Controlling the drug-resistant tuberculosis epidemic in India: challenges and implications / 한국역학회지

India has a higher tuberculosis (TB) burden than any other country, accounting for an estimated one-fourth of the global burden. Drug-resistant tuberculosis (DR-TB) presents a major public health problem in India. Patients with DR-TB often require profound changes in their drug regimens, which are invariably linked to poor treatment adherence and sub-optimal treatment outcomes compared to drug-sensitive TB. The challenge of addressing DR-TB is critical for India, as India contributes over 27% of global DR-TB cases. In recent decades, India has been proactive in its battle against TB, even implementing a revised National Strategic Plan to eliminate TB by 2025. However, to achieve this ambitious goal, the country will need to take a multifaceted approach with respect to its management of DR-TB. Despite concerted efforts made by the National TB Elimination Program, India faces substantial challenges with regard to DR-TB care, especially in peripheral and resource-limited endemic zones. This article describes some of the major challenges associated with mitigating the growing DR-TB epidemic in India and their implications.

Controlling the drug-resistant tuberculosis epidemic in India: challenges and implications / 한국역학회지

India has a higher tuberculosis (TB) burden than any other country, accounting for an estimated one-fourth of the global burden. Drug-resistant tuberculosis (DR-TB) presents a major public health problem in India. Patients with DR-TB often require profound changes in their drug regimens, which are invariably linked to poor treatment adherence and sub-optimal treatment outcomes compared to drug-sensitive TB. The challenge of addressing DR-TB is critical for India, as India contributes over 27% of global DR-TB cases. In recent decades, India has been proactive in its battle against TB, even implementing a revised National Strategic Plan to eliminate TB by 2025. However, to achieve this ambitious goal, the country will need to take a multifaceted approach with respect to its management of DR-TB. Despite concerted efforts made by the National TB Elimination Program, India faces substantial challenges with regard to DR-TB care, especially in peripheral and resource-limited endemic zones. This article describes some of the major challenges associated with mitigating the growing DR-TB epidemic in India and their implications.

Evaluation of heat shock proteins for discriminating between latent tuberculosis infection and active tuberculosis: a preliminary report

The diagnosis of a latent tuberculosis infection [LTBI] is of the utmost concern. The available tests, the tuberculin skin test [TST] and the Quantiferon-TB Gold test [QFT-G] cannot discriminate between active TB and LTBI. Therefore, the aim of the study is to identify new biomarkers that can discriminate between active TB and LTBI and can also assess the risk of the individual developing active TB. In total, 55 blood samples were collected, of which 10 samples were from the active TB infection group, 10 were from the high-risk exposure group, 23 were from the low-risk exposure group, and 12 were from healthy controls living in a non-TB endemic area. A panel of heat shock proteins [Hsps], including host Hsp25, Hsp60, Hsp70, and Hsp90 and Mycobacterium tuberculosis [MTB] Hsp16, were evaluated in all of the collected samples using ELISA. The levels of the host Hsp[s] [Hsp25, Hsp60, Hsp70 and Hsp90] and MTB Hsp16 were significantly [p=0.05] elevated in the active TB group compared to the high-risk exposure group, the low-risk exposure group and the control group. Notably, the levels of the same panel of Hsp[s] were elevated in the high-risk exposure group compared to the low-risk exposure group. On follow-up, out of the 10 high-risk exposure participants, 3 converted into active TB, indicating that this group has the highest risk of developing TB. Thus, the evaluated panel of Hsp[s] can discriminate between LTBI and active TB. They can also identify individuals who are at the highest risk of developing active TB. Because they can be rapidly detected, Hsp[s] have an edge over the existing diagnostic tools for LTBI. The evaluation of these proteins will be useful in designing better diagnostic methods for LTBI

Assessment of immunological markers and booster effects of Ag85B peptides, Ag85B, and BCG in blood of BCG vaccinated children: a preliminary report

