Long-term survival of patients treated for tuberculosis: a population-based longitudinal study in a resource-poor setting.

OBJECTIVE: We assessed the long-term survival of TB patients belonging to the Saharia tribe, a high TB burden community in Shivpuri district, Madhya Pradesh, central India. METHODS: Population-based, longitudinal study conducted among 9756 Saharia population in 2013, and a resurvey done 2 years later in 2015 using the same methods. The status of the individuals during resurvey was recorded as non-TB, relapse and death. The deaths recorded in this period were used to measure the mortality among TB-affected population and the non-TB population in this cohort. RESULTS: The standardised mortality ratio for the study cohort was 122.9 per 1000 population; males had higher mortality than females (129.9 vs. 96.8). The expected mortality among the non-TB population was 30.2, and the observed mortality among TB-affected population was 122.9 per 1000 population. CONCLUSION: In the Saharia tribe, post-treatment mortality in the TB-affected population is significantly higher than in the general population. This highlights an urgent need for implementation of effective public health strategies to prevent disproportionate deaths among TB-affected individuals in resource-poor settings, and the importance of periodic follow-up of patients after cure/completion of treatment, especially in vulnerable populations.

TB diagnostic cascade among patients registered under the Revised National TB Control Programme in Chennai, South India.

OBJECTIVE: To discern and quantify the TB diagnostic cascade among patients registered under the Revised National TB Control Programme, Chennai city, Tamil Nadu, South India. METHODS: This cross-sectional study was conducted in metropolitan Chennai from February 2017 to March 2018. We interviewed TB patients retrospectively on their diagnostic attempt in different health facilities. RESULTS: Of 455 TB patients, only 4.4% received their diagnosis at their first health facility. Of 1250 visits to health facilities, the vast majority (79.4 vs. 20.6%) was in the public rather than the private sector. 56% of patients went to a public facility as the first point of care, of whom 1.6% shifted to private facilities subsequently. The remaining 54.4% shifted between up to five government health facilities. Male patients and those with a higher family income were more likely to shift from private to public. CONCLUSION: Most shifts between diagnostic facilities occurred in the public sector. This necessitates interventions at public health facilities for strengthening and extending services to TB patients at their first point of care.

OBJECTIF: Discerner et quantifier la cascade de diagnostic de la TB chez les patients enregistrés dans le Programme National Révisé de lutte contre la TB, dans la ville de Chennai, dans le Tamil Nadu, dans le sud de l'Inde. MÉTHODES: Cette étude transversale a été menée dans la région métropolitaine de Chennai de février 2017 à mars 2018. Nous avons interviewé rétrospectivement des patients TB sur leur tentative de diagnostic dans différents établissements de santé. RÉSULTATS: Sur 455 patients TB, seuls 4,4% ont reçu leur diagnostic dans le premier établissement de santé visité. Parmi 1250 visites dans les établissements de santé, la grande majorité (79,4 vs 20,6%) était dans le secteur public plutôt que le privé. Parmi les 56% des patients qui sont allés dans un établissement public comme premier point de soins, dont 1,6% sont ensuite passés dans des établissements privés. Les 54.4 restants se sont déplacés entre cinq établissements différents de santé publics. Les patients de sexe masculin et ceux dont le revenu familial était plus élevé étaient plus susceptibles de passer du privé au public. CONCLUSION: La plupart des changements entre les établissements de diagnostic se sont produits dans le secteur public. Cela nécessite des interventions dans les établissements de santé publique pour renforcer et étendre les services aux patients TB à leur premier point de soins.

Declining tuberculosis prevalence in Saharia, a particularly vulnerable tribal community in Central India: evidences for action.

