GLOBAL TRENDS OF TUBERCULOSIS - AN EPIDEMIOLOGICAL REVIEW

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1 Epidemiology NTI Bulletin 1997,33/1&2,11-18 GLOBAL TRENDS OF TUBERCULOSIS - AN EPIDEMIOLOGICAL REVIEW V.K Chadha* SUMMARY The epidemiological trends of tuberculosis since the pre-chemotherapy era to the recent resurgence in developed countries and further worsening of the problem in developing countries are presented in this review article. The declining trend of magnitude of tuberculosis observed in most of the developed countries since the beginning of this century as a natural phenomenon hastened after the introduction of chemotherapy. However, no such downward trend was observed in most of the developing countries including India even after the introduction of chemotherapy. In recent years, the declining trend of tuberculosis in developed countries has witnessed a reversal as a result of HIV epidemic, socio-demographic factors and emergence of multi-drug resistance. These factors have also led to further wo rsening of the problem in developing countries. In fact, the global incidence of tuberculosis is expected to increase further in the coming years, more significantly in the countries of Africa and South-East Asia including India. This calls for more intensive and sustained efforts at decreasing the reservoir of infection and reducing transmission. KEY WORDS: TRENDS, TUBERCULOSIS MORTALITY, INCIDENCE, ANNUAL RISK OF INFECTION, HIV & TB. INTRODUCTION Information on epidemiological trend of a disease in the community gives an insight into its behavioural pattern over a period of time and enables us not only to assess the impact of intervention programmes but also to foresee the likely scenario in future. Tuberculosis (TB) has been known to be a scourge to mankind for a long time. The disease behaviour in pre-chemotherapy era was assessed using TB mortality, rates as an epidemiological index. With the advent of chemotherapy leading to reduction in TB deaths, mortality rates do not provide the correct picture of disease situation. Annual notification rates in developed countries, where most of the population has access to health care services and reporting by health care providers is mandatory and comprehensive, represent incidence of TB. On the other hand, reliability of morbidity data from developing countries is affected by lack of adequate access to health care, availability of diagnostic procedures and completeness of notification or reporting systems. Since repeated disease surveys are difficult and impracticable, Annual Risk of Infection (ARI) is currently the preferred epidemiological indicator of TB situation and its trend in developing countries. The age distribution of incidence cases also helps to assess the transmission patterns. Knowledge of epidemiological behaviour of TB in a community is vital for planning and execution of control measures, as any change in disease situation has direct relevance to the methods for control. This article traces the epidemiological trends of TB since pre-chemotherapy era, especially in view of the recent trends of resurgence in developed countries and further worsening of the problem in developing countries. TRENDS IN THE PRE CHEMOTHERAPY ERA Developed countries There is ample evidence that TB problem in developed countries had been declining since the turn of this century. The disease specific mortality data show that TB in England peaked around 1740 with about 900 TB deaths per lakh population per year 1. Most of the capitals of other western European countries attained their mortality peaks in first half of l9th century and those of east Europe, a few * Epidemiologist, National Tuberculosis Institute 8, Bellary Road, Bangalore