PURPOSE: In the present study, the protective immunological markers in serum and peripheral blood mononuclear cells (PBMCs) of bacillus Calmette-Guerin (BCG) vaccinated and unvaccinated children were evaluated after vaccination. Further, PBMCs of children with low protective levels were boosted with BCG, Ag85B, and Ag85B peptides to study their booster effects to increase waning BCG induced immunity. MATERIALS AND METHODS: Fifty children from 1 month to 18 years of age were randomized for the study. Blood samples were collected from 27 participants with/without BCG vaccination. Immunological markers (anti-BCG, interferon gamma [IFN-gamma], and adenosine deaminase activity) were assessed in both serum and PBMCs of children. Children with low levels of protective immunological markers were further recruited and their PBMCs were boosted with BCG, Ag85B, and Ag85B peptides. RESULTS: Children in age group of 4-6 years were associated with significantly (p<0.05) higher BCG-specific IgG and IFN-gamma levels compared to those in age group greater than 10 years. Vaccinated children had greater repertoire of immunological memory which on in vitro stimulation with BCG showed increase in BCG-specific response compared to unvaccinated controls. Assessment of booster effects of BCG, Ag85B, and Ag85B peptides in PBMCs of children revealed greater potential of peptides to boost BCG induced immunity compared to BCG and Ag85B. CONCLUSION: To conclude, children within age 4-6 years are associated with high immunological markers which eventually diminish with age thereby suggesting need for booster dose in later years. Mycobacterium tuberculosis peptides along with BCG may be used as attractive candidates to boost such waning BCG induced immunity in children.

assessment of cytokines in quantiferon supernatants for the diagnosis of latent tb infection in a tribal population of Melghat, India

The tuberculin skin test [TST] and interferon-gamma release assays [IGRA], namely, the QuantiFERON-TB Gold test [QFT], remain the standard immuno-logical diagnostic tools for latent tuberculosis [TB] infection [LTBI]. However, the sub-optimal detection rates of both of these tests are major impediments in recognizing the population at risk. This study was aimed at evaluating additional cytokines besides interferon-gamma [IFN-gamma] as biomarkers for improving LTBI diagnosis in the tribal population of Melghat, India. Seventy-four close TB contacts were stratified by QFT and TST results into: [i] QFT+/TST+ [n = 26], [ii] QFT+/TST- [n = 12], [iii] QFT-/TST- [n = 35] and [iv] QFT-/TST+ [n = 1] groups. A panel of cytokines [IL-6, IL-10, TNF-alpha and IL-2R] was then evaluated in antigen-stimulated QFT cell-free culture supernatants using IMMULITE-1000, an automated immunoassay analyzer. Cytokine estimation showed significantly higher levels of IL-6 in the QFT+/TST+ group, while significantly higher levels of IL-10 were found in the QFT-/TST- group. Correlation analysis identified a positive correlation between IL-6 and the QFT response [r = 0.6723, P< 0.0001], while a negative correlation was seen between QFT and IL-10 expression [r=-0.3271, P = 0.0044]. Similarly, IL-6 was positively correlated with TST levels [r = 0.6631, P< 0.0001], and conversely, a negative correlation was found between TST and IL-10 expression [r=-0.5698, P<0.0001]. The positive and negative predictive values of IL-6 were found to be 92.59 and 93.33%, respectively, and the positive and negative predictive values of IL-10 were 96.55 and 91.18%, respectively. No significant impact of the demographic characteristics on cytokine positivity was observed. Our preliminary results suggest that the evaluation of additional cytokines in QFT cell-free culture supernatants may be valuable for the identification of LTBI. Combining IL-6 and IL-10 with QFT and/or TST could markedly improve the detection accuracy of LTBI. Our observations require investigation in larger well-characterized cohorts along with follow-up studies to further confirm the study outcome

Investigation of Immune Biomarkers Using Subcutaneous Model of M. tuberculosis Infection in BALB/c Mice: A Preliminary Report

