FIRST REGIONAL ~ULOSIS TRAINING COURSE

Sponsored by the

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

in collaboration with the Governments of the

REPtlELIC OF SINGAPORE

end

REPUBLIC OF CHINA

Singapore/China () 14 Februar,y-14 May 1966 •

FINAL REPORT

•

World Health Organization Western Pacific Regional Office Manila, Philippines

July 1966

vlPR/189/66 CONTENTS

1. INTROOOCTION ...... 1

2. AIMS AND ODJECTIVES ...... 1

3. ORGANIZATION ...... 1

4. PARTICIPANTS ...... " ...... " ...... 2 5· FACILITIES MADE AVAILABLE BY THE GOVERNMEN'lB ...... 2 6. S'!AFF ...... 7· TIME AND DURATION OF THE COURSE ...... 8. TEACHING PROGRAMME ......

9. OFFICIAL OPENING CEREMONY ...... 5 • 10. REPORTING BY PARTICIPAN'lB ...... 6

11. CLOSING CEREMONY ...... 6

12. DISCUSSION AND RECOMMENDATIONS ...... " ...... 6

ANNEX 1 List of Participants

ANNEX 2 - List of Resource Personnel in the Training Programme

ANNEX 3 Programme of the Course

ANNEX 4 Pe rticips.nts t Report on the Weekly Proceedings :)f the Trs.ining Course 1. INTROIUCTIOl'l

If tuberculosis is eventUB.lly to be eliminated, national key organ­ izers must be trained in the public health application of tuberculosis control methods end techniques. During the period 1956-1959, the former WHO Tuberculosis Resea.rch Office, in co-operation with the Government of Denmarl:, undertook the resp::msibility of training llRO fellows in this field. Follo~n.ng the closure of the WHO Tuberculosis Resee rch Office in 1959, internati::mal training courses ha.ve been orga.nized annually since 1961 in Prague, Czechoslovakia a.nd in Rome, Ita.ly (the f::;rmer in English and the latter in French), 1r1th WHO assistance. Some participants, however, felt that since conditions in Europe were so different to th?se in their Olm countries some of the techniques and methods suitable for Europea.n countries would not be applicable in their own communities. WHO Head­ qua.rters, therefore, suggested the organization of regione.l training courses, so tha.t a. more practical approach, suitable to the regions concerned, could be adopted. The Regional Training Course on the Epidemiology a.nd Control of Tuberculosis, held in Singapore a.nd Chine. (Taiwan), was the first one organ­ ized in response to this recommendation. The Governments of Singapore and China Itindly agreed to act as hosts.

2. AIMS AND OBJECTIVES

The general objectives of the course were to give training in the modern methods a.nd techniques of tuberculosis control, and to prepare the pa rticipa.nts for their future ta.sks in the effective a.pplication of control mea.sures on a IIlS.SS scale under the local technical and socio-economic con­ ditions in their own countries. The specific objectives were to a.cquaint the partiCipants with the following subjects:

(a) the epidemiological approach to the problem;

(b) prevention of tuberculosis;

(c) detection of infectious sources in the community;

(d) methods of reducing transmission through efficient and economics.l neutra.lization of infectious sources on a na.tion-wide scale;

(e) planning, organization, execution and evaluation of a na.tional tuberculosis control programme in coun­ tries with va.r1ous epidemiological and socio­ economic conditions.

3. ORGANIZATION

3.1 The course was orge.nized by the Ministry of Health, Singapore a.nd the Provincial Health Department, China (Taiwan), 1nth the assistance of WHO. The min part ws.s held in Singapore. This was folbwed by a two­ week field trip in Te.iwan. "'- ... j - 2 -

3·2 Dr. R. S. Wong, Assistant Director of Medics.l Services (Tuberculosis), Singapore, served ss the Course Di rector s.nd Dr. R. T. Lin, Director, .. Provincial Tuberculosis Control Centre, as Deputy Director. The Operational Officer ws.s Dr. J.C. Tao, Regional Tuberculosis Adviser. Dr. H.M. va.n der Wall, Epidemiologist s.nd Tea.m Leader of the WHO Regional Tuberculosis Advisory Team, served as the Deputy Operational Officer.

3.3 A full-time secretary wa.6 employed by WHO when the course was con- ducted in Singapore, a.nd the governments supplied additional a.ssistance whenever required.

4. PARTICIPANTS

In August 1965, governments of countries and territories in the Western Pa.cific Region 1-Tere invited to nominate participants. In countries where voluntary associations are ta.king active part in the operation of the national tuberculosis programme, participants were also invited. It 1n1S lD!I.de clea.r to governments that the pEI.rticipents recommended should be l~ey personnel in their respective tuberculosis services, with experience in the • field of tuberculosis for at least five years. In all, eleven medical officers were a.warded WHO fellovTships for pa.rticipe.tion in the course: two from China (TaivTSn), one from Japan, two from the Republic of Korea, one from Malaysia (Sebeh), three from the Phil1ppines, one from Ryukyu Islands, and one from Singapore. Of these, three participants also represented voluntary aSSOCiatiOns, 1. e., one from the Philippines, one from Korea. and the third from Japa.n. In addition, two observers were nominated by the Government of Singapore. One pa.rticipant from Cook Isle.nds, who happened to be in Singa.pore and in Taiwan on a WHO fellowship, elso participated in the course. A list of the partiCipants appears in Annex 1.

5. FACILITI&:l MADE AVAILABLE BY THE GOVERNMENTS

5.1 The New Lecture Theatre in Tan Tock Seng Hospital, Singapore, ws.s mede available when the course i:aS held in Singspo.e. This consisted of a. large hell la.rge enough to accoTJlllX)dste 250 persons. The lecture theatre ws.s used unpartitioned for the opening ceremony, after 1~hich it was diVided into three rooms: one for lecture purposes, one as a cOTJlllX)n-room s.nd librsry for • the participants, a.nd the third ss the administra.tive office. In addition. an air-conditioned room on the ground floor vlSS ms.d.e avail'lble for the con- sultants and project staff. In Taipei, the conference hell of the newly- built TB.ipei Provincis.l TUberculosis Control Centre "Tas made svailable to the course. The lecture hall of the University Hospital was used for the closing ceremony.

5.2 Through the courtesy of the University of Singapore, arrangements were made for sll the partiCipants to be housed in the King Edward VII Hall in the compound of the Genersl Hospita.l, Singapore. Es.ch participant ws provided "T1th a. single furnished room. All the soc18.1 facilities provided by the King Edward VII BB.ll were made ava.llable to the participa.ots. In addition, temporary membership of the library of the Medical Faculty, University of Singapore was granted to both partiCipants s.nd consultants . .. . / - 3 - .. - 5.3 Transport

Transport w.s provided by both Governments for members of the pro­ ject staff and for visiting consultants. In addition,buses were made available to transport the participants to and from the mep.ting he.ll deily on all ,fOrking days. The buses uere also available to ta.l~e the partici­ pants on field visits and social functions connected ,11th the course.

6. STAFF

A list of a.ll those who pa.rticipated in the tea. ching programme appears in Annex 2. This includes members of the WHO Regiona.l Tuberculo­ sis Advisory Team, visiting lecturers and ne.tionel specie.lists. EveI"J effort was made to '!nsure the maximum participation of the latter group in the course, especially in the presentation of locs.l data. and field .. demons t ra t ions •

7. TIME AND DURATION OF THE COURSE

The first part of the course was held in Singapore from llj. February to 28 April 1966, inclusive. This w.s immediately followed by a fortnight's second session in Chine. (Taiwan). The Singapore session included a three­ dey trip to Kuala. Lumpur, MalaYSia, to observe the Tuberculosis Control Programme in Malaya. The second pert included visits of five cities a.nd eight counties in the Province of Taiwan.

8. TEACHING PROGRAMME

8.1 A genera.l programme w.s dra ..m up in Me.nila in October 1965 setting out the purpose of the course end the subject matter to be covered (Annex 3). This was circula.ted to the administrative officers end visiting consultents and formed the basis for the preparation of the weekly programmes throughout the course.

8.2 Weekly programme

The weekly programmes ,vere dra.WD up well in adve.nce by the Course Director end the Deputy Operations.l Officer in consulte.tion vith the l.ocsl specialists concerned.

8.3 Program~~liS[

The teaching was conducted in English. At least two of the parti­ cipants had an inadequate knowledge of the langusge and extra.-murB.l dis­ cussions and explanations were frequently required for the cla.rificstion of difficulties and misinterpretations.

...j - 4 - ...

The tea. ching programme extended from Monday through Friday each l'leek, except on the day of the opening ceremony (Monday, 14 February 1966), on pu;'lic holidays (1 April and 8 April 1966 to 11 April 1966) a.nd on the occa.sion (7 March 1966) of a herbour tour, organized by the Port Authority of Singapore. There were three teaching sessions a day: from 9:00 a.m. to 10:00 a.m., 10:15 a.m. to 12 noon and 2:00 p.m. to 4:00 p.m. There were occasional deviations Xrom this time schedule: e.g., on two days with a scheduled field programme from 5:00 p.m. to 10 :00 p. m. and a morning l-lhen ;.rork sta. rted before :;: :00 a. m. On mos t weeks, Saturday was reserved for library reference or for individus.l dis­ cussions '\-lith members of the resource sta.ff.