BACKGROUND: In spite of an alarmingly high tuberculosis (TB) burden amongst the Saharia tribe of central India, there is hardly any study to investigate the impact of DOTS implementation on the magnitude of tuberculosis disease and the changes over time. This article present the findings of TB prevalence surveys conducted amongst this indigenous population in two different time periods to know the change in the prevalence of TB. METHODS: A cross sectional survey was conducted among Saharia population in Shivpuri district, Madhya Pradesh during February 2013 to May 2013 and resurvey during March 2015 to July 2015. All individuals (≥15 years) were examined for chest symptoms suggestive of TB. Sputum samples were collected from all presumptive TB cases and were confirmed by laboratory examination by Ziehl-Neelsen smear microscopy and solid media culture methods. All detected cases were referred to health facility for anti-tuberculosis treatment as per RNTCP guidelines. RESULTS: There was significant reduction (trend Chi square 19.97; OR = 1.521; p = 0.000) in the prevalence of TB at the endline (1995 per 100,000) as compared to baseline (3003 per 100,000). The reduction was significant among males as compared to females (OR 1.55; p = 0.000) and in the age group of 25-34 years (OR 2.0; p = 0.007) and 45-54 years (OR 4.39; p = 0.003). There was significant reduction in the prevalence in both smear (OR 1.29; p = 0.02) and culture positive (OR 1.57; p = 0.000) TB at the endline survey. CONCLUSION: The study findings highlight a reduction in the prevalence of TB among Saharia tribal population. Further studies are needed to identify the factors associated with reduction in prevalence among this population and also further surveys to monitor the prevalence trend over a period.

Rapid molecular diagnostics for multi-drug resistant tuberculosis in India.

INTRODUCTION: Rapid molecular diagnostic methods help in the detection of TB and Rifampicin resistance. These methods detect TB early, are accurate and play a crucial role in reducing the burden of drug resistant tuberculosis. Areas covered: This review analyses rapid molecular diagnostic tools used in the diagnosis of MDR-TB in India, such as the Line Probe Assay and GeneXpert. We have discussed the burden of MDR-TB and the impact of recent diagnostic tools on case detection and treatment outcomes. This review also discusses the costs involved in establishing these new techniques in India. Expert commentary: Molecular methods have considerable advantages for the programmatic management of drug resistant TB. These include speed, standardization of testing, potentially high throughput and reduced laboratory biosafety requirements. There is a desperate need for India to adopt modern, rapid, molecular tools with point-of-care tests being currently evaluated. New molecular diagnostic tests appear to be cost effective and also help in detecting missing cases. There is enough evidence to support the scaling up of these new tools in India.

Research on tuberculosis in tribal areas in India: A systematic review.

BACKGROUND: Tuberculosis (TB) remains a major public health problem in resource-poor countries including India. Scientific knowledge is used to guide policy and practice. There is however, a limited, systematically collected data required for guiding the scale-up of interventions particularly amongst vulnerable populations including tribal groups in the country. In view of this, a systematic review of the TB research studies carried out in tribal areas of different parts of the country was undertaken. OBJECTIVE: To undertake a systematic review of the TB research studies carried out in tribal areas of India between 1996 and 2016. METHODS: A systematic review of English articles published between 1996 and 2016 on any aspect of TB was done through internet searches using Literature search EndNote programme. The words used for searching were tuberculosis, India, tribal, indigenous, disadvantaged, adivasi. The most common topics classified as annual risk of tuberculosis infection (ARTI), prevalence of TB, laboratory studies, clinical symptoms of TB, risk factors for TB, knowledge attitude practice, community Directly Observed Treatment (DOT) providers, performance of Revised National Tuberculosis Control Programme (RNTCP), and drug resistant TB. Classification was also done on the basis of the type of tribe studied and place of study conducted. A total of 47 studies identified through the search were included in the review. RESULTS: Of the 47 studies reviewed, 12 were on TB prevalence, 7 were laboratory studies, four on ARTI and 5 on performance of RNTCP in tribal areas. Among these, majority (23 studies) of the tribal studies did not mention the type of tribe. Ten studies were conducted among Saharia, a particularly vulnerable tribal group in the Indian state of Madhya Pradesh mainly by the National Institute for Research on Tribal Health, five were among the mixed tribes and very few on other tribes. CONCLUSION: The systematic review indicates that the research studies on TB among tribal population are very few. There is a need to invest and encourage researcher to work on the research plans for the control of TB in tribal areas.