Evaluation and screening of vaccines against tuberculosis depends on development of proper cost effective disease models along with identification of different immune markers that can be used as surrogate endpoints of protection in preclinical and clinical studies. The objective of the present study was therefore evaluation of subcutaneous model of M.tuberculosis infection along with investigation of different immune biomarkers of tuberculosis infection in BALB/c mice. Groups of mice were infected subcutaneously with two different doses : high (2x10(6) CFU) and low doses (2x10(2) CFU) of M.tuberculosis and immune markers including humoral and cellular markers were evaluated 30 days post M.tuberculosis infections. Based on results, we found that high dose of subcutaneous infection produced chronic disease with significant (p<0.001) production of immune markers of infection like IFNgamma, heat shock antigens (65, 71) and antibody titres against panel of M.tuberculosis antigens (ESAT-6, CFP-10, Ag85B, 45kDa, GroES, Hsp-16) all of which correlated with high bacterial burden in lungs and spleen. To conclude high dose of subcutaneous infection produces chronic TB infection in mice and can be used as convenient alternative to aerosol models in resource limited settings. Moreover assessment of immune markers namely mycobacterial antigens and antibodies can provide us valuable insights on modulation of immune response post infection. However further investigations along with optimization of study protocols are needed to justify the outcome of present study and establish such markers as surrogate endpoints of vaccine protection in preclinical and clinical studies in future.

Comparative evaluation of booster efficacies of BCG, Ag85B, and Ag85B peptides based vaccines to boost BCG induced immunity in BALB/c mice: a pilot study

PURPOSE: In the present study booster efficacies of Ag85 B, Bacillus Calmette-Guerin (BCG), and Ag85B peptides were evaluated using prime boost regimes in BALB/c mice. MATERIALS AND METHODS: Mice were primed with BCG vaccine and subsequently boosted with Ag85B, BCG and cocktail of Ag85B peptides. RESULTS: Based on analysis of immune response it was observed mice boosted with Ag85B peptides showed significant (p < 0.001) cytokines levels (interferon gamma, interleukin 12) and BCG specific antibodies (anti-BCG and anti-purified protein derivative titre) compared to booster dose of BCG, Ag85B and BCG alone. CONCLUSION: Our pilot results suggest that prime boost regimes with Ag85B peptides can boost waning BCG induced immunity and may improve immunogenicity of BCG vaccine. However, lot of work is further needed using experimental model of tuberculosis infection to justify the result.

Evaluation of Mycobacterium tuberculosis 16 and 71 Heat Shock Proteins in the Cerebrospinal Fluid of Tuberculous Meningitis Patients.

Aims: To evaluate the efficiency of two potential Mycobacterium tuberculosis (M. tb) heat shock proteins (Hsps) towards the improvement of tuberculous meningitis (TBM) diagnosis. Study Design: The patients were divided into TBM (confirmed and suspected) and non TBM group. The cerebrospinal fluid (CSF) was collected and evaluated for M. tb Hsp 16 and 71.The Indirect ELISA results of M. tb Hsp 71 were compared with polymerase chain reaction (PCR). Place and Duration of Study: Biochemistry Research Laboratory, Central India Institute of Medical Sciences, Nagpur between June 2009 and July 2010. Methodology: 29 TBM and 22 non TBM CSF samples were collected. Indirect ELISA was performed for evaluating the, M. tb Hsp16 and Hsp71 in the collected samples, individually as well as in combination. The ELISA method for detection of M. tb Hsp 71 was also compared with in house PCR technique for TBM diagnosis. Results: The data analysis was done with MedCalc® Software. M. tb Hsp16 showed positivity of 58.62% and negativity of 68.18%. Similarly for M. tb Hsp71, positivity is 89.65% and negativity is 68.18%.The results of ELISA for M. tb Hsp71 was compared with PCR technique and concordance was also calculated. Of the Hsp ELISA positive group for M. tb Hsp71, 24 were PCR positive and 2 were PCR negative with the 92.30 % concordance in TBM patients and in non TBM patients the concordance was observed to be 93.30%. Use of the monoclonal antibody Hsp 71 appear preferable over individual use of M. tb Hsp 16 and combined use of both Hsp and yield optimum results. Conclusion: Our data suggest that the detection of M. tb Hsp 71 in the CSF sample of TBM patients can be useful for the diagnosis of TBM patients. These predictors, however, need further work to validate reliability.

