the epidemiology of pulmonary tuberculosis
TRANSCRIPT
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THE EPIDEMIOLOGY OF PULMONARY TUBERCULOSIS
IN THE BAHAMAS FROM 1965 - 1981
by
Nathalee P. Bonimy
SRN, RM
Project report submitted in partial fulfilment of the
requirements for the Diploma in Community Health
(General), Department of Social and Preventive Medicine,
University of the west Indies, November, 1982
)
I
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ACKNOWLEDGEMENTS
I wish to express my sincere gratitude to all those
persons who assisted in making this study possible.
Special thanks go to the following persons:
The commonwealth Fund for Technical co-operation and the
Ministry of Health, Bahamas, for funding the course.
Dr carlos Mulraine, my field supervisor for his untiring
guidance and support in the preparation of the preliminary
draft.
Dr Cora Davis and the staff at the Public Health Depart
ment; Dr Perry Gomez, Mrs Poitier-Mortimer and the staff at
the Tuberculosis Unit; Mrs Beverley Ford and the staff at
the Community Nursing Servicesr Mr Moses Deveaux and the
staff at the Medical Records Department for their cooperation
and assistance during the period of data collection.
To Miss Zella Major for encouragement and constructive
suggestions and Mrs Lillian Jones who reviewed critically the
material.
To the lecturers and staff a t soc ial and Preventive
Medicine for their gu i dapoe tnrou~hout t h e course and
especially during the preparat i on o f t h e final draft.
J - ii -
To my typist, Mrs Angela colebrooke for retyping this
work to print.
Lastly, to my family, especially Edgar and the children
for their understanding, which helped me to complete this
study.
'
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ABSTRACT
In the Bahamas, during the 40's, the programmes for the
control of tuberculosis were poorly organised and the in
cidence of the disease remained very high.
After a survey by Santon Gilmour in 1945, there was a
gradual improvement and a decline in the incidence.
The purpose of this study was to describe the epidemio
logical features of pulmonary tuberculosis in the Bahamas over
a 17 year period, extending from 1965 - 1982.
Results showed a population of 1394 case s over the study
period. New Providence contributed 69 percent of the cases.
The age group 20 - 29 years accounted for the highest percent
age of cases (41 percent), while the lowest (9 percent),
occured among the 10 - 19 year age group.
The x-ray and sputum ·results were only found for the last
5 years. The population for both was 266: of these 85 per
cent had positive x-rays, 71 percent had positive smears and
67 percent had positive cu+t~r~s .
In the Bahamas, fo r the 1 7 yeq r per iod, every year ther e
were more males than female patients.
several reco~endqtions were ma de i.n order to i mprove
the control programme in the Bahamas.
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CONTENTS
Acknowledgements
Abstract
Table of contents
List of tables
List of figures
List of appendices
chapter 1
Chapter 2
INTRODUCTION
Background information
General description of the Bahamas
History of tuberculosis -
Tuberculosis throughout the world
Tuberculosis in the Caribbean
Tuberculosis in the Bahamas
RATIONALE, AIM, OBJECTIVES AND METHODS
Rationale for present study
Aim of study
Objectives of study
Methods
Data collection
Pretesting data collection methods
nata collection sheets
page
i
iii
iv
vi
vii
viii
1
1
1
7
10
11
14
26
26
26
26
27
27
29
30
\
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chapter 3 RESULTS
Number of reported cases
Geographical distribution
Age Group
sex
Radiological results
Bacteriological results
Nationality
chapter 4 DISCUSSION
Limitation of methods
Interpretation of results
conclusions
Recommendations
References
Appendices
Page 31
31
31
34
40
40
40
44
46
46
46
55
55
58
60
Table No.
1 .
2
3
4
5
6
7
8
9
10
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LIST OF TABLES
f{eacU ng s
Population distr i bution of the Bahama. s 1980-
Tube~c~losis (al~ types) cases repo~ted to CAREC 1977 - 1981, with rates per 100,000 population.
Reported cases of tuberculosis by islands of the Bahamas 1965 - 1981.
Reported cases of pulmonary tuberculosis by age group 1965 - 1981.
Percentages of reported pulmonary tuberculosis cases by age group 1965 - 1981.
Reported pulmonary tuberculosis cases by sex for the Bahamas
page
3
12
32
35
1965 - 1981. 36
Distribution of tuberculosis cases by t ype of x-ray results in the Bahamas, 1965 - 1981. 41
Reported cases of pulmonary tuberculosis by sputum result in the Bahamas 1977 - 1981. 42
Detailed sputum result or reported cases of pulmonary tuberculosis in the Bahamas from 1977 - 1981. 43
Nationality of reported cases of pulmonary tuberculosis in the Bahamas 1977 - 1981. 45
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LIST OF FIGURES
Fig. No. Heading Page
1 Map of the Bahamas. 2
2 Number of reported pulmonary tuberculosis cases by year. 33
( 3 Percentages of reported pulmonary tuberculosis cases by age group for the Bahamas 1965 - 1981. 37
4 Reported pulmonary tuberculosis cases by sex, for the Bahamas 1965 - 1981. 39
Appendix No.
1
' 2
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3
4
5
6
7
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LIS 'f ___Q:;,:;J'--=A=P:...::P....:::El:.::.:.N.t.;.;p:=C C=E=S
ljeaq.j. ng
List showing t p e d ise a ses that are notifiable to t h e Public Health Department, Bahamas.
page of chest ward admi ssion and discharge book.
Page of chest clini c admission and
60
63
discharge book. 64
Chest clinic attendance card. 65
work sheet for data collection. 66
Medical records request form. . 67
Notification form of infectious disease. 68
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CHAPTER 1
INTRODUCTION
Background information
General description of the Bahamas
The Bahama Islands lie between latitude 20 - 27° north
and longitude 72 - 79° west. This archipelag consists of
more than 700 islands, rocks and cays, which, with the
exception of New Providence and the city of Freeport are known
as Family Islands. The archipelage begins approximately 50
~miles fr~ the west coast of Florida, and extends in a south
easterly direction for a distance of some 750 miles. Its
southern most island, Inagua, i s 90 miles north of Haiti
(figure 1 shows a ma p of the Bah~mas ).
There are no mountains, the highest point being Mount
Alvernia on cat Island, which is only 206 feet above sea
level. Andros is the largest island with an area of 2,300
square miles. ~ Table 1 shows the 1980 population distribution
of the islands according to their land area in square miles.
The 1980 census showed the total population of the
Bahamas as 209,595 residents, of whom 135,437 (64.7 percent)
lived on the island of New Providence, where the capital,
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Table 1
Population Distribution of the Bahamas by Island, 1980
Island
New Providence
Grand Bahama
Abaco
Acklins Island
Andros
Berry Islands
Biminis, Cay Lobos and Cay Sal
Cat Island
Eleuthera, Harbour Island and Spanish Wells
Crooked Island
Exuma and Cays
Inagua
Long Cay
Long Island
Mayaguana
Ragged Island
San Salvador and Rum Cay
Total with other Cays added ..