2 decades later 1. TB mortality declined considerably from /lakh population per year at the turn of the century during the next 40 years in Czechoslovakia, Norway, Netherlands and other developed countries including USA. Mortality records in Canada showed 3% per annum decline in TB mortality prior to introduction of specific treatment 2. Information on TB morbidity during pre-chemotherapy era available from few countries also indicated a decline in disease rates. In Denmark, the incidence of cases fell by 58% from 1921 to New cases of bacillary pulmonary TB also decreased in Norway from 1927 to 1947, more so in pediatric age group 3. In Netherlands, 5.4% annual decline in ARI 4 was observed in the pre-chemotherapy era. It was similar to 5.7% annual decline in TB mortality rates. Repeated tuberculin surveys in children showed 3.8% annual decline in the risk of infection in Vienna and 4.7% in Prague 5. A similar decline was also observed in France 6. In fact, introduction of milk pasteurization in 1940s in most of the European countries leading to drastic reduction in transmission of bovine TB was also responsible for the decline in the prevalence rates of tuberculous infection among human populace in these countries. Since chemotherapy was non-existent during this period and BCG vaccination does not affect transmission of infection, this trend in developed countries can at best be termed as natural. Developing countries Only a little information about TB situation and its trend during the first half of this century is available from developing countries because of lack of reliable data on mortality and morbidity of TB or even prevalence of infection. In Alaska, TB mortality accounting for 35% of all deaths remained constant at 65 per lakh population from 1920 to Tuberculin surveys carried out in Algeria and Tunisia showed negligible decline in risk of infection from 1938 to Therefore, an inference can be drawn that in contrast to developed countries, there was no downward trend in the TB problem prior to chemotherapy era in the developing countries. TRENDS FOLLOWING INTRODUCTION OF CHEMOTHERAPY Developed countries After 1945, the fall in TB mortality rates accelerated in countries of western Europe and north America 6. This coincided with introduction of Streptomycin in 1946, PAS in 1948 and INH in The incidence of new cases of TB also showed a similar declining trends in most of the developed countries. In Federal Republic of Germany, incidence rate of bacteriologically confirmed cases declined from 78 per lakh population in 1949 to 15 per lakh in Similar decline was observed for bacteriologically unconfirmed and extrapulmonary cases. In German Democratic Republic also, TB of all forms declined rapidly from 1955 to In Canada, complete coverage of the population with casefinding and treatment was achieved by Since large proportion of population was already infected, notification rates were not immediately affected but later on declined at the rate of 10% per annum 3 and most of the new cases occurred in elderly and old persons. In Netherlands, morbidity of TB in younger people (0-30 years) fell by about 12% per year 6. In most developed countries like Canada, Federal Republic of Germany, France, Britain and Norway, 12-13% annual decline in risk of infection was observed after introduction of case-finding and treatment programmes 7 in contrast to 4-5% decline per annum prior to chemotherapy. As a result of high sputum conversion rates achieved on treatment of bacillary cases in Netherlands, the risk of infection decreased 15% per annum during Thus, TB problem declined rapidly after the advent of chemotherapy in developed countries, especially among children and young adults. Developing countries Morbidity data from developing countries are incomplete since only a third of the new smear positive cases are detected annually and thus cannot be relied upon for assessment of TB problem. Moreover, comparison with developed countries is undesirable since definition of a new case differs depending upon the resources available for diagnosing a case. The main source of information for studying the epidemiological situation of TB in developing countries is tuberculin surveys for estimation of ARI. The risk of tuberculous infection remains high in most developing countries and on an average, it is estimated to be 50 to 100 times of that in developed countries. The most recent data from African countries indicate that the current ARI is around 1 to 2.5 percent 7. Though a slow decline has been observed in countries like Ethiopia, Cameroon, Burundi, Boatswana and moderate decline in Algeria, no such decline has been observed in other countries like Tanzania, Lesotho and rural Gambia.