Investigation of the risk factors for pulmonary tuberculosis: A case-control study among Saharia tribe in Gwalior district, Madhya Pradesh, India.

BACKGROUND & OBJECTIVES: Prevalence of pulmonary tuberculosis (PTB) is known to be high in the indigenous tribal community Saharia in Madhya Pradesh, India. The risk factors for PTB are not well known among them. This study was done to determine various risk factors associated with PTB in the indigenous community Saharia. METHODS: A prevalence survey was conducted among Saharias of Gwalior district of Madhya Pradesh. The population surveyed was 12,123 which was the source of cases and controls for the present study. All the bacillary-positive cases and controls in the ratio of 1:5 were included in the survey. Data were collected by the trained health workers from the patients and controls using a semi-structured pre-coded and pre-tested questionnaire which included data on risk factors including demographic factors, host-related factors and household factors. The individuals were also screened for diabetes mellitus and HIV. RESULTS: Malnutrition and history of asthma were associated with an increased risk of PTB. More than 56 per cent cases were attributed to malnutrition and 12 per cent attributed to asthma. Low family income, alcohol consumption and smoking were the other contributors. The risk was higher in males as compared to females. INTERPRETATION & CONCLUSIONS: The study emphasized that the main contributors were social factors. Nutrition supplementation, especially in tuberculosis (TB) patients and integrated approach to improve their living conditions are needed to control TB in this community.

Dilemmas in the diagnosis and treatment of intracranial tuberculomas.

Tuberculosis (TB) remains a major public health problem across the globe. A common form of extrapulmonary TB (EPTB) with high mortality and morbidity is neuro TB or tuberculosis of the nervous system. The management of brain TB remains a big challenge due to the lack of specific diagnostic tools and appropriate treatment guidelines. In this context, this manuscript discusses clinical, diagnostic and treatment dilemmas in the management of intracranial tuberculomas. Brain tuberculoma may occur at any site within the cranium, no part of the brain substance or ventricular surface being exempt. The diagnosis of tuberculoma is often based on imaging techniques such as CT brain and MRI/MRS, even though, no radiological feature is confirmative or specific for tuberculoma. In this regard, a promising development is a new MRS marker that is currently being assessed. Based on a single peak at 3.8ppm, it may differentiate tuberculoma from tumors. This lack of diagnostic tools results in an increased cost to patient on average three times that for pulmonary TB. The increase in cost stems from multiple laboratory tests with diagnosis often achieved only after biopsy. As for treatment, the choice of drugs for treatment and the duration for treatment is also not clearly understood. The recent increase in drug resistant TB adds to the problem. The possible pitfalls during treatment include paradoxical response, hyponatremia, and development of hydrocephalus. These and other treatment related complications require follow-up and monitoring. A fraction of patients may even require emergency surgery due to increased intracranial tension. This can further increase cost to the patient and family. Overall, there is a need for continued efforts to develop new diagnostic tools for brain TB. Until such tools are available, high degree of awareness among treatment providers is necessary to avoid delays in diagnosis and increased costs.

Smoking and alcohol consumption: Risk factors for pulmonary tuberculosis among the tribal community in central India.