8. ,.2 Sequential arrangement

~lberever pOSSible, formal lectures were followed by a general dis­ cussion session, with emphesis on the presentation of relevs.nt nationBl data. by the participants.

8. ,., Programme assessment

After si.'C weeks of training, each participant and each of the observers were given an assessment form for completion and return (without signature) through a representative selected by the participants. The eva.lus.tion of the a.nawers was foll::JWed by a.n inforlll31 meeting with the partiCipants at King Edivard VII Hall on the next public holiday (1 April 1966), a meeting i,hich was fruitful as it stimulated a friendly interchenge of ideas and Ill3ny useful suggestions. A further questionna.ire was issued just before the termination of the course in Singapore.

8.4 The progra.mme

14 Februa ry 1966 Registration and opening ceremony .,.

15-1:; February Tuberculin testing

21-26 February X-ray examination •

23 February-5 MB.rch Bacteriological exs.mination

1-12 Me.rch Discussions on general subjects on tuberculosis control

14-19 March Prevention

21-26 March Treatment

28 March to 2 April Epidemiology • ... j - 5 -

4-9 April _ Biostatistics

11-13 April Field trip to Kuale Lumpur

14-18 April Sociological aspects in tuber­ culosis control

19-20 April Biostatistics (continued)

20-27 April Tuberculosis control programme

27 April WHO' s role in the globe 1 con­ trol of tuberculosis

2-14 May Field trip to China (Taiwan)

A detailed procramme of the course is given in Annex 3.

" ~~sits and demonstrati~~ Institutions for field visits and demonstrations, including Kandang Kerbeu Maternity Hospita.l, lIIS.terna.l and child health clinics, schools, the Tuberculosis Control Unit, Te.n Tock Seng Hospital and its treatment clinics, were chosen to demonstrate a.ll a.spects of the tuberculosis control programme in SingE-pore. A schedule of visits ,res prepared to coincide with the different subjects discussed in the course. In addition, s small villBge in Nee Soon Area '\-IaS selected as a demonstration area for mass case-finding and BCG vaccine.tion.

The field trip in KuelB. Lumpur (11-13 April) ,-laS arranged so tb8t Dr. J.S. Sodhy, Senior TuberCUlosis SpeCialist, National Tuberculosis Centre, could discuss his control programme with the pa.rticipsnts. A field trip was tIIl.de to the Aborigines Hospital under the cb8rge of Dr. Bolton on the outsr-..irt of KuelB Lumpur to study the ca.re of sick aborigines.

The sec:>nd part of the course in China (Teirren) took plB.ce from 2 May to 14 May. The main objective ws to observe the various s.ctivities of a tuberculosis control programme in e province of tuelve million populB­ tion uhich b8.s relatively stringent resources. Following tuo days of intensive briefing on the background informa.tion concerning the development of the progra.mme, field visits were made to f~r provincial tuberculosis centres, ten health stations and nine health bureaus on the ;rest cos.st of the province.

9. OFFICIAL OPENnm CEREMONY

The ceremony was conducted on Monday, ll~ February 1966, in the Tan Tock Seng Hospital Lecture Theatre. After registration of the fellows and observers, the official opening ceremony was conducted at 10:00 a.m• . .. / - 6 -

• Following introductory relll6r::s by the Course Director, Dr. H.S. vlons, Dr. J.C. Tao (Regional Tuberculosis Adviser) spoke on behalf of WHO and fina.lly the Honoura.ble Mr. Yong Nyuk Lin, Minister of Health, f0rlll6l1y declared the training course open. About 250 guests were present at this opening and they included high officials in the Ivlinistry of Health, senior sta.ff of the Medica.l Faculty, University of Singapore, tuberculo­ sis workers in both the Government and vOluntary organization and staff of the Tuberculosis Control Unit, all IIHO staff in Singapore, and local press representatives.

The opening ceremony "as well covered by the local English and Chinese press in Singapore on 15 February 1966.

10. REPORTING BY PARTICIPAnTS

Immediately a.fter the opening ceremony, there was a. short session • with the partiCipants, when the Course Director briefed them on the basic concepts of the course, and requested them to elect a. representative. By una.nimous consent, Dr. Rafa.el Ge.rcia of the Philiwines was elected, • and due tribute is paid to his constant and friendly co-operation during the course. In consultation with him and with the partiCipants it wa.s arranged that each teaching session should be covered by a. report, pre­ pAred by one of the pa.rticipa.nts a.nd cleared with the consultant in-charge of the particular subject. A summary of the reports is presented in Annex 4.

11. CLOSING CEREMONY

The closing ceremony was held at 9 :00 a.• m., on Saturday, 14 May 1966, a.t the lecture hall of the University Hospital, Ta.ipei. Follo'ving introductory relll6.rks by the Deputy Director of the course, Dr. H.T. Lin, the Honourable Minister of Interior, Mr. Lien Cheng-tung, spoke on behalf of the Government of the Republic of China. Follm-Ting a speech delivered by Dr. 1. C. Yuan, Secretary General, Aca.demia Sinica, Dr. J. C. Tao spoke on beha.lf of WHO and finally Dr. Garcia spoke as the representative of all the pa rticipants. Over one hundred guests a.nd loca.l press correspond­ ents were present a.t the session.

12. DISCUSSION AND RECOMMENDATIONS

It is not an easy task for the Course Directors and Operational Officers to lIl6ke unbiased comments on a course which they, inevitably, had to plan a.nd direct. But they ta.ke courage from the written comments of the pa.rticipants, the a.ssessment meetings and from numerous personsl conts.cts, in a.ddition to personal impressions. In spite of lIl6.ny unforeseen problems, it can be sts.ted with confidence that the course .Tas generally successful and productive. To a very large extent this WB.S directly due to the heart­ warming co-operation, cameraderie, personal friendship and understanding of • the pa rticipa.nts. ...j - 7 -

It is hoped thB.t this course will be succeeded by others. It w.s generally successful but, with an appreciation of the lessons leerned, subsequent courses cen be even more so. The following recommendBtions are made in the light of the experience ge.ined:

12.1 Adequate pla.nning should be a ~ qua~. All those to be nominated for the conduct of teaching sessions should meet, if possible, with the administrative officers a.t least two rontha before the commence­ ment of the course to dra.w up an integrated programme. Each teacher should. knm! what every other tea.cher is going to say, so ths.t there is the minimum of repitition and. an adequate balance between conflicting views (e.g., whether revaccination with BeG within fifteen years of the first vs.ccinetion is useful or useless; whether INH therapy to INH-resistant pa.tients is of va.lue or 1>Thether it contributes to a public hea.lth problem).

• 12.2 All partiCipants should have clear a.nd unequivocal instructions before the commencement of the course, as to whB.t lIl8.teria.l and dBta they should bring with them, and 1.hBt individua.l and group participation would be expected of them.

12.3 Biostatistics should be introduced a.t the beginning of the course.

12.4 Fewer hes.lth a.genc1es should be visited during the field trip 60 that m::>re time cen be s.ll::>tted for detsiled enquiries s.nd discussions. • n - 0 -

ANNEX 1 •

LIST OF PARTICIPAIqTS

1. .----Fellov.s China. Dr. C. C. Chang Director Provincial Tuberculosis Control Centre Public Health Department Taiwan Provincial Government vfu.feng Taichung, Tsi\;l8n Republic of China

Dr. T.J. Tseng Director Provincial 'l'ainan Tuberculosis Centre , Taiuan Republic of China.

Cool: Islands Dr. Steven K.9vana Director of Tuberculosis Sanatorium Hea lth Depa rtment Rarotonga, Cool~ Islands

Japan Dr. A. Takase Chief, Physician's Section Post-Graduate Training Course Tuberculosis Research Institute Japan Anti-Tuberculosis Association To~:yo, Japan

... / ,

• - 9 - Annex 1

Dr. J.H. Pek Supen':i.sory Medica 1 Off'icel' 62-20, 1st ka, Chong Ps Dong Yang Sal: Ku Se::-ul, Koree

Dr. B.J. S::mg Seni::>r It.edical O:fricer National ~~sao Tuberculosis Hospital Mesen, Korea

Me. lays ia Dr. R. Roy (Sebeh) Tuberculosis Contr~l Officer Chest Hosp1te.l, Jesseit:Jn Sabeh, Naleysie

Philippines Dr. A. G. Dumlao Regional Tuberculosis Consulte!lt Regional Hea.lth Office No. 8 Daveo City, Philippines

Dr. R.A. Ge.rcia Physician-in-charge Cebu Tuberculosis Pavilion Cebu City, Philippines

Dr. E.B. Cate.len Regional Tuberculosis Consultent Regional Health Office No. 7 Zamboanga City, Philippines

R;yul;:yu Isle.ods Dr. M. Oshiro Director Kin Tuberculosis Sanat.or1uCl No. 7924, Azs Kin, Kin-son Okinawa, Ryukyu Islands

Singapore Dr. Yook Kim Ng Senior Registrar ~n Tbck Seng Hospital 142 Moulmein Road Singapore 11 Republic of Singapore

... / - 10 -

Annex 1 ..

