Brit. 07. Dis. Chest (x959) 53, 372.

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA

A P R E L I M I N A R Y R E P O R T ON 7,858 CASES T R E A T E D IN T HE T R A N S K E I A N T E R R I T O R I E S

J. F. TAUTE AND C. J. RABIE

Tembuland Hospital, Umtata, South Africa

THE Transkei is an area in the north-eastern Cape Province, i6,554 square miles in extent, and mostly undulating grassland country in nature. The climate varies from a subtropical one along the coast to one of extremes of heat and cold at the higher inland altitudes. The average summer rainfall is 3o inches.

The population comprises 1.6 million Bantu and 180oo Europeans. The Europeans live in 28 villages with populations varying between x5o and 6oo; the distance between these villages varies from 2o to 5o miles.

The Bantu live a rural life under the tribal system: their huts--single wattle and daub structures with thatched roofs and clay floors--are fairly evenly distributed over the entire area.

An estimated 24o,ooo Bantu males are continually away from the area, working in mines and industrial centres: there is thus a continuous flow of labourers to and from the cities. The majority of Bantu are par t ly dependent upon relatives employed in urban areas.

The main crop is maize: cattle are still regarded as a measure of wealth rather than as a source of food.

The Transkei is traversed by I,I5O miles of main road and 5,ooo miles of subsidiary roads: large stretches of the latter are, for days on end, impassable during the rainy seasons.

DOMICILIARY TREATMENT

Domiciliary treatment of tuberculosis was instituted in September 1955: at that time the estimated number with active pulmonary tuberculosis was 25,000 to BO,OOO (Wiles and Rabie, 1955).

About 500 beds were available for patients with pulmonary tuberculosis. The assistance of 3 ° part-time district surgeons, eleven Mission Hospitals

and one Health Centre was enlisted. By ufilising the clinics thus available, domiciliary treatment could be carried out at some 300 points in the area.

Twelve X-ray machines were scattered throughout the area, and it is estimated that 75 per cent. of clinical diagnoses were radiologically confirmed.

The standard treatment consisted of one weekly injection of 2 g. of strep- tomycin and 400 rag. of I N A H daily. In April 1957 the dose of INAH was doubled and fixed at I O to I2 mg./kilo/day.

O f the cases diagnosed, roughly 80 per cent. live within a radius of 5 miles (Received for publication aVune I5, I959.)

DOMICILIARY T R E A T M E N T OF PULMONARY TUBERCULOSIS IN A R U R A L AREA 373

f rom the nearest t r ea tmen t point. Patients walk to their centres: only very occasionally is use made o f t r a n s p o r t - - b y sledge or on horseback.

After the scheme had been in opera t ion for two years the gathering of certain informat ion was a t t empted : the total diagnosed now n u m b ered 16,ooo.

In compil ing this informat ion the districts concerned were l imited to those where the original X-rays of cases on t rea tment were reasonably available. Districts excluded were those wi thout X- r ay facilities or those where the X - r ay filing systems prec luded the finding of requi red plates.

The selected districts were visited by a mobile X- ray unit and its staff (a European dr iver -opera tor a n d a Bantu clerk); each pa t ien t present was X- rayed and also furnished a spu tum specimen. In addit ion, the a t t endance card or register for each pat ient was scrutinised. T h e two mobile X- ray units thus visited 2o 3 different t r ea tment points.

T h e informat ion collected is reflected in Tables i to 13.

TABLE I . - -DISEASE CLASSIFICATION OF 7,858 CASES OF PULMONARY TUBERCULOSIS DIAGNOSED OVER A TWO-YEAR PERIOD. T H E DISEASE GROUPS ARE DIVIDED IN SEX AND AGE GROUPS

Disease classif.

M i n . . . , , Mod . . . . . Adv . . . . . Gr. des . . . . . Prim . . . . . P1. eft. . . . .

Size of groups ..

-5Y. 6-I5y.

