to the new tuberculins andprior vaccination was associated with increasedpositivity to the slow-growing species. Furtherstudies may add to the information, thus pavingthe way to optimal BCG vaccination strategies inthis region.References1. Guld, J., Waaler, H., Sundaresan, T.K.,Kaufmann, P.C. and Ten dam, H.G. : Theduration of BCG-induced tuberculin sensitivity inchildren, and its irrelevance for revaccination.Bull. World. Hlth. Org.; 1968, 39, 829.2. Stanford, J.L., Shield, M.J., Rook, G.A.W. : Howenvironmental mycobacteria may predeterminethe protective effect of BCG. Tubercle; 1981, 62,55.3. Palmer, C.E. and Long, M.W. : Effects ofinfection with atypical mycobacteria on BCGvaccination and tuberculosis. Am. Rev. Resp.Dis., 1966, 94, 543.4. Tuberculosis Prevention Trial, Madras. Trial ofBCG vaccines in south India for tuberculosisprevention. Ind. J. of Med. Res.; 1979, 70, 349.5. Stanford, J.L., Ganapathi, R., Revankar, C.R.,Lockwood, D., Price, J., Ashton, P., Ashton, L.,Rees, R.J.W. : Sensitization by mycobacteria andthe effects of BCG on children schools in theslums of Bombay, 1988.6. Stanford, J.L., Cunningham, F., Pilkington, A.,Sargeant, I., Batti, N. and Bennet, E. : Aprospective study of BCG given to youngchildren in Agra, India - A region of high contactwith environmental mycobacteria. Tubercle;1987, 68, 39.7. Narain, Raj, Krishna Murthy, M.S. andAnantharaman, D.D. : Prevalence of non-specificsensitivity in some parts of India; Ind. J. Med.Res.; 1975, 63,1098.V. Vijayalakshmi, P.C. Sadhana and K.J.R. MurthyBhagavan Mahavir Medical Research Centre,Hyderabad

170CONCORDE TRIAL :PRELIMINARY RESULTSJ.P. Aboulker and A.M. Stewart, writing inLancet (April 3, 1993) have given preliminaryresults of the joint Anglo-French trial (calledCONCORDE) started in 1988 at a number ofcentres in U.K., Ireland and France to determinewhether symptoms free HIV infected individualswould benefit from starting treatment withZidovudine (AZT) immediately (Group Imm)rather than deferring it until onset of symptoms(Group Def, who initially received placebo). Theend points were progression to CDC Group IVdisease, i.e. AIDS, or 'minor' AIDS relatedcomplex (ARC) based on one or more minoropportunistic infections or one constitutionalsymptom, death, and severe drug toxicity. Thefindings, which cover the period upto December1992, are based on 1,749 persons (877 allocated toGroup Imm receiving 250 mg AZT four times aday and 872 to Gfoup Def given matchingplacebo). The average period of follow up was 3years.The trial did not show any significant benefitfrom the immediate use of AZT compared wjchdeferred therapy in symptoms free individuals interms of survival or disease progressionirrespective of their initial CD4 count. Thediscrepancy between this result and the significanteffect of “immediate AZT” on CD4 counts castsdoubt on the value of using “changes over time inCD4 count” as a predictive measure for effect ofanti-viral therapy on disease progression andsurvival. CONCORDE provides a validcomparison of the strategies of immediate versusdeferred treatment with AZT since there was aCONTEMPORARY ISSUESstriking difference between the two groups in theamount of AZT taken before progression to ARCor AIDS.Of the 877 persons in Group Imm, 'minor'ARC, AIDS or death were recorded in 263. Thecorresponding figure for Group Def was 284 outof 872.It may be of interest to note that three othersuch trials in the USA were stopped early on thebasis of improved CD4 counts in patientsreceiving AZT early in the disease but the averageperiod of follow up was only about 1 year. TheCONCORDE trial confirms improvement insymptom free HTV positive individuals receivingimmediate AZT 1 gm daily. However, follow upin CONCORDE is much longer than in previoustrials; at 3 years there was virtually no differencebetween the two groups. The findings will notdoubt be received with some gloom and suggestthat CD4 counts are not the best measure ofdisease severity.PREVALENCE OF INITIALDRUG RESISTANCETwo reports on “primary drug resistance” appearin Tubercle and Lung Disease; 1992, 73(April issue). In the Taif region in Saudi Arabia,initial drug resistance was 22.6%, with 