Surveillance, Evaluation of Programmatic Management of Drug Resistant Tuberculosis (PMDT) at DR-TB Centre, NITRD, New Delhi

Background: PMDT was launched in 2007 in our country but drug resistant TB remains to be a public health problem. Effective surveillance is the backbone for success of any programme and true stands for PMDT. Aim & Objectives: To identify the strengths and constraints of the surveillance evaluation system. Material & Methods: A cross sectional study was conducted in January 2015 at DR-TB Centre of NITRD, New Delhi which caters to a population of 29 lacs. PMDT surveillance system was evaluated using attributes like simplicity, data quality, acceptability, positive predictive value, representativeness and timeliness defined by CDC, USA guidelines. Relevant information was collected using data abstraction form and interview with stakeholders. Data was analysed using EpiInfo 07 version. Results: Nodal officer and District TB officer are responsible for surveillance system activities of PMDT at DR-TB centre and district level, respectively. All the reports (100%) were submitted on time and all the districts were reporting to DR-TB centre. 75% of TB-HIV coordinators found reporting formats to be simple but all the quarterly reports were found to be complete. Data quality was not found to be optimal. Conclusion: Private sector needs to be taken on board as they have no to minimal involvement in PMDT. For data quality improvement time to time training of medical officers and health workers should be organized.

Early detection of multi-drug resistance and common mutations in Mycobacterium tuberculosis isolates from Delhi using GenoType MTBDRplus assay.

Purpose: There is scarcity of prevalence data of multi-drug–resistant tuberculosis (MDR-TB) data and common mutations responsible in North India. This study aimed to detect MDR-TB among MDR-TB suspects from Delhi and mutation patterns using GenoType MTBDRplus assay. Materials and Methods: All MDR suspects in fi ve districts of New Delhi were referred to the laboratory from 1st October 2011 to 31st December 2012 as per criterion defi ned by Programmatic Management of Drug Resistant Tuberculosis (PMDT). GenoType MTBDRplus assay was performed on 2182 samples or cultures and mutations in the rpoB gene for rifampicin (RIF) and katG and inhA genes for isoniazid (INH) were analyzed. Results: A total of 366 (16.8%) MDR-TB cases were diagnosed. MDR rate was found to be 32%, 16.6% and 10.2% during criterion A, B and C respectively. The most common mutation detected for RIF was S531L (59.0%) and for INH was S315T1 (88.3%). Mutations S531L and S315T1 occurred signifi cantly higher in MDR strains as compared to RIF mono-resistant and INH mono-resistant strains, respectively. Average laboratory turn-around time (TAT) for dispatch of result to districts for test conducted on samples was 4.4 days. Conclusion: GenoType MTBDRplus is a useful assay for rapid detection of MDR-TB. The common mutations for RIF and INH were similar to those seen in other regions. However, mutations determining MDR strains and mono-resistant strains differed signifi cantly for both RIF and INH.

Differentiation of different brands of alcoholic beverages by trace element profile: A pilot study.

A pilot study was conducted to differentiate various brands of alcoholic beverages commonly sold in Hyderabad city (Andhra Pradesh, India). Various brands of liquor were scanned up to parts per billion (PPB) level for more than 72 elements using the following method – Inductively Coupled Plasma Atomic Emission Spectroscopy (ICP-AES). The results obtained showed significant difference in the elemental profiles of various brands of liquor. Absence of some elements such as copper showed marker parameter for the liquor brands. This survey shows that trace elemental profiling could be a reliable method for differentiating various brands of liquor.

Smear microscopy as surrogate for culture during follow up of pulmonary MDR-TB patients on DOTS plus treatment.