M. F. eL •

0.8 1.7 20. 3 18. 5 I4"O 15"3 4"5 2"8

60" I 60. 3 0"3 0"4

627 629

M. F. , x.____,

5"6 5"8 13"8 23"3 26"1 22-0 9,7 7"5

44"0 39"7 0.6 I "7

268 399

I6-34Y. 35Y. and over Whole group

M. F. M. F. 34. ~ M . & F .

8.8 io. 7 8.2 8, 4 6.6 7"5 7"2 32"8 28.0 32"8 37"6 38"I 37"4 39"0 40"5 I4"6 19"6 13"3 9"7

I '5 I '2 0.6 0. 4 4"2 3"1 6.i 3"4

6 2 I I ,O23 ~ 2,I42 2,082

29"8 30"2 30'2 34"2 34"I 34"0 IO'6 IO '7 IO'6 I4.6 I4.8 I4. 5 4"2 2"7 3"5

3,658 4,200 7,858

Age groups as % of total

ioo% ioo%

1,323 I6"9%

ioo% ioo%

667 8.5%

Recent disease in adult group . . . . Fibrotic disease in adult group . . . .

Size of groups

ioo% ioo%1

1,644 21"10//0

53"3 56"7 46"7 43"3

630 979 ioo% ioo%

IOO% IOO%

4,224 53 "4%

49"3 53"0 50"7 47"0

2,o46 2,o2o IOO% I00%

ioo% ioo% lOO%

7,858 1OO%

50"2 55"6 52 "5 49"8 44"4 47'5

2,676 2,999 5,675 lOO% lOO% ioo%

T h e figures regarding X- ray improvemen t are not based on the total n u m b e r of pat ients in any par t icu lar g r o u p - - i n a considerable n u m b e r the progress remained unknown for reasons indicated below.

At t imes inclement wea ther made it impossible to visit cer tain points on the day specified: patients a t tending such points could therefore not be X-rayed. Bad roads, b reakdown of the X- ray unit and poor organisat ion in some dis- tricts were addi t ional reasons why follow-up X-rays could not always be done.

Grea t difficulty was also encountered in the spelling of Bantu names: the use of al ternat ive names by the same pat ient on different occasions resulted in the loss of a large n u m b e r of follow-up X-rays.

374 TAUTE AND RABIE

Final ly there were those cases who, for no known reason, failed to turn up on the occasion the X- r ay unit visited their t r ea tmen t point. This group pos- sibly stayed away for some reason related to X- r ay c lea r ing- - such reason, how- ever, cannot be envisaged. (See Tables 6 and 7-)

This aspect of the investigation, at first sight, appeared unsatisfactory. After careful consideration, however, and also with the expressed approva l of the Depar tment ' s statistical consultant , it was decided tha t the figures obta ined are p robab ly significant.

TABLE ~,--DIsEASE CLASSIFICATION OF A FEW SUB-GROUPS

Disease Classif.

Minimal . . . . Moderate . . . . Advanced . . . . Gross destruction.. Primary P.T.B. .. Pleural effusion ..

Number of cases ..

Recent dis. .. Fibrous dis. ..

Number of cases ..

Cases diagnosed over 6-month period two years ago

7"4% 26"8% 36"6% I5"o% Io"7% 3"5%

1,55I I00%

49"5% 5o'5%

1,346 100%

Cases diagnosed during past

6-month period

8.I% 32"7% 33"4%

7"3% I4"8 % 3"7%

2,599 IOO%

58.8% 41"2%

2~I3I 100%

Cases diagnosed but never

reported for treatment

8"3% 30"0% 28.7% m'7% I9"5% 2.8%

515 I00~o

55"0% 45"0%

4o2 I00%

Cases diagnosed by Mobile

Unit (Suspects)

1o'3% 42"I% 355%

5"I% 2"7% 4"3%

647 100%

58-5% 41 "5%

608 I00%

DISEASE CLASSIFICATION

(a) Disease Classification of 7,858 Cases of Pulmonary Tuberculosis diagnosed during a Two-year Period (Table I)

In the age group " 5 years and younger," about 4o per cent. have more than a primary complex.

The age group " 6 to 15 years," as is expected, is a small group. Here, too, 33 per cent. have advanced or grossly destructive lesions.

In the " i6 to 34 years " group the females predominate: 62 per cent. to the 38 per cent. males. This is also the group having the highest percentage of grossly destructive lesions; furthermore the percentage among the females is higher than among the males. This is doubtless explained by the fact that this age group covers the child-bearing period of the female-- the period asso- ciated with greatly increased physiological stresses.

In the group " 35 years and older," which forms 53 per cent. of cases on treatment, the cases with advanced lesions form 51 per cent.

