Designated Microscopy Centres Research Articles

Operational feasibility and multi-centric evaluation of ‘TBDetect sputum microscopy kit’ for the direct detection of Mycobacterium tuberculosis in field settings

Background India relies primarily on direct smear microscopy for tuberculosis (TB) diagnosis. However, the low sensitivity of smear microscopy emphasizes the need to improve its performance. We recently described the development of ‘TBDetect’ kit which showed improved performance over direct smear microscopy at National Reference Laboratories (NRLs) in India. Methods The present study was aimed to assess the operational feasibility of ‘TBDetect’ microscopy in field settings. This was evaluated by (i) assessing the performance of ‘TBDetect’ microscopy vs. LED-fluorescence microscopy (LED-FM) on consecutive presumptive pulmonary TB patients (n = 5300) who attended Designated Microscopy Centres (DMCs, n = 13) under 4 NRLs at Bhubaneswar, Bhopal, Chennai, and New Delhi, and (ii) obtaining feedback from Scientists (n = 10) and laboratory technicians (n = 42) using semi-structured questionnaires under the following parameters: feasibility of initiation of ‘TBDetect’ microscopy in DMCs, sample preparation and testing, training, time-to-result, logistics, and troubleshooting. A scoring questionnaire was also used to assess ‘TBDetect’ microscopy vs. LED-FM and statistical significance of the scores was calculated using paired t-test. Results The overall positivity of ‘TBDetect’ microscopy was 10.32% (547/5300) vs. 8.96% (475/5300) of LED-FM at all sites and the increment in positivity was significant (p = 0.019). In addition, ‘TBDetect’ microscopy yielded an increment in smear grade status over LED-FM (p = 0.043). The feedback from the study-in-charge and kit users indicated that ‘TBDetect’ microscopy was easily adapted in point-of-care settings. An analysis of scoring feedback suggested that it was easy to perform and observe in comparison to LED-FM (p < 0.005). Conclusions This study established the feasibility of ‘TBDetect’ microscopy in field settings.

“Intensified Case Finding of Tuberculosis among Diabetes Mellitus Patients attending Non-Communicable Disease Clinic in a Tertiary Care Hospital – An Implementation Research”

BackgroundFor ending the epidemic of TB by the year 2030, along in line with Sustainable Development Goals, it is essential to address the TB associated co-morbidities. Prevalence of diabetes influencing TB incidence and mortality is higher when compared to other co-morbidities like HIV infection, cigarette smoking, alcohol use and under-nutrition. Therefore, this study was conducted with the following objectives: 1.To evaluate the effectiveness of the intervention on implementation of TB-DM collaborative activity using four symptom complex strategy and to explore the patient and health providers related factors that contribute to implementation of activity. Material and MethodsThe present study was undertaken by Department of Community Medicine, Sri Manankula Vinayagar Medical College and Hospital, Puducherry for a period of 18 months in the Out Patient Departments of General Medicine, General Surgery, Obstetrics and Gynecology, Orthopedics, DOTS center and Designated Microscopy Centre. It was an embedded sequential experimental study, done among the health care professionals (CRRI, Postgraduates and staff nurse) who were involved in process of 4s complex screening for DM patients and the stakeholders who were involved in implementation of NTEP activity. The study was conducted in three phases. Phase I: baseline survey and identification of intervention strategies, Phase II: implementation of the intervention and Phase III: end line survey. Data entry and analysisManual content analysis was done for Qualitative data. The Quantitative data were entered into Epi Info software (version 7.2.2.6) and analyzed in SPSS software (version 24). Comparison of knowledge among the health care professionals before and after sensitization was calculated using Mc nemar test. It was considered statistically significant when the p value was <0.005. The analysis of free list and pile sort data was undertaken using Anthropac 4.98.1/X software. ResultsChallenges obtained from stakeholders in implementing the activity were categorized as patient related factor, health care professional related factor and screening and reporting related factor. Suggested solutions were generating awareness at patient level, display of IEC tools, periodical sensitization for the staff, inter-departmental co-ordination, monitoring and re-enforcing the activity in core-committee meetings. After sensitization, the knowledge on joint TB-DM collaborative activity was significantly improved among the health care professionals. By implementing the four symptom complex screening activity in NCD clinic, 6480 DM patients were screened and 176 (2.7%) presumptive TB cases were identified. Of which, 136 of them reached DMC for sputum examination. Among them 44 (35.4%) had active TB infection. The Number Needed to Screen to yield a case of TB was 147. Conclusionand recommendations: We found improvement in identification of TB cases using ICF approach with minimal resources. Thus, we recommend a support group to maintain and strengthen the ongoing activity. The challenges and solutions identified may help in optimizing the screening process. Implementing the activity in special clinics like oncology OPDs, nephrology OPDs, antenatal clinics can be recommended.