Mosquito biting activity on humans & detection of Plasmodium falciparum infection in Anopheles stephensi in Goa, India.

Background & objectives: Knowledge of the bionomics of mosquitoes, especially of disease vectors, is essential to plan appropriate vector avoidance and control strategies. Information on biting activity of vectors during the night hours in different seasons is important for choosing personal protection measures. This study was carried out to find out the composition of mosquito fauna biting on humans and seasonal biting trends in Goa, India. Methods: Biting activities of all mosquitoes including vectors were studied from 1800 to 0600 h during 85 nights using human volunteers in 14 different localities of three distinct ecotypes in Goa. Seasonal biting trends of vector species were analysed and compared. Seasonal biting periodicity during different phases of night was also studied using William’s mean. Results: A total of 4,191 mosquitoes of five genera and 23 species were collected. Ten species belonged to Anopheles, eight to Culex, three to Aedes and one each to Mansonia and Armigeres. Eleven vector species had human hosts, including malaria vectors Anopheles stephensi (1.3%), An. fluviatilis (1.8%), and An. culicifacies (0.76%); filariasis vectors Culex quinquefasciatus (40.8%) and Mansonia uniformis (1.8%); Japanese encephalitis vectors Cx. tritaeniorhynchus (17.4%), Cx. vishnui (7.7%), Cx. pseudovishnui (0.1%), and Cx. gelidus (2.4%); and dengue and chikungunya vectors Aedes albopictus (0.9%) and Ae. aegypti (0.6%). Two An. stephensi of the total 831 female anophelines, were found positive for P. falciparum sporozoites. The entomological inoculation rate (EIR) of P. falciparum was 18.1 and 2.35 for Panaji city and Goa, respectively. Interpretation & conclusions: Most of the mosquito vector species were collected in all seasons and throughout the scotophase. Biting rates of different vector species differed during different phases of night and seasons. Personal protection methods could be used to stop vector-host contact.

Antioxidant potential of fagonia arabica against the chemical ischemia-induced in PC12 cells

The imbalance between pro-oxidants and anti-oxidants leads to generation of oxygen/nitrogen free radicals which are implicated in several neurodegenerative diseases. Fagonia arabica is an ethno-pharmacologically important Ayurvedic herb known to have many medicinal properties like anti-inflammatory, analgesic and antipyretic effects. However, its antioxidant potential has not been investigated so far. The present study was designed to investigate the antioxidant potential of F. arabica and its neuroprotective effect on chemical ischemia induced in PC12 cells. Chemical ischemia was induced through exposing the cells to uncoupler of oxidative phosphorylation sodium azide [5.0 mM] and competitive inhibitor of glycolysis 2-deoxy-glucose [2.0 mM] for 2 h followed by 24 h reperfusion with normal culture medium. Total polyphenolic content [TPC] and antioxidant potential of the herb was measured using DPPH and ABTS + scavenging and ferric ion reducing antioxidant potential [FRAP] assays; its effect on neuroprotection and energy metabolism was also studied. The ischemic injury was characterized by impaired energy status as indicated by decreased ATP levels in the cells, accompanied by increased lactic acid content. Both the changes favourably responded to F. arabica and offered considerable neuroprotection from ischemia and helped to maintain the cellular viability and mitochondrial integrity of the cells. F. arabica showed considerable amount of TPC and antioxidant activity. This study reveals the antioxidant potential of F. arabica and its protective efficacy against ischemia/reperfusion mediated cell death. F. arabica thus can be considered for further studies for the development of the prophylactic or therapeutic agent for the treatment of ischemic stroke

Geographical distribution and evaluation of mosquito larvivorous potential of Aphanius dispar (Rüppell), a native fish of Gujarat, India.