Land Area (Sq. Miles)
80
530
649
192
2,300
12
11
150
200
84
112
599
9
230
110
14
90
5,382
Population 1980
Total
135,437
33,102
7,324
616
8,397
509
1,432
2,143
10,600
517
3,672
939
33
3,358
476
146
804
209,595
Population pei Square Mile
1,692.9
62.5
11.3
3.2
3.7
42.4
130.2
14.3 .
53.0
6.2
32.8
1.6
3.7
14.6
4.3
10.4
8.9 ' .
38.9
Source: Preliminary Report of 1980 Census, Department of Statistics, Nassau, Bahama~.
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Nassau is located. The second most populated island is
Grand Bahama, on which is located the nation's second
city, Freeport.
Nassau has become a financial and business centre and
has direct· air communication with several countries, in
eluding the united states of America, canada, the united
Kingdom, Jamaica and Bermuda. communication among the
islands is maintaine d p y a regula~ mail boat service. The
national airline - ~ah~m~sai~ , provides ~egular ai~ links
between Nassau and many Q! the aQt ! y i ng population centres .
several companies also ope~ate inter-island air charter
services.
A few of the islands have a direct telephone service,
while others have telephone stations in the main settle
ments. These stations are opened at intervals during the
day, but urgent messages are carried over the radio stations,
whenever the need arises. There are three radio stations,
two in New Providence, and the other in Freepor t . They
service the entire Bahamas.
The islands are at different stages of development;
some have the basic infrastructure, such as water and
electricity throughout; while others have to rely
largely upon individual supplies of water and electricity.
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over the years there has been a population drift from
the less developed areas to the urban centres of Nassau and
Freeport.
Tourism is the main industry, with more than well over
a million tourists visiting the Bahamas each year.
Thousands of Bahamians depend on it for their livelihood.
other important industries in the country include:-
(i) A cement manufacturing plant
(ii) An oil refinery
(iii) Manufacture of chemicals
(iv) Agriculture, mainly fruits and vegetables
(v) Fishing
(vi) Making of straw goods.
There are three government hospitals in the Bahamas.
1. The Princess Margaret Hospital is the largest
and is situated in New Providence. It has 455
beds and is a multidisciplinary hospital, which
is recognised as a centre for training medical
interns.
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2. The sandilands Rehabilitation centre, also in New
Providence is a combination of a 150 - bed
geriatric unit and a 250 - bed psychiatric hospital.
3. The Rand Memorial Hospital, situated in Freeport, is
a 62 - bed acute care hospital, which provides on a
smaller scale many of the services available at the
Princess Mar~arat ~o~pi~al,
The Public Health oe~a~tment p;qvi des ~ternal anQ child
health services from three community health centres and
three satellite clinics in N~w Pr ovidence. In addition
there are also the following services:-
(1) Food handlers clinic
(2) venereal diseases clinic
(3) school health
(4) Home care
(5) Home-visiting
(6) Health education programmes
(7) General epidemiological services
The family Islands are divided into health districts,
which are served by health centres and manned by 19 District
Medical Officers and 73 Nurses.
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The nurses who work on the family islands and in the
Public Health Department constitute the community Nursing
Service.
Private medical services are provided through one
general hospital and a number of medical centres and clinics.
The Department of Environmental Health services is
responsible for the collection and disposal of refuse,
general environmental control and health inspectorate
services.
The Bahamas became independent on the lOth July, 1973,
ending some 250 years of British colonial rule.
History of tuberculosis
The name
Its earliest medical name was phthisis, derived from
the Greek verb phthinein, 'to waste away'. In the nine
teenth and even in the early twentieth century, it was
generally known as 'consumption'. But a s long ago as the
seventeenth century, the Dutchma n pranc i scus Silvius of
Leyden first used the te+m ' t ubercle' t o describe nodular
lesions found in the l~ngs o f p eople who had died of the
wasting disease. Johann schonlien, in 1839, was probably
the first person to have used the name tuberculosis.
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Milestones
Traces of tuberculosis lesions have been found on
3000-year old Egyptian mummies.
The Greek physician Hipprocrates (460-370 B.C.) - "the
father of medicine" was the first to describe the disease
(World Health, Jan; 1982).
one of the ~~ ipo~fal land~a~ks in the nineteenth
century development ot scientific knowledge of tuberculosis
was the work of Villemin, a French investigator, who in
1865 showed that the disease cou~d be experimentally trans~
mitted from animal to animal. It also demonstrated the
unity of the disease in different hosts.
Koch's discovery of the tubercle bacillus in 1882 and
his clear demonstration of its etiologic role were the two
most important events in the whole scientific history of
tuberculosis (Comstock, 1980).
In 1895, Roentgen discovered, in Vienna, the x-rays
which allowed an examination of the chest. For the first
time there were radiological images available which showed
the extent of the iesions in patients and, occasionally, in
people who had no symptoms. Actual confirmation of the
diagnosis depended on bacteriological examination for the
tubercle bacillus.
( ·
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In 1921, French scientists A. calmette and c. Guerin
discovered BCG (Bacillus calmette-Guerin), an ·attenuated
form of the bovine bacillus, and used it as a vaccine
against tuberculosis.
In 1944, Selman A. waksman and his colleagues, in the
United states, discovered streptomycin, the first antibio
tic effective against tuberculosis. Para-amino salicylic
acid (PAS) was discovered in 1946 and isoniazid (INH) in
1952.
During the period 1948 - 1957, the first mass vacci
nation campaign was carried out by the sca·ndinavian Red
cross society with support £rom the united Nations Children's
Fund (UNICEF). From 1957 the World Health organization
(WHO) became involved and helped governments to set up their
own BCG programme.
In 1966 rifampicin proved to pe an excellent drug
against tuberculos~a . p t972 ~+~~C FOX qnd members from
the British Medica l R~'ea~eh CQur~e! l, i n collaborat ion wi t h
several centres in ~ast Africa, showeq that the addition of
rifampicin, or of pyrazinamide, to the regime containing
isoniazed made it possible to reduce the duration of treat
ment (world Health, 1980).
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Tuberculosis throughout the wor ld
Despite the excellent weapons to combat tuberculosis,
the disease is stil+ a wor +dwide publ i c health problem
(Comstock 1980).
The anti-tube r culos is p r oblem was one of the main pro-
gramrnes at the bi+th o f WHO· At ~east 3.5 million people
develop tuberculos is eaor yea~, anq mo+e than fifty percent
died from the disease. The objective of the tuberculosis
control is to break the chain of transmission of the infec
tion. This is achieved by detecting the sources of the
infection as early as possible rendering them non-infectious
by chemotherapy given in the patients horne rather than in a
special institution, and by providing BCG vaccinations".
(Zahra, 1980).
Tuberculosis takes its greatest toll in regions with a
low standard of living and among the underpriviliged.
Although other factors are involved, it is to some degree a
barometer of social welfare. The downward trend of tuber
culosis incidence in many countries has followed improve
ments in housing, nutrition, working conditions and the
standard of living (comstock, 1980).
The health statistics which are compiled in the less
/
- 11 -
developed countries tend to underestimate the prevalence of
all diseases, including tuberculosis. In such countries
many cases remain unnoticed by the health authorities
because only a fraction of the population has access to
regular health services.
