Reliability of involving community volunteers as DOT providers in DOTS strategy under RNTCP.

Set up: One Tuberculosis Unit (TU) in Tiruvallur district, Tamil Nadu, where Tuberculosis (TB) patients treated under Directly Observed Treatment Short Course (DOTS) programme. Objective: To assess the reliability and accountability of Government health workers and community volunteers as DOT Providers (DPs) and to assess treatment outcome and problems encountered by patients managed by different DPs and the acceptability of community providers in the RNTCP. Methods: The 189 DPs in the study area during the first and second quarters of 2005 and 303 patients who were treated by these DPs were interviewed. Univariate analyses were used to identify the factors influencing the success rate. Results: Of 303 patients treated, the success rates of the patients treated by Government DOT providers (GDP) and community DOT providers (CDP) were 85.3% (209/245) and 86.2% (50/58) respectively. The difference in the success rates by GDP and CDP was not statistically significant. Among the 259 patients who successfully completed treatment, 82% (172/209) under GDP and 84% (42/50) under CDP were regular for treatment and there was no association between the type of DOT providers and regularity of treatment. Conclusion: Community volunteers could be inducted as DPs into the DOTS strategy for efficient supervision and management of the patients.

Plasma Efavirenz in HIV-Infected Children Treated with Generic Antiretroviral Drugs in India.

We measured plasma concentration of efavirenz (EFV) in 16 HIV-infected Indian children receiving antiretroviral treatment at Government ART centres. The mean 12-hour concentration was 2.39 μg/mL (range: 0.72- 7.82 μg/mL). The majority of children treated with generic EFV at currently recommended doses had blood levels within the therapeutic range.

Assessment of X-ray Readers in TB Prevalence Surveys.

A prevalence study was carried out a rural community in Tiruvallur district in Tami Nadu to standardize the method of assessing an X-ray reader in tuberculosis (TB) prevalence surveys by means of different measures of agreement between the reader and a Standard Reader (SR). The exercise on assessing the X-ray readers was carried out on two occasions; one involving three trainee readers (R1, R2, and R3), and the other involving one trainee reader (R4). The extent of agreement was estimated using Kappa statistics (K), over-diagnosis, under-diagnosis, crude agreement and prevalence adjusted bias adjusted kappa (PABAK). The overall performance of readers R1, R2 and R3 was not satisfactory in terms of K (21, 34 and 14%) in the first assessment. The K, over-diagnosis and under-diagnosis were estimated to be 61, 28 and 4% for R1, 63, 18 and 4% for R2 and 58, 31 and 5% for R3 in the final assessment. This suggested that R2 performed well compared to the other two readers. The K was 68% for R4 in the first assessment. As the over-diagnosis was to the extent of 40%, the trainee reader underwent one more assessment. The K was 64% which was as good as before, but there was no improvement in the over-diagnosis (43.5%) in the second assessment. Based on the performance, only one reader (R2) was certified as qualified for X-ray reading in the first occasion while the reader (R4) assessed in the second occasion was not qualified. These findings were subject to the inherent variation in the SR’s readings against which the readers were assessed.

'Primary cutaneous mucormycosis during induction chemotherapy in a child with acute lymphoblastic leukemia'.

We report a child with acute lymphoblastic leukemia who developed primary cutaneous mucormycosis at the site of lumbar puncture during induction chemotherapy. Though high mortality rates are reported with invasive mucormycosis, prompt biopsy, early identification and antifungal therapy using a combination regime of amphotericin-B and rifampicin along with extensive surgical debridement led to complete cure of the lesions in the index case.

Perceptions of tuberculosis patients about private providers before and after implementation of revised national tuberculosis control programme.

Background: Most of the persons with chest symptoms in India approach private providers (PPs) for health care. It has been observed that patients who start treatment with PPs for tuberculosis (TB) frequently switch over subsequently to the public sector. The reasons for this discontinuation and their perceptions of the TB care provided by the PPs are unknown. Objective: To document the perceptions about PPs India’s Revised National TB Control Programme (RNTCP) and the reasons for discontinuation of treatment with PPs and subsequent attendance at a public provider. Methods: This was a cross sectional study on patients registered under TB programme during 1997 and 2005in rural and urban areas. During this period patients who were initially diagnosed and treated for TB in a private clinic and subsequently shifted to public health facility were considered for the study. A semi-structured interview schedule was used to collect the factors related to patient’s perceptions on PPs, the factors responsible for initiating treatment with PPs, reasons for discontinuing treatment with PPs, and their willingness to continue treatment from government health facilities were collected. This data was compared with data collected in 1997 before implementation of the RNTCP. Results: A total of 1000 and 1311 TB patients were registered during 1997 and 2005 respectively. Among them, 203 (20%) and 104 (8%) patients were identified as having been initially diagnosed and started on TB treatment by PPs and subsequently shifted to government health facilities. There were significant changes in reasons for selecting PPs between the two periods: being convenient (47% vs 10%; p<0.001), quality care (41% vs 19%; p<0.001), motivated by others (49% vs 19%; p<0.001), confidentiality (19% vs 9%; p<0.05) and known doctor (6% vs 28%; p<0.001) respectively. Financial problems were the most common reason for discontinuation of treatment in both periods. The use of sputum test for diagnosing TB by PPs was significantly increased after RNTCP implementation. Conclusion: This study suggests that slowly perceptions of patients have changed towards PPs, and RNTCP has begun to gain acceptance amongst patients in terms of convenience, confidentiality and personal care.

Weight gain in patients with tuberculosis treated under directly observed treatment short-course (DOTS).