Smoking and alcohol consumption are important risk factors for pulmonary tuberculosis (PTB). A cross-sectional survey was undertaken among the Gond tribe in Jabalpur district of Madhya Pradesh, and information on smoking and alcohol consumption was collected. As compared to females, males had an increased odds for PTB prevalence (odds ratio (OR) 3.2; 95% CI 486.4-1358.4; p=0.01). Similarly smokers and alcohol consumers had an increased odds for PTB compared to non-smokers and non-alcohol consumers, respectively [(OR 3.2; 95% CI 516.4-1986.4; p=0.003); (OR 3.2; 95% CI 480.8-2254.8; p=0.009)]. Persons who were both smokers and alcohol consumers had an equally increased odds of PTB than those who did not smoke and consumed alcohol (OR 4.1; 95% CI 477.6-2581.6; p=0.001). The study findings highlight the need to develop and implement culturally appropriate awareness raising activities among the tribal community to support TB control efforts.

Tuberculosis among the homeless in Chennai city, South India.

Background: In India from a national perspective, the incidence/prevalence of active tuberculosis (TB) among the homeless are unknown. Methods: Homeless individuals, aged 15 years and above, were screened for TB by radiography and smear examination in Chennai city. Results: 301 individuals were enrolled and screened for TB; 8% (24/301) had chest symptoms; 5.6% (17/301) found X-ray abnormalities. The overall prevalence of TB was 1661/100 000; prevalence of culture-positive TB was 997/100 000 and smear-positive TB was 664/100 000 population. Conclusion: There is a need to address TB control among homeless populations. The current pilot study showed that the prevalence of TB was disproportionately high and there is a need for a larger study with an adequately powered sample size.

Effectiveness of TB sensitization initiatives in improving the involvement of self help group members in rural TB control in south India.

Background: The 'End TB strategy' has highlighted the importance of inter-sectoral collaboration and community mobilization for achieving zero TB deaths by 2020. Objective: The aim of the study was to develop and test a model TB sensitization programme involving self help groups (SHGs). Methodology: This experimental study was conducted in two blocks (intervention and control), in Tiruvallur district. The intervention content included short-lecture, musical story telling activity, role play, short film on TB. The impact was compared at baseline, third and sixth months in terms of SHGs' awareness, promotion of awareness, identification and referral of presumptive TB cases and provision of TB treatment. Results: A total of 764 vs 796 SHGs were enrolled in control and intervention groups, respectively. The knowledge attitude, and practice score (lower score indicated a better attitude and practice), from baseline to 6 months was significantly reduced (29 to 24) in the intervention group. Similarly, a significant difference was observed in identification and referral of chest symptomatics in the intervention group at 3 and 6 months. During the 3 month follow-up a significantly higher proportion of SHG members were involved in TB awareness activities in the intervention (623/748 [83.3%]) vs control group (471/728 [64.7%]; p<0.001). Conclusions: Findings from this study highlight the feasibility of involving SHGs through a model TB sensitization program for strengthening TB prevention and control activities.

Performance of Revised National Tuberculosis Control Programme (RNTCP) in tribal areas in India.

BACKGROUND & OBJECTIVES: The Revised National Tuberculosis Control Programme (RNTCP) provides free diagnostic and treatment services to all tuberculosis (TB) patients registered under it. Equitable access, implying a preference for the most hard-to-reach groups particularly for tribal areas, is a major concern for RNTCP. This study was conducted to assess the performance of RNTCP in terms of case detection and cure rates in areas dominated by tribal groups in India. METHODS: We used the RNTCP data collected by the Central TB Divison, Government of India. RNTCP has a systematic monitoring mechanism which tracks the outcome of every patient put on treatment. There is a standardized recording and reporting structure in place; indicators are monitored regularly at every level of the health system; and regular supervision ensures quality of the Programme. The main indicators include the number of cases diagnosed and the percentage of patients who are successfully treated. These indicators were used to assess the RNTCP performance in tribal areas. RESULTS: We observed a poor performance in terms of case detection rate (CDR) in tribal and backward districts as compared with other districts in India. Among tribal districts 53 per cent in 2010, 45 per cent in 2011 and 56 per cent in 2012 had CDR of new smear positive <70%. It was also observed that 26 per cent of tribal dominated districts had CDR of <51 per cent in 2012. More than 50 per cent of tribal districts were not able to achieve more than 85 per cent of cure rate. INTERPRETATION & CONCLUSIONS: The findings of this study suggested that the overall RNTCP performance in tribal areas was not optimal, and the target of >85 per cent of core rate was achieved by less than half of the tribal districts.

