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This is to certify that the

thesis entitled

TUBERCULOSIS SCREENING IN CIALES AND MANATI,
PUERTO RICO
presented by

Sonia Arbona

has been accepted towards fulfillment
of the requirements for ‘

Master Geography

degree in

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Mati'rno.‘ c‘f‘nv 4.-

TUBERCULOSIS SCREENING IN
CIALES AND MANATI, PUERTO RICO

BY

Sonia Arbona

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS

Department of Geography
1983

Copyright by
SONIA ARBONA
1983

ABSTRACT

TUBERCULOSIS SCREENING IN
CIALES AND MANATI, PUERTO RICO

BY

Sonia Arbona

This study was conducted to investigate under-
reporting of tuberculosis cases in Ciales and Manati. In
Manati the TB rate reported by the health authorities in
1980 was ten times higher than for Ciales, indicating the
existence of more favorable conditions for the development
of the disease in Manati.

The level of infection in both municipalities was
obtained through a tuberculin screen survey. A total of
fifteen hundred tuberculin tests, Mantoux method, were
administered on the basis of aprOportionete sample by barrio.
The reaction to the test and a number of socio-economic
variables were recorded through a questionnaire completed
for each individual tested.

Some twenty-one percent of the tested persons in
Ciales reacted positively and fifteen percent in Manati.
Only slight differences in socio-economic conditions were
observed. Underreporting was concluded to be a problem for
the control of TB in both Ciales and Manati, but of greater

magnitude in Ciales.

To my parents Carmen and Charles Arbona
for their love and assistance with this
research.

ii

ACKNOWLEDGMENTS

I wish to express my sincere thanks to the Puerto
Rico Department of Health for their interest and c00peration
in this study. Thanks are due to Dr. Jaime Rivera Duefio,
Secretary of Health, and to Dr. Yamil Kouri, Director of
the Center of Communicable Diseases.

I am particularly grateful to the Tuberculosis
Control Program and its director Dr. Arturo Cordova. To
the staff of the tuberculosis clinic in Manati and to
Dr. Ada Martinez, I extend my appreciation.

I would like to thank the members of my committee
for their valuable suggestions, Dr. Robert N. Thomas,
Professor of Geography, and especially Dr. John M. Hunter,
Professor of Geography who provided invaluable assistance
and guidance.

I wish to express my gratitude to Nurse Aida Acevedo
for her technical contribution in the administration of the
test, and to my husband and parents for their encouragement

and support.‘

iii

LIST OF TABLES - .

LIST OF FIGURES - .

INTRODUCTION - - -

Chapter
CLINICAL ASPECTS OF TUBERCULOSIS

I.

II.

III.

IV.

Agent .
Pathology
Symptoms
Treatment

TABLE OF CONTENTS

Tuberculin Testing . . . .
Prevention and Control . .

Epidemiology and Social

HISTORY OF TUBERCULOSIS IN

Factors .

PUERTO RICO

Interviews on Historical Aspects of

Tuberculosis

METHODOLOGY

Problem .
Hypotheses

Methodology . . . . . . . .
Resources and Limitations .

ANALYSIS . .

Tuberculin
Percent of
Tuberculin
Tuberculin
Tuberculin
Tuberculin

Test Reaction by
Reaction Sizes -
Test Reaction by
Test Reaction by
Test Reaction by
Test Reaction by

Urban Location . . . . .
Tuberculin Test Reaction by
Tuberculin Test Reaction by

of Persons Per Room . .

iv

in Ciales and Manati

Age Group .

Occupation

Barrio
Sex .

Rural and

House Type

Number

Vi

Vii

10
12
20
23
27

30

43
52

52
52
54
61

62

62
69
72
84
85

86
91

91

V. CONCLUSIONS AND RECOMMENDATIONS . . . . .

Conclusions . . . . . . . . . . . . .
Recommendations . . . . . . . . . . .

APPENDIX A:

INTERVIEWS ON HISTORICAL ASPECTS OF

TUBERCULOSIS IN CIALES AND MANATI

APPENDIX B:

BIBLIOGRAPHY

QUESTIONNAIRE . . . . . . . . . .

96
96
98
100
134

136

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(I)

10.
ll.
12.
13.
14.
15.
16.
17.
l8.
19.
20.
21.
22.

23.
24.

25.

LIST OF TABLES

Chemotherapy Drugs in Treatment of Tuberculosis
Ciales Population Sample . . . . . . . . . . .
Manati POpulation Sample . . . . . . . . . .
Millimeters of Reaction By Age Group for Ciales
Millimeters of Reaction By Age Group for Manati
Millimeters of Reaction By Age Group Below 20 .
Percentage Distribution of Tuberculin Reactions

By Size 0 O O O I O O I O O D O O O O O 0 O
Tuberculin Positive Reactions By Occupation
for Males . . . . . . . . . . .

Tuberculin Positive Reactions By Occupation

for Females . . . . . . . . . . . . . . . .
Age Distribution of Occupations for Males . . .
Age Distribution of Occupations for Females . .
Distribution of Reactions By Barrios for Ciales
Distribution of Reactions By Barrios for Manati
Reactions Not Read from Ciales . . . . . . . .
Reactions Not Read from Manati . . . . . . . .
Distribution of Reactions By Sex . . . . . . .

Distribution of Reactions By Age Group for Females

Distribution of Reactions By Age Group for Males

Distribution of Reactions By Sectors . . . . .
Distribution of Reactions By Sectors for Ciales
Distribution of Reactions By Sectors for Manati
Distribution of Reaction By House Type for

Ciales and Manati . . . . . . . . . . . . .
Distribution of Flush Toilets By House Type . .
Distribution of Reactions By Density for

Ciales and Manati . . . . . . . . . . . . .
Number of Persons Per Room By Age Groups . . .

vi

15
59
60
65
65
66

71
73

74
75
77
80
81
83
83
87
87
88
88
90
90

92
93

95
95

O

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13.

Puerto Rico Tuberculosis Mortality
Tuberculosis Mortality 1934-1936
Tuberculosis Mortality 1950

LIST OF FIGURES

Tuberculosis Rates 1980 .

Survey Area of Ciales and Manati
Reactions By Age Groups In Ciales
Reactions By Age Groups In Manati

Distribution of Reactions

Names of
Positive
Positive
Positive
Positive

Barrios . . .
Reactions . . . .

and Reported Positive Reactions
Reactions By Age and Sex

Reactions By Zone

vii

0

1920-1950

34
37
42
53
55
63
64
7O
78
79
82
89
89

INTRODUCTION

In Puerto Rico, where tuberculosis was the leading
cause of death during the 1940's, measures taken by the
Department of Health achieved a remarkable reduction in the
prevalence of the disease. It was believed that the disease
was controlled and, for all purposes, eradicated. The
control measures began to weaken and in 1979 mortality and
morbidity statistics revealed an unexpected increase of
tuberculosis in the population.

It was necessary to reorganize the tuberculosis
control program. Tuberculosis clinics for out-patient
treatment were re-structured at different locations
throughout the island. Each clinic had a number of
municipalities assigned as its service area. Tuberculosis
sections in several public hospitals were also created.

The fact that tuberculosis persisted as a public
health problem in Puerto Rico, suggested that a substantial
portion of tuberculosis cases were not being reported and
that there was a need for education of the population
concerning the first symptoms of the disease. Both
problems are related to the quality of the medical services
and their capacity to reach out into the community.

With the reorganization of the tuberculosis program,

adequate treatment has been offered at the clinics. But

to successfully achieve the prime objective of the control
program, to reduce the number of infectious cases, it is
necessary to reach all sectors of the population. The
tuberculosis municipality rates, which are based on the
number of cases detected at the different health facilities,
present a pattern that suggests better reporting exists in
those municipalities where the clinics are located. Higher
rates are reported there.

Underreporting is still a major problem for the
control of the disease. But it seems to be a problem of a
greater magnitude in selected locations, namely the
municipalities without tuberculosis centers. It appears that
reported rates are not accurate since they are a creation
of the health services.

It is the purpose of this study to compare infection
rates in two municipalities where the reported tuberculosis
rates are of a low and of a high degree when compared with
the rest of the island. The municipality with the higher
rate has a tuberculosis clinic; the other has not.

Infection levels will give ani indication of the
magnitude of the transmission process in both communities.
Since standards of living, and density of pOpulation, are
two factors related to the prevalence of tuberculosis,
variables that serve as indexes of those two factors were

included in the analysis.

The principal objective of this study is to serve
as an indicator of the need for better reporting of
tuberculosis cases and to point out where the need is the
greatest. It is expected that this study will contribute
to the process of identification of the problems interfering
in the effective control of tuberculosis in Puerto Rico.

The whole population on the island will benefit from this.

CHAPTER I

CLINICAL ASPECTS OF TUBERCULOSIS

Agent

The most common agent of tuberculosis is the
bacillus Mycobacterium tuberculosis. The microbial family
of the Mycobacteria includes many microorganism with
certain common properties: they are all acid fast,
obligate aerobes, and all of them grow and metabolize
rather slowly. Mycobacteria bovis can also cause the
disease, but bovine tuberculous infections of the
digestive system have been largely controlled since the
advent of pasteurization of milk and the inspection of
dairy herds. As far as human beings are concerned,
M. tuberculosis is the most important of the mycobacterial

pathogens (Wyngaarden and Lloyd, 1982).

Pathology

 

The infection process is usually initiated by
inhalation of the bacilli in airborne droplet nuclei from
sputum of infected persons. The inhaled bacillus may
multiply or it may be eliminated by alveolar macrophages
before it is detectable by radiograph.

M. tuberculosis can produce infection and disease

in almost every tissue and organ of the body, but the most

common focus is the lung where the tubercle bacillus
multiplies most rapidly (Fishman, 1980). When infection
with M. tuberculosis takes place in a person who has had
no previous experience with the tubercle bacillus, it

is referred to as primary infection. At this point,
resolution of the disease may take place to such a

point that little or no residue of the infection will
remain. The affected individual will become tuberculin
positive, but with no further clinical significance.

Secondary tuberculosis or reinfection occurs as
a result of recrudescence of an old infection from an
active case, in those who have been previously infected.
Nutritional status, mental and physical stress, and
exhaustion modify the course of tuberculosis. Any factor
that lowers resistance to infection will promote the
development of tuberculosis disease in previously infected
people (Youmans, 1979).

Basically, there are two ways in which pulmonary
tuberculosis may have its origin: the exacerbation of an
old focus already present in the lungs, or the development
of a new disease process independent of the old. Pulmonary
tuberculosis begins as a small patch of pneumonia surrounding
a growing bacterial colony. Intense inflammation may
progress to caseous necrosis derived from tubercle bacilli
and dead cells. No connective tissue is found in the
caseous area. In time, caseous foci may calcify or even

ossify. Bacilli may grow in solid caseous areas, but are

generally inhibited by a low oxygen tension. More often
the bacilli grow intracellularly in the live young
macrophages of the surrounding tuberculous granulation
tissue. When uncontrolled, such bacillary growth results
in an extension of the caseous necrosis (Wehrle and Top,
1981).

Tuberculosis is defined as a local disease in the
sense that each lesion is handled by the host as if the
other lesions do not exist. Thus lesions in one area of
the lung may progress, while lesions in another area may
stabilize or even regress. Even parts of a single
lesion may progress, while other parts remain stable.

The disease as a whole often fluctuates between periods of
exacerbation and remission.

There are different types of tuberculous lesions
and diseases. The first type of lesion that can be seen
on the chest radiograph is the encapsulated caseous or
calcified nodule. The nodule usually remains inactive
for the life of the patient. In the proliferative type
of lesion, connective tissue contributes to its compact,
nature. Proliferative lesions may become chronic,
with some areas undergoing fibrosis. In the exudative
type, lesions are either small, or small to large areas of
tuberculous pneumonia. Caseous necrosis is common.
Proliferative and exudative may occur concurrently in
different parts of the lungs. The lesions can be limited

or extensive in scope and sometimes change from one

7
predominant form to the other. In miliary tuberculosis,
many small tubercles of uniform size occur simultaneously
in the lungs.

Caseous necrosis may liquefy when it is discharged
into the bronchial tree. This process is responsible
both for the spread of the disease and for infection of
others (Wehrle and Top, l98l).

By coughing, the patient aerolizes the infectious
material and disseminates it via the bronchial tree into
various parts of the lung and to the outside world. A
cavity varying in size from five millimeters to almost
the size of the lung is formed when a caseous focus is
evacuated into the air passages.

Tuberculosis cavitation constitutes a dominant
event in progressive pulmonary tuberculosis. These lesions
may never heal during the lifetime of the patient. They
may enlarge or shrink or may remain in a more or less
stable condition. A healed cavity, like a healed caseous
focus, is seldom completely free of tubercle-bacilli,
which may persist for years, frequently in a dormant state.
In the era previous to chemotherapy, closure of a cavity
was often done by one of the forms of collapse therapy.

Progression in tuberculous lesions can be slow or
rapid. The most common type of progressive tuberculosis
in adults consists of slowly progressing caseous foci and/
or cavities. Progression is intermittent. The advancing

edge consists of fresh tubercles and of alveoli containing

8

fresh and organizing pneumonia. Satellite lesions are
frequent and cavitation and extension via the bronchial
passages are not rare (Fishman, 1980).

In most infections the clinical manifestations of
tuberculosis depend on the age of the infected individual.
The combination of disease in the pulmonary parenchyma
and in regional lymph nodes occurs more consistently and
prominently in children than in adults. In the primary
tuberculous infection of the child, pulmonary parenchymal
involvement is sometimes quite insignificant by clinical
or radiological examination, while disease of the lymph
nodes that drain the infected area is massive. Many
complications of tuberculosis in the child result from
local or distant spread of disease of the lymph node
foci. In contrast, disease of the lymph nodes in primary
infection in the adult is often so small and inapparent
that it cannot be recognized clinically.

The site of tuberculosis in the lungs is different
between children and adults. In the child the initial
lesion can occur in any part of the lung, but most commonly
in the anterior and basal segments. In the adult, even
when infection is recent, the initial lesion usually
affects the upper and posterior segments.

Extrapulmonary tuberculosis. The clinical
manifestations of extrapulmonary tuberculosis may become

apparent after long periods of quiescence. The most common

forms of extrapulmonary tuberculosis are in lymph nodes,

9

pleura, genitourinary tract, and bone. Certain organs,
such as skeletal muscles, the pancreas, thyroid gland,
brain, stomach, and heart, are rarely the site of
tuberculous infection. Acute miliary, meningeal,
pericardial, and peritonial tuberculosis are also less
common.

Tubercle bacilli reach extrapulmonary organs by
at least three routes. First, in advanced pulmonary
tuberculosis, secretions containing large numbers of
tubercle bacilli can be carried to any of the organs that
connect with the lung by canalicular passages.
Tuberculosis of the larynx, oral cavity, tongue, middle
ear, ileocecal region and rectum are infections that occur
in this way. Tuberculosis in any of these sites almost
never occurs except as complication of advanced, active
pulmonary tuberculosis. Secondly, tuberculosis also occurs
by extension from an adjacent structure. Tuberculosis
extending from the lung to the pleura, from the cerebral
cortex to the meninges, from the fallopian tubes to the
peritoneum, and from lymph nodes to the pericardium,
are examples of this type of spread. Thirdly, dissemina—
tion of tubercle bacilli by the bloodstream or lymphatics
to distant organs results from the invasion of blood
vessels or lymphatics in the lung or some other tuberculous
organ. Tuberculosis of lymph nodes, bone, kidney,
fallopian tube, and brain come about in this way (Pfuetze

and Radner, 1966).