3 Of the Latin American countries 7, lower risk of infection at less than 1 percent have been recorded in recent years. However, the steep decline observed in earlier years in cities of Argentina appears to have been averted of late. On the other hand, ARI in Brazil on an average is high at 1-2 percent with wide variation between different regions of the country. ARI of 5-10% was observed in south and south east Asian countries in 1950s and continues to be high in most countries of this region 7. These are highest in Indonesia being as high as 3 to 4% in some regions where an actual increase has been reported in recent years. Similarly, ARI rates are high in India at 1 to 2.5% 8 and more than 2% in Thailand 7 with no signs of any declining trends. In the eastern Mediterranean region 7, ARI rates are high in Pakistan at around 2% and in Afghanistan at around 2.5%. However, low recent levels of infection risks have been reported in most of the middle east countries like Baharain, Libya, Kuwait and Syria after steep decline in recent years. In the Western Pacific region 7, ARI remains high in Korea and Philippines at about 2% and 1% in China, though it is relatively low in Malaysia. across the globe are expected to have been infected with HIV with an estimated 3 million AIDS cases 9. According to WHO projections, the maximum increase in HIV-seroprevalance is going to be witnessed in the developing countries of Asia and Africa. In 2000 A.D., 90% of HIV infected individuals will be residing in these two continents (Table 1). The association between HIV & TB is evident as high risk of TB at the rate of 5-8% per year has been observed among persons infected with both HIV and tubercle bacilli 11 (Table 2). This means HIV positive people infected with tubercle bacilli are about 30 times more likely to get sick with TB each year than HIV negative individuals. Moreover, high HIV seroprevalence among TB patients and high rates of TB among AIDS patients have been observed in many countries. Worldwide, about 5.6 million people were estimated to be dually infected with HIV and tubercle bacilli with 4% of new TB cases attributable to HIV 12. The impact of HIV pandemic is expected to be more serious in developing countries where most of the young adults are already infected with tubercle bacilli. TABLE 1 PROJECTED HIV SEROPREVALENCE IN 2000 A.D. The above data suggests that though improvement in living standards and TB control activities led to reduction in ARI in some of the developing countries like in developed ones, ARI in most other countries remains high with no indication of any decline. Thus, the problem of TB remained high in most of the developing countries even after the advent of chemotherapy. This was mainly because of low case-finding efficiency and poor treatment programmes. RECENT TRENDS OF TUBERCULOSIS Australasia, Europe & North America Latin America & Caribbean Africa Asia 1 million > 2 million > 9 million > 8 million Just when it was being projected that TB has been conquered in the west, research was stopped and funding was decreased; there was a dramatic change in epidemiological situation of TB. The declining trend of TB in industrialised countries and some of the middle income countries since the beginning of the century witnessed a reversal after mid-eighties, as a result of the advent of HIV epidemic and other socio-demographic factors. There was further worsening of the TB problem in developing countries as well. HIV & TB HIV infection has been observed as a single most important risk factor for TB. About 17 million persons USA Zaire TABLE 2 HIV INFECTION & ANNUAL RISK OF TB Country Rwanda HIV+/TB Status of Infection HIV-/TB

4 Developed Countries The recent epidemiological trend of TB in developed countries can be most appropriately illustrated by the TB situation in USA 13 where, after a dramatic decline in the incidence of TB during this century, there has been a 20% increase in the disease notification rates from 1985 to Most of the increase is accounted for by those heavily populated urban areas that have greatest concentration of Asian Blacks and foreign born immigrants from countries with high prevalence of TB. These are also the areas with highest incidence of reported AIDS cases. Overall 31% of the rise in incidence of TB in USA is attributed to HIV epidemic. Significantly, the median age of persons with TB decreased from 49 years in 1985 to 43 years in 1992 mainly due to increase in incidence among years aged people, who are most affected by HIV epidemic. Increased transmission of infection has also resulted in higher incidence