53% resistantto two drugs, in South Africa, resistance to 5major drugs had actually decreased among theblack population, after a uniform procedure hadbeen followed for the last 25 years. Resistance toINH and Ethambutol fell significantly in the nineteeneighties compared to the seventies, but nonsignificantreduction was seen for other drugs exceptfor Streptomycin, where there was a marginalincrease. Some of the findings are given below:Resistance Patterns1965-70 1971-79 1980-88Pts. Res. Pts. Res. Pts. Res.INK 15960 28.8% 16322 23.2% 16430 14.2%Streptomycin 15963 33.8% 16344 10.6% 16420 12.1%Rifampicin 377 6.4% 2376 2.0% 16429 1.8%Ethambutol 2210 1.5% 4866 1.5% 16430 1.2%

Sir,The letter from Dr. M.M. Singh 1 is of greatinterest. It highlights the career prospects andproblems faced by the speciality of pulmonarymedicine. Over the last two decades, there havebeen rapid advances in pulmonary physiology,diagnostics, acute respiratory care andmanagement 2 . The departments of tuberculosisand chest diseases failed to apply enough financialresources to maintain pace with thesedevelopments. As a result, the training givenduring DTD and MD courses in respiratorydiseases has been limited only to tuberculosis,satisfying the initial objectives that wereintroduced in the 1960s. In a highly competitiveatmosphere, a medical graduate is keen to avail ofthe more challenging and dynamic opportunities.Unfortunately, due to the inadequate facilitiesavailable in the respiratory medicine departments,they fail to realise that respiratory infections arethe leading cause of death in developing countries.The problem is further complicated by theinternists who are unwilling to separate out thespeciality of pulmonary medicine 2 . Top calibrestudents also do not like to get involved with theavailable courses, like DTD and MD in respiratorydiseases.To develop the speciality of. pulmonarymedicine it would be necessary to attract and trainspecialists who shall devote full-time attention topulmonary medicine 3 . The task seemed difficult,but was correctly addressed by late Dr. S.K,Malik 2 . He appealed to the minds of internists andconvinced them of the necessity of having thesuper-speciality of pulmonary medicine, parallelwith that of cardiology and neurology. Twoattempts were made to achieve the goal: one wasthe upgradation of the training centres and theother was restricting training to only post-graduatestudents. The first one looked beyond the horizonof common respiratory problems and the secondattracted those in search of a firmer footing. Thebenefits of this system are expected to reach allthe corners of India in due course of time. But, theneed of the hour is to introduce the system at morecentres at the earliest.FORUMReferencesInd. J. Tub., 1993, 40, 1711. Singh, M.M. (Letter). Ind. J. Tub; 1992, 39,2. Malik S.K. Developing pulmonary medicine(pneumology) in India - a viewpoint. Ind. J.Chest Dis. All. Sci.; 1985, 27,254.3. Jain S.K. Is teaching and research in respiratorymedicine keeping pace with the clinical needs?(Editorial). Ind. J. Chest Dis. All. Sci.; 1988, 30,1.Sir,Ravindra M.SarnaikPGIMER, ChandigarhI read with great interest the article by Mohantyet al (Ind. J. Tub.; 1993, 40, 5) which raises somequestions. Lungs are the portal of entry for manyinfections. That may be the reason fe^ their notedpredisposition to infections when there isimmuno-suppressipn due to HIV and AIDS.Tuberculosis is, therefore, one of the mostcommon complications of AIDS.In this article, among the 37 patients suspectedof having pulmonary tuberculosis, only 31.59%were found to be positive for AFB. Nothing hasbeen mentioned about AFB culture results. Ifculture was negative too, fibreoptic bronchoscopycould have been done for aetiological diagnosis. Ithas been recommended that both bronchoalveolarlavage and transbronchial biopsy be performed asthe complementary yield from both the proceduresis very high. The use of induced sputum collectionhas also been recommended in the evaluation ofHIV-1 antibody positive patients with respiratorysymptoms as it reduces the number ofbronchoscopic examinations.Most of the cases of pulmonary tuberculosiswere diagnosed by chest roentgenograms. Thechest X-ray manifestations of pulmonarytuberculosis often correlate with the degree ofHIV induced immunosuppression. Amongpatients with relatively well preserved immunefunction, as manifested by die positive tuberculintest and HIV associated infection, chest X-rayfindingsare often similar to those of reactivation

