Final Report of PGIMER Epidemiological Study of cancer cases in Talwandi Sabo block

Final Report
An Epidemiological Study of cancer cases
Reported from villages of
Talwandi Sabo block,
District Bathinda, Punjab

Conducted by:

School of Public Health
Department of Community Medicine
Post Graduate Institute of Medical Education & Research
Chandigarh 160012, India


=======================================================
ABBREVITIONS

Abbreviations Full Name
As Arsenic
Cd Cadmium
Cr Chromium
Ni Nickle
Se Selenium
Hg Mercury
DDT Dichloro Dipheny Trichloroethane
BHC Benzene Hexachloride
AIDS Acquired Immuno Deficiency Syndrome
ppm Parts per million
OR Odds Ratio
ND Not Detected
NGO Non Government Organization
CBO Community Based Organization
USEPA United States Environment Protection Agency
COPD Chronic Obstructive Pulmonary Disease


========================================

Investigators

Dr. J.S Thakur
Assistant Professor
Department of Community Medicine,
PGIMER Chandigarh
Prof. Rajesh Kumar
Head
Department of Community Medicine,
PGIMER Chandigarh
Prof.Arvind Rajvanshi
Head
Department of Gynecological Pathology
PGIMER Chandigarh
Field Staff
Dr. Prabh Sharan Singh, MBBS

Dr. Arwinder Singh, MBBS

Dr. Mahesh Singla, MBBS

Mr. Rajesh Paul, M.Sc

Mr. S.S Sangwan, M.Sc

Mr. Harsarbjit Singh, MA

Mr. Manoj Kumar, M.A

Mr. Deepak Kumar, M.A

Mr. Bhupinder Singh, B.Sc

Mr. Amarjit Singh, B.Sc

Mr. Rajinder Singh, B.A

Mr. Par minder Singh, B.A

Ms.Sukhmail Kaur, B.A

Ms. Akhwinder Kaur, B.A




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Contents

Executive Summary 1-2

Introduction 3

Objectives 3

Methodology 4-7

Results 8-43

Discussion 44-49

Recommendations 49-51

Reference 52

Annexures 53-68

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ACKNOWLEDGMENT

It is our proud privilege to express a sense of gratitude to Professor K.K. Talwar, Director, PGIMER Chandigarh for allowing the faculty and staff of the institute to participate in the study. We thank Mr.Tripal Inder Singh Baja, MLA & Chairman Punjab Pollution Control Board, Patiala for reposing confidence and entrusting this study to us. We are also grateful to Mr. Malwinder Singh, Member Secretary, Punjab Pollution Control Board, Patiala for his valuable guidance. We also express our sincere thanks to Prof. B.D Gupta, Former Professor and Head, Department of Radiotherapy, PGIMER, Dr. G.L. Goel, Director Health Services, Punjab and Er.Manmohanjit Singh, Chief Engineer Public Health Punjab, Members of Technical committee of this project for guidance and critical review of the project over a period of time. Prof. Gupta could also spare his valuable time for editing this report.

We thank Er. N.S.Tiwana, Executive Director, Punjab State Council for Science and Technology, Dr.S.k Goyal, Civil Surgeon, Bathinda and Dr. Rana Harinder, Civil Surgeon, Roop Nagar for their guidance and help.

We express our special thanks to dr. (Mrs.) H.K. Parwana, Senior Scientific Officer and other Scientific and field officer of Punjab Pollution Control Board (PPCB) for their valuable support and suggestions. Special thanks are also due to SMO's of Talwandi Sabo, Morinda and Chamkaur Sahib, representative of panchayats for extending their active support in fieldwork, without their assistance this study would not have seen possible.

We extend our gratitude to Dr. K.S. Sandhu, Director Punjab Horticulture Post Harvest Technology Centre, PAU, Ludhiana for laboratory support for the project. We are also thankful to Dr. Jai Raj Behari, Scientist (F) ITRC, Lucknow and their support staff namely Mr. B.K. Singh, Mr. Satgur Parsad, Mr. Ramesh Chander, Ms. Poonam Saxena, Dr. Rakesh Kumar and Mr. Ranjan Kumar for evaluation of heavy metals and pesticides in water, vegetable. Blood and urine samples.

We are also thankful to Prof. Suresh Sharma, Head, Deptt. Of Radiotherapy, PGIMER Chandigarh, Head, Deptt. Of Radiotherapy at Acharya Tulsi Regional Cancer Treatment and Research Institute, Bikaner and Mohan Dai Oswal Cancer Hospital Ludhiana respectively for allowing us to retrospectively review of their records and of patient data.

Last but not the least we are indeed very grateful to staff of Community Medicine and Cytology and Gynecological Pathology department for their assistance.

Prof. Rajesh Kumar
Head
Department of Community Medicine
PGIMER CHANDIGARH

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Executive summary

In the developed world, life expectancy has increased substantially during the last century. Deaths due to infectious diseases also declined in these countries whereas deaths due to cancer and other cardiovascular diseases increased. With the rising socio-economic status, similar health transition is occurring in some of the developing countries. In India, though infectious diseases continue to be a public health problem but an increase in the occurrence of non-communicable diseases has also been noted particularly in urban areas and in economically advanced states.

Citizen groups has observed a rising trend of cancer deaths in jajjal and Giana villages of Bathinda District. Punjab Health Department conducted a preliminary inquiry and found that the prevalence of cancer cases in these villages is similar to the other parts of India. The reasons for higher number of cases were attributed to better awareness about the diseases and availing of medical facilities for its diagnosis. As local population has suspected water to be cause of this problem, Punjab Pollution Control Board tested the water samples and found traces of DDT and BHC in the canal-based water supply. However, these insecticides were not detected in the underground water. Based on these preliminary observations, it was decided that Community Medicine Department of PGIMER Chandigarh should conduct an epidemiological study to investigate weather cancer cases are higher in Talwandi Sabo block of District Bathinda compared to other areas and if that is the case then what are the possible causes of this problem?

