Paediatrica Indonesiana 15 ; 303 314. Nov. — Dec. 1975. 303

From the Department oj Child Health, Medical School, University of and Tuberculosis Control, Provincial Health Service of North Sumatra

Tuberculosis in Children and BCG Vaccination in North Sumatra

b y

JO KIAN TJAY, ROBENCIUS SARAGIH, SAHAT HALIM, TJUT I RAW ATI, P. HARNOPIDJATI, S.M. MANOEROENG and M.V.O. SITOMPUL

Abstract

Data of child tuberculosis, clinical visits and those who were treated in the three hospitals, visits to the 6 public health centers (Puskesmas) and figures of BCG immunization in the North Sumatra Province were presented. Although the tuberculin index in children in (1965) was lower than that in Java (BCG Mass Campaign, 1954 - 1964), primary tuberculosis patients treated in the General Hospital (RSUPP) constituted 1.14% of the total patients admitted to the hospital in 1963 - 1972, whereas in the ”PNP IX ” hospital it was 0.84%. From a survey of families (1962 - 1969) it revealed that infection in the families was ± 50%. While 76.1% of the meningitis patients were under the age of 4 years. From a survey of 6 public health centers we found through a Pilot Project that 1.02% patients had a positive sputum. The above mentioned figures gave the indication that BCG immunization had to be performed in children under the age of 4 years. However, the figures of the BCG campaign (1970 - 1973) at the above mentioned Pilot Project revealed that coverage in the under 5 - years - old age was 20.5%, whereas in the 5 - 14 years age group it was 49.2%. In practice the realization of massal BCG immunization was certainly the simplest with school age children who were already grouped and registered; nevertheless, partly of them hai already got infected and had been released from tuberculous meningitis complication. BCG immunization as mentioned above (probably it was also given mother areas in ) did obviously not reach its right target. Received 11th Sept. 1974. 304 JO K IA N T JA Y E T ALi

Introduction The Mantoux test was carried out with 1/100 of Old Tuberculin and Tuberculosis in Indonesia is stil a was read after 3 x 24 hours. It was public health problem and is one of interpreted positive when the indu­ the main causes of death. After the ration was 10 x 10 mm or more. TB/BCG workshop in Ciloto, January 1969, the Ministry of health has ta­ This Mantoux test was carried out ken steps din the prevention and the­ in the Hospital and (in the field sur­ rapy of tuberculosis, such as BCG vey as well. The reason for using vaccination without pre-test in chil­ 1/100 concentration of Old Tubercu­ dren of 0-14 years, and supervision lin is primarily to reduce the number of intermittent chemotherapy to of drop outs. adult patients with a positive sputum The O.P.D. in the Top Provincial Re­ in every Province. At the first Cong­ ferral Hospital (RSUPP 1961-1965) : ress of the Indonesian Tuberculosis Association, Jakarta July 1973, one Fifteen thousand and ten children (under the age of 6 years) and 1948 of the decisions was to assist the Government in the eradication prog­ children (age group 6-12 years) were tested with the Mantoux test, ramme of tuberculosis and especially 9682 and 1182 children of each group that of pulmonary tuberculosis. respectively returned. This paper will deal with a survey ■of tuberculosis in children in 3 hospi­ The in-patients in the RSUPP and tals Un Medan (1959-1972), the BCG PNP-IG hospital (1962-1969): vaccination in North Sumatra (1970- As a routine all the admitted chil­ 1973) and the results of the Super­ dren were tested with 'tuberculin. vised ambulatory treatment of tuber­ When the Mantoux test was positive, culosis in the Pilot Project TB Con­ chest X-ray films were made and the trol in the Health Centre of Stabat siblings .under the age of 5 years (1971-1973). were also tested. Their parents were sent to the chest clinic for check up Material and Method and the (sputum was examitned with Private 'practice iin the Elisabeth the Z'ehl-Neelsem method, when a Hospital (1959-1960): lung process was present. The spu­ tum of the children was not exami­ Nine hundred and twenty children ned. under the age of 6 years and 130 •children in the age group of 6-12 The tuberculosis patients from the years were tested with tuberculin Chest Clinic (1962-1969): (Mantoux test), 909 and 126 children In 29 families in which both of of each group respectively returned. the parents had tuberculosis, the TUBERCULOSIS AND VACCINATION 305 children were tested and chest X-ray since April 1973 it was included in films made when the Mantoux test the immunization programme (cam was positive. ed out with the smallpox vaccina­ tion). Follow up (home visit) studies (1969-1971): The BCG vaccination was done by paramedical personnel1 after getting A pediatrician together with some some training, and it was applied to nurses from 'the Chest Clinic made children i(n the elementary school home visits for a follow up study of (age group 6-14 years). the children from tuberculous famili­ es, whose previous Mantoux tests Toddlers and older children, who were negative. did not attend school were gathered by the Head of the ’’kamipung” and All patients admitted with convuls­ vaccinated according to the date and ion (196k - 1972): place announced In advance. With the sweeping system the BCG vacci­ Their cerebrospinal fluid (CSF) nation was carried out in each regen­ was examined. When the CSF was cy, one after another. clear, the Pand!y and Nonne reaction was positive, and the cell count more The BCG vaccination in the PNP- than 20/mm3 with predominantly IX tobacco plantation was done to­ lymphocytes, with either a positive gether with the routine chotypa or negative tuberculin test, it was (Cholera, Typhus and paratyphoid considered as tuberculous meningitis. vaccine) injection and smallpox ino­ culation. Labourers, employees and Chest X-inay films (1970 -19 72): their families were regularly vacci­ nated every 6 months. A survey was made of the chest X-ray films from the children admit­ Babies under the age of 3 months ted with tuberculosis. In general only got , only BCG vaccination, between the postero-anterior photo was made. the age of 2-3 months - 1 year BCG At the reading the lung field was di­ and smallpox vaccination were done vided into approximately 3 equal at the same time. Children over 1 fields: the upper 1/3, the mid 1/3 year of age got chotypa injection and and the lower 1/3. Only distinct lesi­ smallpox revaccination together with ons were classified. BCG. The BCG vaccination in North Su­ In the RSUPP, newborn babies matra (1970 - March 1973): (1-5 days old) were vaccinated with It was carried out with the swee­ BCG before leaving the maternity ping system until April 1973, while ward. 306 JO K IA N TJA Y E T AL,