10

The clinical manifestations of tuberculosis in
these diverse organs vary considerably. Although systemic
manifestations in the form of fever, weight loss, and
malaise are common to tuberculosis infection in any of
these organs, the occurrence and severity of any particular
symptom depends on the acuteness of the infection, the
amount of tissue involved, and immunologic factors.

As in the lung, extrapulmonary tuberculosis responds
to chemotherapy: inflammation promptly subsides, and if
chemotherapy is prolonged, complete healing ensues (Wehrle

and Top, 1981).

Symptoms

In chronic pulmonary tuberculosis, constitutional
symptoms usually begin unnoticed and progress slowly.
Some patients with pulmonary tuberculosis are asymptomatic.
In others symptoms are predominantly systemic, or are
attributable to concurrent tuberculosis infection of an
extrapulmonary organ, or some combination of these
(Youmans, 1979).

I Once the disease becomes symptomatic, the principal
manifestation arises from the destructive and inflammatory
. process in the pulmonary parenchyma. Cough and production
of sputum are the most common local symptoms. The gross
appearance of the sputum varies greatly and is in no way
diagnostic.

Minor blood spotting is a common occurrence in

11

patients who have more than minimal disease. Life-
threatening hemorrhage is unusual in pulmonary tuberculosis;
it does occur occasionally in the untreated patient with
extensive cavitary disease. Once effective chemotherapy

is started, the likelihood of a large hemorrhage decreases,
and is quite rare after a month of therapy. Chest pain

is a signal that pulmonary tuberculosis has caused a
localized pleural inflammation. The pain is usually sharp,
aggravated by deep breathing and other respiratory motions,
and is relieved by body postures that limit motion of the
painful area (Fishman, 1980).

Fever, night sweats, weight loss, anorexia, and
fatigue are common constitutional manifestations in advanced
tuberculosis. Fever does not usually appear until the
disease is extensive and is largely exudative. As in other
infections, the temperature of the tuberculous patient
varies diurnally: it is usually low or normal in the
morning, rises gradually during the day, and reaches its
peak in the late afternoon and evening. At-night the fever
falls and is often accompanied by a striking diaphoresis,
the night sweat of advanced tuberculosis. In cases of
untreated pulmonary tuberculosis several months of daily
fever often precedes death.

Shortness of breath is an unusual symptom in
pulmonary tuberculosis, unless the disease is very
extensive or is complicated by other problems (Wyngaarden

and Lloyd, 1982). Accurate diagnosis of tuberculosis

12

disease depends on bacteriologic examination, tuberculin

testing and roentgenographic findings.

Treatment

 

In the past, much of the treatment of tuberculosis
consisted of domiciliary care because the disease was
usually so advanced that no other available treatment
was indicated (Myers, 1951). The early concepts of treatment
were empiric and, in general, based upon efforts to enhance
host immunity by means of better nutrition and physical
rest. Isolation of patients came to play a significant
role in an effort to prevent further transmission of the
disease. The outcome of this conception was the development
of specialized tuberculosis institutions or sanatoria.
In addition to serving as isolation centers, the sanatoria
became highly specialized medical and surgical hospitals.
Collapse therapy, accompanied by prolonged bed rest was
the most common treatment in pulmonary tuberculosis
(Youmans, 1979). The closure of tuberculosis cavities
in the lung, when attainable, greatly accelerated the
healing process. Since the advent of chemotherapy,
surgery is rarely used in the treatment of pulmonary
tuberculosis, however, it may be required in some special
cases such as in massive hemoptysis (Pfuetze and Radner,
1966).

Once highly effective chemotherapy became

available for the treatment of tuberculosis, the role of

13
patient became increasingly important. Prolonged
hospitalization no longer was necessary, and outpatient
chemotherapy became very important. Two major factors
determine whether chemotherapy will be successful:
1) provision of an adequate drug regime for the particular
patient, and 2) the reliability with which the patient
takes the medication.

Chemotherapy is an antimicrobial treatment. Its
effect is judged by the sterilization of lesions and the
elimination of bacilli from the sputum (Fishman, 1980).

As a rule, regimes should contain a combination of two

or more drugs, particularly in the initial phase of
treatment, otherwise failure due to the emergence of drug
resistance is likely to result. In the early days of
chemotherapy, patients were treated with one drug, and,

if that failed, further drugs were successively substituted
one at a time, with the result that these people eventually
became chronic patients with organisms resistant to all

the drugs they had received (Toman, 1979).

Drug resistance. Large bacterial populations
contain a small proportion of organisms that are not
susceptible to a particular drug. While the susceptible
bacterial organisms are killed by the drug, the nonsus-
ceptible organisms survive, and they multiply and replace
the susceptible organisms.

Drug resistance due to incorrect chemotherapy is

called secondary drug resistance. Primary drug resistance

14

is caused by infection of drug resistant organisms from
another patient.

The success or failure of chemotherapy is dictated
by the results of the first ninety days of treatment.

Some ninety percent of patients should be culture-

negative by the nineteenth day. Treatment of any patient
who continues to excrete viable tubercle bacilli 120 days
after the initiation of antituberculosis chemotherapy must
be considered a potential and probable failure, and evidence
should be sought for emerging drug resistance.

For years, drug resistance in previously untreated
patients has remained at a low level in the United States
and Great Britain (approximately two percent for INH
and SM and substantially less for RIF, see Table 1),
somewhat higher in continental Europe, and still higher in
Asia, Africa, and South America. Recently much higher
percentages of primary resistance have been demonstrated
in Oriental and Hispanic immigrants, and in areas with
large numbers of such persons, as well as in selected
major urban centers in the United States. As high as ten
percent primary resistance to either INH or SM has been
documented. Primary resistance to RIF and EMB remains
less than 0.5 percent (Toman, 1979).

Antituberculosis drugs. Antituberculosis drugs
of proven excellence with minimal and controllable side
effects are often referred to as first-line drugs. These

include isoniazid, ethambutol, rifampin, and streptomicin,

15

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18

listed in order of desirability. The second-line drugs
have inferior potency, are less acceptable to patients,
or are prone to produce dangerous or undesirable side
effects, when compared with the first-line drugs.

Second-line drugs are indicated for retreatment
or relapsing TB, or for initial failure when the infecting
strain is not sensitive to at least two first-line drugs.
These include aminosalicylic acid (PAS), pyrazinamide,
cyclocerine, ethionamide, capreomycin, viomycin, thiaceta-
zone, and kanamycin (Youmans, 1979).

However it has been said that these drugs should
not be categorized as major or minor, primary or secondary,
or first-line or second-line drugs, since their use in
any specific patient should be for major and primary
purposes. Thus, if any drug is selected, its efficacy
becomes major in terms of its antibacterial role, and
its impact is of paramount importance even though it may
be one of the less used antituberculosis agents (Fishman,
1980).

Effective drug therapy requires the administration
of appropriate drugs in sufficient doses for adequate
periods. The most appropriate therapy for a given
patient will be determined by the extent of the patient's
disease, the likelihood that drug resistant organisms are
present, social and medical problems that might complicate
therapy do not exist, and the nature of the drugs themselves

(Wehrle and Top, 1981).

19

All the effective antituberculosis drugs have one
feature in common: they interfere with essential metabolic
activities within tubercle bacilli in one way or another.
In consequence, their antituberculosis efficacy is related
to the fact that these drugs are effective only against
actively metabolizing tubercle bacilli, and have no
significant inhibitory or adverse action against nonmetab-
olizing bacterial cells. This characteristic is crucial
in tuberculosis since at any single point in time, many
of the tubercle bacilli present in tissue are in a resting
state and thus not responsive to the drugs. Therefore,
for antituberculosis chemotherapy to be effective it
must be sufficiently prolonged to ensure drug concentrations
that will destroy tubercle bacilli when they become
metabolically active (Fishman, 1980).

The currently preferred treatment is a program of
eighteen to twenty-four months administration of isoniazid
and ethambutol, which has a high degree of efficacy.
Unfortunately, the long duration of treatment has created
other problems such as poor patient compliance, high costs,
and logistic difficulties in delivery of services. These
problems are especially severe in developing countries.
This situation has provided the incentive for the study of
drug regimes that might permit shorter durations of
treatment and still produce high rates of cure.

Short course chemotherapy. It is not yet clear

whether a total of one year or only six months of treatment

20

will yield results comparable to the traditional two—years
regime. INH, 300mg, plus RIF, 600mg, daily by mouth on an
empty stomach for nine months is the recommended short-
course regime. EMB, 15mg per kilogram of body weight, or
SM, one gram, has often been added as a third drug during
the early stages of treatment. The advantage of the

third drug in this combination is to make allowances for
the possibility that the infecting organism is resistant
to one or the other of the major drugs while awaiting
sensitivity studies.

In order to allow for some lapses of self—admin-
istration of drugs, a twelve—month treatment course might
be safer. An intermittent schedule following two months
of initial daily therapy has proved equally effective

over the same duration of treatment (Fishman, 1980).

Tuberculin Testing

 

The tuberculin skin test has been considered the
most important tool for modern epidemiologic studies.
Tuberculin skin testing can be accomplished by a variety
of methods. The most commonly used technique, described
by Mantoux involves the administration of an intradermal
test that requires a syringe and needle thereby permitting
an exact dose of PPD (Purified Protein Derivative) and a
measurable reaction to be obtained. The standard dose is
0.1 m1 of PPD which is equivalent to S TU (Tuberculin
Units). This dosage is commonly designated as intermediate

strength PPD. The injection is made into the skin of the

21
volar surface of the forearm using a calibrated tuberculin
syringe and a 26 or 27 gauge needle, preferably with
a chisel edge. The site of injection should be identifiable
as a raised bleb; if not, the antigen has been injected
subcutaneously, and the test cannot be interpreted. The
reaction is recorded as diameter of the area of increased
skin thickness (induration) at the site of injection 48 to
72 hours later. While this diameter often corresponds
to the zone of erythema, it may not do so. Erythema per
se does not constitute a positive reaction. Interpretation
of the diameter of the area of induration is generally as
follows:

10 mm or more - positive reaction

9 to 5 mm - doubtful reaction
4 to 0 mm - negative reaction

There are several multiple puncture tests such as
the Heaf test, the Sterneedle test, and the Tine test which
are simple, more convenient, and less frightening to
children. However, all but large or vesiculated positive
reactions must be verified with the more reliable Mantoux
method.

The tuberculin skin test has limited value in
diagnosing tuberculosis. A positive reaction indicates that
a mycobacterium, most probably M. tuberculosis or M. bovis,
has replicated in the tissues of the individual at some time,
but it does not tell whether an active disease state is

present. Sensitivity develOps in two to ten weeks after

22
initial infection with the bacteria.

In children and young adults with a known recent
exposure, a positive skin test has considerable diagnostic
significance. A doubtful reaction raises the possibility
that mycobacteria have replicated in the body, but the small
reaction may be due to infection with one or several
mycobacteria other than M tuberculosis. Cross reactions
from infection with other mycobacteria are often indistin-
guishable from specific reactions due to infection from M.
tuberculosis. However a negative second-strength tuberculin
reaction is strong evidence against an infection with M.
tuberculosis and tends to exclude tuberculosis (American
Lung Association, 1981).

In diseased persons the tuberculin reaction may
be falsely negative. Rubeola, infectious mononucleosis,
mycoplasma, pneumonia, and influenza may depress the
tuberculin reaction. Live rubeola, rubella, and polio-
myelitis vaccines may also convert a tuberculin reaction
to negative temporarily.

The tuberculin test may be used as a diagnostic
aid to detect tuberculosis infection and to determine the
prevalence of infection in groups of people. Furthermore,
patterns of reaction to the test are useful in establishing
priorities for follow-up and preventive therapy with
isoniazid. Studies from many parts of the world have
shown that, generally, the larger the tuberculin reaction,

the greater the risk of developing tuberculosis (American

23

Lung Association, 1981).

Tuberculin testing can sometimes be of great
epidemiologic value in planning programs for community
control of tuberculosis by identifying areas of high
prevalence of infection, and by disclosing potential
cases. Periodic testing in selected high incidence
areas is the best measure of trends of tuberculosis
infection, and is thus a useful technique for monitoring

the effectiveness of the control program (Youmans, 1979).

Prevention and Control

 

The prevention of tuberculosis involves one set
of measures to prevent initial infection and another to
prevent the development of progressive disease in people
who are already infected.

Initial infection arises from breathing air
contaminated with tubercle bacilli by a contagious case.
An approach to the prevention of initial infection is to
disinfect the air with ultraviolet radiation in places
which are likely to be frequented by people with active
tuberculosis. This approach is highly desirable in hos-
pitals where tuberculosis patients are more likely to be
found and where other patients with low resistance to
infection share the same confined atmosphere. Since air
disinfection offers protection only in sites equipped with
ultraviolet devices, it can only be recommended for high
risk areas and is not feasible for widespread application

in the community.

24

The ideal plan for control of tuberculosis prevents
the development of old infection into disease, or discovers
each new case before transmission of infection can occur.
If even the latter could be accomplished, in most cases,
the decline in tuberculosis morbidity would be accelerated.
In actuality, two-thirds of new cases are not discovered
until the patient seeks medical attention (Fishman, 1980).

Models for case-finding has been sought which take
into account cost and productivity. The most effective
technique presently used is skin testing of household
contacts of newly diagnosed cases, where ten to twenty
percent may be newly infected, and one to two percent show
clinical disease (Fishman, 1980). Routine chest radiographs
of persons who are hospitalized or seen in a health care
facility are productive. Especial attention should be
given to older persons since they are at a higher risk
of developing tuberculosis. Persons with a history of
tuberculosis which was never treated with isoniazid, and
tuberculin reactors who have upper lobe scarring, compatible
with healed tuberculosis both have a risk of developing
tuberculosis of about one percent per year..

Yearly tuberculin skin testing of nonreactors
working with sick and older persons, such as hospital and
nursing home personnel and welfare workers, is useful and
cost-effective, if preventive therapy is given to persons

showing new infections.

25

Vaccination. BCG vaccine (Bacillus Calmette-
Guerin) has been used since 1921 to promote resistance
to tuberculosis infection. The vaccine produces between
twenty to eighty percent protection in groups at high risk
to develop tuberculosis, but at the cost of development
tuberculin positivity, sacrificing the most important
indicator that infection has occurred. BCG is also of
benefit in that vaccinated persons who do develop tuber-
culosis have less progressive disease.

Many authorities advise the use of BCG in tuberculin
negative children in areas in which twenty percent or more
of secondary school children are tuberculin positive.
Vaccination may also be appropriate for missionary or
government personnel assigned to areas of known high
prevalence, in groups of health professionals with high
(over twenty percent) incidence of infection, and in
some military personnel (Wyngaarden and Lloyd, 1982).