Background: DOTS Plus site at LRS Institute, New Delhi, covering 1.8 million population. Aims: To ascertain if sputum smear could be used as a surrogate for culture during intensive phase of treatment of MDRTB patients thereby enabling early shift from intensive phase to continuation phase, reducing the need for frequent cultures and saving time and cost in their management. Methods: The study is a retrospective analysis of 138 MDR-TB patients on DOTS Plus treatment whose sputum samples were simultaneously subjected to smear microscopy and culture, monthly during Intensive Phase and once in two months during Continuation Phase. Sputum results in the treatment card were supplemented from laboratory register, if required, and analyzed. Predictive values, sensitivity and specificity of smear were compared with culture results. Results: The Negative Predictive Value (NPV) of smear was high from the 3rd month onwards (above 91%), at four months 98% or more and approached 100% from eight months onwards. The specificity of smear test gradually increased during treatment and from five months onwards, it was above 90%. Conclusions: Considerable correlation was observed between sputum smear and culture during follow up of DOTS Plus treatment in the Intensive Phase. Accordingly, sputum smears can be recommended instead of culture.

Simultaneous detection of strychnine and brucine in biological matrix by gas chromatography-mass spectroscopy.

A new gas chromatography-mass spectroscopy (GC-MS) method is being presented for the separation and detection of strychnine and brucine, alkaloids of Strychnos nux vomica in a single run. The analysis was carried out using 5% phenyl methyl silicone capillary column, electron impact ionization mode and quadrupole mass analyzer. The extracts of the exhibits were analyzed using the new method. The peaks of the two alkaloids were found to be well resolved, and there was clear separation between the two. The retention time and mass fragmentation pattern, base peaks, molecular peaks of strychnine and brucine standard/NIST library and crime case exhibits matched, establishing the presence of the two active principles of Strychnos nux vomica. The new method has the advantage of better separation of the two alkaloid peaks over the conventional GC-MS methods, and is useful for the identification and confirmation of Strychnos nux vomica constituents in biological matrices of poisoning cases that have ended in death.

Development of spray reagent for TLC detection of pyrethroid insecticides using picric acid.

There have been a variety of approaches developed since the 1970s to detect pyrethroid pesticides based on gas chromatography (GC), thin layer chromatography (TLC), and high performance liquid chromatography (HPLC) with ultraviolet detection. A new thin layer chromatographic method was developed for the detection of common pyrethroids in forensic toxicology case exhibits. Various solvent systems were tried as mobile phase with different spray reagents; picric acid was used as specific spray reagent for deltamethrin, fenvalerate, and cypermethrin. The method developed is rapid and sensitive and can be used for routine case analysis with better separation. A new modified spray reagent was developed for the detection of synthetic pyrethroids containing a hydrolysable nitrile group such as deltamethrin, fenvalerate and cypermethrin using picric acid, that produces reddish-orange spots on a yellow background.

Detection of paracetamol in skin tissue by GC-MS: A case study.

A 13 year-old child suffered an anaphylactic reaction to a drug combination and died in the clinic. The Investigating Officer collected an assortment of drugs and injection vials from the clinic and forwarded them along with the injection site of the victim's skin and some viscera to the laboratory for examination. At the laboratory, the samples were subjected to chemical and chromatographic analysis. After extracting the drug from the biological samples, TLC was done using a new solvent system, which improved the separation of drug from the matrix. A gas chromatographic-mass spectrometric (GC-MS) method devised for the determination of paracetamol residue in skin tissues was done. This method allows for detection of residual drug in biological tissues by using single-ion monitoring, and confirmation by a full scan electron impact (El) mass spectrum. Paracetamol was extracted with ether/chloroform from the samples after acidic and basic extraction procedures, cleaned up and washed, followed by partition between chloroform. The cleaned up extract was injected into the GC-MS, and detection was done using single ion monitoring at m/z 109.

Improved case detection of tuberculosis through a public-private partnership.

Case detection of tuberculosis under public DOTS programmes is still low and there is currently a search for new ways to improve these programmes. We investigated the impact of a public-private partnership DOTS programme on tuberculosis case detection in New Delhi, India. Time series of case detection in an intervention and a control area were analysed through segmented linear regression modelling. We found that a significant positive trend shift occurred in the intervention area as compared to the control area after the partnership was initiated. The study indicates that public-private partnership is feasible way to improve TB case detection.

Profile of geriatric patients under DOTS in Revised National Tuberculosis Control Programme.

