Whither Tuberculosis?: A Statistical Review of Reports from Selected American and European Communities

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  • 1)

    Tuberculosis mortality has been declining at an accelerated rate, especially during the past few years. Between 1945 and 1950, the death rate fell in England and Wales by 36 per cent; in the United States, 41 per cent; in Canada, 43 per cent; in France, 49 per cent; in Finland, 50 per cent; Italy, 53 per cent; Norway, 55 per cent; Denmark, 58 per cent; Sweden, 63 per cent; Iceland, 71 per cent; and in the Netherlands, 78 per cent.

  • 2)

    Tuberculosis morbidity, on the other hand, has tended to remain on a high level: 100,772 new cases reported in the United States in 1940 and 121,228 in 1950; in Canada, 10,226 formerly and 12,429 lately; in England and Wales, 49,967 notifications ten years ago and 52,062 last year; in Denmark, 2,687 new pulmonary cases in 1940 and 2,507 in 1950. Effective prevention of tuberculosis obviously remains elusive so far.

  • 3)

    Improved forms of treatment in tuberculosis are responsible for the lowering of “community case fatality rates” which ranged between 50 and 60 per cent in 1940, but were reduced in 1950 to 31 per cent in England and Wales, 29 per cent in Scotland and in Canada, 28 per cent in the United States, and only 20 per cent in Denmark.

  • 4)

    Children have generally enjoyed greater reductions of tuberculosis mortality than older groups of the population. Their death rate in the United States, in spite of an increasing concentration of population in urban, congested centers and large Negro groups has been steadily reduced. Among those under 15 years of age, in the year 1949 it averaged for the entire country 3.9 per 100,000. In the state of Minnesota, it was as low as 1.3. Abroad, the same year, the death rate of the children in Denmark was 3.6; but, in Norway, it was 8.1; and in England and Wales 12.1.

  • 5)

    BCG vaccination has been widely used in the Scandinavian countries—little in Iceland—and only very recently to any extent in the United States or in England and Wales.

  • 6)

    In the state of New Jersey, special measures for the protection of school children—periodic x-ray examination of school personnel along with tuberculin testing and x-raying of pupils annually—resulted in 1949 in reducing the death rate of children under 15 to 2.7 or only one-third of that prevailing in Norway. The death rate of the children in Denmark was 44 per cent of that of Norway.

    Appreciative acknowledgments are due particularly to the following European authorities who promptly made available their latest tuberculosis data: Miss Julie E. Backer, Chief of the Demographic Section of the Norwegian Central Bureau of Statistics; Dr. Konrad Birkhaug, former Director, National B.C.G. Laboratory, Bergen, Norway; Dr. Tobias Gedde-Dahl, Secretary-General, Norwegian National Tuberculosis and Public Health Association; A. Koller, Director, Swiss Federal Bureau of Statistics; Prof. Giovanni L'Eltore, General Secretary, Italian Federation Against Tuberculosis; Valter Lindberg, Central Statistical Office, Finland; Miss Marie Lindhardt, Head, Statistical Section, The National Health Service of Denmark; Dr. John Lundquist, Secretary-General, Swedish National Association against Tuberculosis; Dr. Sigurdur Sigurdsson, Medical Director, Tuberculosis Control, Iceland; Dr. Norman Smith, Deputy Senior Medical Officer, Ministry of Health, England; Dr. J. Ch. W. Verstege, Deputy Director General, Netherlands Central Bureau of Statistics.

Section snippets

PART I MORBIDITY DECLINING AT LESSER RATE THAN MORTALITY

Tuberculosis mortality, it must be acknowledged, is declining at the present time at an accelerated rate. A review of reports from a selected number of countries and large areas reveals particularly in 1950 unusually low tuberculosis death rates: In the United States, 22 per 100,000 population; in Canada, 26; in Sweden, 22; even in Iceland, 20. Preliminary reports for part of 1951 indicate a further striking decline; it may even be estimated, if one considers only the white population of the

Recent Changes

It is especially during the very last few years that tuberculosis mortality has been falling at an accelerated rate. If one compares the change in the death rates in the last five years, namely between 1945 and 1950, declines are found to range anywhere, in the areas surveyed, from 32 per cent to 78 per cent—except in Spain and Portugal where there has been little improvement. The lower percentage of decline, 32 per cent, was noted in Scotland where between 1946 and 1949 a new epidemic of

Scandinavian Countries

Of particular interest are the present tuberculosis death rates in the Scandinavian countries. In 1950, the following rates were prevailing: In Finland, 93; in Norway, 29; in Sweden, 22; in Iceland, 20; in Denmark, 14; and, in the Federal German Republic (Western Germany) the rate was 39.