The epidemiological situation in many developing coun-
j(. tries, involving a population of more than two billion, is
now worsening due to the poor results in case-finding and
treatment. The total number of cases of tuberculosis has
doubled during the last three decades, due to the doubling
of the population. The developing countries therefore must
bear a much heavier burden if they are to undertake treat-
ment of their tuberculosis cases. In addition, the must be
rapidly brought under control, otherwise the absolute number
of cases will continue to increase and the situation will
get even worse (Styblo, 1980).
Tuberculosis in the Car ! pbean •~ re r ""*
The number of tuberc~losis oases reported to the
caribbean Epidemiology centre by 18 different territories,
for the period 1977 - 1979, shows ~n irregular pattern.
over the 5 year period the rate per 100,000 population
ranged from 1 to 44, with the lowest being reported for
Grenada and the highest for St. Lucia
(
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Table 2
Tuberculosis (all t y pes) Cases Reporte d to CAREC 1977 to 1981 With Rate ~ Per 100 ,000 Porulation
Country in order of Rate p e r 100,000 po£ulation
population size +97? 1978 1979 1980 1981
Bermuda - 5.1 5.1 1.7 3.3
St. Kitts/Nevis 4.8 1.6 1.6 14 8.0
Virgin Islands (U.S. ) 3 7.5 6.0 - 1. 5-t
Antigua 8.3 11.0 2.7 11 4
Dominica 20 14.1 6.4 24 35
Grenada 11.2 - 10.1 16 1.0
St. Vincent . . . . 18.6 16.8 30 9.2
St. Lucia 33 44 31 31 32
Belize 21 10.6 22 13 21
Bahamas 15.1 11.6 28 37 34
Barbados 5.4 6.1 8.8 26 1.2
Guyana 13.3 12.9 . . . . 14 13
Trinidad & Tobago 6.7 10.5 8.8 .... -Jamaica 16.7 14.1 6.6 6.3 4.7
Puerto Rico 11.5 11.2 9.1 14 15+
Haiti 24 12.6 29 63 16
Dominican Republic 28 30 39 . . . . -Cuba 12.9 13.0 11.0 12 8.6
Key: •... Insufficient information; -no cases
Source: CAREC Survei llance Unit 1979 and 1981.
+ Reports taken from Commun icable Disease Centre Morbidity and Mortality Weekly Reports.
(
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Jamaica, cuba and Bermuda show a d ecline for the 5-
year period. Table 2 shows the rate per 100,000 population,
of all types of tub~rculosis reported to_ caribbean Epidemic-
logy centre (CAREC) from 1977 - 1981 by 18 different
territories.
within the caribbean, one of the most difficult aspects
of the control programme to be organised adequately is that
of systematic case-finding. The organization and operation
of health facilities are generally not oriented towards the
detection of large numbers of new cases, and this is parti-
cularly true at the peripheral level where such capabilities
are most needed.
Throughout the region there are three different levels
of laboratory services p eing used ~-
1. oist+ict mic~q~cop¥ oqt¥
2. Microscqpy ~nq cu+t~r~
3. Microscopy , oq l t ufe , a n~ itivi ty test and
identific~tion pf a typic~l mycobacteria.
There is a variation in the caribbean in both quality
and availability services for microscopy and culture.
.... 14 -
Chemotherapy protocq ls f or qcti ve oases are variable
and are often subject to individ~al discretion. Prolonged
treatment courses are common even when drugs and resources
are abailable for short term alternatives.
Chemoprophylaxis with isoniazid is being .practised in
most countries,. but criteria for application differ greatly
according to local experience and the definition of risk
groups.
There are different policies for BCG vaccination with
in the region. In some countries the target population is
still newborn babies while in others this policy has been
discontinued. (CAREC, 1979).
Tuberculosis in the Bahamas
Sir Frank Stockdale, comptroller for Development and
welfare in the west Indies made special reference to tuber
culosis in his report for 1940 - 1942, stating that:
11 The death rates for pulmonary tuberculosis in the west
Indies, so far as can be determined, are between 80 and 100
per 100,000 population". (Gilmour, 1945). Therefore berore
making recommendations to assist tuberculosis schemes f
the west Indies, he wanted the situation to be surveyed and
studies by a recognised authority on the subject.
- 15 -
As a result, Santon Gilmour was invited by the council
of the National Association for the Prevention of Tubercu-
losis and the colonial Office in London to carry out a
survey in Trinidad and Tobago and in as many of the British
west Indian colonies as possible. Although the Bahamas
Government did not want to be included generally in the
activities of development and welfare, they made a request
to the comptroller to be included in this survey. Special
arrangements were made and the survey was done between
December 1944 and March 1945, following the completion of
the surveys of the south caribbean area.
The Bahamas su~vey ~arr!eq out two lines of investi
gation:-
1. By the Qae of t~e tt~p~~ou~in skin test, to
obser~e the extent of infection in the apparently
healthy, particularly ~chool children.
2. By clinical observation of those already sick,
both the known cases in hospital or elsewhere
and the cases referred for diagnosis or treatment.
At the time of the survey the tuberculosis unit
consisted of 12 beds. .Most of the cases ended in death.
This could be attributed to the fact that they came for
- 16 -
treatment when the d i sease was qt a very advanced stage.
contact tracing and follow-up care were minimal because
of inadequate staff.
The main recomme ndations made at the end of the survey
were:-
1. A medical officer should be appointed to deal with
tuberculosis cases specifically.
2. There should be a central clinic for diagnosis
and treatment and an administration office for
recording and for organising the campaign. The
clinic should have a p e rmanent sta f f , with one well
experienced tuberculosis health visitor and an
experienced clerk.
3. The public health activities should be extended.
4. A tuberculosis hospital (180 beds) with adequate
staff and a modern x-ray plant, capable of pro
ducing high quality radiography , should be
provided.
5. There should be an improvement in housing,
education and economical conditions.
6. Mass radiography should be used to increase case
finding.
7. The government should introduce legislation to
compel infectious cases of tube rculosis to enter
an institution for isolation and to remain there
(
- 17 -
until rendered non-infectious.
In 1947, the Royal Air Force (RAF} military hospital
at Prospect was leased from the oakes' Estate for 5 years,
so that. a new hospital could be built. In october of the
same year, the private and general wards from the Bahamas
General Hospital were transferred there. As a result the
tuberculosis unit was increased to 26 beds. The new
accommodation allowed more patients to be admitted in
earlier stages and the re~ults were good.
Another survey was r~commended to the Government but
unfortunately this was pq~ ca~ried out, due to insufficient
funds. In 1947, the pup~ic H~~ lth ~ursing staff investi
gated 63 tuberculosis cases of whic~ 10 (20 per cent} were
new. There were 61 patients referred to hospital (Abridged
Medical Report, 1947}.
In 1948 out of 77 cases treated at the hospital, 58
(75 per cent) died (Annual Medical Report, 1948} Although
accommodation was still inadequate, there were more patients
who were recovering sufficiently to be discharged home.
In 1949, the number of cases was still high, but this
probably was due to the following:
(i} More facilities for treatment
(
- 18 -
(ii) Activities of the public Health and welfare
Nurses.
(iii) A More enlightened public seeking examination.
The public Health Nurses again investigated 26 cases,
performed 77 tuberculin tests and referred 33 patients for
x-ray.