Risk factors of treatment interruptions among drug-sensitive and drug-resistant pulmonary tuberculosis patients - A study from South Delhi, New Delhi, India

BackgroundA variety of factors influence adherence to the lengthy duration of anti-tuberculosis treatment, making it a complicated and dynamic problem. The objective of this study was to investigate the treatment interruption patterns using pre-defined criteria among a cohort of pulmonary tuberculosis patients and to elicit the associated factors. MethodsThis prospective, observational study was conducted between October 2016 to May 2018. All smear and culture positive pulmonary tuberculosis patients (age ≥ 14 years) enrolled between October 1, 2016 to March 31, 2017 across 3 Designated Microscopy Centers (DMCs) were included and followed up till end of treatment for outcome in drug-sensitive, and till interim outcome at 6 months for drug-resistant TB patients. Patterns and reasons for interruptions were recorded as per the study protocol. Results171 patients were enrolled in this study, of which 135 (78.94 %) were on Category-I and Category-II treatment (drug-sensitive tuberculosis), 23 (13 %) were multidrug-resistant (MDR) and 13 (8 %) were extensively drug resistant (XDR) tuberculosis patients. Among the drug-sensitive group, 65 (48 %) patients completed their treatment without any interruption while 70 (52 %) patients interrupted with at least one missed dose. Among the 36 MDR/XDR patients, 19 (53 %) patients did not interrupt treatment, but 17 (47 %) patients interrupted with at least one missing dose. The 87 patients in both sub-groups interrupted for 232 times/episodes of which 140 were short and 84 were long interruptions. The main reasons for interruption were found to be busy schedule in 63 (29 %) patients, adverse drug reactions in 40 (18.4 %) and comorbidities in 43 (19.8 %) patients. Feeling of early improvement/no improvement in 23 (10.5 %) patients, addictions in 27 (12.4 %) patients, lack of family support in 14 (6.4 %), unawareness of dosage and duration of treatment in 7 (3.20 %) patients were other common reasons. ConclusionThe plurality of patients studied were found to be in the younger age group i.e., 14–25 years (n = 75), constituting nearly 44 % of all the patients included and male treatment interrupters (62 %) outnumbered the females (38 %), possibly owing to work schedule or addictions. The majority of interruptions were related to patient related factors (93.5 %), followed by DOTS provided factors (6.40 %) and system related factors (3.01 %). Further studies should be conducted to classify the factors of treatment interruptions in detail and also to study the impact of these interruptions’ patterns on final outcomes.

Utilization of Nikshay Poshan Yojana scheme among tuberculosis patients registered in a designated microscopy center, Bangalore

Background: Nutritional support plays an important role in the management of tuberculosis. To reduce malnutrition among those suffering from TB, the government of India started the Nikshay Poshan Yojana in 2018, offering a monthly incentive of INR 500 to each patient enrolled under the programme. Objective was to assess the utilization of financial benefits among tuberculosis patients registered under the scheme Nikshay Poshan Yojana. Methods: Descriptive study was conducted among 137 tuberculosis patients registered under Nikshay portal of designated microscopy center (DMC). Interview was conducted and obtained necessary information. Results: Among 116 responded tuberculosis patents, 83 (71.5%) received full and partly incentives throughout the course of treatment, among the beneficiary 61 (71.5%) were using their incentives for nutritional purpose. Conclusions: Beneficiaries under Nikshay Poshan Yojana received incentives but not on timely basis.