A house-to-house survey was conducted in Talwandi Sabo Block in Bathinda District and Chamkaur Sahib Block of Roop Nagar District to identify the number of existing cancer cases, and the number of cancer deaths that have occurred in last 10 years. Cancer cases and deaths were found to be significantly higher in Talwandi Sabo compared to Chamkaur Sahib Block. The prevalence of confirmed cancer cases was 103 per lakh at Talwandi Sabo (107/85315) and 71 per lakh at Chamkaur Sahib (71/97928). Cancer of female reproductive system, i.e., breast, uterus/cervix and ovary were more common in Chamkaur Sahib Block. Cancer deaths per lakh per year were 52 in Talwandi Sabo compared to 30 per lakh at Chamkaur Sahib.

A comparison of the characteristics of randomly selected individuals, from the villages where a cancer cases existed of death due to cancer had occurred in last 2 years, revealed that involvement in cultivation, pesticides use, alcohol and smoking were more common in Talwandi Sabo Block as compared to Chamkaur Sahib Limited studies show that in drinking water the levels of heavy metals such as As, CD, Cr, Se, Hg were generally higher, and pesticides such as heptachlor, ethion, and Chlorpyrifos were also higher in samples of drinking water, vegetables, and blood in Talwandi Sabo as compared to Chamkaur Sahib.

The cancer cases and deaths are higher Talwandi Sabo probably due to more use of pesticides, tobacco and alcohol. It is found that multiple factors were responsible for cancer cases in the Talwandi Sabo area. Therefore, a multi-pronged strategy to provide safe water supply, discouraging the indiscriminate use of pesticides. Tobacco and alcohol is recommended. A cancer registry should be established in the region for monitoring the trend of cancer cases in future.

==============================

Recommendations: As cancer cases and deaths are significantly higher in Talwandi Sabo due to multiple factors such as indiscriminate use of pesticides, tobacco and alcohol, the technical committee of the project recommended that

Agriculture Department should educated people involved in agriculture about pesticides storage, use, and proper disposal of the empty pesticides containers. Steps should be taken so that pesticides are used judiciously and safely.

Public Health Department should monitor the level of pesticides and heavy metals in drinking water periodically and monitoring reports should be communicated to Director, Health Services for necessary action

Local Health Authority designated by Health Department under the prevention of food Adulteration act should monitor the level of pesticides and heavy metals in food

Medical colleges/institutions should set up a cancer registry in the state for monitoring the trend of cancer cases and should also enhance prov- ision of screening, diagnosis and treatment facilities for cancer cases.

Health Department should start a Non-Communicable Diseases Control Programme focused on behavior change communication so as to change the harmful life styles, i.e. tobacco, alcohol, and other substance abuse.

A comprehensive study of the status of environmental health in other cotton growing areas of Punjab should be conducted for which a scheme may be prepared in consultation with Punjab Pollution Control Board and forwarded to Ministry of Environment and Forests for the sanction of founds.

==========================

Introduction

Cancer patterns very not only throughout the world but also between different population groups within the same country including India. With the control of infectious diseases and increased longevity of the growing population in a country like India the spectrum of diseases is changing and the burden of cancer is on the increase. Of the ten million new cases of cancer diagnosed every year over half and from the developing world. It is estimated that by the year 2020, over 10 million people worldwide would die of cancer every year and that 70 percent of these would be from the developing world. Study of the magnitude and patterns of cancer is the first step in determining clues to the cause of cancer and in having a baseline to plan and Asses control measures. Epidemiologic studies help in knowing what is happening and what can be done about it. In India, though infectious diseases continue to be a public health problem but an increase in the occurrence of Non-communicable diseases has also been noted particularly in urban areas and in economically advanced states.

Punjab is one of India's most prosperous states. This prosperity has been largely due to its success in the agriculture green revolution. Seventy percent of the population is directly or indirectly associated with agriculture. As per 2001 census, 70% people live in villages and 30% in the urban areas. The villagers of Jajjal and Giana of Talwandi Sabo Block had reported increased occurrence to unhygienic living condition and poor quality of drinking water. Preliminary investigation conducted by Punjab Health services, and Punjab Pollution Control Board (PPCB) was inconclusive (report in annexure 1). Hence a study was planned to find out weather the cancer cases are higher in Talwandi Sabo as compared to Chamkaur Sahib and if it is so, than what were the possible reasons for the same?


Objectives
Detailed study was planned with the objective to find out.
Whether cancer cases are higher in the area of Talwandi Sabo Block?
If yes, what are the possible reasons for increased occurrence of cancer in this area?

3. Methodology

3.1 Area

In this study the number of cancer cases in Talwandi Sabo Block of Bathinda district (study) was compared with those in Chamkaur Sahib Block of Roop Nagar district (control). The reasons for selection of Chamkaur Sahib Block as a control or reference area were similar socio-economic conditions butt different cropping pattern and source of drinking water.


Parameter
Talwandi Sabo
Chamkaur Sahib
Rationale of Selection
Water supply
Canal Water
Underground water
To see if canal water is responsible
Cropping pattern
Cotton
Rice/Wheat
Cotton needs more pesticides/insecticide

Study: 36 villages of Talwandi Sabo Block of Bathinda district were surveyed, starting at Talwandi Sabo and proceeding concentrically till the required sample size was achieved.

Control:93 villages of Chamkaur Sahib block of Roop Nagar district were surveyed; starting at Chamkaur Sahib and proceeding Concentrically till the required sample size was achieved.

3.2 Study Design: Ecological cross sectional study followed by a case control study.

3.3 Household Survey:

A total sample size of 356000 (178000 at Talwandi Sabo and 178000 at Chamkaur Sahib) was calculated on the basis of estimated cancer prevalence of 1.1/1000 in the unexposed population and 1.4/1000 in the exposed population with 95% confidence level and 80% power. It was to detect 25% difference in the exposed and unexposed populations. In the mid term review of the project by the technical committee, it was observed that prevalence of cancer was about two times higher at Talwandi Sabo as compared to cancer prevalence at Chamkaur Sahib. So it was decided to reduce the sample size, thus a sample of 85315 at Talwandi Sabo and 97928 at Chamkaur Sahib was surveyed.