At the end of 1949, a chest clinic was established in
the x-ray department. The department's staff volunteered
their services and held clinics twice per week. A card
index was kept and the discharged patients were encouraged
to attend.
contact tracing was improved in 1950 because a register
was provided. This served as a reference book to the Public
Health Department and the Red cross. In october of the same
year 16 more beds were made available in the old Alexandria
ward of the Bahamas General Hospital.
At the end of 1950, the Chief Medical Officer (CMO) in
his annual Medical Report wrote, "Generally speaking, there
has been a definite improvement in the situation although
the figures show an indicatiqn that more is being done about
the disease". Thiosemioarbqzone (TDI) and PAS were intro
duced and used on s elected cases with good results (Annual
Medical Report, 1950).
- 19 -
In 1951 the che st clinic wa s tr a nsferred from the
x-ray department ot the new out-patient's department of the
Bahamas General Hospital. The tuberculosis cases were now
being referred to the unit through the clinic. Earlier
cases came from private doctors and from contacts of known
cases, who were referred by the Public Health Nurses, the
Red cross and the Infant welfare Centre. There was still
relatively little organised follow-up care and when patients
defaulted there was a b e ak in t re&tment. Treatment was
effective in those wh d!q no t deta~lt .
The Public Health Department investigated the homes of
all patients before discharge. There was no available in-
formation for 1952 and 1953 at the Archives department.
On 21st May, 1954 male and female tuberculosis patients
were separated for the first time and placed in 30 beds wards.
During 1954 there were 64 admissions with 13 (20 percent)
deaths, and some patients were still waiting in the general
wards for admissions to the unit when there was a vacancy.
The new Bahamas General Hospital was completed in 1955
and therefore all the wards excluding the tuberculosis unit,
were transferred. In March of the same year, the hospital's
name was changed to the Princess Margaret Hospital.
(
(
- 20 -
of all types of tube rculosis inc r e a s e d t o 171, with 22
deaths (13 percent) Annual Me dical Report, 1955).
Unfortunately the r e were no reports available at the
Archives Department for the years 1956 to 1961.
In 1962 there was a dramatic c ha nge in the tuber
culosis situation. The patients from Prospect Hospital
were transferred to the New King George VI Memorial Chest
wing in March. This unit was attached to the Princess
Margaret Hospital and had a total of 150 beds. There were
also an x-ray depa rtment and a chest cl i nic. A new chest
specialist, Dr Richard Cory, from Jamaica was responsible
for the tuberculosis patients.
The male wards consisted of three sections, one with
25 beds and two with 17 beds each. The females also had
three sections, but only two were occupied; the wards
with 25 beds and 17 beds. There we re also 9 single rooms
for private patients. The children•s ward had 23 beds.
The patients were divide d into three categories;
infectious, non-tQfea t iou s ana surgical . A var ie~y of
surgical procedures was performed accord i ng to the need s
of particular patients.
All patients 1er.e given PJ\S INH qnd streptomycin. Chest'
x-rays were done on admission and e very 6 weeks. Sputum
- 21 -
for smear and culture was done at monthly intervals until
there were three consecutive negative specimens. If the
sputum smear was not negative after 6 weeks and there was
no improvement in the chest x-ray, the patient was placed
on second line drugs e.g. thiazina and ethambutal. Due to
the lack of eye and ear specialists, children were not
given ethambutal and st~e~tomycin be cause of the risk of
the side effects caqseq P¥ t hem. p~ti ents were never sent
home early, unless their home environment was investigated
and the reliability for taking their drugs was good.
Unreliable patients were supervised by the District Nurses,
twice per week.
Patients who absconded were sought by the police and
on their return were confined in a special room provided
for that purpose. Mentally retarded patients were sent to
Sandilands Rehabilitation centre as soon as the sputum
became negative, to continue their treatment until they
were fit for discharge. They then returned to the Chest
Clinic for follow-up care.
Family island patients on discharge were given referral
letters to the nurse or District Medical Officer on the
island, who in turn was responsible for refilling prescript
ions. They returned to Nassau at intervals for follow-up care
- 22 -
at the Chest-Clinic. Discharged patient s in New Providence
were followed up by the Public Health Nurse at the chest
clinic. Her duties included follow-up care, contact tracing
record keeping and supervision of the Clinic.
Mantoux tests a nd x-ra ys were done on all the contacts.
The results were treated as follows:-
1. Those with negative mantoux and x-rays had them
repeated after three months.
2. Those with positive mantoux test and negative
x-rays were placed on prophylactic INAH for one
year, excluding those over 35 years old.
3. Patients with positive mantoux and suspicious
x-rays were admitted for further investigations.
4. All contac t s were followed up for one year then
discharged.
Dr Cory left the Bahamas in 1967, and by 1978 the
position of Chest Specialist had been occupied by four
different physicia~s . Genera l ~y. principles of treatment
and follow up care ~emain~d t~e ~arne .
In 1976 the Chest C~in ic was tr a nsfer red t o the new
Ambulatory care Departm~nt ot th h osvital . Aga i n i n 1976
the medical records departme nt cha nged t heir numbering
system from straight numerical to color coded terminal
(
- 23 -
digits. The notes for the tuberculosis patients were inte
grated into the general cases records and kept in the Medical
Records Department. Prior to that the tuberculosis cases
records, were kept separately at the Chest Clinic. Since the
patient's transfer, durin~ clinic sessions the community
Health Nurse was assisp~Q by t~e s ta f f from that area.
Since 1978 the unit has been headed by a medical consul
tant, who has received training in infectious diseases. The
treatment regime of patients was changed and also that of
the contacts.
Hospital medication consisted of INH, etharnbutal and
rifampicin daily as a single dose. During the first week
of admission, sputum specimens were sent on three consecutive
mornings for smear and culture. x-rays were done every four
weeks. Hospital stay normally ranged from 4 to 6 weeks.
The majority of the patients were discharged on INH and
etharnbutal, but the relapsed cases were also given rifampicin.
Discharged patients were given a one week appointment
to the chest clinic, where they were followed up weekly for
one month. Thereafter intervals depended on the patient and
the discretion of the doctors. The patients remained on
treatment for one year, and then were given yearly appoint
ments for four years before they were discharged from the
clinic.
(
- 24 -
All children who were close contacts were placed on
prophylactic treatment for three months, even if their
mantoux and x-ray were negative. When the mantoux and x-ray
were repeated after three months, if they were both negative
the treatment was discontinued and they were discharged.
Adult patients were also discharged if their repeated in
vestigations were still negative. contacts who were followed
up had their x-rays repeated after three months and prior to
discharge. The regime from 1978 is still being used today.
In october 1980, a monthly follow-up clinic for tuber
culosis patients was commenced in Freeport, Grand Bahama,
conducted by the medical consultant from the Princess
Margaret Hospital. All the patients from that island after
discharge from the hospital are followed up there.
In addition to the Princess Margaret Hospital, labo-
ratory and x-ray services are offered at a number of private
centres in New Provictence and Freeport. Limited x-ray facil
ities are also available privately at Marsh Harbour, Abaco
and at the government health centres in Rock sound, Eleuthera
and Matthew Town, Inagua.