Chemoprophylaxis. Agents that had proved effective
in treating tuberculosis have been applied to the prevention
of tuberculosis infection and disease. The only drug which
has been carefully evaluated with respect to preventive
therapy is isoniazid. In all the trials of preventive
therapy isoniazid has been given for twelve months.
However, the possibility has been raiSed that a shorter
duration of treatment might be equally effective.

Isoniazid hepatoxicity has led to misgivings about

‘

the wisdom of using isoniazid for the preventive therapy

26

of tuberculosis. In contrast to the original practice

of recommending that all tuberculin reactors receive
isoniazid chemoprophylaxis, the current recommendations
are more limited. It is only used for persons with
documented new infection, for household contacts of

newly diagnosed infectious cases, and for tuberculin
reactors who have not been treated for tuberculosis and
whose chest radiographs show lesions in the upper lobes,
suggestive of tuberculosis disease (Wehrle and Top, 1981).
Because of the low risk of hepatitis below middle age and
because individuals with strongly positive tuberculin
tests have a cumulative risk of developing tuberculosis
during their lifetime, which approaches ten percent,
preventive therapy should be offered to tuberculin reactors
under age 35. Preventive therapy should not be considered
in tuberculin reactors over 35 unless they have other risk
factors, such as documented new infection or a chest lesion
suggestive of tuberculosis. This recommendation is made
not only because of the high mortality rate for hepatitis
when it does occur, but also because the life expectancy
of these individuals is less, and thus their cumulative
risk of developing tuberculosis is lower.

When preventive therapy is used, the precautions
recommended by the American Thoracic Society should be
followed: monthly monitoring for drug toxicity, and prompt
investigation of symptoms or signs suggesting hepatitis.

When hepatitis is detected, isoniazid must be discontinued

27

at once.

The principle involved in the use of a drug such
as isoniazid is exactly the same as the principle involved
in the use of a vaccine such as BCG for prevention. The
aim in both cases is to raise the average level of
resistance of the population at risk to the development of

tuberculosis disease (Youmans, 1979).

Epidemiology and Social Factors

 

In some areas of the world, bovine tuberculosis
remains a problem and infection by ingestion of infected
milk occurs. In western countries, infection is almost
always initiated by inhalation of the dried residues of
droplets aerolized by coughing, which may remain suspended
in air for prolonged periods, and are sufficiently small
to reach terminal air passages where removal is difficult
and bacterial multiplication can begin. The overwhelmingly
most significant source of infection is the person with
active pulmonary tuberculosis prior to diagnosis and
initiation of treatment. The closer the contact and the
younger the age, the greater the risk. Studied epidemics
in closed environments indicate that one person with
active disease may contaminate the environment with
droplet nuclei and infect virtually all susceptibles in
the same environment, even in the temporary absence of
the person himself (Fishman, 1980).

The level of urbanization probably influences

tuberculosis mortality and morbidity more than any other

28

single factor, except for the inherent feature of selection
of persons with increased natural resistance. Industrial-
ization and urbanization increase the opportunity for
transmission due to crowded living conditions. The urban
focality of tuberculosis continues today, so that in the
United States the highest rates are found in the ghetto
areas of large cities where there is crowding of the poor
and ill-nourished, with the elderly who often harbor dormant
infection and may sporadically develop clinical and infec-
tious tuberculosis (Fishman, 1980).

The inverse relationship between socioeconomic
status and tuberculosis mortality has been clearly
demonstrated. For persons under age thirty-five living
in large cities, tuberculosis mortality in both sexes
is three times higher in the lowest compared to the
highest economic group. This difference increases for
males over thirty-five, where the ratio may reach 6:1
(Fishman, 1980). Of importance is the recognition that
it is people of low socioeconomic status who develop the
disease, suggesting that crowded conditions experienced
by the urbanized poor are an important factor. Poor
nutrition probably has less effect, since in experimental
animals, nutritional deficiencies must be extreme to
reduce resistance to infection. Racial differences,
particularly in urban ghettos, have been offered as an
additional reason for the increased risk observed in

cities and in economically deprived groups, but there are

29
no data to show clearly that there is any racial
susceptibility to tuberculosis (Fishman, 1980). Other
persons at increased risk are those with diabetes mellitus,
chronic medical illness associated with debilitated
states such as chronic rheumatoid arthritis, postgastrec-
tomy status, and cancer, persons with silicosis, and those

receiving immunosuppresive drugs (Weg, 1978).

CHAPTER II

HISTORY OF TUBERCULOSIS

IN PUERTO RICO

Tuberculosis was probably brought to America by
the European colonizers. The history of Puerto Rico has
references to the disease since the beginning of the Spanish
colonization in the 16th century. It reached epidemic
levels especially among the Indians, and later among
Africans, two population groups that had scarcely any prior
contact with the bacilli (Rodriguez, Morales, Payne, 1935).
In 1875, a report by Dr. Enrique Dumont describes
tuberculosis as "certainly progressive in the island of
Puerto Rico," (Padro, 1955). But in the 20th century
some studies began to report morbidity and mortality rates
of TB in Puerto Rico. From October 1922 to April 1923,
Dr. J. G. Townsend, a surgeon of the U. S. Public Health
Service, carried out a tuberculosis survey in Puerto Rico.
The objectives of the survey were: 1) to determine the
number of active cases on the Island, their distribution
and location, 2) to investigate the factors responsible
for the propagation and spread of tuberculosis and,
3) to ascertain the most practical means of combating

tuberculosis in the Island. Dr. Townsend reached the

30

31

following conclusions: 1) accurate estimation of morbidity
was impossible, because of universal failure to report
cases, 2) death records were of value, as permits were
required for burial; but, it was estimated that sixty
percent of the deaths due to tuberculosis were not so
recorded; and, 3) the total death rate in Puerto Rico
appeared to be nearly twice that of the United States,
while the TB rate in ratio to the general population
appeared about the same. Its distribution was not uniform,
varying with towns and districts (Townsend, 1923).

Townsend reported pulmonary tuberculosis to be
the predominant type, with bone, joint and gland
tuberculosis rare. The rate seemed low in children,
first infections apparently not developing until early
adult years. Townsend considered predisposing factors
as: 1) poor housing conditions, with crowding of large
families, 2) exclusion of fresh air at night, 3) malnutri-
tion, 4) bad industrial conditions, leading to spread of
infection, especially in the tobacco industry, 5) poverty,
6) ignorance of the simplest sanitary precautions, 7) other
diseases, especially hookworm, malaria and venereal
diseases and finally, 8) lack of clinics, social service
work and hospitals for tuberculous patients (Rodriguez
and Janer, 1952).

During the time of Townsend's survey the economic
conditions for a large proportion of the population of

Puerto Rico, were such as to facilitate the development of

32
diseases caused directly or indirectly by poor nutrition.

Laborers were poorly paid and had difficulty finding full-
time employment. This situation created overcrowded
housing and lack of proper diet, both predisposing causes
of tuberculosis (Rodriguez and Janer, 1952). After the
First World War, internal migration from rural areas to
towns and cities, as well as unemployment and under-
employment, created slums in practically every town on the
Island. In these slums, families were large, standards

of living low, and the opportunity for the spread of
contagious diseases great.

The tuberculosis mortality statistics from 1923
to 1928, showed that the number of deaths from tuberculosis
occurring among females was one and a half to two times
greater than the number of deaths among males. This could
be attributed to the indoor life usually led by the woman,
and to the fact that it was the woman of the house who
usually took care of the tuberculous patient, and thus
had the most opportunities for contagion, from personal
contact (Rodriguez and Janer, 1952).

The hurricanes of 1928 and 1932 affected tubercu-
losis mortality of the following years. These two
hurricanes brought about great destruction of dwellings
and crops, increasing overcrowding and poverty, spreading
contagion. The tuberculosis death rate for the year
following the hurricane of 1928 was 19 percent higher than

that of 1927; the mortality for 1933 was 22.5 percent

33
higher than that of the year previous to the hurricane of

1932.

The tuberculosis mortality for 1933 was the
highest ever recorded in Puerto Rico. It constituted
fifteen percent of the total number of deaths on the Island
during that year with a rate of 332.5 deaths per 100,000
inhabitants (Figure 1). In those years many of the Puerto
Ricans who migrated to New York City from the slums
in the Island were heavily infected with tubercle bacilli.
Under the struggle for existence in a strange environment
many of them developed the disease (Rodriguez and Janer,
1952).

In 1935 three tuberculosis surveys were done in
Puerto Rico: a study of a coast and a mountain
municipality; a study of two urban communities; and a
survey of slums in San Juan. The first survey was conducted
in Cataho and Adjuntas, two contrasting municipalities
in relation to location, climate, occupation, overcrowding
and race composition according to the U. S. Census of the
Island. The coast municipality, Catano, with a relatively
large proportion of urban population, had a high tubercu-
losis mortality. The mountain municipality, located in
the center of the Island, with a predominantly rural
population, had a relatively low tuberculosis mortality.
The survey of the two municipalities was undertaken to:

1) estimate the number of tuberculosis cases in two

communities representing different environmental, climatic,

PUERTO RICO TUBERCULOSIS MORTALITY

1920-1950

 

_ p p .
O 0 0 O
5 0 5

p
O

o

3 3 1

250-
200'-
150*

p
O
O
4

mb2<h_m<12. acade— mmm >h_..<._.¢02 m...

Figure 1

After Rodriguez . Janor 1952

35

and racial conditions; 2) to gather data regarding the
extent of tuberculous infection in these communities, as
revealed by the Mantoux test; 3) to determine the factors,
especially those of living conditions, that facilitate
infection in these communities; and, 4) to gain insight
into the causes of the high tuberculosis mortality in
Puerto Rico at that time (Pastor, Morales, and Payne, 1935).

After all variables were considered the most
probable important factors in the causation of the high
tuberculosis mortality and morbidity in Catano as compared
with Adjuntas were the great overcrowding of dwellings,
and nearness to large centers of population where the
tuberculosis incidence was high. The proportion of cases
of TB in relation to the population was 2.4 percent in
Cataho and 1.1 percent in Adjuntas (Pastor, Morales, and
Payne, 1935).\

The second survey was done in two urban zones
inhabited by poor people: Barrio Obrero in San Juan, and
Bayamon. Eight hundred and sixty-six homes were visited
and a tuberculin test applied to each individual. All
subjects reacting positively and many vflm; did not react
had X-ray pictures of the chest taken. The incidence of
pulmonary tuberculosis among the population of the survey
area was 2.3 percent. The survey identified as significant
factors: 1) the conditions of extreme overcrowding and
poverty which prevail among the inhabitants of the

surveyed areas; 2) the widespread infection with M.

36

tuberculosis, as shown by the Mantoux test; 3) the
prevalence of fibro-caseous type of pulmonary tuberculosis;
and, 4) the large proportion of cases with definite
tuberculous infiltrations of the lung extending below the
clavicle (Rodriguez and Morales, 1935).

The third survey included four slums, which were
believed to be the poorest and most crowded of San Juan:

La Perla, a section of Puerta de Tierra, Melilla, Tras
Talleres, and San Ciprian in Santurce, and Shanghai and
San Ciprian in Barrio Obrero. The method used differed
from that used in other surveys in that the regular health
department personnel employed in the area were utilized,
and the work of the survey was carried out without
interference with the routine work. Case-finding and
follow-up disclosed an estimated incidence of one percent,
which is about half the incidence found in other urban
areas by more critical procedures. They concluded that the
methods used gave only partial information in regard to
pulmonary tuberculosis but that they were useful under
conditions where more accurate methods could not be

used (Arruza, Payne and Rodriguez, 1935).

In 1934 the annual deaths from tuberculosis amounted
to more than 3,000 in the larger cities alone (See Figure
2). The total number of beds for tuberculosis patients
in government hospitals was about fourteen hundred. This

number of beds was insufficient, and it was then determined

 

 

TUBERCULOSIS MORTALITY

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38

to operationalize an extensive program for the application
of collapse therapy to ambulatory patients, in order to
prevent the spread of tubercle bacilli by the large

number of active cases who remained at home because of the
lack of sufficient hospital beds. Home isolation was not
effective in preventing the spread of the disease,
however, given the low living standards and overcrowding
among the majority of the people on the Island. The
program started in 1935, while at the same time, an inten-
sive case-finding campaign was launched. Roentgenographic
facilities were made available for free chest examinations
over the Island, physicians were trained in the use of the
fluoroscope, and laboratory facilities for sputum
examinations were increased, and nineteen pneumothorax
clinics were organized. The personnel in these clinics
also carried out an epidemiologic study among the contacts
of the case, testing them with tuberculin and through
photofluorographies or chest X-rays.

The application of artificial pneumothorax in
clinics was the most effective and inexpensive method
known in those days for the control of pulmonary tubercu-
losis. It also helped in the case-finding campaigns
since more people were attracted and were confident in the
kind of treatment given (Garrido and Rodriguez, 1941).

In 1949 a vaccination trial in the Island was
conducted by the Puerto Rico Departments of Health and

Education and the U. S. Public Health Service. The

39

campaign was limited to children and designed to resemble
as closely as possible the mass BCG vaccination campaigns
being conducted at that time in many parts of the world.
The purpose of the trial was to test two main assumptions:
first, that most tuberculosis would arise from recently
infected persons and that BCG vaccination would decrease
their risk of developing the disease and; secondly, that
healthy tuberculin reactors contribute relatively little
to the tuberculosis problem (Comstock, Livesay, and
Woolpert, 1974).

The program started in the poorer parts of the
cities, because tuberculin sensitivity was presumed to
be very high in these areas. A total of 191,827 children
from one to eighteen years of age were included in the
study population. They were divided into three groups:
82,269 of them could not be vaccinated because of positive
reaction to tuberculin; a control group of 27,338 children
who had negative tuberculin reaction and were not
vaccinated; and a group of 50,634 vaccinated with BCG.
The tuberculosis morbidity in all groups was recorded for
twenty years. The frequency of children with reactions
measuring 6mm or more in diameter increased in almost a
linear fashion with age, attaining a level of nearly
seventy-five percent by age eighteen for urban residents.
Among them, 976 cases were estimated to have occurred
without vaccination, 29 percent were nonreactors to

tuberculin and hence were eligible for vaccination.

40

Although vaccination resulted in a twenty-nine percent
reduction in tuberculosis among nonreactors, the overall
reduction in tuberculosis that would have resulted from

a complete vaccination program was less than nine percent.

Questions about the potency of the strains of
BCG used were raised since the results were in contrast
with the high degree of effectiveness reported in other
studies. But even if a vaccine had been highly protective,
it had 1K) significant impact upon morbidity since most of
the cases came from persons who could not have been
vaccinated since they were positive tuberculin reactors
(Comstock, Livesay, and Woolpert, 1974).

The efforts were then directed toward persons
already infected and the contacts of tuberculosis cases.
The isoniazid chemoprophylaxis trials among this group
were satisfactory in terms of reduction of infection,
morbidity and mortality from tuberculosis in Puerto Rico.
Among the contacts who took isoniazid eighty percent of
the time for ten months the reduction in morbidity was
eighty-eight percent during the treatment year and
sixty percent during the subsequent ten years of
follow-up. 0n the basis of these results, beginning in
1959 the Puerto Rico Department of Health adopted
isoniazid chemoprophylaxis instead of BCG as a method of
tuberculosis control (Sifontes, 1961). Isoniazid was
administered to contacts of newly diagnosed cases of

tuberculosis, as well as to people with positive tuberculin

41

reaction of all ages. Today, isoniazid is recommended for
those who have positive tuberculin reactions and are
younger than thirty-five years of age.