2. Observers

Si!l.<~ap':lre J.I'.. !'ambyah, lvi.B. l'leulmeiu -10.00(-:'- Singapore 11 Republic of Singapore

S. Doraisingoom, 1'1.B. Medical Officer Tan ~clc Seng Hospita.1 142 Mou1mein R~ed SinG;spore 11 • Republic of Singapore

•

• - 11 -

ANNEX 2

LIST OF RESOU... 'tCE PERSONNEL IN THE TRAINING COURSE

1. Visiti~ lecturers

Dr. D. Banerji, Assistant Professor, National Institute ~f Health Administrati?n a.nd Education, Nev Delhi-l, India.

Dr. J. Frimodt-MBller, Research Director, Tuberculosis Research Unit, Msdenapalle, India

Dr. J. Holm, Executive Director, InternetiollB.l Union Against Tuber­ culosis, Pa ris • Dr. D.R. Na.gp8ul, Director, NatiotlB.l Tuberculosis Institute,Ba.ngel::>re, India.

• 2. National lecturers

2.1 Republic {)i' Singapore

Sister Av Nye Sim, Public Health Sister, Tuberculosis Control Unit, Singa.pore

Dr. Chen Chiang Hoang, Medical Officer, Tuberculosis Control Unit, Singa.pore

Dr. Chia. Kim Boon, Radiotherapist, General Hospital, Singapore

Dr. S. Devi, Senior Registrar, TB.n Tock Seng Hospite.l, Singapore

Dr. Hu Pir Ya, Medical Officer, Tuberculosis Control Unit, Singapore

Dr. F. Y. Khoo, Senior Radiobgist, General Hospital, Singapore

Professor Lim Koh Ann, Dean Medical Faculty a.nd Pr~fessor of Bacteriology, University of Singapore

Mrs. Lo Kvee Lee, Bacteriology Officer, TubercJ.losis Control Unit, Singapore

Dr. N.C. Sen-Gupta, Medical Director, Singapore Anti-Tuberculosis Association

Dr. J .M.J. Supramaniam, Chest Physician, Tan Tock Sens Hospita.l, Singapore

• Dr. B.S. Wong, Assistant Director of Medical Services (Tuberculosis), Tuberculosis Control Unit, Singapore Dr. Mosea Yu, Bacteriologist, Genera.l Hospital, Singapore ... / - 12 - •

Annex 2 "

2.2 China (Taiwan)

Miss C.C. Chang, Chief', Nursing Department, Tuberculosis Control Centre

Miss P.L. Chao, Chief, Nursing Department, Ta1chung Tuberculosis Control Centre

Dr. C.C. Chu, Chief, Epidemiological Department, Taipei Tuber­ culodis Control Centre

Miss H.C. Chu, Chief, Nursing Depa.rtment, Taipei Tuberculosis Control Centre

Dr. T.C. Fuh, Chief, Therapeutic Department, TB.ipei Tuberculosis Control Centre l Dr. L.S. Hau, Acting Director and Chief of Preventive Department, Chiayi Tuberculosis Control Centre

Dr. Y.H. Ku, Acting Director snd Chief of Preventive Department, Tainsn Tuberculosis Control Centre

Miss C. Y. La.i, Chief, Nursing Department, Ta.ins.n Tuberculosis Control Centre

Dr. H.T. Lin, Director, Taipei Tuberculosis Control Centre

Dr. Y.C. Tsu, Chief, Central La.bora.tory, Taipei Tuberculosis Control Centre

Dr. Y. T. Tung, Acting Director s.nd Chief of Preventive Department, Taicbung Tuberculosis Control Centre

Dr. S.K. vlang, Chief', Therapeutic Department, Ta.iDB.n Tuberculosis Control Centre

Mr. S. T. Wu, Acting Chief, Training Depa.rtment, Taipei Tuberculosis Control Centre

Miss Y.H. Wu, Chief, Statistical Room, Taipei Tuberculosis Control Centre

. .. / •

• • - 13 -

Annex 2

3· WHO lecturers

Mr. R.A. Acham, WHO X-ray Technologist, Regional Tuberculosis Advisory Team

Dr. J.J. Huang, WHO Bacteriologist, Regiona.l Tuberculosis Advisory Team

Dr. H. Stott, WHO Senior Medical Officer, Tuberculosis Chemo­ therapy Centre, Ma.dra.s, India.

Dr. A. Tanaka, ,mo Statistician, Regional Tuberculosis Advisory Team

• Dr. J. C. Tao, WHO Regional Tuberculosis Adviser

Dr. H.M. van der Wall, WHO Epidemiologist and Team Leader, Regional Tuberculusis Advisory Team

!

• - 14 - •

ANNEX 3 ..

PROGRAMME OF THE COURSE

De.te Subject Lecturer

14 FebrueI",Y 1966 Registration Opening Ceremony Introduction eud general information on the course

15 Feb rue I",Y Tuberculin; brief histoI",Y, different Dr. Moses Yu kinds of tuberculin; prepa.ra.tion s.nd standardization; sources of supply; .. storage s.nd hB.ndUng

The techni~ue of tuberculin testing Dr. H. S. \'1ong (lTith reference to the different tests) contra-indications, complica­ tions.

Demonstra.ti::>n: BeG kit; sources of Miss Wilhelmsson supply, contents of kit, use in the field; Imintenance. Recordsj lD9.inte­ nsnce of records

Initial discussion on preparation of Sister N.S. Aw and programme end prepsra.toI",Y work necessaI",Y Miss E. Wll­ before tuberculin testing in schools. helmsson Demonstra.tion of tuberculin testing end lllEl.intenance of records. •

16 Feb rue I",Y The nature of the tuberculin reaction, Dr. H.M. van der \'1al1 its measurement enQ interpretation, fre- quency distribution of tuberculin reac- tions according to sge, sex, contact, c:)UntI",Y and in persons suffering from tuberculosis; interpretation of frequency distributions s.nd the epidemiologica.l value of such interprete.tions, chBnging patterns of tuberculin sensitivity; non- specific tuberculin sensitivity.

Group Discussion: After demonstra.tion Dr. P. Y. Hu of data on tuberculin patterns in Singapore. • ... / • • - 15 -

• Annex 3

17 February The r~le ~f tuberculin testing in a Dr. H.M. van der 'I'1all tuberculosis' control programme.

Reading of tuberculin reactions; dua.l Sister N.S. Aw and readings, with pa.rticipati~n; record­ Miss V1llhelmsson ing of readings for subsequent discussion.

18 February Group Discussion: After presenta.tion of da ta from diffe rent countries by some of the perticipa.nts

Group Discussion: Records of tuber­ • culin testing; a.ssessment of dual rea.dings.

• 21 February Organization and administration of a Mr. R.A. Acha.m mobile case-finding team. ChOice of X-ray viewer Mr. R.A. Acham

X-ray apparatus (c~mponents and Mr. C.F. Reincastle operati~nal) •

Different makes of X-ray units. Mr. R.A. ACha.lll

22 February Preventive maintenance; supplies. Mr. R.A. Acham

Common causes of breakdown Mr. a.A. Acha.m

Field dem:)Ustrat10n Dr. C.C. Cheng

23 February Minia.ture film interpretati~n; epidem­ iological significance of a.bn~rmal Dr. F. Y. Khoo X-ray Sha.dovTS in the chest.

Differential diagnosis ~f abnormal Dr. C.L. Don pulmone ry shadows Dr. K.W. Chow Dr. J.C.B:. Yiu

24 Februa l"Y RB.dia.tion: Hazards and protective Dr. K.B. Chia measures

Recording procedures for mass minia.­ Dr. C.C. Chen ture ra.diography

Group Discussion (General): 'With I presentation of data from different countries on X-ray lllB.SS min1a.ture radiogra.phy ... j - 16 - •

•

25 February Role of ra.dio'Ph~togral?hy in B tuber­ Dr. H.S. Wong culosis control p~grBmme.

Organization of B. mess CBse-finding Dr. H.M. van der p~gramme; follolT-up of defaulters. Wall

Field demonstration. Dr. C.C. Cheng

28 February BB.sic concepts in microbiol~gy Prof. Lim Kok Ann

Characteristics, classification and Dr. J.J. Huang typing ~f II\Ycobscteria.

Demonstra.ti~n: Laboratory techniques; Mrs. K.L. Lo • Ziehl-Nielsen microscopy B.nd culture. Mr. A. Y. Eng

1 M&. rch 1966 Collection, transport a.nd stora.ge of Dr. Moses Yu pathological specimens.

Microscopical and cultural techniques Dr. Moses Yu fo r dem~ns t ra t ion of II\Ycoba cte rial tuberculosis.

