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Tuberculosis in the South Pacific; Israel Tuberculosis Convention
HERE
AND TttERE
~2_'23
Kingdom, USSR and Yugoslavia. Elsewhere they have been given in many of the countries also receiving help with control programmes and, in addition, in the Belgian Congo, Mozambique, Rhodesia and Nyasaland, Argentine, Dominican Republic, Mexico, Uruguay, Somalia, United Arab Republic and Korea. Ahhough the list of countries is long, the number of fellowships granted in each is small, usually only one. Possibly, if fimds are available, more might be done in future to enable medical staff to travel, particularly to the major centres of teaching and research. The Director-General emphasizes the advance made in x958 by the world-wide malaria eradication programme, which W H O has been developing since 1955. In the Americas, for instance, with the exception of one country, the conversion of national control projects into eradication programmes has been completed. So far, unfortunately, there has been little talk of tuberculosis eradication programmes in any country. In the report on the progress of the control programme in Iran it is stated that the Anti-tuberculosis Demonstration Centre in Teheran has, after many difficulties, been established; but 'no immediate or spectacular improvement of the tuberculosis situation should be expected, since tile needs are greater than the present r e s o u r c e s . . . ' C A L C I U M BENZOYL PAS Attention is drawn to tile article by Drain, Lazare and Tattersall on p. 2oI concerning estimates of the inhibitory effect on tubercle bacilli of serum from persons taking calcium benzoyl PAS. This interesting paper was not received until after publication of the leading article on the drug in the February number.
HERE
AND
THERE
T U B E R C U L O S I S IN T H E S O U T H PACIFIC The South Pacific Commission held a Tuberculosis Conference in Pago Pago, Samoa, in November 1958 . The Commission is an advisory and consultative body that was established in I947 by the six governments responsible for administering the island territories in this region: Australia, France, tile Netherlands, New Zealand, tile United Kingdom and the United States of America. T h e proceedings of tile conference have been collected together into three v o l u m e s - t i l e Report, tile Collected Papers and a Selected List of Bibliographical References to Tuberculosis in the South Pacific. The volnme of Collected Papers contains fifteen contributions on the problems of tuberculosis in the various islands of the region, giving background information for tile Conference discussions. Pelerson and Paulsen comment on the rapid and apparently lasting regression of lesions in newly diagnosed patients in Guam, many having no radiographic evidence of tuberculosis after three or four months of drug treatment; they have not seen a single relapse in the past five years in this group of previously untreated patients. In the Trust Territories.theprevalence of all forms of tuberculosis was reported as 24 per x,ooo and of pulmonary tuberculosis 17. 3 per I,ooo (Conover). Approximately I6 per cent of hospital deaths in i957 were due to tuberculosis; and the mortality rate was 6 per Io,ooo population inl I956. One-fifth of the total population of the Territory have been tuberculin tested;
224
TUBERGLE
4:3 per cent had positive reactions. Allison and'Palaci0s state that there is some doubt whether all radiographic abnormalities attributed to tuberculosis in the Saipan district are in fact tuberculous; they quote the case of a patient found at necropsy t o have organisms resembling Histoplasma capsulatum in the lung. A histoplasmin skin test survey is to be done. In the British Solomon Islands Protectorate sample surveys suggest that there m a y be 3,ooo cases of active tuberculosis in a population of about xo9,ooo (Macgregor). Tuberculosis in New Caledonia is described by Lalouel, and in the New Hebrides by Torresi, who finishes his report by quoting four recommendations submitted to the British Resident Commissioner in i947, including the building o f a small tuberculosis ward and isolation and t r e a t m e n t centres in villages, and t h e training of New Hebridean male nurses to help treating patients at home. Torresi states that: 'No action has been taken on these proposals to date'. During I958 in Netherlands New Guinea a mass x-ray survey was undertaken in some rural 9villages; 6,4:41 (98 per cent) of the population were examined. There were 256 with active tuberculosis (4 ~ per I,OOO) (IVijsmuller). -: 9In a full report by IVigley on the territories of Papua and New Guinea figures are given of the principal causes of death in the Administrative Hospitals in Papua in I956157:26 per cent of deaths were due t o pneumonia , 13 per cent to pulmonary tuberculosis and I2 per cent to malaria. Surveys have shown that the infection rate rises with increasing degrees of urbanization and contact with Europeans. Wigley also comments on the frequently astonishing speed and extent of the response to anti-bacterial treatment of patients with pulmonary tuberculosis. Three schemes for treating patients out of hospital have been begun in the past