Drug treatment for tuberculosis on the Island
started in 1947 with streptomycin and included large
numbers of people by 1952. As a result, the mortality
rate for TB began to decrease markedly (See Figure 3).
In 1952, TB mortality rate was 94 per 100,000, in 1953
it dropped to 47, and Ln1954,ii;was 38. The morbidity
rates for those years were 216, 186, and 152 per 100,000
for 1952, 1953, and 1954 respectively (Rodriguez and
Janer, 1952).

In the 1960's the Island had six tuberculosis
hospitals. Alejandro Ruiz Soler Hospital, located at
Bayamon, provided specialized services to the other
tuberculosis hospitals, such as surgery, autopsy,
obstetrics and pediatrics. Tuberculosis ranked eighth
among the principal causes of death in Puerto Rico
(Puerto Rico Department of Public Health Annual Report,
1969).

In 1971 the Department of Health established a
policy of integrating tuberculosis patients into general
hospitals, and in consequence, most of the sanatoriums
on the Island closed. The Ruiz Soler Hospital was converted
into an area subregional hospital, reserving a section
for individuals with tuberculosis and other pulmonary

illnesses. 131that year the morbidity rate was 29 and the

 

 

TUBERCULOSIS MORTALITY

 

 

 

InmuIIIIIIIIIIII‘IIIIIIIII-

IIIIIIIIIA

 

 

 

   

   

 

 

 

 

43

mortality rate 7.4 per 100,000 (Puerto Rico Department of
Public Health Annual Report, 1972).

The morbidity rate continued declining during the
1970's until 1980 when there was an increase of seventy-
seven percent from the previous year. In 1979 several
factors indicated the existence of a significant
tuberculosis problem: first, eighty percent of the
reported cases had the disease in the advanced stage,
second, approximately thirty percent of the cases were
identified at death and, third, studies made in the
United States that showed high prevalence rates of tuber-
culosis infection among Puerto Ricans in New York also
pointed toward the problem (Cordova, 1979). In 1980
the reported morbidity rate was of 26 per 100,000. This
evidence definitely presents tuberculosis as a cause of
primary concern for the health status of the people of
Puerto Rico.

Interviews on Historical Aspects of
Tuberculosis in Ciales and Manatf

 

 

As in the rest of the Island, Ciales and Manati,
the two municipalities under study, have a history of
tuberculosis. From 1934 to 1936 Manati, the coastal
municipality, had a tuberculosis mortality rate between
300 and 399 per 100,000 inhabitants. Ciales, located in
the mountains and a coffee producer, had a mortality rate
'for the same period years between 100 and 199. During

these years the reported mortality rate for the entire

44

Island was 298. In 1950 a reduction in the tuberculosis
mortality rate in Manati to between 100 and 199 put that
municipality in the same position as Ciales which did not
experience any change. The TB mortality rate for the
Island also declined, and a rate of 128.9 was reported.

That the disease was prevalent and a cause of
concern:h3evident in the fifty interviews made among the
population of those two municipalities. There the memories
of friends and relatives who died victims of tuberculosis
are still fresh and vivid:

Interview #15

Male, 60 years old, resident of Cordillera, Ciales:

I was born in Cordillera and have always lived here.
When I was seven years old my father died of tuber-
culosis. In that neighborhood my family was only
one more affected by the disease.

The population was frightened by the disease and
their inability to deal with it. Misconceptions about the
disease and how it was transmitted also created confusion.
Early symptoms of the disease were not recognized, and were
related to other diseases like bronchitis, influenza, or
pneumonia. As a consequence the tuberculosis cases that
were discovered usually were in the advanced stage which
explains the apparently sudden death of the affected
population by the disease.

Interview #10

Female, 60 years old, resident of Pesas, Ciales:

My brother died suddenly-of tuberculosis when he
was very young. During his sickness nobody in

45

the family suspected he had TB. We believed it
was bronchitis.

Tuberculosis gained the reputation of being an
incurable disease. This image was modified with the intro-
duction of chemotherapy and the subsequent decline in
the mortality rate. But the idea that TB is an incurable
disease still persists and places a stigma on the
tuberculous person. Some people were cautious even to
admit that they had a positive tuberculin reaction, as
they did not want their neighbors to know.

But although people were afraid of the disease,
in almost all cases they took care of the tuberculous
patients in the family. They remained at home probably
because of the lack of beds in the sanatoriums in Puerto
Rico. Being at home suffering from tuberculosis required
isolation from the rest of the family; but this was not
always achieved, and in many instances undoubtedly caused
the spreading of the disease to other family members.
However, in an attempt to prevent transmission, anything
used by the sick individual could not be used by anybody
else and sometimes social ostracism was displayed.

Broken homes resulted in many cases when the patient
was discarded or avoided. Sometimes feelings of rejection
remained for the rest of the affected individual's life.

When the mother was the patient, care of the
children was a major problem. Usually relatives looked

after the youngsters, but they were not allowed to visit

46

the mother causing anxiety in both the mother and the
children.
Interview #7
Female, 55 years old, resident of Jaguas, Ciales:
My aunt raised me. She looked after me when my
mother died of tuberculosis. I don't remember
her [my mother]. I was only a child and my
aunt did not let me get too close to her.
Interview #11
Female, 46 years old, resident of Ciales Town:
My mother died of tuberculosis when she was
still young. My brothers and I went to live
with a relative; we did not see much of my
mother. When she died, my father made us
promise not to tell anybody about the cause
of her death.
The economic problem was an important one; it
was such as to facilitate the inroads of all those diseases
caused directly or indirectly by poor nutrition. On the
other hand, tuberculous fathers had a difficult time
trying to rest and spend the day in bed, with a wife and
children to support. They continued working until they
could not work any longer. At that point the disease
was too advanced and generally death occurred shortly
afterwards. It has been said that stress and tension both.)
contribute to the developing of the disease and delay
recovery.
In some cases the persons affected with the disease
ran away from reality and tried home remedies, diagnosing
themselves as having "only influenza," thereby reducing

the feelings of fear. Some went even further, disbelieved

47
the doctor, refused treatment, and succumbed to the disease
untreated.

Interview #3

Female, 59 years old, resident of Fronton, Ciales:

My mother died of tuberculosis when she was forty
years old. She did not want to take any kind of
treatment for TB. She did not accept she had
tuberculosis.

Interview #30

Female, 57 years old, resident of Coto Sur, Manati:

My grandfather died of tuberculosis. He always
insisted that he did not have TB but pneumonia.
I think he was frightened by the idea of having
tuberculosis and did not want to admit it.

During those years without chemotherapy, what
worried the patients the most was the condition of not
knowing how long the illness would last, or whether they
would ever recover. Even in the cases when the person
was cured, the fear of reactivation persisted in his or
her mind and in that of the people surrounding them.

Patients and families found it difficult to adjust
themselves to various personal and economic stresses that
accompany an experience of tuberculosis. First, there
was the shock of the diagnosed tuberculosis, and the fear
of the outcome of the disease. Tuberculosis was not only
a medical problem. The patient had social, economic,
psychological and educational needs. This is still true
today.

It is certain that many undetected cases were

spreading the disease. Children of tuberculous parents

48
did not have any chance to escape infection. Lack of
necessary nutrients aggravated the problem. AS a result,
many children were tuberculin reactors and some were suf-
fering from the disease in early adolescence. Usually
when one member of the family suffered from the disease,
the rest were likely to contract it.

Most of the interviewed peOple agreed that their
first reactions to the diagnosis of tuberculosis was one
of a shock, fear and depression. Some of them had intense
feelings of terror and apprehension. The feeling was one
of suddenly losing the security of one's family, or
specifically of losing friends, jobs, financial security or
even social status. One of the TB patients of those days
expressed it this way: "I began worrying about my
family and how they will get along without me."

The causative factor of the disease was mainly
attributed to self-neglect and other irregularities in
daily living habits. The main reasons were low physical
resistance caused by overwork, lack of personal care, and
unrestrained living.

Interview #49

Female, 70 years old, resident of Tierras Nuevas
Poniente, Manati:

When I first moved here, my neighbor died of
tuberculosis. He was an old man who lived by
himself and was almost always drunk. He

caused his own sickness and death.

Other patients who were cured had the fear of

49

relapse. This was related to the social isolation and
helplessness suffered during the period of sickness. Many
others disliked the long treatment period.

There were feelings of having done something wrong,
or that the affliction or relapse was a direct consequence
of sinful actions.

Interview #14

Female, 37 years old, resident of Ciales Town:

I suspect my father has tuberculosis. His
wife might have transmitted the disease to
him. She was previously married to a man
who right now has been under treatment for
TB for a year. A few months ago she was
diagnosed in New York as having tuberculo-
sis, but she does not want to follow any
treatment. Her tuberculosis is the direct
result of her evil wish for her husband to
contract tuberculosis.

The community or neighborhood fear of contagion
also contributed to these feelings, which condemned
the tuberculous to isolation, and which, in some instances,
made the person feel unclean and shameful. But in many
other cases, sorrow and pity were expressed by family and
neighbors for the tuberculous.

Relapse or a quick decline of the sick individual
was often mentioned in the interviews. As pointed out,
the necessary rest was not always achieved, given the poor
economic conditions of most of the families and the need
for a breadwinner to support the family. But the lack of

compliance with the ordered bed rest, and moderation in

activities, has to be understood in the sense that it put

50

the individual in a position where he or she was obliged
to lean heavily on others. This dependency relation was
not always accepted, especially by the men, since it

ran counter to their inclinations and the individual's
self-image.

Interview #45

Female, 88 years old, resident of Tierras Nuevas
Salientes, Manati:

When I was young, my father became sick with
tuberculosis. He kept working for months.
He said that there was no reason for him to
stay in bed all day long.

Despite the educational campaigns acquainting the
public with the facts of tuberculosis, and the highly
effective anti-tuberculosis drugs, many persons still feel
intense fear and anxiety over the possibility of contamina-
tion with the disease. This is a direct consequence of the
magnitude of the problem in the past not only in Ciales
and Manati but also on the rest of the Island.

It is not surprising that many deaths occurred
without ever receiving medical attention. Symptoms that
were warnings of possible lung involvement like a persistent
cough, pain in the chest, difficult breathing, and spitting
of blood, were regarded as serious enough to seek medical
attention. Blood spitting was considered the most serious
symptom, but a persistent cough was apparently considered

somewhat less serious, and sometimes was not considered

sufficiently important to require medical assistance.

51
Interview #26
Male, 71 years old, resident of Coto Norte, Manati:
My brother died of tuberculosis when there was
a cure for the disease, but he never wanted to
go to a doctor. He said it was a waste of time.
He never received any treatment and he kept
working for as long as he could.
Home remedies were used to treat tuberculosis, the
most common being cod liver oil, honey, or syrup for a
persistent cough, and tea and rubs of alcohol for the
fever and pain in the chest.
Interview #46
Female, 70 years old, resident of Tierras Nuevas
Saliente, Manati:
My mother died of tuberculosis thirty years ago.
The only kind of treatment that she ever received
was honey for the cough, and an alcohol bath for
the fever. She did not have confidence in
anything else.
Interview #6

Male, 72 years old, resident of Jaguas:

My wife never wanted to take any medicine apart
from herbal teas that she used to prepare. She
died of tuberculosis when she was forty-five
years old.

The problem of taking a sick person to a doctor
or hospital was more serious in the municipio of Ciales
than in Manati. The distances to travel in Ciales were
considerable, as well as the steep, rough paths over

which the sick must be carried. This certainly also

contributed to the delay in seeking medical attention.

CHAPTER III

METHODOLOGY

Problem

The tuberculosis rates in 1980 for the municipalities
in Puerto Rico show that high rates almost always correspond
with municipalities in which health services for tuberculosis
are offered (See Figure 4). As the distance from a clinic
increases, the tuberculosis rate reported decreases. Those
municipalities with tuberculosis clinics are likely to
have better reporting of cases than those without clinics.
It is suspected that these clinics mostly serve the
p0pulation of the municipalities in which they are located.
Under-reporting of TB cases on the Island is a non-random
phenomena. The location of a clinic selects which sector

of a given area has more accurate reporting of cases.

Hypotheses

 

In order to investigate this problem, the following
general hypotheses will be tested. The hypotheses will be
accepted at a level of significance of .05.

A) Under-reporting of TB cases is greater in those
municipalities without health facilities for the prevention

and treatment of tuberculosis

52

54

B) The geographic variations in the reported TB
rates are the result of under-reporting and not of the

absence of TB cases

Methodology

 

Selection of the Area

After analysis of the reported rates in 1980, Ciales
and Manati were selected as the study area. Both municipal-
ities represent a geographical transect from a mountain area
to the coast (See Figure 5).

The municipality of Manati is located in the north
central plain of the Island. It had a population of 36,562
inhabitants in 1980 in an area of 46 square miles (U. S.
Census, 1980). A center for the control of TB is located
in Manati Pueblo. This center serves the populations of
Manati, Ciales, Vega Baja, Barveloneta, and Morovis.

The municipality of Manati reported a TB rate of 66 per
100,000 in 1980.

Ciales, contiguous to Manati, is located in the
central mountain range of the Island. Its population
consisted of 16,211 inhabitants in 1980 in an area of 66
square miles (U. S. Census, 1980). Ciales does not have
health facilities for TB. All cases are referred to Manati.
The reported TB rate in 1980 was of 6.2 per 100,000.

Accessibility to the area through a highway and
support from the public health unit in Manati were elements

considered in the selection of this area. Limited time,

 

 

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56

personnel, and resources in general did not allow the

inclusion of other possible areas of study.

Data Collection

A tuberculin screen survey was made in order to
obtain an indication of tuberculosis infection rates in
the populations of Ciales and Manati. A nurse from the
tuberculosis control program injected a dose 5 T.U.
(Tuberculin Units) through the Mantoux method to each person
in the sample. The tuberculin was carried in a portable
cooler with ice to protect it from heat and sunlight.

A questionnaire was designed to collect data for
each house visited and for the persons injected in that
house (Appendix B). In a typical interview the purpose of
the tuberculin test was explained to the person(s) living
in the selected house to be sampled. If at least one
person agreed to receive the test, the nurse proceeded with
the injection. At this point the questionnaire was completed
with information concerning type of house construction,
utilities available (piped water, electricity, flush
toilet), number of persons in the house, number of rooms,
and the barrio (subdivision of the municipality). A
number was assigned to each house in a barrio. Each person
tested had a number assigned by municipality.

All persons injected in the same house were included
on the same questionnaire. If more persons than the number
allowed per sheet were injected in one house, a second sheet

was used. For each person injected the following information

57

was obtained: name, sex, nationality, years of school
completed, innoculation date, treatment received for TB,
present diSeases, previous tuberculin testing, and previous
BCG vaccination.

After forty-eight to seventy-two hours the reaction
to the test was read and the size of the induration was
recorded in millimeters. Reaction and reading date were
included in the questionnaire. When a person injected was
absent during the day of reading, his or her family was
asked about the appearance of the forearm where the
tuberculin was injected. These reactions were recorded
as reported positive, negative, or no information, according
to the description obtained.