among 0-4 years aged children. The increase in cases of multi-drug resistant tuberculosis (MDR- TB), mainly in urban and minority population due to rising number of intravenous drug users who also have high prevalence of HIV infection and homeless persons because of their erratic living situations and non-adherence to chemotherapy is an added variable responsible for the recent rising trend of TB. The isolates with drug resistance tended to come from younger persons indicating that drug resistance was associated with more recent infections. The declining trend of TB situation in Australia and Canada, seen in earlier years has stopped and incidence has remained constant since In Japan, there is slowing down of the declining trend and in New Zealand, an actual increase in case notifications has been observed recently. Majority of the cases in these countries are reported among foreign born individuals. While no data is available about the impact of HIV epidemic on TB in Canada, adverse impact has been observed in Australia, New Zealand and Japan. Similar trends have been observed in west European countries 3 viz., England, Italy and Switzerland. In England, where notification rates were falling every year, rose for the first time in 1991 by 4% than the previous year. Immigrants from Asia and east Europe were the worst affected. There was 20% increase in areas with highest number of AIDS patients. Italy where TB is common among HIV infected persons and Switzerland observed a 30% increase from 1986 to High levels of HIV seroprevalence have also been observed in certain urban areas of France and Spain leading to rise in reported TB cases. In eastern Europe, HIV problem is poorly defined 9 and not yet considered an important factor for epidemiology of TB. However, increase in TB incidence has been observed in many countries 14 mainly due to disturbed conditions because of economic and civil strife, resulting in shifting of priorities, breakdown of drug supply and health care system. Developing countries While resurgence took place in developed world after years of continuous decline, it was never controlled in developing world and more recently, there has been further rise in TB cases, especially in developing countries of Africa and south east Asia. At present, Africa account for more than 75% of dually infected persons 10 and HIV is the major cause of large increase in incidence of TB in a number of sub-saharan countries. Some of these countries have experienced a 3 or 4 fold increase in TB case notification and deaths as a result of HIV associated TB. HIV seroprevalence rates of more than 40% are common among patients with TB in many African countries 11,15 and even higher rates have been observed among extrapulmonary cases. Overall, 30-40% of TB cases in Africa and Caribbean countries are attributable to HIV 11. In HIV affected African countries, TB has been reported in 20-44% of AIDS patients 11, thus becoming one of the most common opportunistic diseases associated with AIDS. South East Asia and western pacific region contribute more than 60% of global TB incidence and HIV is making rapid inroads in several Asian countries including India, Thailand and Myanmar 9. This may result in significant increase in TB cases in Asia, as almost two-thirds of the world s TB-infected population lives here. HIV seroprevalence among TB patients is on the rise in South East Asia. In one region of Thailand, it rose from 5.1 % in 1989 to 14% in High HIV seroprevalence rates has been observed in some of the Latin American countries 9 like Haiti, Honduras, Argentina and Brazil. In the eastern Mediterranean and western pacific regions, HIV seroprevalence rates among TB cases are not available for most countries. MDR-TB, once thought to be an insignificant problem outside USA is spreading in Thailand. There are reports of rising resistance to Rifampicin in Tanzania. Thirty percent of China s TB patients are already resistant to Rifampicin and India is the most likely breeding ground for MDR-TB. 14