After BCG vaccination a Main toux quiescent period the patients got test survey was conducted on 237 INH 400 mg, B6 10 mg daily for one infants out of 2175 itn the RSUPP year. Control (home visit) was con­ vaccinated newborns, on 281 children ducted every 3-6 months, depending (1-14 years old) in PNP-IX and on on the distance between, the HC and 167 children (1-6 yeans old) ,in Ka- the patient’s residence. After one banjahe (Tanah Karo), who all had year of quiescence, the TB process been vaccinated; with BCG 3 months was classified as ’’cured” and no to 2 years before and who had a scar treatment was given; nevertheless in the regio deltoûdeus dextra. they still had to be controlled every There are 6 TB Control Pilot Pro­ six months. If after one year of tre­ jects iin North Sumatra and one of atment the sputum remained positi­ these is the Health Centre Stabat. ve, the patients were sent to the In this Pilot Project the BCG vacci­ Referral Hospital for consultation nation was performed by sweeping and further treatment. system; the TB patients (most of them adults) were given free medical Results treatment. Before starting this pro­ ject a TB campaign was held: all I. Out-patients department/priva- persons, who coughed for more than te practice Elisabeth Hospital (1959- 2 weeks or with bloody sputum, were 1962) : 56 out of 909 children (aged advised to .visit tlhe Health Centre 3 months - 6 years) or 6.2% and 27 for examination. out of 128 children (aged 6-12 ye­ ars) or 21.4% showed a positive test. The diagnosis of TBC was only based on the finding of the Mycobac­ II. Out-patients department RS­ terium in the sputum (no X-ray UPP (1961-1983) : 332 out of 9682 examination). If the sputum was ne­ children (aged 3 months - 6 years) gative on the first examination, it or 3.4% ;and 170 out of 1183 children was re-examined 3 times in a week. (aged 6 - ¡12 years) or 14.4% had a positive tuberculine test. The patiente with positive sputum were treated twice weekly with III. Fifty-one families belonging Streptomycine injection 1 gram and to 66 children (aged' 4 months - 5 INH 14 mg/kg BW and B@ 10 mg years) with ia. positive tuberculin reaction (1962-1966) were checked orally. for fluoroscopy and sputum exami­ The tuberculous process was clas­ nation with the following results sified as ’’quiescent” when on the (these 66 children consisted of 14 10th, 11th, 12th month the sputum children from the PNP-IX hospital had become negative. During the and 52 children from the RSUPP): TUBERCULOSIS AND VACCINATION 307 a. ,in 15 families fathers and mothers sputum (infected 2 of their children. were checked1: all the 15 fathers From the remaining 12 families or showed some lesion on fluorosco­ 41% - consisting of 7 fathers with py (one with a cavity), 5 fathers positive sputum - at the beginning had positive sputum, one was they did not infect their children but negative and on the -others there 5 years afterwards tin 7 families with were no data about the sputum. 7 fathers and one mother with posi­ Also all the 12 mothers showed tive sputum those ’’escaped” children pulmonary lesion, 3 had positive were eventually infected, and so were sputum, one was negative and on 11 of their siblings below the age of the others were no data. 5 years. b. in 5 families only mothers were Three out of 66 hospitalized pa­ checked: all the mothers showed tients died; one died with miliary pulmonary lesions (two with a tuberculosis, one with tuberculous cavity), 2 had positive sputum, meningitis and one with spondylitis. and on the 3 others were no data. Further data of the other 63 patients after discharge were not known. c. in 5 families only fathers were checked: all the fathers showed V. Tuberculous meningitis (1964- pulmonary lesions, but none had 1972) (see table 1 and 2): positive sputum. Out of 312 children with meningi­ tis, 242 or 77.5 % were under 5 years d. din 24 out of 51 families or 47%, of age and 70 or 22.5% were older. the parents had no pulmonary One hundred and forty nine children lesions; b-uit there were 4 grand­ (47.8%) died, 119 children out of mothers (iilne of them had posi­ 149 or 79.7% were under 5 years of tive sputum); one aunt and two age and 30 children (20.3%) were uncles showed pulmonary lesions. above this group (see table 1). Ne­ arly all the admitted children were IV. Parents with tuberculosis seriously ill and also in poor nutriti­ (Chest Cllni'c) from 29 families had onal condition. The mortality rate infected their children (under the within the first 24 hours was 28.2%. age of 5 years). Ten fathers with Only 62 children out of 312 (26.8%) positive sputum infected 10 of their had a positive Manitoux test, from 13 children. In 6 other families, mothers children the CSF was sent for bacte­ with positive sputum infected 11 of riological examination but no Myco- their children. In one family, both bactervum was found on culture. Only father and mother with positive 15 famil'iles of the patients could be 308 JO KIAN TJAY ET AL examined, 9 of them had specific field 118, in the right lower field pulmonary