(
- 25 -
BCG vaccination was done on a 11 new born babies at
the Princess Margaret ~ospital from the early sixties,
but was discontinued in May 198l.
In october 1981, a trained ol~nical nurse was trans
ferred to the Chest clinic to assist the community health
nurse with follow-up care.
- 26 -
CHAPTER 2
RATIONALE, AIM, OBJECTIVES AND METHODS
Rationale for present study
Santon Gilmour in his report of 1945 made several
recommendations for tuberculosis control in the Bahamas,
some of which have been implemented.
His survey appears to have been the last comprehensive
report on tuberculosis in the Bahamas and therefore the
author decided to do this epidemiologival study to find out
what has been the tr e nd of the disease since that time.
Aim of study
The aim of t qe study was to descr~be the epidemiological
features of pulmonar y tuperculosi~ in t h e Ba hamas f rom 1965
to 1981.
objectives of study
The objectives of the study were to:
1. Find out the number of new cas e s of pulmonary
tuberculosis occur ring in the Bahamas during
the study p e riod.
2~ Determine the geographical distribution, age and
sex of these case s.
3. Find out the following chara c teristics of the
cases from 1977 to 1981:-
(
- 2 7 -
(i) Radiolo g ical teatures
(ii) Bacteriologicql features
(iii) Nationality
Methods
This study is descriptive in nature and includes all
the pulmonary tuberculosis patients notified to the public
Health Department in Nassau, Bahamas from 1965 to 1981.
Included also are 17 cases who did not appear on the
Infectious Disease Register at the department but were
obtained from the admission and discharge books from the
chest wards and chest clinic.
For the entire period a total of 1,394 patients were
identified. The survey was done in two sections:-
(i) over the 17 year period, with information
concerning the sex, age, and geographical
location.
(ii) A more in depth study over a five year period
to include the following: initial x-ray result,
results of sputum smear and culture and the
nationality of the cas es.
Data collection
Discussions with the following health personnel were
carried out in order to elicit their support and co
operation in the exe cution of the study, ~d to obtain
- 28 -
information related to their respective functions:
(i)
{ii)
(iii)
Infectious Disease consultant, Princess Margaret
Hospital.
Nursing Officer in charge of the chest wards
Nursing Of ficer in charge of Chest Clinic
The records used for obtaining the data were:-
1. public Health Department Notifiable Disease
Register
This register contains a record of all the diseases notified
to the Public Health Department of the Bahamas. All of the
data on pulmonary tuberculosis w&s extracted year by year
from this registe~. App~ndi~ + ~h ws t~a various diseases
that are notified.
2. Admissions anq pischarge poo~s of the chest wards
pf the Princess Margaret Hospital. The particulars
recorded in them were:- name, address, age, sex, date of
admission and discharge, smear and culture results, treatment,
final diagnosis and hospital registration numbers. Appendix
2 shows the headings used in the books.
3. The admission and discharge book for the chest
clinic has the same information as the books for the wards.
The chest clinic attendance card was also used. Appendix III
shows the headings used for the Chest clinic book and
~ 29 -
Appendix 4 shows a c opy o f the Ch~s t clin i c at t enda nce
card.
4. The hospital records o f the tuberculosis patients.
These notes are numbered and are kept in the medical records
department after the patients are discharged. The same
notes are used for the return visits to the Chest clinic.
Each tuberculosis patient has a contact folder, within which
are kept the notes of all the contacts investigated. If a
contact became a patient, his hospital records were requested
and his contact sheet placed with his other notes.
Pretesting of data collection methods
As a pre-test prior to the commencement of data
collection, some of the records needed for the survey were
viewed. The researcher had intended to do the study from
1962 - 1981, but unfortunately the notifiable disease
register could only be found for 1965 onwards. In addition
several of the hospital records for the cases from 1962 -
1976 were missing. After discussion with the field super
visor, it was decided to do a 17 year period, with the
last 5 years in more detail. The last five years were
chosen because it was thought that finding the record for
that period would not be difficult.
(
- 30 -
nata collection sheets
The actual data were collected on work record sheets,
which were drawn up with the necessary columns to achieve
the objectives stated. Appendix 5 shows a sample of the
sheets. The name, sex and address of each case were
taken from the notifiable disease register. The cases
were numbered.
In order to fulfill objective number 3, the researcher
had to obtain the patients records, a total of 266, for
the five year period. The ~egistr. ation ~umber of each
patient had to b e found ~efpre ~ eques ting the notes. This
was done by using the recorps f rom the chest wards and the
clinic as outlined previously. While filling in the
registration numbers, the sputum smear and culture results
were also added when found.
After obtaining the hospital record numbers the notes
were requested from the records department using a special
form provided for that purpose. See Appendix 6 for a copy
of the form.
Number of reported cases
- 31 -
CHAPTER 3
RESULTS
The population consisted of 1394 pulmonary tuberculosis
cases. The highest number of cases reported in any one
year was 140 in 1965 and the lowest 24 in 1978. Since 1965
there was a decline until 1978 when the trend was reversed;
in that in 1979 the number of cases was 56. with 72 and 75
respectively for 1980 and 1981. In 1970 the number was
117 but since then it has been less than 100. (Table 3).
Figure 2 shows the number of reported pulmonary tuberculosis
cases from 1965-1981 in the Bahamas by year. For the 5-year
period 1977 to 1981, out of ·a total of 266 notes, 78 percent
were found and examined.
Geographical distribution
Of the 1,394 cases 956 (69 percent) gave their address
as New Providence and there were 152 cases (11 per cent) from
Grand Bahama. The other islands of significance were:
Andros ( percent, Abaco 3 per cent; Eleuther a and Long Island
2 per cent each. The remaining islands together accounted
for 4 per cent while addresses were not recorded for 4 per
cent of cases.
New Providence contributed as many as 76 per cent of
the cases, in 1966 and as low as ~6 per cent in 196 9.
N ('Y')
M
(!) r-l
~ 8
Year
1965
1966
1967
·1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
Total
1965 to 1981 Reported Cases of Tuberculosis by Island of the Bahamas
Number of Cases by Island
New Grand Long Providence Bahama Andros Abaco Eleuthera Island Others
88 10 7 10 3 8 6 94 9 13 3 3 - 2 94 ~Q 10 6 2 1 4 86 11 6 7 2 1 2 58 15 6 - 1 7 6
77 ll.. 13 1 2 2 4 52 g 6 1 - - 1 57 6 8 - 2 1 6 44 7 4 1 - 1 3 51 4 7 - - - 5 33 '9 2 1 5 - 4 26 13 - 3 - - 1 29 7 2 - - 1 -14 7 - - 1 - -44 4 1 3 2 - 2 55 7 1 6 1 - 2 54 16 1 1 2 - 1
956 154 87 43 26 22 49
."----"
Not Stated Total
8 140
- 124
1 12 8
10 125
10 103
7 117
5 73
4 84
6 66
2 69
- 54
2 45
- 39
2 24
- 56
- 72
- 75
57 1,394
Figure 2.