Background & objectives: Certain indigenous fish can play potential role in vector control. The study recorded distribution of Aphanius dispar (Rüppell) in its native habitats in Gujarat, India and evaluated its larval propensity for Indian mosquito vectors. Methods: Fishes were surveyed in various districts of Gujarat and samples were collected from coastal habitats and were identified to species. Physicochemical properties of water samples were analysed in the laboratory. Five laboratory acclimatized adult fish (2.2–3 cm) released in chlorine-free water in glass jars were provided with 500 larvae daily. Five replicates were run. Daily consumption of I to IV instars of Anopheles stephensi, Aedes aegypti and Culex quinquefasciatus was recorded separately for three days. Anopheles stephensi larval control using the fish in industrial tanks (9–180 m2) was evaluated. Results & conclusion: The fish was found in large numbers in estuarine waters, rivulets, backwaters and small dams in the districts of Kutch, Jamnagar, Patan and Anand in Gujarat. Mean daily consumption of larvae in laboratory was as follows: An. stephensi 128 ± 0.2 to 204 ± 6; Cx. quinquefasciatus 24 ± 4 to 58 ± 10; Ae. aegypti 43 ± 5 to 68 ± 2. In water tanks, A. dispar reduced 93% larval counts by Day 7 and 98% by Day 21 (p <0.01), showing high larval propensity. A consolidated information on bionomics, tolerance and physicochemical properties of water taken from natural habitats of A. dispar indicate its high larvivorous potential. Large-scale evaluation is warranted to evaluate its potential in vector-borne disease control.

Effect of repeat dose of BCG vaccination on humoral response in mice model.

BCG is the only vaccine presently available against tuberculosis but it is estimated to prevent only 5% of the all potentially vaccine-preventable deaths due to Tuberculosis. Keeping these in view the present study has been undertaken to evaluate the efficacy of BCG and the effect of repeat dose of BCG on antimycobacterial humoral response in mouse model. To improve BCG immunogenicity, specific anti-mycobacterial immune responses (anti-BCG titre and total IgG level) were evaluated in mouse model using boost immunization protocols with the BCG vaccine. Mice induced with a repeat dose of BCG showed an increased anti mycobacterial humoral response, which gradually declined few weeks after single dose of BCG administration. The results suggest improved efficacy of BCG vaccine by giving repeat dose of BCG that can enhance the level of immunoprotection against tuberculosis as opposed to a single BCG dose.

Tuberculosis of the ilium: a case report.

A twenty year old man presented with pain in the upper part of right hip. CT scan showed multiple osteolytic areas in the right ilium, suggesting malignancy. CT guided needle biopsy was done and diagnosis of tuberculosis was made. The patient was cured with medical management only. Isolated tuberculosis of the ilium is an extremely rare condition. It is important to have a high clinical suspicion to diagnose early and manage the patient without surgical intervention.

Outcome of multi-drug resistant tuberculosis cases treated by individualized regimens at a tertiary level clinic.