Demonstra.tion: Fluorescent microscopy. Mr. Eng Ah Yew Mrs. K..L. Lo

2 Ma.rch Atypica.l II\Ycobacterial - the epidem­ Dr. J.J. Huang iologicB.l B.nd clinicBl significance.

Isolation and identifiCBti~n of II\Yco­ Dr. J.J. Huang bacteria ft'Om tropical s.rea.s. •

Demons tra tion: Identifies tion methods Mr. Eng Ah Yew Mrs. K.L. Lo • 3 March La.boratory tests for determiTlB.tion of Dr. Hoses Yu drug sensitivity of M. Tuberculosis. Epidemiological and clinica.l signifi­ cance of resistant bacilli.

Significance of bacteriologiCB.l exam- Dr. J.J. Huang iTlB.tion in the diagnosis of tuberculosis a.nd in follow-up of disea.se activity.

Sensitivity tests Mrs. K.L. Lo Mr. Eng Ah Yew

... j • - 17 -

Annex 3

4 March The role of laboratory diagnosis in a Dr. J.J. Huang tuberculosis control progra.mme.

Design of a simple tuberculosis labor­ Dr. J.J. Huang atory unit - peripheral a.nd provincial levels.

Demonstration: Tests for INH in urine. Dr. J.J. Huang and BeG viability counts. Mr. Eng Ah Yew

B March Our fight against the tubercle Dr. J. Holm bacillus.

Epidemiological concepts. Dr. J. Holm

Handicraft and industry in medicine. Dr. J. Holm • 9 March Tuberculosis services - specialized Dr. J. Holm and integrated.

Human factors in tuberculosis control. Dr. J. Holm

10 Me.rch Tuberculosis control programme in Dr. J. Holm country X.

11 Me.rch Field trip to the Singapore Anti­ Dr. N.C. Sen-Gupta Tuberculosis Association.

, 14 March Basic concepts of immunology of Dr. J. Holm tube rculosi s •

• Protective vs.lue of DCG vaccine. Dr. J. Holm Methods of BeG VS.ccination. Miss E. Wilhelmsson

Visit to a school: Demnstration Miss E. Wllhelmsson a.nd participation in BeG va.ccination.

15 March BeG vaccine Dr. Moses Yu

Organization of DJ8.ss BeG vaccination Dr. J. Holm programme.

• ...J - 18 - •

Annex 3 ..

16 March Visit to KBndang Kerbs.u Maternity Hospita.l

Direct BeG vaccination. Dr. J. Holm Simultaneous BeG a.nd sma.llpox va.ccinations

BeG a.ssessment Dr. J. Holm

11 March Chemoprophylaxis Dr. J. Holm

Contact investigations Dr. H.S. Ibng

BCG assessment Dr. J. Holm

18 Ma.rch Evaluation and discussions of tuberculosis Dr. J. Holm programmes proposed by participants for province X.

Demonstration and Participation: Extrac­ Miss E. Wilhelmsson tion, tabulation and assessment of BeG vaccination data and records.

21 Ma.rch Cha.nging concepts in the methods of diag­ Dr. H. Stott nosis and the a.ssessment of progress of patients with pulmonary tuberculosis.

The control tria.l in the evaluaUon of Dr. H. Stott chemothers.peutic regimens.

22 March An assessment of out-patient (ambulatory) Dr. H. Stott and in-patient (sanatorium)·treatment of pulmonary tuberculosis.

Isoniazid a.lone in the treatment of pulmon- Dr. H. stott ary tuberculosis, and the clinical signifi- cance of isoniazid-resistant organisms.

. .. /

• • - 19 -

Annex 3

23 March PAS 8S 8. companion drug to isoniazid. Dr. H. Stott Isoniazid plus thiacetazone in the treat­ ment of pulmona ry tuberculosis.

Local experience in PAS and thia.cetazone Dr. S. Devi as companion drugs to isoniazid.

The rationale of intermittent chemo­ Dr. H. Stott therapy and the efficacy of twice weekly and once weekly strepto~cin plus isoniazid.

• 24 March Treatment regimens for patients who have Dr. H. Stott failed in prilll8ry chemotherapy.

The problem of the chronic infectious Dr. Supralll8nia.m cases.

The diagnosis, incidence and prevention Dr. H. Stott of rela.pses.

25 March The chellOtherapy of tuberculosis in Dr. H. Stott developing countries. •

Visit to Ten Tock Seng Rotary Clinic Ta.n Tock Seng Clinical Sts.ff

28 MB.rch Epidemiology - General introduction. Dr. J.F. MOller

Tuberculosis epidemics. Dr. J.F. Moller

Epidemiologiesl methods. Dr. J.F. MOller •

... / - 20 -

Annex .3 •

29 March Surveys: By tuberculin testing Dr. J. F. Moller

Surveys: By Me ss radiophotography Dr ••T.F. Moller

Surveys: By bacteriology Dr. J .F. l-f6ller

Demonstration: Centra.l Tuberculosis Dr. H. S. Wong Registry, Singapore •

.30 March Preva lence of tube rculosis. Dr. J.F. MOller

Presentation of prevalence data by pa.rticipa.nts.

Non-specific sensitivity incidence Dr. J.F. MOller

.31 March The problem of bacillary drug resistance Dr. J.F. MOller

Longitudius.l studies and trends in deve­ Dr. J.F. MOller loped and developing countries.

Epidemetric models. Dr. J.F. MOller

4 April 1966 Introduction to biostatistics Dr. A. Tanaka •

Sa.mpling methods. Dr. A. Ta.oska How to conduct a survey.

Demonstra.tion of use of calculating Dr. A. Tanaka machine.

5 April Statistics relating to tuberculin test­ Dr. A. Tanaka ing a.nd BGG vaccios.tion.

Comparison of mea.ns. Dr. A. Taoska

...j • - 21 -

'!' Annex 3

6 April Assessment of practical work.

Statistics relating to tuberculosis cs.se­ Dr. A. Ta.naka finding.

7 April Statistics relating to treatment. Dr. A. Tanaka

11 April Participants and members of the teaching • stat't' left for Kuala Lumpur.

12 and 13 April Tuberculosis control in Malaya - Dr. J. S. Sodhy • lectures, demonstration and field visits.

13 April Participants and members of the teaching sta.ff left Kus.la Lumpur for Singa.pore.

14 April Sociological views on the problem of Dr. D. Banerji tuberculosis.

Soc1ul sciences in the field of Dr. D. Banerji tuberculosis.

SOCiological interpretation of epidemio­ Dr. D. Banerji logical de.ta.

15 April UGes of social service data in the formula.- Dr. D. Banerji tion of 8. national tuberculosis control programme:

(a) nationally applicable and acceptable methods;

(b) organizationa.l and a.d.m1nistrative structure of the programme.

16 April Social science considers.tions in the im­ Dr. D. Banerji plementat1cn"of a national tuberculosis control programme.

• ... / - 22 - •

Annex :5

18 April. Methods of social sciences~ 'With specia.l Dr. D. Ba.nerji reference to these applications on tuber­ culosis control programmes.

Social aspects of tuberculosis.

Evaluation of an integrated tuberculosis control programme.

19 April Correlation co-efficient. Dr. A. Tans.kB

20 April Sampling methods for 8 tuberculosis pre­ Dr. A. Tanaka. valence survey.

Epidemetric mode~s. Dr. A. Tana.kB

The concept of tuberculosis control. Dr. D.R. Nagpe.ul

Pla.nning for tuberculosis control: Dr. D. R. Nagpaul Size of the probl.em.

21 April Planning for tuberculosis control: Dr. D;JR. Nagpeul (a) Available methods snd tools.

(5) Resources. c (c) Practical problems.

22 April Pla.nning for tuberculosis control Dr. D. R.· NSgp8ul (continued) : (d) Economics. (e) Training.. and organization •

... / •

• • - 23 -

r Annex 3

23 April India I s fight s.gainst tuberculosis Dr. X;agp8ul till 1960.

An outline of a socially acceptable Dr. Nagpaul tuberculosis control progratmrle in Indis. after 1960.

25 April tuberculosis programme. Dr. NSgp8ul

Health education and its problems. Dr. NSgp8ul

26 April Record keeping and reporting. Dr. Nagp8ul Denx:mstration: Record keeping a.od Dr• Wong a.nd • reporting. Dr. NS.gp8ul

Progralllllle a.ssessment. Dr • NSgpB.ul • 27 April Legislation/Rehabilitation - General Dr. Nagp8ul pra.ctitioners.

Voluntary 8ssocis.tions in tuberculosis. Dr. NagpBul

Operatic~l research in tuberculosis. Dr. Nagpaul

WHO s.nd its role in tuberculosis Dr van der Wall control and resea.rch.

I 2 May 1966 Orientation on the schedule for field Dr. H.T. Lin .. observs.tion in Tai~ren • Briefing on the Tuberculosis Control Dr. H.T. Lin Progra.mme in Taiws.n:

(8) Background inforuetion about Ta.iwan.

(b) Policy and organizational structure of the Programme.

(c) Chronological development of the Programme.