Each person tested was given a certificate signed
by the nurse stating the nature of the reaction. The
positive and doubtful cases (5 mm or more) were referred
to the TB center in Manati for follow-up. A list of all
persons tested with their reactions, names, and addresses
was given to the health clinic in Manati and-to the Tuber-
culosis Control Program.

After all injections were administered and analyzed,
fifty residents of Ciales and Manati were interviewed in
order to obtain a general impression of the history of
tuberculosis in those municipalities. Fears, beliefs, and
practices related to the disease were ascertained during
the interviews. An analysis of these interviews is included
in the second chapter as part of the history of tuberculosis

in Puerto Rico. All interviews are included in Appendix A.

58

Population and Sample

A total of fifteen hundred tuberculin tests were
administered during the survey: eight hundred in Manati,
or two percent of the population in Manati, and seven
hundred in Ciales, or four percent of the population in
Ciales.

Following the U. S. Census classification, each
subdivision was classified as being rural, an urban zone
(pueblo) or a village (aldea). A number of injections were
allocated to each zone and its barrios as a proportion of
its population and the total number of injections assigned
to the municipality (See Tables 2 and 3).

Topographic sheets with the barrios of Ciales and
Manati were used to identify the boundaries of municipalities,
barrios, and zones. Previous to the beginning of the
tuberculin survey, field trips were made for a general
reconnaissance of the area.

During the survey, those neighborhoods that showed
low income characteristics, such as overcrowding and poor
quality of house construction, were selected for testing.
In many, especially rural barrios, differences in housing
quality were not readily discernible. The location of each
house visited was plotted in the map by its house number,
helping to identify location at the time of the reading of
the injections, and to identify the neighborhoods visited

in the area.

59

TABLE 2

CIALES POPULATION SAMPLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Barrio Population Sample Houses
Urban Zone
Ciales Pueblo 1,428 67 18
Cordillera 294 13 ll
Jaguas 1,860 120 45
Total 3,582 200 74
Rural Zone
Cialitos 1,405 53 17
Cordilerra 1,606 73 18
Fronton 1,883 92 41
Hato Viejo 1,518 65 31
Jaguas 2,330 51 19
Pesas 1,693 70 40
Pozas 1,316 62 22
Toro Negro 878 34 9
Total 12,629 500 197
Ciales Total 16,211 700 271

60

TABLE 3.

MANATI POPULATION SAMPLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Barrio Population Sample Houses
Urban Zone
Manati Pueblo 8,352 179 69
Coto Norte 3,403 21 91
Coto Sur 5,592 111 29
Total 17,347 379 189
Villages (Aldea)
Coto Norte

(Coto Norte) 1,154 32 9

Tierras N. Poniente
(La Luisa) 2,343 48 18

Tierras N. Saliente
(Tierras N. Poniente) 1,494 17 6
Total 4,991 97 43

Rural Zone

Bajura Adentro 2,127 45 16
Bajura Afuera 262 9 4
Coto Norte 3,238 125 48
Coto Sur 2,270 61 20
Rio Arriba Poniente 1,599 35 9
Rio Arriba Saliente 2,298 50 20
Tierras N. Poniente 498 12 3
Tierras N. Saliente 1,932 55 22
Total 14,224 392 142
Manati Total 36,562 800 374

61

Resources and Limitations

 

The tuberculin tests and a graduate nurse to
administer them were provided by the Department of Health
through its Tuberculosis Control Program.

The survey was restricted to Ciales and Manati given
the number of injections available for the study.

All injections were administered during working
hours (8:00 A.M. - 5:00 P.M.) Mondays, Tuesdays, and
Wednesdays. This time schedule inevitably restricted the
number of males in the sample, as well as that of working

females.

CHAPTER IV

ANALYSIS
The analysis of the data consists of contingency
tables of the percent of individuals in each category of
reaction in relation with a set of variables such as age,
sex, occupation, and location. Graphs and maps were plotted
for some of the tables in order to permit cartographic

analysis.

Tuberculin Test Reaction bynge Group

 

The relationship between sensitivity to the tuber-
culin protein and age presents a general pattern in which,
as age increases, so does the proportion of reactions greater
than 10mm. This is also true individually for Ciales
(Figure 6) and for Manati (Figure 7). These relationships
have a level of significance of .01.

In the younger age group no positive reaction was
obtained in Ciales and only 0.7 percent of the individuals
tested in this age category reacted positively in Manati
(Tables 4 and 5). Manati has a slighly greater risk of
infection with M. tuberculosis in this age group, when
compared to Ciales. A closer look at the below 10 age
group in Manati shows no positive reactions for the ages

2 to 7 years of age (Table 6). This group is referred

62

Reaction: by Age Groups in Ciales

 

 

     

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Ago Groups

     

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Figure 5

Ago Groups in Manati

by

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20-29 30-39 40-49 50-59 60-69 70+

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65
TABLE 4

MILLIMETERS OF REACTION
BY AGE GROUP FOR CIALES

 

 

 

 

 

 

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total

Age Group N 8 N % N % N %
Below 10 28 100.0 0 0 0 0 28 4.7
10-19 160 93.6 0 0 11 6.4 171 28.7
20-29 101 89.4 4 3.5 8 7.1 113 19.0
30-39 53 75.7 1 1.4 16 22.9 70 11.7
40-49 33 56.9 3 5.2 22 37.9 58 9.7
50-59 34 60.7 4 7.1 18 32.1 56 9.4
60-69 27 47.4 4 7.0 26 45.6 57 9.6
70+ 20 46.5 1 2.3 22 51.2 43 7.2
Total 456 76.5 17 2 9 123 20.6 596 100.0

TABLE 5

MILLIMETERS OF REACTION
BY AGE GROUP FOR MANATI

 

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total

Age Group N % N r,% N % N %
Below 10 141 99.3 0 0 l .7 142 19.9
10-19 152 96.8 4 2.5 l .6 157 22.1
20-29 76 92.7 2 2.4 4 4.9 82 11.5
30-39 70 76.9 0 0 21 23.1 91 12.8
40—49 31 51.7 3 5.0 26 43.3 60 8.4
50-59 39 60.0 2 3.1 24 36.9 65 9.1
60-69 33 68.8 1 2.1 14 29.2 48 6.7
70+ 48 71.6 0 0 19 28.4 67 9.4
Total 590 97.2 12 -2 0 110 18.12 607 100.0

 

 

 

 

 

66

TABLE 6

MILLIMETERS OF REACTION BY AGE
GROUP BELOW 20 FOR MANATI

 

 

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total
Age Group N % N % N % N %
2 17 100.0 (1 0 0 O 17 2.4
3 15 100.0 0 0 O 0 15 2.1
4 23 100.0 0 O O 0 23 3.2
5 15 100.0 0 0 0 0 15 2.1
6 16 100.0 0 0 0 0 16 2.2
7 20 100.0 0 O O 0 20 2.8
8 18 94.7 0 0 l 5.3 19 2.7
9 17 100.0 0 0 0 0 17 2.4
10 17 94.4 1 5.6 0 0 18 2.5
11 19 95.0 1 5.0 0 0 20 2.8
12 21 100.0 0 O 0 0 21 2.9
13 13 92.9 0 0 1 7.1 14 2.0
14 12 100.0 0 0 0 0 12 1.7
15 22 95.7 1 4.3 0 0 23 3.2
16 18 94.7 1 5.3 0 0 19 2.7
17 16 100.0 0 O 0 O 16 2.2
18 8 100.0 0 O 0 0 8 1.1
19 6 100.0 0 O 0 0 6 0.8
Total 293 97.9 4 1.3 2 0.67 299 ---

 

 

 

 

 

67
to as the very young who, from the epidemiological point
of view, are at the highest risk for develOping TB disease
given that favorable conditions for disease transmission
are present.

In the age group 10-19 years, 2.5 percent of the
injections had doubtful reactions and 0.6 percent were
positive. In adolescence the chance of developing TB is
less than in the very young, but there remains a definite
risk of developing the disease especially if the infection
was acquired during childhood. Infection in adolescence
comes chiefly from adults, often from within the extended
family, but some contacts can also be made in the wider
community.

Although children have benefited from the program
to conquer tuberculosis, their level of security is not
yet good enough. It is necessary to protect them from the
tuberculous adult. Investigation of any contact child
must begin immediately after a TB case has been diagnosed.

In the next age groups, both Ciales and Manati show
a gradual increase in the percent of positive reactions.
Manati reaches its peak of positive reactions in the 40-49
age group. Forty-three percent of the individuals tested
in that age had positive reactions. Positive reactions
were almost double those of the 30-39 age group. After
this peak, the percent of positive reaction declined with
age. In the oldest age category, 28.4 percent of the

injections reacted positively.

68

Both municipalities had a decrease in positive
reactions in the age group 50-59. In other tuberculin
testing surveys, similar results have been found in which
the percentage of reactors rises steadily with age to
adulthood but may show a slight decline after the age of
50 or 60 (Comstock, 1973). In Ciales the decrease in the
age group 50-59 is followed by an even higher increase of
reactors that reaches its peak in the oldest age category.
I The highest proportion of infection is found in the very
old, whereas in Manati it is found at an earlier age.

It is feasible to say that, according to the
results obtained, children have been subjected to lower
risk of infection than adults and that some of the older
individuals may have lost their sensitivity to tuberculin.
The decline in the percent of reactors after age 50 in
Manati may be explained in part by the fact that the loss
of responsiveness seems to accelerate with increasing age.

Most of the positive reactions occurred in persons
40 years of age and older. Probably this population group
was infected with M. tuberculosis several decades ago when
the infection rate was high and the chemotherapy era was in
its beginnings. All of these persons are at some risk of
developing tuberculosis disease. Aging is associated with
a decrease in resistance which may reactivate old tuber-

culosis foci.

69

Percent of Reaction Sizes

 

Reactions caused by infection with mycobacteria
other than M. tuberculosis (that is cross-reactions)
commonly occur in tropical areas. As a consequence,
what is considered a significant tuberculin reaction is
not precise. In general the larger the reaction, the
greater the probability that the reaction represents
infection with M. tuberculosis. Cross—reactions tend to
be smaller than reactions caused by tuberculous infection.

Two assumptions are made in order to estimate the
proportion of persons with M. tuberculosis. First, reactions
among persons infected with M. tuberculosis form a symmetric
frequency distribution centering close to 15mm of
induration. The second assumption is that there are no
cross-reactions larger than 15mm.

The distribution of reaction size for Ciales and
Manati has its peak or central value at 20mm of induration
(See Figure 8 and Table 7). A second and smaller peak is
presented in the 15mm. The relatively low percentage of
indurations 16mm in size indicate the possibility of
erroneous measurement or observer bias favoring 5, 10, 15,
and 20. Reactions that were in fact of 16mm, may have been
read as 15mm. The general configuration of the distribution
is, however, bimodal: a high peak of 0mm and a second
peak in the 20mm of induration. Bimodal distributions are
typical among populations with history of household contact

with tuberculosis (American Thoracic Society, 1981).

W (\-

 

35

 

 

 

 

 

 

 

 

 

 

Distribution of Reactions

 

300163008 ,0 80.31.‘

oi Rooction

Millimoiors

Finuro 8

71

TABLE 7

PERCENTAGE DISTRIBUTION OF
TUBERCULIN REACTIONS

 

 

 

BY SIZE
Reaction (mm) Percentage Reaction (mm) Percentage
0 79.40 17 1.30
3 0.20 18 1.98
4 0.40 19 1.68
5 0.76 20 2.29
6 0.46 21 0.46
7 0.23 22 0.76
8 0.23 23 0.68
9 0.54 24 0.23
10 0.99 25 0.54
11 0.54 27 0.23
12 0.76 28 0.20
13 0.54 29 0.07
14 1.45 33 0.07
15 2.20 35 0.07
16 0.68 38 0.07

 

 

 

72

Tuberculin Test Reaction
by70ccupation

 

The distribution of positive reactions by occupation
shows thirty percent or more reactors in the following
occupation categories: farmer, construction worker, bus
driver, cosmetologist, carpenter, retail trader, mason,
fisherman, waiter, salesmen, and pensioner (Table 8). In
some of these occupations the number of individuals tested
is minimal and does not allow any far reaching conclusions
to be drawn. Those occupations are: bus driver,
'cosmetologist,electrician,carpenter, mason, fisherman, and
waiter.

In the female occupations, a high percentage of
reactors was found in the categories of housewife and
pensioner. Other occupations with high reactor percentages
were teacher, nursemaid, and factory worker, but the number
of persons tested in those occupations was limited
(Table 9). The level of significance of the relationship
reaction by occupation was of .01 for both males and
females. '

Persons tested of 40 years of age and older repre-
sented the highest percentage of individuals in those
occupations with the highest percentage of reactors. Those
occupations are for males, farmer, construction worker, and
pensioner (Table 10); and for females, housewife and
pensioner (Table 11). The high percentage of reactors in

these occupations seems to be related to the age of the

73
TABLE 8

TUBERCULIN POSITIVE REACTIONS
BY OCCUPATION
FOR MALES

 

 

 

Number of
Positive Percent Positive
Occupation Cases (10+ mm)
Unemployed 17 13.4
Farmer 12 32.4
Construction Worker 8 29.6
Student 8 4.1
Tinsmith 2 11.8
Painter 0 0
School Bus Driver 1 33.3
Pensioners 32 33.3
Industry Worker 0 0
Shoe Factory Worker 0 0
Car Junk Salesmen 0 0
Cosmetologist 1 100.0
Steel Industry Worker 1 50.0
Mechanic 1 11.1
Truck Driver 0 0
Retail Trader 1 33.3
Chemical Industry Worker 0 0
Teacher 0 0
Electrician 1 25.0
Carpenter 3 42.9
Mason 2 100.0
Fishermen 1 33.3
Chauffer (Electric Company) 0 0
Gardener 0 0
Barber 0 0
Salesmen 5 45.5
Cashier 0 0
Waiter 1 33.3
Upholster 0 0
Sculptor (Religious Images) 1 100.0
Veteran 0 0
Cook 0 0
Keeper 0 0
Store Attendant 0 0

 

 

 

74
TABLE 9

TUBERCULIN POSITIVE REACTIONS
BY OCCUPATION
FOR FEMALES

 

 

 

Number of
Positive Percent Positive
Occupation Cases (10+ mm)
Housewife 121 23.9
Student 4 1.6
Unemployed 2 5.7
Clothes Factory Worker 1 12.5
Cook 0 0
Store Attendant 0 0
Secretary 0 0
Teacher 1 11.1
Nursemaid 1 50.0
Pensioned 4 28.6
Cosmetologist 0 0
Administrator 0 0

 

 

 

75
TABLE 10
AGE DISTRIBUTION OF
OCCUPATION FOR MALES

 

 

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10-19
20-29
30-39
40-49
50-59
60-69

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76

TABLE 10 Continued

 

AGE DISTRIBUTION OF

OCCUPATION FOR MALES

 

 

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20-29
30-39
40—49
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60-69

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77
TABLE 11
AGE DISTRIBUTION

OF OCCUPATIONS
FOR FEMALES

 

 

 

 

 

Factory
Housewife Pensioned Nursemaid Worker
Age
Groups N % N % N % N %
Below 10 0 O 0 0 0 O 0 0
10-19 16 4.3 1 0.3 0 0 0 0
20-29 104 41.9 2 0.8 1 0.4 l 0.4
30-39 114 61.0 0 0 0 0 4 2.1
40-49 50 61.1 1 0.8 0 0 2 1.5
50—59 83 62.4 0 0 1 0.8 0 0
60—69 62 52.5 5 4.2 0 O 1 0.8
70+ 47 39.8 5 4.2 0 0 0 0

 

 

 

 

 

 

 
 
  
 

  
   
   

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Poniente

   
 

Tierras
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Sofiente

   

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Boiura

Afuera a

 
  
 
  
 

MANATI

    
  

Rio Arriba
Saliente

  
 

Rio Arriba
Poniente

  

CIALES

Figure 9

Names of Barrios

0 . §km
0 SIM

 

 

 

 

 

 

 

80

TABLE 12

DISTRIBUTION OF REACTIONS

BY BARRIOS FOR CIALES

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total

Barrio N % N % N % N %
Hato Viejo 34 56.7 3 5.0 23 38.3 60 10.1
FrontOn 57 75.0 6 7.9 13 17.1 76 12.8
Pozas 37 78.7 3 6.4 7 14.9 47 7.9
Jaguas 122 80.8 2 1.3 27 17.9 151 25.3
Peses 40 69.0 1 1.7 17 29.3 58 9.7
Cordillera 54 70.1 0 O 23 29.9 77 12.9
Pueblo 41 82.0 1 2.0 8 16.0 50 8.4
Cialitos 45 95.7 1 2.1 l 2.1 47 7.9
Toro Negro 26 86.7 0 0 4 13.3 30 5.0

 

 

 

 

 

DISTRIBUTION OF REACTIONS
BY BARRIOS FOR MANATI

81

TABLE 13

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total
Barrio N % N % N % N %
Coto Norte 128 79.0 1 0.6 33 20.4 162 22.8
Coto Sur 132 85.7 3 1.9 19 12.3 154 21.6
Rio A.

