REPORr OF THE REGIONAL COMMITTEE
ANNEX 4
(WP/RC10/16) TECHNICAL DISCUSSIONS
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::"1JBJECT
In accordance with the decision of the ninth Regional Committee the subject of the Technical Discussions was ftTuberculosis Control'. The purpose of the discussions was to present the concept of tuberculosis . control as an integral part of a general public health programme. a control programme might be based on three main principles, viz. Prevention, Prevalence Surveys, and Domiciliary Chemotherapy of those cases 'Which are found. Such
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ORGANIZATION Three sessions were held, each occupying one half day.
2.1 The first session was .opened by the Chairman who explained the procedures and techniques, and designated the leaders of the discussion groups. The first topic)}prevention, was introduced by a member of the The meeting then
Secretariat in a talk of thirty minutes duration.
broke up into three groups, each of which discussed the 'Whole topic as it wished.
2.2 The second session was a plenary dealing with ;Prevalence Surveys. An expert panel 'Which included a public health administrator as
Moderator, discussed the subject for thirty minutes.
The members then
broke up into small groups of three to four members and considered questions which they wished to present to the panel. These questions
were then presented to the panel by one member of each group, and the
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REGIONAL COMMITTEE: TENrH SESSION
panel replied to as many questions as could be handled in the time available. Moderator. 2.3 The third and final session was a plenary session dealing with the topic of Domiciliary Chemotherapy. At this session, the group The whole discussion was concluded with a summary by the
also heard an expert panel discuss some of the problems of domiciliary chemotherapy, and this was followed by questions from the floor. The
Technical Discussion group also at this session considered the reports of the two previous sessions, and held a final summary discussion of the subject as a whole. Formulation of recommendations to the Regional
Committee for the subject of 1960 Technical Discussions took place.
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DISCUSSION GROUPS
During a thirty-minute presentation, the Secretary presented in broad outline some of the aspects of Prevention, which included health education of the public as a means of ensuring their co-operation in a control programme, prevention by means of vaccination, and management of the chronic case by the use of iso-nicotinic acid hydrazide as a continuous form of therapy. The difficulty in
re-orientation of the people to a realization that tuberculous disease is a community problem rather than a purely individual one, and should be dealt with through community co-operation, may require a revision of the approach to health education. In regard to BCG vaccination,
the remaining reservations in regard to the freeze-dried vaccines \V"ere noted. It was emphasized that selection of those persons most likely
to benefit by protective vaccination is not easily carried out without preliminary studies of tuberculin reactivity in the particular areas.
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In the handling of the chronic cases, segregation may not always be practical nor economically feasible. For this reason, and in view of
some of the experimental studies performed "\-nth INH resistant tubercle bacilli, there may be valid justification for the use of INH alone in the permanent therapy of these people, rather than in the use of many drugs in different combinations. The three discusslon groups considered all the .]!oints which had been raised. All three groups considered i-"""'~
the public health workers
are most suitable to carry out health education of the public and that they are doing so during the course of their work in tuberculosis control. All agreed that health education in the schools, particularly
of the young people, is important, and that this eventually leads to better attitudes on the part of the ~eople
as a whole.
It was also
agreed that any method which brings the control programme to the attention of the con~unity
is a form of health education.
This applies
to "Demonstration Areas If as 'fell as to general health activities. In regard to BCG v&ccination, all groups agreed that BCG vaccination is an important part of ~
control programme, but that its applicaIn regard
tion may vary from place to place depending on local factors.
to freeze-dried vaCCine, some discussants pointed out that in certain areas which are very c1.:....fZicc..:.:G "-': c.ccess, a BCG progremme could only be carried out if a freeze-dried preparation can be used. For this
reason, although the consensus of opinion was that a wet vaccine should be used where this is practicable, the freeze-dried preparation, despite some still unanswered questions, might be used in areas where problems of supply and dc~ivery
preclude the use of wet vaccine.
Some fears
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REGIONAL COMMITTEE: TENTH SESSION
were expressed that a BCG campaign may destroy the value of the tuberculin test in those areas where this has been used as a method of determining tuberculosis rates in the past. In the management of the chron).c case, all groups were of the opinion that segregation is the most ideal means of management. However, it was also the opinion of all groups, that this method is not practical, even where the Government is able to provide free hostel type of permanent accommodation for such people. It was
generally agreed that at present, the best way of handling such cases is by the continued administration of anti-tuberculous drugs on a domiciliary and ambulant basis. In regard to the pathogenicity of
INH resistant organisms, the discussants noted that observations had been made suggesting that these organisms are less pathogenic to animals, but preferred to reserve their opinions in regard to the pathogenicity of such organisms in humans.