(d) AChievements in the ~st with spe­ Cial reference to the results of two prevalence surveys and to the financia.l expenditures. BeG programme. Dr. H.T. Lin ... / _ 24- - •

Annex 2.

Case-finding by means of spltum exam­ Dr. I.C. Tsu ina.tion. Comprehensive tuberculosis control campaign Dr. C.C. Chu in the communities.

3 MB.y A pilot srea project in the national tuber- Dr. H.T. Lin culosis programme.

Training of vs.rious cstegories of tuber­ Mr. S. T. Wu culosis ,,,orkers.

Changing concept in public health nursing Mis:! H.C. Chu in tuberculosis.

Statisti~~l phase of the programme: Miss I.H. Wu

(e) Registration of infectious cs.ses.

(b) Collection of field data. end compila­ tion of oonthly, quarterly end ennual reports.

Case-finding and mnagement of pe.tients Dr. T.C. Fuh B.t the out-pe.tient clinic.

Visit to the Nationa.l Tuberculosis Asso­ D.r. H.T. Lin ciation a.nd the First Tuberculosis Clinic.

Functions B.nd activities of the National Dr. C.T. Haing Tuberculosis Association.

Tea.chers I tuberculosis control programme Miss C.M. He in Ts.iws.n " Health educs.tion activities of the Mr. C.H. Ku National Tuberculosis Association.

4- May Visit to the City Health Bureau Drs. C.C. lCuo and and ICeelung City Tuberculosis Control S.C. Me. StB.tion.

Visit to the Jenai Health Station and Dr. T.H. Ho observe the simultaneous BeG/smellpox vaccination in operation.

Visit the Chung-hsiung Prime ry School Mr. S. I. lto to observe BeG vaccination activities in school. ... / - 25 - Annex 3

Visit to the Ss.ntzu Hes.lth Sta.tion and Drs. C.L. Lei and see the results of comprehensive tuber­ C.L. Chin culosis control campa.ign.

Visit to the Tamsui Health Station s.nd Dr. K.H. Tsai see the results of comprehensive tuber­ culosis control campaign.

5 May Visit to the Taoyua.n Hsien Hes.lth Bureau Drs. L.T. Hsia. s.nd. the TB.oyuan Hsien Tuberculosis Con­ and T.A. Fu trol Station.

Briefing on the trial of case-finding by mobile clinic in Taoyusn Haien.

Visit to the Kueisha.n Health Station and Dr. Y.C. Li see the results of case-finding by mobile clinic.

Visit to the Tahsi Hea.lth Station a.nd see Dr. C.P. Chien the results of ca.se-finding by mobile clinic.

Observe the ca.se-finding activities vTith Dr. C. Y. Li the approach employed in the comprehens­ ive cOllllllUnity tuberculosis control cam­ paign st Hsinwu Hsiang.

6 May Visit to the Toufen Health Station and Dr. H.C. L1 observe the registration and D18.usgement of infectious and suspect cases.

Visit the Hsien Health Bureau Dr. H. Y. Taai and the Tuberculosis Control Sta.tion.

Visit the Ta.ichung Tuberculosis Control Dr. Y.C. Tung .. Centre.

Visit the Institute of Maternal and Child Dr. K. Y. Fan Health and the Population Council.

7 May Visit to the Provincial Hea.lth Department Dr. L.P. Chou a.nd briefing on the health sta.tus in Ta.iwen.

. .. / •

• - 26 - • Annex 3

Les.ve the Provincial Heslth Department Dr. L.P. Chou for Nsntou and en route to see the Pro­ vincial Assembly and the Provincis.l Government.

Visit the Nsntou Hsien Health Bures.u s.nd Dr. T.H. Wei the Tuberculosis Control Station.

Visit the Yuchu Health Station and observe Dr. P.H. Li the case-finding sctivities by a mobile clinic.

9 M9y Visit the Cbiayi Tuberculosis Control Drs. L.S. Hau, Centre, the Chisyi Health Bureau and C.K. Cheng and the Provincis.l Ch1syi Hospital. C.S. Chen

Visit the Tainen Haien Hea.lth Buree.u Dr. C.H. Lin

~ Visit the Matou Heelth Ste.tion end observe Dr. Li the I118negement of infectious and suspect cases by lay-home visitors.

10 M9y Visit the Tainen Tuberculosis Control Dr. Y.S. Ku Centre and Hospital.

Arrive s.t Jenwu Hsisng end attend the Mr. M.T. Liu snd community tuberculosis conference st Dr. S. T. bng the to,·msbip office.

Visit Hsien Hea.lth Bures.u and Mr. C.H. Wsng the Tuberculosis Control Sta.tion.

Observe the case-finding sctivities of the Dr. M.e. Chuang comprehensive community tuberculosis con­ trol campaign at Fengshen Li.

Visit Pintung Health Burea.u and the Mr. W.Y. Chen s.nd Tuberculosis Control Station. Dr. C.P. Jus.n

Visit Likang Health Sts.tion and see a. Dr. Y.H. Su long-term attempt on ca.se-finding by means of sputum exa.m1us. tion.

Arrive in Kaohsiung and visit the Kaoh­ Drs. T.L. Lin and siung City Health Bureau s.nd the W.S. Tseng Tuberculosis Control Station...... / • - 27 - Annex 3 •

12 May Visit the 'l'e.ipei Public Health Teaching Dr. K.P. Chen and Demonstration Centre.

Visit the Uational Taiwan University Dr. S.J. Chiu Hospital.

Visit the Vetera.ns I Administration Dr. C.T. Lu General Hospital

Visit the National Art Museum Dr. C. T. Lu

13 May Final discussion. Dr. J'. c. Tao and staff

• Discussion on the draft of the field Dr. H.T. Lin observation report. and staff • H.T. Lin 14 May Cloning ceremony Dr.

..

•

• - 28 -

PARTICIPANTS I REPORT ON THE WEEXLY PROCEEDINGS OF THE TRAINING COUBSE

1. FIRST WEEK: 15-19 Februe ry 1966 - TUBERCULIN 'l'E:lTING

Dr. Moses Yu (Bacteriologist, General Hospitel, Singapore) started the course 'With e. f0l'l!l8.1 lecture on the history, types of preparst10n s.nd sources of tuberculin. He went into detail about the sources of supply, sta.nds.rdiza.tion, storage s.nd handling in the field. Empha.sis was p18ced on the s.ttempt to have a standard tuberculin for e.ll tuberculosis workers in the form of the RT PPD prepared in the State Serum Institut~, Copen­ hagen. Dr. H.S. Wong (ASSistant Director of Medica.l Services, Tuberculosis) discussed the various methods of tul:lercul1n testing available and gave s detailed account of the sts.nderd tuberculin test edvocated by the Horld Ues.lth Organization using Mantoux intraderml test with 1 TU PPD RT 23 with Tween 80. The complicatiOns snd contra-indications of the test were discussed.

Miss E. lVilhelmason (Public Health Nurse, WHO Regional Tuberculosis Advisory Team) then took over with a demonstration of the standsrd BOG kit end its use in the field. Record-keeping was discussed s.nd demonstrated.

Dr. H.M. VB:l der Wall (Epidemiologist, l1HO Regional Tuberculosis Advisory Teem) continued with s lecture on the nature of the tuberCUlin test, its mea.surements B.no. interprets.tion. Preparation of histograms was demonstrated. The importance of frequency distribution of tuberculin rea.c- • tions Bccording to age, sex, conts.ets, country and in tuberculous patients were gone into with emphasis placed on (a) disgnosis; (b) screening test for BeG; snd, (c) as an epidemiological tool.

Field demonstrations in the schools were arranged nn two afternoons and perticipa.nts were given opportunities to perform the sta.nderd tuber­ culin test and to measure the results after seventy-two hours. Their res.d­ ings were used as materia.l for each participant to prepare his own histogram and corre18tion chart and his own reading was compared with the standard reader, Miss E. Wilhelmssoc.

The tuberculin da.ta of the various countries represented by the fellows were discussed during the week.

... / • - 29 -

• Annex 4

2. SECOND WEEK: 21-26 FebI'UBry 1966 - MASS X-RAY EXAMI:NATION

Mr. R.A. Acham (X-ray Technologist, HHO Regional 'l'..tberculosis Ad­ visory Team) opened this subject. The component parts of a mobile photo­ fluorographic unit l'lere discussed in deta.il a.nd the actual taking of an X-ra~ films was demonstrated. Merits and demerits of the various types of t~mers, cameras and screens available were discussed. He stressed the import8nc~ of' preventive maintenance and the need for regular servicing of the unl.ts available to keep them in good condition. Processing of films in the fie1_d 'Was demonstrated. The various rolea played by each individual member of the team in 8 mobile X-ra.y unit wss gone into and the importance of "public relations" being understood by ea.ch member, if a case-finding programme were to be successful, wa.s emphasized.

Mr. Reincastle (Principal, School of Radiography, Singapore) • demonstrated the various component parts and vlorlting procedures of a Watson Odelca 70 mm ~nit on the afternoon of the first de.y, followed by a demonstra.tion of the different lllB.keS of mobile X-ra.y units a.vailable in .. Singapore. The Watson, the Siemens and. the Philips units were demonstrated. Common causes of brea.kdovm and their remedies were demonstrated by Mr. Acbam.