3.3.1 Study Tools:

(a). Village Profile Proforma: A detailed villages wise environmental profile of the area was made pertaining to the cropping pattern, water and food sources including local as well as outside sources of food for the last 30 years period to see the trend over a period of time (annexure 2).

(b). Household Proforma: A pre-designed and a pre-tested questionnaire was used to survey families in both the areas. It included history of symptoms of cancer, information about deaths in the family during the last 10 years (1993-2003) above the age of 5 years and self reports of various life style diseases like cancer, diabetes, stroke, cardiovascular diseases etc (annexure 2).

(c). Verbal diagnosis report: For any suspected case of cancer in the family, a detailed verbal diagnosis report, I.e., symptoms, signs, investigation and treatment was written which was reviewed by two physicians to make the diagnosis of cancer ( annexure 4).

(d). Verbal autopsy report: To find out the cancer deaths in the area, all the deaths above 5 years of age over last 10 years were enlisted and cause of deaths was assigned by verbal autopsy method by a physician (annexure 5).

3.3.2. Survey Teams: Two teams having 4 surveyors and I supervisor each with one physician conducted house-to-house survey. The staff had received 6-days intensive theoretical training and one week field training. They were sent for field surveys after the investigator were convinced about their competence for undertaking the activity.

3.3.3 Survey Techniques: The supervisor filled the village profile proforma by recording the information given by the village sarpanch / panch (head of village or member of village committee) about village population, cropping pattern, water sources and food sources. Each surveyor visited about 30 families per day recording the name of the head of family, all the family members above 5 years age with their age and sex, any history of chronic diseases (Hypertension, Heart Diseases, Stroke, Diabetes, Cancer, Asthma, HIV/AIDS) and any person with following symptoms i.e. a non healing ulcer of blister in mouth, unusual bleeding or discharge from genital tract in women, lump in the breast, difficulty in swallowing or indigestion, continuing of cough and hoarseness of voice, change in bowel or bladder habits and change in wart or mole. If there was any member in the family who had any of these symptoms, the symptoms and signs, investigation and treatment taken was inquired. For deaths in the family in last 10 years above the age of 5 years then verbal autopsy form was filled noting the sequence of events leading to death of the person. Physicians reviewed the case reports and categorized the detected cases and deaths into confirmed benign tumor, confirmed malignant tumor, suspected benign tumor, suspected malignant tumor and no cancer.

3.4. Laboratory investigation: Relevant laboratory investigation were undertaken which included examination of surface and ground water for heavy metals and pesticides, vegetable and fruits testing for pesticides, blood and urine examination was also done. The sampling was done for three months from March 2004 to May 2004. Three samples each of tap, ground and vegetable/fruits were taken from study and reference area. Three samples of blood (2 from cases and 1 from a control) and three urine samples (2 from cases and 1 from control) were taken in the month of May 2004 from each of the study and reference area.

3.5 Case Control Study: Case was defined as any person living or dead who has any of the seven symptoms of cancer (described earlier) and was diagnosed as having cancer by a qualified medical practitioner or died due to cancer in year 2002-03 in the area.

3.5.1 Sample size: A total of 179 cases were selected from Talwandi Sabo and 129 from Chamkaur Sahib who were histologically. Proven cancer cases/deaths and 264 controls were chosen from Talwandi Sabo and 182 from Chamkaur Sahib. Out of 179 cases at Talwandi Sabo, 83 were histologically confirmed cancer cases and 96 were cancer deaths in the year 2002-03. Similarly, out of 129 cases at Chamkaur Sahib, 46 were cancer cases and 83 cancer deaths. Controls were selected from the same village randomly by matching age group, sex who had no sign/symptom of cancer. For each case two age group and sex matched control (1:2) with one control from Talwandi Sabo and second from Chamkaur Sahib were taken. The number of controls selected from both the areas were higher because initially controls were also selected for clinically diagnosed cases. Although some people refused on first visit however on subsequent visit they agreed to participate in the study.

3.5.2 Method of data collection: A pretested questionnaire was used for collection of information from cases and controls regarding source of water, health profile, use of pesticides, dietary habits, life style and menstrual history (in case of females only) (annexure 6).

3.6 Exclusion Criteria: Camps were organized at Talwandi Sabo and Chamkaur Sahib to confirm clinically suspected cancer cases by biopsy/FNAC. Those who were found to have no cancer were excluded from the study. Only histological proven cancer cases were taken into consideration.

3.7. Data entry and analysis: Every from was given a code number and data was entered in EPI INFO 2000 and SPSS package. The data was further crosschecked and analyzed using standard statistical methods.

3.8 Quality Control: Following measures were taken to maintain the quality of data

O The supervisor independently re-assessed one death per village per surveyor and physician checked one death per village randomly

O Physician reviewed the work done by surveyor and supervisor every week.

O Regular feedback was given to supervisors and surveyors about the quality of the work done.

O Re- survey of one village per team covered by other team to check quality of work.

O All diagnosed and suspected cancer cases were visited and verified by physician.

O Camps were organized at Talwandi Sabo and Chamkaur Sahib for confirmation of the suspected cancer patients.