During the five years from 1945 to 1950, in Norway the death rate came down from 65 to 29, or by 55 per cent; in Sweden, it fell from 59 to 22, or by as much as 63 per cent; and, in Denmark, from 33 to 14, or

Changes, Past Twenty Years

If one reviews the tuberculosis mortality over a longer period, for instance during the 20 years between 1930 and 1950, in the communities whose reports are at hand it will be seen that the decline in their rates has ranged anywhere from only 16 per cent in Spain, to 91 per cent in Iceland. In the United States, the tuberculosis death rate fell from 71 in 1930 to 22 in 1950, or by 69 per cent; in Canada, by 67 per cent; in England and Wales, by 59 per cent; in France, by 63 per cent.

Actual Prevalence of Tuberculosis

In countries where there have been active campaigns against tuberculosis there is, on the whole, undoubtedly a lesser prevalence of the disease. Tuberculin-testing surveys, especially in the United States, reveal a lower proportion of infected children, though not necessarily so among adults. It would be a serious mistake, however, to conclude because of the fast declining mortality that the disease is now prevailing on similar low levels. Unfortunately there are only limited data available

Influence of Mass Surveys on Registration of Cases

Before commenting further on the probable reason for the differences between morbidity and mortality trends we must answer the possible criticism that the rise in registration of new cases is due to the increased number of mass chest x-ray surveys for the detection of tuberculosis. But, close study of the findings in mass surveys will show that the contribution they make to the registration of cases is fairly limited. For instance, during 1949 and 1950, in New York City the Department of Health

Trend of Hospitalization

With regard to morbidity from tuberculosis and its trend, there are unique figures for the United States to be had from the reports of the Council on Medical Education and Hospitals of the American Medical Association. Annually, this responsible authority conducts a survey of the number of patients in various types of hospitals throughout the country. During 1930 a total of 80,846 tuberculosis patients were admitted to the then 511 tuberculosis institutions, reported the Council (Table II). In

“Community Case Fatality”

Another measure of the influence of treatment in modifying mortality rates is readily to be had by studying the relationship between the rate for new cases and the death rate in the communities for which reports are at hand with regard to registration of both cases and deaths.

In the United States, in 1930, when there were 124,940 new cases of tuberculosis registered, the deaths from tuberculosis numbered 88,010, indicating what might well be called a “community case fatality” of 70 per cent (

PART II HOW MUCH CONTROL OF TUBERCULOSIS IN CHILDREN?*

Just as infant mortality, generally speaking, is a sensitive index of general health conditions, so in tuberculosis the incidence particularly of active cases among children is a prime index of the prevalence of tuberculosis in the community.

Experience has shown that the main factors in controlling tuberculosis in children, as well as in adults, are the following: First of all, adequacy of hospital facilities for the isolation particularly of open cases of tuberculosis; second, elimination of

Mortality Among Children

Detailed figures very kindly made available by Backer, the Chief of the Demographic Section of the Central Bureau of Statistics of Norway, and Lindhardt of the Danish National Health Service, permit interesting precise evaluation, at least from the angle of mortality, of the prevalence of tuberculosis in these two countries for ready comparison with similar information for the United States as a whole and especially for the State of New Jersey where, as just mentioned, additional steps have

Death Rate Among School Children

It would seem from the data available that in New Jersey the effect of the special regulations for tuberculin testing, x-raying, examination of school personnel and of school children, has been to accelerate the decline of tuberculosis mortality to a greater extent than for the entire United States. In 1938, the year prior to the enactment of the law in New Jersey previously quoted, the tuberculosis death rate among children 5–14 years old in the United States was 6.6 per 100,000 and that of

Death Rate Among Young and Older Children

The detailed reports from Norway and Denmark permit close comparisons of particular groups of children during the past 20 years. During the five-year period 1931-35, in Norway the average annual tuberculosis death rate of children of both sexes under five years of age was 55 per 100,000 population; by 1949, this had been reduced to 12 (Table VI, part 1). In Denmark whereas formerly the rate for these young children was 50, lately it was 6 (Table VI, part 2). During those years, the tuberculosis

Twenty-year Changes

The greater benefits accruing to children from the conditions and measures against tuberculosis in the United States may be gauged from the following broader review of the mortality records here and abroad during the 20-year period 1930-1949.