A two-day lecture demonstration on clinical chest X-ray was organ­ ized by Dr. F. Y. Khoo (Senior Radiologist, General Hospita.l, Singapore) a.nd his assistants, Dr. IC.W. Chow, Dr. J.e.Ie. Yin and Dr. C.L. Oon. The theme of this lecture demonstra.tion 'l-Ta.S miniature X-ray film interpretation and the dif:f'iculties of rwking a definite diagnosis from one X-ray film alone, even using standard large films. Differential diagnosis of vs.rious non­ tuberculous conditions Simulating tuberculosiS vTaS demonstrated.

The la.st ds.y of this lecture demonstra.tion in the Genera.l Hospita.l was covered i~ the morning by a lecture by Dr. K.B. Chia (Radiotherapist, Singapore) on "radiation hazards and protective measures". He spoke in great deta.il a.bout ra.dia.tion. hazards for both the examinees and X-ray workers a.nd went into the various measures that should be ta.ken to minimize seneral radiation, stressing the importa.nce of regular medical exe.mination of X-ray v10rkers with suitable monitoring to check the radiation exposure.

Dr. H.S. \vong spoke about the role of mss X-ray in a tuberCUlosis control programme. After giving a. brief summery of the historical events leading to the present mass X-ray service, he discussed the present stetus of mass X-ray as a pe.rt of tuberculosis control programme. The humn errors in interpretation of mass X-ray films were gone into in detail. The difficulties of diagnosis of en infectious case from one X-ray examination wa.s a.gain stressed a.nd it vTaS pointed out tha.t as an index of infection, it 'WaS not as reliable as becteriologica.l examination of the sputum. The relative costs between X-ray and sputum exa.mination vres compared. However, he 'Was of the opinion that if X-ray units of whatever make or type are available, they should be put to optimum use, and should be combined with • sputum examination of X-ray suspects in arty tuberculosis control programme • .. ... / - 30 - •

Annex It-

Dr. van der Wall spoke ab::>ut the ::>l"gan:Lzsti::>n ::>f a DlBSS case-finding Progra.mme am the importa.nce of foll::>w-up of defaulters. He stressed the need f::>r differentiating between a tuberculosis » ca.se » and» a suspec t" and finally stressed the fact thBt case-finding should only be carried out to the extent ::>f the trea.tment facilities available in the c::>untry.

A mess X-ray case-finding and tuberculin testing programme was con­ ducted in a sma.ll village in the Nee So::>n Area. in Singapore by the sta.ff of the Tuberculosis Contr::>l Unit, Singapore, to illustrate the points covered in the lectures and discussions during the week. On the last dey the films taken in this survey were rea.d by the participants end their findings checked against ea.ch ::>ther and against the readings of the l::>cal staff.

3. THIRD WEEK: 28 February-5 March 1966 - BACTERIOWGY

The bacteriol::>gy teaching was shared by Dr. J.J. Huang (Bacteri::>lo­ gist, WHO Regiona.l Tuberculosis Advis::>ry Team), Dr. M::>ses Yu (Government Bacteriol::>gist) a.nd the staff of the Central Tuberculosis Laborat::>ry. The sessi::>n \185 so arranged that lectures end group discussions to::>k place in the oornings, tnth the supporting laborat::>ry demonstrations in the afternoon.

The basic concepts of tuberculosis bacteriol::>gy were first dealt with, followed by the behaviour cba.racteristics ::>f mycobacteria. Isolation and identification 'Here thoroughly covered, with particular reference to morpho­ logy (microscopic and culture), biochemical rea.ctions, animel pathogenicity, serology and pha.ge typing. Atypi ca. 1 mycobacteria were discussed a.nd listed t::>gether with their epidemiological and clinic significance. The identifica­ tion techniques were covered, a.nd the participants were given the a.ddresses of the reference laboratories in ~kyo and Perth in case of final identifica­ tion being requ::.red for mycobacteria suspected of being atypical.

The rela.tive merits of direct microscopy of sputum and laryngeal st-reb specimens were considered and the advantages and disadva.nta.ges of direct smears and concentrati::>n methods. The collection of sputum and laryngeal swabs was demonstrated, along with the choice of the sa.mple for making a smear. Ge.stric lavage, etc. J were mentioned. EmphB.sis wa.s pa.rticularly placed on the tech­ niques of storage and transport of specimens, especially in surveys where local laboratory fa.cllities might not be available.

Drug sensitivity 118S a.lso dealt with and the laboratory tests were discussed and demonstrated. Brief reference 118S made to the epidemiol::>gica.l and clinica.l significance of mycobacteria resista.nt to drugs.

Training a,nd supervision of staff, consta.nt vigilance in laboratories to reduce hazards to a minimum, a.nd the checldng of equipment and the service a.nd lIBintenance of microscopes a.nd other equipment, were also discussed. • ... / • - 31 - Annex 4 ---_ ... - • Finally, particular emphasis wes given to the value of microscopy in case-finding and its practical a.pplication at the periphery.

4. FOURTH WEEK: 7-12 Ma rch 1966 - TUBERCULOSIS CONTROL

Dr. J. Holm (Executive Director of the International Union Against Tuberculosis,. Paris) conducted the lecture during this week , with the except~on of one day on which a visit "a.s made to the Hea.dquarters of the Singapore Anti-Tuberculosis Association.

His lectures covered a ,vide field, based on ca.usation and, sub­ sequently, the general philosophy of tuberculosis control. When dealing with the planning of control programmes based on epidemiological priorities, ~T1thin the framework of limited budgets, Dr. Holm presented a theoretica.l Situation - a population of 100 000 in Province X, with a budget of US$lO 000 and with a given infection rate in the five to nine years age group. He then a.sl{ed each of the partiCipants to plan a tuberculosis con­ trol programme for this pro-lince, for presentation and discussion the follow­ • ing weel{. In addition, Dr. Holm discussed the role of voluntary associations in tuberculosis control, and Dr. Selvaratnam from Ceylon, "ho helped to organize the Internationa.l Union Against Tuberculosis field project in Jaffna. (Ceylon) J and who was on a viSit to Singapore, gave an account of the project. Finally, Dr. Holm discussed the functions of the International Union Against Tuberculosis and its close relationship to WHO so that no duplication of functions a_nd activities would recur.

One whole day was spent at the Singapore Anti-Tuberculosis Associa­ tion and Dr. Sen Gupta (Medical Director, Singapore Anti-'fuberculosis Asso­ ciation) gave an initial lecture on the history and functions of his organization. The rest of the morning was spent in group discussions, followed by a conducted tour of the Singapore Anti-Tuberculosis Association in the afternoon, with a.ssocia.ted group discussions.

5. FIFTH WEEX: 14-19 March 1966 - PREVENTION

Dr. Holm gave most of the lectures during this session, with parti­ cipation by Dr. Wong and Dr. vs.n der Wall.

BCG vaccination we_s first dealt with, commencing with the history of vaccination and going on to a consideration of the basic concepts of immuno­ logy in tuber.culosis. Thb vaccine wes discussed in deta_il, and specia.l reference was made to storage, transport and handling. The efficacy of BCG vaccination in the control of tuberculosis ws.s documented by data from Aronson end others. The technique of veccina.tion we.s discussed, in B_ddition to direct BCG vaccinB_tion. Assessment we_s elso considered. The lectures and group discussions were supplemented by en afternoon visit to a primary school, for the ree.ding of post-vaccinal tuberculin rea.ctions and the .. ·1 - 32 - •

Annex 4

collecti:m of data for correlation tables. The ta.bles were subsequently filled in, for compa.rison of the individual readings 'nth those made by Miss Wilhelmsson.

C:mtact exa.mina.tion and chemoprophylaxis 'Tere subsequently dealt with, and one day was finally devoted to an assessment and discussion of the programmes drawn up by the participants (originally referred to in the previous section).

6. SIXTH HEEK: 21-26 M9rch 1966 - CHEMYrBERAPY

Dr. H. Stott (WHO Senior Medical Officer f'rom the Tuberculosis ChelllOthera.py Centre in M9dras, India) did most of' the teaching during this session, in addition to contributions by Dr. J. Supra.lDB.niam (Chest Physi­ cian, ~n Tocl~ Seng Hospital) and Dr. S. Devi (Registrar, Te.n Tock Seng Hospital) •

Af'ter a.n initial coverage of' chemotherapeutic techniques, with reference to the action of each specific drug on the tubercle bacillus, Dr. stott, in planned order, presented the results of the trials carried out a.t the Chemotherapy Centre in Madras, stressing the advantages and dis­ advantagE's of different regimens and with particula.r emphasis on sputum conversion.

Drug resista.nce was ref'erred to in detail, a.s 'lSS the problem of' treatment of these cases. In this connection, Dr. SupralDBniam presented the local experience 'nth "chronic" ca.ses B.nd their treatment, raising the interesting point t~t no adequate definition of' the "chronic" case is as yet availa.ble.