O Retrospective study of the recorded cancer cases belonging to study and control are registered in following institutes i.e. PGIMER Chandigarh (Radiotherapy Deptt), Acharya Tulsi Das Regional cancer Research institute, Bikaner and Mohan Dai Oswal Cancer Hospital, Ludhiana
4. Results/observations

4.1. House Hold Survey Results

A total population 1,83,243 was surveyed consisting of 39,732 families in 129 villages. A total of 7,441 deaths were recorded which occurred in last 10 years (1993-2003). The crude death rate in Talwandi Sabo area was 4.48 as compared to 3.69 per 1000 for Chamkaur Sahib. Similarly, the crude death rate of adults>15 year was 4.7 per 1000 at Talwandi Sabo as compared to 4.5 per 1000 at Chamkaur Sahib (p<0.05). n="489" n="314" href="http://sr.no/" target="_blank">Sr.No.
Chronic Disease

Prevalence per 1000 population

Talwandi Sabo
N=85315
Chamkaur Sahib
N=97928
p-value
1.
Hyper tension
42.3
34.6
< n="36" n="93" n="179" n="264" n="443" n="129" n="182" n="311"> 0.05) (table 9).

Table 10
Sex distribution of cases and controls

Sex

Talwandi Sabo (T.S)

Chamkaur Sahib (C.S)

Cases
N=179
Controls
N=264
Total
N=443
Cases
N=129
Controls
N=182
Total
N=311
Male
66
(36.9)
86
(32.6)
152
(34.3)
45
(34.8)
55
(30.2)
100
(32.1)
Female
113
(63.1)
178
(67.4)
241
(54.4)
84
(65.1)
127
(69.8)
211
(67.8)
Figures in parenthesis are percentages

Table 10 shows the sex distribution of cases and control of Talwandi Sabo and Chamkaur Sahib. A total of 179 cases were selected from Talwandi Sabo out of which 66 ( 36.9%) were males and 113 (63.1%) were females. Similarly, 129 cases were selected from Chamkaur Sahib (reference are), out of which 45 (34.8%) were male and 84 (65.1%) were females (table 10). As shown in Table 11 sources of water used for drinking among cases and control were hand pump, canal water and tap water. The main source of water among cases at Talwandi Sabo was hand pump ( 61.5%) followed by tap water (41.3%). While at Chamkaur Sahib 78.6%) controls were using hand pump water and 23.6% tap water as source of drinking water (Table 11).

Table 11
Source of Drinking Water


Source of drinking water

Talwandi Sabo (T.S)

Chamkaur Sahib (C.S)

Cases
N=179
Controls
N=264
Total
N=443
Cases
N=129
Controls
N=182
Total
N=311
Hand pump
110
(61.5)
174
(65.9)
284
(64.1)
94
(72.9)
143
(78.6)
237
(76.2)
Canal Water
6
(3.4)
4
(1.5)
10
(2.2)
0
(0.0)
0
(0.0)
0
(0.0)
Tap water
74
(41.3)
94
(35.6)
168
(37.9)
36
(27.9)
43
(23.6)
79
(25.4)
Figures in parenthesis are percentage

Table 12
Perception of people about water pollution and water treatment
Variables

Talwandi Sabo (T.S)

Chamkaur Sahib (C.S)

Cases
N=179
Controls
N=264
Total
N=443
Cases
N=129
Controls
N=182
Total
N=311
Water pollution
57
(31.8)
59
(22.3)
116
(26.2)
3
(2.3)
4
(2.2)

7
(2.2)
Treated Water
8
(4.5)
5
(1.9)
13
(2.9)
2
(1.6)
1
(0.5)
3
(3.

Figures in parenthesis are percentage


Table 12 shows that 31.8% cases at Talwandi Sabo reported that the water used for various purposes including drinking was polluted, while among the controls at Chamkaur Sahib only 2.2% said so. The difference between the two was statistically significant (p<0.001). n="179" n="264" n="443" n="129" n="182" n="311" or="3.37(1.38-8.48)" n="179" n="264" n="443" n="129" n="182" n="311" p="0.001)" n="179" n="264" n="443" n="129" n="182" n="311" n="179" n="264" n="443" n="129" n="182" n="311" n="179" n="264" n="443" n="129" n="182" n="311" r="0.27(0.12-0.59)," x2="12.28" p="0.0004" p=" 0.0004)." n="179" n="264" n="443" n="129" n="182" n="311" p=" 0.0002)." p="0.01)." p="0.002)" n="179" n="264" n="443" n="129" n="182" n="311" p=" 0.001)." p="0.001)." n="179)" n="129)." n="264)" n="182)." n="3" n="3" n="3" n="3" n="3" n="3" n="179)" n="264)" n="129)" n="182)" n="4430" n="311)" or =" 2.70)." 1="Yes," 2="No" 1="Industry," 2="Chimney" 3=" other" 1="Yes," 2="No" 1="sewerage," 2=" industry," 3=" pond" 4="other" 1=" Tubewell," 2=" Handpump," 3="other" 1=" Canal" 2=" pond" 3="other" 1=" Yes," 2="No">_15
yrs .
Age
(Yrs.)
Sex
1=M
2=F
Is there any history
Of chronic diseases?
1=yes, 2=No
If yes.
Specify*
Suspected
Cancer
Symptoms**
(Write code)
No. Of
Deaths in
Last 10
Years
(8-N.A)
Form filled ( √- Yes, X-No)


Remarks
Suspected
Cancer form II A
Verbal
Autopsy
Form II B
Risk
Assessment
Form III

HH-Household. MM-Member
*Chronic disease:
1- Hypertension, 2-Heart disease, 3-Stroke, 4-Diabetes, 5-Cancer, 6-Asthma, 7-HIV/AIDS, 8-None
**Suspected cancer symptoms: Name of investigator____________

Signature_______________

2- A persistent change in digestive and 5- A swelling or sore that does not get better 8- A Excessive loss of blood at the
bowel habits1- A change in wart or mole 4- Blood loss from any natural orifice 7- A lump or hard area in the breast
period or loss of blood outside the usual dates

HH
No.
MM
No.

