Occurrence of Pulmonary Tuberculosis in Supposedly Screened Selectees

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1) Mobilization Regulations 1-9 contain the physical standards designed to exclude active or potentially active tuberculosis from the armed forces. As currently written these regulations exclude any type of tuberculosis believed to be active, and also scarred, infiltrative tuberculosis exceeding a total area of 5 sq. cm. in conventional “flat” films. They permit acceptance of men with scarred, apparently arrested lesions of less than this extent, provided stability has been confirmed by at least six months’ observation. They permit acceptance of small, calcified lesions of arrested primary tuberculosis without question and leave to the judgment of qualified medical examiners decision as to acceptance or rejection in the case of large or numerous calcified lesions. 2) (a) Results in excluding tuberculosis from the Army are indicated in reports from National Headquarters of the Selective Service System and several induction stations based on experience in 1940, 1941, and 1942. In the majority of reviews reported the rate of rejection has been about one per cent after initial screening by the local selective service boards. The rejection rate has been slightly higher for colored registrants (1.3 per cent) than for white. During the period of increasing utilization of roentgenography in induction stations the national rate for rejection for tuberculosis rose. However, recent liberalization of standards as regards calcified lesions has reduced the rejection rate appreciably. (b) Current unpublished statistics from National Headquarters of the Selective Service System record a total local board and induction board tuberculosis rejection rate of slightly over one per cent in registrants. The rejection rate for 18- and 19-year-old registrants is definitely lower than that of all ages combined, averaging 0.68 per cent in a sampled group. 3) Of the individuals rejected for tuberculosis in the examination of all registrants about one-half might be estimated as inactive cases, potentially significant. The other half, including many advanced cases already known or detectable by other means, are made up largely of cases of minimal active tuberculosis that would have escaped attention without x-ray examination. 4) The extent of error in the screening process has been studied by: (1) Re-reading 53,400 x-ray films of accepted men, which are filed with the Veterans Administration in Washington. These films were made in the months of April to September, 1942, and were sampled from 89 of 90 to 95 induction stations in operation at the time. The review indicated that during this period approximately 1500 cases of active tuberculosis per million men were being overlooked. Errors were considered due to lack of skill on the part of some roentgenologists, speed, fatigue, monotony, and clerical error. (2) Analysis of 360 case records of tuberculous soldiers admitted to Fitzsimons General Hospital from January 1, 1943, to June 30, 1943. These men had been accepted originally as free from tuberculosis in 81 induction stations. The cases were classified on admission to the hospital as 42 per cent minimal, 37 per cent moderately advanced, and 21 per cent far advanced. It was not estimated that tuberculosis was present on admission to the Army in all of these cases. However, a sampling of 100 cases showed that tuberculous lesions were present in 66 and not definite in 34 at the time of induction. Several films in the latter group were of such inferior quality as to be inadequate for diagnosis. In 17 of the positive group the lesion was moderately or far advanced. (3) Analysis being currently made of discharges from the Army on certificate of disability. 5) Army induction station x-ray examinations have revealed a large amount of tuberculosis and have been of value also in the detection of significant nontuberculous diseases. As noted, some cases of tuberculosis have escaped discovery in the induction stations. Symptoms or subsequent routine Army examinations have resulted in discovery of the majority of these cases before great advance has occurred. A recent survey indicated that approximately 30 per cent were diagnosed within one month and nearly 80 per cent within six months. 6) Routine chest x-ray films are required on every individual at time of discharge from the Army. It may reasonably be anticipated that this procedure will result in discovery of the vast majority of previously undiscovered cases of tuberculosis admitted to the Army or developing after induction. 7) More than 10 per cent of the total population of the country will have been x-rayed in the physical examinations incident to military service. Approximately 150,000 men will have been rejected for tuberculosis. Thousands of these open cases will undergo treatment with resultant arrest of a great number of cases and prevention of further spread of the disease.