BACKGROUND: With an increase in life expectancy and the resultant elderly population, there has been an increase in the number of tuberculosis (TB) cases including those in geriatric age as well. However using Directly Observed Treatment-Short Course (DOTS), all categories of TB patients have been sucessfully treated within the country. A need was felt to study the profile of geriatric TB patients under the Revised National Tuberculosis Control Programme (RNTCP). METHODS: A retrospective study of 7439 patients enrolled under DOTS from January 1996 to March 2001 was carried out in a tertiary care referral institute in Delhi and the profile was analysed in terms of the gender, type of TB and ratio of sputum smear-positive to negative patients for both the younger and geriatric age groups. Further, treatment outcomes of the two age groups were analysed and compared for the 2655 new sputum smear patients. RESULTS: The male : female ratio of 315 geriatric TB patients enrolled under DOTS was observed to be 3 : 1 as against the 1.4 : 1 in younger TB patients. The occurrence of pulmonary TB was significantly higher than extra-pulmonary TB in geriatric age group (16:1) as compared to the younger age group (4:1). The ratio of new smear-positive to smear-negative patients was almost similar in the two age groups. Further, the treatment outcomes of new smear-positive geriatric TB patients in comparison to younger TB patients showed significantly lower sputum conversion (75.3% vs 85.7% respectively) and cure rates (69.2% vs 80.7% respectively), significantly higher exclusion rates from DOTS (2.3% vs 0.15% respectively) and relatively higher default and treatment failure rates. CONCLUSIONS: The present study has identified certain issues in the Indian TB patients of geriatric age. These include a lower reported prevalence amongst females, poor sputum conversion as well as cure rates and higher exclusion as well as default rates. Further studies are needed to address the issues under operational conditions of Indian RNTCP.

Revised National Tuberculosis Control Programme: Indian perspective.

The global tuberculosis programme has promoted the revision of National Tuberculosis Programme by strengthening the focus on Directly Observed Treatment Short-course (DOTS). National Tuberculosis Control Programme (NTCP) which was established in 1962 had less than 30 per cent treatment completion. Based on an in-depth review of the programme by a high level committee in 1992, a Revised National Tuberculosis Control Programme (RNTCP) was envisaged with a view to achieve a cure rate of at least 85 per cent amongst newly detected sputum positive cases under DOTS. By December 1999, 130 million of population had been covered in the country under DOTS. However, there are many challenges that are required to be met before RNTCP can become a success story in our country.

A study of ectopic pregnancy and high risk factors in Himachal Pradesh.

Although the total number of pregnancies have declined over the past decade, the rate of ectopic pregnancies has increased dramatically. Incidence was maximum in 26-30 years of age group (37.6%) and in para 2 (32.9%). Pain was the commonest symptom (91.7%) followed by bleeding per vaginum (71.7%) and amenorrhoea (41.4%). High risk factors were present in 67% of cases (57 out of 85 cases, 7 patients had 2 high risk factors).

A comparative study between hysterosalpingography and laparoscopy in case of infertility.

From the present study it can be concluded that both the procedures have their own importance and no one can substitute the other, in diagnosing all the diseases. HSG has been found to be more rewarding in cases of abnormalities of the lumen of uterus and fallopian tubes for their patency. On the other hand laparoscopy has been more rewarding for the abnormalities of the surface of uterus, fallopian tubes and ovaries. It is suggested that in all the cases of infertility both the procedures should be done and the HSG should be done first followed by laparoscopy.

Protection to testicular activity by a combination of 5-hydroxy L-tryptophan with a thiol compound in whole body gamma irradiated rats.

Radiation induced changes in testicular activity were studied by estimating sialic acid content in plasma and testis and 17-ketosteroids in 24 hr urine samples of male Sprague Dawley rats following 8 Gy whole body gamma ray exposure with and without pretreatment with 2-aminoethylisothiuronium bromide hydrobromide (AET) or with a combination of 5-hydroxy L-tryptophan (5-HTP) and AET. Combination of 5-HTP with AET or AET alone in optimum radioprotecting dose has significantly modified the radiation damage to the testis.