Saliente 33 78.6 1 2.4 8 19.0 42 5.9
Rio A.

Poniente 22 73.3 1 3.3 7 23.3 30 4.2
Pueblo 129 83.2 3 1.9 23 14.8 155 21.8
Bajura

Atuera 6 66.7 0 0 3 33.3 9 1.3
Bajura

Adentro 35 89.7 0 0 4 10.3 39 5.5
Tierres N.

Saliente 56 83.6 3 4.5 8 11.9 67 9.4
Tierres N.

Poniente 49 90.7 0 0 5 9.3 54 7.6

 

 

 

 

 

 

 

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REACTIONS NOT READ

83

TABLE 14

FROM CIALES

 

 

 

 

 

 

 

 

 

 

 

 

 

Reported Reported No Infor-
Positive Negative mation Total
Barrio N % N % N % N %
Hato Viejo 1 16.7 4 66.7 1 16.7 6 5.7
Fronton 3 18.8 7 43.8 6 37.5 16 15.1
Pozas O O 5 83.3 1 16.7 6 5.7
Jaguas 2 6.7 23 76.7 5 16.7 30 28.3
Pesas O 0 8 66.7 4 33.3 12 11.3
Cordillera O O 6 66.7 3 33.3 9 8.5
Pueblo 0 0 11 64.7 6 35.3 17 16.0
Cialitos 5 83.3 1 16.7 0 O 6 5.7
Toro Negro 0 0 2 50.0 2 50.0 4 3.8
TABLE 15
REACTIONS NOT READ
FROM MANATI
Reported Reported No Infor-
Positive Negative mation Total
Barrio N % N % N % N %
Coto Norte 0 o . 3
Coto Sur 1 5.6 i: Bg’g 3 20-0 15 16 9
Rio A, ° 11-1 18 20 2
Saliente
Rio A. 0 0 5 62.5 3 37.5 8 9.0
P gonlente 0 O 6 100'° 0 0 6 5.6
“3 1° 2 8-7 9 39 1 12
. - 52.2 23 25.8
Bajura Ad. 1 14.3 5 71.4 1
Tierres N. 14-3 7 7-9
‘ Saliente 1 20.0
Tierres N. 4 80'0 0 0 5 5'6
Poniente
2 25 ° 5 62-5 11 12.5 8 9.0

 

 

 

 

 

84

individuals occupied in them. The unemployed, who constitute
a high percentage of the pOpulation, are not related to
positive reaction to the test. An analysis of their age
structure reveals that their highest percentages fall

within the 20-29 years age group. As discussed, the younger
age groups have the lowest percentage of reactors.

Tuberculin Test Reactions
by Barrio

 

 

The distribution of percentages of reactors in the

barrios of Ciales and Manati is shown in Figure 10,

Tables 12, and 13. A very different pattern occurs when

the reactions that were not read, but were reported positive
are added (Figure 11, Tables 14 and 15). The reported
positive reactions are relatively reliable classifications
since the inexperienced person will underestimate the
reaction to the test, therefore, the reactions reported
positive, were probably large enough to be noticed by the
persons in contact with the individual tested.

Hato Viejo in Ciales, and Bajura Afuera in Manati
are the barrios with the highest percentage of reactors
(Figures 9-11). In sector Cumbre in Hato Viejo, one of
the five sectors visited during the survey in that barrio,
62.5 percentage of the persons tested reacted to the test
with 10mm or more of induration. In that sector a 40 year
old female was interviewed. She was an ex-tuberculosis
patient twelve years ago. She has been living in Cumbre

for fifteen years. Her husband and neighbors, reacted

85

positive to the test, including a 22 year old male.
Infection in this neighborhood with M. tuberculosis may
have had its focus in the ex-TB patient. This neighborhood
in Cumbre accounts for the high percentage of reactors in
Hato Viejo. Bajura Adentro, in Manati has a small population
and the number of injections administered in that barrio
were therefore small and no meaningful conclusion can be
drawn from such a sample. But it follows the general
distribution pattern with higher percentages of reactions
in the older age groups. The reactors in Bajura Adentro
were in the 60-69 age group.

The remaining barrios in Ciales and Manati, with
the exceptions of Cordillera and Pesas have percentages
of reactors of between 10-19 percent and present no
difference in the rate of tuberculosis infection between
Ciales and Manati. The total percentage of reactors in
Ciales was 20.6 and in Manati 15.5 percent. In contrast
to these results, Manati reports a TB rate ten times that
of Ciales, suggesting underreporting of tuberculosis cases

particularly in Ciales.

Tuberculin Test Reactions by Sex
The general percentage of tuberculin reactors in
the sample was 19.7 percent for males, and 17.2 percent
for females (See Table 16). The distribution of reactors
by sex and age shows a slight difference between the sexes

and a general increase of reactors with age (See Figure 12,

86

Tables 17, and 18). It was expected to have an excess of
male reactors in the older age groups; This is typically

the pattern since males are more likely to have a wider

range of contacts outside the home, increasing the
opportunity to come in contact with a person with tubercu-
losis disease. A larger number of females were tested.
Injections were administered during working hours when most
of the males were not at home. The number of working females
was also reduced for the same reason.

Tuberculin Test Reaction by
Rural and Urban Location

 

 

Tuberculosis cases are usually higher in urban
areas. Urban living and concentration of people, increases
the risk of becoming infected with tuberculosis. This
difference may not be related to the quality of housing,
although lifestyle may be a contributory factor. In Puerto
Rico, tuberculosis has been historically higher in urban
areas. The analysis of the sample presents rural areas
having the higher percentage of reactors, 19-8 percent
in rural areas and 14.5 percent in urban areas (Figure 13
and Table 19). Higher percentages for rural areas are
also found in Ciales (Table 20) and in Manati (Table 21).
This pattern is in accordance with the tuberculosis rates
reported in the municipalities of the Island in 1980.
Municipalities classified as being rural have equal or
higher rates as those classified as urban municipalities.

Employment of rural labor force in urban areas, increasing

87

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 16
DISTRIBUTION OF REACTIONS
BY SEX
0—4 mm 5-9 mm 10+ mm Total
Sex N % N % N % N %
Male 412 79.5 9 1.7 97 18.7 618 44
Female 634 80.2 20 2.5 136 17.2 790 56
TABLE 17
DISTRIBUTION OF REACTIONS BY
AGE GROUP FOR FEMALES
0-4 mm 5-9 mm 10+ mm Total
Age
Group N % N % N % N %
Below 10 92 100 0 0 0 0 92 11.6
10-19 168 96.0 2 1.1 5 2.9 175 22.2
20-29 120 92.3 4 3.1 6 4.6 130 16.9
30-39 97 81.5 1 0.8 21 17.6 119 15.1
40-49 41 51.3 5 6.3 34 42.5 80 10.1
50-59 49 60.5 5 6.2 27 33.3 81 10.3
60-69 35 55.6 3 4.8 25 39.7 63 8.0
70+ 32 64.0 0 0 18 36.0 50 6.3

 

 

 

 

 

88

TABLE 18

DISTRIBUTION OF REACTIONS BY

AGE GROUP FOR MALES

 

 

 

 

 

 

 

 

 

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total

Age
Group N % N % N % N %
Below 10 77 98.7 0 O 1 1.3 78 15.1
10-19 144 94.1 2 1.3 7 4.6 153 29.5
20-29 57 87.7 2 3.1 6 9.2 65 12.5
30—39 26 61.9 0 0 16 38.1 42 8.1
40-49 23 60.5 1 2.6 14 36.8 38 7.3
50-59 24 60.0 1 2.5 15 37.5 40 7.7
60-69 25 59.5 2 4.8 15 35.7 42 8.1
70+ 36 60.0 1 1.7 23 38.3 60 11.6

TABLE 19
DISTRIBUTION OF REACTIONS BY SECTORS
FOR CIALES AND MANATI
0-4 mm 5-9 mm 10+ mm Total

Sector N % N % N % N %
Rural 648 77.6 22 2.6 165 1918 835 63.8
Urban 319 83.9 6 1.6 55 14.5" 380 29.1
Aldea 79 84.9 1 1.1 13 14.0 93 7.1

 

 

 

 

 

50. Positive Reactions by Sex and Age

40‘ I’ ‘\ J~‘

30‘

  
 

20‘
—males

/ ----temales

Percent of Reaction

104

 

 

10 20 3O 4O 50 60 70

Years of Age

Figure 12

301 Positive Reaction By Zone

to
9

   

d
‘?

 

Percent at Reaction

  

 

 

Villages
(Aldees)

Rural Urban

Figure 13

90

TABLE 20

DISTRIBUTION OF REACTIONS BY

SECTOR FOR CIALES

 

 

 

 

 

 

 

 

 

 

 

 

 

0-4 mm 5-9 mm 10+ mm Total
Sector N % N 8 N % N %
Rural 377 75.7 16 3.2 105 21.1 488 83.6
Urban 79 8O 6 1 1.0 18 18.4 98 16.4

TABLE 21
DISTRIBUTION OF REACTIONS BY
SECTOR FOR MANATI

0-4 mm 5-9 mm 10+ mm Total
Sector N % N % N % N %
Rural 364 82.2 8 1.8 71 16.0 443 62.2
Urban 147 83.5 3 1.7 26 14.8 176 24.7
Aldea 79 84.9 1 1.1 13 14.0 93 13.1

 

 

 

 

 

91
the opportunities for infection among rural residents can

be a partially explanatory variable.

Tuberculin Reaction by House Type

In all three categories of housing construction the
percentage of reactors is between 18 and 19 percent, showing
no relationship between percent of reactors and type of
housing (Table 22) as indicated by the level of significance
of .49. Other variables related to the quality of housing
are the available utilities such as electricity, piped
water, and flush toilet. All of the houses in the sample
had electricity and running, piped water. Only 6.1 percent
of the persons lived in houses that did not have toilet
facilities (See Table 23). The high percentage of houses
with utilities is the result of Government efforts to bring
electricity and piped water to rural areas. The fact that
most of the houses had flush toilets, electricity and piped
water put most of the houses at the same level of quality.

Tuberculin Reactign and Number
of Persons Per Room

For most of the sample, tuberculin sensitivity was
found to be negatively related to the number of persons
per room in the house (See Table 24). Unexpectedly, the
highest percent of reactors was found at the lowest
room density. The level of significance obtained was
0.01. Age is an influence in this relationship. An analysis

of the age composition shows that 66 percent of the persons

living at less than one person per room were aged 40 years

92
TABLE 22
DISTRIBUTION OF REACTION BY

HOUSE TYPE FOR CIALES
AND MANATI

 

 

 

 

0—4 mm 5-9 mm 10+ mm Total
House Type N % N % N N %
Concrete 611 80.6 13 1.7 134 17. 758 58.0
Concrete/
Wood 69 76.7 4 4.4 17 18. 90 6.9
Wood 366 79.6 12 2.6 82 17. 460 35.2

 

 

 

 

 

93

TABLE 23

DISTRIBUTION OF FLUSH TOILETS
BY HOUSE TYPE

 

 

 

 

Concrete/
Concrete Wood Wood Total
Availability N % N % N % N %
yes 868 61.5 97 6.9 447 31. 1412 93.9
no 6 6. 11 6.6 74 81. 91 6.1

 

 

 

 

 

94

and older (See Table 25). The room density with the lowest
percent of reactors, two persons per room, has only 20.2

percent of its inhabitants in that age group (See Table 25).

95

TABLE 24

DISTRIBUTION OF REACTIONS BY
DENSITY FOR CIALES

 

 

 

 

 

 

 

 

 

 

 

 

 

AND MANATI
0-4 mm 5-9 mm 10+ mm Total
Persons
Per Room N % N % N % N
Below 1 65 57.0 4 3.5 45 39.5 114 8.7
1 743 81.4 17 1.9 153 16.8 913 69.8
2 217 85.8 8 3.2 28 11.1 253 19.3
3 19 82.6 0 0 4 17.4 23 1.8
4 2 50.0 0 0 2 50.0 4 0.3
5 0 0 0 0 1 100.0 1 0.1
TABLE 25
NUMBER OF PERSONS PER ROOM
BY AGE GROUPS
Below 1 1 2 3 4
Age
Group N % N % N % N % N % N
Below 10 0 O 154 81.5 35 18.5 0 0 o o o 0
10-19 19 5.1 241 64.1 98 26.1 15 4.0 3 0.8 0 0
20-29 17 6.8 174 69.3 55 21.9 5 2.0 O 0 0 0
30-39 6 3.2 147 78.6 33 17.6 1 0.5 0 0 0 0
40-49 15 ll 5 91 69.5 21 16.0 3 2.3 l 0.8 0 0
50-59 15 11.3 101 75.9 16 12.0 1 0.8 0 O 0 0
60-69 31 26.3 78 66.1 9 7.6 0 0 0 0 0 0
70+ 21 17.8 85 72.0 10 8.5 l 0.8 0 0 l 0.8

 

 

 

 

 

 

 

CHAPTER V

CONCLUSIONS AND RECOMMENDATIONS

Conclusions

 

This study has been concerned with screening for
tuberculosis infection in the municipalities of Ciales and
Manati. Its aim has been to identify tuberculin reaction
rates to see how they compare with the reported tuberculosis
morbidity rates in those municipalities.