Tuberculosis health services during advent of COVID-19 pandemic in Sonipat district of Haryana

Background: India put efforts to achieve TB free status by 2025 but, advent of COVID-19 Pandemic compelled to repurposing of health facilities and services to manage the situation, which greatly affected the TB management in the country. This study was aimed to find out the situations faced by Health care providers in diagnosis and initiation/continuation of ATT under NTEP during the COVID-19 pandemic period. Methods: This descriptive cross-sectional study conducted in Sonepat District of Haryana State among Medical officers posted in Health Centres and Lab Technicians posted in Designated Microscopy Centres, responsible for managing Tuberculosis during second and third quarters of 2020. Data were collected using separate, pretested semi-structured schedules and results were compiled and described in percentages and proportions. Results: Almost half (54%) of the LTs were posted at DMCs daily. Only three of the facilities had CB-NAAT facilities, of which two (66.66%) were partially diverted for COVID-19 testing. Majority (68.2%) of the MOs reported regular OPD facilities at their facilities during lockdown, with regular TB diagnostic lab facilities (68.2%). More than 81% of the MOs reported non-availability of In-Patient (IP) facilities during lockdown, and diversion of staff for COVID-19 was observed as the major reason (66.7%) for facility non-availability. Conclusions: The pandemic affected the provision of TB services in the region. Preparedness, timely interventions on regular feedbacks can mitigate such difficulties in future.

FLUORESCENCE MICROSCOPY VS TRUENAT- WHICH METHOD IS BETTER FOR DIAGNOSIS OF TUBERCULOSIS?

Background: Despite the advent of newer drugs, modern diagnostic techniques and improvement in management strategies, India continues to be the leader in tuberculosis burden. Several methods for diagnosis exist, such as light microscopy, fluorescent microscopy, solid culture, liquid culture (Mycobacterium growth indicator tube [MGIT] culture) to molecular methods. However, each of these methods have variable sensitivity and specificity. Very few studies have been done evaluating the role of TrueNAT with fluorescent microscopy, thereby evaluating the performance of a designated microscopy center under the national tuberculosis elimination programme. Methods and Materials: This is a retrospective observational study performed in a designated microscopy center in Santhiram Medical Center, Nandyal. This is to compare the fluorescence microscopy and TrueNAT provided as part of the National Tuberculosis Elimination programme. A total of 342 patients underwent testing at this center and were diagnosed with tuberculosis. Results:Majority of the study participants were males, smokers, in the age groups of 31-40 years. The mean age of males was found to be higher than that of females. (37.64 vs 32.39 years). 89.42% of patients were diagnosed on fluorescent microscopy, while 94.23% were diagnosed with TrueNAT. Sensitivity of TrueNAT was 91.61%, specificity was 87.80% and accuracy was 90.76%. Conclusion: TrueNAT appears to be superior to Fluorescent microscopy in a setting of a designated microscopy center.This can be used for rapid diagnosis, with high sensitivity with specificity when compared to the traditionally accepted fluorescent microscopy.

A study of rifampicin and isoniazid resistance in pulmonary tuberculosis patients with various radiological presentations at a designated microscopy center

A study of rifampicin and isoniazid resistance in pulmonary tuberculosis patients with various radiological presentations at a designated microscopy center

Status of universal drug-susceptibility testing among sputum smear-positive tuberculosis patients diagnosed at a tertiary care centre.