AIM: To determine the clinical, radiological and drug resistance profile as well as the factors associated with treatment outcome of Multi-Drug Resistant Tuberculosis (MDR-TB). MATERIAL AND METHODS: All newly diagnosed patients with pulmonary MDR-TB from August 2002 to December 2004 enrolled at New Delhi Tuberculosis Centre, were included in the study. They were followed up clinically, radiologically and bacteriologically by sputum smear, culture and Drug Susceptibility Testing (DST) at regular intervals. According to their DST pattern and previous history of Anti-Tubercular Treatment (ATT), individualized treatment regimens were tailored for each patient. RESULTS: Out of total 27 bacteriologically proven cases of MDR-TB included in this study, 19 were males (mean age and weight 38.5 years and 52.6 kgs, respectively) and eight females (mean age and weight 34.3 years and 40.7 kgs, respectively). A majority (18) were residents of Delhi and the rest hailed from different parts of North India. All of them had a history of previous treatment ranging from six to 34 months. Cavity on chest X-rays was seen in 81%, while 44% showed extensive involvement. The patients received at least four "second line drugs" during their treatment with a mean of 6.2 anti-tubercular drugs during their intensive phase. Of the 27 patients, 13 were cured, 10 defaulted, one died, one is still on treatment and two were referred for surgery. Radiological improvement was observed in two third of cases and chest X-ray of two patients showed a complete resolution. Six predictors were identified for successful outcome of MDR-TB. They include weight gain at six months, culture conversion, radiological improvement during treatment, disease with M. tuberculosis strains exhibiting resistance to less than or up to three anti-tubercular drugs, use of less than or up to three second line drugs in treatment and no change of regimen during treatment. CONCLUSION: Default from treatment was observed to be a major challenge in the treatment of MDR-TB due to long duration and expense of ATT.

Cardiotoxic Manifestations of Yellow Oleander (Thevetia nerifolia) Poisoning and its Treatment: A Case Report.

A 30-year-'old female came to the hospital with complaints of vomiting, drowsiness and bradycardia after ingesting five seeds of yellow oleander (Thevetia nerifolia - pila kaner) with the intent of committing suicide. Whereas the usual complication is hyperkalemia, she was suffering from hypokalemia. She responded to conventional treatment, consisting of atropine and correction of electrolytes. This report discusses the cardiotoxic and neurotoxic manifestations of yellow oleander poisoning, its early diagnosis and prompt treatment. We would like to emphasize the importance of taking an electrocardiogram in all cases of poisoning.

Secretory factors of human neuroblastoma (IMR-32) and human glioblastoma (U87MG) cell lines induce neurite outgrowths in PC12 cells.

Neurite outgrowth is essential for the communication of the nervous system. The rat Pheochromocytoma (PC12) cells are commonly used in the neuronal cell study. It is well known that exogenous stimuli such as Nerve Growth Factor (NGF) induce neurite outgrowth. In the present study it has been investigated whether or not the conditioned medium from human neuroblastoma cell line (IMR-32) and human glioblastoma cell line (U87MG) may augment neurite outgrowth in PC12 cells. PC12 were cultured with and without conditioned media of IMR-32 and U87MG. The result showed that both the conditioned media induce neurite outgrowth within 48 hr and stops further proliferation of PC12 cells. However no outgrowth was noted in PC12 cells incubated without conditioned medium. In conclusion, it is shown that both the conditioned media (IMR-32 and U87MG) have the potential to induce the neurite outgrowth in the PC12 cells.

Health related quality of life (HRQL) scoring (DR-12 score) in tuberculosis--additional evaluative tool under DOTS.

The study was conducted among patients diagnosed as pulmonary or extra pulmonary tuberculosis attending DOTS facilities at New Delhi Tuberculosis Centre, Delhi. The objectives of the study are; to evaluate the impairment of health related quality of life in patients of tuberculosis by evolving a HRQL questionnaire (DR-12 score) and to validate the new scoring method by making serial assessments of health related quality of life of the patients during anti-tubercular therapy initially, at the end of intensive phase (IP) and at the completion of treatment. Seventy eight consecutive patients aged between 15-60 years put on DOTS treatment at New Delhi Tuberculosis Centre, Delhi were subjected to a HRQL questionnaire (DR-12 score) at 0 week, 8 weeks and at the completion of treatment. The new scoring method contained questions on twelve parameters related to symptoms, physiological, psychological and social well-being of TB patients. The patients were asked to evaluate these twelve parameters on a score of 1-3. All the individual parameters were equally weighted. The data so obtained regarding these scores was analysed using unpaired t-test, paired t-test, one way Anova test and Pearson corelation coefficient test. The patients who converted at the end of intensive phase had a significantly higher gain in scores as against, those who failed to convert even after extension of intensive phase (p=0.019). Significantly higher scores were observed among those who had a favourable outcome as against those who had unfavourable outcome at the completion of treatment (p=0.029). Thus, DR-12 score was found to have a strong construct validity and useful additional evaluative tool for patients under DOTS therapy.