5 CURRENT GLOBAL TUBERCULOSIS SITUATION About 3 million TB deaths annually are the largest from a single pathogen 15. Of these, 2.7 million people die in developing countries accounting for 6.9% of all deaths. One million of these deaths occur in south east Asia region 16 and half of them occur in India alone. More deaths are concentrated in productive age group leading to social and economic consequences. Approximately, 8.8 million new cases of active TB are expected to have occurred in ; about half of them are estimated to be infectious cases. While altogether 95% of these cases occur in developing countries 16, India and China together contribute to 44% of the total global incidence. Most of the TB morbidity in industrialised countries occurs in elderly as a result of endogenous reactivation and only a small percentage as a result of recent infection mainly in ethnic minorities and emigrants. On the other hand, in developing regions, TB is the most common in the productive age groups of years and is the largest single cause of loss of DALYs 17 (Disability adjusted life years). Currently, ARI in developed countries is estimated to be between.01 to.1%, while the same in developing countries varied from 1 to 2.5% which is upto more than 100 times than in advanced countries (Table 3). TABLE 3 ESTIMATED ARI IN African region 1.5 to 2.5% Central & South America 0.5 to 1.5% Eastern Mediterranean 0.5 to 1.5% South East Asia 1.0 to 2.25% Western pacific region 1.0 to 2.25% Europe & other countries 0.01 to 0.1% While TB has come back to haunt the developed world, it never went away and continues to rage in the developing world. FUTURE TRENDS Global TB situation is expected to worsen in the immediate future, as a result of demographic factors (population growth and changes in age structure of the population) and increase in HIV seroprevalence rates, especially in developing countries of south-east Asia and sub-saharan Africa. Assuming that the efficiency of national tuberculosis programmes remains at current levels, projections have been made for likely trend of TB while assuming that the notification trends observed during 1985 to 1990 shall continue in future 15 (Table 4). Year TABLE 4 Estimated global TB incidence HIV attributable cases million 0.32 million (4.2%) million 0.74 million (8.4%) million 1.41million (13.8%) million NA This shows that the incidence of TB will increase by 36% in 2000 and by 58% in 2005 compared to that in Three fourths of this increase is expected to be due to demographic factors and the rest from a balance between decline in incidence due to intervention measures and increase in incidence due to HIV epidemic 19. Much higher relative increase is predicted in developing countries compared to western Europe and other developed countries. Africa and south east Asian regions are predicted to account for three-fourths of this increase in global incidence of TB. In south east Asia region, an additional 1.3 million cases will occur annually by The impact of HIV on TB epidemic will increase in a most significant manner in this region including India as large proportion of population is infected with mycobacterium TB and HIV epidemic is showing a rising trend. Currently, 4% of TB cases in south-east Asia are attributable to HIV and this is expected to rise to about 20% by In the African region where epidemic factors are stronger than demographic factors, the number of incidence cases are expected to triple by Globally, 4.2% of all cases were attributable to HIV in 1990 and this will increase to about 14% in 2000 AD 15,19. More people died of TB in 1995 than in any other year in history. As the drug resistance spreads, TB threatens to become an incurable disease for future generations and TB deaths will rise further, also because of higher mortality of HIV associated TB. At least 30 million people are expected to die of TB in next 10 years 15, if control activities are not intensified on an urgent basis. TUBERCULOSIS TRENDS IN INDIA Though TB has been known to be a major public health disease in our country for a long time, its magnitude was not known until National Sample 15

6 Survey (NSS) by ICMR in revealed the country-wide burden 19. Subsequent disease surveys in various parts of the country (Table 5) during last 40 years indicate that TB remains a major problem even after introduction of chemotherapy and implementation of NTP. The longitudinal studies in Delhi 20, Bangalore 2l and Tumkur 22 did not indicate any change in disease incidence over the periods of study and only a marginal decline in disease prevalence and incidence was observed over a period of 15 years in BCG trial area of Chingleput 23, where initial prevalence of disease was much higher 24. However, a small shift in disease prevalence to older age groups, specially among males has been observed in these longitudinal studies. Continued high rates of disease prevalence 25,26, incidence 27 and ARI (1-2.5% ) 8.28,29 (Table 6) suggest that TB remains a major public health problem. In fact, the TB problem is likely to increase further because of demographic cum socio-environmental changes, increasing incidence of MDR- TB 30,31, and