lesions and dm 4 families 132, in the left lower field 41, and in the father was iM. 13 with miliary lesions. So the lesi­ ons were located mainly in the upper The statistics concerning tubercu­ right and in the middle lung field. lous meningitis in Bandung, Jakarta, Massive consolidations were found Makasar, Yogya and Surabaya also only in 45 children. showed that the prevalence and the mortality were very high dm young VIII. Results of the supervised children below the age of 5 years intermittent chemotherapy ¡in the (see table 2). Pilot Project TB Control ait Stabat Health Center (1971-1973): VI. Nutritional status In the second year of treatment, Eighty-six children out of 231 96 patients (83.5%) out of 115 were patients (37.7%) with tuberculous classified as quiescent. There were 19 meningitis (RSUPP and PNP-IX) drop out patients (16.5%): 8 patients were undernourished in a moderate who lived far from the Health Cen­ to severe degree, according to the ter. There were 2 patients who died classification of Gomez (Poey Seng after 9 months of treatment, one Him, 1956). patient moved to another place and 8 ¡other patients could not be traced. VII. X-ray lesions (see table 3): In the third year of treatment 93 patients (96.8%) were classified as During 1970-1972 a survey of the cured. chest X-ray films was carried out on all admitted tuberculous patients : in IX. BCG vaccination in North RSUPP 142 children and in RS PNP Sumatra (see table 4) IX i 88 children. The lesions varied from marked (linear streaks, patchy, The population of North Sumatra mild to massive consolidation and according to the age group was as miliary lesions. As mentioned above, follows: 0 - 4 years 1.283.299, 5 - 14 the lesions were classified as being years 2.114.026 and above 15 years present in the one third upper, mid­ 3.621.704. The target of the BCG dle and lower ipart and not according vaccination with at least 75% cove­ to the segmental division, because rage in the age group below 14 year- no X-ray in lateral position was old was estimated as 2.847.600 chil­ made. The results were as follows : dren. But in the period of 3 years in the right upper field 54, in the (1970 - 1973) the coverage was only left, upper field 34, in the right 34.4% or 1.169.290 children. When middle field 163, in the left middie classified in the three age groups the TUBERCULOSIS AND VACCINATION 309 coverage was as follows: 0 - 4 years toux test. Twenty-seven out of these 27.7% (348.578), 5 - 14 years 38.8% 51 families (53%), either the father (820.712) and above 15 years 0.9% or the mother, had pulmonary tuber­ (32.483). The coverage of the BCG culosis with positive sputum and be­ vaccination at Stabat Health Center sides there was also a grandfather in the age group of 0 - 4 years was with positive sputum. On the other 20.5%, of 5 - 14 years it was 49.2% hand in 22 families with the parents and in the age group above 15 years suffering from pulmonary tuberculo­ it was 3.2%. However, there were sis with positive siputum, the children some districts in North Sumatra under the age of 5 years were also which had a coverage rate of more infected. In 9 families (60%) out of than 75% such as in the regency of 15 with children suffering from tu­ Karo, the towns of , Tebing berculous meningitis, it was found Tinggi and the PNP-IX plantation. that either the father or the mother The high coverage in T. Karo was was the source of infection. In other achieved due to the medical minded­ words about 50% of the tuberculous ness of the population and the sup­ infection m children occurred In fami­ port given by the regency in the lies with parents suffering from pul­ form of providing transport expen­ monary tuberculosis. From 312 chil­ ses and financial incentive to the dren of the age of 3 months to 14 vaccinators, in addition to the finan­ years suffering from tuberculous cial incentive given by the Health meningitis it was found that 77.5% department. In the towns of Tebing were under the age of 5 years, and Tinggi and Binjai the population is the highest mortality rate (79.7%) small, so the entire children popula­ was also found in the same age gro­ tion could easily be covered. In the up. So it is clear that children under PNP-IX estate the coverage was also the age of 5 years were vulnerable high due to the existing system of and these should be prevented from routine immunization every 6 months tuberculous infection. as mentioned above. Since 1970 the Health Department Discussion in North Sumatra has started the TB eradication program, i.e. BCG During 1959 - 1973 in the three vaccination without preceding test hospitals in Medan, all the admitted has been performed in children of children were routinely tested with 0 - 14 years old' and in some health Old Tuberculin. During that period centers - as a pilot project supervi­ 66 children (*from 51 families) under sed ambulatory intermittent chemo­ the age of 5 years suffering from all therapy was given in patients with kinds of diseases had a positive Man- pulmonary tuberculosis (mostly 310 JO KIAN TJAY ET AL