There appears to be no great difference in the stage of advancement of the disease at the time of diagnosis between the two adult age groups, or between males and females.

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA

TABLE 3A.--ATTENDANCE AND PERCENTAGE NOT COMPLETING TREATMENT

Attendance during first six months o f treatment

375

Dis. dassif.

Minimal .. Moderate .. Advanced .. Gross destr... Primary .. Pleural e f t . . . Recent d i s . . . Fibrotic dis... Unclassif. ..

Whole group Size of group

°.

° .

I 6

. .

C l a s s

I att.

54"0% 52"8% 5,'8% 52"2% 38-4% 45"% 50"3% 54.8% 45"5%

48"5% 3,499

Class 2 art.

23-3% 22.8% 22"7% I9"7% 24"9% 26-':'% 23"6 % 2 I ' 5 % ,8-,%

2o-6% 1,484

C/ass 3 att.

9"7% 9"7% 9.8%

,0.8% I3"6 % I,'7% 10"7% 8"9%

IO'I~/o

IO.6% 753

a¥ot compltg.

,3"0% 14"7% I5"7% '7"3% 23",% i7.o % '5"4% ,4"8% 26"3%

~o'3% ,,467

No. cases

3oo lOO% I ,")88 IO0~o 1,569 lOO%

522 ,00% 652 ioo% I53 I00%

2 ,o6 I IOO°/o 1,649 IOO% 2,729 lOO%

7,2'3 ,00% 7,213

• Attendance during second six months o f treatment

Minimal .. Moderate .. Advanced .. ~ross destr. ~. Primary .. Pleural eft. .. Recent d i s . . . Fibrotic dis... Unclassif. . .

Whole group Size of group

. °

° . I O

. °

Class I art.

49"3% 46"7% 42"5% 46.o% 3 2 " I % 4o'3% 42"5% 47"8% 433%

43"4% ,,6,6

L

Class 2 art.

27"0% 26.6% 28'5% 22.20/0 26.7% 27"3% 29"2% 24"7% 20"0~o

24"2% 896

Class 3 att.

,3"0% ,6"o% 18"3%

,4-6% 22"1% 26"o% 17"3% ,5"2% ,6"9%

17"2 % 64o

Not cmpltg.

io-8% Io'7% lO'7% I7"2% I9"I% 6"4%

I I "0% I2"3% 19"8%

,5"2% 565

d~O. c a s e s

( ,,,

'73 ,GO% 638 lOO% 857 1oo% 308 IOO% 262 lOO% 77 lOO%

I,O63 ,oo% 927 lOO%

,,4o2 ioo%

3,717 lOO% 3,717

52.5 per cent. are diagnosed as disease of recent standing (minimal, moderate or advanced) and 47"5 per cent. as predominantly fibrofic disease. Fifty-five per cent. of adult females have recent disease.

The classification into recent and fibrotic disease was attempted despite the fact that radiological differentiation between the two can at times be difficult. The consistent variation in radiological response to treatment (Tables 8 and i o), however, suggests that such differentiation becomes a useful prognostic aid.

As will become evident, this high incidence of fibrotic disease constitutes a great obstacle to the effective treatment of pulmonary tuberculosis in the Transkeian native population.

Of 3,991 patients commencing domiciliary treatment, 1,636 had resided in urban areas for periods exceeding two months. Of these urban dwellers, i, 105 had worked underground in gold mines.

376 TAUTE AND RABIE

TABLE 3B.--PERCENTAGE NOT COMPLETING THIRD AND FOURTH Six MONTHS OF TREATMENT

Minimal . . . . Modera t e . . . . Advanced . . Gross destruct ion . . Pr imary . . . . Pleural effusion . . Recent disease . , Fibrous disease . . Unclassified . .

Third six months' treatment

,,X

No. cases % treated

NO. cases treated

94 11"7 40 295 I I ' 2 97 417 I6"8 II 9 '

88 14"8 31 I I3 15'9 36 43 23"2 15

477 I7 '8 I22 425 9"8 I7I 541 17.6 I I6

1,598 I5"8 454 I3"6

Fourth six monthS' treatment

%

~'O 15" 5 I4" 3 9"7

19" 5 20"0 15-6 12- 3 I3"O

(b) Disease Classification in a Few Sub-groups (Table 2) Table ~ indicates that cases are now being diagnosed earlier in the course

of the disease: more now classify as having moderately advanced lesions and less as grossly destructive lesions than applied two years ago. The percentage of patients with recent disease (as contrasted with those having fibrotic lesions) is also greater now than two years ago.