year. In the island of Kiriwina, for instance, IOO patient~ are living in their own villages and receive treatment either at their homes or at village aid posts. T h e homes are visited frequently by native medical orderlies; and a recent random check of urine samples showed that all patients were taking the PAS as advised. In the Cook Islands 8,074 persons have been tuberculin tested; 4,62o had negative reactions and all but 3I were vaccinated with B C G . . I t is reported by Hogg that there are between 300 and 400 cases of tuberculosis notified each year in the Gilbert and Ellice islands out of a population of about 42,700 living on the 37 coral islands scattered over 2 million square miles of sea. Murphy, after surveying the growth of the tuberculosis service in Fiji concludes t h a t the curative aspects have been developed beyond the preventive and that 'contact chasing' and 'hygienic disposal o f t h e untreatable' are weaknesses in the present system. There is still considerable room for improvement in the degree of co-operation and self-help shown by patients, .pztrticularly the Fijians. T h e situation in French Polynesia is described by Laignet. I n 1957, 387 patients were treated in hospital, 22 of them for tuberculous meningitis. Sateki Tupou, in an account of tuberculosis in the K i n g d o m of Tonga, states that it is very rare for a T o n g a n to seek treatment at hospital early, for the p e o p l e h i d e the disease and d o not want the name tuberculosis- mahaki fatafata- mentioned in connexion with their names or the names of their family. Even after being told their have tuberculosis t h e y will hide the nature of their disease from the rest of the village, calling it a 'cold' or a 'little water in the chest'. Jones and Thieme deal with the position in American Samoa and Western Samoa respectively. These reports,' m a n y of them detailed and all interesting, together with the selected list of references and abstracts, are a valuable contribution. T h e y g i v e statistical information o n morbidity and mortality, tuberculin and x-ray surveys, .the e x t e r / t o f treatment and.the personnelavailable to carry it out. But of greater interest to those'concerned primarily with tuberculosis in the weU-favoured countries is the picture that emerges of the great efforts "needed to control and finally eradicate tuberculosis in regions such as those of the: South Pacific, and the difficulties that "confront those who work there. i: r
LETTERS TO TIlE
225
EDITOR
ISRAEL T U B E R C U L O S I S C O N V E N T I O N The Israel Association of Chest Physicians is organizing a Convention on Epidemiological Problems of Tuberculosis in Jerusalem, Israel, on September-22 and 23, i959, after the I5th International Conference of the International Union Against Tuberculosis in Istanbul. Organized tours of the Holy Land will be included in the programme of the Convention. The detailed programme will be published shortly. Applications for registration should be sent to the Israel Association of Chest Physicians, P.O.B. 8123, Jaffa, Israel; and particulars about.travel facilities may be obtained through'.the Convention Travel Agency: Peltours, 28, Ahad H a a m Street, Tel-Aviv, Israel.
LETTERS
TO
THE
EDITOR
TRIAL OF IsONIAZID WITH SULPHONE The M.R.C. report on sulphone ahd isoniazid was of interest to me as I was involved in the first trial of diamino-diphenyl-sulphone (DDS) in pulmonary tubei'culosis. As the report on this pilot trial (Edwards, P. W., Penman, A. (3. and Cutbill, L.J., Brit. reed. ft., I952, i, x224) was published several years ago it is perhaps worth reiterating the essential findings. (I) Europeans did not tolerate the dosage of DDS which Africans take With impunity. Haemolytic anaemia forced us to reduce the dose from 200 mg. da!ly to 5 ~ mg. daily. (2) In combination with streptomycin, I g. daily, the clinical, radiographic and bacteriological response was poor. (3) DDS did not prevent the emergence ofstrains resistant to streptomycin. O f the 12 strains recovered after approximately twelve weeks' treatment, only one remained fully sensitiqe to streptomycin and 8 showed a high level of resistance. DDS is not the only anti-tuberculous drug that has shown encouraging results in mice and in human leprosy, but has been a failure in human tuberculosis. Trials of these promising drugs must obviously be made, and fortunately the answer is normally forthcoming before too much harm has been done. In the case of our DDS Trial, the answer was obtained from 22 patients. Such pilot trials are ideally suited to tlie small team working in a single hospital. In conclusion, may I state a guiding principle which is so obvious that it is occasionally forgotten. No patient should be admitted to a trial of a new anti-tuberculous drug until it has been shown by sensitivity tests that there is an effective pair ofdrugs ill reserve. Cheshire ffohzt Sanatorium, CLARK PENMAN.
3[arkel Dra.ylon, Salop. While admiring this carefully co-ordinated trial and congratulating the East African staff particularly - I know their difficulties, having been there - as a reactionary, and a fervid believer in the 'drugs', may'I ask - are these trials ahvays really necessary ?