Adverse drug reactions observed during DOTS.

A total of 8.37% of the 1195 patients treated at NDTB Centre with DOTS under RNTCP between January 2002 to June 2003 presented with adverse drug reactions. Patients showing any sort of adverse reactions were studied in detail by personal interviews and a semi-structured questionnaire. The profile of patients presenting with adverse reactions showed that majority of the patients (53%) had gastrointestinal reactions, the commonest presenting complaint being nausea and vomiting. General aches and pains were complained by about 35% and giddiness was the presenting complaint in 27% irrespective of the use of streptomycin, although giddiness was observed more often in Category II patients (59%). Skin rash and itching was complained by about 17% of patients and 11% complained of arthralgia, while only 1% had hepatotoxicity during treatment. Majority of the adverse reactions (67%) were observed within the first four weeks of treatment and only 0.25% of patients treated with DOTS had interruption of treatment for short periods.

Treatment of tuberculous pleural effusion patients and their satisfaction with DOTS - 1½ year follow up.

Background: Under the Revised National Tuberculosis Control Programme, patients who are sputum negative after 3 smear examinations are subjected to radiological examination after they fail to respond to a course of antibiotics for a period of two weeks. Those showing radiological evidence of pleural effusion are examined physically and investigated further by tuberculin testing and diagnostic aspiration. Those confirmed to be suffering from tuberculous pleural effusion by naked eye examination, biochemical tests and cytology of pleural fluid are given a fixed schedule of drugs. The treatment is stopped after six or eight months as per category, and outcome is reported as “Treatment Completed”. Many a time, patients question the validity of stopping treatment without radiological examination. Physicians treating are also at times not confident themselves and often fail to reassure such patients. Presence of residual symptoms in such patients before stopping treatment creates further uneasiness among the treating physicians. Methodology and Results: A study carried out among 58 patients of TB pleural effusion, of which 36 (62.1%) could be followed for a period of 1½ years, revealed that 63.9% were satisfied with the DOTS policy of stopping treatment without x-ray at the end of treatment whereas 36.1% expressed dissatisfaction with this policy. As many as 16.7% even got their x-rays elsewhere before stoppage of treatment, for their own satisfaction. Conclusion: The 1½ year follow up revealed only one case of relapse i.e. a relapse rate of 2.8% after DOTS therapy. Almost all (97.2%) were, however, satisfied with the medicines dispensed under DOTS.

Tuberculosis in the elderly and their treatment outcome under DOTS.

Summary: A retrospective study of the profile and treatment outcome in the elderly TB patients taking DOTS was carried out in an urban TB clinic of Delhi. Out of 2118 tuberculosis patients treated between 1999-2001, a total of 238 (11.4%) patients were over 50 years of age and of these 45(2.2%) were over 65 years of age. A total of 78.6% of the 283 TB patients of all the categories included in the study had a successful outcome (cure/ completion). The overall case fatality, default and failure rates among the TB patients over 50 years were found to be 7.1%, 8.8% and 4.6%, respectively, despite directly observed treatment being given under RNTCP. The case fatality rate was significantly higher (15.6%) in the age group >65 years as compared to patients between 50-65 years (5.2%). The failure rate was significantly higher (13.3%) in the age group >65 years than among patients in the 50-65 years age-group (2.6%). This emphasizes the need for intensive motivation and stringent monitoring among tuberculosis patients over 65 years of age.