4
FIRST EXPERI' PANEL
The panel presented their views regarding the essential difference between case-finding surveys and those which were planned and carried out as prevalence surveys. The need for accurate data on which to
establish a tuberculosis programme was presented as a reason for carrying out such a survey, although in some areas where there is a good and well-established system of notifications, this may now be of less importance than in other areas. Methods and techniques which
could be employed were reviewed by the panel and it was considered that a combination of techniques was better than one method alone. The need for standardized methods which would be applicable in many
REPORI' OF THE REGIONAL COMMI:TTEE
areas, and the importance of standardization in making comparative studies between countries were discussed. The panel thought that polyvalent After the groups
surveys could be valuable in certain circumstances.
had discussed the various points, several groups expressed the thought that prevalence surveys are desirable and that international standards should be used. During the general discussion which followed it was agreed that mortality rates are no longer adequate to assess the problem in a community and that morbidity figures based on notifications are often inaccurate. ~~ere
communications are poor and facilities so lacking
that a survey is impractical, this usually also indicates that in such an area, a tuberculosis progranune is also impractical, and that these areas should be excluded from the survey. The duration of the survey
may be variable, but should be as short as is possible and should be repeated at appropriate intervals. The answer as to what use is made
of the data acquired was that this should enable the programme efforts to be concentrated on those areas where the prevalence is highest, and when cases are found in the survey, treatment should be initiated on a domiciliary basis through the existing health agencies. Finally,
it was stated that villO has for some time been stimulating the X-ray manufacturers to develop a truly portable machine and that some progress has been made in this direction.
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SECOND PANEL PRE 51!:NrATI ON
The third session commenced with a panel presentation of the third topic, Domiciliary Chemotherapy. The organization necessary to implement
such a programme must include a means of drug distribution which may be
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REGIONAL COMMITTEE: TENTH SESSION
either through existing health agencies or through new special agencies planned for the management of tuberculosis. \-)here agencies already
exist, they should be utilized, and if there are none in the area concerned, the panel considered that voluntary organizations might be encouraged to carry out the distribution of drugs, with supervision by technical staff from some health body at a higher level. The use
of polyvalent health personnel has much to commend it, and the use of vOluntary worl"ers is also valuable as a part of the health education of the public. The panel considered that the most valuable drug was INH, used either alone or in combination with PAS. However, as PAS sometimes
produces unpleasant side reactions and must be taken in large doses, patients may reject it or it may lead to their ceasing to take other drugs prescribed in association with it. For this reason some of the
panel members favoured the use of INH alone, and as PAS is costly, the economy of using INH alone also makes this drug more acceptable from a budgetary aspect when supplied by governments. treatment under ideal conditions, ~th
The results of
many home visitors and close
supervision of the patients, is very good, but the rates of sputum conversion similar to those obtained in the Madras study cannot be expected under less favourable conditions. So far as hospitalization
is concerned, the panel considered that hospital beds should be used only for those cases requiring surgery or those who were acutely toxic, such as cases of miliary disease or of meningitis. other
social and financial problems involved in domiciliary therapy programmes were not considered by the panel because the time was limited.
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Some questions from the floor were concerned with the organization of drug distribution, and the panel considered that this could be done by untrained workers provided there was some technical supervision. Some panel members thought that a token payment for drugs is desirable, but others considered that, as tuberculosis control is a community matter, drugs should be provided free of charge to the patients. There
was considerable discussion on the meaning of the word "chemoprophylaxis", when INH might be used prophylactically, what dosage of INH should be given, and for what period of time. These questions were not resolved.
Most panel members did not favour the use of a tablet containing both INH and PAS because of the large numbers of tablets which need to be taken, and the possible side reactions to the PAS which might mean that patients did not take any drug if two drugs were combined in one tablet. The care of family contacts of cases under domiciliary
chemotherapy must be cased on BCG vaccination, the education of the family in health care, and the continued observation of those family members who are liable to become infected.
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GENERAL DISCUSSION In the course of general discussions, it was considered by the
group that special tuberculosis hospitals are probably no longer required in any newly established scheme, and that beds for tuberculosis patients might with advantage :e provided in general hospitals. In regard to chemoprophylaxis of the uninfected person, the insufficient knowledge available might preclude any such scheme at the present time. It was also emphasized that improvements in sanitation, nutrition, social and economic conditions have played a very important part in
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reducing the prevalence of tuberculosis in some countries, and these factors should not be ignored. It was concluded that the new trends
in tuberculosis control have made control programmes practical in many areas where they had previously been too costly for implementation.
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SUBJECl' FOR 1960 The group recommends to the Regional Committee that the subject
for the Technical Discussions in 1960 should be ftThe Organization and Administration of Rural Health Services ft •
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EVALUATION QUESTIONNAIRE
T"l,renty-eight evaluation questionnaires were returned, and of these, six regarded the discussions as excellent, seventeen rated the discussions as very good, and five as reasonably good.