Pulmonary tuberculosis - a health problem amongst Saharia tribe in Madhya Pradesh.

BACKGROUND & OBJECTIVES: The information on tuberculosis (TB) situation amongst Saharia, one of the particularly vulnerable tribal groups (PVTGs) in Madhya Pradesh, is not available from Gwalior division of the s0 tate. Hence, this study was undertaken to estimate the prevalence of pulmonary tuberculosis (PTB) disease amongst them. METHODS: A community based cross-sectional TB prevalence survey was undertaken among Saharia PVTG in Gwalior district of Madhya Pradesh. A random sample of villages predominated by Saharia tribe was selected from all the blocks in proportion to the size of Saharia population in each block of the district. All eligible individuals were questioned for chest symptoms relating to TB. Two sputum samples were collected from each of the eligible individuals, transported to the laboratory, and were examined by Ziehl-Neelsen(ZN) smear microscopy and solid media culture methods. RESULTS: Of the total 10,259 individuals eligible for screening, 9,653 (94.1%) were screened for symptoms. Overall prevalence of PTB was found to be 3294 per 100,000. The prevalence increased with age and the trend was significant ( p<0.001). The prevalence of TB was significantly higher amongst males (5497/100,000) as compared to females (1376/100,000) ( p<0.001). INTERPRETATION & CONCLUSIONS: The study results provide vital information on the current situation of pulmonary TB disease among the Saharia tribal community in Gwalior district of Madhya Pradesh. In view of high PTB disease prevalence among this PVTG, there is an urgent need to improve and further intensify TB control measures in this area.

Situation of drug resistant tuberculosis in Saharia tribe of central India.

BACKGROUND & OBJECTIVES: The information on multidrug resistant tuberculosis (MDR-TB) situation amongst Saharia, one of the Particularly Vulnerable Tribal Groups (PVTGs) in Madhya Pradesh, India, is not available. Hence, this study was undertaken to find the situation of MDR-TB amongst Saharia PVTG in two districts of Madhya Pradesh. METHODS: Community based cross-sectional TB prevalence surveys were conducted among Saharia PVTG in Gwalior and Shivpuri districts of Madhya Pradesh. Chest symptomatics were identified from the individual registered for the study. Two sputum samples were collected from each of the eligible individuals, transported to the laboratory, and were examined by Ziehl-Neelsen (Z-N) smear microscopy and solid medium culture methods. Drug susceptibility testing of the isolates was done by indirect proportion method on solid medium. RESULTS: MDR rate was 2.2 per cent of new cases and 8.2 per cent among the previously treated cases of TB in Gwalior while it was two per cent among the previously treated cases in Shivpuri district. INTERPRETATION & CONCLUSIONS: Though the prevalence of tuberculosis in these districts was alarmingly high, the MDR rates were more or less similar to national average. However, the findings of this study highlight the need for active intervention so that the MDR-TB is kept under control.

Health literacy on tuberculosis amongst vulnerable segment of population: special reference to Saharia tribe in central India.