This study was aimed at estimating the proportion among sputum smear-positive tuberculosis (TB) patients diagnosed at a tertiary care centre in India, who did not undergo universal drug-susceptibility testing (UDST), assessing the sociodemographic and morbidity-related factors associated with it, ascertaining the reasons for not getting tested and estimating the proportion with any drug resistance (DR). TB Notification Register and TB Laboratory Register, maintained in Designated Microscopy Centre and Intermediate Research Laboratory, respectively were used to obtain the patient details and information regarding UDST and DR-TB status. Under UDST, the TB patients had undergone rapid molecular tests to check for any DR. TB patients who dropped out of this strategy (those who did not submit a sputum sample for DR testing even after being instructed) were telephonically contacted and asked regarding reasons for not getting themselves tested. Of the 215 patients, 74 [34.4%, 95% confidence interval (CI): 28.1-41.2] did not undergo UDST. Of these 74 participants, 60 per cent reported the reason that they were not informed regarding the drug-susceptibility test. Among the 141 patients who underwent UDST, six (4.3%, 95% CI: 1.58-9.03) had DR. Non-UDST patients were significantly more in percentage among TB patients who were aged <30 years (adjusted prevalence ratio 2.36; 95% CI: 1.19-4.68) compared to >60 years. The present findings point towards a need to sensitize healthcare workers and TB patients to improve UDST.

Referral process in tuberculosis − Human immunodeficiency virus collaborative activities – Need for a relook into policy implementation in Uttarakhand

Background: Provider-initiated testing and counselling (PITC), an essential component of tuberculosis (TB) human immunodeficiency virus (HIV) collaborative activities, is intended to translate into the increased rates of HIV testing in TB patients. Aim: The study intends to assess compliance with the referral process and other attributes of HIV testing in TB patients. Methods: The study was conducted at various designated microscopy centres (DMCs) in four randomly selected districts in the Garhwal region of Uttarakhand and included 346 patients. Results: Only 46.8% of patients went for HIV testing. The most common reason cited for not going was the absence of specific advice by the health staff at DMC. In addition, the long waiting time at Integrated Counselling and Testing Centres favoured the spread of infection to susceptibles in the waiting area. Binary logistic regression analysis also found that patient's importance towards HIV testing, advice by the health worker and higher education and age were significant predictors of HIV testing. Conclusions: The referral process at DMC requires closer monitoring and supervision for improvement in qualitative parameters. Training and supportive supervision of health staff at DMC for 'counselling' of patients during referral for testing are also necessary to preserve the essence of PITC.

Intensified case finding for screening tuberculosis among antenatal women in Delhi, India; A facility-based prospective observational study

BackgroundTuberculosis (TB) during pregnancy accentuates the risk of adverse maternal and fetal outcomes, including perinatal deaths, preterm births, and low birth weight babies. Screening for active TB during pregnancy by healthcare providers can potentially allow early identification of the disease to initiate prompt treatment in this vulnerable population. ObjectivesTo determine the yield of presumptive TB using the four symptom complex screening model as an intensified case finding tool. MethodsWe conducted a prospective observational study among pregnant women attending the outpatient antenatal clinics at a secondary and tertiary care government hospital in Delhi, India from February to July 2020. The participants were symptomatically screened for presumptive TB and appropriately referred for smear examination at designated microscopy centers. ResultsWe recruited a total of 1306 participants in the study, having a mean (S.D.) age of 24.9 (3.9) years. The yield of presumptive tuberculosis among pregnant women attending the antenatal clinic was 3.0% (95% CI: 2.1–3.9) and the yield of TB was 0.23%. Multigravida mothers (aPR = 2.1, 95% CI: 1.04–4.4), Muslim religion (aPR = 2.8, 95% CI: 1.5–5.4) and mothers in the first trimester (aPR = 3.4, 95% CI: 1.6–7.4) had a statistically significant higher prevalence of presumptive TB than primigravida, non-Muslims and other trimesters respectively. ConclusionThe yield of TB obtained through systematic symptom screening was low among antenatal women attending the two antenatal health clinics of Delhi. However, the process has minimal resource requirements which advocate its implementation among pregnant mothers as per the recommendations from the collaborative framework for management of TB in pregnant women.

