Effect of a Comprehensive Training Programme for Tuberculosis Health Care Providers and Tuberculosis Patients on Diabetes – A Report from South India.

Aims: High prevalence of diabetes mellitus (DM) in TB patients demands that TB health care providers are sensitized and updated on risk factors, screening, diagnosis and management of DM. This study was designed to assess the impact of one day training programme on screening, detection and management of DM. Study Design: One group – pre and post test design. Place and Duration of Study: The one day training session with an inbuilt awareness programme was conducted for TB health care providers and TB patients with diabetes, over a period of 3 years, from since November 2010 involving 22 tuberculosis units of 3 districts in Tamil Nadu, India. Methodology: The impact was assessed using a pretested questionnaire pre and post training, based on the improvement in knowledge among physicians and other health care providers and awareness among patients. Similarly, using a separate questionnaire before and six months after the training programme, improvement in practice was assessed based on an increase in the proportion of staff involved in screening, educating and referring TB patients with diabetes. Appropriate statistical analysis was done using SPSS version 16. Results: There was a significant increase in the knowledge of physicians and other health care providers and in patient’s awareness on all components covered under the training and awareness session respectively. No significant improvement was noted in the knowledge of other TB health care providers, in diet category on the questionnaire. There was a significant improvement in practice based on the substantial increase in the proportion of tuberculosis unit staff conducting DM screening for TB patients using appropriate methods and in referrals for proper management of DM. Conclusion: The training session on DM with an inbuilt awareness campaign for TB patients had a significant impact on the knowledge and practice of TB health care providers.

Serum ALT: LDH Ratio in Typhoid Fever and Acute Viral Hepatitis.

In 100 consecutive children aged below 18 years with confirmed typhoid fever, 29 had moderate hepatitis. Serum alanine amino transferase: lactate dehydrogenase (ALT: LDH) ratios of these 29 children at the time of hospitalization were compared with that of 29 children with acute viral hepatitis. The serum ALT: LDH ratio levels (expressed in multiples of upper limit of normal) was found to be less than 9 in typhoid hepatitis and more than 9 in acute viral hepatitis. Serum ALT: LDH ratio helps to differentiate typhoid hepatitis from acute viral hepatitis.

Influence of drug susceptibility on treatment outcome and susceptibility profile of failures to category II regimen.

Objective: To assess the influence of drug resistance on treatment outcome among patients treated with Category-II regimen and document drug susceptibility pattern of “Failures” to this regimen. Design: A retrospective analysis of patients registered from May 1999 through December 2004. Results: Treatment success was 42% among 572 patients and was similar among patients with fully susceptible or resistant but non-MDR organisms (41% of 254 and 40% of 128 patients, respectively). Among 49 MDR-TB patients, 27% had successful treatment outcome. The failure rates among patients with fully susceptible, resistant but non-MDR and MDR bacilli, were 6%, 12% and 27% respectively. Default was significantly higher among males (53% vs. 34%: p<0.01) smokers (57% vs. 36%: p <0.001), alcoholics (58% vs. 39%: p <0.001) and patients with higher initial smear grading (2+ or 3+, 56% vs. scanty or 1+, 44%: p <0.01). DST results were available for 60% (31 of 52) of failures and 10 had MDR-TB. Conclusion: The low success rate to the re-treatment regimen was mainly due to non-compliance. Failure was observed among 9% of patients and MDR-TB was 32% among Category II failures. The currently recommended Category II regimen appears to be adequate for majority of re-treatment cases.

Performance of a DOTS programme: Administrative and Technical Challenges - A field report from a district in south India.

Background: Performance of tuberculosis (TB) control programme depends on the functioning of health facilities (HFs). TB control programmes have been evaluated based on the programme indicators of conversion and cure. We have attempted to correlate the programme performance based on the availability of staff and their performance at the HF level. Objective: To correlate the performance of HFs to programme indicators, conversion and cure of patients treated under DOTS, in a district of south India. Design: Analysis of the data on new sputum smear-positive cases registered in 17 HFs during 1999-2003 was undertaken using TB register. The HFs with a low conversion or cure rates were identified and the reasons for the same were analysed. A scoring system was designed for the functioning of the HFs based on staff availability, supervision and review meetings which was correlated with programme performance. Univariate and multivariate analyses were performed. Results: Of 1893 new smear-positive patients registered during the study period, conversion was 1582 (83.6%) with cure rate of 76.4% (1447 of 1893), 254 (13.4%) default, 94 (5.0%) failure and 85 (4.5%) death. The conversion rates increased from 76% in 1999 to 87% in 2003; a statistically significant trend (c2 = 15.9; P<0.001). Similarly, a significant increase in trend (c2 = 4.0; P < 0.05) was observed in cure rates also (71 to 80%). The HFs were broadly classified into four groups namely; poor, fair, good and very good based on functioning scores .Correlation co-efficient was 0.77 between functioning of the HFs and conversion, and 0.76 between functioning and cure (P<0.01). Lack of regular review meetings was found to be independently associated with poor programme performance. Conclusion: Availability of staff such as Medical Officer, Laboratory Technician, and regular supervisory visits and review meetings are essential for a well functioning of programme. There is significant impact on DOTS with good functioning of HFs.