SET UP: One Tuberculosis Unit (TU) in Tiruvallur district, Tamil Nadu, India where Tuberculosis (TB) patients treated under Directly Observed Treatment Short Course (DOTS) programme. OBJECTIVE: To identify the effects of weight gain among TB patients at the end of treatment on different factors such as socio-economic and demographic characteristics, smoking and drinking habits, treatment under supervision, the type of DOTS centres and problems in taking drugs. METHODS: TB patients registered between May 1999 and December 2004 formed the study population. Multiple regression method was used for the analysis. RESULTS: Among 1557 smear-positive TB patients registered under DOTS programme, the changes in weight ranged from a loss of 4 kgs to a gain of 20 kgs at the end of TB treatment; the average change in weight was 3.22 kgs. The gain in weight at the end of treatment was associated with age (<45 years), DOT at government centres, no problems in taking drugs as reported by patients and cure rate. CONCLUSION: The findings showed that there is an association between gain in weight with DOT at government centres and cure of patients.

Annual risk of tuberculosis infection in Chennai city.

AIM: To study the proportion of children infected with Mycobacterium Tuberculosis in Chennai city. METHODOLOGY: A cluster sampling methodology was adopted to select an estimated sample size of 7000 children from five corporation zones selected systematically from ten zones of the city. A total of 7098 children aged 1-9 years were subjected to Mantoux and test read; 1897 (27%) from slum area and 5201 (73%) from non-slum area. RESULTS: The prevalence of infection among children without BCG scar was estimated to be 10.5 % (ARTI of 2.0%) and was similar to that among children irrespective of scar status. The prevalence of infection was higher among children in slum areas (11.1%; ARTI 2.1%) compared to non-slum areas (8.9%; ARTI 1.7%); but the difference was not statistically different. CONCLUSION: The tuberculosis situation in Chennai as measured by risk of infection was higher in urban city area than rural areas and comparable to that found in other cities as reported from earlier studies. This information can be used as baseline information for monitoring the epidemiological trends in Chennai city in future.

Survival of tuberculosis patients treated under DOTS in a rural Tuberculosis Unit (TU), south India.

OBJECTIVE: To estimate survival probabilities and identify risk factors for death of tuberculosis (TB) patients during treatment period. METHODS: TB patients registered during May 1999 to December 2004 from a rural TB unit (TU) with a population of 580,000 in Tiruvallur district, South India, formed study population. Life table and Cox's regression methods were used. RESULTS: Of the 3818 TB patients who were initiated on treatment, 96, 94 and 97% of category--I, II and III respectively, were surviving after completion of treatment. Higher death rates were independently associated with patient's age (45 years), previous history of treatment, alcoholism and initial body weight (<35 kgs). CONCLUSION: The survival probability was found to be similar in all patients irrespective of categorization. Necessary actions need to be initiated in the programme to improve body weight and abstain from alcoholism.

Hemispherotomy for intractable epilepsy.

Context: Hemispherotomy is a surgical procedure for hemispheric disconnection. It is a technically demanding surgery. Our experience is presented here. Aims: To validate and compare the two techniques for hemispherotomy performed in patients with intractable epilepsies. Settings and Design: A retrospective study 2001-March 2007: Nineteen cases of hemispherotomies from a total of 462 cases operated for intractable epilepsy. Materials and Methods: All the cases operated for intractable epilepsy underwent a complete epilepsy surgery workup. Age range 4-23 years (mean 5.2 years), 14 males. The seizure frequency ranged from 2-200 episodes per day; four were in status; three in epilepsia partialis continua. The pathologies included Rasmussen's, hemimegelencephaly (unilateral hemispheric enlargement with severe cortical and subcortical changes), hemispheric cortical dysplasia, post-stroke, post-traumatic encephalomalacia and encephalopathy of unknown etiology. The techniques of surgery included vertical parasaggital approach and peri-insular hemispherotomy. Neuronavigation was used in seven cases. Results: Class I outcome [Engel's] was seen in 18 cases and Class II in one assessed at 32-198 weeks of follow-up. The four patients in status epilepticus had Class I outcome. Four patients had an initial worsening of weakness which improved to preoperative level in five to eight weeks. Power actually improved in three other patients at 32-36 weeks of follow-up, but hand grip weakness persisted. In all the other patients, power continued to be as in preoperative state. Cognitive profile improved in all patients and 11 cases returned back to school. Conclusions: Both techniques were equally effective, the procedure itself is very effective when indicated. Four of our cases were quite sick and were undertaken for this procedure on a semi-emergency basis.

Comparison of tuberculin reaction sizes at 48 and 72 hours among children in Tiruvallur district, south India.

SETTING: A rural population in Tiruvallur district, south India. OBJECTIVE: To study the variability of skin test reaction sizes between 48 and 72 hours. METHODS: A tuberculin test survey was conducted among children aged less than 10 years. The reaction sizes were read by the same reader at 48 hours and 72 hours independently. The results of the tuberculin test were compared. RESULTS: Of 957 children aged below 10 years were included in the study; the male and female ratio was 1: 1.1. There were no significant differences between the readings of reaction size at 48 and 72 hours. CONCLUSION: The tuberculin test results can be read either at 48 hours or 72 hours without compromising the validity.

Risk factors for non-adherence to directly observed treatment (DOT) in a rural tuberculosis unit, South India.

OBJECTIVE: To identify risk factors for non-adherence of tuberculosis (TB) patients to DOT. METHODS: Retrospective study of TB patients by logistic regression analysis to identify risk factors for non-adherence. RESULTS: Of the 1666 patients interviewed, 1108 (67%) adhered and 558 (33%) did not adhere to DOT. Of 558 patients, the risk factors associated with non-adherence were illiteracy (39%), difficulty in accessing health facility (57%), and non-government DOT centre (43%). CONCLUSION: Patients should be educated about tuberculosis and importance of DOT. All DOT centres, including Non-government DOT centres, should be made more accessible and patient-friendly.