(
L
e.~i:~2~~i: ~1!~~~~~ ~=:j;~~]~~~:~~~ml~ill~:.t(~~~=4t~~~~~~~J~;~;1:;ri;.~l:~~jt~ =~-- -=--=:::·
- . I
ISE.E. " / w
-- - · ----~-~· -- ·· ·· -· '-'-...........
- 34 -
Grand Bahama had 29 percent in 1976 and 5 percent in 1974.
Andros, which had no cases, in 1976 a nd 1978 had 11 percent
in 1910. Table 3 shows the ge ographical distribution of the
cases.
Age Group
The age group 2P-2 . year (rab le 4) was responsible for
24 percent of the ca ~e ~ . Second to t h at wa s less than 10 years
old with 20 percent and third was the g oup 30-39 with
18 percent. The age groups 40-49 and 50 plus accounted for
12 and 14 percent re spectively. The age group 10-19 was
responsible for the lowe st number of cases, that is 9 percent.
The ages for the remaining 4 percent were not recorded.
Table• 5 shows the reported cases of pulmonary tuberculosis
by age group for the Bahamas from 1965 to 1981.
The less than 10 year old had as high as 32 percent of
the cases in 1972 and as low as 4 percent in 1978. This age
group had the highest range. The age group 10-19 years had
its highest percentage of 15 in 1967 and its lowest 3 in 1970
and 1977. Table 5 and Figure 3 show the p e rcentages of the
reported pulmonary tuberculosis cases by age group for the
Bahamas 1965 to 1981.
Table 4
Year
1965
( 1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
Total
%
- 35 -
Reported Cases o f Pulmonary Tuberculosis by Age Group for the Bahamas
1965 to 1981
Age Group of Cases in Years
under over not 10 10-19 20-29 30-39 40-50 50 stated
25 8 37 20 20 22 8
33 9 28 19 18 16 1
19 19 32 23 16 19 -36 15 23 15 14 12 10
26 12 26 14 5 10 10
32 4 24 23 10 16 8
10 4 21 12 10 11 5
27 5 14 15 11 8 4
8 8 14 14 10 8 4
10 9 9 22 6 11 2
4 7 11 16 7 9 -5 3 14 10 7 5 1
4 1 15 7 7 5 -1 2 3 5 4 9 -
15 4 13 5 10 8 1 '
12 4 21 l-2 9 11 3
6 7 24 20 6 12 -
273 1 21 329 252 170 192 57
20 9 24 18 12 14 4
Total
140
124
128
125
103
117
73
84
66
69
54
45
39
24
56
72
75
1,394
100
- 36 -
Table 5
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
Percentages o f Repo~ted Pulmon~ry Tuberculosis Cases py Age Group for Bah amas
----------~--~--~~9~6~5~t~.a~l~9~8~1 ________________ __
Percentage Distribution by Age Group (Years)
under over not %
10 10-19 20-29 30-39 40-50 50 stated Total
18 6 26 14 14 16 6 100
27 7 23 15 15 13 1 100
15 15 25 18 13 15 - 100
29 12 18 12 11 10 8 100
25 12 25 14 5 10 10 100
27 3 21 20 9 14 7 100
14 5 29 16 14 15 7 100
32 6 17 18 13 10 5 100
12 12 21 21 15 12 6 100
14 13 13 32 9 16 3 100
7 13 20 30 13 17 - 100
11 7 31 22 16 11 2 100
10 3 39 18 18 13 - 100
4 8 13 21 17 37 - 100
26 7 23 9 18 14 2 100
17 6 29 17 13 15 4 100
8 9 32 27 8 16 - 100
(
E~t~~~~~~~~~;~~~~-e;~~~ ~ :;.,_==!. -=1-- ·;~-- 1-------···- ·-· ....... . :t . . .. +· . ~ .. :K-E:!}.:. ---=+--- ::1-~= ·-· ___,. ·~
BEE W I ..
Table 6
Year
1965
1966
1967
1968
1969
1970
1971
1972
( 1973
1974
1975
1976
1977
1978
1979
1980
1981
Total
- 3 8 -
Reported Pulmonary 'fub~rct+los is Cases by S~x for the aah&mas
1965 to 1981
s E X
Male Female Not Stated
88 52 -
67 57 -
69 59 -
76 47 2
61 41 1
81 32 4
48 24 1
54 30 -
41 23 2
50 19 -
42 12 -
33 12 -
23 16 -
16 8 -
32 24 -
47 25 -
49 26 -
877 507 10
Total
140
124
128
125
103
117
73
84
66
69
54
45
39
24
56
72
75
1,394
(
<•
- 40
Se x
In each year during the study period males out-numbered
fema les. The overal l ratio b eing 7:4. In 1975 it was 7:2
but in 1972 it was almost 1:1.
Table 6 and Figure 4 show the number of reporte d cases
by sex for the Bah ama s.
Radiological resul t s
From 1977 to 1981 there wa s 266 initial x-rays; of
these 227 {85 per c e nt) we re positive , 2 p e r c e nt were
negative and 13 per cent were not found. The percentage
of positives ranged from 77 in 1977 to 93 in 1979. Table 7
shows the initial x-ray result of the patients from 1977
to 1981.
Bacteriological results
A total of 266 sputum specimens we re examined, of the se
reports for 242 {91 per cent) sme ars an d 232 {87 per c e nt)
culture swere locate d. The result of 24 {9 per cent) smears
and 34 {13 per cent) cultures we re not recorded. There wer e
172 {71 per cent) posit ive sme ars and 150 {67 per cent)
positive cultures. The neg1tive smears and cultures were
70 and 82 respect ively, Table 8 s hows the reported cases of
.... _ ...__
Table 7
Year
1977
1978
1979
1980
1981
Total
- 4 1 -
Distribution o f Tube rculos i s Cases by Type o f X-ray Result in t h e Bahamas
1977 to 1981
Initial X-ray Result
Positive Negative Unknown Total
30 0 9 39
22 1 1 24
52 1 3 56
58 0 14 72
65 3 7 75
227 5 34 266
Positive (%)
77
92
93
81
87
85
N ~
CO'
Q)
~I
Reported Cases of Pulmonary Tuberculosis by Sputum Result in the Bahamas, 1977 to 1981
S P U T U M RESULT
SMEAR CULTURE
Year +ve -ve Unknown Total +~e +ve -ve Unknown Total
197 7 29 2 8 39 7 4 21 8 10 39
1978 21 2 1 24 87 12 8 4 24
19 79 33 20 3 56 59 19 32 5 56
19 80 38 26 8 72 53 46 16 10 72
1981 51 20 4 75 68 52 18 5 75
Total 172 70 24 266 65 150 82 34 266
K E Y
+ve = positive
-ve = negative
+~e
54
50
34
64
69 l
56
(
- 43 -
Table 9
Detailed Sputum Results of Reported Cases of Pulmonary Tuberculosis in the Bahamas
1977 to 1981
y E A R
Sputum Results 1977 1978 1979 1980 1981 Total
Smear+ Culture+ 19 11 14 32 37 113
Smear+ Culture- 9 10 19 6 12 56
Smear- Culture+ 2 1 5 14 16 36
Smear- Culture- 1 1 15 13 5 35
Smear+ Culture? - - - - 2 3
Smear?- Culture+ - - - - 1 1
Smear?- Culture? 9 1 3 7 2 22
Total 39 24 .56 72 75 266
K E Y
+ = positive
= negative
? = unknown
%
42. 5
21.1
13.5
13.2
1.1
0.4
8.3
100.1
44 -
pulmonary tuberculosis by sputum result 1n the Baha mas
1977-1981.
