Analysis of Risk Factors Affecting Sputum Conversion at the End of Intensive Phase Under DOTS for Treatment of Pulmonary Tuberculosis

Introduction: Microbiologically confirmed pulmonarytuberculosis patients under Revised National TuberculosisControl Programme (RNTCP) are treated with a 6-monthshort-course chemotherapy (SCC) regimen irrespectiveof co-morbid conditions. The aim of present study was todetermine the time taken for SSC conversion with standardcurrent treatment with anti-tubercular drugs and analysis ofrisk factors if any delaying it. We undertook this prospectivestudy to compare sputum conversion rates (smear) at the endof intensive phase (IP) of Category regimen.Material and methods: was a prospective study which wasconducted for a period of eleven months from August 2018 toJune 2019 at Department of Respiratory Medicine, K.N ChestHospital, S.N Medical College, Jodhpur Rajasthan India.Patients visiting Department of Respiratory medicine and whowere diagnosed as pulmonary tuberculosis by sputum smearexamination were included in study.Result: Sputum smear-positive patients are infectious to closecontacts as well as to community as they continue to expelbacilli for a variable period of time after initiation of DOTSregimen. Most patients undergo sputum conversion by theend of 3rd month. Patients who have predominant cavitatorydisease in radiology, high smear grading before treatment, aprior history of DS/DR tuberculosis are more likely to havedelayed sputum smear conversion.Conclusion: There need to mandate DST at the starting ofDOTS in line with latest RNTCP guidelines to prevent thedevelopment of MDR strains and failures. Also there is astrong need to constitute strong infection control measures tillpatients are labelled as noninfectious.

Gender Differences in Treatment Outcome of Tuberculosis Patients under the Revised National Tuberculosis Control Programme

Aim: The present study was undertaken to find out the sex differences in the notification rates and treatment outcomes of Tuberculosis (TB) patients, registered under the Revised National Tuberculosis Control Programme (RNTCP) in a rural Tuberculosis Unit (TU) in Thorrur, Warangal Dist., Telangana. Methods: This is a retrospective record based study was carried out among a total of 585 cases registered under the RNTCP between January'2011 to December'2012. Notification rates of TB, clinical forms of Tuberculosis and disease treatment outcomes recorded in the registers were analysed. Based on genders outcomes were defined in accordance with the standard RNTCP definitions. Results: Among the total of 585 patients 220 (80%) were male and 55 (20%) were female with male female ratio of 4:1. In patients less than 20 years of age the notification rates among males and females were similar. In other age groups male were more likely to be notified compared to females and the difference was statistically significant, while new smear positive and retreatment cases were significantly more than females, among females new smear positive and new extra pulmonary cases significantly lower. Among the new smear positive in females 39.3% were cured compared to 49.4% males which was again significant statistically. Male patients outnumbered female in all unfavorable outcome like death, failure, and default. Conclusion: The present study demonstrates a gender difference in the notification rates, clinical presentations and treatment outcomes of patients with TB integrated research is necessary to find the reasons for these differences. Such studies will be helpful in improving the efficacy of the RNTCP

How better is random blinded re‑checking results in Revised National TB Control Programme, India.

Background: The Revised National Tuberculosis Control Programme (RNTCP) is implementing the External Quality assurance (EQA) and Random blinded re-checking (RBRC) as one of its important component. This nationwide study was conducted to determine (1) the number and types of RBRC errors and (2) the sensitivity and specificity among rechecked slides. Materials and Methods: The study was based on the monthly RBRC reports submitted by ~13,000 designated microscopy centres (DMCs) across the country under routine programmatic settings in 2010. The DMCs reports were compiled at district, state and national level. Results: A total of 11, 89,564 slides were rechecked from 11,039 DMCs. Of which 99.5% of rechecked slides did not have any errors. The sensitivity and specificity of the rechecked slides had 98% sensitivity and 100% specificity. Conclusion: RBRC is the crucial component of EQA and the results from the programme are found to be satisfactory. Based on the study findings, the earlier value of 80% sensitivity used for calculation of annual sample size for RBRC has been increased to 90% sensitivity. The annual RBRC sample size for DMCs has been increased by 1.5–2 folds.

Contribution of medical colleges to tuberculosis control in India under the Revised National Tuberculosis Control Programme (RNTCP): Lessons learnt & challenges ahead.

Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India were involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). This report documents the unique and extraordinary course of events that led to the involvement of medical colleges in the RNTCP of GOI. It also reports the contributions made by the medical colleges to TB control in India. For more than a decade, medical colleges have been providing diagnostic services (Designated Microscopy Centres), treatment [Directly Observed Treatment (DOT) Centres] referral for treatment, recording and reporting data, carrying out advocacy for RNTCP and conducting operational research relevant to RNTCP. Medical colleges are contributing to diagnosis and treatment of human immunodeficiency virus (HIV)-TB co-infection and development of laboratory infrastructure for early diagnosis of multidrug-resistant and/or extensively drug-resistant TB (M/XDR-TB) and DOTS-Plus sites for treatment of MDR-TB cases. Overall, at a national level, medical colleges have contributed to 25 per cent of TB suspects referred for diagnosis; 23 per cent of ‘new smear-positives’ diagnosed; 7 per cent of DOT provision within medical college; and 86 per cent treatment success rate among new smear-positive patients. As the Programme widens its scope, future challenges include sustenance of this contribution and facilitating universal access to quality TB care; greater involvement in operational research relevant to the Programme needs; and better co-ordination mechanisms between district, state, zonal and national level to encourage their involvement.

