Status of tuberculosis control in Thailand.

The national tuberculosis control program (NTP) was implemented in Thailand as integrated with the provincial general health services since 1967, with BCG vaccination successfully introduced from the beginning, but progress in expansion of case-finding and chemotherapy had only been achieved following the establishment of hospitals at the district level since the late seventies. At present, case-detection and treatment have operated in more than 95% of the 600 district hospitals and 87 hospitals at provincial and regional levels, with patient follow-up by health centers, logistically supported and technically supervised by 12 zonal TB centers. The trend of the disease has shown noticeable decline as indicated by the three national surveys in 1962, 1977 and 1991, that is, morbidity rate as suspected by x-ray of 2.1%, 1.4% and 1.01%; infectious case rate of 0.5%, 0.31% and 0.24% respectively, a reduction of about 2-3% per year. The infection rate of children 0-14 years of age was found to be 15.2% in 1977; 8.9% in 1983; and 5.18% in 1987, giving the annual risk of infection (ARI) of 4.9%, 2.3% and 2.0% respectively. Currently the program detects and treats about 31,000 smear-positive TB cases plus an equal number of smear-negative cases per year. Short-course chemotherapy was introduced since 1985 and expanded to cover all the former by 1991, resulting in improvement of the treatment success rate from less than 50% when using the old standard 18-24 months regimen to 70-80%. As the coverage of case detection and treatment is still only about 60% of the incidence or 30% of the prevalence, trials of primary health care approach have yielded substantially increased case detection coverage as well as improved cure rates. BCG vaccination as part of the Expanded Program on Immunization has reached 90-100% coverage of infants.

The effectiveness of BCG vaccination of the newborn against childhood tuberculosis in Bangkok.

PIP: The Central Chest Clinic, Bangkok, Thailand, undertook a study among child contacts of newly discovered sputum-smear-positive patients with pulmonary tuberculosis to determine the effectiveness of BCG vaccination in young children. The study design resembled that of a controlled trial except that it was retrospective for vaccination, i.e., the vaccinated and control groups were not randomly selected. For this reason a number of measures were taken to allow for the comparability of groups to be verified and for adjustments to be made if necessary. The study was initiated in September 1981 and terminated in June 1984, after 971 index cases who reported contact with young children had been registered. Registration and initial examinations were completed for 1506 child contacts. The field teams could not trace 124 reported child contacts. In the case of 8 children, the initial examination was refused. Within a week of the detection of the index case, a visit was made to the household and personal data were collected. The contact children then were offered a clinical and X-ray examination at the Central Chest Clinic for the examinations. A clinical record was prepared for each child contact, the site of BCG vaccination was covered with a dressing (even if there had been no vaccination or scar), and the pediatrician administered a clinical examination and made a full-plate postero-anterior X-ray. The X-ray picture was examined by 2 readers. Suspect children were followed up for as long as there were medical indications. When indicated by the clinical or X-ray examination, a laryngeal swab was taken for culture and gland biopsies were made and examined by histopathology and culture. If tuberculosis was strongly suspected, treatment was initiated at once with rifampicin and isoniazid. For each child a final diagnosis was made at the end of the study. A scoring system proposed by WHO was used to obtain an indication of the probability of tuberculosis. As many as 1218 (81%) of the children had a BCG scar, and among those without a scar, 35 had a record of vaccination. Vaccination coverage as well as disease risk appeared to be associated with age. Stratification by age showed that this did not affect the calculated effectiveness of BCG vaccination. Apart from age, no differences between the vaccinated and the unvaccinated children were observed that call for stratification of the material. 284 tuberculosis suspects were found, 218 among the 1253 vaccinated and 66 among the 253 unvaccinated participants. The total incidence of tuberculosis was 14.5%; it was 12.6% among the vaccinated and 23.6% among the unvaccinated. Based on the data presented in Tables 1 and 8, and adjusting for the estimated 55 vaccinated children included among those without a scar or a vaccination record, the observed efficacy is 53% with 95% confidence limits of 64% and 38%; the observed number of cases among the vaccinated is 185 less than expected. Thus, although efficacy appears less, the effectiveness is far higher than with a more stringent diagnostic criteria.^ieng