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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 23-26

Arrack shops as probable hot spots of tuberculosis transmission in urban Puducherry, South India: An exploratory study

Department of Preventive and Social Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission30-Sep-2019
Date of Acceptance17-May-2020
Date of Web Publication18-Aug-2020

Correspondence Address:
Dr. Mahalakshmy Thulasingam
Department of Preventive and Social Medicine, 4th Floor Admin Block, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJAMR.IJAMR_123_19

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Background: Alcohol use is common among male tuberculosis (TB) patients of Puducherry, particularly from lower socioeconomic strata who consume liquor from local arrack shops. These shops could be hot spots for the transmission of infection. Hence, this study aimed to explore whether arrack shops could be probable hot spots for the transmission of infection. Materials and Methods: An exploratory, descriptive study was conducted at three primary health-care centers in Puducherry, among male pulmonary TB patients using a pretested semistructured questionnaire. Home visits and visit to the arrack shop were made to assess for factors conducive to the transmission of TB. Results: Most of the patients belonged to lower socioeconomic status and consumed alcohol, mostly from arrack shops. The arrack shops had poor sanitation, were overcrowded, and multiple persons with TB visited the shop. Many had the behavior of spending more than an hour at the arrack shops. Conclusion: There is a possibility of TB transmission of at the arrack shops. Active case finding in the arrack shop may be beneficial.

Keywords: Arrack shop, hot spot, pulmonary tuberculosis, Puducherry

How to cite this article:
Singh S, Thulasingam M, Giriyappa D, Devasia JT, Sarkar S. Arrack shops as probable hot spots of tuberculosis transmission in urban Puducherry, South India: An exploratory study. Int J Adv Med Health Res 2020;7:23-6

How to cite this URL:
Singh S, Thulasingam M, Giriyappa D, Devasia JT, Sarkar S. Arrack shops as probable hot spots of tuberculosis transmission in urban Puducherry, South India: An exploratory study. Int J Adv Med Health Res [serial online] 2020 [cited 2023 Mar 29];7:23-6. Available from: https://www.ijamhrjournal.org/text.asp?2020/7/1/23/292394

  Introduction Top

As per the global tuberculosis (TB) report 2018, India accounts for about a quarter of the world's TB cases.[1] Heavy alcohol use is strongly associated with the risk of recent TB transmission and development of active TB.[2],[3] Such high risk is postulated to be due to the specific social mixing patterns and derangements in the immunity system caused by alcohol use.[2] Veerakumar et al. also in their study found that the prevalence of alcohol use disorder (AUD) to be higher among the TB patients in urban Puducherry. Three-fourths of the TB patients in Puducherry are male, and alcohol use was found in 54% of them. They also reported that in 2013, among the male TB patients of Puducherry the prevalence of alcoholism at the time of diagnosis was 59%.[4] In urban Puducherry, patients with TB who consume alcohol are mostly males from lower socioeconomic strata and are known to drink liquor from local arrack shops.[4] These shops sell Arrack, a low cost, distilled alcoholic drink typically produced in the Indian subcontinent and Southeast Asia, made from the fermented sap of coconut flowers, distinguishing it from commercially sold alcoholic beverages at liquor stores. There is a high likelihood that persons with TB come in close contact with each other in these arrack shops. Exploration of the TB transmission at these shops will help to frame measures for TB control. Hence, this study aimed to explore whether arrack shops could be probable hot spots for the transmission of TB infection.

  Materials and Methods Top

Study type and setting

An exploratory, descriptive study was conducted in the Puducherry district of the Union Territory of Puducherry, India. Puducherry, one of the districts of Puducherry (UT), has a population of 0.95 million and has one TB unit.[5] The annual TB case notification rate of Puducherry is 114 / 100,000, with treatment success of 89%.[6] The study was restricted to urban primary health-care centers (PHC). The study included males diagnosed with pulmonary TB and registered under the Revised National Tuberculosis Control Programme (RNTCP) from January 2017 to December 2017. Patients who were seriously ill and unable to respond to the interview were excluded from the study.


Since very few studies have explored the possibility of TB transmission at arrack shops, assuming 15% anticipated frequency with 10% absolute precision and 95% confidence interval, the sample size was calculated to be 49 individuals consuming alcohol using OpenEpi (Version 3.01; Emory University Atlanta, Georgia, USA). Convenience sampling was used to select three out of 27 urban PHCs in Puducherry. All eligible people were interviewed at their house after obtaining written informed consent. Those who could not be contacted even after two attempts were excluded from the study.

Study procedure

Participants were interviewed at the PHC/Anganwadi/participants' home according to the convenience of the participants. Participants were interviewed using a pretested semistructured questionnaire. The questionnaire included items on sociodemographic characteristics, housing condition, alcohol consumption behavior, and history of contact at home/neighborhood/workplace. The investigators also visited the arrack shops present in the PHC service area. Each arrack shop was visited thrice at different time points (morning, afternoon, and evening). The environmental conditions that affect TB transmission were observed and noted. The geocoordinates of the arrack shops were also noted. Digital global positioning system (GPS) was used for spatial data collection and spatial analysis, and visualizations were done in QGIS 2.18.