This tendency towards earlier diagnosis can only be considered a favourable trend if the total number diagnosed during successive periods diminishes.

It is of interest that the ratio of cases commencing treatment to diagnosed cases who never present for treatment is relatively constant and unaffected by the disease classification. The probable explanation is that the decision to undergo treatment or not is a question, generally, of Bantu temperament rather than of any appreciation of the severity of the disease.

The small percentage with primary tuberculosis of those diagnosed by the mobile unit (as contrasted with the main group) is due to the fact that children under Io years of age are not being X-rayed by these units.

TABLE 4.--COMPARISON OF ATTENDANCE OF THE " E x T.B. HOSPITAL" GROUP OF OUT- PATIENTS WITH THOSE WHO STARTED TREATMENT AS OUT-PATIENTS FROM THE TIME OF DIAGNOSIS

Ex Hosp. Group

Non Hosp. Group

ATTENDANCE

First term Second term

2,515

No. of Class cases Z

745 64"°~

67"3~

Class Class I I I I I

23"8% i2.2%

23"6 % 9"o%

No. of Class Class case______~sI____~ I I _

423 57"0% 24"0%

1,558 56.0% [ 28.2%

Class I I I

18.3%

I5"2%

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA 377

ATTENDANCE AND CONTINUATION OF TREATMENT

Class I a t t enders - - those who a t t end on 75 per ccnt. or more of all possible occasions. Class I I a t t cndcr s - -as above, 5 ° to 75 pe r cent. Class I I I a t t ender s - -as above, less t han 50 per ccnt.

(a) Attendance during Four Successive 6-month Periods (Tables 3 a and 3 b) The overall attendance for treatment is disappointing; it is slightly better

during the first six months than during the second. As with patients failing to commence treatment, it is noted that the ratio

of good to bad attenders is relatively constant and unaffected by the disease classification. The proportion who fail to complete treatment is similarly constant.

The worst offenders are the mothers responsible for the attendance of those cases with primary tuberculosis--in this group the percentage who fail to complete treatment is also the highest.

Of patients who commence treatment, 2o per cent. fail to complete the first six-month term. This figure drops to about I4 per cent. per term for the second, third and fourth six-month terms.

TABLE 5.--THE DISEASE DISTRIBUTION AMONG THE ABSCONDERS AT THE ]~ND OF FOUR SUCCESSIVE SIX-MONTH PERIODS

Min. T.B . . . . . Mod. T.B. .. Adv. T.B . . . . . Gross destr. I Pleural eft. Prim. P.T.B. ..

No. of absconders . .

ist term 2nd term 3rd term 4th term

5"3% 26.8% 33.o% I2"3% 3"5%

20"1%

6"5% 24.1% 32"I% 18"3% 1.7%

I7"3%

7"2% 21"3% 45"x% 8.4%

6 . 4 % i 1.6%

739 xoo% I 289 lOO% 155 IOO%

4"4% 33"3% ~7"8% 6.7% 2"O°/o

I5"6%

45 ioo%

Of patients who commence treatment, 50 per cent. fail to complete the two-year period.

It has not been possible to determine the fate of these patients--the magni- tude of such a task can only be appreciated if the terrain and the nature of the people is known. An attempt to achieve this will, however, be made in the near future.

(b) Attendance o f " ex-tuberculosis hospital" group (Table 4) These cases all belong to a group who were X-rayed at the time of the visit

of the mobile unit, i.e. they all attended on a particular day specified two to three weeks previously. The chances were, therefore, that they would be better attenders generally--confirmed by the fact that the Class 1 attenders are higher (66"5 per cent.) than in the overall group.

The figures indicate that the ex-hospital group attends no differently from those whose treatment was instituted without prior hospitalisation.

378 TAUTE AND RABIE

TABLE 6.--R.ELATION BETWEEN RADIOLOGICAL EVIDENCE OF IMPROVEMENT AND SUBSEQUENT ATTENDANCE

Radiological Second term attendance of first term Class I attenders changes during

the 1st term No. Class treatment cases I

Improved ..

i.s.q . . . . .

Deter. ..