For the 5-year period, out of a total of 266 specimens,
113 had positive smear a nd culture 56 had positive smear
only; and 35 had negative sme ar a nd culture . Table 9
shows the detailed sputum result of reported cases of
pulmonary tuberculosis in the Bahama s from 1977 to 1981.
In some cases, although both admissions and discharge
books had both smear and culture recorded as positvie, the
culture report was not placed in the patie nts note s, and
for others no record of the r esult wa s available.
Nationality
For the 5-year period 151 or 57 percent of the cases
were from the Bahamas, 107 or 40 percent were Haitians and
8 or 3 per cent were of other nationality of which 3 were
Turks Islanders, 1 Chine se, l Vietname se, 1 Indian,
1 Jamaican and the nationa l i ty of one was not stated.
The lowest numbe~ o~ f ~itians w9a 2 or 8 percent i n 1978
but went up as high as 5~ p e r cent iD 1980 and 49 percent
in 1981. Table 8 shows the national ity of the reported cases of
pulmonary tuberculosis i n the Bahamas from 1977 - 1981.
Table 10
Year
1977
1978
1979
1980
1981
Total
- 45 -
Nationality of Reported Cases of Pulmopary Tuberculosis in the Bahamas
1977 to 1981
N A T I 0 N A L I T y
Bahamian % Haitian % Other
24 62 15 38 0
21 88 2 8 1
40 71 15 27 1
31 43 38 53 3
35 47 37 49 3
151 56 107 40 8
% Total
0 39
4 24
2 56
4 72
4 75
3 266
..
r
- 4.6 -
CHAPTER 4
DISCUSSION
Limitations of methods
The following are limitations of methods.
1. The Public Health Departme nt notification register
for 1962, 1963 and 1964 could not be located therefore the
. study period was shortened to 17 years.
2. The hospital r e gistration numbe rs for some of the
patients notes were not recorded in the admission and dis
charge books so their notes could not be requested from the
records department, therefore the necessary in£)~mation was
not available.
3. Members of the records department staff, who were
otherwise engaged wi th heavy work load we re the only personnel
allowed to search for the notes, ~s a result only a limited
number of notes could be requeste d eacn day , therefore the
data collection period was unduly prolonged.
Interpretation of results
The study population consis ted of 1394 cases, of which
17 (1 p~ cent) did not appear on the Public Health Register.
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They were later discovered during colle ction of data for
the 5 year period ( ~977 - 1981) fr om the admissions and
discharge books, when a more d e ·tailed study was done.
The hospital notes of these patients were also checked and
the notes did not indicate that they were relapsed c a ses.
The total number for these 5 years was 266. Thus 6.4
percent of cases identified by the Chest Clinic had not
been recorded at the Public Health Department, which is
responsible for reporting to CAREC, the number of cases
of notifiable diseases in the country. It is possible
that these cases were not reported to the Public Health
Department. Alternatively reports may have been prepared
by Tuberculosis Unit, but they had not reached the depart
ment or had been accidentally omitted from the register.
Notification is done by completion of a specially
printed form (Appendix 7) which is forwarded through the
interdepartmental messenger service.
If the other 12 years were examined more closely also,
the likelihood of finding more or fewer cases, that might
not have been on the register, would have been greater.
If there were more accuracy in record keeping, the 22
percent of the records that could not be found because of
incorrectly written registration rumbers or no number at all,
- 48 -
could have been prevented. Therefore it would appear that
there was insufficient monitoring of the records. Probably
this was due to insufficient staff, whereby routine ward work
had to be given greater priority. The notes which were not
on file at the medical records department, were either still
in the various wards or clinics or had been returned and
were misplaced or misfiled.
The notes that were eventually found after being
requested more than once, were probably returned to the
department.
During the 17 years, the names of 10 cases appeared on
the Infectious Disease ~egister twice. This probably was
due to two separate notifications, or that the person trans
ferring the information into the register wrote them twice
in error. All patients are admitted to the wards via out
Patients Department therefore if the case was investigated
by the doctor, he might have been repeated in the case where
private physicians refer tuberculosis patients to the hospital
for treatment.
The Haitian national, who was admitted twice within the
same year and who had used two different names, was probably
recognised by the ward staff and they in turn
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requested his first notes and incorporated them with his
second record. Unfortunately they did not make the
necessary adjustment regarding the name . The case was
notified again and they did not inform the Public Health
Department.
There were 57 cases with the age and address missing
and also 10 cases with the sex not stated. The information
for the above was collected from the public Health Register.
They probably were missing either because they were not on
the notification form or they were left out when being
transferred to the register.
Throughout the 17 year period, 69 percent of the cases
gave their addresses as New Providence and second to that
was Grand Bahama with 11 percent. The possible explanations
are:-
1. Nassau the capital of the Bahamas is situated on
New Providence and according to the 1980 census the popula-
tion was 137,437. with a population density of 1692.2 per
square mile, there are definitely over crowding and poor
housing conditions in some areas. such living conditions
are conducive to the spread of tuberculosis.
2. At the time of admission to hospital, although some
of the patients were from the family islands, they
( l
(
- 50 -
probably gave their address as New Providence, where they
were temporarily residing.
3. Freeport, which is the capital of Grand Bahama,
is the nation's second city. In 1980 the i sland had a
population of 33,102, with most of the people living ln or
or near Freeport. There are also some areas of poor
housing as in Nassau, on the outskirts of the city. There-
fore one would expect more cases from those areas. Another
important factor is that both Nassau and Freeport have
diagnostic facilities.
The more developed islands such as Eleuthere, Andros,
Long Island and Abaco had more casep than those less
developed and sparsely pppqlat~d islands (See Table 1 on
Page 3).
There was a decline in the number of reported cases
from 1965 to 1978. However since 1978 there has been an
increase in the incidence (Figure 2). The decline was
effective control programme and an improvement in the
educational and economic conditions.
However the reason for the increase since 1978 is not
so clear, because socio-economic conditions continue to
improve. Prior to 1978 the treatment consisted of INAH,
PAS and Streptomycin. The Streptomycin was given daily for
6 weeks.
> I
j
(
- 51 -
and the others were given three times a day for 2 years.
Moreover the patients were not discharged until they had
three consecutive negative sputum examinations.
ment was the same from 1962 until 1978.
The treat-
In 1978 not only was there a change in doctor, but
also a change in the treatment regime. The medication
consisted of INAH, ethambutal and rifampicin while in
hospital, which was given daily in one dose. sputum speci
ment were sent during the first week of admission on three
consecutive days. on discharge rifampicin was only given
to relapsed cases, and most of the cases were discharged
after six weeks.
Another aspect worthy of examination is the follow-up
care because it is an important part of the control of tuber-
culosis. Basically from 1962 to 1981 there was only one
nurse responsible for the follow-up care and other duties of
the chest clinic. It was not until october 1981, that the
community nurse at the Clinic was provided with an assistant.