172FORUMtuberculosis including cavitation and upper lobeinfiltrates. Among the more severelyimmunosuppressed patients with HIV infection,chest X-ray findings are typically those of primarytuberculosis in immunocompetent patients, suchas hilar adenopathy, pleural effusion and miliarypattern of the disease. Mediastinallymphadenopathy and pleural effusion may be dueto Kaposi's sarcoma or lymphoma. Miliary patternand lobar consolidation may be an atypicalpresentation of pneumocystis carinii pneumoniawhich may present as bilateral basal Sir,bronchiectasis or pleural effusion only. So, thediagnosis should be confirmed either by sputuminduction or bronchoscopy.Most of the patients in the study were treatedwith INH, Rifampicin and Ethambutol. However,it is recommended that tuberculosis with AIDSshould be treated with INH, Rifampicin andPyrazinamide initially and Elhambutol can beadded if initial drug resistance is suspected,especially in developing countries. It is felt thatthe 11 deteriorations during treatment could havebeen avoided.Gajanan Gaude,J.N. Medical College,BelgaumThe author replies :Culture for AFB is not done routinely in ourDepartment. Sputum is examined thrice for AFBby the smear test which is considered as good asculture Fibreoptic bronchoscopy is also not aroutine procedure. Comparisons were made on thesame basis in both groups..There are two temporal consequences oftuberculosis and HIV infection.(1) When tuberculosis infection is acquiredbefore HIV infection.This situation prevails in most developingcountries. After HIV infection, there isimmunosuppression which can cause breakdowninto active tuberculosis. The clinicalmanifestations of such a breakdown were given inour study.(2) When tuberculosis infection occurs afterHIV infection.This situation is met with in developedcountries. Tuberculosis, then, is of a disseminatedtype with lower sputum positivity rate and usuallynegative tuberculin test.Short course chemotherapy is adequate to treattuberculosis among HIV infected persons. Indeveloped countries 2HRZ+4HR regimen is used.However, we used the drugs that were available :2HRE+4HR and in extra pulmonary cases2HRE+7HR. The death of 11 patients in our serieswas due to complications.Short course chemotherapy (SCC) has come tostay in our country and the world over. Shortcourse chemotherapy regimens are beingrecommended for the treatment of all forms oftuberculosis, in children as well as adults, and byspecialists as well as general practitioners. It hasbeen shown that SCC is one of the best and mostefficient interventions as far as cost effectivenessis concerned.Now, with the spread of HIV infection, thedemand for anti-TB drugs has risen sharply in allcountries including India. Thus, the continuousavailability of these drugs has become all themore important.The demand for anti tuberculosis drugs varieswith the regimens chosen for use under theNational Tuberculosis Control Programme (NTP),the number of patients expected to be treated in ayear under the NTP and^also the chemotherapyregimens adopted by treating physicians in theirday-to-day practice.WHO & TAI already had a criterion toestimate the number of TB patients to be treatedin the country, i.e. yearly new detected cases± 10% - 15%, and this should give a fairly goodidea of the requirements of drugs for the country.Hence, it is high time for the Government of Indiato assess realistically the requirements of allGovernment, local bodies, charitable TB Centresas well as the general practitioners. But the basicneed is for ensuring low cost of drugs, withcontinuous supply to institutions and the market.The high cost of anti-TB drugs i.e. Rifampicin,Pyrazinamide, Ethambutol- and Isoniazid is amajor obstacle in practicing SCC treatment morewidely in India. This may also apply to otherdeveloping countries.

