THE EPIDEMIOLOGY OF PULMONARY TUBERCULOSIS

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THE EPIDEMIOLOGY OF PULMONARY TUBERCULOSIS

IN THE BAHAMAS FROM 1965 - 1981

by

Nathalee P. Bonimy

SRN, RM

Project report submitted in partial fulfilment of the

requirements for the Diploma in Community Health

(General), Department of Social and Preventive Medicine,

University of the west Indies, November, 1982

)

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ACKNOWLEDGEMENTS

I wish to express my sincere gratitude to all those

persons who assisted in making this study possible.

Special thanks go to the following persons:

The commonwealth Fund for Technical co-operation and the

Ministry of Health, Bahamas, for funding the course.

Dr carlos Mulraine, my field supervisor for his untiring

guidance and support in the preparation of the preliminary

draft.

Dr Cora Davis and the staff at the Public Health Depart­

ment; Dr Perry Gomez, Mrs Poitier-Mortimer and the staff at

the Tuberculosis Unit; Mrs Beverley Ford and the staff at

the Community Nursing Servicesr Mr Moses Deveaux and the

staff at the Medical Records Department for their cooperation

and assistance during the period of data collection.

To Miss Zella Major for encouragement and constructive

suggestions and Mrs Lillian Jones who reviewed critically the

material.

To the lecturers and staff a t soc ial and Preventive

Medicine for their gu i dapoe tnrou~hout t h e course and

especially during the preparat i on o f t h e final draft.

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To my typist, Mrs Angela colebrooke for retyping this

work to print.

Lastly, to my family, especially Edgar and the children

for their understanding, which helped me to complete this

study.

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ABSTRACT

In the Bahamas, during the 40's, the programmes for the

control of tuberculosis were poorly organised and the in­

cidence of the disease remained very high.

After a survey by Santon Gilmour in 1945, there was a

gradual improvement and a decline in the incidence.

The purpose of this study was to describe the epidemio­

logical features of pulmonary tuberculosis in the Bahamas over

a 17 year period, extending from 1965 - 1982.

Results showed a population of 1394 case s over the study

period. New Providence contributed 69 percent of the cases.

The age group 20 - 29 years accounted for the highest percent­

age of cases (41 percent), while the lowest (9 percent),

occured among the 10 - 19 year age group.

The x-ray and sputum ·results were only found for the last

5 years. The population for both was 266: of these 85 per­

cent had positive x-rays, 71 percent had positive smears and

67 percent had positive cu+t~r~s .

In the Bahamas, fo r the 1 7 yeq r per iod, every year ther e

were more males than female patients.

several reco~endqtions were ma de i.n order to i mprove

the control programme in the Bahamas.

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CONTENTS

Acknowledgements

Abstract

Table of contents

List of tables

List of figures

List of appendices

chapter 1

Chapter 2

INTRODUCTION

Background information

General description of the Bahamas

History of tuberculosis -

Tuberculosis throughout the world

Tuberculosis in the Caribbean

Tuberculosis in the Bahamas

RATIONALE, AIM, OBJECTIVES AND METHODS

Rationale for present study

Aim of study

Objectives of study

Methods

Data collection

Pretesting data collection methods

nata collection sheets

page

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iv

vi

vii

viii

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7

10

11

14

26

26

26

26

27

27

29

30

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chapter 3 RESULTS

Number of reported cases

Geographical distribution

Age Group

sex

Radiological results

Bacteriological results

Nationality

chapter 4 DISCUSSION

Limitation of methods

Interpretation of results

conclusions

Recommendations

References

Appendices

Page 31

31

31

34

40

40

40

44

46

46

46

55

55

58

60

Table No.

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2

3

4

5

6

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9

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LIST OF TABLES

f{eacU ng s

Population distr i bution of the Bahama. s 1980-

Tube~c~losis (al~ types) cases repo~ted to CAREC 1977 - 1981, with rates per 100,000 population.

Reported cases of tuberculosis by islands of the Bahamas 1965 - 1981.

Reported cases of pulmonary tuberculosis by age group 1965 - 1981.

Percentages of reported pulmonary tuberculosis cases by age group 1965 - 1981.

Reported pulmonary tuberculosis cases by sex for the Bahamas

page

3

12

32

35

1965 - 1981. 36

Distribution of tuberculosis cases by t ype of x-ray results in the Bahamas, 1965 - 1981. 41

Reported cases of pulmonary tuberculosis by sputum result in the Bahamas 1977 - 1981. 42

Detailed sputum result or reported cases of pulmonary tuberculosis in the Bahamas from 1977 - 1981. 43

Nationality of reported cases of pulmonary tuberculosis in the Bahamas 1977 - 1981. 45

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LIST OF FIGURES

Fig. No. Heading Page

1 Map of the Bahamas. 2

2 Number of reported pulmonary tuberculosis cases by year. 33

( 3 Percentages of reported pulmonary tuberculosis cases by age group for the Bahamas 1965 - 1981. 37

4 Reported pulmonary tuberculosis cases by sex, for the Bahamas 1965 - 1981. 39

Appendix No.

1

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3

4

5

6

7

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LIS 'f ___Q:;,:;J'--=A=P:...::P....:::El:.::.:.N.t.;.;p:=C C=E=S

ljeaq.j. ng

List showing t p e d ise a ses that are notifiable to t h e Public Health Department, Bahamas.

page of chest ward admi ssion and discharge book.

Page of chest clini c admission and

60

63

discharge book. 64

Chest clinic attendance card. 65

work sheet for data collection. 66

Medical records request form. . 67

Notification form of infectious disease. 68

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CHAPTER 1

INTRODUCTION

Background information

General description of the Bahamas

The Bahama Islands lie between latitude 20 - 27° north

and longitude 72 - 79° west. This archipelag consists of

more than 700 islands, rocks and cays, which, with the

exception of New Providence and the city of Freeport are known

as Family Islands. The archipelage begins approximately 50

~miles fr~ the west coast of Florida, and extends in a south

easterly direction for a distance of some 750 miles. Its

southern most island, Inagua, i s 90 miles north of Haiti

(figure 1 shows a ma p of the Bah~mas ).

There are no mountains, the highest point being Mount

Alvernia on cat Island, which is only 206 feet above sea

level. Andros is the largest island with an area of 2,300

square miles. ~ Table 1 shows the 1980 population distribution

of the islands according to their land area in square miles.

The 1980 census showed the total population of the

Bahamas as 209,595 residents, of whom 135,437 (64.7 percent)

lived on the island of New Providence, where the capital,

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Table 1

Population Distribution of the Bahamas by Island, 1980

Island

New Providence

Grand Bahama

Abaco

Acklins Island

Andros

Berry Islands

Biminis, Cay Lobos and Cay Sal

Cat Island

Eleuthera, Harbour Island and Spanish Wells

Crooked Island

Exuma and Cays

Inagua

Long Cay

Long Island

Mayaguana

Ragged Island

San Salvador and Rum Cay

Total with other Cays added ..

Land Area (Sq. Miles)

80

530

649

192

2,300

12

11

150

200

84

112

599

9

230

110

14

90

5,382

Population 1980

Total

135,437

33,102

7,324

616

8,397

509

1,432

2,143

10,600

517

3,672

939

33

3,358

476

146

804

209,595

Population pei Square Mile

1,692.9

62.5

11.3

3.2

3.7

42.4

130.2

14.3 .