The study was reviewed and approved by the Institute Scientific Advisory Committee and Institute Ethics Committee. Permission was also obtained from the RNTCP panel and the State TB Officer.

Data collection and analysis

Data were entered and analyzed in Microsoft Excel 2013. Continuous variables were summarized as mean or median with standard deviation (SD) or interquartile range, respectively. Categorical variables were summarized as proportions. Spatial data of participants' household and arrack shops' locations were collected using Garmin 550 digital GPS. The GPS coordinates were imported into a shapefile using DNR Garmin software (Version 5.4.1; Minnesota Department of Natural Resources, Saint Paul, Minnesota, United States). GIS data was analyzed using QGIS (Las Palmas Version 2.18.33; Open Source Geospatial Foundation, Beaverton, Oregon, United States). The distribution of TB patients and arrack shops was visualized as dot maps and TB patients attending arrack shops were visualized as bubble maps.

  Results Top

Fifty patients with pulmonary TB were included in the study. The average age of participants was 49 (SD = 13) years. About 34% of the participants were employed in skilled jobs. One each was employed as a bar cashier and a laboratory technician at TB hospital. The median family income was 6000 INR [Table 1]. Majority of the participants' family size was four or less (72%), 66% lived in a pucca house, and 86% used liquid petroleum gas for cooking. Nearly half of the participants' house was overcrowded (52%). Eleven participants (22%) had a history of contact with TB. Of them, seven had contact at home from family members and four at the workplace. There was no history of contact in 39 (78%) participants, and of the 39 participants, 15 participants were consuming alcohol from the arrack shops.
Table 1: Socioeconomic characteristics of men with tuberculosis in the study area, (n=50)

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Around 74% (n = 37) of the participants were currently consuming alcohol, and 8% (n = 4) had quit alcohol use before the diagnosis of TB. The mean duration of alcohol consumption was 26 (SD = 11) years [Table 2]. Around 46% of current alcohol users purchased liquor from bars, and 29% purchased from the arrack shops. Approximately 20% bought either from bars or arrack shops depending on accessibility to the shop and their current financial situation. The rest 5% of them did not purchase alcohol and consumed alcohol only during parties. About 63% of participants consumed alcohol almost every day. Participants in lower socioeconomic strata preferred arrack shops as liquor was available at cheaper rates. In our study, it was noted that the mean individual income of participants who purchased alcohol from the arrack shop was lower (mean = INR 4250) than those who purchased alcohol from bars (mean = INR 17,000). The study participants reported that they spent around 30 min at the bars/arrack shops. Twelve participants (29%) said that they spent more than 1 h at the bar/arrack shops.
Table 2: Alcohol consumption behavior of men with tuberculosis in the study area

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Arrack shops are ubiquitous in Puducherry and are in high demand due to low cost of locally made alcohol. Five arrack shops were there in the study area. They were located in the periphery of a given area, although in a well-connected and approachable landmark. It was noted that 2–5 of the study participants with TB were visiting each of the arrack shops [Figure 1]. The arrack shop covered an area of around 2500 m2 and was fenced. It had a small built area where arrack was sold. The premises had arrangements for sitting and drinking. There were no washroom facilities. Hygiene of the site was poor, especially around the boundary wall where people were urinating. Waste materials were discarded indiscriminately in the area. The number of consumers in the arrack shop varied from 5 to 100. The shops were crowded from 8 a.m. to 10 a.m. and evening 4 p.m–8 p.m. The arrack shops were crowded with as many as thirty persons, (loosely packed), and most spent at least 4–10 h/week. Around 3–5 men were lying in an intoxicated state in and around the arrack shops. A few of them were noticed to be spending a significant part of the day, i.e., up to 8 h in the arrack shops. They spent their time sitting and drinking with their friends. On appearance, the age of the persons in the arrack shops varied from 20 to 70 years.
Figure 1: Map showing the distribution of arrack shops and the number of study participants with tuberculosis visiting each arrack shop

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  Discussion Top

Most of the study participants belonged to lower socioeconomic status, as indicated by a lower median family income. They consumed alcohol mostly from the arrack shops. Murray et al. developed a scorecard to assess the risk of TB transmission in various social gathering places. The scorecard was designed based on the sources of case, intensity, and duration of exposure and number of people exposed.[7] We compared the arrack shops with the scorecard developed by Murray et al.[7] for assessing the transmission risk at the various places of social gathering. Crowding and longer duration of time spent inside the arrack shop were the facilitating factors for the risk of TB transmission. The wide range of the age of the people who gathered at the arrack shops also increased the risk of TB transmission at arrack shops. Besides, 2–5 persons with TB visited each of these arrack shops. The positive aspect that lessened the TB transmission risk was that most of the arrack shop did not have a roof. A considerable number of participants spent more than an hour per day in the arrack shops.