advent of HIV epidemic. TABLE 5 PREVANCE OF PULMONARY TB PER 1000 POPULATION Area Period Age in year Prevalence rate National Sample > * Survey Tumkur > > Bangalore Rural > > Delhi 1976 > Chingleput > Wardha > Jabalpur(Tribal) > *Prevalence rate varied from 2-8 per 1000 population in different parts of the country TABLE 6 ANNUAL RISK OF TUBERCULOSIS INFECTION Area Period % Bangalore Rural Chinglepput Bangalore Periurban Bikaner A rising trend in the prevalence of HIV infection among high risk groups has already been observed in India. Sharp increase in HIV positivity rates has been observed among high risk groups viz., female sex workers, blood donors & STD clinic attenders, antenatal clinic attenders in various cities and intravenous drug users, especially in north eastern states. In Bombay, as many as 52% of female sex workers are reported to be seropositive 32. A rising trend of HIV seropositivity rates have been observed among TB patients attending hospitals/sanatoria in cities 38,39,40. A sharp rise in reported TB cases has also been observed over the last 5 years in the state of Manipur which accounts for highest HIV seropositivity rate in the country. Therefore, intensive and sustained efforts are required to be made to decrease the reservoir of infection and reduce transmission. Considering the present situation and future projections, it has been realised that the goal of world-wide control of TB can only be attained by addressing the problem of endemic TB in developing countries. WHO has declared TB a global emergency and has laid down targets of 70% casefinding efficiency and 85% cure rate to be achieved in developing countries, in order to achieve a reversal of the current epidemiological trends of TB. REFERENCES 1. Grigg ERN: The arcana of tuberculosis with a brief epidemiological history of the disease in USA, Ame Rev Resp Dis 1958, 78, Styb1o K, Meijer J & Sutherland I: The transmission of tubercle bacilli: Its trend in a human population: Tuberculosis Surveillance Research Unit, Report No. 1; Bull IUAT 1969, 42, Raviglione MC, Sudre P, Reider HL, Spinaci S & Kochi A: Secular trends of tuberculosis in Western Europe: Bull Wld Hlth Org 1993, 71, Styb1o K & Meijer J: Recent advances in tuberculosis epidemiology with regard to formulation or readjustment of control programmes: Bull IUAT 1978, 53, Styblo K: Recent advances in epidemiological research in an urban community: Indian J TB 1978, 25, Styb1o K: Epidemiology of tuberculosis; selected papers, Vol.24, 1991, Pub by Royal Netherlands TB Association, Holland. 7. Cauthan GM, Pio A & Ten Dam HG: Annual risk of tuberculosis infection; WHO/TB/88, Chakraborty AK: Tuberculosis situation in India: Measuring it through time: Indian J TB 1993, 40, 21 16

7 9. Global programme on AIDS: the HIV/AIDS pandemic; 1994, Overview, World Health Organization. 10. The HIV/AIDS and TB epidemics: Implications for TB control; WHO/TB/CARG(4)/ Narain JP, Raviglione MC, & Kochi A: HIV-associated tuberculosis in developing countries, epidemiology and strategies for prevention; Tubercle & Lung Dis 1992, 73, Decock KM: Interaction HIV/TB, Tubercle & Lung Dis 1995, 76/(suppl.2), Rom WN &, Garay S: Tuberculosis, Boston: Little Brown & Company, Raviglione MC, Hapa L, Reider, Styblo K, Alexander G, Khomenko, Karim Esteves & Kochi A: TB trends in Eastern Europe and former USSR; WHO/TB/ Dolin RJ, Raviglione MC & Kochi A: A review of current epidemiological data and estimation of future TB incidence and mortality; WHO/TB/ Kochi A: The global tuberculosis situation and the new control strategy of the World Health Organisation; Tubercle 1991, 72, World development report, 1993; investing in health: The global burden of disease 1990, P Murray CJL, Styblo K & Rouillon A: Tuberculosis in developing countries: burden, intervention and cost; Bull IUAT & Lung Dis 1990, 65, Indian Council of Medical Research: Tuberculosis in India - A sample survey, , Special Report Series No.34, ICMR, New Delhi. 20. Goyal SS, Mathur GP & Pamra SP: Tuberculosis trends in an urban community; Indian J TB 1978, 25, Chakraborty AK, Singh H, Srikantan K, Rangaswamy KR, Krishnamurthy MS and Steaphen JA: Tuberculosis in a rural population of south India; Report on five surveys; Indian J TB 1982, 29, Gothi GD, Chakraborty AK, Nair SS, Ganapathy KT and Banerjee GC: Prevalence of tuberculosis in a south Indian district - twelve years after initial survey; Indian J TB 1979, 26, Tuberculosis Research Centre, Madras: Trial of BCG vaccines in south India for TB prevention: Second Report; Unpublished. 