The increase in staff should have been since 1978 when there
was a change in the treatment and the stay in hospital was
shorter, for unreliable patients need close supervision.
It is also very difficult to follow-up Haitians because
they change their address frequen t ly, a nd
(
- 52 -
in most cases the new address is not known. There is also
a language barrier between Haitians and Bahamians because
Haitians speak French and the Bahamians speak English.
The incidence among the Haitian patients admitted to
the chest wards has also increased since 1978. The percent
age ranged from 8 to 53 for the period 1977 - 1981, with 8
percent recorded for 1978 and 53 percent for 1980. However,
if the Haitians were excluded tnere would still be an
increase in the number of cases.
The Haitians have ~lways been significant users of the
health facilities. ~n l97+ accp+qipg to a survey (Marshall,
1979) done in the carmichael area of New Providence, out of
a total of 71 households, which included 135 adults and 55
children, over 90 percent reported that they attended the
hospital frequently. Haitians are also screened for work
permits, either privately or by the Public Health Departm8nt.
If they attend the public Health Department x-rays and other
tests are done. Therefore there are good opportunities for
tuberculosis cases to be identified among the Haitian
population.
Throughout the Bahamas, most of the Haitians can be
found living in the lower income areas, where there is
overcrowding
( (
- 53 -
and poor housing conditions. rt is also known that some
Haitians return to strenuous work soon after discharge,
due to economic problems. If their diet is also deficient,
added to the fact that they might not be taking their
medication properly, this could lead to relapse, causing
their families to be more at risk. The incidence of pul-
mcnary tuberculosis is probably much higher among the
Haitian nationals than the Bahamians since they constitute
a minority of the total population but contribute up to
50 percent of the cases with this disease.
The age group 20 - 29 year accounted for 24 percent
of the cases, the under 10 year olds (20 percent) and 10 -19
years, (9 percent). usually infants, adolescents and young
adults are the main victims of pulmonary tuberculosis
(Pagel et al). However the results of this study reveal
that adolescents are the least affected.
For the entire period 1965 - 1981 the sex ratio was 7:4
this differed from 1943 when the number of cases was 97 with
47 males and 53 females giving a ratio of 1:1 (Gilmour, 1945).
This suggests that in the Bahamas :for the 17 year period
males were more suscep·t;ible to pult ona ry tuberculosis than
females.
(
- 54 -
The x-ray results showed that 85 percent were positive
for the five year period 1977 - 1981. A positive x-ray is
a film showing tuberculosis cavities, shadows or densities
suggestive of active cases. In the case of primary tuber
culosis the film shows enlarge hilar glands. For the
sputum, 65 percent of smea1=s and 57 percent of cultures
were positive. This sugge~ts that most of the patients
were being diagnosed at an infectious stage.
Abnormal x-+ay densities inQ~.cative of pulmonary
infiltration and cavitation occur before clinical manifesta-
tion, while localizing symptoms of cough, chest pain etc.
become prominent only in advanced cases. This indicated
therefore that most of the cases were still being diagnosed
at a relatively late stage, just as they were being done in
1945.
There were 36 (14 percent) sputum specimens which were
positive by culture, although the smears were negative.
These cases could have been missed if the laboratory had
been doing only smears.
The study shows that the nationality of the cases was
the best kept record, because out of a total of 266 cases,
there was only one patient whose nationality was not stated.
J
- 55 -
Conclusions:
In conclusion the results show show that there was a
decline from 1965 - 1978 but since then the incidence has
increased. Unfortunately the study could not show the
reasons for the increase.
Recommendations:
since the above study has raised a number of unanswered
questions, another epidemiological study should be carried
out as soon as possible. During that particular study a
structured questionnaire should be used, so that all the
patients or a representative sample could be interviewed.
Information such as living conditions, reliability of taking
drugs, occupation, etc. which may not be recorded in the
notes could then be obtained.
In view of the fact that the majority of the cases are
diagnosed late, this indicates that close contacts have a
greater chance of becoming infected. There is a need to
find new cases earlier. Therefore, case finding programmes
should be incre~sed. f O+ exa~ple, Mant oux surveys and mass
chest x-rays among the under 10 year olds and the age group
20 - 29, since these two age groups accounted for most of
the cases in the study population.
• - 56 -
Record keeping needs to be improv ed in both chest wards
and chest clinics. Presently all cases at the hospital are
being notified from chest Clinic, therefore the clinics
staff would be able to verify easily whether or not a case
was notified by checking the s t u p of tne notification book ,
Since the change i n treatment coincided with the
increase in the incidence, the p r esent treatment regime and
the follow-up care sho~ld be e valuate d.
x-ray facilities are on Eleuthera and Inagua at the
government clinics and privately at Abaco. It would be
advantages if the government would consider the feasibility
of providing partial laboratory services at these islands,
with microscopes and reagents for doing direct smear
examinations.
one of the most important aspects of tuberculosis
control is drug taking. It is imperative that the patients
take the treatment prescribed. Since most of the patients
are discharged after 6 weeks, follow-up care should be
intensified. until 1981 one nurse was responsible for the
investigations and follow-up care. In order to improve this
situation there are two possibilities; either to increase
the staff at the chest clinic or to assign the follow-up
care to the 4 main clinics in New Prov idence.
I
- 57 -
This study has shown that tuberculosis is still a
problem in the Bahamas. There is a need for a Medical
Officer to deal specifically with tuberculosis cases.
He should be responsible for planning a National control
Programme so that by the year 2000 tuberculosis in the
Bahamas would be under control.
- 58 -
REFERENCES
Annual Medical Reports , Bap amas , 1947 - 1951, 1954 and 1955. Archives Def~'tment , Un ubl ished.
Benenson, A.S. {1980 } c ontrol o f commun i cable dis ease in man. American public Health As sociation, New York, pp • 3 7 2 - 3 7 8 •
caribbean Epidemiology c e ntre (1979) Review o f communicable disease in the car i bbean. caribbean Epidemiology centre, Trinidad.
comostock, G.W. (1980) Tuberculosis. public Health and Preventive Medicine. Last, J.M., Maxcy - Rosenau (eds) Appleton-century-Crofts. New York~ pp. 206-220.
Gilmour, s. Tuberculosis in t he we st I ndies. National Association for the Prevention of Tuberculosis. London. pp. 206 - 220.
Marshall, D. (1979) The Haitian problem - Institute of social and Economic Research. University of the west Indie s, Jamaica. pp. 141 - 194.
Pagel, w. McDonald , Nassau, Simmonds (1964) Pulmonary Tuberculosis. Oxford University Press, London.
Richardson, R.K. (1979) Advanc e s in tuberculosis control. Four decades ·of advance in h ealth in the commonwealth Caribbean: Pan Amer i can Health Organization Scientific Publications No. 383 , pp. 55 · - 64.
World Health Organization (1982) Tube rculos i s profile, world Health organization, Jan: pp. 8 - 9.
styblo, K. (1982) The number of cases o f tuberculosis throughout the world ha s increas e d over the last 30 years. Defeat TB now and f or ever. world Health Organization, Geneva.
- 59 -
zahra, A. (1980) world Health organization's communicable disease programme. communicable diseases. world Health organization Geneve. November.