Delay in diagnosis and treatment among registered TB patients in Directly Observed Treatment Short Course cum Designated Microscopy Centres in South Delhi

Background: Knowing delays in treatment seeking and subsequent treatment initiation among the TB patients is important and its detailed understanding is crucial in modifying the treatment seeking behaviour which can help in reducing the TB burden and the transmission in the community. Aim &amp; Objective: To study the treatment seeking behaviour including the delays in initiation of treatment along with its determinants; among tuberculosis patients aged &gt; 15 years in Mehrauli area of Delhi. Settings and Design: A longitudinal follow up study conducted in two randomly selected DMC cum DOTS centres in Mehrauli area of Delhi from January 2018 to April 2018. Methods and Material: Patients of both sexes of age &gt; 15 years, registered under RNTCP from January to April 2018 in the randomly selected DOTS centres i.e. Mehrauli DMC cum DOTS and Chattarpur DMC cum DOTS centre were included in the study. Self-designed, pretested interview schedule and records of DMC were used to collect the relevant information. Statistical analysis used: Information collected in the Performa was coded and entered in Statistical Package for Social Sciences (SPSS) version 12. Results: The mean patients delay, diagnostic delay, treatment delay, health care system delay and total delay was 48.91 ± 130.38 days, 91.09 ± 155.97 days, 6.25 ± 6.29 days, 62.72 ± 119.48 days and 97.33 ± 155.06 days respectively. The median patients delay, diagnostic delay, treatment delay, health care system delay and total delay was 15 days, 45 days, 5 days, 35 days and 54 days respectively. Conclusions: The major reasons for patient’s delay were lack of awareness regarding the symptoms of TB and self-medication and for health care system delay it was treatment from private health care providers.

Compatibility of a novel filter paper-based bio-safe sputum transport kit with line probe assay for diagnosing drug-resistant tuberculosis: a single-site evaluation study.

BackgroundNear-patient access to appropriate tests is a major obstacle for the efficient diagnosis of tuberculosis (TB) and associated drug resistance.MethodsWe recently developed the “TB Concentration & Transport” kit for bio-safe, ambient-temperature transportation of dried sputum on Trans-Filter, and the “TB DNA Extraction” kit for DNA extraction from Trans-Filter for determining drug resistance by DNA sequencing. In the present study, we evaluated the compatibility of Kit-extracted DNA with Hain's line probe assays (LPAs), which are endorsed by National TB programmes for the detection of drug resistance in sputum collected from presumptive multidrug-resistant TB patients (n=207).ResultsTrans-Filter-extracted DNA was seamlessly integrated with the LPA protocol (Kit-LPA). The sensitivity of Kit-LPA for determining drug resistance was 83.3% for rifampicin (95% CI 52–98%), 77.7% for isoniazid (95% CI 52–94%), 85.7% for fluoroquinolones (95% CI 42–100%) and 66.6% for aminoglycosides (95% CI 9–99%), with a specificity range of 93.7% (95% CI 87–97) to 99.1% (95% CI 95–100) using phenotypic drug susceptibility testing (DST) as a reference standard. A high degree of concordance was noted between results obtained from Kit-LPA and LPA (99% to 100% (κ value: 0.83–1.0)).ConclusionsThis study demonstrates successful integration of our developed kits with LPA. The adoption of these kits across Designated Microscopy Centres in India can potentially overcome the existing challenge of transporting infectious sputum at controlled temperature to centralised testing laboratories and can provide rapid near-patient cost-effective “Universal DST” services to TB subjects residing in remote areas.

Study of Active Screening to Detect Un-Registered Open Cases of Tuberculosis in Rural Areas of Capital District of Rajasthan, India

Tuberculosis is one among top 10 causes of deaths worldwide. Access to effective diagnosis by every TB patient is one among five missions of Global Plan. Active case finding among vulnerable groups has been the key focus area of National Strategic Plan to control TB in India 2017-25. This cross-sectional study was carried out to find out the additional open cases of TB through active screening of general & rural population in selected villages of Jaipur, the capital district in Rajasthan state of India. An active screening team of trained staff visited each house-hold in selected study villages for interviewing the head of house-hold or other adult member available at the time of visit. Family members of age ≥ 15 years were screened for complain of chronic cough of duration 2 weeks or more with study questionnaire. Presumptive cases found at screening were referred for seeking medical consultations from nearest designated microscopy centre. The referred patients were followed up on telephone up to five times for results of medical consultancies. Laboratory technicians of catchment DMCs were also followed up for verification of results. Total 19,306 individuals were covered. Study included 52.8% male, 69.3% ≥ 15 years age, and 99.3% Hindu participants. There were total 153 presumptive TB patients. Out of these, total 10 cases were confirmed as TB. The yield of detection was 0.51 cases/1000 population screened. Study finds active screening as a feasible and effective strategy in detecting additional cases of TB from general and rural population.