Survival analysis and risk factors for death in tuberculosis patients on directly observed treatment-short course.

Background : Tuberculosis is a disease with a high case fatality of 4.65%. Objectives : To describe the survival pattern of patients on Directly Observed Treatment-Short course (DOTS) according to categories, age and sex of patients. Settings : Tuberculosis unit (TU) at District Tuberculosis Centre (DTC), Yavatmal, India Design : Retrospective cohort study. Materials and Methods : Data of patients registered for DOTS in the year 2004 were collected from the tuberculosis register. Statistical Analysis : Kaplan Meier plots and log rank tests to assess the survival pattern. Cox proportional hazards model for multivariate analysis. Results : A total of 716 patients were registered at the TU. The survival rates by the end of the intensive phase were 96%, 93% and 99% in categories I, II and III of DOTS, respectively. The cumulative survival rates were 93%, 88% and 96% in the three DOTS categories, respectively. There was a significant difference in the survival curves amongst the three DOTS categories (log rank statistic= 7.26, d.f..= 2, P=0 0.02) and amongst the different age groups [log rank statistic= 8.78, d.f.= 3, P= 0.012). There was no difference in the survival curves of male and female patients (log rank statistic= 0.05, d.f.= 1, P= 0.80) and according to type of disease (log rank statistic= 5.63, d.f.= 2, P= 0.05). On Cox proportional hazard analysis, age groups of 40 to 60 years [adjusted hazard ratio= 7.81 (1.002-60.87)] and above 60 years [adjusted hazard ratio= 21.54 (2.57-180.32)] were identified as significant risk factors for death. Conclusions : Age above 40 years is a significant risk factor for death in patients of tuberculosis. There was a significant difference in survival curves of the three DOTS categories and age groups.

Performance of a Non-Government Institution, working as a 'District Tuberculosis Centre' under RNTCP.

Background: The RNTCP has envisaged the role of non-governmental organizations (NGOs) in the control of tuberculosis in India, and five schemes have been developed. The RK Mission Free TB Clinic, as an exceptional case, was included under Scheme- 5, known as the ‘tuberculosis unit model’, with additional independent status of a District Tuberculosis Centre (DTC), to provide all RNTCP services. Aim: To assess the performance of the RK Mission Free TB Clinic as a full-fledged independent DTC over a 4-year period from 1999 to 2002. Material and Methods: A total of 5209 patients were initiated on anti-tuberculosis therapy under DOTS during 1999-2002. The yearly data in terms of case detection, follow-up and treatment outcome of new and retreatment cases were compiled. Results: Of the 5209 patients initiated on ATT under DOTS, 4125(79%) were new patients and 1084(21%) were retreatment cases. Of the 4125 new cases, 3049(74%) had pulmonary tuberculosis while 1076(26%) were treated for extra-pulmonary tuberculosis. In the newly detected pulmonary tuberculosis cases, the ratio of smear positive to smear negative patients was 1:0.65. The sputum conversion rates at 3 months in the new smear positive patients were 86% (1999), 85% (2000), 88% (2001) and 91% (2002). The cure and treatment completion rates in the new smear positive patients with pulmonary tuberculosis were 79% and 81% respectively in 1999. These rates were comparable for the years 2000, 2001 and 2002, with the respective values being 83%, 86% and 87%. The treatment completion rates in the new smear negative pulmonary tuberculosis cases as well as in the new extra-pulmonary tuberculosis patients were always greater than 85% in the study period. Conclusion: These results serve as a successful example of an NGO functioning within the parameters of the RNTCP.

Evaluation of Directly Observed Treatment Providers in the Revised National Tuberculosis Control Programme.

Background: Non-governmental personnel such as Anganwadi workers and community volunteers have been used as directly observed treatment (DOT) providers in the Revised National Tuberculosis Control Programme (RNTCP), but their effectiveness has not been documented. Aim: To assess the treatment outcome and problems encountered by patients managed by different DOT providers in the RNTCP. Material and Methods: Patients diagnosed with tuberculosis at 17 Primary Health Institutions (PHIs) in Tiruvallur District during a 3-year period received DOT from one of the four types of trained DOT providers (PHI staff, governmental outreach workers, Anganwadi workers, community volunteers), and their treatment outcomes were compared. Of the 1131 new smear-positive patients treated between May 1999 through June 2002, 199 (18%) received DOT from PHI staff, 238(21%) from outreach workers, 496 (44%) from Anganwadi workers, and 170 (15%) from community volunteers. Twenty-eight patients (2%) collected drugs for self-administration. Results: Treatment success rates among patients treated by different DOT providers, Anganwadi workers (80%), governmental outreach workers (81%), community volunteers (76%) and PHI staff (76%), were statistically similar. Patients who received drugs for self-administration were significantly more likely to fail to treatment or die than patients who were treated by a DOT provider (5/28 versus 84/1103; odds ratio=4.1; 95% confidence interval=1.2-12.6; p=0.02). Conclusion: In addition to governmental staff, Anganwadi workers and community volunteers can be effectively utilized as DOT providers.

Journey of tuberculosis control movement in India: National tuberculosis programme to revised national tuberculosis control programme.

The presentation passes through the saga of important landmarks of the past dealing with Era of prechemotherapy, Conventional and Short Course Chemotherapy (SCC) over two decades and the present era of Directly Observed Treatment Short course (DOTS) spanning more than a decade. It also touches upon the likely challenges to be faced in the near future for Tuberculosis (TB) control.