Improved ..

i.s.q . . . . .

Deter. ..

Improved

i.s.q...

Deter.

o.

3o4 lO0~/o 217 IOO~/o 25 I00~/o

7 2"0

60.0

80.2

Class I Class H III

I8-1 4.8

IO'I 5"3

28.0 8.0

Second term attendance of first term Class II attenders

No. Class Class Class cases I II III

1o3 IO0~/O 77

IOO~/o i8

1OO~/o

No. cases

3I 1OO%

I7 I00~/o 6

lO0~/o

9"7

I3.O

22.8

54"4

63 "7

22"8

23 "3

z4.2

22"2

Second term attendance of first term Class III attenders

Class Class I II

3"2 22"5

o 23"5

o 16.6

Class III

64"7

59"o

33 "4

Not completing

5"I

4"4

4.o

,Not completing

12.6

9.1

22"2

Not completing

9.6

17.6

50.0

(e) Disease Distribution among those who failed to complete the Four Successive Six-month Terms (Table 5)

Tab le 3 indicates tha t the proport ions of those failing to complete the various terms are very similar; Tab le 5, however, indicates that , o f all who fail to complete their t rea tment , almost hal f classify as having advanced or grossly destructive lesions.

The difference in the percentages in Tables 3 and 5 are accepted as being due to the difference in size o f the disease groups.

(d) The Relationship between Radiological Improvement and Subsequent Attendance (Tables 6 and 7)

General ly, the best at tenders dur ing the second te rm are those whose X-rays remained unchanged dur ing the first term.

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA 379

The worst attenders during the second term (and also the greatest percent- age failing to complete the second term) are those who deteriorated during the first term.

The cases who show radiological improvement fall between the above two groups as regards their subsequent attendance.

It is suggested that those who improve feel well enough to become irregular and to discontinue their treatment, while those who deteriorate become dis- couraged or too ill to persevere with their treatment.

It must be noted, however, that the vast majority of patients remain in the same attendance class during the first and second terms: again a pointer that the attendance is related to temperament rather than radiological change.

TABLE 7.--SEcoND, THIRD AND FOURTH TERM ATTENDANCE AND PERCENTAGE NOT COMPLETING

(Not taking first te rm at tendance into account)

Radiological improvement during prec.

term

+ + + + + . .

l.s.q. . . Deter. . .

No. c a s e s

116 163 I58 292 49

Second term attendance

Class I

art.

53"1 45"0 52"o 59"7 39-1

Class Class H I I I art. art.

17.8 2I'I 33"4 11.8 22"3 13"9 23"4 9"8 26-I 15.2

% not comptg.

] '"

8"0 9.8

11.8 7.1

i9.6

Third term not completing

No. /o not :ases mptg.

123 13"5 lO 5 15.~ 86 14.o

182 9'9 60 28. 4

Fourth term not completing

dVo. % not "ases emptg.

60 I 1"6 39 5 "o 36 o 71 14"1 ~6 69"0

RADIOLOOlCAL EVlDENC~ OF I~PROVEMENT (a) The Whole Group (Table 8)

It must be borne in mind that almost half of the patients in this large group had predominantly fibrotic lesions and therefore ilO dramatic radiological improvement could be expected. Furthermore, of the remainder with recent disease, more thai1 half had advanced lesions.

After six months' treatment, 15"8 per cent. showed excellent (S-plus) improvement; after 12 and 18 months, 23" 5 per cent. and 2.7.o per cent. respectively showed excellent improvement.

I f those who showed a moderate (2-plus) improvement be combined with the 3-plus group, a satisfactory improvement is found in 38.7, 43"5 and 43.6 per cent. after 6, 12 and 18 months of treatment respectively.

Considering the sub-group recent disease, 3o per cent. showed an excellent (3-plus) improvement after six months' treatment, while another 3 ° per cent. showed a moderate (2-plus) improvement during the same period. After a year's treatment 42"4 per cent. showed excellent clearing while 27- 5 per cent. showed moderate improvement--implying a satisfactory response after a year's treatment in almost 7 ° per cent. of cases.

380 TAUTE AND RABIE

In the sub-group predominantly fibrotic disease, however, the response to treatment is entirely different: after six months' treatment only 1.8 per cent. showed an excellent response, while 60" 3 per cent. remained unchanged. After 12 and 18 months the respective figures are 2"2 and 6" 4 per cent. showing an excellent improvement and 53"0 and 44"0 per cent. remaining unchanged.