53.0

6.2

32.8

1.6

3.7

14.6

4.3

10.4

8.9 ' .

38.9

Source: Preliminary Report of 1980 Census, Department of Statistics, Nassau, Bahama~.

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Nassau is located. The second most populated island is

Grand Bahama, on which is located the nation's second

city, Freeport.

Nassau has become a financial and business centre and

has direct· air communication with several countries, in

eluding the united states of America, canada, the united

Kingdom, Jamaica and Bermuda. communication among the

islands is maintaine d p y a regula~ mail boat service. The

national airline - ~ah~m~sai~ , provides ~egular ai~ links

between Nassau and many Q! the aQt ! y i ng population centres .

several companies also ope~ate inter-island air charter

services.

A few of the islands have a direct telephone service,

while others have telephone stations in the main settle­

ments. These stations are opened at intervals during the

day, but urgent messages are carried over the radio stations,

whenever the need arises. There are three radio stations,

two in New Providence, and the other in Freepor t . They

service the entire Bahamas.

The islands are at different stages of development;

some have the basic infrastructure, such as water and

electricity throughout; while others have to rely

largely upon individual supplies of water and electricity.

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over the years there has been a population drift from

the less developed areas to the urban centres of Nassau and

Freeport.

Tourism is the main industry, with more than well over

a million tourists visiting the Bahamas each year.

Thousands of Bahamians depend on it for their livelihood.

other important industries in the country include:-

(i) A cement manufacturing plant

(ii) An oil refinery

(iii) Manufacture of chemicals

(iv) Agriculture, mainly fruits and vegetables

(v) Fishing

(vi) Making of straw goods.

There are three government hospitals in the Bahamas.

1. The Princess Margaret Hospital is the largest

and is situated in New Providence. It has 455

beds and is a multidisciplinary hospital, which

is recognised as a centre for training medical

interns.

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2. The sandilands Rehabilitation centre, also in New

Providence is a combination of a 150 - bed

geriatric unit and a 250 - bed psychiatric hospital.

3. The Rand Memorial Hospital, situated in Freeport, is

a 62 - bed acute care hospital, which provides on a

smaller scale many of the services available at the

Princess Mar~arat ~o~pi~al,

The Public Health oe~a~tment p;qvi des ~ternal anQ child

health services from three community health centres and

three satellite clinics in N~w Pr ovidence. In addition

there are also the following services:-

(1) Food handlers clinic

(2) venereal diseases clinic

(3) school health

(4) Home care

(5) Home-visiting

(6) Health education programmes

(7) General epidemiological services

The family Islands are divided into health districts,

which are served by health centres and manned by 19 District

Medical Officers and 73 Nurses.

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The nurses who work on the family islands and in the

Public Health Department constitute the community Nursing

Service.

Private medical services are provided through one

general hospital and a number of medical centres and clinics.

The Department of Environmental Health services is

responsible for the collection and disposal of refuse,

general environmental control and health inspectorate

services.

The Bahamas became independent on the lOth July, 1973,

ending some 250 years of British colonial rule.

History of tuberculosis

The name

Its earliest medical name was phthisis, derived from

the Greek verb phthinein, 'to waste away'. In the nine­

teenth and even in the early twentieth century, it was

generally known as 'consumption'. But a s long ago as the

seventeenth century, the Dutchma n pranc i scus Silvius of

Leyden first used the te+m ' t ubercle' t o describe nodular

lesions found in the l~ngs o f p eople who had died of the

wasting disease. Johann schonlien, in 1839, was probably

the first person to have used the name tuberculosis.

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Milestones

Traces of tuberculosis lesions have been found on

3000-year old Egyptian mummies.

The Greek physician Hipprocrates (460-370 B.C.) - "the

father of medicine" was the first to describe the disease

(World Health, Jan; 1982).

one of the ~~ ipo~fal land~a~ks in the nineteenth

century development ot scientific knowledge of tuberculosis

was the work of Villemin, a French investigator, who in

1865 showed that the disease cou~d be experimentally trans~

mitted from animal to animal. It also demonstrated the

unity of the disease in different hosts.

Koch's discovery of the tubercle bacillus in 1882 and

his clear demonstration of its etiologic role were the two

most important events in the whole scientific history of

tuberculosis (Comstock, 1980).

In 1895, Roentgen discovered, in Vienna, the x-rays

which allowed an examination of the chest. For the first

time there were radiological images available which showed

the extent of the iesions in patients and, occasionally, in

people who had no symptoms. Actual confirmation of the

diagnosis depended on bacteriological examination for the

tubercle bacillus.

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In 1921, French scientists A. calmette and c. Guerin

discovered BCG (Bacillus calmette-Guerin), an ·attenuated

form of the bovine bacillus, and used it as a vaccine

against tuberculosis.

In 1944, Selman A. waksman and his colleagues, in the

United states, discovered streptomycin, the first antibio­

tic effective against tuberculosis. Para-amino salicylic

acid (PAS) was discovered in 1946 and isoniazid (INH) in

1952.

During the period 1948 - 1957, the first mass vacci­

nation campaign was carried out by the sca·ndinavian Red

cross society with support £rom the united Nations Children's

Fund (UNICEF). From 1957 the World Health organization

(WHO) became involved and helped governments to set up their

own BCG programme.

In 1966 rifampicin proved to pe an excellent drug

against tuberculos~a . p t972 ~+~~C FOX qnd members from

the British Medica l R~'ea~eh CQur~e! l, i n collaborat ion wi t h

several centres in ~ast Africa, showeq that the addition of

rifampicin, or of pyrazinamide, to the regime containing

isoniazed made it possible to reduce the duration of treat­

ment (world Health, 1980).

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Tuberculosis throughout the wor ld

Despite the excellent weapons to combat tuberculosis,

the disease is stil+ a wor +dwide publ i c health problem

(Comstock 1980).

The anti-tube r culos is p r oblem was one of the main pro-

gramrnes at the bi+th o f WHO· At ~east 3.5 million people

develop tuberculos is eaor yea~, anq mo+e than fifty percent

died from the disease. The objective of the tuberculosis

control is to break the chain of transmission of the infec­

tion. This is achieved by detecting the sources of the

infection as early as possible rendering them non-infectious

by chemotherapy given in the patients horne rather than in a

special institution, and by providing BCG vaccinations".

(Zahra, 1980).

Tuberculosis takes its greatest toll in regions with a

low standard of living and among the underpriviliged.

Although other factors are involved, it is to some degree a

barometer of social welfare. The downward trend of tuber­

culosis incidence in many countries has followed improve­

ments in housing, nutrition, working conditions and the

standard of living (comstock, 1980).

The health statistics which are compiled in the less

/

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developed countries tend to underestimate the prevalence of

all diseases, including tuberculosis. In such countries

many cases remain unnoticed by the health authorities

because only a fraction of the population has access to

regular health services.