FORUMIt is a well known fact that the basic price ofdrugs does not correspond with the price at whichthese reach the patient. To the basic price,exorbitant overhead expenses are added, whichputs the drug beyond the reach of poor patients.It is suggested that Government of India berequested by the TAI to control the market priceof anti-TB drugs so as to reach the needy patientsat a low cost: price should not be more than 10%above the production cost plus taxes. TheGovernment should also be urged to ensure acontinuous supply (allocating more budget,centrally as well as by the states) of anti-TB drugsfor the NTP and TB Institutions. Alternatively, thegovernment may have a dual price policy i.e.drugs in the market may be sold at a higher priceand supplied to TB Institutions at a lower price.Genuine patients getting treatment from generalpractitioners may also get the drugs through thelocal TB Associations at the lower fixedinstitutional price.R.P. BhagiDelhi TB AssociationThe Editor comments :Ensuring low cost of drugs to the consumer is a173very complex proposition. In neighbouringBangladesh, Dr. Zafrullah Chowdhry hassucceeded in putting in place a people-orienteddrug policy, following largely the HathiCommittee recommendations (Editorial, Ind. J.Tub.; 1992, 39,65) of 1974, whereas we could notput our own house in order. Keeping the list ofdrugs available in the market to the bareessentials, reducing practices (such as hosting ofConferences, advertising, peddling of samples andliterature, etc.) which add huge overheads to thecost of production of drugs, rational drugprescription policies and consumer awareness aswell as education are the essential ingredientswhich can ensure availability of low priced drugsand drug formulations. While the WHO list ofessential drugs is about 270, it is believed thataround 60,000 drug formulations are available inthe Indian market. Whereas Dr. Zafrullah hasbeen honoured with the prestigeous MagsaysayAward, in 1984, for services to the people ofBangladesh, we are still arguing with our powerfulpharmaceutical corporations. Now, thecontroversy regarding our patent laws and theintellectual property rights leading to royalty to bepaid for a process or product has added to thedifficulties.

48TH NATIONAL CONFERENCE ON TU-BERCULOSIS AND CHEST DISEASESThe 48th National Conference on Tuberculosisand Chest Diseases will be held at GandhiMedical College Auditorium, Bhopal, from 9th to12th December, 1993. Those who wish to attendthe Conference may kindly contact the Secretary-General, Tuberculosis Association of India, 3, RedCross Road, New Delhi, 110 001 for furtherdetails.TECHNICAL COMMITTEE OF TUBER-CULOSIS ASSOCIATION OF INDIADr M.M.S. Siddhu, Honorary Secretary, UttarPradesh State TB Association has been nominatedas Chairman of the Standing TechnicalCommittee of the Tuberculosis Association ofIndia for the year 1993-94 vice Dr D.P. Vermawhose term came to a close with the lastTechnical Committee meeting held on 28thNovember, 1992. Dr M.M.S. Siddhu will also bePresident of the 48th National Conference on TB& Chest Diseases to be held at Bhopal from 9th to12th December, 1993.ORISSA STATE ANNUAL TBCONFERENCEInd. J. Tub., 1993, 40,174NEWS & NOTESREFRESHER COURSE ON TB & ALLERGYThe Moradabad Division TB Association, U.P.,held a refresher course on “Tuberculosis andAllergy” on 14.3.1993 at Moradabad. The Coursewas inaugurated by Dr D.P. Manchanda,Secretary, Vivekanand Research Hospital,Moradabad.ALL INDIA MEDICAL CONFERENCEThe 69th All India Medical Conference will beheld under the auspices of the Indian MedicalAssociation at Calicut in Kerala from 25th to 30thDecember, 1993. For further details, kindlycontact Dr K. Mohan Kumar, OrganizingSecretary, 69th All India Medical Conference,'Pushpanjali', Chalapuram, Calicut - 673 002(Kerala).SEMINAR ON “TUBERCULOSIS- A RATIO-NAL APPROACH TO MANAGEMENT”The Mandvi District Tuberculosis Associationorganised a seminar in collaboration with theIndian Medical Association, Kachh Branch, on“Tuberculosis- A Rational approach toManagement” on 14th March, 1993, at