A review of the history of tuberculosis on the
Island pointed out the magnitude of the disease problem in
the past. The attempts of the public health authorities
to control the disease have been well oriented, and very
successful. The reduction of TB rates of mortality and
morbidity can be considered as a major step toward the
control of tuberculosis in Puerto Rico. But the detection
of cases has not been as effective, thus allowing the
transmission of tuberculosis to continue.

The data analyzed supported the research hypotheses.
In Ciales, the municipality with the lower tuberculosis rate
reported of the two municipalities, and the one without.a
health center for the control of tuberculosis, the higher
percent of reactors to the tuberculin test was obtained.

The percent of reactors for both municipalities were

96

97

twenty-one percent for Ciales and fifteen percent for
Manati.

Both Ciales and Manati had an increase in their
reaction rates with advanced age. The high rate of tuber-
culosis infection previous to, or a little after the
beginning of the chemotherapy era, may explain the higher
percentage of reactors in groups of people forty years of
age and older.

The percent of reactors in relation to other
variables was also related to the age composition of the
groups of persons tested in the different categories.
Variables such as occupation and room density are the best
two examples.

The distribution of reactors in the barrios of Ciales
and Manati presented no specific pattern. Certainly no
difference in the percent of reactors in those barrios
close to the TB center and those distant from it, was
found. This suggests that underreporting of TB cases may
also be a health service problem in Manati, where the center
is located.

Rural reactors percentages were higher than the
urban percentages in both municipalities. The answer to
this historical inversion cannot be given in this study,
but an urban health care services effect is suggested.

As a group, males had a slightly greater percentage
of reactors. No significant variations in the age distri-

bution of reactors in both sexes was found. This represents

98
a change from previous surveys in which an excess of male

reactors in the older age groups was obtained.

The percent of reactors was not related to the type
of house construction. Availability of running piped water
and electricity in all the houses, and flush toilet in
almost all of them, made housing quality relatively uniform

throughout the sample.

Recommendations

 

Wherever a scheme exists to eliminate tuberculosis,
most of the attention should be focused upon decreasing the
number of infectious cases. If the latter increase, the
total number of tuberculosis cases subsequently increases.
Although a priority of the tuberculosis control program in
Puerto Rico is to reduce the spread of tuberculosis in the
community, some additional procedures are suggested to
ensure that more infectious cases are found and at an
earlier stage.

A well organized outpatient treatment is the basis

for the control of the disease. It can undertake health

education measures to teach the early signs of tuberculosis,

the importance of early detection and the need for prolonged

treatment. The knowledge is also relevant that the disease

is curable and that discovery of tuberculosis no longer

automatically leads to isolation. The great majority of the

population should have ready access to TB centers. Perhaps,

it will be necessary to establish new centers for outpatient

care. Mobile units can be introduced in the health system

99

to complement service of the centers.

Education of the public should be aimed primarily
at those who would not normally come for treatment. With
the assistance of social workers, propaganda can be
distributed to make both the sufferer and the community
aware of the significance of the disease—related symptoms.
The public should be as well informed of the tuberculin
test as a public health procedure as they are about
immunization against other communicable diseases.

The tuberculin testing of children is an important
measure already taken on the Island. But tubercle bacilli
have taken refuge among older people in higher proportion
than in any other segment of the population. The requirement
of the tuberculin test for the issuance of health certifi-
cates certainly increases the number of persons tested with
tuberculin. Periodic tuberculin surveys among different
sectors of the population can help in the detection of TB
cases among individuals that are not in the need of such
certificates.

In any community the epidemiological situation of
tuberculosis is always changing. An effective tuberculosis
control program should have the mechanisms to detect those

changes.

APPENDIX A

INTERVIEWS ON HISTORICAL ASPECTS OF
TUBERCULOSIS IN CIALES AND MANATI

APPENDIX A

INTERVIEWS ON HISTORICAL ASPECTS OF

TUBERCULOSIS IN CIALES AND MANATI

INTERVIEW 1

8/9/82

Municipio: Ciales

Barrio: Pozas
Sex: Female
Age: 75

My son died of TB 35 years ago. He was only 20
years old. I took care of my son until he died. He was my
only child. It was a very common disease in those times,
but I have never accepted that my boy died so young.

Tuberculosis can be cured today with some drugs.

I don't know how the disease is transmitted.

INTERVIEW 2

8/9/82

Municipio: Ciales

Barrio: Pozas
Sex: Male
Age: 62

100

101

Forty years ago my family was living in Pozas. In
those times, tuberculosis was very common and frightening.
We considered ourselves lucky because in our family nobody
had had tuberculosis. With the pass of the years, new
medicines for tuberculosis were discovered, and the disease
ceased to take so many lives. Sixteen years ago my family
had its first TB case. My brother, 45 years old, had
diagnosticated tuberculosis. Fortunately the treatment
for the disease is very effective and my brother was cured.

Tuberculosis is transmitted by a bacilus when the
sick person coughs or talks. The disease can be cured with

drugs.
INTERVIEW 3

3/8/82

Municipio: Ciales

Barrio: Fronton
Sex: Female
Age: 59

My mother died of tuberculosis when she was 40 years
old. She refused any kind of treatment and always said that
she did not have tuberculosis. Her grandmother died of
tuberculosis and she was very close to her. She just did
not want to think that she was going to die of the same
disease.

Tuberculosis is transmitted by close contact with

the sick person and can be cured with medicines.

102

INTERVIEW 4

8/8/82

Municipio: Ciales

Barrio: Jaguas
Sex: Female
Age: 79

My sister died of tuberculosis when she was 50
years old, about 30 years ago. Her husband had died one
year before in Cialitos where they were living. I took
care of their children.

Tuberculosis can't be cured and is transmitted

by coughing.

INTERVIEW 5
8/9/82

Municipio: Ciales

Barrio: Pesas
Sex: Male
Age: 73

My brother spent nine months in a sanatorium
where he died. This happened in 1949. He always looked
healthy and strong before he got the disease. During his
sickness, he did not look like my brother anymore. His
wife had tuberculosis also ten years ago, but she received

treatment and was cured.

103
I know that tuberculosis can be cured with some
medicines, but I don't know how it is transmitted. Some

people said it is through the clothes of the sick person.

INTERVIEW 6

8/4/82

Municipio: Ciales
Barrio: Jaguas
Sex: Male
Age: 72

My wife died of tuberculosis thirty years ago when
she was 45. She refused to take any medicine apart from
herbal teas that she used to prepare. She always said that
all she needed to do was rest and that she was weak because
she was working in the house all the time.

You can get tuberculosis when you don't eat

well, and in most cases it kills.

INTERVIEW 7

8/4/82

Municipio: Ciales

Barrio: Jaguas
Sex: Female
Age: 45

My aunt raised me. She looked after me when my

mother died of tuberculosis. I don't remember her. I was

104
only a child, and my aunt did not let me get too close to
her. Some years ago my aunt developed tuberculosis. She
was immediately put under treatment and now she is cured.
Every year she gets a chest X-ray, as it was suggested by

the doctor.

INTERVIEW 8

8/4/82

Municipio: Ciales
Barrio: Jaguas
Sex: Male
Age: 62

Two of my cousins died of tuberculosis forty years
ago. They were teenagers. They always looked pale and
sick and almost all the time had cold and fatigue. Nobody
was surprised that they were coughing all the time and had
that sick look on their faces. The family had so many
problems at that time that the weakness of my cousins was
only one more. When one of them died, the family then
knew he had tuberculosis. They also knew his brother was
going to have the same end. He died two months later.

Tuberculosis is a transmissible disease, but I
don't know how it is transmitted. Today it can be cured

with medical attention.

105

INTERVIEW 9

8/4/82

Municipio: Ciales

Barrio: Jaguas
Sex: Female
Age: 26

My ex-husband had diagnosticated tuberculosis two
years ago. I was still married to him. He was put under
treatment for 18 months, but he did not finish. He said
that he was tired of taking pills every day; plus he felt
considerably better after a few months. I tried to make
him finish with the treatment because the doctor told
me this was very important. As always, he did not listen.
I don't know how he is now because I divorced him.

Last month I was tested with tuberculin and had a
chest X-ray. The doctor told me I had tuberculosis. Now,
I am under treatment for 18 months. I want to be cured.

I am going to finish the treatment.

The disease is transmitted when the sick person
coughs, talks, sneezes, the person should cover the mouth
as a way to prevent transmission. Once the person is
under treatment for four weeks, the disease ceases to be

infectious.

106

INTERVIEW 10

8/9/82

Municipio: Ciales

Barrio: Pesas
Sex: Female
Age: 60

My brother died of tuberculosis 30 years ago
when he was a teenager. When he was sick nobody in the
family realized he had TB. He was coughing all the time
and looked pale and weak. We believed it was bronchitis.
He was taken to the doctor who identified the disease
as being tuberculosis, and the doctor prescribed some pills
for him to take over a long period of time every day. As
soon as he began to take those pills, he began to feel
better. So, he decided not to take them anymore. One
year later he was looking bad again, and he died a little
after.

Tuberculosis can be cured sometimes with medicines.

I don't know how it is transmitted.

INTERVIEW 11

8/4/82

Municipio: Ciales
Barrio: Ciales Town
Sex: Female

Age: 46

107

My mother died of tuberculosis when she was still
young. .My brother and I went to live with a relative.
We did not see my mother much. When she died, my father
made us promise not to tell anybody about the cause of
her death.

Today tuberculosis can be cured but I don't know

what is the treatment.

INTERVIEW 12

8/9/82

tunicipio: Ciales
Barrio: Pozas

Sex: Female
Age: 45

My sister died of tuberculosis when she was 14
years old. Few years before my grandmother had died of
TB. My sister loved her very much and was always in her
company. It is possible that my sister got the disease
from my grandmother. The family was living in Barranquitas
when all this happened.

Tuberculosis is transmitted by coughing. Some
people use honey for the cough, but it doesn't cure

tuberculosis. A prescribed medicine is necessary.

108

INTERVIEW 13

8/3/82

Municipio: Ciales

Barrio: Cordillera
Sex: Female
Age: 68

My mother was a TB patient ten years ago. Now,
she is cured. My neighbor Rufino Cardona died of tubercu-
losis last year. He was 65 years old. We all used to
visit him and did not know he had tuberculosis. When my
mother was sick, nobody came to visit us. The neighbors

were afraid to catch tuberculosis, and we had a hard time
trying to make them believe she was cured. I am not
afraid of tuberculosis. It is not a good thing to have,

but it can be cured. It is not like in the past.

INTERVIEW 14

8/3/82

Municipio: Ciales

Barrio: Ciales Town
Sex: Female
Age: 37

I suspect my father has tuberculosis. His wife
might have transmitted the disease to him. Thirty years

ago, she was married to‘a man who right now has been under

109

treatment for TB for a year. Few months ago she had
tuberculosis diagnosticated in New York, but she does not
want to follow any treatment. Her tuberculosis is the
direct result of her evil wish for her husband to contract
tuberculosis.

The disease is transmitted when a person coughs

or talks and can be cured with adequate medicines.

INTERVIEW 15

8/3/82

Municipio: Ciales

Barrio: Cordillera
Sex: Male
Age: 60

I was born in Cordillera and have always lived
here. When I was seven years old my father died of
tuberculosis. In that neighborhood my family was only
one more affected by the disease. Other members of the
family that were not living with us also died of tubercu-
losis.

Tuberculosis is transmitted through the personal
contact with the sick person. It can also be transmitted
by touching personal belongings. A person with tubercu-
losis should be isolated to avoid transmission. The

disease can be cured only in some cases.

110

INTERVIEW 16

8/8/82

Municipio: Ciales

Barrio: Jaguas
Sex: Male
Age: 52

I was separated from my mother when I was five
years old. She had tuberculosis and was only 25 years old.
I don't know who my father is. I went to live with my
grandparents. My mother was living alone attended by
members of the family who took turns to care for her. I
used to go to visit her, but I was only permitted to
talk with her through a window in her bedroom. Sometimes
she was too weak to talk. One day she died after years
of suffering.

I don't know how the disease is transmitted, but
I know that it can be cured with some drugs. There are

not so many persons with tuberculosis these days.

INTERVIEW 17

8/8/82

Municipio: Ciales
Barrio: Jaguas
Sex: Female

Age: 51

111

My uncle died of tuberculosis last year. He did
not finish his treatment. He is not the first member in
the family to die of tuberculosis. Thirty-five years
ago the family lost two of its members who were victims
of the disease.,

Tuberculosis is transmitted by the bacteria of the
tuberculosis when the sick person talks or coughs. The

disease can be cured with drugs.

INTERVIEW 18

8/8/82

Municipio: Ciales

Barrio: Hato Viejo
Sex: Female
Age: 68

Both of my parents died of tuberculosis. Three
years after my father died, my mother died. I was three
years old. I don't remember them. I lived with my uncle.
In those years, almost every family had one member with
tuberculosis. There were no cures for the disease, and
everybody was afraid to get it.

I don't know how the disease is transmitted, but
close personal contact seems to help. New medicines are

used now for the treatment and cure of the disease.

112

INTERVIEW 19

8/3/82

Municipio: Ciales

Barrio:‘ Jaguas
Sex: Female
Age: 78

My mother died of tuberculosis forty years ago.
At that moment, my mother was fifty years old. I took
personal care of her. I have always been strong. I
have never had tuberculosis.

Tuberculosis is a disease transmitted by cough,
sometimes is sufficient to talk to a sick person to get
the disease. Tuberculosis can be cured with good
nutrition and medicines.

INTERVIEW 20

8/7/82

Municipio: Ciales

Barrio: Cordillera
Sex: Female
Age: 49

My sister is a tuberculosis patient. She has been
under treatment for a year. She lives in Cordillera too.
In our family she is the first case of tuberculosis. When
the doctor told her she had TB, she came to me crying and

very nervous. It took a while for her to accept she had

113

tuberculosis. We all felt better when the doctor told us
that the treatment is effective and she can be cured. At
this point she feels better, not as weak as she was feeling
before. She has less than one year to go to finish the
treatment.

Tuberculosis is transmitted by coughing. Can

be cured if it is discovered on time.

INTERVIEW 21

8/7/82

Municipio: Ciales

Barrio: Fronton
Sex: Female
Age: 76

Three of my brothers died of tuberculosis. The
family was living in Fronton. In ten years, we lost them.
They were 35, 40 and 45 years old. All of them had
families, and the three widows had tuberculosis also. But,
they received treatment. One of them finished treatment
two years ago.

I think that tuberculosis is transmitted when you
live with a person who has the disease. The cure is possible

if the person follows the treatment.

114

INTERVIEW 22

8/7/82
Municipio: Ciales
Barrio: Cordillera
Sex: Female
Age: 67
My brother Tomas died of tuberculosis thirty
years ago. He was 25 years old and lived in Jaguas with
his wife. He was the first case of tuberculosis in my

family. Five years after his death my husband had
tuberculosis. I was very afraid thinking that he was
going to die. But he was put under treatment over a long
period and he was cured.

Tuberculosis is transmitted by the personal contact

with the sick. The disease can be cured with medicines.