The epidemiological situation in many developing coun-

j(. tries, involving a population of more than two billion, is

now worsening due to the poor results in case-finding and

treatment. The total number of cases of tuberculosis has

doubled during the last three decades, due to the doubling

of the population. The developing countries therefore must

bear a much heavier burden if they are to undertake treat-

ment of their tuberculosis cases. In addition, the must be

rapidly brought under control, otherwise the absolute number

of cases will continue to increase and the situation will

get even worse (Styblo, 1980).

Tuberculosis in the Car ! pbean •~ re r ""*

The number of tuberc~losis oases reported to the

caribbean Epidemiology centre by 18 different territories,

for the period 1977 - 1979, shows ~n irregular pattern.

over the 5 year period the rate per 100,000 population

ranged from 1 to 44, with the lowest being reported for

Grenada and the highest for St. Lucia

(

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Table 2

Tuberculosis (all t y pes) Cases Reporte d to CAREC 1977 to 1981 With Rate ~ Per 100 ,000 Porulation

Country in order of Rate p e r 100,000 po£ulation

population size +97? 1978 1979 1980 1981

Bermuda - 5.1 5.1 1.7 3.3

St. Kitts/Nevis 4.8 1.6 1.6 14 8.0

Virgin Islands (U.S. ) 3 7.5 6.0 - 1. 5-t

Antigua 8.3 11.0 2.7 11 4

Dominica 20 14.1 6.4 24 35

Grenada 11.2 - 10.1 16 1.0

St. Vincent . . . . 18.6 16.8 30 9.2

St. Lucia 33 44 31 31 32

Belize 21 10.6 22 13 21

Bahamas 15.1 11.6 28 37 34

Barbados 5.4 6.1 8.8 26 1.2

Guyana 13.3 12.9 . . . . 14 13

Trinidad & Tobago 6.7 10.5 8.8 .... -Jamaica 16.7 14.1 6.6 6.3 4.7

Puerto Rico 11.5 11.2 9.1 14 15+

Haiti 24 12.6 29 63 16

Dominican Republic 28 30 39 . . . . -Cuba 12.9 13.0 11.0 12 8.6

Key: •... Insufficient information; -no cases

Source: CAREC Survei llance Unit 1979 and 1981.

+ Reports taken from Commun icable Disease Centre Morbidity and Mortality Weekly Reports.

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Jamaica, cuba and Bermuda show a d ecline for the 5-

year period. Table 2 shows the rate per 100,000 population,

of all types of tub~rculosis reported to_ caribbean Epidemic-

logy centre (CAREC) from 1977 - 1981 by 18 different

territories.

within the caribbean, one of the most difficult aspects

of the control programme to be organised adequately is that

of systematic case-finding. The organization and operation

of health facilities are generally not oriented towards the

detection of large numbers of new cases, and this is parti-

cularly true at the peripheral level where such capabilities

are most needed.

Throughout the region there are three different levels

of laboratory services p eing used ~-

1. oist+ict mic~q~cop¥ oqt¥

2. Microscqpy ~nq cu+t~r~

3. Microscopy , oq l t ufe , a n~ itivi ty test and

identific~tion pf a typic~l mycobacteria.

There is a variation in the caribbean in both quality

and availability services for microscopy and culture.

.... 14 -

Chemotherapy protocq ls f or qcti ve oases are variable

and are often subject to individ~al discretion. Prolonged

treatment courses are common even when drugs and resources

are abailable for short term alternatives.

Chemoprophylaxis with isoniazid is being .practised in

most countries,. but criteria for application differ greatly

according to local experience and the definition of risk

groups.

There are different policies for BCG vaccination with­

in the region. In some countries the target population is

still newborn babies while in others this policy has been

discontinued. (CAREC, 1979).

Tuberculosis in the Bahamas

Sir Frank Stockdale, comptroller for Development and

welfare in the west Indies made special reference to tuber­

culosis in his report for 1940 - 1942, stating that:

11 The death rates for pulmonary tuberculosis in the west

Indies, so far as can be determined, are between 80 and 100

per 100,000 population". (Gilmour, 1945). Therefore berore

making recommendations to assist tuberculosis schemes f

the west Indies, he wanted the situation to be surveyed and

studies by a recognised authority on the subject.

- 15 -

As a result, Santon Gilmour was invited by the council

of the National Association for the Prevention of Tubercu-

losis and the colonial Office in London to carry out a

survey in Trinidad and Tobago and in as many of the British

west Indian colonies as possible. Although the Bahamas

Government did not want to be included generally in the

activities of development and welfare, they made a request

to the comptroller to be included in this survey. Special

arrangements were made and the survey was done between

December 1944 and March 1945, following the completion of

the surveys of the south caribbean area.

The Bahamas su~vey ~arr!eq out two lines of investi­

gation:-

1. By the Qae of t~e tt~p~~ou~in skin test, to

obser~e the extent of infection in the apparently

healthy, particularly ~chool children.

2. By clinical observation of those already sick,

both the known cases in hospital or elsewhere

and the cases referred for diagnosis or treatment.

At the time of the survey the tuberculosis unit

consisted of 12 beds. .Most of the cases ended in death.

This could be attributed to the fact that they came for

- 16 -

treatment when the d i sease was qt a very advanced stage.

contact tracing and follow-up care were minimal because

of inadequate staff.

The main recomme ndations made at the end of the survey

were:-

1. A medical officer should be appointed to deal with

tuberculosis cases specifically.

2. There should be a central clinic for diagnosis

and treatment and an administration office for

recording and for organising the campaign. The

clinic should have a p e rmanent sta f f , with one well

experienced tuberculosis health visitor and an

experienced clerk.

3. The public health activities should be extended.

4. A tuberculosis hospital (180 beds) with adequate

staff and a modern x-ray plant, capable of pro­

ducing high quality radiography , should be

provided.

5. There should be an improvement in housing,

education and economical conditions.

6. Mass radiography should be used to increase case

finding.

7. The government should introduce legislation to

compel infectious cases of tube rculosis to enter

an institution for isolation and to remain there

(

- 17 -

until rendered non-infectious.

In 1947, the Royal Air Force (RAF} military hospital

at Prospect was leased from the oakes' Estate for 5 years,

so that. a new hospital could be built. In october of the

same year, the private and general wards from the Bahamas

General Hospital were transferred there. As a result the

tuberculosis unit was increased to 26 beds. The new

accommodation allowed more patients to be admitted in

earlier stages and the re~ults were good.

Another survey was r~commended to the Government but

unfortunately this was pq~ ca~ried out, due to insufficient

funds. In 1947, the pup~ic H~~ lth ~ursing staff investi­

gated 63 tuberculosis cases of whic~ 10 (20 per cent} were

new. There were 61 patients referred to hospital (Abridged

Medical Report, 1947}.

In 1948 out of 77 cases treated at the hospital, 58

(75 per cent) died (Annual Medical Report, 1948} Although

accommodation was still inadequate, there were more patients

who were recovering sufficiently to be discharged home.

In 1949, the number of cases was still high, but this

probably was due to the following:

(i} More facilities for treatment

(

- 18 -

(ii) Activities of the public Health and welfare

Nurses.

(iii) A More enlightened public seeking examination.

The public Health Nurses again investigated 26 cases,

performed 77 tuberculin tests and referred 33 patients for

x-ray.