Jainpuri,Mandvi.The 8tli Orissa State Annual Conference on TB& Chest Diseases, organised jointly by M/s TataRefractories Ltd. and the Indian MedicalAssociation, Belpahar Branch was held atBelpahar on 14th February, 1993. The Conferencewas presided over by Prof. M.A. Rahi, Retd. Headof the Department of TB & Chest Diseases.Eighty-three delegates attended the Conference.NEW TB SEALThe Tuberculosis Association of India hasselected five photographs of VINTAGE CARS ININDIA as designs for the next TB Seal Campaign,the 44th in the series. It is expected that the sealswill prove popular, specially because the theme isof interest to children.GENERAL HEALTH CHECK-UP CAMPUnder the joint auspices of the TuberculosisAssociation of Andbra Pradesh and CosmopolitanEmployees' Cultural Association, a Health CheckupCamp was organised at Sharada KanyaVidyalaya School, Koti, Hyderabad on 30thJanuary, 1993. In all, 240 students were examined.ANTI-TB WEEK CELEBRATIONS INANDHRA PRADESHThe anti-TB week was celebrated in AndhraPradesh in the following districts:Ranga Reddy - The anti-TB week celebrationswere organised in Rariga Reddy from 17th to 23rdFebruary, 1993.

NEWS & NOTESHyderabad - The anti-TB week celebrationswere organised at State TB Centre, Irumnuma,Hyderabad, on 6.3.1993. The function wasinaugurated by Sliri P. Janordhun Reddy, Hon'bleMinister for Labour, Government of AndhraPradesh. Sliri Mohd. Khader Khan, DistrictRevenue Officer, presided over the function.Tarnaka - The anti-TB week celebrations wereorganised at A.P.S.R.T.C. Hospital, Tarnaka on26.2.1993. Dr K-.J.R. Murthy, Consultant,Mahaveer Hospital inaugurated the celebrationswhile Dr D. Padmanabhan, Chief Medical Officer,A.P.S.R.T.C. Hospital, presided.Karimnagar - The anti-TB week wascelebrated by the Karimnagar District TBAssociation from 17th to 23rd February, 1993.Chittoor - During the anti-TB weekcelebrations, the Chittoor District TB Associationorganised an “Update Session on TB and ChestDiseases” on 20th February, 1993, at Z.P.P.Meeting Hall, Chittoor. Shri T. Janardhana Naidu,District Collector & Magistrate was the ChiefGuest. Dr M. Kuppaiah Chetty, District Medical& Health Officer, Chittoor, presided over thefunction.WORLD CONGRESS ON CLINICALCARDIOLOGYThe World Congress on Clinical Cardiology(WORLDCON-93 & ECHOVISION '93), officialcongress of the International Society forCardiovascular Ultrasound will be held from 9thto llth December, 1993, at Siri Fort Auditorium,New Delhi. An eminent faculty is incharge of theConference. There will be no registration fee. APERFECT HEALTH MELA '93 will also be heldfrom llth to 19th December, 1993, at TalkatoraGardens, New Delhi as part of the mass awarenessprogramme. A medical exhibition for doctors and175general public is also being organised. For details,kindly contact : Dr K.K. Aggarwal, Vice-President, B-95, Defence Colony, New Delhi.RESEARCH ON RESURGENCE OFTUBERCULOSIS DUE TO AIDSAccording to AIDS (1992, 6,744-746), WHOhas accorded high priority to studies on preventivechemotherapy against tuberculosis in countrieswith high incidence of tuberculosis and high orthreatened increase in HIV infection.ANNUAL CONFERENCE OF NCCP (I)The postponed 32nd Annual Conference ofNCCP (I) will be held at Varanasi Ashok Hotel(ITDC), Varanasi, from 28th to 30th August,1993. For further details, kindly contact Prof. D.C.Roy, Organising Secretary, Dept. of TB &Respiratory Diseases, Institute of MedicalSciences, Banaras Hindu University, Varanasi.17TH GUJARAT STATE TB WORKERS'CONFERENCEThe 17th Gujarat State TB WorkersConference, organised by the Gujarat State TBAssociation, was held on - : - th April, 1993 atAhmedabad. The Conference was inaugurated byH.E. Dr Sarup Singh, the Governor of Gujarat andpresided over by Dr S.H. Patel, Chairman of theAssociation. Dr-Mukul Shall, the Governor ofAhmedabad Municipal Corporation, distributedthe TB Seal Sale Trophies. Dr D.R. Nagpaul,Hony. Technical Adviser, TB Association ofIndia, delivered a Guest Lecture on “PulmonaryTuberculosis & AIDS”. In all about 425 delegatesattended the Conference.