adults) with positive sputum (Ci'lo- However, if those children who are to, 1969). The results in one of the older than 5 years will become infec­ Health Centers (Stabat) were excel­ ted, the chance of getting tubercu­ lent: 96,8% were ’’cured” in the lous meningitis as a compilation is third year of therapy. The purpose much smaller ; and even if they might of the BCG vaccination was to give contract tuberculous meningitis, the immunity in children against tubercu­ mortality rate will also be much lo­ lous infection, whereas the ambula­ wer (± >/i time) (see table 2). tory to adult patients with the posi­ It is generally believed that the tive sputum was aimed at reducing/ BCG efficacy diminishes after 10 eradicating the source of infection. years. For a country with a high The BCG vaccination was carried prevalence of tuberculosis (like In­ out with the so-called sweeping me­ donesia), ,i:t would be advisable to re­ thod until April 1973. Due to inade­ vaccinate after 10 years (Toman, quate budged of the Ministry of 1973). This means Ithat after 10 Health, the Foundation of the Indo­ years all ¡the children at the age of nesian Tuberculosis Association was 10 - 14 years should be revaccinated, established in 1968 to assist the Mi­ and also those children (10 - 14 nistry of Health in the eradication years old) without BCG scar should of pulmonary tuberculosis. be vaccinated (primarily BCG vacci­ nation). The prospect of the BCG The coverage of the BCG vaccina­ vaccination, now included in the tion in North Sumatra was, however, smallpox vaccination program of far below the target, i.e. only 34,4%, achieving a coverage more than with the following specif ication : 75% in the young children below 27,2% for the age group of under 5 the age of 5 years, is certainly much yeans and 38,8% for the age group better. It will be even hopeful if more of 4 - 14 years. Probably the cove­ aid could be obtained from the Indo­ rage of the BCG vaccination in other nesian Tuberculosis Association. provinces of Indonesia is more or less The results of the tuberculin test equally low. So as a. matter of priority of 3 months to 2 years after the BCG it would be more rational and ef­ vaccination showed a wide range: fective if all the available funds and 33,7% in children (1 - 14 years old) forces (which are still inadequate) of the PNP- estate, 65,9% in for the BCG vaccination be given to children 6 years old) in ¡the re­ those age groups of under 5 years, gency of Tanah Karo, and 78,9% so that the 75% coverage might be in infants born iln the RSUPP. achieved in due time. This of course What does it means? Ôoes it mean means sacrificing the older children that the potency of the BCG vaccine by not giving them BCG vaccination. is variable or that the (errors in the) TUBERCULOSIS AND VACCINATION 311 technique of the BCG vaccination is therapy, which in fact can reduce different? Errors in the tuberculin the /source of infection in the family, testing are less likely, for old tuber­ should he introduced in many more culin used was from the same batch Health Centers. and freshly prepared by the person. The tuberculin injection and the rea­ From all patients hospitalized in ding of the Mantoux test in the PNP- the RSUPP (1964 -1972) 18.9% had IX estate and Tanah Karo were done malnutrition, whereas from the tu­ by the same pediatricians. The /tuber­ berculous patients 37.7% were suf­ culin testing and reading of the in­ fering from malnutrition. Therefore fants in the RSUPP were, however, in the TB eradication programme carried out by 'another pediatrician. the problem of Protein Calorie Mal­ Could 'the A-typlical mycobacterium nutrition, j especially in young child­ as well as nutritional status play a ren under the age of 5 years, should factor of influence ? Could it be assu­ also be dealt with. med that the BCG efficacy was equ­ ally strong despite ¡the discrepancy Conclusion of the tuberculin testing? A conduc­ ted trfial could possibly answer to As the incidence of tuberculous me­ these questions. As the BCG vaccina­ ningitis with a high mortality rate tion will conltinue for a considerable occurs mainly ,in young children be­ time throughout Indonesia, it would low tihe age of 5 years and the avai­ be beneficial if the Ministry of He­ lable funds /and forces for 'the TB alth could fully support Biofarma eradication programme are still not Bandung in the production and' utili­ sufficient yet, it is recommended that BCG vaccination should be imple­ zation of the BCG vaccine. At pre­ mented in children below the age of sent Biofarma Bandung produces 5 years, in order to achieve a cove­ BCG vaccine approximated 400.000 rage of more than 80%. ampoules (a 50 doses), which are nearly the total amount neeted for As the BCG efficacy decreases the BCG campaign in the whole In­ considerably after 10 years, revacci­ donesia (Kaligis, 1974). nation is advisable to children in the Since the results of the supervi­ age group of 10 - 15 years. To decre­ sed ambulatory intermittent chemo­ ase the source of TB infection in the therapy in the Health Center chosen family which occurred about 50%, as a phot project proved to be sati­ the supervised ambulatory treatment sfying (83,5% ’’quescent” in the 2nd should be introduced to many more year and 96.8% ’’cured” in the 3rd Plealth Centers. Besides BCG vacci­ year), it seems that the method of nation and chemotherapy, the nutri- 312 JO K IA N T JA T E T AL, tioual status of children should also PNP-IX estate and the Board of the be improved. Last but not least, for PPTI of North Sumatra for all the the successful ¡implementation of the survey of tuberculin testing, and to TB eradication programme more aid is needed from the Indonesian Tuber­ the Heads of Ithe .Department of Pe­ culosis Association (PPTI). diatrics in Bandung, Jakarta, Yogya­ karta, Ujung Pandang and Surabaya Acknowledgement for coleciting data of tuberculous The authors like to express their meningitis. . gratitude to both the Board of the