BACKGROUND & OBJECTIVES: Health literacy on tuberculosis (TB) is an understanding about TB to perform activities with regard to prevention, diagnosis and treatment. We undertook a study to assess the health literacy on TB among one of the vulnerable tribal groups (Saharia) in central India. METHODS: In this cross-sectional study, 2721 individuals aged >15 yr from two districts of Madhya Pradesh State of India were interviewed at their residence during December 2012-July 2013. By using a short-form questionnaire, health literacy on cause, symptoms, mode of transmission, diagnosis, treatment and prevention of TB was assessed. RESULTS: Of the 2721 (Gwalior 1381; Shivpuri 1340) individuals interviewed; 76 per cent were aged <45 yr. Living condition was very poor (62% living in huts/katcha houses, 84 per cent with single room, 89 per cent no separate kitchen, 97 per cent used wood/crop as a fuel). Overall literacy rate was 19 per cent, and 22 per cent had >7 members in a house. Of the 2721 respondents participated, 52 per cent had never heard of TB; among them 8 per cent mentioned cough as a symptom, 64 per cent mentioned coughing up blood, and 91 per cent knew that TB diagnosis, and treatment facilities were available in both government and private hospitals. Health literacy score among participants who had heard of TB was <40 per cent among 36 per cent of respondents, 41-60 per cent among 54 per cent and >60 per cent among 8 per cent of respondents. INTERPRETATION & CONCLUSIONS: The finding that nearly half of the respondents had not heard of TB indicated an important gap in education regarding TB in this vulnerable population. There is an urgent need to implement targeted interventions to educate this group for better TB control.

Yield of pulmonary tuberculosis cases by symptoms: Findings from a community survey in Madhya Pradesh, central India.

A cross-sectional tuberculosis prevalence survey was undertaken in Jabalpur district, Madhya Pradesh, central India. All individuals were questioned for chest symptoms. Sputum samples were collected and examined for microscopy and culture. Overall prevalence of sputum positive pulmonary tuberculosis was found to be 255.3 per 100,000 population. Cough, with or without other symptoms, was present in 75.5% individuals and yielded 88.2% of the detected pulmonary tuberculosis cases. Elicitation of a previous history of treatment yielded 5.9%, and chest pain 4.5% cases. History of fever alone yielded no cases. The findings suggest that a history of fever alone may be safely excluded from the list of symptoms to be elicited in future TB prevalence surveys in India.

Tobacco smoking: a major risk factor for pulmonary tuberculosis--evidence from a cross-sectional study in central India.

BACKGROUND: This paper provides information on the association of tobacco smoking and alcohol consumption with pulmonary TB (PTB) in central India. METHODS: A community based cross-sectional TB prevalence survey was conducted in Jabalpur district of the central Indian state of Madhya Pradesh. The information on tobacco smoking and alcohol consumption was collected from individuals aged ≥15 years. Using logistic regression analysis, the risk factors for PTB were identified. RESULTS: A total of 94 559 individuals provided information on tobacco smoking and alcohol consumption. Persons aged 35-54 years and 55 years and above had, respectively, a 2.19 (95% CI 1.57-3.07) and a 3.26 (95% CI 2.23-4.77) times higher risk of developing PTB compared to persons aged below 35 years. Males had a 2.35 (95% CI 1.66-3.32) times higher risk than females. Tribals (indigenous population) had a 2.32 (95% CI 1.68-3.21) times higher risk than non-tribal population. The adjusted prevalence odds ratio for mild, moderate and heavy tobacco smokers were 2.28, 2.51 and 2.74 respectively as compared to non-smokers. Alcohol consumption was not found to be a risk factor on multivariate analysis. CONCLUSION: Tobacco smoking is significantly associated with PTB in this central Indian district. Smoking cessation services need to be integrated into the activities of the TB control programme.

Expenditure Pattern for TB Treatment among Patients Registered in an Urban Government DOTS Program in Chennai City, South India.