Ind. J. Tub., 1993, 40, 176GUIDELINES FOR CONTRIBUTORSGeneral1. All correspondence relating to the IndianJournal of Tuberculosis (IJT) may please be addressedto:The Editor, Indian Journal of Tuberculosis,Tuberculosis Association of India,3, Red Cross Road, New Delhi-110 001.While forwarding an article for publication, theletter must be signed by all the authors. It shouldalso be certified therein that the article has notalready been published or submitted forpublication and if accepted by IJT will not later bepublished elsewhere.2. The four issues of IJT, appearing everyyear in January, April, July and October, containoriginal articles on all aspects of tuberculosis andnon-tuberculous respiratory diseases, case-reports,reviews and leading articles (see item 6) as well asabstracts of articles/matter published in other scientificjournals and books dealing with same subjects.Besides, each issue has an Editorial, sectionson Contemporary issues and Continuing MedicalEducation, News and Notes as well as Forumwherein readers can express opinions on the publishedarticles or ask questions on the subjectscovered by the Journal. Orations and guest lecturesare published in the July issue, along withthe most important papers presented at the AnnualConference of Tuberculosis and Chest DiseaseWorkers and the summaries of unpublishedpapers.3. Two copies of the article (including diagramsand photographs) typed on one side of thepaper with double spacing and wide margins shallbe submitted.4. It is understood and accepted that thesubmitted matter would be editorially revised tomake it suitable for publication. The decision ofthe Editor regarding acceptance or revision cannot be contested. However, every effort is made tocommunicate the reasons or deficiencies to theauthor(s) in order to associate him with the stepsto improve the article.5. All the received articles are serially registeredand usually published in the order of registration.However, the date of registration will beafter the completion of the basic formalities, if theauthor(s) has overlooked these guidelines. The articlesregistered are reviewed by the IJT EditorialBoard to judge suitability for publication and togive suggestions for improvement.6. Original articles deal with planned studiesthat have been duly completed and conveydefinite conclusions from the data presented in thetext. However, preliminary communication fromresearch still in progress could be submitted, exceptionally,if the topic is important and the interimresults could be of interest. Case-reportspresent problems of unusual clinical interestwhich have been systematically and fully investigatedand where a firm diagnosis has been establishedwith reasonable certainty or the result oftherapeutic management is of great significance.Review Article are those specially requested frompersons who have acknowledged competence ingiven subjects. These are useful for updatingknowledge. Leading articles are contributed bythose who have expertise in selected aspects of asubject.Forum provides a platform to readers forexpressing opinions and a channel ofcommunication with the Journal and its otherreaders. It could be used for making suggestions,scientific critique on published articles or forreaching independent conclusions, askingquestions on the subjects covered by the Journaland for providing supplementary informationeither confirming or contradicting the conclusionsreached in the articles.7. Twenty-five reprints of each publishedarticle are supplied free of cost to the authorwhose address is indicated for correspondence.More reprints are, exceptionally, supplied if theorder is placed at the time of acceptance of the article.The cost of the order will be intimated andmust be paid for in advance of the publication ofthe article.Format and Procedure8. All submitted articles shall have a definiteformat. Each article should comprise sectionsad seriatim, on Summary, Introduction, Materialand Methods, Results, Discussion, Acknowledgements(if necessary) and References. Additional