At the end of 1949, a chest clinic was established in

the x-ray department. The department's staff volunteered

their services and held clinics twice per week. A card

index was kept and the discharged patients were encouraged

to attend.

contact tracing was improved in 1950 because a register

was provided. This served as a reference book to the Public

Health Department and the Red cross. In october of the same

year 16 more beds were made available in the old Alexandria

ward of the Bahamas General Hospital.

At the end of 1950, the Chief Medical Officer (CMO) in

his annual Medical Report wrote, "Generally speaking, there

has been a definite improvement in the situation although

the figures show an indicatiqn that more is being done about

the disease". Thiosemioarbqzone (TDI) and PAS were intro­

duced and used on s elected cases with good results (Annual

Medical Report, 1950).

- 19 -

In 1951 the che st clinic wa s tr a nsferred from the

x-ray department ot the new out-patient's department of the

Bahamas General Hospital. The tuberculosis cases were now

being referred to the unit through the clinic. Earlier

cases came from private doctors and from contacts of known

cases, who were referred by the Public Health Nurses, the

Red cross and the Infant welfare Centre. There was still

relatively little organised follow-up care and when patients

defaulted there was a b e ak in t re&tment. Treatment was

effective in those wh d!q no t deta~lt .

The Public Health Department investigated the homes of

all patients before discharge. There was no available in-

formation for 1952 and 1953 at the Archives department.

On 21st May, 1954 male and female tuberculosis patients

were separated for the first time and placed in 30 beds wards.

During 1954 there were 64 admissions with 13 (20 percent)

deaths, and some patients were still waiting in the general

wards for admissions to the unit when there was a vacancy.

The new Bahamas General Hospital was completed in 1955

and therefore all the wards excluding the tuberculosis unit,

were transferred. In March of the same year, the hospital's

name was changed to the Princess Margaret Hospital.

(

(

- 20 -

of all types of tube rculosis inc r e a s e d t o 171, with 22

deaths (13 percent) Annual Me dical Report, 1955).

Unfortunately the r e were no reports available at the

Archives Department for the years 1956 to 1961.

In 1962 there was a dramatic c ha nge in the tuber­

culosis situation. The patients from Prospect Hospital

were transferred to the New King George VI Memorial Chest

wing in March. This unit was attached to the Princess

Margaret Hospital and had a total of 150 beds. There were

also an x-ray depa rtment and a chest cl i nic. A new chest

specialist, Dr Richard Cory, from Jamaica was responsible

for the tuberculosis patients.

The male wards consisted of three sections, one with

25 beds and two with 17 beds each. The females also had

three sections, but only two were occupied; the wards

with 25 beds and 17 beds. There we re also 9 single rooms

for private patients. The children•s ward had 23 beds.

The patients were divide d into three categories;

infectious, non-tQfea t iou s ana surgical . A var ie~y of

surgical procedures was performed accord i ng to the need s

of particular patients.

All patients 1er.e given PJ\S INH qnd streptomycin. Chest'

x-rays were done on admission and e very 6 weeks. Sputum

- 21 -

for smear and culture was done at monthly intervals until

there were three consecutive negative specimens. If the

sputum smear was not negative after 6 weeks and there was

no improvement in the chest x-ray, the patient was placed

on second line drugs e.g. thiazina and ethambutal. Due to

the lack of eye and ear specialists, children were not

given ethambutal and st~e~tomycin be cause of the risk of

the side effects caqseq P¥ t hem. p~ti ents were never sent

home early, unless their home environment was investigated

and the reliability for taking their drugs was good.

Unreliable patients were supervised by the District Nurses,

twice per week.

Patients who absconded were sought by the police and

on their return were confined in a special room provided

for that purpose. Mentally retarded patients were sent to

Sandilands Rehabilitation centre as soon as the sputum

became negative, to continue their treatment until they

were fit for discharge. They then returned to the Chest

Clinic for follow-up care.

Family island patients on discharge were given referral

letters to the nurse or District Medical Officer on the

island, who in turn was responsible for refilling prescript­

ions. They returned to Nassau at intervals for follow-up care

- 22 -

at the Chest-Clinic. Discharged patient s in New Providence

were followed up by the Public Health Nurse at the chest

clinic. Her duties included follow-up care, contact tracing

record keeping and supervision of the Clinic.

Mantoux tests a nd x-ra ys were done on all the contacts.

The results were treated as follows:-

1. Those with negative mantoux and x-rays had them

repeated after three months.

2. Those with positive mantoux test and negative

x-rays were placed on prophylactic INAH for one

year, excluding those over 35 years old.

3. Patients with positive mantoux and suspicious

x-rays were admitted for further investigations.

4. All contac t s were followed up for one year then

discharged.

Dr Cory left the Bahamas in 1967, and by 1978 the

position of Chest Specialist had been occupied by four

different physicia~s . Genera l ~y. principles of treatment

and follow up care ~emain~d t~e ~arne .

In 1976 the Chest C~in ic was tr a nsfer red t o the new

Ambulatory care Departm~nt ot th h osvital . Aga i n i n 1976

the medical records departme nt cha nged t heir numbering

system from straight numerical to color coded terminal

(

- 23 -

digits. The notes for the tuberculosis patients were inte­

grated into the general cases records and kept in the Medical

Records Department. Prior to that the tuberculosis cases

records, were kept separately at the Chest Clinic. Since the

patient's transfer, durin~ clinic sessions the community

Health Nurse was assisp~Q by t~e s ta f f from that area.

Since 1978 the unit has been headed by a medical consul­

tant, who has received training in infectious diseases. The

treatment regime of patients was changed and also that of

the contacts.

Hospital medication consisted of INH, etharnbutal and

rifampicin daily as a single dose. During the first week

of admission, sputum specimens were sent on three consecutive

mornings for smear and culture. x-rays were done every four

weeks. Hospital stay normally ranged from 4 to 6 weeks.

The majority of the patients were discharged on INH and

etharnbutal, but the relapsed cases were also given rifampicin.

Discharged patients were given a one week appointment

to the chest clinic, where they were followed up weekly for

one month. Thereafter intervals depended on the patient and

the discretion of the doctors. The patients remained on

treatment for one year, and then were given yearly appoint­

ments for four years before they were discharged from the

clinic.

(

- 24 -

All children who were close contacts were placed on

prophylactic treatment for three months, even if their

mantoux and x-ray were negative. When the mantoux and x-ray

were repeated after three months, if they were both negative

the treatment was discontinued and they were discharged.

Adult patients were also discharged if their repeated in­

vestigations were still negative. contacts who were followed

up had their x-rays repeated after three months and prior to

discharge. The regime from 1978 is still being used today.

In october 1980, a monthly follow-up clinic for tuber­

culosis patients was commenced in Freeport, Grand Bahama,

conducted by the medical consultant from the Princess

Margaret Hospital. All the patients from that island after

discharge from the hospital are followed up there.

In addition to the Princess Margaret Hospital, labo-

ratory and x-ray services are offered at a number of private

centres in New Provictence and Freeport. Limited x-ray facil­

ities are also available privately at Marsh Harbour, Abaco

and at the government health centres in Rock sound, Eleuthera

and Matthew Town, Inagua.

(

- 25 -

BCG vaccination was done on a 11 new born babies at

the Princess Margaret ~ospital from the early sixties,

but was discontinued in May 198l.

