Abstract               Background: Epidemiology of pulmonary tuberculosis is most likely to provide new insight. In view of rapidly changing and evolving evidence base in terms of epidemiological parameters and determinants of Pulmonary Tuberculosis in various settings, the present study has been designed to elicit and validate presumed epidemiological correlates and variables affecting Pulmonary Tuberculosis among field practice areas of population of Himalayan Institute of Medical Sciences. Methods: Our study comprised among all the families under the jurisdiction of Field practice areas (particularly in four villages i.e. Rajeev Nagar, Dharmuchak, Keshavpuri and Doiwala), of the Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, The total population of our study was 5934, and we divided it in three age groups ranged from 15 to 60 years. It was a survey and cross sectional based study. The period of the study was one (01) Year beginning from2015 to2016. Results: Area wise population of the Universe of the Study which comprised the field practice areas of the department of community medicine. Age and sex-wise distribution of Pulmonary Tuberculosis and statistical association of its prevalence with age highest prevalence i.e. 32(0.53%) was in 31-45 years age group, The male was 21(0.35%) and female was 11(0.18%) This difference in prevalence of pulmonary tuberculosis in terms of age and sex group was statistically significant. Conclusion: It will be observed from the study that prevalence of Pulmonary Tuberculosis was found to be directly proportional to client’s advancing age.

Key Words: Pulmonary Tuberculosis.

INTRODUCTION

Robert Koch (1843–1910), a pupil of Henle’s. As a gifted microscopist, he produced irrefutable evidence in 1882 that a specific microbe is the fundamental cause of tuberculosis. At a dramatic lecture delivered to the Physiological Society at the Charity Hospital in Berlin on 24^th March 1881 under the title Die Ätiologie der Tuberkulose, he demonstrated for the first time the bacteria that Villemin and later Klebs had sought for so long in vain. Using special staining techniques he succeeded in visualizing slender rods – which he called tubercle bacilli, Mycobacterium tuberculosis – within the tuberculous tissue. At first Koch was unable to culture the demonstrated bacteria, get them to grow again in a laboratory animal and finally close the chain of evidence by histological examination of the resulting tuberculosis tissue. Although tuberculosis is a communicable disease, it is relatively difficult for tubercle bacilli to invade the body and establish active disease. Primary infection with tubercle bacilli is the beginning of all forms of tuberculosis. The interplay between the agent, the host and the environment influences the course of infection to disease to death or cure. In most of the infected persons, equilibrium for co-existence is established between the host and the agent. In a large majority of persons, the primary infection, regardless of age at which it occurs, passes off unnoticed without progressing into active disease. the biological forces, mobilised by the individuals against tubercle bacilli, constitute the most dependable and effective mechanism of preventing the infection from progressing into disease or recovery from disease. The entire course of infection to disease in an individual could be divided into five phases, which occur at different times subsequent to infection. Phase (I) Primary Tuberculous Infection. Phase (II) Primary Illness. Phase (III) Generalized Dissemination. Phase (IV) Localized Extra pulmonary Tuberculosis. Phase (V) Satellite or of Adult Type of Disease. M. tuberculosis is most commonly transmitted from a person with infectious pulmonary tuberculosis to others by droplet nuclei, which are aerosolized by coughing, sneezing, or speaking. The tiny droplets dry rapidly; the smallest (<5–10 mm in diameter) may remain suspended in the air for several hours and may reach the terminal air passages when inhaled. There may be as many as 3000 infectious nuclei per cough. In 2006, nearly 9.2 million new cases and 1.7 million deaths were reported due to TB, and over 90% of these occurred in the low and middle income countries^1. In these regions, TB is the one of the leading cause of adult mortality, ranking third after HIV/AIDS and ischemic heart disease as a cause of death among those aged 15-59 years and 7th globally among all age group. Global TB control has made great progress in the past decade. The widespread implementation of the internationally recommended Directly Observed Treatment, Short-course (DOTS) strategy has proved to be an effective tool in controlling TB on a mass basis and is being practiced in over 180 countries. While maintaining the current status, the prime task for the next decade is to achieve the Millennium Development Goals (MDGs) and related Stop TB Partnership targets for TB control.

MATERIAL AND METHODS

Our study comprised among all the families under the jurisdiction of Field practice areas (particularly in four villages i.e Rajeev Nagar, Dharmuchak, Keshavpuri and Doiwala), of the Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun.