REFERENCES

1. CILOTO WORKSHOP ON TB/BCG, letter PPTI th. HI, No. 10 (June & January (1969). July 1973). 2. GUNARDI, A.S. : Dasar-dasar pem- 8. MORRISON, J.B. : Natural history ‘ berantasan penyakit Tbc paru-paru. of segmental lesion in primary pulmo­ N ew sletter P P T I th. IV jhal. 9 - 10 nary tuberculosis. Arch. Dis. Childh. A pril 1974. 48 : j90 - 98 (1973). 9. POEY SENG HIN : Kwashiorkor di 3. JO KIAN TJAY : Pidato pengukuhan Jakarta dan sekitarnya (Thesis, Uni­ guru besar dalam Ilmu Kesehatan versitas Indonesia, Jakarta 1956). Anak, Fakultas Kedokteran Universi­ tas Sumatra Utara, 1965. 10. P P T I : Kongres I Ja k a rta Juli 1973.

4. JO KIAN TJAY, P. HARN OPID J ATI 11. SOEJONO D. POESPONEGORO dan dan ¡SYARIKAT TARIGAN : Meni­ JO KIAN TJAY : Tuberculosis Pri- ngitis tuberculosis pada anak di tiga mair pada anak, Maj. Kedokt. Indones. rumah sakit di Medan. Seminar Tuber­ 8 : 91 (1958). culosis yang diselenggarakan oleh Pa­ 12. SUHAIMI HARUN T, : Setahun Pi­ nitia Peningkatan Ilmu Fak. Ked. lot Proyek TB. Kontrol di Puskesmas USU Medan, A gustus 1971. Stabat Sumatra jUtara. Newsletter P P T I th. n i No. 5 Jan. 1973. 5. JO KIAN TJAY, T. IRAWATI, S. HALIM, SYARIKAT TARIGAN dan 13. SULASTOMO : Pusat Kesehatan Ma­ H.R. SOEROSO : Epidemiologi primer syarakat dalam pemberantasan TBC. tbc pada anak di Medan. Seminar Tu­ Newsletter PPTI th. IV |No. 1 hal berculosis yang diselenggarakan oleh 16 - 18. Panitia Peningkatan Ilmu Fak. Ked. 14. TATSURO IWASAKI : Tuberculosis USU Medan, A gustus 1971. problem in Asian Countries. Newslet­ te r P P T I th. IV No. 1, 3, 4, 5. 6. KALIGIS, A.J.J. : Produksi BCG vak­ 15. TOMAN, K. The present status sin (Komunikasi pribadi, 30 April of technical knowledge concerning 1974). Immunization ¡against tuberculosis, 7. LOTTE, A. : Tuberculosis in children. Boletin de la OSP. Vol. VH No. 2, A cooperative study in Europe, News- 1973 (English Edition). ; TUBERCULOSIS AND VACCINATION 313

TABLE 1 : Tuberculous Meningitis in Medan (196/t - 197$).

Survive d Died Total 0-4 y 5-12 y Total 0-4 y 5-12 y j Total

RSU PP 206 82 27 109 78 19 (1964 - 1972) 97

RS PNP - IX 25 8 3 11 12 2 14 (1964 1972)

RS ELIZABETH 81 33 10 43 29 9 38 (1964 - 1970)

312 123 40 163 119 30 149 (79,7%) (20,3%) (47,8%)

Note: 242 children or 77.5% out of 312 patients were under the age of 5 years.

TABLE 2 : Mortality rate i/n Tuberculous Meningitis

C a s e s Died

0 - 14 y 0 - 4 y 0 - 4 y 5 - 14 y

Medan 242 119 30 312 (1964 - 1972) (77.5%) (79.7%) (20.3%) Jakarta 753 320 69 919 (1968 - 1973) (81.9%) (82.3%) (17.7%)

Bandung 348 52 11 630 (1968 - 1972) (55.2%) (82.5%) (17.5%)

Ujung Pandang 151 59 8 167 (1970 - 1973) (90.4%) (88.1%) (11.9%)

Yogyakarta 50 13 7 64 (1972 - 1973) (78.1%) (65%) (35% ) Surabaya 85 81 21 0 (1971 - 1973) (94.1%) (100%) (0%) 314 JO KIAN TJAY ET AL

TABLE 3 : Distribution of lesions in chest X-ray film in childhood tubercu­ losis , Medan. (1970 - 1972).

Upper field Middle field Lower field Total cases M iliary R ight Left R ight L eft R ight | L eft

RSUP 142 40 24 98 68 79 24 13

RS PN P 88 14 10 65 50 53 17 0

Total 230 54 34 163 118 132 41 13

Mild - M oderate Lesion : R ight lung . 349 Middle field : 281 L eft lung : 193

Massive consolidation : 45 children or 19,6%.

TABLE 4 : BCG Vaccination in North Sumatra (1970 - 197S).

0 - 14 y A g e > 15 y 1 0

<< 5 - 14 y 0 - 14 y

Population 1.283.299 2.114.026 3.397.325 3.621.704

BCG vac. 348.578 820.712 1.169.290 32.483

Coverage 27.2% 38.8% 34.4% 0.9%