INTERVIEW 23

8/6/82

Municipio: Ciales

Barrio: Pesas
Sex: Male
Age: 69

My father's two brothers died of tuberculosis
_about 45 or 50 years ago. They were living with their

families in Utuado. We were living there too, but when

115

they died my father did not want to stay in Utuado any more.
He said that the coolness of the mountains made his brothers
sick. We moved to Vega Baja and there were people dying
of tuberculosis too. Twenty years ago, I came to Ciales
with my family and the neighbors were telling me about all
the people who had tuberculosis here. It seems that the
whole island had tuberculosis. '

Tuberculosis is transmitted when a sick person
coughs. It can be cured with medicines and a long

treatment.

INTERVIEW 24

8/9/82

Municipio: Ciales

Barrio: Pozas
Sex: Female
Age: 80

When I was a teenager, my father died of tuber-
culosis. During his sickness, he was living with us in
the same house, but he spent most of the time in his
bedroom. I remember there was a separate glass, plate,
a set of forks, spoons, and knives just for him. My
mother didn't let me get too close to him. She was
afraid I was going to catch the disease. My father's
sickness lasted two years. He died in the house. The

day of the funeral another person was buried victim of

 

116
TB too.
Tuberculosis is transmitted by the close contact

with the sick person. The disease can't be cured.

INTERVIEW 25

8/7/82

Municipio: Ciales

Barrio: Cialitos
Sex: Female
Age: 71

My husband and I were living in Cialitos 33 years
ago when he died of tuberculosis. In the 40's, we did not
have good treatment for TB. My husband spent six months in
a sanatorium where he died. I visited him every day.

The hospitals were full with tuberculosis cases.

Tuberculosis is transmitted if you live in close
contact with the sick person. Today it can be cured.

There are not hospitals for tuberculosis any more.
INTERVIEW 26

8/10/82

Municipio: Manati
Barrio: Coto Norte
Sex: Male

Age: 71

117
My brother died of tuberculosis when there was a
cure for the disease but he never wanted to go to a doctor.
He said it was a waste of time. He never received any
treatment, and he kept working for as long as he could.
Tuberculosis can be cured with medicines. Nobody should
die of tuberculosis anymore. I don't know how it is trans-

mitted.

INTERVIEW 27

8/10/82

Municipio: Manati
Barrio: Coto Norte
Sex: Female
Age: 68

My cousin died when she was thirty years old.
When the TB was diagnosticated in her, she was put under
treatment. She had to take some pills every day. But
she didn't take the medicine as instructed.. She didn't
eat well and didn't take care of herself. Sometimes I
wonder if she wanted to kill herself.

Tuberculosis can be cured with some medicines,
but the sick person has to cooperate and follow the

treatment .

118

INTERVIEW 28

8/10/82

. . . (
Mun1c1pio: Manati

Barrio: Coto Norte
Sex: Male
Age: 60

When we were living in Fajardo, twenty years
ago, my wife had tuberculosis. I was very afraid because
my mother died of tuberculosis when I was a child. But
my wife was put under medical treatment for two years and
she was cured. During those two years, she had to take
a drug with a strange name every day. She wanted to live
for our children, and eventually she finished the
treatment. Now she has a chest X-ray taken every year, and
she is healthy.

Tuberculosis is transmitted by coughing. It

can kill, but with treatment can be cured.
INTERVIEW 29

8/10/82

Municipio: Manati
Barrio: Cato Norte
Sex: Male

Age: 86

119

My wife was a TB patient twenty years ago. She
was cured because luckily by the time she got sick there
was cure for tuberculosis. Now she has medical examination
every year. Other members of her family in Aguadilla
had tuberculosis but for some of them the cure didn't get
on time.

Tuberculosis is transmitted when a sick person
coughs or sneezes. The disease can be cured with special

drugs for tuberculosis.
INTERVIEW 30

8/10/82

. . . l
Mun1c1pio: Manati

Barrio: Cato Sur
Sex: Female
Age: 57

My grandfather died of tuberculosis fifteen years
ago. He always insisted that he did not have TB, but
pneumonia. For that reason, he did not want to receive
any treatment for tuberculosis. I think that he was
afraid to have the disease and did not want to recognize
that he had it.

Tuberculosis is transmitted when the sick person

coughs. The disease can be cured under medical supervision.

120

INTERVIEW 31

8/11/82

0 I O I
Mun1c1p10: Manati

Barrio: Coto Sur
Sex: Female
Age: 72

My daughter was a TB patient ten years ago. She
received treatment with antituberculosis drugs and now she
is cured. At the beginning she did not know she had
tuberculosis, but she was feeling weak and had fever
without any other symptoms. When she went to the doctor
the last thing she expected to hear was tuberculosis.

We thought this was a disease of the past. It is
surprising to know that there are still people with this
disease on the island.

Tuberculosis is a disease transmitted by a bacilus
when a sick person coughs, talks or sneezes. The disease

can be cured with antituberculosis drugs.

INTERVIEW 32

8/11/82

Municipio: Manati
Barrio: Manati Town
Sex: Male

Age: ' 69

 

121

My parents were living in Monte Bella (Taro Negro)
when they died of tuberculosis. My father died first, and
two years later, my mother died. They were under treatment
for a period of time, but it seems that it wasn't the best
treatment. They died anyway. My sister who was living
with them told me that sometimes they refused to take the
medicine because they were cured already and tired of the
medicine.

I don't know how the disease is transmitted. I

don't think that the disease has any cure.

INTERVIEW 33

8/11/82

Municipio: Manati

Barrio: Cato Sur
Sex: Female
Age: 80

I lost two sons who had tuberculosis. We were
living in Ponce at the time. In a period of five years,
they both died. They were in their twenties. In the 1940's,
the treatment for tuberculosis did not exist. The common
practice was to put the person in a clean place, feed her
or him and pray. The advancement of medicine didn't
get here on time to save my two sons. But I know that

other people were more lucky and are cured now.

122

Tuberculosis can be mortal without treatment.

This disease is transmitted when the sick person coughs.
INTERVIEW 34

8/11/82

Municipio: Manati

Barrio: Manati Town
Sex: Female
Age: 67

My husband was a tuberculosis patient fourteen
years ago. He received treatment from the clinic in
Manati and now he is cured. I have been in contact with
tuberculosis since my childhood. Two of my uncles died
of tuberculosis when I was a child. One of them was
living in Ciales and the other in Utuado. My husband
enjoyed better times since he was able to receive
treatment and be cured.

Tuberculosis is transmitted when a sick person

coughs. The treatment with drugs is very effective.
INTERVIEW 35

8/16/82

Municipio: Manati

Barrio: Rio Arriba Saliente
Sex: Female

Age: 85

123

I had eleven brothers and sisters, four of whom
died of tuberculosis when they were young. It was a very
common disease, and I know that many of my neighbors at
that time had it. The symptoms were always the same:
the person looked thin and pale, had fever every day and
was coughing all the time, sometimes with blood. I am
glad that now there is a cure for the disease. It is a
bad thing to have.
Tuberculosis is transmitted when a sick person coughs

or talks. It can be cured with antituberculosis drugs.
INTERVIEW 36

8/11/82

Municipio: Manati

Barrio: Manati Town
Sex: Male
Age: 86

I was born in this town and I have been living
here all my life. In the past, I have lost neighbors and
good friends all of whom were victims of tuberculosis.

In the past, so many people were dying of tuberculosis
that I thought I was going to be one of them at some
point. The tuberculosis problem was aggravated by the
economical situation. Many people did not have anything
to eat. I always managed to feed my family. Sometimes,

we only had beans and cornmeal but we were eating.

124

Maybe that is the reason why none of us got TB.

I am not familiar with how the disease is
transmitted. I know that there is a treatment for TB,
but I don't know how it is. I think that a good

nutrition helps.
INTERVIEW 3 7

3/12/32 1

Municipio: Manati

 

Barrio: Manati Town E
Sex: Male
Age: 89

I lost my wife thirty years ago to tuberculosis.
Her cause of death was identified at that moment. She
never wanted to go to a doctor and kept working until
the end. My son, who is 67 now, was a TB patient fifteen
years ago. He received treatment and is cured.

Tuberculosis can be cured if it is discovered on
time. The drugs used in the treatment for tuberculosis
are very effective. The disease is transmitted by

coughing.

125

INTERVIEW 38

8/12/82

l
Municipio: Manati

Barrio: Manati Town
Sex: Male
Age: 78

We have never had any tuberculosis case in our
family, but our friends and neighbors have died of the
disease. I took care of my best friend when she got sick
with tuberculosis forty years ago. She was living in
Vega Alta, and I used to go there from Manati every day.
She was very thin and weak. It was a desperate situation
to me to see her dying and to not be able to do anything
about it. Here in Manati, we lost friends, and I think
the situation was the same on the whole island.

Tuberculosis can be transmitted by the contact
with the sick person's belongings. It is also transmitted
by coughing. In some cases the disease can be cured with

medicines.

INTERVIEW 39

8/13/82

Municipio: Manati
Barrio: Manati Town
Sex: Female

Age: 26

126

My cousin died of tuberculosis ten years ago. She
was only twenty—five years old. She was under treatment,
but apparently she didn't finish it. My grandmother had
TB also, but she finished her treatment, and now she is
cured.

Tuberculosis is transmitted by the tuberculosis
bacilus when the sick person coughs or talks. It can be

cured with drugs if the person finishs the treatment.
INTERVIEW 40

8/13/82

. . . l
Mun1c1p10: Manati

Barrio: Tierras Nuevas Poniente
Sex: Female
Age: 90
I have always lived here. I can tell you that

many years ago everybody had at least one member of the
family sick with tuberculosis. There was no treatment
for the disease, and many people died. We lacked the
proper diet which didn't help. I survived those years
and consider myself lucky. Today I live alone, close
to the place where I lost my husband fifty years ago.
He was another case of TB.

Tuberculosis can be cured if discovered in the
early stages. I don't know what kind of medicines are
used for that disease and I don't know how it is

transmitted.

127

INTERVIEW 41

8/13/82

. . . l
Mun1c1p1o: Manat1

Barrio: Bajura Adentro
Sex: Male
Age: 71

My father and my brother died of tuberculosis.
My father died in 1943, and my brother died twenty years
ago. When my father died, there was no treatment for
the disease. Not many people survived. But when my
brother died antituberculosis drugs were already used.
As many people, he never had time to go to a doctor. It
was a waste of time for him. When he decided to go, it
was too late then.

He wasn't living in Manati. He was living in
Ciales with his family.

Tuberculosis is transmitted when the sick person
coughs or talks. The disease can be cured with antituber-

culosis drugs.

INTERVIEW 42

'8/13/82

Municipio: Manati

Barrio: Bajura Adentro
Sex: Female

Age: 69

128

My oldest brother died of TB forty years ago. He
spent six months in a sanatorium and then two months in my
house where he died. My husband and I were living in
Jayuyas, and we took care of him. He didn't have anybody
else. I think he got the disease from his fiance who
died one year before he did. In those years, TB was a
terrible disease.

Tuberculosis almost always is fatal, but in some
cases it can be cured with drugs for tuberculosis. I

don't know how the disease is transmitted.
INTERVIEW 43

8/14/82

0 O I I
Mun1c1pio: Manat1

Barrio: Bajura Adentro
Sex: Male
Age: 94

My brother and a cousin died of tuberculosis.
They were in their thirties and were healthy looking people.
Their deaths were very close in time. It was a tragic
year for the family. I think it was 1938. We never
knew why it happened. They spent one year in New York
working, but things did not work out the way they expected,
and they came home. They were looking pale when they came,
but we thought it was the lack of sunshine that made them

look pale. Soon, it was discovered they had tuberculosis.

129

We could not do much, and three years later they died.
I am not familiar with the mode of transmission,
but I do know there are some medicines that can cure TB

if they are taken consequently.
INTERVIEW 44

8/14/82

. . . l
Mun1c1p10: Manat1

Barrio: Bajura Adentro
Sex: Female
Age: 73

My mother died of TB forty years ago. She was
fifty years old at that time, and we were living in
San Juan. The situation was very difficult for us.
My husband was unemployed, and my father was sick. He
suffered a heart attack. Everybody was in the same
situation. We considered to go to New York, but I knew
the cold weather was not going to be good for my mother
who always looked very sick. I did not know for sure
what she had, but I began to suspect TB. Some way she
managed to live five years more, but eventually she died.
Tuberculosis is transmitted by the close contact

with the sick person. The disease can't be cured.

130

INTERVIEW 45

8/14/82

Municipio: Manati

Barrio: Tierras Nuevas Salientes
Sex: Female
Age: 88

When I was young, my father became sick with
tuberculosis. He kept working for months. He said
there was no reason to stay in bed all day long.
Tuberculosis was a real problem on the island.

I don't know how the disease is transmitted. It

can be cured with medicines for tuberculosis.
INTERVIEW 46

8/15/82

Municipio: Manati

Barrio: Tierras Nuevas Saliente
Sex: Female
Age: 70

My mother died of tuberculosis thirty years ago.
The only kind of treatment that she ever received was
honey for the cough, and sometimes alcohol frictions for
the fever. She did not have confidence in anything else.

Tuberculosis can be transmitted by touching the
clothes of a person with tuberculosis. The disease can

be cured but I don't know how.

131

INTERVIEW 47

8/15/82

0 I e l
Mun1c1pio: Manat1

Barrio: Tierras Nuevas Ponientes
Sex: Female
Age: 78

My husband died of tuberculosis when he was forty.
He never was a strong individual. He always had some kind
of ailment. We did not pay too much attention to his
sickness which lasted years. We did not know how serious
it was. At his death we discovered that he was another
case of tuberculosis.

Tuberculosis is transmitted by coughing. It can

be cured with some drugs.

INTERVIEW 48

8/15/82

0 l e ‘
Mun1c1pio: Manat1

Barrio: Tierras Nuevas Ponientes
Sex: Female
Age: 80

My husband had tuberculosis twenty years ago.
He received treatment, and now he is cured. When he was
a child, his father died of tuberculosis. For that reason,

we were afraid of the disease. But luckily my husband

132

could benefit from the advances in medicine. Today, he has
to have a chest X-ray every year.
I don't know how the disease is transmitted. It

can be cured with antituberculosis drugs.

INTERVIEW 49

8/16/82
Municipio: Manati
Barrio: Tierras Nuevas Poniente
Sex: Male
Age: 70
When I first moved here in the 1950's my neighbor
died of tuberculosis. He was an old man who lived by

himself and was almost always drunk. He caused his own

death. Other people in the community had tuberculosis but

they were cured. They did not die of tuberculosis.
Tuberculosis is a transmissible disease that can

be cured with drugs for tuberculosis. I am not sure I know

how it is transmitted.
INTERVIEW 50

8/16/82

Municipio: Manati

Barrio: Rio Arriba Saliente
Sex: Female

Age: 74

APPENDIX B

QUESTIONNAIRE

133

My husband died of tuberculosis twenty-five years
ago. He was fifty years old at that time. He did not want
to go to the doctor. I was very afraid because I knew
his father had died of tuberculosis, and I recognized
the symptoms. He did not listen to me and died in our
house in the town of Ciales.

Tuberculosis can be transmitted by the close
contact with the sick person. The disease can be cured

with medicines for tuberculosis.

 

134

 

 

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BIBLIOGRAPHY

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