TABLE 8.--R.ADIOLOOICAL ]7,VIDENCE OF IMPROVEMENT OF VARIOUS DISEASE GROUPS After six months' treatment

Radiological Min. Mod. Adv. Gross Rec. Fibr. Whole improvement T.B. T.B. T.B. destr, dis. dis. group

+ + + - . 9"3 20"9 I7"5 2"0 30"0 1.8 I5. 8 + + . . 14"9 2I '7 29 "I I2"9 30"4 9"4 22"9 + . . . . 16.8 21. 5 22.2 20. 7 2I. 9 22- 3 2i. 3 Ls.q . . . . . 56"8 29"6 24"O 54"5 IO'1 6O" 3 33"2 Deter. . . 2"2 6" 3 7"2 9"9 7 .6 6"2 6.8

Number ex- I48 520 631 203 748 718 1,5o2 amined IOO% Ioo% lOO% lOO% lOO% IOO% IOO%

Not examined I31 666 799 269 I,O56 823 1,865

After one year's treatment

Radiological improvement

+ + + . . + + . .

1.s.q . . . . . Deter. . .

Number ex- amined . .

min. • T.B.

I9" 7 I3"I 12"2 55"o

O

IO6 100%

Mod. T.B.

30"0 18. 4 I7.2 25"4

9.0

379 I00%

Adv. T.B.

26"8 24"1 16"2 20- 4 I2"5

5II IO0~o

Gross destr.

2"2 15"6 I6.2 44"2 21.8

I79 IO0~/O

Ree. dis.

42 "4 27"5 I3"O 7"o

IO'I

621 IO0~o

Fibr. dis.

2"2 I I ' I 20"0 53"4 13" 3

557 IO0~/o

Whole group

23"5 20"0 I6"2 28- 7 i i-6

1,I75 IO0~o

Not examined 62 239 312 121 388 352 734

A f t e r e ~ e n months't~atment

Radiological improvement

+ + + . . + + . . @ . . . . i.s.q . . . . . Deter. . .

Number ex- amined . .

Not examined

Min. Mod. T.B. T.B.

21 "7 34 .0 13.2 17. 5 i5-i i5.8 46.7 23-2

3"3 9"4

60 189 ioo% lOO%

24 7 °

Adv. T.B."

29"5 I7" 7 I8" 9 17" 7 ~6"2

~65 IO0~/o

9 8

Gross Rec. destr, dis.

8.6 49"3 14.6 18.o II-O I3" 7 38"5 6" 3 27"5 12"7

91 29o lOO% lOO%

45 119

Fibr. Whole dis. group

6. 4 27"0 15.2 i6-6 18"3 16"3 44"0 25"5 16-1 I4.6

322 605 lOO% lOO%

121 237

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA 38I

(b) The Radiological Improvement in the Three Attendance Classes (Tab le 9)

T h e r a d i o l o g i c a l i m p r o v e m e n t in t h e Class I a t t e n d e r is o n l y s l i g h t l y b e t t e r t h a n t h a t in t he Class I I I a t t e n d e r - - t h e l a t t e r a t t e n d s o n c e o r tw ice p e r m o u t h for s t r e p t o m y c i n a n d I N A H .

T h e p e r c e n t a g e o f Class I I I a t t e n d e r s w h o d e t e r i o r a t e , h o w e v e r , is m o r e t h a n tw ice t h e p e r c e n t a g e o f Class I a t t e n d e r s w h o d e t e r i o r a t e .

W h e t h e r a p a t i e n t r ece ives one , two o r f ive i n j e c t i ons o f s t r e p t o m y c i n p e r m o n t h a p p e a r s to b e o f n o c o n s e q u e n c e ; t he p a t i e n t w h o t akes his I N A H r e g u l a r l y , h o w e v e r , is e x p e c t e d to d o fa r b e t t e r t h a n the one w h o t akes I N A H for, say, o n e o r t w o weeks o u t o f e v e r y four . I n a n a t t e m p t to show w h e t h e r

TABLE 9.--RADIOLOGICAL CLEARING OF THE THREE ATTENDANCE GROUPS AFTER SIX MONTHS AND ONE YEAR'S TREATMENT

Radiological r e s p o n s e

+ + + . . . . . . + + . . . . . .

us.q . . . . . . .