GUIDELINES FOR CONTRIBUTORS 177sections could also be interposed. In Case Reports,the sections on Material and Methods and Resultsare replaced by the section “Clinical Record” andall other sections are appropriately shortened.Care shall be exercised in making the languagegrammatically correct and free flowing, as far aspossible, ensuring that all pertinent informationhas been included, irrelevant details omitted andrepetitions, especially from section to section,avoided. Tables and figures must be self explanatoryand their number kept to the minimum.It is not usually necessary to present thesame information both in a table as well as diagram:the more effective of the two presentationshas, therefore, to be chosen. Tables mustbe numbered, have a descriptive legend on thetop, minimum essential data in the body and necessaryexplanatory notes at the bottom. Tables(and diagrams) should be made on separate sheetsof paper, with their place in the text indicatedclearly, and attached at the end of the article.Drawings are best made with black India Inkand of a size larger than required in the text.Legends for the photographs should be typedseparately with appropriate indication regardingthe photograph to which a legend pertains. Photographs(black and white prints) should be clear,glossy and unmounted. The attached sheetsshould carry the title of the paper and name ofthe author in pencil on the backside. Photographswith poor contrast may not be accepted.Photographs, inscribed in pencil at the back,should be put in an envelope and properly labelledon the outside and attached to the article last.It is understood that the planning of the studysubmitted for publication as well as the analysis ofthe data, presentation in the text and the reachingof conclusions have been done in consultationwith a statistician.9. After the title of the article, the name ofthe principal author should be followed by surnameof each author.10. The position held by each author in anyinstitution is indicated only in the footnote againstArabic numerals indicated on the top of eachname. This information is followed by any specialannotation such as title of oration, or, say, paperpresented at a scientific conference, etc. Lastly,the name and address of the author to whom correspondenceregarding the article has to be sentshould be indicated.11. In respect of preliminary communications,the nature of the paper must be clearlyindicated so that editorial processing could bespecially expedited.12. References cited in the text and at the endshould conform to the procedure recommended bythe International Steering Committee of MedicalEditors. Therefore, special care must be taken toensure that:- Only the most important publishedpapers related directly to the study inhand are cited in the text.- Text reference should be numbered inArabic numerals as a suffix in the orderof their mention, avoiding the names(s)of authors(s) and year of publication.- While citing an abstract (when it is thesole source of information) or personalcommunication or unpublished work inthe text, authors must provide thenecessary particulars of the source, butthis is not a preferred mode of citation.Permission from the source(s) ofinformation for citing their work must beobtained beforehand.- AH the numbered references in the textshould be typed out in detail, in thesame consecutive order, on a separatepage and attached at the end.Abbreviation of the titles of the citedjournals should be according to theIndex Medicus. Example;Kakar, A., Aranya, R.C. and Nair,S.iC. : Isolated gastric tuberculosis;Ind. J. Tuber.; 1979, 26, 205.Crofton, J. and Douglas, A. : RespiratoryDiseases, 1st Edition, Edinburgh,Blackwell Scientific Publications Ltd.1969.13. The abbreviations or acronyms used inthe text must be defined at the first mention. Theirnumber should be kept to a minimum.14. Contributions to Forum should be in theform of letters to the Editor. Such letters must bebrief and to the point : only the most importantagreements/disagreements/suggestions on publishedpapers may be chosen for commenting. It isusual to send a copy of such letters to the authorconcerned for obtaining a response, if any, aftereditorial reformulation. The response, similarly,has to be selective, brief and relevant.