Age
(Yrs.)
Sex
1=M
2=F
Is there any history
Of chronic diseases?
1=yes, 2=No
If yes.
Specify*
Suspected
Cancer
Symptoms**
(Write code)
No. Of
Deaths in
Last 10
Years
(8-N.A)
Form filled ( √- Yes, X-No)


Remarks

Suspected
Cancer form II A
Verbal
Autopsy
Form II B
Risk
Assessment
Form III

==============================================

Annexure – 4

Cancer Survey, Bathinda

Department of Community Medicine, PGIMER, Chandigarh

Verbal Diagnosis Report

1. Household ID
2. Member ID___________
3. Name of the village_____________________________ Block District
4. Name of Household_____________________________________
5. Name of Respondent_____________________________________
6. Respondent's age in years_______________
7. Respondent's sex (Male –1, Female-2)
8. 8. Respondent's education (lIliterate-1, Literate (without formal education)-2,
Below primary-3, Primary-4, middle-5, Secondary/metric (class 10) –6, Hr
Sec/Sec/Class XII/Pre-univ-7, graduate and above-8, Unknown-9)
9. 9. Religion (Hindu-1, Islam-2, Christian-3, Sikh-4, Buddhist-5, Jain-6, No religion-7, other-9)
10. Occupation (Agriculture labour-1, Cultivator-2, Service-3, Business-4, Non worker-5 other-9)
11. 11. Main health services used during illness (Government hospital-1, private hospital-2, qualified professionals-3, Untrained functionaries-4, other-5, None-6, unknown-9)
11. Past history of cancer diagnosed by doctor. Yes-1, No-2
12. If yes, specify site of cancer
If there was any suspected cancer symptom as given in form –1, and/or past
History of cancer, then write verbal diagnosis report.
______________________________________________________________

______________________________________________________________

FOR MEDICAL REVIEW (CANCER)
Member Id


1. Cancer
1=Y, 2=N

2. If yes, site of cancer
Specify Details

3. Was some investigations done for diagnosis?
1=Y, 2=N

4. If yes, specify.
1=X-Ray, 2=Endoscopy, 3=Blood film,
4=Cytology, 5=Biopsy for histopathology
6=Clinical only, 7=other (specify)

5. Clinical extent of disease.
1=Localized, 2=Regional lymph nodes,
3= Direct extension, 4=other (specify)

6. If there was regional (Neek, Axilla,
groin etc) lymph node enlargement,
then specify site.
1=Neck, 2=Axilla, 3=Groin,
4=other (specify)

7. If Biopsy/Cytology, specify
a) Report_________________

b) ICDO
c) Site of tumor___________
d) TNM_______________


8. Have you any treatment taken for the same?
1=Y, 2=N

9. Is yes, Name of the Hospital.


10. Treatment received
1=Surgery, 2=Radiotherapy, 3=Chemo
therapy, 4=Combination, 5=Unknown

Name of Health professional______________________________

Signature___________________ Date_____________
========================================================================
Annexure-5

Cancer Survey, Bathinda

DEPARTMENT OF COMMUNITY MEDICINE, PGIMER, CHANDIGARH

Verbal Autopsy Report

12. Household ID
13. Name of the village__________________Code Block District
14. Name of Household_________________________________
15. Name of respondent_________________________________
16 Relationship of respondent with deceased (Head-1, Spouce-2, Son or Daughter
-3, Son-in law or Daughter in law-4, Grand child-5, Parent-6, Parent in law-7,
Brother/Sister-8, other relative-9 Neighbour/no relation-10)
17. Did the respondent live with the deceased during the illness
that led to death? (Definitely yes-1, definitely no-2, Unknown-9)
18. Was the respondent present at the time of death?
(Definitely yes-1, definitely no-2, Unknown-9)
19. Respondent's age in years_________________
20. Respondent's sex (Male-1, Female-2)
21. 10. Respondent's education (llliterate-1, Literate (without formal education)-2,
Below primary-3, Primary-4, Middle-5, Secondary/matric (class 10) –6, Hr
Sec/Sec/Class XII/Pre-univ-7, graduate and above-8, Unknown-9)
22. Deceased full name________________________________________
23. Sex (Male-1, Female-2):
24. Age at death days____ months_____ years____
25. Address: __________________________________________________________
_________________________________________________________________
26. Father's name/Mother's name/Spouse name__________________________
27. Date of Death (DD/MM/YY): _______/_____/______
28. Place of death (Home-1, Hospital-2, other place-3, Unknown-9):
29. 18. Main health services used during illness in the period leading to death:

(Government hospital-1, private hospital-2, qualified professionals-3,
Untrained functionaries-4, other-5, None-6, Unknown-9)
30. 19. Religion (Hindu-1, Islam-2, Christian-3, Sikh-4, Buddhist-5, Jain-6, No
religion-7, other-9)
31. Marital Status (Never married-1, Married-2, Remarried-3,
Widow / Widow-4, Divorced-5, Separated-6, Unknown-9)
32. 21. Education (llliterate-1, Literate without formal education-2,
Below primary-3, Primary-4, Middle-5, Secondary/matric (class10
-6, Hr Sec/Sec/Class XII/Pre-univ-7, graduate and above-8, Unknown-9)
33. Occupation (Agriculture labour-1, Cultivator-2, Service-3, Business-4, Non
Worker-5 other-9)
3.4 23. In your opinion what did this person die of (allow the respondent to Tell the illness in his or her own words):
____________________________________________________________________

35. Write Verbal Autopsy report for any death in the last 10 years in the family. Use separate page in case of more than one death in the family during the period.
Please describe the symptom in order of appearance, doctor consulted or hospitalization, history of similar episodes, report of the investigations if available.
______________________________________________________________
____________________

VA DIAGNOSIS FOR MEDICAL REVIEW

Underlying causes of death in words_________________________________________
Underlying Causes of death, ICD 10 (3 digit minimum):

Name of Health professional____________________________________

Signature__________________Date (day, month, year): _______________

=====================================================================
Annexure-5
Cancer Survey, Bathinda

DEPARTMENT OF COMMUNITY MEDICINE, PGIMER, CHANDIGARH
Environmental and Health risk assessment

Part A: GENERAL INFORMATION

1. 1. ID No.