Deter . . . . . . .

Number examined

Not examined . .

First six months' treatment

Class I att.

16" 9 22.8 20"2 34"8

5"3

87o I00~/o

1,o57

Class H att.

14-2 24-0 22.8 3 ° "4 8.6

382 I00~o

45o

C/ass I I I att.

I5-8 20"2 23"7 28.0 12"3

I14 IOO~/0

243

Second six months' treatment

Class Class i/i H/n

25"o 24"7 18.2 22"2 16.8 18.8 32 "3 25"5

7"7 8.6

535 I49 lOO% lOO%

294 75

Class 111/111

2I ' 0 21"0 19" 4 19" 3 19" 4

62 I00%

52

TABLE Io.--COMPARISON OF RADIOLOGICAL RESPONSE BETWEEN GROUP I AND GROUP I I I ATTENDERS, TAKING INTO ACCOUNT THE CHARACTER OF THE DISEASE: RECENT OR FIBROUS

Radiological response

+ + + . . . . + + . . . . . . @ • . . . . .

i.s.q . . . . . . . Deter . . . . . . .

First six months

Recent disease

~ A

Class Class I I I I

att. art.

29 "8 29"0 34"7 27 .0 19. 4 24-0 io. 7 6. 4 5"4 12"9

Fibrous disease

f

Class Class I I I I

art. att.

2" 4 o 9"3 I i "3

21.2 22"7 62-o 54"7

5.1 11. 3

Second six months

Recent disease

Class Class I I I I

art. art.

45"9 34 .0 23"8 32"0 15.6 lO.6 8.1 4"2 7.1 19.2

F/b~0us disease

Glass Class I I I I

att. art.

2 - 4 1 " 4

13"4 3"9 18.I 23"5 58.0 43"5

8-i 27. 7

Number examined . . 458 62 420 53 295 94 28I 76 100% I00% 100% IO0~/O 100% IO0~/O 100% IO0~o

Not examined . . • • 58I 149 483 95 158 93 161 65

voL Lnl. 4 4

382 TAUTE, AND RABIE

Class I I I attenders take their I N A H regularly some district surgeons have kept records of I N A H issues to individual patients, and the information gained is that only a small number do not require I N A H as frequently as anticipated.

On the basis of attendance it was calculated that I oo patients would require only 7 ° patient-units of streptomycin over a given period; i.e. for every Ioo patient-units of streptomycin approximately I4o patient-units of I N A H would be required if patients were taking their I N A H regularly.

(This excludes babies and young children: if these were included in the cal- culation the requirements would become 13 ° patient-units of I N A H for every Ioo patient-units of streptomycin.)

Drug issues in the Transkei during the past two years have been i i 4 patient-units of I N A H for every ioo patient-units of streptomycin--this im- plies that patients have been using slightly more than 80 per cent. of the quantity of I N A H prescribed for them. As four of every five district surgeons issue a two-to-four-week supply of INAH, it would seem that patients are, in fact, taking their I N A H fairly regularly, notwithstandng any irregular atten- dance for weekly injections of streptomycin.

TABLE I I.--RADIOLOGICAL RESPONSE OF THE MODERATELY ADVANCED MAINLY E XUDATIVE OR RECENT CASEOUS GROUP, WHO ATTENDED 75 PER CENT. OR MORE DURING FIRST AN D SECOND

SIX MONTHS PERIOD

Radiological First six months' Second six months' resbonse treatment treatment

+ + + . . . . . . 35"4 52"2 + + . . . . . . . . 3o.9 x6.8 + . . . . . . . . 19. 7 x6.8 i.s.q . . . . . . . . . IO'3 8.o Deter . . . . . . . . . 3"7 6.2

Number examined . . . . 188 x 13 IO0~o IOO%

Not examined . . . . 245 63

(c) Radiological Response of Class I and Class I I I Attenders in two Disease Sub-groups (Table io)

The figures again indicate the similarity of response in Class I and Class I I I attenders, whether they have recent or fibrotic disease.

The striking difference in the responses of those with recent disease and those with fibrotic disease is also manifest.

The higher incidence of radiological deterioration among the Class I I I at tenders--which is cause, and which effect ?