In 1930, in Norway deaths from tuberculosis at all ages numbered 4,197 and those of children under fifteen 414, the latter being therefore 9.9 per cent of the total mortality. A similar proportion of nearly 10 per cent existed in Sweden. In Denmark at that

New York City Children

Incidentally, it is of interest to see what was the death rate in New York City in 1949 among children under 15 in comparison with the rate of 8.1 in Norway.* Here in this highly congested center of almost 8,000,000 people including a Negro population of 750,000, the tuberculosis death rate among children the same year was only 3 per 100,000. In a child population of over a million and a

Hospital Facilities

Reference has already been made to the importance of hospital facilities in the control of tuberculosis. It is therefore important to set down here a few reports as to their extent in some of the countries or areas under discussion.

According to recent correspondence in the Journal of the American Medical Association (January 27, 1951): Norway, “With a population of only a little more than 3,000,000 is now endowed with more than 100 tuberculosis cottage hospitals or homes with more than 3,000

BCG Vaccination

Passing reference having been made in this review to BCG vaccination, it is therefore pertinent to mention a few figures relative to the frequency of its use. First, in the United States it must be said that the use of BCG has been rather limited until recently.

In New York City, in 1926, a study was undertaken by the Department of Health, under the direction of Park.11 Over a period of a few years 1,011 children were vaccinated; they were all from tuberculous families. In Chicago, Rosenthal12

RESUMEN

  • 1)

    La mortalidad por tuberculosis ha venido descendiendo a un paso acelerado, especialmente durante los últimos años. Entre 1945 y 1950 el índice de mortalidad en Inglaterra y Gales fué de 36 por ciento; en los Estados Unidos de 41 por ciento; en el Canadá de Sweden National Association against Tuberculosis; Dr. Sigurdur Sig43 por ciento; en Francia de 49 por ciento; en Finlandia de 50 por ciento; en Italia de 53 por ciento; en Noruega de 55 por ciento; en Dinamarca de 58 por ciento; en Suecia de

RESUME

  • 1)

    La mortalité tuberculeuse a diminué dans des proportions accélérées, surtout dans ces toutes dernières années. Entre 1945 et 1950, les statistiques de mortalité ont diminué de 36% en Angleterre et dans le pays de Galles, de 41% aux Etats-Unis, de 43% au Canada, de 49% en France, de 50% en Finlande, de 53% en Italie, de 55% en Norvège, de 58% au Danemark, de 63% en Suède, de 71% en Islande, et de 78% aux Pays-Bas.

  • 2)

    D'autre part, la morbidité tuberculeuse a tendance àrester àun niveau élevé:

REFERENCES (19)

  • SnellW.E.

    “Immediate Results of Sanatorium Treatment,”

    Lancet

    (1951)
  • De AbreuManoel

    “Diagnostic et Traitement précoces, Facteurs décisifs dans la Prophylaxie de la Tuberculose,”

    XI Conf. Union Internationale contre la Tuberculose, Copenhague

    (1950)
  • MyersJay Arthur

    “Tuberculosis Prophylaxis,”

    Dis. of Chest

    (1951)
  • VorwaldA.J.

    “BCG Vaccination in Silicosis,”

    Am. Rev. Tuberc.

    (1950)
  • DubosRené J. et al.

    “The Effect of Diet on Experimental Tuberculosis of Mice,”

    Am. Rev. Tuberc.

    (1948)
  • DubosRené J.

    “Biological and Social Aspects of Tuberculosis,”

    Bull. New York Acad. Med., June

    (1951)
  • LindhardtMarie

    “Tuberculosis Statistics, The Fight against Tuberculosis in Denmark,”

    Nat. Assn. Against Tuberc., Copenhagen

    (1950)
  • DroletG.J.

    “Tuberculosis—Year 1950, Changing Forms of Treatment,”

    A Report to the Tuberculosis Sanatorium Conference of Metropolitan New York

    (February 20, 1951)
  • BarnwellJohn B.

    “Care of the Tuberculous Veteran,”

    J.A.M.A.

    (1951)
There are more references available in the full text version of this article.

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Respectively Consultant Statistician and Assistant Statistician, New York Tuberculosis and Health Association

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