Background. Tuberculosis (TB) patients registered in the government clinics under the DOTS (Directly Observed Treatment, Short Course) program in Chennai city catering to about 4.3 million population. Objective. To estimate the pattern and overall costs incurred by the new patients (who have never had treatment for tuberculosis or have taken antituberculosis drugs for less than one month) registered under DOTS program in the treatment of tuberculosis in Chennai city. Methodology. A cross-sectional survey among new TB patients, who had completed intensive phase of antituberculosis treatment, was done using a precoded semi-structured questionnaire between March and June 2007. Information was collected on demographic, socioeconomic characteristics and expenditure for before and during treatment. Mean costs were used for comparison. Results. Among the 300 TB patients, most economically productive age group and 186 (62%) were males. The overall estimated total costs incurred right from the onset of symptoms until treatment completion was found to be Rs. 3211 (3.8% of annual family income) under DOTS program, which is less compared to previous studies. The overall mean total cost was significantly high among male (Rs. 3270; P < 0.01), employed (Rs. 3945; P < 0.01), and extrapulmonary patients (Rs. 3915; P < 0.01). Conclusion. The study has reiterated the fact that DOTS helps in reducing out-of-pocket expenses to patients with tuberculosis and hence is a cost-effective health intervention. This cost reduction may help to increase the access to the poor people which would help in achieving universal access to TB care services.

Prevalence and Risk Factors of HIV Infection among Clients Attending ICTCs in Six Districts of Tamilnadu, South India.

Objective. To assess the HIV serostatus of clients attending integrated counseling and testing centres (ICTCs) in Tamilnadu, south India (excluding antenatal women and children), and to study its association with demographic, socioeconomic, and behavioral risk factors. Design. In a prospective observational study, we interviewed clients attending 170 ICTCs from six districts of Tamilnadu during 2007 utilizing a standard pretest assessment questionnaire. All the clients were tested for HIV with rapid test kits. Multiple logistic regression analysis was used to identify determinants of HIV infection. Results. Of 18329 clients counseled, 17958 (98%) were tested for HIV and 732 (4.1%; range 2.6 to 6.2%) were tested positive for HIV. Median age of clients was 30 years; 89% had never used condoms in their lives and 2% gave history of having received blood transfusion. In multivariate analysis HIV seropositivity was associated with HIV in the family (adjusted odds ratio) (AOR 11.6), history of having sex with sex workers (AOR 2.9), age ≥31 years (AOR 2.8); being married (AOR 2.5), previously tested for HIV (AOR 1.9), illiteracy (AOR 1.7), unemployment (AOR 1.5), and alcoholism (AOR 1.5). Conclusion. HIV seroprevalence being high in ICTC clients (varied from 2.6 to 6.2%), this group should also be included in routine programme monitoring of sero-positivity and risk factors for better understanding of the impact of the National AIDS Control Programme. This would help in evolving appropriate policies and strategies to reduce the spread of HIV infection.

Why do tuberculosis suspects bypass local services to attend tuberculosis sanatorium?

BACKGROUND: The Government Hospital of Thoracic Medicine (GHTM), Tambaram, in Kanchipuram district (formerly known as tuberculosis [TB] sanatorium), Tamil Nadu, draws patients from all over India although RNTCP services have been in place country-wide for a number of years. OBJECTIVE: To document the reasons for patients with chest symptoms attending GHTM, Tambaram. MATERIALS AND METHODS: In a prospective observational study, on a simple random sample basis, TB suspects attending the out-patient department of GHTM during the period January-March, 2006, were interviewed using a semi-structured interview schedule. Information on demographic, socio-economic characteristics and reasons for attending GHTM for health care was collected. RESULTS: A total of 2,023 respondents attended GHTM during the study period; 56% were males, 67% were aged <45 years, 63% were literates and the average annual family income was Rs 25,000. Multiple reasons for attending GHTM were given: popularity of the centre (82%), perceived availability of good treatment (52%), referral by earlier treated patients (36%), expectation of specialized care (22%), referred by treating physicians (13%), and came for inpatient care (11%). CONCLUSION: Despite the availability of local RNTCP health services, many patients with chest symptoms made use of GHTM services due to the reputation of the former "TB sanatorium" in the community. The findings suggest that there is a need to improve community awareness of the availability of free diagnostic and treatment facilities locally under RNTCP.

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.