2. 2. Household ID: Member ID:

3. 3. Proxy/Direct interview (with name): _______________________________

4. 4. Status Code (1= Cases, 2= Control):
5. 5. If case, write code1= Clinically suspected, 2= Histologically proven, 3=Cancer death.
6. 6. Name ___________________________________

7. 7. Father's/ Husband's Name: ___________________

8. 8. Age _________(Yrs.) Sex: 1=m, 2=F

9. 9. Address: Village: __________________ Mohalla Name: ____________
Tehsil/Block: ________________ District: ______________
10. Number of years residing in the present place? ______________ Yrs.

11. (a) If migrant, area/state from which migrated: _________________

(b) If migrant, write years of migrated: _____________

12. Locality of house (1= Residential area, 2=Industrial area, 3= Market place,
4=Farm land)
==============================================================================
PART B: ASSESSMENT OF ENVIRONMENATL QUALITY

A. A. Water pollution

1. What is the source of drinking water:
Source of drinking water
Percentage
Hand Pump

Canal Water

Tap (Govt. Supplies)

Other, specify


2. Do you think water is polluted? 1=Yes, 2=No
If yes, specify ____________________________________________________
3. Do you provide any treatment to water before drinking the water? 1=Yes, 2=No
4. If yes, specify the purification method used.
Purification method
Code: 1= Yes, 2=No
1. Boiling

2. Filter

3. Chlorination

4. Bleaching Powder

5. Specify others:

5. Where do you store the treated drinking water (specify the equipment used like utensils etc).

Utensils
Code: 1= Yes, 2=No
1. Pitcher

2. Hodi

3. Plastic Container

4. Aluminium Container

5. Specify others:

B: Occupational Exposures

1 a) Which is your usual occupational? Please give exact title of your Job.


Utensils
Code: 1= Yes, 2=No
1. Cultivator

2. Agriculture Labourer

3. Construction worker

4. Business

5. Service:

6. Specify other:



b) What kind of work do you do in the job? Your main activity:

c) Do you have to supervise other worker? 1=Yes, 2=No

2. Is your occupation is agriculture? (1=Yes, 2=No)

a) Do you use pesticides & insecticide? 1=Yes, 2=No

b) If yes, (I) For Rabi crop (hari)
1=Leader, 2=Topic, 3=Metsulfuro, 4=Orilolon, 5=Puma power
6=Tata mattery, 7=other (specify) _______________________
(ii) For Karif crop (Sauni)
1=Mono croto fas, 2=Imida Super, 3=Rogon, 4=Action-999,
5=Endo sulfan, 6=Ethion, 7=other (specify)
(iii) For Karif crop (Rice)
1=For eight,, 2=Pedam, 3=Hero don, 4=Beta carlo,
5=Anelo Phose, 6=Alert, 7=other (specify) ________________

c) Were you involved in spraying insecticides/pesticides? 1=Yes, 2=No
d) If yes, do you use any protective device while using pesticides or
insecticides? 1=Yes, 2=No
e) If yes, specify (1=Face mask.2=Cloth, 3=other specify __________)
f) For how many years do you use insecticides?
g) How many times to use the pesticides/insecticides in the last one year.
h) Were do you store insecticides/pesticides? (1=Home, 2=Farm)
i) Where do you make mixture for spraying insecticides? (1=Home, 2=Farm)
j) Where do you wash your utensils after spraying? (1=Canal water, 2=Home,
3=Farm water, 4=other, specify___________________)
k) On average how many hours do you work per day? ___hrs. ____min
i) Average hours of exposure to direct sunlight per day. ______hrs. ___min.

C. Industrial Air Pollution


1. Is there an industry close to your residence? 1=Yes, 2=No
2. If yes, (a) specify type of industry (N.A. =9) ______________
(b) Approximate distance of industry from your residence (in Km.)

3. How many smoke emitting factories are situated near your house?
4. How much is exposure to smoke. 1=Occasional, 2=Frequent

D. Diet
On how many of the last seven days did you eat each of the following foods?
In cash row, please give code of one of the choice given and specify quantity in gm/day:
1. Not at all in last 7 day 2. On one day only
3. Tow or 3 days in last 7 days 4. On most days

Freq. Quantity
Per in grams
a) Vegetables Week

1. Cauliflower
2. Cabbage
3. Reddish
4. Turnip
5. Brinjal
6. Peas
7. Potato
8. Green leaf vegetables
9. Beans
10. Other (specify)
b) Rice
c) Chapati
d) Parontha
e) Dal
f) Milk & its products
g) Tea
h) Fruits
i) Chicken
j) Mutton
k) Fish
l) Egg
m) Oil
1. Sarson oil
2. Vanaspati
3. Desi Ghee
4. other vegetable oil (specify)
n) Spices & Pickles