Data in connection with the local thiacetazone tria.l were presented by Dr. Devi, while Dr. R. Ga.rcia. (Philippines), Dr. J. H. Pak (Republic of • Korea.) and Dr. H.M. van der Hall presented data from the trials in Cebu, Philippines and Yong Dong Po, Republic of' Korea..

Of' particula.r interest during this session were the discuasion periods, during which numerous problems were brought up not only by the pa.rticipa.nts but also by the other doctors who a.ttended, and particular emphasis we.s given to the necessity of initiating drug tria.ls in the coun­ tries in the Region, to obtain local a.nd compa.rative da.ta.

1. SEVENTH WEEK: 28 March to 2 April 1966 - EPIDEMIOLOGY

This subject was covered by Dr. Johannes Frimodt-MDller (Research Director, Tuberculosis Research Unit, Madana.pa.lle, India). After a defini­ tion of' terms, Dr. Frimodt-MOller went on to discuss the basic concepts of' epidemiology, the epidemiological tools available, and the place of the • epidemiologist in a. tuberculosis control programme. . .. / • - 33 - ---Annex 4

Interesting data from Dr. Frimodt-MOller's long experience in India were ~resented, some. of it by means of slide projection. Special emphasis was g~ven to the subJect of surveys, their planning, conduct and interpreta­ tion, a.nd factors affecting the prevalence of tuberculosis (such a.s social habits, customs and beliefs, population composition, and "eographic variations). ~

Case-finding ,ISS also stressed, with the relative merits and de­ merits of the different methods, and with particular emphasis on microscopy.

Dr. Frimodt-MOller referred to the high prevalence of non-specific infection, and the relatively lower virulence of the human tubercle baCillus, in India, mentioning the possible epidemiological connection between the two factors.

: Chemotherapy was a.lao discussed supported by presentation of data. in connection with different regimens.

• A particularly useful ~spect of this session ~lSs the discussion sessions, a.t which all the pa.rticipa.nts presented epidemiological da.ta from their own countries for general discussion, follolled, in each case, by Dr. Frimodt-MOller's summing up. The recent prevalence surveys in Cebu (Philippines) and in the Republic of Korea were also discussed, with re­ ference to the different techniques, and especially the selection of sampling units.

8. EIGHTH HEEK: 4-9 April 1966 - BIOSTATISTICS

The lecturer for this weclt '1a.s Dr. Akio 'I'ena.kB (Statistician, WHO Regiona.l Tuberculosis Advisory Team). The first lecture was devoted to the definition of terms used in biostatistics and vita. 1 statistics, followed by a discussion of sampling methods and their application in a national or dis­ trict tuberculosis survey. In the afternoon ·the pa.rticipants were ta.ught hoy to use the Fecit calculating machines 'Ihich the Course Director mana.ged • . to borrow from the Department of Metheuetics, University of Singapore (one copy ofBB.rlow's tables per participant and one calculating ue.chine for two participants) .

Statistics relating to tuberculin testing aOO BeG vaccination were then considered. The pa rticipa.nts were taught how to compute the means, sta.ndard deviation and variance and their relationship to the "normal" distribution.

The next subject discussed ~s the comparison of two mesns a.od its epplication.

Standard er~rs a.nd probable errors in sa.mpling "1ere gone into briefly. ···1 • - 34 -

Annex 4

Practical sessions were held where da.ta from the Cebu survey collect­ ed by Dr. TB.naka were 1IB.de available to permit the pa.rticipants to CB.lculate the v8.rious formulae brought out by the talks.

9· NINTH mmc: 11-16 April 1966 (a) TUBERCUIDSIS CONTBOL IN MALAYA (b) SOCIOLOGICAL ASPECTS OF 'IUBERCULOSIS CONTROL

9.1 Field trip to Kuala. Lumpur

On Monday, 11 April 1966, which VIas a public hOliday, the partici­ pants went to Kuala Lumpur by train, a.ccompanied by Dr. D. Benerji (Assistant Professor, National Institute of Health Administration and Education, New Delhi) who had a.rrived three days before, Dr. llong, Dr. Tanaka, Miss Hil­ helmsson a.nd Dr. van der llall. They were met at Kuala Lumpur Station by Dr. J. S. Sodby (Senior Tuberculosis Specialist and Director of the Na.tions.l Tu.berculosis Control Campe.ign in Malaya), members of his staff, the other two members of the WHO Regional Tuberculosis Advisory Team (Dr. J.J. Huang and Mr. R.A. Acham) a.nd Mr. Krishnan (Administrative Assista.nt of the WHO Representative's Office).

On the following morning the entire group went to the National Tuberculosis Centre where Dr. Sodhy first gave a general lecture on tuber­ culosis control, and then described the tuberculosis control programme in Malaya. Both lectures were illustrated by slides. There was, as usual, general participa.tion in the group discussiOns after each lecture.

In the afternoon there was a. conducted tour of the clinic and the hospital, including the laboratory, the X-ray unit and the records office.

On the following lOOming a. visit was paid to the Hospital for Abori­ gines, tuelve miles from Kuala Lumpur, and a. lecture WB.S first given by Dr. Bolton, the Medical Officer-in-charge, before he and his staff took the entire group around the hospita.l. Of particular interest were the communica- tion fs.cilities between the hospital a.nd aboriginal groups far away (two-way ::: transmitters and receivers), the helicopter service for patients to be brought to the hospital, and the emphasis placed on the "do-it-ourselves" policy (practically the entire hospital uas put up by staff and aborigines).

The group left Kuala Lumpur by the night train at 10 p. m., on 13 April 1966.

Dr. D. Banerji did all the teaching in this session. In his intro­ ductory lectures he explained that, before one can understa.nd SOCial science, a systellE\tic knowledge should be obtained of the cOllllllWlity a.nd its components; • .. . / - 35 -

Annex 4 • ----

s.nd thB.t socisl planning for hes.lth problems would involve the considera­ tion of ecologics.l, epidemiologicsl, cultural, social, economic and tech­ nological factors. Socia.l scientists, in addition to may..ing important contributions j.n the traditionB.l field of their profession, are thus given the opportunity of bringing together contributions from these various disciplines to formulate ple.ns which will contribute to increa.sing the beneficial effect of s given investment of resources.

The felt needs of the papule.tien were discussed in deta.ll, with emphasis on their satisfaction before promoting the a.wsreness of their needs. The problem was considered as a problem of economic suffering, a problem of pbysics.l suffering; the socisl consequences, and the patients' reaction to the problem were also discussed.

India. 's tuberculosis problem .Tas presented, and the steps taken for the formulstion of a. nation-wide programme were explained in detail. Information was s.leo given on the reses.rch projects uhich it involves.

During this session participa.nts were encouraged to present and • discuss their own national problems.

10. TENTH WEEK: 18-23 April 1966 (a) SOCIOLOGICAL VIEHS ON THE PROBLEMS OF TUBERCUIDSIS (b) BIOSTATISTICS (continued) (c) TUBERCULOSIS CONTroL PROGRAMME

Due to the late arrival of Dr. Nagpaul s.nd also shorta.ge of time to cover the whole subject a.llocs.tedto the lecturers on biostatistics and sociology, thi.s week's programme was a composite one to cover three subjects •

• The first day of the week was tsken by Dr. Banerji covering the methods of social sciences with specis.l references to their applics.tion in a tuberculosis control programme. In the afternoon the subjects "social aspect of tuberculosis" and "evalus.tion of an integrated programme" were discussed. The second dey was ta.lten by Dr. Tsnalts., who devoted the dey to co­ efficient of correlation and preps.rations of scatter diagnosis, etc. The third dey ws.s devoted to sampling methods for prevalence surveys and epidemetric models. Dr. D.R. NagpBul (Director, National Tuperculosis Institute, Banga­ lore, India) took over from the afternoon of Wednesday, 20 April, starting off with a lecture on the "Concept of Tuberculosis Control". He then went systematics.lty through the "PlB.nning for Tuberculosis Control", a topiC wbich extended right to Saturday, 2) April. a ... / - 36 -

_.-Annex 4

11. SECOND HALF OF TENTH WEEK AND ELEVENTH WEEK - 20-27 April 1966 - PROBLEMS OF TUBERCULOSIS AND CONTROL

The objectives of tuberculosis control were mentioned (e.) to e.lle­ viate the suffering of people, (b) to treat the pa.tients B.nd (c) to bring human happiness. There is no definition of tuberculosis control; it has to rema.in a concept. It is said that tuberculosis control is a deliberate interference in relationship between man B.nd the tubercle ba.cillus which changes favourably the epidemiologicB.l trend. In most countries the epidemic is on the downward trend and the problem is on the decline, but this cannot be termed a.s control. Repea.ted prevalence surveys ce.n give reliable evidence of a fall in morbidity but it is a.lmost impossible to ascribe a rise or fa.ll to a particular cause.