Estimating provider cost for treating patients with tuberculosis under Revised National Tuberculosis Control Programme (RNTCP).

Background: The Indian tuberculosis control programme is the second largest health programme in the world. Sustaining this programme in India will require continued financial support, particularly for drugs and contractual personnel. In addition, the costs for diagnosis, supervision and salaries for regular programme personnel need to be sustained. Objective: To measure unit provider cost for treating patients with tuberculosis. Methods: All government health facilities situated in one tuberculosis unit (TU) of Tiruvallur district were visited in order to evaluate daily practice of TB diagnosis and treatment. We interviewed administrators in these health facilities to gather data on modalities for diagnosis, treatment and monitoring of tuberculosis patients. In addition, relevant financial records from all health facilities were scrutinised for data collection. The cost analysis was done for diagnosis, treatment and monitoring of TB patients treated under DOTS programme in the year 2002 For this study only the recurrent cost (not the capital cost) is considered, even though the programme puts in a lot of investment at the preparatory stage of the programme e.g. upgrading of labs and drugs stores, microscopes, motorcycles etc. Cost incurred on smear microscopy, chest X-ray and drugs were classified as direct cost. Indirect cost is calculated based on proportion of staff time for TB care delivery and for supervision of TB services. The exchange rate at the time study was 1$=Rs 46. Results: Unit cost for smear microscopy was estimated to be Rs 10/-; for radiography Rs 25/-; and drug cost for Category I Rs 392/-; Category I with extension Rs 495/-; Category II Rs 729/-; Category II with extension Rs 832/- and Category III Rs 277/-. Including other recurrent expenditures like salary, materials, and maintenance, the overall unit provider cost to treat a TB patient was Rs 1587/- for Category I, Rs 1924/- for Category II and Rs 1417/- Category III. Conclusion: TB inflicts considerable economic burden on the overall health system. This information is vital for policy makers and planners to allocate adequate budget to the programme.

Is it worth treating Category I failure patients with Category II regimen.

Background: Very little information is available on the drug susceptibility profile among patients who are treated with standardized short-course chemotherapy regimens under programme conditions. Methods: Sputum samples were collected from new sputum smear-positive patients declared ‘failure’ after treatment with Category I regimen under tuberculosis control programme using DOTS strategy from a rural area of Tamil Nadu. Results: Of 1463 patients started on Category I regimen between May1999 and December 2002, 74 cases were declared as ‘failures’ (smear positive at 5/6 months of treatment). We collected sputum samples from 60 (81%) of 74 ‘failures’ and 27% (16 of 60) of them were culture-negative for M tuberculosis and 17% (10 of 60) had organisms resistant to Isoniazid and Rifampicin (MDR TB). Conclusion: Based on the drug susceptibility profile at the time of ‘failure’, treating Category I ‘failures’ with Category II regimen with close monitoring appears to be justified.

A double-blind study of oral salbutamol supplement and repeat sputum smear microscopy in enhancing diagnosis of smear-negative pulmonary tuberculosis in south India.

Background: As routine culture facilities are not available in TB control programme in low income countries like India, there is an urgent need to improve the sensitivity of sputum microscopy, especially in diagnosis of smear negative pulmonary TB. Methodology: In a double blind placebo controlled study, the role of repeat sputum microscopy after antibiotics and oral salbutamol supplement in improving the diagnosis of smear negative TB suspects was investigated in an urban TB clinic. We undertook culture examinations for all study patients to find out proportions of TB cases in this series. Results: Of 206 enrolled, (101 salbutamol (S), 105 placebo (P) groups) 26 were positive by repeat sputum smear examination; similar in two groups (S 16, P 10, p = 0.25). In all, 40 (S 23, P 17) including 26 smear- positives, were culture -positive for M. tuberculosis. Conclusions: Two thirds of initially smear negative but culture positive TB patients were smear positive on repeat sputum examination. Thus, repeat sputum smear microscopy for TB suspects improved the diagnosis, nevertheless oral salbutamol therapy was not beneficial. In resource poor settings, repeat sputum smear microscopy after a trial of antibiotics, could significantly improve the diagnosis of smear-negative PTB patients.