(d) Radiological Response of Class I Attenders with Moderately Advanced Recent Disease(Table H) This group clears well: 66 per cent. show satisfactory improvement during

the first six months and 69 per cent. during the second.

DOMICILIARY TREATMENT OF PULMONARY TUBERCULOSIS IN A RURAL AREA 383

During the first six months of treatment this group forms 8 per cent. of all cases; during the second six months, only 6 per cent.

I f it is accepted that the good and bad attenders do about equally well, then approximately 12 per cent. of the total on treatment during the first six months and I o per cent. during the second can be expected to do as well as this group.

(In this group of 188 patients, I56 received 5 to 7 reg./kilo/day of INAH, while the rest received io to i2 reg./kilo/day.)

TABLE 12--RADIOLOGICAL RESPONSE OF A GROUP OF CASES WITH MODERATELY ADVANCED RECENT DISEASE WHO HAD I2 m g . INAH PER KILO OF BODY WEIGHT DAILY, AND 2 G.

OF STREPTOMYCIN ONCE A WEEK FOR SIX MONTHS

+ + + + + .. + . .

i.s.q. .. De te r . . .

TOTAL

Radiological response

. °

Class I attenders

47% 25% i6% 3% 9%

32

Class I, H and I I I attenders

33.6% 26",% 22.6% 5"I%

i2.6%

II9

TABLE I3.--SP~uM RESULTS Sputum results at commencement of treatment

Min. Mod. Adv. Gross T.B. T.B. T,B. dest.

Cases examined .. ] 67 % Pos. in each group 13

Rec. Fibr. dis. dis.

249 316 27 419 21 44 67 33

240 34

Sputum results after six months' treatment

Total

659 lOO% 33%

min, T.B.

Cases examined 68 326 352 % Pos. in each 8.8 I4-I 27. 3

group

Mod. Adv. Gross Rec. Fibr. Un- T.B. T.B. dest. dis. dis. clasf d. Total

• 88 475 368 36o I,I94 lOO% 44"4 19"6 25 .6 16.1 2o. 5

Sputum results after one year's treatment

Min. Mod. Adv. Gross Rec. Fibr, Un- T.B. T.B. T.B. dest. dis. dis. clsf d.

Cases examined 9I 348 469 175 550 54 ° 400 % Pos. in each 4"4 14"6 39'2 62"4 26"3 37"4 17"8

Total

1,483 xoo% 28.2%

384 TAUTE AND RABIE

(e) Radiological Response of Group with Moderately Advanced Recent Disease, Receiving IO to I2 Mg./Kilo/Day of INAH (Table I2)

The figures suggest that these patients do better than those with similar lesions receiving a smaller dose of INAH.

Seventy-two per cent. of Class I attenders and 6o per cent. of all attenders show a satisfactory response to treatment.

SPUTUM RESULTS (Table 13) Onc spccimcn only of sputum was collcctcd from paticnts at thc time of

diagnosis and/or the follow-up X-ray. Only straight smcars wcrc cxamincd. Thc discasc distribution in the total 7,858 paficnts, and in thosc whosc sputa

wcrc cxarrdncd at diagnosis or aftcr six or twclvc months of trcatmcnt, docs not differ greatly. Of those whosc sputa wcrc cxamincd at thc time of diagnosis, only 4 per ccnt. had grossly destructive lesions, whcrcas thc othcr groups had i o to 16 per ccnt. of cascs with similar lesions. Had this not bccn so, paticnts with a posifivc sputum would have constitutcd morc than 33 pcr ccnt. of thc group.

Thc figures indicatc that from a third to a half of positivc sputa at diagnosis bccomc negative during thc first six months of trcatmcnt, but paticnts with advanccd disease or grossly destructive lesions tcnd to bccomc posifivc again during thc sccond tcrm of trcatmcnt.

Summary and Conclusions In the Transkei I6,OOO cases of pulmonary tuberculosis were diagnosed

during a two-year period. A very high percentage have advanced lesions, nearly half being pre-

dominantly fibrotic lesions. The attendance for treatment is rather poor and a disconcertingly large

number of patients fail to complete their treatment. Patients with recent disease do well on treatment; the fibrotic group show

but little clearing. Sputum conversion of those with advanced lesions is unsatisfactory. On the strength of available information i t is not possible to predict the

effect of the present approach on the tuberculosis problem in the Transkeian Territories.