In october 1981, a trained ol~nical nurse was trans­

ferred to the Chest clinic to assist the community health

nurse with follow-up care.

- 26 -

CHAPTER 2

RATIONALE, AIM, OBJECTIVES AND METHODS

Rationale for present study

Santon Gilmour in his report of 1945 made several

recommendations for tuberculosis control in the Bahamas,

some of which have been implemented.

His survey appears to have been the last comprehensive

report on tuberculosis in the Bahamas and therefore the

author decided to do this epidemiologival study to find out

what has been the tr e nd of the disease since that time.

Aim of study

The aim of t qe study was to descr~be the epidemiological

features of pulmonar y tuperculosi~ in t h e Ba hamas f rom 1965

to 1981.

objectives of study

The objectives of the study were to:

1. Find out the number of new cas e s of pulmonary

tuberculosis occur ring in the Bahamas during

the study p e riod.

2~ Determine the geographical distribution, age and

sex of these case s.

3. Find out the following chara c teristics of the

cases from 1977 to 1981:-

(

- 2 7 -

(i) Radiolo g ical teatures

(ii) Bacteriologicql features

(iii) Nationality

Methods

This study is descriptive in nature and includes all

the pulmonary tuberculosis patients notified to the public

Health Department in Nassau, Bahamas from 1965 to 1981.

Included also are 17 cases who did not appear on the

Infectious Disease Register at the department but were

obtained from the admission and discharge books from the

chest wards and chest clinic.

For the entire period a total of 1,394 patients were

identified. The survey was done in two sections:-

(i) over the 17 year period, with information

concerning the sex, age, and geographical

location.

(ii) A more in depth study over a five year period

to include the following: initial x-ray result,

results of sputum smear and culture and the

nationality of the cas es.

Data collection

Discussions with the following health personnel were

carried out in order to elicit their support and co­

operation in the exe cution of the study, ~d to obtain

- 28 -

information related to their respective functions:

(i)

{ii)

(iii)

Infectious Disease consultant, Princess Margaret

Hospital.

Nursing Officer in charge of the chest wards

Nursing Of ficer in charge of Chest Clinic

The records used for obtaining the data were:-

1. public Health Department Notifiable Disease

Register

This register contains a record of all the diseases notified

to the Public Health Department of the Bahamas. All of the

data on pulmonary tuberculosis w&s extracted year by year

from this registe~. App~ndi~ + ~h ws t~a various diseases

that are notified.

2. Admissions anq pischarge poo~s of the chest wards

pf the Princess Margaret Hospital. The particulars

recorded in them were:- name, address, age, sex, date of

admission and discharge, smear and culture results, treatment,

final diagnosis and hospital registration numbers. Appendix

2 shows the headings used in the books.

3. The admission and discharge book for the chest

clinic has the same information as the books for the wards.

The chest clinic attendance card was also used. Appendix III

shows the headings used for the Chest clinic book and

~ 29 -

Appendix 4 shows a c opy o f the Ch~s t clin i c at t enda nce

card.

4. The hospital records o f the tuberculosis patients.

These notes are numbered and are kept in the medical records

department after the patients are discharged. The same

notes are used for the return visits to the Chest clinic.

Each tuberculosis patient has a contact folder, within which

are kept the notes of all the contacts investigated. If a

contact became a patient, his hospital records were requested

and his contact sheet placed with his other notes.

Pretesting of data collection methods

As a pre-test prior to the commencement of data

collection, some of the records needed for the survey were

viewed. The researcher had intended to do the study from

1962 - 1981, but unfortunately the notifiable disease

register could only be found for 1965 onwards. In addition

several of the hospital records for the cases from 1962 -

1976 were missing. After discussion with the field super­

visor, it was decided to do a 17 year period, with the

last 5 years in more detail. The last five years were

chosen because it was thought that finding the record for

that period would not be difficult.

(

- 30 -

nata collection sheets

The actual data were collected on work record sheets,

which were drawn up with the necessary columns to achieve

the objectives stated. Appendix 5 shows a sample of the

sheets. The name, sex and address of each case were

taken from the notifiable disease register. The cases

were numbered.

In order to fulfill objective number 3, the researcher

had to obtain the patients records, a total of 266, for

the five year period. The ~egistr. ation ~umber of each

patient had to b e found ~efpre ~ eques ting the notes. This

was done by using the recorps f rom the chest wards and the

clinic as outlined previously. While filling in the

registration numbers, the sputum smear and culture results

were also added when found.

After obtaining the hospital record numbers the notes

were requested from the records department using a special

form provided for that purpose. See Appendix 6 for a copy

of the form.

Number of reported cases

- 31 -

CHAPTER 3

RESULTS

The population consisted of 1394 pulmonary tuberculosis

cases. The highest number of cases reported in any one

year was 140 in 1965 and the lowest 24 in 1978. Since 1965

there was a decline until 1978 when the trend was reversed;

in that in 1979 the number of cases was 56. with 72 and 75

respectively for 1980 and 1981. In 1970 the number was

117 but since then it has been less than 100. (Table 3).

Figure 2 shows the number of reported pulmonary tuberculosis

cases from 1965-1981 in the Bahamas by year. For the 5-year

period 1977 to 1981, out of ·a total of 266 notes, 78 percent

were found and examined.

Geographical distribution

Of the 1,394 cases 956 (69 percent) gave their address

as New Providence and there were 152 cases (11 per cent) from

Grand Bahama. The other islands of significance were:

Andros ( percent, Abaco 3 per cent; Eleuther a and Long Island

2 per cent each. The remaining islands together accounted

for 4 per cent while addresses were not recorded for 4 per

cent of cases.

New Providence contributed as many as 76 per cent of

the cases, in 1966 and as low as ~6 per cent in 196 9.

N ('Y')

M

(!) r-l

~ 8

Year

1965

1966

1967

·1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

Total

1965 to 1981 Reported Cases of Tuberculosis by Island of the Bahamas

Number of Cases by Island

New Grand Long Providence Bahama Andros Abaco Eleuthera Island Others

88 10 7 10 3 8 6 94 9 13 3 3 - 2 94 ~Q 10 6 2 1 4 86 11 6 7 2 1 2 58 15 6 - 1 7 6

77 ll.. 13 1 2 2 4 52 g 6 1 - - 1 57 6 8 - 2 1 6 44 7 4 1 - 1 3 51 4 7 - - - 5 33 '9 2 1 5 - 4 26 13 - 3 - - 1 29 7 2 - - 1 -14 7 - - 1 - -44 4 1 3 2 - 2 55 7 1 6 1 - 2 54 16 1 1 2 - 1

956 154 87 43 26 22 49

."----"

Not Stated Total

8 140

- 124

1 12 8

10 125

10 103

7 117

5 73

4 84

6 66

2 69

- 54

2 45

- 39

2 24

- 56

- 72

- 75

57 1,394

Figure 2.

(

L

e.~i:~2~~i: ~1!~~~~~ ~=:j;~~]~~~:~~~ml~ill~:.t(~~~=4t~~~~~~~J~;~;1:;ri;.~l:~~jt~ =~-- -=--=:::·

- . I

ISE.E. " / w

-- - · ----~-~· -- ·· ·· -· '-'-...........