Added to these environmental factors, heavy alcohol use of the contacts and high infectivity of index case due to poor adherence to treatment among alcoholics[8],[9] also makes the arrack shop a hot spot for TB transmission. In the United States, an outbreak of TB among regular patrons of a bar was reported. In the outbreak, the index case was a regular customer of the bar with highly infectious pulmonary TB.[10] It has been noted that contact outside the household is important for TB transmission.[11] Among alcohol users, these contacts often occur while drinking in social groups. Arrack shops could serve as sites for active for early identification of TB. The arrack shop salespersons should be involved in such case detection activities. The active screening could lead to improved case finding and control of transmission, thereby reducing the burden of TB disease.[12] Further studies need to be conducted to measure the impact of active case-finding for TB in arrack shops.

It is noted that default rates are higher among patients who consume alcohol. Since many such persons with TB visit the arrack shop, arrack shop owners/salespersons could be involved in encouraging patients to adhere to treatment. Such similar activities are undertaken in HIV control in the Sonagachi Project at Kolkata. In this project, all people involved in the sex work industry such as those who rent room for sex workers and those who arrange clients for sex workers, and local mafias were involved in condom promotion.[13] Since this is a cross-sectional study, temporal association between arrack shop as a source of infection and spread could not be established.

  Conclusion Top

There is a possibility of TB transmission at arrack shops. The involvement of arrack shop owners/sales persons for active case finding and for monitoring treatment adherence could be beneficial.


We are grateful to the State TB Officer, Puducherry, RNTCP Task Force, and Medical Officers of UHCs for granting permission to conduct this project.

Financial support and sponsorship

This project was awarded the GJ Straus by JIPMER, the award for UG student research projects.

Conflicts of interest

There are no conflicts of interest.

  References Top

WHO. Global Tuberculosis Report 2018. WHO; 2019. Available from: https://www.who.int/tb/publications/global_report/en/. [Last accessed on 2019 Sep 24].  Back to cited text no. 1
Rehm J, Samokhvalov AV, Neuman MG, Room R, Parry C, Lönnroth K, et al. The association between alcohol use, alcohol use disorders and tuberculosis (TB). A systematic review. BMC Public Health 2009;9:450.  Back to cited text no. 2
Lönnroth K, Williams BG, Stadlin S, Jaramillo E, Dye C. Alcohol use as a risk factor for tuberculosis – A systematic review. BMC Public Health 2008;8:289.  Back to cited text no. 3
Veerakumar AM, Sahu SK, Sarkar S, Kattimani S, Govindarajan S. Alcohol use disorders among pulmonary tuberculosis patients under RNTCP in urban Pondicherry, India. Indian J Tuberc 2015;62:171-7.  Back to cited text no. 4
Puducherry (Pondicherry) District Population Census 2011-2019, Puducherry Literacy Sex Ratio and Density. Available from: https://www.census2011.co.in/census/district/482-puducherry.html. [Last accessed on 2019 Sep 24].  Back to cited text no. 5
TB India Report 2018: Ministry of Health and Family Welfare. Available from: https://tbcindia.gov.in/showfile.php?lid=3314. [Last accessed on 2019 Sep 24].  Back to cited text no. 6
Murray EJ, Marais BJ, Mans G, Beyers N, Ayles H, Godfrey-Faussett P, et al. A multidisciplinary method to map potential tuberculosis transmission 'hot spots' in high-burden communities. Int J Tuberc Lung Dis 2009;13:767-74.  Back to cited text no. 7
Burman WJ, Cohn DL, Rietmeijer CA, Judson FN, Reves RR, Sbarbaro JA. Noncompliance with directly observed therapy for tuberculosis. Chest 1997;111:1168-73.  Back to cited text no. 8
Bagchi S, Ambe G, Sathiakumar N. Determinants of poor adherence to anti-tuberculosis treatment in Mumbai, India. Int J Prev Med 2010;1:223-32.  Back to cited text no. 9
Kline SE, Hedemark LL, Davies SF. Outbreak of tuberculosis among regular patrons of a neighborhood bar. N Engl J Med 1995;333:222-7.  Back to cited text no. 10
Classen CN, Warren R, Richardson M, Hauman JH, Gie RP, Ellis JH, et al. Impact of social interactions in the community on the transmission of tuberculosis in a high incidence area. Thorax 1999;54:136-40.  Back to cited text no. 11
Rangaka MX, Cavalcante SC, Marais BJ, Thim S, Martinson NA, Swaminathan S, et al. Controlling the seedbeds of tuberculosis: Diagnosis and treatment of tuberculosis infection. Lancet 2015;386:2344-53.  Back to cited text no. 12
Jana S, Basu I, Rotheram-Borus MJ, Newman PA. The Sonagachi Project: A sustainable community intervention program. AIDS Educ Prev 2004;16:405-14.  Back to cited text no. 13


  [Figure 1]

  [Table 1], [Table 2]


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