PART C: HEALTH ASSESSMENT FOR ADULTS

Ask the following question with code definite yes=1, definite no=2 and unknown=9

Case / Deceased
Code
1. 1. Did she/he smoke tobacco?
1 2 9

1.1 If yes, what type? Bidi=1, Cigarette=2, other Specify=3 ………
1 2 3 9

1.2 How may per day?


1.3 What age did she/he start? (age in years)


1.4 Did she/he ever quit smoking?
1 2 9

1.5 If yes, for how many yrs did they quit?
1 2 9

2. 2. Are you exposed to passive smoking?
1 2 9

2.1 If yes, specify the place.
1=Home, 2=Worksite,
3=Community
4=Other (specify)

3. 3. Did she/he chew tobacco
1 2 9

3.1 If yes, what type? Pan with tobacco (1),
Pan with out tobacco (2)
1 2 9

3.2 How many times per day?


3.3 What age she/he starts? (age in year)


3.4 Did she/he ever quit chewing?
1 2 9

3.5 If so, for how many yrs?


4. 4. Did she/he drink alcohol at least once
a week during most weeks?
1 2 9

4.1 If yes, number of days per week drink
Was taken (1 to7, or unknown-9)
1 2 3 4 5 6 7 8 9

4.2 If he drink alcohol, then write quantity
1=Pauwa, 2=Adhia
3=Full Bottle 4= __ml.

5. 5. Have you had yellowness of eyes?
1=Y, 2=N

6. 6. Have you ever been told that you had
Hepatitis B or C?
1=Y, 2=N

6.1 If yes, specify.
Hepatitis B=1, C=2

7. History of any drug abuse
1 2 9

7.1 Type of drug used


8. History of any unprotected sexual
1 2 9

9. Is there any baby in your family born with any congenital disorder?
1=Y, 2=N

9.1 If yes, specify.


10. Do you have any skin problem?
1=Y, 2=N

10.1 If yes, specify
================================================================

PART D: HEALTH ASSESSMENT FOR FEMALES

1. What was her age at menaeche (in years)? _____________Yrs.
2. What was her age at the time of marriage? _____________Yrs.
3. How many kids did she had? ___________
4. Whether the women had taken any contraceptive pills during her lifetime? 1=Y, 2=N
4.1 If yes, for how many years? __________Yrs.
5. Whether the women had taken any harmone replacement therapy? (1=Yes, 2=N)
5.1 If yes, for how many years? _____________Yrs.
6. Whether mother/sister of the deceased died of breast cancer (1=Yes, 2=No)

PART E: LAB INVESTIGATIONS

1.Whether his histology of tissues done? (1=Yes, 2=No)
2. Any other sample taken. 1=Urine, 2=Blood, 3=Both, 4=other


Consent of the interviewer:

I have been explained the objectives of the study entitled "An epidemiological study of cancer cases reported from villages of Talwandi Sabo block, District Bathinda. Punjab" By the investigator. Iherby give my consent to participate in the study.


Name of the investigator______________ Name of respondent_________

Date___________ Signature____________

Punjab in horrifying situation of environmental and health crisis

Punjab in ecological and health devastation: An activist perspective for mitigation

By Umendra Dutt

For the last three months, our visits to over 100 villages in Malwa region of Punjab have left us upset and speechless. Each one of these villages where my colleagues from Kheti Virasat Mission (KVM) and I spent time is in severe health crisis. During our visit, we noted that there was not a single village in Malwa which has not witnessed cancer deaths in last five years. I might not be and “expert” in the scientific sense; but being one who believes in nature’s glory, it is evident to me that that this present scenario is clearly a result of the environmental devastation caused by green revolution agriculture technologies and nature abusive developmental paradigm.

The village visits were at different points of time. For instance, during KVM's Water Literacy Yatra during third week of July we visited 21 villages in six districts Ferozepur, Faridkot, Muktsar, Bathinda, Mansa and Sangrur and interacted with farmers from around 50 villages. KVM had also did a preliminary survey in 55 villages of Faridkot district and apart from this we had an interaction with farmers in nearly 18 village or cluster level workshops on natural farming in Malwa.

Every where there is same miserable story; one can get the sorrow tales in whole of Malwa region, once called Makheon meetha Malwa The Malwa - sweeter then honey. But now things have been changed drastically.

What is most astonishing is dance of death by cancer every where. Every village has faced cruelty of deaths- young, old, married, single, man, women, rich, poor, farmer, laborer – there is no distinction. Even children are not spared. No discrimination at all. The death count starts from 4-5 and goes upto 60 or even more in a single village and one can find same number of cancer patients too.

What is important to note is also that cancer does not just bring death to a family but also carries burden of debt. Several farmers are forced to sell piece of their lands to get their wards treated properly. But then it is not just cancer which is chasing the people and their prosperity. We met large number of teenagers with gray hair, joint pains and other ageing abnormalities. It is very dark to see teenagers of fourteen and fifteen years developing such ageing effects. We also came across the several cases of childhood arthritis.

I have no words to spell the feeling which has shaken my spine during interface with youth.

Then there are diseases related to reproductive health, with women being the worst victims. The number of childless couples was also found to be alarmingly high. There is a related social baggage with this, as it is the women who have to bear the sufferings and is blamed for not being able to bear children. Most people don’t even know what went wrong in last few years and beyond imagination.

We also met quite large number of kidney patients, mentally challenged children, diabetic patients and young males with infertility in these villages. Most of people feel that the general graph of health is slumped significantly. They also added that despite their being hardly any medicine shop and hospital in the area, the number of diseases and death toll was much less earlier than now.

Aged people have seen the link. Interestingly, we found that their general perception was that all this doom began after introduction of chemical fertilizers and pesticides.

It is important to talk about this issue with reference to whole of Punjab or Malwa in this regard. Talking about a single village like Jajjal, Gyana or Mal Singh Wala will only present a distorted picture. When disease, death, debt and displacement become far-reaching and wide, one cannot help but delve into the gravity of the crisis. The fact is that whole of Malwa is on brink of ecological and environmental health collapse, which ultimately will lead to a severe economic, social and civilizational calamity.

Today, Punjab needs a fresh thinking and bold initiatives to deal with this reality. The present government needs to look beyond stereo-typed solutions. Here are few suggestions for that:

I. Research Project on Pesticide consumption and residue: As Punjab has one of highest levels of pesticide consumption in India, it subsequently has the highest pesticide load on its people and eco-system. Punjab is already facing severe adverse impacts of agro-chemicals used in last four decades. Now at this crucial juncture, the Punjab Government should take bold steps to ensure a safe environment and eco-system to the future of generations of Punjab. For this the Government should:

1. Complete a detailed study on pesticide consumption patterns in Punjab.
2. Ban aggressive marketing of pesticides including all forms of advertisements, publicity and promotion schemes for pesticides and other agro-chemicals. This needs to go along with a stop on all incentives given to the pesticide and agro-chemical dealers' network.
3. Raise awareness about the dangers of pesticide use through well-financed education campaigns. These must ensure the dissemination of information on ill effects of pesticides to all users.
4. The government should evolve an action plan for the immediate and time-bound phasing out of the most deadly pesticides: class I a, I b and II
5. The vital task of properly compiling residue data, already generated by the agriculture universities.