Study Population: All persons aged from 15 to 65 years belonging to the families under the jurisdiction of Field Practice areas of the Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun were included as study population. The total population of our study was 5934, and we divided it in three age groups: (i). 15-30 years,(ii) 31-45 years, and (iii) 46-60 years. The period of the study was one (01) Year beginning from 2015 to2016.

Study Design: Community based survey, Cross –sectional study.

Study Tools

1. Questionnaire
2. Clinical assessment of pulmonary tuberculosis.
3. Sputum for AFB

Sample Size: Total study population was 5934 ranged from 15 years to 60 years of age.

Methodology

House to house survey was conducted on all the families under the jurisdiction of Field practice areas (particularly in four villages i.e. Rajeev Nagar, Dharmuchak, Keshavpuri and Doiwala), of the Department of Community Medicine, Himalayan Institute of Medical Sciences, and socio-demographic profile of each house-hold was recorded. All members ranged 15-60 years of age from the surveyed house-holds having either history and or presenting complaints of cough for three weeks or more in duration and those already diagnosed cases of Pulmonary Tuberculosis included either as ‘defaults’, ‘relapsed’ ‘failure’, ‘not completed treatment’ or ‘chronic’ cases and undergoing treatment either from any Category of DOTS or non-DOTS regimen. A detailed clinical assessment of the study subjects was then carried out including general and systemic examination with particular reference to Respiratory system. All newly detected Behavior Pic were subjected to sputum microscopy as per standard RNTCP Protocol. Sputum specimen sent to Department of Microbiology, Himalayan Institute of Medical Sciences for Direct Microscopic examination for AFB and culture of Mycobacterium tuberculosis . And investigation of Chest x-ray-Pa/Lat view was done. Three sputum samples were collected over two consecutive days: Spot – morning- spot. Respondents have history of risk Behavior/risk situations and either having symptoms suggestive of pulmonary tuberculosis or already diagnosed as Pulmonary Tuberculosis cases, were counseled and motivated to report and seek counseling from Integrated Counseling and Testing Centre (ICTC), Himalayan Institute of Medical Sciences. After pre-test counseling and on a bilateral agreement such clients were subjected to diagnostic test for HIV.

Exclusion Criteria

1. Those patients who were cured or had already completed their treatment regimen with negative smears at the end of the treatment by either DOTS or non-DOTS regimen were excluded from the study.
2. Those patients who were found HIV positive in the ICTC centre were excluded from our study.

RESULTS

Table 1: Area wise Population of the Study

Table 1: The total population under the jurisdiction of Field practice areas, were 5934, (particularly in four villages i.e. Rajeev Nagar (753), Dharmuchak (1527), Keshavpuri (3126) and Doiwala (528), in the Department of Community Medicine, Himalayan Institute of Medical Sciences.

Table 2: Distribution of study population among Age and Sex wise

Table 2: Shows distribution of study population according to age and sex. It can be observed from the table that out of a total population of 5934 studied, 3441 (58%) were males and 2493 (42%) were females. It is obvious that the largest proportion of the study population and for both the sexes belonged to the age group of 15-30 years i.e. out of a total 3086 (52%) population from this age group 1721 (29%) were males and 1365 (23%) were females. The number and proportion of study population was inversely proportional to the increasing age group for both male and female.

Table 3: Distribution of Study Population by Religion, Family size and Socio Economic Status

Table 3.1: Shows distribution of study population according to Religion. Majority of the study population i.e. 4094 (69%) were Hindus followed by Muslims 1662 (28%), Christians were 119 (2%) and the others were 59 (1%). Distribution of study population in terms of Family size is presented in table (3.2) It can be observed from the table that highest proportion of study population i.e. 4332 (73%) belonged to families with family size 3-5. The above table (3.3) also shows profile of the study population according to socio economic status; most of the families with as lower classes 3501 (59%) either belonged to Middle classes 2255 (38%) and upper lower classes were 178 (3%).

Table 4: Distribution of Study Population (Female) by Occupation (n=2493)

The above table at 4 gives occupational profile of female study population. It can be seen that as many as 1304 (52.30%) women fell under the category of ‘House wives and Others’ which also included study. These were followed by 355 (14.23%) women who were ‘Laborers’ and another more 214 (8.59%) ‘Farmers’. 175 (7.01%) shopkeeper and govt services 239 (9.58%).