- 34 -

Grand Bahama had 29 percent in 1976 and 5 percent in 1974.

Andros, which had no cases, in 1976 a nd 1978 had 11 percent

in 1910. Table 3 shows the ge ographical distribution of the

cases.

Age Group

The age group 2P-2 . year (rab le 4) was responsible for

24 percent of the ca ~e ~ . Second to t h at wa s less than 10 years

old with 20 percent and third was the g oup 30-39 with

18 percent. The age groups 40-49 and 50 plus accounted for

12 and 14 percent re spectively. The age group 10-19 was

responsible for the lowe st number of cases, that is 9 percent.

The ages for the remaining 4 percent were not recorded.

Table• 5 shows the reported cases of pulmonary tuberculosis

by age group for the Bahamas from 1965 to 1981.

The less than 10 year old had as high as 32 percent of

the cases in 1972 and as low as 4 percent in 1978. This age

group had the highest range. The age group 10-19 years had

its highest percentage of 15 in 1967 and its lowest 3 in 1970

and 1977. Table 5 and Figure 3 show the p e rcentages of the

reported pulmonary tuberculosis cases by age group for the

Bahamas 1965 to 1981.

Table 4

Year

1965

( 1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

Total

%

- 35 -

Reported Cases o f Pulmonary Tuberculosis by Age Group for the Bahamas

1965 to 1981

Age Group of Cases in Years

under over not 10 10-19 20-29 30-39 40-50 50 stated

25 8 37 20 20 22 8

33 9 28 19 18 16 1

19 19 32 23 16 19 -36 15 23 15 14 12 10

26 12 26 14 5 10 10

32 4 24 23 10 16 8

10 4 21 12 10 11 5

27 5 14 15 11 8 4

8 8 14 14 10 8 4

10 9 9 22 6 11 2

4 7 11 16 7 9 -5 3 14 10 7 5 1

4 1 15 7 7 5 -1 2 3 5 4 9 -

15 4 13 5 10 8 1 '

12 4 21 l-2 9 11 3

6 7 24 20 6 12 -

273 1 21 329 252 170 192 57

20 9 24 18 12 14 4

Total

140

124

128

125

103

117

73

84

66

69

54

45

39

24

56

72

75

1,394

100

- 36 -

Table 5

1965

1966

1967

1968

1969

1970

1971

1972

1973

1974

1975

1976

1977

1978

1979

1980

1981

Percentages o f Repo~ted Pulmon~ry Tuberculosis Cases py Age Group for Bah amas

----------~--~--~~9~6~5~t~.a~l~9~8~1 ________________ __

Percentage Distribution by Age Group (Years)

under over not %

10 10-19 20-29 30-39 40-50 50 stated Total

18 6 26 14 14 16 6 100

27 7 23 15 15 13 1 100

15 15 25 18 13 15 - 100

29 12 18 12 11 10 8 100

25 12 25 14 5 10 10 100

27 3 21 20 9 14 7 100

14 5 29 16 14 15 7 100

32 6 17 18 13 10 5 100

12 12 21 21 15 12 6 100

14 13 13 32 9 16 3 100

7 13 20 30 13 17 - 100

11 7 31 22 16 11 2 100

10 3 39 18 18 13 - 100

4 8 13 21 17 37 - 100

26 7 23 9 18 14 2 100

17 6 29 17 13 15 4 100

8 9 32 27 8 16 - 100

(

E~t~~~~~~~~~;~~~~-e;~~~ ~ :;.,_==!. -=1-- ·;~-- 1-------···- ·-· ....... . :t . . .. +· . ~ .. :K-E:!}.:. ---=+--- ::1-~= ·-· ___,. ·~

BEE W I ..

Table 6

Year

1965

1966

1967

1968

1969

1970

1971

1972

( 1973

1974

1975

1976

1977

1978

1979

1980

1981

Total

- 3 8 -

Reported Pulmonary 'fub~rct+los is Cases by S~x for the aah&mas

1965 to 1981

s E X

Male Female Not Stated

88 52 -

67 57 -

69 59 -

76 47 2

61 41 1

81 32 4

48 24 1

54 30 -

41 23 2

50 19 -

42 12 -

33 12 -

23 16 -

16 8 -

32 24 -

47 25 -

49 26 -

877 507 10

Total

140

124

128

125

103

117

73

84

66

69

54

45

39

24

56

72

75

1,394

(

<•

- 40

Se x

In each year during the study period males out-numbered

fema les. The overal l ratio b eing 7:4. In 1975 it was 7:2

but in 1972 it was almost 1:1.

Table 6 and Figure 4 show the number of reporte d cases

by sex for the Bah ama s.

Radiological resul t s

From 1977 to 1981 there wa s 266 initial x-rays; of

these 227 {85 per c e nt) we re positive , 2 p e r c e nt were

negative and 13 per cent were not found. The percentage

of positives ranged from 77 in 1977 to 93 in 1979. Table 7

shows the initial x-ray result of the patients from 1977

to 1981.

Bacteriological results

A total of 266 sputum specimens we re examined, of the se

reports for 242 {91 per cent) sme ars an d 232 {87 per c e nt)

culture swere locate d. The result of 24 {9 per cent) smears

and 34 {13 per cent) cultures we re not recorded. There wer e

172 {71 per cent) posit ive sme ars and 150 {67 per cent)

positive cultures. The neg1tive smears and cultures were

70 and 82 respect ively, Table 8 s hows the reported cases of

.... _ ...__

Table 7

Year

1977

1978

1979

1980

1981

Total

- 4 1 -

Distribution o f Tube rculos i s Cases by Type o f X-ray Result in t h e Bahamas

1977 to 1981

Initial X-ray Result

Positive Negative Unknown Total

30 0 9 39

22 1 1 24

52 1 3 56

58 0 14 72

65 3 7 75

227 5 34 266

Positive (%)

77

92

93

81

87

85

N ~

CO'

Q)

~I

Reported Cases of Pulmonary Tuberculosis by Sputum Result in the Bahamas, 1977 to 1981

S P U T U M RESULT

SMEAR CULTURE

Year +ve -ve Unknown Total +~e +ve -ve Unknown Total

197 7 29 2 8 39 7 4 21 8 10 39

1978 21 2 1 24 87 12 8 4 24

19 79 33 20 3 56 59 19 32 5 56

19 80 38 26 8 72 53 46 16 10 72

1981 51 20 4 75 68 52 18 5 75

Total 172 70 24 266 65 150 82 34 266

K E Y

+ve = positive

-ve = negative

+~e

54

50

34

64

69 l

56

(

- 43 -

Table 9

Detailed Sputum Results of Reported Cases of Pulmonary Tuberculosis in the Bahamas

1977 to 1981

y E A R

Sputum Results 1977 1978 1979 1980 1981 Total

Smear+ Culture+ 19 11 14 32 37 113

Smear+ Culture- 9 10 19 6 12 56

Smear- Culture+ 2 1 5 14 16 36

Smear- Culture- 1 1 15 13 5 35

Smear+ Culture? - - - - 2 3

Smear?- Culture+ - - - - 1 1

Smear?- Culture? 9 1 3 7 2 22

Total 39 24 .56 72 75 266

K E Y

+ = positive

= negative

? = unknown

%

42. 5

21.1

13.5

13.2

1.1

0.4

8.3

100.1

44 -

pulmonary tuberculosis by sputum result 1n the Baha mas

1977-1981.