In planning, the size of the problem must be determined by using eI-idemiological yardstick. It is essentia.l to assess the need for tuber­ culosis beds, personnel, cliniCS, drugs, etc., a.nd to find where the effect has to be concertrated. This serves as baseline information for assessing the effectiveness of control measures in the course of time. The lessons derived from the sample surveys cS.rried out in India. in 1955- 1958 were:

(a) Tuberculosis is as common in the rural areas as in the cities. The problem is mainly rural and in the cities it is concentrated in the slums (4-5% pre- valence) .

(b) Tuberculosis is more concentra.ted in men and is usually found in the older age groups. One-third of the total ca.sas a.re males l1hose ages are from thirty-five years and over. t

(c) There B.re no signs of special focalizations of the problem a.ccording to geographica.l, SOCial, economic or racial criteria.

Should every country do a prevalence sUL~ey? Countries which can afford to do a. prevalence survey, must do the survey a.nd this must be repeated every ten years. For developing countries, such surveys are not absolutely necessary because they a.re expensive, involve greet research investment, large population groups and ta.ke a. long time to perform.

In planning, the methods availa.ble for control are:

(a) BCG vaCCination,

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Annex 4

treatment-institutiotl81, as well as domiciliary,

and

(c) chemothere.py.

The bad and good pOints of mass approach and the general health service approach were discussed.

BeG vaccina.tion is considered a very important control mea. sure when it is used in conjunction "lith other methods. Post-primary complica­ tions tha.t follow tl8.tural infection a re completely a.voided when BeG vaccination is given. Allergy and immunity that follow va.ccination confer upon the vaccitl8ted persons a protection against a.ctive lung disease. The degree of this protection has varied in various BeG reses.rch trials. Un­ : fortutl8tely, there is no direct method to measure the immunity given by BeG, nor is there evidence that the immunity conferred is absolute. The period of protection is 6.1so uncertain but it nml appea.rs that protection may last five to ten years. BeG vaccination should sa.tis1'y the following criteria:

(a) Is it effective?

(b) Is it safe?

(c) Is it operat10tl81ly feasible?

(d) Is it accepta.ble to the population?

(e) Is it within the economic and hUllll.n resources of the country'?

• BeG trials .::onducted in India provided 71% protection as regards X-ray cases and f'J:Y1, protection a.S rega rds sputum cs.ses. The important aspects .. in the operatiotl8l feasibility of BeG vaccitl8tion are: (a) training of staff and msintena.nce of correct techniques;

(b) proper preserv6.tion of biologicals;

(c) enlisting co-operation of the public; andl (d) correct recording and reporting.

The types of campaign to be considered are:

(a) mass campaign - centre type or hou&e-to-house type;

• . .. / - 38 -

Annex 4

(b) va.ccination of organized groups; and,

(c) use of direct va.ccination.

The available tools for dia.gnosis are:

(a) tuberculin testing,

(b) X-ra.y, and

(c) bacteriological examination.

Technical limitations and adva.ntages of the tuberculin test make it a suit­ able tool only for group investigationa, mainly for epidemiological purposes. X-ray diagnosis is non-specific and needs to be confirmed. A wide range of varia.tions introduces a great margin of error. Studies a.broad show that an experienced X-ray reader under-reads 32.2{0 and over-reads 1.7/0 films in the first reeding. In the second reading he agrees with himself only in 40% cs.ses. There is no specia.l advanta.ge of B le.rge picture over the radiophoto­ gra:ph, nor of two pictures over one. The pros and cons of static X-ray units over mobile X-ray units were mentioned. lle.cteriological diagnosis is the only confirmatory evidence. The extent of bacteriologics.l confirmation varies with the situation under ~~hich it is cs.rried out. Under clinic condi­ tions, ,·rhere symptomatics are reporting for diagnosis, culture adds lPf/o cases only, while under survey conditions the addition by culture may be of 30-40%. While for diagnosis both smear and culture examinations are valuable, culture is not so necessary for follow-up. The district tuberculosis progra.mme ha.s been accepted as the basic for a national tuberculosis control programme. It makes use of known methods of dis.gnoais~ treatment and prevention e1llilloyed by tuberculosis w~rkers for many years. The basic principres of a district tuberculosis programme B.re:

(a) diagnosis and treatment in any a.rea should be fully integrated ~nth the general health service; .. (b) majority of tuberculous patients can be dea.lt ruth by attending to persons seeking relief for their symptoms;

(c) domiciliary trea.tment offered from centres near to patients I homes ensures good regula.rity in treatment; and,

(d) adequate BeG coverage of the programme.

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Annex 4

The adva.ntages of the district tuberculosis programme a.re:

(a) five to ten times more tuberculosis patients can be diagnosed and treated then in a tuberculosis clinic,

(b) the extra cost is not much,

(c) more systellY3tic BeG can be done in an ordins ry cam­ paign; and,

(d) more rations.l use of the few tubercul::Jsis beds, rehebilitation centres, etc., and.

(e) the Diatrict Tuberculosis Programme holds budget pros­ pects of winning the confidence of people and control­ ling tuberculosis by alleviating their suffering . .. Resources consist of money, men, and l!I9.teris.l s.nd not merely funds. Training proJrammes and administrative :>rga.niza.tions are equally importsnt.

A planned s.nd systematic sppr::JSch is needed to des.l with the health problems in developing countries because of inadequate resources. Since the applicstion of specific control measures is not necessarily the only wsy to control tuberculosis in developing countries, it appears reasonable to aim first at defining the problem. For selecting control measures, drug regimens, a.nd the· methodology of application, the direct cost should be the deciding factor. For running a.n organized and co-ordinated tuberculosis control pro­ gra.mme, the nationsl che.racter of the campaign should be recognized right at the start and maintained until the objective bas been achieved . • 12. TWELFTH AND THIRTEENTH WEEK - 2-14 May 1966 - FIELD OBSERVATION OF TIIE TUBERCULOSIS CON­ TROL PIPGRAltoIE IN CHINA (TAItWl)

The second pa.rt of the training course \-18.S continued in Chins (Taiwan). This consisted of a tvo-week field observation, from 2 to 14 May 1)66. The objective of the field trip we.s to observe the various a.ctivities of a tuber­ culosis control programme in a. countI"lJ with limited resources. A two-day intensive briefing on the tuberculosis control programme in TaiPEiwes given with special mention of the following points:

(a) its be.ckground inforootion and its developmelltj

(b) policy and orge.nizetbns.l structure;

(c) BeG programme; ... / - 40-

Annex 4 •

(d) emphasis on sputum examination as a esse-finding method;

(e) tuberculosis pilot area project (comprehensive tuber­ culosis control trial);

(f) training of different categories of personnelj

(g) tuberculosis public health nursing,

(h) statistical phase which includes the registration of infectious cases, collection of field de.ta and compila­ tion of monthly, quarterly a.nd annual reports,

(i) case-finding and lIJ3nagement of out-patients;

(j) national tuberculosis association;

(k) results of the two prevalence surveys; and,

(1) financial expen:litures involved in the programme.

Discussions as well as demonstrations were encouraged, especially on the pa.rt of the participa.nts. This wa.s followed by a visit to at least ten health stationa, namely: Jenai, Santzu, Tamsui, Kueishan, Tahsi, Toufen) Yuchu, Nantou, Jemm and LikB.ng. Nine hea.lth bureaus and four provincial tuberculosis control centres were also visited during the field trip.

The observa tions made by the group \.ere a.s follows:

(1) The group agreed that Taiwan's Tuberculosis Control Programme is well orga.nized, cheap, effective and , has a nation-\dde coverage.

(2) Some of the health workers involved in the progre.mme .. are efficient and dedicated to their work.

(3) Uniform methods are being employed in all of the health stations.

(4) Sputum examinations, as a means of case-finding, especially at the periphera.l areas where X-ray facili­ ties are not. available a.re emphasized. The use of microscopes in health stations is popular.

(5) Lay home visitors and volunteers in the supervision of domiCiliary chemotherapy are employed in some communities •

.. . / - 41 -

Annex 4 •

(6) The training of' health 1~orkers to make them more qualified for the job is constantly conducted.

(7) The majority of the group agreed that the integra­ tion of tuberculosis activities into the general hea.lth services is satisfactory if such services are to rea.ch the perip:1eral area.s.

(8) There is a need for the creation of supervisory tea.1IIS to check on the uork of the peripheral health workers.

(9) The group noticed that there wes a lack of voluntary organizations a.t local level which would help the Government to carry out its tuberculosis control p rog ra lIIIIle.

(10) One of the pa.rticipants mentioned that the records .. were kept routinely without a critical analysis being lWde of the data a.nd that the data obtained were not used to assess a.chievements.

(n) The employment of lay home visitors was good although some participants doubted their efficiency. especia.lly when they were working without close supervision.

(12) One of the pa.rticipants noted that some laboratory tech­ nicians preferred to use laryngeal swab cultures ra.ther than direct smears.

(13) The group unanimously agreed that the co-operation of the public. as well as of the voluntary agencies. was needed to ensure a.ctive community participation.

(14) The group thought tha.t there were too many visits to health stations of the sa.me type.