AND TttERE
~2_'23
Kingdom, USSR and Yugoslavia. Elsewhere they have been given in many of the countries also receiving help with control programmes and, in addition, in the Belgian Congo, Mozambique, Rhodesia and Nyasaland, Argentine, Dominican Republic, Mexico, Uruguay, Somalia, United Arab Republic and Korea. Ahhough the list of countries is long, the number of fellowships granted in each is small, usually only one. Possibly, if fimds are available, more might be done in future to enable medical staff to travel, particularly to the major centres of teaching and research. The Director-General emphasizes the advance made in x958 by the world-wide malaria eradication programme, which W H O has been developing since 1955. In the Americas, for instance, with the exception of one country, the conversion of national control projects into eradication programmes has been completed. So far, unfortunately, there has been little talk of tuberculosis eradication programmes in any country. In the report on the progress of the control programme in Iran it is stated that the Anti-tuberculosis Demonstration Centre in Teheran has, after many difficulties, been established; but 'no immediate or spectacular improvement of the tuberculosis situation should be expected, since tile needs are greater than the present r e s o u r c e s . . . ' C A L C I U M BENZOYL PAS Attention is drawn to tile article by Drain, Lazare and Tattersall on p. 2oI concerning estimates of the inhibitory effect on tubercle bacilli of serum from persons taking calcium benzoyl PAS. This interesting paper was not received until after publication of the leading article on the drug in the February number.
HERE
AND
THERE
T U B E R C U L O S I S IN T H E S O U T H PACIFIC The South Pacific Commission held a Tuberculosis Conference in Pago Pago, Samoa, in November 1958 . The Commission is an advisory and consultative body that was established in I947 by the six governments responsible for administering the island territories in this region: Australia, France, tile Netherlands, New Zealand, tile United Kingdom and the United States of America. T h e proceedings of tile conference have been collected together into three v o l u m e s - t i l e Report, tile Collected Papers and a Selected List of Bibliographical References to Tuberculosis in the South Pacific. The volnme of Collected Papers contains fifteen contributions on the problems of tuberculosis in the various islands of the region, giving background information for tile Conference discussions. Pelerson and Paulsen comment on the rapid and apparently lasting regression of lesions in newly diagnosed patients in Guam, many having no radiographic evidence of tuberculosis after three or four months of drug treatment; they have not seen a single relapse in the past five years in this group of previously untreated patients. In the Trust Territories.theprevalence of all forms of tuberculosis was reported as 24 per x,ooo and of pulmonary tuberculosis 17. 3 per I,ooo (Conover). Approximately I6 per cent of hospital deaths in i957 were due to tuberculosis; and the mortality rate was 6 per Io,ooo population inl I956. One-fifth of the total population of the Territory have been tuberculin tested;
224
TUBERGLE
4:3 per cent had positive reactions. Allison and'Palaci0s state that there is some doubt whether all radiographic abnormalities attributed to tuberculosis in the Saipan district are in fact tuberculous; they quote the case of a patient found at necropsy t o have organisms resembling Histoplasma capsulatum in the lung. A histoplasmin skin test survey is to be done. In the British Solomon Islands Protectorate sample surveys suggest that there m a y be 3,ooo cases of active tuberculosis in a population of about xo9,ooo (Macgregor). Tuberculosis in New Caledonia is described by Lalouel, and in the New Hebrides by Torresi, who finishes his report by quoting four recommendations submitted to the British Resident Commissioner in i947, including the building o f a small tuberculosis ward and isolation and t r e a t m e n t centres in villages, and t h e training of New Hebridean male nurses to help treating patients at home. Torresi states that: 'No action has been taken on these proposals to date'. During I958 in Netherlands New Guinea a mass x-ray survey was undertaken in some rural 9villages; 6,4:41 (98 per cent) of the population were examined. There were 256 with active tuberculosis (4 ~ per I,OOO) (IVijsmuller). -: 9In a full report by IVigley on the territories of Papua and New Guinea figures are given of the principal causes of death in the Administrative Hospitals in Papua in I956157:26 per cent of deaths were due t o pneumonia , 13 per cent to pulmonary tuberculosis and I2 per cent to malaria. Surveys have shown that the infection rate rises with increasing degrees of urbanization and contact with Europeans. Wigley also comments on the frequently astonishing speed and extent of the response to anti-bacterial treatment of patients with pulmonary tuberculosis. Three schemes for treating patients out of hospital have been begun in the past year. In the island of Kiriwina, for instance, IOO patient~ are living in their own villages and receive treatment either at their homes or at village aid posts. T h e homes are visited frequently by native medical orderlies; and a recent random check of urine samples showed that all patients were taking the PAS as advised. In the Cook Islands 8,074 persons have been tuberculin tested; 4,62o had negative reactions and all but 3I were vaccinated with B C G . . I t is reported by Hogg that there are between 300 and 400 cases of tuberculosis notified each year in the Gilbert and Ellice islands out of a population of about 42,700 living on the 37 coral islands scattered over 2 million square miles of sea. Murphy, after surveying the growth of the tuberculosis service in Fiji concludes t h a t the curative aspects have been developed beyond the preventive and that 'contact chasing' and 'hygienic disposal o f t h e untreatable' are weaknesses in the present system. There is still considerable room for improvement in the degree of co-operation and self-help shown by patients, .pztrticularly the Fijians. T h e situation in French Polynesia is described by Laignet. I n 1957, 387 patients were treated in hospital, 22 of them for tuberculous meningitis. Sateki Tupou, in an account of tuberculosis in the K i n g d o m of Tonga, states that it is very rare for a T o n g a n to seek treatment at hospital early, for the p e o p l e h i d e the disease and d o not want the name tuberculosis- mahaki fatafata- mentioned in connexion with their names or the names of their family. Even after being told their have tuberculosis t h e y will hide the nature of their disease from the rest of the village, calling it a 'cold' or a 'little water in the chest'. Jones and Thieme deal with the position in American Samoa and Western Samoa respectively. These reports,' m a n y of them detailed and all interesting, together with the selected list of references and abstracts, are a valuable contribution. T h e y g i v e statistical information o n morbidity and mortality, tuberculin and x-ray surveys, .the e x t e r / t o f treatment and.the personnelavailable to carry it out. But of greater interest to those'concerned primarily with tuberculosis in the weU-favoured countries is the picture that emerges of the great efforts "needed to control and finally eradicate tuberculosis in regions such as those of the: South Pacific, and the difficulties that "confront those who work there. i: r
LETTERS TO TIlE
225
EDITOR
ISRAEL T U B E R C U L O S I S C O N V E N T I O N The Israel Association of Chest Physicians is organizing a Convention on Epidemiological Problems of Tuberculosis in Jerusalem, Israel, on September-22 and 23, i959, after the I5th International Conference of the International Union Against Tuberculosis in Istanbul. Organized tours of the Holy Land will be included in the programme of the Convention. The detailed programme will be published shortly. Applications for registration should be sent to the Israel Association of Chest Physicians, P.O.B. 8123, Jaffa, Israel; and particulars about.travel facilities may be obtained through'.the Convention Travel Agency: Peltours, 28, Ahad H a a m Street, Tel-Aviv, Israel.
LETTERS
TO
THE
EDITOR
TRIAL OF IsONIAZID WITH SULPHONE The M.R.C. report on sulphone ahd isoniazid was of interest to me as I was involved in the first trial of diamino-diphenyl-sulphone (DDS) in pulmonary tubei'culosis. As the report on this pilot trial (Edwards, P. W., Penman, A. (3. and Cutbill, L.J., Brit. reed. ft., I952, i, x224) was published several years ago it is perhaps worth reiterating the essential findings. (I) Europeans did not tolerate the dosage of DDS which Africans take With impunity. Haemolytic anaemia forced us to reduce the dose from 200 mg. da!ly to 5 ~ mg. daily. (2) In combination with streptomycin, I g. daily, the clinical, radiographic and bacteriological response was poor. (3) DDS did not prevent the emergence ofstrains resistant to streptomycin. O f the 12 strains recovered after approximately twelve weeks' treatment, only one remained fully sensitiqe to streptomycin and 8 showed a high level of resistance. DDS is not the only anti-tuberculous drug that has shown encouraging results in mice and in human leprosy, but has been a failure in human tuberculosis. Trials of these promising drugs must obviously be made, and fortunately the answer is normally forthcoming before too much harm has been done. In the case of our DDS Trial, the answer was obtained from 22 patients. Such pilot trials are ideally suited to tlie small team working in a single hospital. In conclusion, may I state a guiding principle which is so obvious that it is occasionally forgotten. No patient should be admitted to a trial of a new anti-tuberculous drug until it has been shown by sensitivity tests that there is an effective pair ofdrugs ill reserve. Cheshire ffohzt Sanatorium, CLARK PENMAN.
3[arkel Dra.ylon, Salop. While admiring this carefully co-ordinated trial and congratulating the East African staff particularly - I know their difficulties, having been there - as a reactionary, and a fervid believer in the 'drugs', may'I ask - are these trials ahvays really necessary ?