For the 5-year period, out of a total of 266 specimens,

113 had positive smear a nd culture 56 had positive smear

only; and 35 had negative sme ar a nd culture . Table 9

shows the detailed sputum result of reported cases of

pulmonary tuberculosis in the Bahama s from 1977 to 1981.

In some cases, although both admissions and discharge

books had both smear and culture recorded as positvie, the

culture report was not placed in the patie nts note s, and

for others no record of the r esult wa s available.

Nationality

For the 5-year period 151 or 57 percent of the cases

were from the Bahamas, 107 or 40 percent were Haitians and

8 or 3 per cent were of other nationality of which 3 were

Turks Islanders, 1 Chine se, l Vietname se, 1 Indian,

1 Jamaican and the nationa l i ty of one was not stated.

The lowest numbe~ o~ f ~itians w9a 2 or 8 percent i n 1978

but went up as high as 5~ p e r cent iD 1980 and 49 percent

in 1981. Table 8 shows the national ity of the reported cases of

pulmonary tuberculosis i n the Bahamas from 1977 - 1981.

Table 10

Year

1977

1978

1979

1980

1981

Total

- 45 -

Nationality of Reported Cases of Pulmopary Tuberculosis in the Bahamas

1977 to 1981

N A T I 0 N A L I T y

Bahamian % Haitian % Other

24 62 15 38 0

21 88 2 8 1

40 71 15 27 1

31 43 38 53 3

35 47 37 49 3

151 56 107 40 8

% Total

0 39

4 24

2 56

4 72

4 75

3 266

..

r

- 4.6 -

CHAPTER 4

DISCUSSION

Limitations of methods

The following are limitations of methods.

1. The Public Health Departme nt notification register

for 1962, 1963 and 1964 could not be located therefore the

. study period was shortened to 17 years.

2. The hospital r e gistration numbe rs for some of the

patients notes were not recorded in the admission and dis­

charge books so their notes could not be requested from the

records department, therefore the necessary in£)~mation was

not available.

3. Members of the records department staff, who were

otherwise engaged wi th heavy work load we re the only personnel

allowed to search for the notes, ~s a result only a limited

number of notes could be requeste d eacn day , therefore the

data collection period was unduly prolonged.

Interpretation of results

The study population consis ted of 1394 cases, of which

17 (1 p~ cent) did not appear on the Public Health Register.

- 47 -

They were later discovered during colle ction of data for

the 5 year period ( ~977 - 1981) fr om the admissions and

discharge books, when a more d e ·tailed study was done.

The hospital notes of these patients were also checked and

the notes did not indicate that they were relapsed c a ses.

The total number for these 5 years was 266. Thus 6.4

percent of cases identified by the Chest Clinic had not

been recorded at the Public Health Department, which is

responsible for reporting to CAREC, the number of cases

of notifiable diseases in the country. It is possible

that these cases were not reported to the Public Health

Department. Alternatively reports may have been prepared

by Tuberculosis Unit, but they had not reached the depart­

ment or had been accidentally omitted from the register.

Notification is done by completion of a specially

printed form (Appendix 7) which is forwarded through the

interdepartmental messenger service.

If the other 12 years were examined more closely also,

the likelihood of finding more or fewer cases, that might

not have been on the register, would have been greater.

If there were more accuracy in record keeping, the 22

percent of the records that could not be found because of

incorrectly written registration rumbers or no number at all,

- 48 -

could have been prevented. Therefore it would appear that

there was insufficient monitoring of the records. Probably

this was due to insufficient staff, whereby routine ward work

had to be given greater priority. The notes which were not

on file at the medical records department, were either still

in the various wards or clinics or had been returned and

were misplaced or misfiled.

The notes that were eventually found after being

requested more than once, were probably returned to the

department.

During the 17 years, the names of 10 cases appeared on

the Infectious Disease ~egister twice. This probably was

due to two separate notifications, or that the person trans­

ferring the information into the register wrote them twice

in error. All patients are admitted to the wards via out­

Patients Department therefore if the case was investigated

by the doctor, he might have been repeated in the case where

private physicians refer tuberculosis patients to the hospital

for treatment.

The Haitian national, who was admitted twice within the

same year and who had used two different names, was probably

recognised by the ward staff and they in turn

- 49 -

requested his first notes and incorporated them with his

second record. Unfortunately they did not make the

necessary adjustment regarding the name . The case was

notified again and they did not inform the Public Health

Department.

There were 57 cases with the age and address missing

and also 10 cases with the sex not stated. The information

for the above was collected from the public Health Register.

They probably were missing either because they were not on

the notification form or they were left out when being

transferred to the register.

Throughout the 17 year period, 69 percent of the cases

gave their addresses as New Providence and second to that

was Grand Bahama with 11 percent. The possible explanations

are:-

1. Nassau the capital of the Bahamas is situated on

New Providence and according to the 1980 census the popula-

tion was 137,437. with a population density of 1692.2 per

square mile, there are definitely over crowding and poor

housing conditions in some areas. such living conditions

are conducive to the spread of tuberculosis.

2. At the time of admission to hospital, although some

of the patients were from the family islands, they

( l

(

- 50 -

probably gave their address as New Providence, where they

were temporarily residing.

3. Freeport, which is the capital of Grand Bahama,

is the nation's second city. In 1980 the i sland had a

population of 33,102, with most of the people living ln or

or near Freeport. There are also some areas of poor

housing as in Nassau, on the outskirts of the city. There-

fore one would expect more cases from those areas. Another

important factor is that both Nassau and Freeport have

diagnostic facilities.

The more developed islands such as Eleuthere, Andros,

Long Island and Abaco had more casep than those less

developed and sparsely pppqlat~d islands (See Table 1 on

Page 3).

There was a decline in the number of reported cases

from 1965 to 1978. However since 1978 there has been an

increase in the incidence (Figure 2). The decline was

effective control programme and an improvement in the

educational and economic conditions.

However the reason for the increase since 1978 is not

so clear, because socio-economic conditions continue to

improve. Prior to 1978 the treatment consisted of INAH,

PAS and Streptomycin. The Streptomycin was given daily for

6 weeks.

> I

j

(

- 51 -

and the others were given three times a day for 2 years.

Moreover the patients were not discharged until they had

three consecutive negative sputum examinations.

ment was the same from 1962 until 1978.

The treat-

In 1978 not only was there a change in doctor, but

also a change in the treatment regime. The medication

consisted of INAH, ethambutal and rifampicin while in

hospital, which was given daily in one dose. sputum speci­

ment were sent during the first week of admission on three

consecutive days. on discharge rifampicin was only given

to relapsed cases, and most of the cases were discharged

after six weeks.

Another aspect worthy of examination is the follow-up

care because it is an important part of the control of tuber-

culosis. Basically from 1962 to 1981 there was only one

nurse responsible for the follow-up care and other duties of

the chest clinic. It was not until october 1981, that the

community nurse at the Clinic was provided with an assistant.

