Aspects of tuberculosis control: community based case-finding in a Kenyan rural location

Abstract

Tuberculosis control measures are time-honoured. They are:- Case-finding plus Chemotherapy, BCG Immunization, Chemoprophylaxis and Health Education. Of these measures, the most effective in reducing the disease incidence and prevalence is Case-finding plus Chemotherapy. Despite availability of the knowledge of tuberculosis control "tools", the disease is still a major public health problem especially in developing countries. Only about a third of the actual cases in the communities are diagnosed and treated, rather late, in most less advanced nations. In Kenya, the most commonly used tuberculosis casefinding method is passive screening of symptomatic persons presenting themselves mainly at the hospital outpatient departments. Investigations have been done to broaden the scope of case-finding by actively fetching out suspects from communities. These studies, however, yielded disappointing results. This survey aimed at determining BCG coverage among school children, some sociocultural factors that may influence tuberculosis control in a rural community and also the feasibility of using primary school pupils in active case-finding in such a community.

The research was carried out in Koibarak Location, with an approximated population of 9,850, in Elgeyo Marakwet District. The district has an estimated . tuberculosis incidence of 350 per 100,000 population. The investigation was undertaken from November, 1987 to April, 1988 in two phases: Community Elders interview and Primary School visits. A total of 85 elders from the location and 892 upper primary school pupils from all the 14 schools with upper classes, were interviewed. All the elders and 91% of pupils were consciously aware of tuberculosis as a problem. About 97% and 65% of elders and pupils respectively had knowledge of signs and symptoms of the disease. Both elders and pupils displayed knowledge gaps in their understanding of tuberculosis cause, transmission and treatment. A health education programme carried out in the 'atmosphere' of a well understood sociocultural aspects of the people's life related to the disease is expected to fill these gaps. A The study revealetl that a high proportion of respondents knew of traditional methods of treating tuberculosis. The efficacy of these methods need to be studied further and evaluated.

A majority of elders (62.4%) did not feel that tuberculosis patients were dangerous to contacts as opposed to 81% of pupils who felt they were dangerous and preferred their total isolation from healthy persons. This tuberculosis stigma among the respondents demonstrated a statistically significant association with their educational status, but not with their age nor sex. On inspection for BCG Scar, a total of 1376 pupils (37.1%) had no scars. This gave an estimated immunization coverage of about 62.9% among the primary, school children. All those without scars were given BCG vaccination by the field team. Following a tuberculosis health education, the pupils identified 63 suspects out of whom 55 produced sputum for analysis. Confirmed tuberculosis cases by smear were 5, giving a case yield of 9.1%. This method identified over 70% of the estimated smear positive tuberculosis incidence in the location. Although the population studied is small, this method shows great potential for case-finding in Kenya

particularly as a supplement to the passive case-finding approach at health institutions. Further studies on larger communities are however recommended to validate the efficacy of this approach.