II. Epidemiological and environmental Mapping of Punjab : The first and foremost thing the government should do is to undertake a widespread and multicentric epidemiological and environmental mapping through an extensive study and participatory research, to assess the magnitude and specificity of ill-health especially due to contamination of food, water and air with pesticides and other chemical inputs of agriculture. At present there are no statistics available to know the type of health problems being caused by these poisonous agriculture inputs . In addition to that industry is shamelessly throwing its toxic waste in the water bodies-rivers, canals, seasonal drains, sewers and even in the groundwater through pits, wells and tube wells etc. Burning of fossil fuels is the third devil in this context. Strangely there is either no monitoring for these criminal acts or if it is there, no remedial action is taken. The latest revelations about gross pollution of Kali Benin, Buddha Nalah, Sutlej River and ground water of Ludhiana are well known. The people have a right to know the type and extent of damage being done to our water bodies by the polluting industry. We also want to know what type of health problems are being caused by these acts. But unfortunately there are no research/statistics to know all these vital facts.

This is particularly true about the long term and chronic ill-effects of these poisons like falling body immunity, increasing prevalence of various types of cancers, increasing incidence of spontaneous abortions, congenital abnormities in the new born children and many more.

The existing infrastructure of the health department for the collection, compilation and analysis of data about various diseases is very poor. This is even truer about these newer problems being caused by the toxic effects of various chemical poisons.

The statistics regarding acute poisoning which is also very common are available to some extent. But here also, the reported cases of acute poisoning are only a fraction of the total problem. The reason being that because of the police harassment and social stigma associated with poisoning, people don't come to the government hospitals because they are bound to report to the police (it is worth mentioning here that otherwise also only 25% of the sick people come to government hospitals for treatment).Private hospitals are not reporting such cases- neither to police nor to the health department. If the patient survives it is fine and if he or she dies it is silently cremated. It is an open secret that accidental acute poisoning because of the pesticides is quite common because the prescribed precautions are rarely followed while spraying or handling these insecticides.

These are newer health problems not taught to the doctors by standard textbooks. There is an urgent need to sensitize and train health professionals to identify such health problems and then to evolve the ways to treat, mitigate and educate the people to take preventive measures. This will be possible only if our doctors know the epidemiology of these diseases. To do that, we need public health specialists, who have been fully sensitized to these health problems. We should put at least one such epidemiologist in each district and appoint a team of senior and experienced epidemiologists at the state level to analyze the data and evolve a strategy for the entire state. As there are increasing numbers of reports that the prevalence of cancers has increased significantly, particularly in the cotton belt, the health department should spread awareness to make the cancer easily detectable and should make a cancer registry compulsory in all government and private hospitals.

III. Institute for Environmental Health Research and Studies : Considering the urgency of the situation, and also to act as a research support centre for the Environment Commission and for conducting the environmental audit etc., it is proposed that an Institute for Environment Health Research and Studies be setup. An eminent environmental epidemiologist of international repute and experience must head the institute; with its headquarters preferably at an area worst affected with acute environmental health problems, like Bhatinda. The institute should have regional centers in various regions of the state, and must work collaboratively with environmental, health and farmer-based organizations.

IV. Environmental Health Crisis Mitigation Task Force : Even while the assessment is being done, an environmental health crisis of this intensity can only be mitigated by large scale community intervention and participation. The Punjab government should form an Environmental Health Crisis Mitigation Task Force under the aegis of Institute for Environmental Health Research and Studies with the majority participation from NGOs and farmer groups. A senior Epidemiologist or Environmentalist should head this task force with powers minimum of the secretary rank of the government. This task force should be constituted by taking members from medical fraternity, social activists, and teachers of life sciences, farmers and experts from various governmental departments. The primary work of this task force would be to prepare and implement a Comprehensive Relief and Remedial Programme in the acutely affected areas. The entire medical fraternity and medical students must be involved in this programme to rejuvenate the health of the community. The medical fraternity needs to be sensitized and for that the syllabi of medical studies must be suitably augmented to include specific content on toxicology and contemporary issues.

V. Declare ecological and environmental health emergency in South Malwa: The southwestern Malwa region has been identified as facing the most severe environmental health crisis. The use of toxic chemicals is the highest in this belt. This entire area should be treated as a toxic hot spot. To focus its efforts, the government must declare and impose immediately the state of ecological and environmental health emergency in the entire belt. For this, specially drawn plans are needed with a specific focus on natural and organic farming, with adequately allocated funds for the targeted problem.

Establishment of cancer detection and Cancer Hospital in Malwa: Since cancer has emerged as a major health problem of Punjab, establishment of cancer detection centers and cancer treatment centers is the need of the state. For this, urgent funds may be provided to all medical colleges in the state to establish oncology departments. Post Graduate Institute for Medical Education and Research Chandigarh may be provided funds and asked to supervise establishment of these departments and to provide oncology physicians and surgeons and technical manpower for running the support facilities. In addition to this, Cancer Hospital must be established in Malwa to provide comprehensive advanced care to cancer patients. Presently there is no such center in this part of the country. Patients have to go to neighboring Bikaner and other places for basic treatment of cancer. At the same time, its oncology department may be expanded and upgraded to act as apex referral institution in the line of Tata Memorial Hospital , Mumbai for the patients referred from Medical Colleges and other hospitals in the state. In fact, this should be announced in the budget session of the Punjab assembly. This issue was identified by the SAD and has been promised in their election manifesto also.

The time is running short and so are the hopes of sustainability of Punjab. May some true son of Punjab having clout in government challenge to do some thing?