The increase in staff should have been since 1978 when there

was a change in the treatment and the stay in hospital was

shorter, for unreliable patients need close supervision.

It is also very difficult to follow-up Haitians because

they change their address frequen t ly, a nd

(

- 52 -

in most cases the new address is not known. There is also

a language barrier between Haitians and Bahamians because

Haitians speak French and the Bahamians speak English.

The incidence among the Haitian patients admitted to

the chest wards has also increased since 1978. The percent­

age ranged from 8 to 53 for the period 1977 - 1981, with 8

percent recorded for 1978 and 53 percent for 1980. However,

if the Haitians were excluded tnere would still be an

increase in the number of cases.

The Haitians have ~lways been significant users of the

health facilities. ~n l97+ accp+qipg to a survey (Marshall,

1979) done in the carmichael area of New Providence, out of

a total of 71 households, which included 135 adults and 55

children, over 90 percent reported that they attended the

hospital frequently. Haitians are also screened for work

permits, either privately or by the Public Health Departm8nt.

If they attend the public Health Department x-rays and other

tests are done. Therefore there are good opportunities for

tuberculosis cases to be identified among the Haitian

population.

Throughout the Bahamas, most of the Haitians can be

found living in the lower income areas, where there is

overcrowding

( (

- 53 -

and poor housing conditions. rt is also known that some

Haitians return to strenuous work soon after discharge,

due to economic problems. If their diet is also deficient,

added to the fact that they might not be taking their

medication properly, this could lead to relapse, causing

their families to be more at risk. The incidence of pul-

mcnary tuberculosis is probably much higher among the

Haitian nationals than the Bahamians since they constitute

a minority of the total population but contribute up to

50 percent of the cases with this disease.

The age group 20 - 29 year accounted for 24 percent

of the cases, the under 10 year olds (20 percent) and 10 -19

years, (9 percent). usually infants, adolescents and young

adults are the main victims of pulmonary tuberculosis

(Pagel et al). However the results of this study reveal

that adolescents are the least affected.

For the entire period 1965 - 1981 the sex ratio was 7:4

this differed from 1943 when the number of cases was 97 with

47 males and 53 females giving a ratio of 1:1 (Gilmour, 1945).

This suggests that in the Bahamas :for the 17 year period

males were more suscep·t;ible to pult ona ry tuberculosis than

females.

(

- 54 -

The x-ray results showed that 85 percent were positive

for the five year period 1977 - 1981. A positive x-ray is

a film showing tuberculosis cavities, shadows or densities

suggestive of active cases. In the case of primary tuber­

culosis the film shows enlarge hilar glands. For the

sputum, 65 percent of smea1=s and 57 percent of cultures

were positive. This sugge~ts that most of the patients

were being diagnosed at an infectious stage.

Abnormal x-+ay densities inQ~.cative of pulmonary

infiltration and cavitation occur before clinical manifesta-

tion, while localizing symptoms of cough, chest pain etc.

become prominent only in advanced cases. This indicated

therefore that most of the cases were still being diagnosed

at a relatively late stage, just as they were being done in

1945.

There were 36 (14 percent) sputum specimens which were

positive by culture, although the smears were negative.

These cases could have been missed if the laboratory had

been doing only smears.

The study shows that the nationality of the cases was

the best kept record, because out of a total of 266 cases,

there was only one patient whose nationality was not stated.

J

- 55 -

Conclusions:

In conclusion the results show show that there was a

decline from 1965 - 1978 but since then the incidence has

increased. Unfortunately the study could not show the

reasons for the increase.

Recommendations:

since the above study has raised a number of unanswered

questions, another epidemiological study should be carried

out as soon as possible. During that particular study a

structured questionnaire should be used, so that all the

patients or a representative sample could be interviewed.

Information such as living conditions, reliability of taking

drugs, occupation, etc. which may not be recorded in the

notes could then be obtained.

In view of the fact that the majority of the cases are

diagnosed late, this indicates that close contacts have a

greater chance of becoming infected. There is a need to

find new cases earlier. Therefore, case finding programmes

should be incre~sed. f O+ exa~ple, Mant oux surveys and mass

chest x-rays among the under 10 year olds and the age group

20 - 29, since these two age groups accounted for most of

the cases in the study population.

• - 56 -

Record keeping needs to be improv ed in both chest wards

and chest clinics. Presently all cases at the hospital are

being notified from chest Clinic, therefore the clinics

staff would be able to verify easily whether or not a case

was notified by checking the s t u p of tne notification book ,

Since the change i n treatment coincided with the

increase in the incidence, the p r esent treatment regime and

the follow-up care sho~ld be e valuate d.

x-ray facilities are on Eleuthera and Inagua at the

government clinics and privately at Abaco. It would be

advantages if the government would consider the feasibility

of providing partial laboratory services at these islands,

with microscopes and reagents for doing direct smear

examinations.

one of the most important aspects of tuberculosis

control is drug taking. It is imperative that the patients

take the treatment prescribed. Since most of the patients

are discharged after 6 weeks, follow-up care should be

intensified. until 1981 one nurse was responsible for the

investigations and follow-up care. In order to improve this

situation there are two possibilities; either to increase

the staff at the chest clinic or to assign the follow-up

care to the 4 main clinics in New Prov idence.

I

- 57 -

This study has shown that tuberculosis is still a

problem in the Bahamas. There is a need for a Medical

Officer to deal specifically with tuberculosis cases.

He should be responsible for planning a National control

Programme so that by the year 2000 tuberculosis in the

Bahamas would be under control.

- 58 -

REFERENCES

Annual Medical Reports , Bap amas , 1947 - 1951, 1954 and 1955. Archives Def~'tment , Un ubl ished.

Benenson, A.S. {1980 } c ontrol o f commun i cable dis ease in man. American public Health As sociation, New York, pp • 3 7 2 - 3 7 8 •

caribbean Epidemiology c e ntre (1979) Review o f communicable disease in the car i bbean. caribbean Epidemiology centre, Trinidad.

comostock, G.W. (1980) Tuberculosis. public Health and Preventive Medicine. Last, J.M., Maxcy - Rosenau (eds) Appleton-century-Crofts. New York~ pp. 206-220.

Gilmour, s. Tuberculosis in t he we st I ndies. National Association for the Prevention of Tuberculosis. London. pp. 206 - 220.

Marshall, D. (1979) The Haitian problem - Institute of social and Economic Research. University of the west Indie s, Jamaica. pp. 141 - 194.

Pagel, w. McDonald , Nassau, Simmonds (1964) Pulmonary Tuberculosis. Oxford University Press, London.

Richardson, R.K. (1979) Advanc e s in tuberculosis control. Four decades ·of advance in h ealth in the commonwealth Caribbean: Pan Amer i can Health Organization Scientific Publications No. 383 , pp. 55 · - 64.

World Health Organization (1982) Tube rculos i s profile, world Health organization, Jan: pp. 8 - 9.

styblo, K. (1982) The number of cases o f tuberculosis throughout the world ha s increas e d over the last 30 years. Defeat TB now and f or ever. world Health Organization, Geneva.

- 59 -

zahra, A. (1980) world Health organization's communicable disease programme. communicable diseases. world Health organization Geneve. November.