Table 5: Distribution of Study Population (Male) by Occupation (n=3441)

The above table at 5 gives occupational profile of male study population. It can be seen that as many as 1445 (41.99%) men fell under the category of ‘Others’ which also included study. These were followed by 579 (16.82%) men who were ‘Laborers’ and another more 604 (17.55%) ‘Farmers’. 369 (10.72%) shopkeeper and govt services 164 (4.76%).

Table 6: Area wise Distribution of Symptomatic and Confirmed cases of Pulmonary Tuberculosis diagnosed by either microscopy or criteria other than microscopy (n = 323)

Table 6: Shows area wise distribution of symptomatic and confirmed cases of Tuberculosis and its period prevalence. It can be observed from the table that a total of 323 (5.44%) symptomatic were screened out of a total study population of 5934 from 04 different field practice locations; 55 (0.92%) symptomatic turned out to be cases of Tuberculosis confirmed either as sputum positive cases by Microscopy or by other criteria., the prevalence was as high as 22 (0.37%) population at Keshavpuri and followed by 12 (0.20%) population at Dharmuchak.

Table 7: Distribution of Confirmed cases of Pulmonary Tuberculosis by Sex and Diagnostic Status on the date of Interview (n=73)

Table 7: Shows sex -wise distribution of confirmed cases of pulmonary tuberculosis and their diagnostic status as of the date of interview. It can be seen from the table that 34 (61.8%) of the confirmed cases were found already diagnosed and 21(38.2%) cases were not. Among all the cases already diagnosed, 15 (27.3%) were males as against 6 (10.9%) Females. Likewise, among those who were not diagnosed at the time of interview, 23 (48.8%) were males and 11 (20.0%) were females.

Table 8: Age and Sex wise Distribution among Pulmonary Tuberculosis Cases

                                                                p Value =.001

Table:8. Age and sex-wise distribution of Pulmonary Tuberculosis and statistical association of its prevalence with age. It can be observed from the above table that prevalence of Pulmonary Tuberculosis was found to be directly proportional to client’s advancing age. Highest prevalence i.e. 32(0.53%) was in 31-45 years age group, The male was 21 (0.35%) and female was 11 (0.18%) This difference in prevalence of pulmonary tuberculosis in terms of age and sex group was statistically significant.

Table 9: Pulmonary Tuberculosis and Type of Treatment Regimen

   p Value =0.52

The above table (9) shows statistical association of the difference in number of cases of Pulmonary Tuberculosis seeking or undergoing either DOTS or Non-DOTS Treatment regimen, however it is statically non significant. (p =0.52).