24. Tuberculosis prevention trial, Madras: Trial of BCG vaccines in south India for tuberculosis prevention, Indian J Med Res 1980, 72 (Suppl), Chakma T, Vinay Rao P, Pall S, Kaushal LS, Manjula Dutta & Timany RS: Survey of pulmonary tuberculosis in a primitive tribe of Madhya Pradesh. Indian J TB 1996, 43, Chakraborty AK, Suryanarayana HV, Krishnamurthy VV, Krishnamurthy MS, Sreenivas TR: Prevalence of tuberculosis in a rural area by an alternative survey method without prior radiographic screening of the population; Tubercle & Lung Dis 1995, 70, Ray D, Abel R: Incidence of smear-positive pulmonary tuberculosis from in a rural area under an active health and programme in south India; Tubercle &Lung Dis 1995, 76, Diba Siddiqi, Sanjay Ghose, Krishnamurthy MS and Shashidhara AN: TB infection rate in a rural population of Bikaner district: Indian J TB 1996, 43, Mayurnath S, Vallishayee, Radhamani MP and Prabhakar R: Prevalence study of tuberculosis infection over 15 years in a rural population in Chingleput district (south India); Indian J Med Res 1991, 93(A), Jain SK, Chopra KK & Prasad G: Initial and acquired isoniazid and rifampicin resistance in M.tuberculosis and its implication for treatment; Indian J TB 1992, 39, Paramasivan CN, Chandrasekaran V, Santha T, Sudarsanam NM and Prabhakar R: Biological investigations for short course chemotherapy under the tuberculosis programme in two districts in India; Tubercle and Lung Dis 1993, 74, HIV infection: Current dimensions and future implications: ICMR Bull 1992, 22, Jacob Johan, Nisha Bhushan, George Babu P, Lakshmi Seshadri, Balasubramanium N & Padmini Jasper: Prevalence of HIV infection in pregnant women in Vellore region, Indian J Med Res 1994, 99, National AIDS Control Programme, India: Current scenario, an update, April 1993, National AIDS control organization, Ministry of Health & Family Welfare, Government of India. 35. National AIDS Control Programme, India: Current scenario, an update, September 1994, National AIDS control organization, Ministry of Health & Family Welfare, Government of India. 36. Nisha Bhushan, Ramani Pulimood R, George Babu P & John TJ: Rising trend in the prevalence of HIV infection among blood donors; Indian J Med Res 1994, 99, AIDS in India, AIDS ASIA 1994, 1, 17

8 38. Solomon S, Anuradha S & Rajalakshmi S: Trend of HIV infection in patients with tuberculosis in south India; Tubercle & Lung Dis 1995, 76, Mohanty KC and Basheer PMM: Changing trend of HIV infection and tuberculosis in Bombay area since 1988; Indian J TB 1995, 42, Purohit SD, Gupta RC and Bhatara VK: Pulmonary tuberculosis and human immunodeficiency virus infection in Ajmer; Lung India 1996, 15, India always had paucity of public health workers. There are many reasons for this shortage. For years we have been concentrating on the education of arts graduates to run our administrative machinery. This was the beginning of any organized and planned education in India. Large number of educated men and women that come out of our colleges and universities and remain unemployed is an ample testimony to this statement. Medical College Education The Medical College education was needed to man the developing hospital services and to treat those who got ill, which in turn were necessary for the maintenance of good reputation and benevolent character of governments. These services developed in the areas where there was cry and demand rather than the real need. They were concentrated in and near the cities and towns, big or small. Public Health Services have remained neglected and have little developed in contrast to hospital and treatment facilities. Psychologically individual persons have more liking for a doctor s profession in treating the sick rather than for public health work. Senior public health workers come out of doctors even though they may not have had a keen liking for the kind of work to begin with. Need for Public Health Workers It is only recently that the real need for public health workers has been felt acutely when the governments have planned prevention of communicable diseases on a mass scale like malaria, small pox, tuberculosis, leprosy and water borne diseases. Twenty years ago none thought of total control or eradication of such diseases. People had then not even the ideas to demand such measures as it was considered impracticable and beyond the means of the country. It is for this planned disease control programme that public health workers, not only doctors but other categories of workers, so called para-medical personnel are required in very large numbers. Source: Bordia NL: The Training Programme of the Institute, Bull Dev Prev of TB 1960, 713,