DISCUSSION

Although the relevant facts regarding the present day epidemiology of tuberculosis in India have not yet been fully elucidated, a considerable amount of information, of varying degrees of reliability and accuracy, has accumulated during the course of the last 30 or 40 years enabling us to see at least the outlines of the problem and furnishing the basis for future action ^[2]. Significantly, with atypical parameters like geo-topographical /disadvantaged population living in rural or periurban habitat/slums having varying socio-epidemiological predictors, the study of epidemiology of pulmonary tuberculosis is most likely to provide new insight. In view of rapidly changing and evolving evidence base in terms of epidemiological parameters and determinants of Pulmonary Tuberculosis in various settings, the present study has been designed to elicit and validate presumed epidemiological correlates and variables affecting Pulmonary Tuberculosis among field practice areas of population of Himalayan Institute of Medical Sciences. The design of the present study considered population from the age group 10 years and above as the study population. Precedents of work with the same age group as study population have been documented^3,4.  The largest proportion of study population for both the sexes belonged to the age group of 10-20 years i.e. Out of a total 4724 (26.3%) population from this age group, 2,409 (50.09%) were males and 2,319 (49%) were females. The number and proportion of study population was inversely proportional to the increasing age group for both male and female. Similar demographic pattern can also be seen at SRS (2006), where the national average of population in the age group 10-20 years and 70 years and above were 20% and 2.6% respectively ^[5]. While the percentage of population above 70 years of age in this study 473(2.63%) is well comparable to the national data the difference in percentage of population in the age group 10-20 years is most likely to be due to less acceptance of family planning methods resulting in increased family size and increase in younger population in this area. This observation is also reinforced by another similar study done in rural Aligarh where most of the persons were in the age group of 10-20 years (31.03%), while the least was in the age group of 60 years and above (6.76%)^3. Importantly, while the sex ratio in India has historically been adverse to females owing to cultural and social variables including also in the state of Uttarakhand and study district of Dehradun i.e. 940 Female per 1,000 males and 887 Female per 1,000 males respectively^83,91, The present study shows a much improved scenario. I.e. a male: female ratio of 1.02:1. Khan also observed a skewed sex ratio (1.2:1) citing socio-cultural factors including sex determination as the predominant cause ^[3]. Improved scenario in the present study can be best explained by decrease in sex selective abortion, less gender bias and discrimination by a more aware and sensitized study population and may be due to better implementation of PNDT Act. Regarding literacy among females of the study population, as many as 5658 (64.21%) were found literate and the largest proportion from among them i.e. 1905(21.61%) were educated up to primary standard. The proportion of illiterate women was directly proportional with increasing age. The data on female literacy in NFHS III (Uttarakhand) and DLHS III, (Dehradun) i.e. 61% and 62.8 respectively, though state and district specific, reinforce the findings on female literacy among the present study population^6,7. Epidemiological studies on population with similar female literacy profile were not available for comparison.  As regards educational status of the males as many as 6,239 (68%) were literate and the highest proportion from among them i.e. 2434 (26.63%) were educated up to junior high school standard. The number and proportion of literate men progressively decreased with increasing age. The data on male literacy in NFHS III (Uttarakhand) and DLHS III, (Dehradun) 86%and 82.7respectively, though state and district specific, also corroborate the findings on male literacy in the present study. Population based studies with comparable male literacy profile were also not available for comparison in published literature. Available community based studies in India across different socio-demographic perspective cite literacy of study population at <40%^3,8,9, whereas according to Census 2001, the difference in male and female literacy in rural Uttarakhand was found to be 24 percentage points,  this difference was much less in the present study i.e. 4.2 percentage points which may be essentially ascribed to difference in study setting and a much smaller universe with a purposively sampled block population of a district from the plains. Concerning occupational profile of female study population, It can be seen that largest proportion of population of women in each age group belonged to ‘Housewives and others’ ranging from 2117 (91.44%) women in the age group of 10-20 years to 208 (87.76%) in age group 70 years and above. Women in other occupations including Govt. jobs and professionals were significantly less. Population based studies with similar female occupational profile were not available for comparison in Census 2001. Existing literature mentions a study where ‘Dependents’ (housewives, students, and others unemployed) comprise 32.09% of the population^3. The patriarchal arrangement of society in Uttarakhand is so deeply entrenched that the out-migration of male from the hills to the plains for work and the de facto headship of the household and a dual burden of responsibility. Limited mobility and social subordination deny women opportunities for public communications and transactions; fertility decisions are, as other decisions about finance or land, definitely not in the purview of the women¹⁰. Occupational profile of male study population highlights predominant occupation being ‘Labourer’ i.e. 3178 (34.77%) followed by the category ‘Others’ which mostly included students or those having no work and which was particularly pronounced in the age group 10-20 years. Data on occupational profile of rural and periurban male population in Census 2001for Uttarakhand where76.6 per cent of the population of age group 5-14 years has been attending educational institutions. 41.1 per cent of the population have been recorded as workers, The female Work Participation Ratio of 31.9 per cent is just lower than male (49.9 per cent), a high of 67.9 per cent has been recorded as cultivators, 7.7 per cent as agricultural laborers, 5.2 per cent in the category of household industry, and the remaining 19.2 per cent as ‘other workers’¹¹. Other community based studies also re-inforce the above findings particularly in rural Aligarh proportion of agriculture workers and laborers constituted 46.49% of the study population³. The difference in occupational of study subjects by different authors was essentially due to distinct study settings with varied. Women’s lives in the hills of Uttarakhand are tied up in an oppressive patriarchal system in which women’s labour (productive power), women’s fertility (reproductive power), women’s sexuality and women’s mobility are controlled by men¹².

CONCLUSION

Our study comprised among all the families under the jurisdiction of Field practice areas (particularly in four villages i.e. Rajeev Nagar, Dharmuchak, Keshavpuri and Doiwala), of the Department of Community Medicine, Himalayan Institute of Medical Sciences, Dehradun, The total population of our study was 5934, and we divided it in three age groups ranged from 15 to 60 years. It was a survey and cross sectional based study. Although the relevant facts regarding the present day epidemiology of tuberculosis in India have not yet been fully elucidated, a considerable amount of information, of varying degrees of reliability and accuracy, has accumulated during the course of the last 30 or 40 years enabling us to see at least the outlines of the problem and furnishing the basis for future action.

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