Evaluation of ‘TBDetect’ sputum microscopy kit for improved detection of Mycobacterium tuberculosis: a multi-centric validation study

ObjectivesThe present study aimed to evaluate the performance of the ‘TBDetect’ kit-based bio-safe fluorescent microscopy filter (BioFM-Filter) microscopy in comparison with direct smear microscopy and culture for the detection of pulmonary tuberculosis (TB) in a multi-centric setting in India. MethodsThe TBDetect kit enables sputum concentration through filtration using the BioFM-Filter for improved and bio-safe smear microscopy. We evaluated the performance of the TBDetect kit in a six-site multi-centric validation study on sputum collected from 2086 presumptive TB patients. ResultsThe combined positivity of TBDetect microscopy performed on these sputum samples was 20% (n = 417/2086) vs 16.1% of light-emitting diode fluorescence microscopy (LED-FM, n = 337/2086) and 16% of Ziehl Neelsen (ZN) smear microscopy (n = 333/2086). The increment in positivity of TBDetect over both LED-FM and ZN smears was significant (p < 0.001). The overall sensitivity of TBDetect for six sites was ~55% (202/367, 95% confidence interval (CI): 50, 60%) vs 52% (191/367, 95% CI: 47, 57%) for LED-FM (p 0.14) and 50.9% (187/367, 95% CI: 46, 56%) for ZN smear (p < 0.05), using Mycobacterium Growth Indicator Tube culture (MGIT, n = 1949, culture positive, n = 367) as the reference standard. A bio-safety evaluation at six sites confirmed efficient sputum disinfection by TBDetect; 99.95% samples (1873/1874) were sterile after 42 days of incubation. Scientists and technicians at the study sites indicated the ease of use and convenience of TBDetect microscopy during feedback. ConclusionsTBDetect added value to the smear microscopy test due to its improved performance, convenience and user safety. These findings indicate that equipment-free TBDetect technology has the potential to improve TB diagnosis in basic laboratory settings by leveraging on the existing nationwide network of designated microscopy centres and primary healthcare centres.

Pre-treatment lost to follow up among presumptive tuberculosis patients in a tertiary care centre, South India

Background: At tertiary care centres, presumptive tuberculosis (TB) patients who come from far off places and are more likely to drop out during diagnosis or before treatment initiation. We aimed to describe the proportion lost during diagnosis or before treatment and also assessed the reasons for the loss to follow up.Methods: We did a hospital based descriptive study, reviewing laboratory register and referral register to assess the status of submission of second sputum and referral letter, respectively, for patients visiting a designated microscopy centre at a teaching hospital. Reasons for lost to follow up were assessed through telephonic interviews.Results: Out of a total 2025 presumptive TB patients, 315 (15.6%, 95% CI 14.0-17.2) did not provide a second sputum sample. ‘Symptoms had reduced or subsided’ (30%), ‘not aware that second sample needs to be given’ (23%) and ‘visited other hospital’ (14%) were the common reasons reported for the same. A total of 270 (13.3%) patients were sputum smear positive; of them 92 (34.1% CI 28.4-40.1) did not collect referral letter. Among those who were referred, 66% were referred within a week. Deaths, ‘busy in routine work’ and treatment at other government hospitals were the common reasons reported for not collecting referral letter.Conclusions:One out of seven patients did not submit a second sputum sample and one third of sputum smear positive TB patients did not collect the referral letter. Follow up mechanisms needs to be strengthened in the national program to reduce this pre-treatment lost to follow up.

Does mobile phone instructional video demonstrating sputum expectoration improve the sputum sample quality and quantity in presumptive pulmonary TB cases? Protocol for a prospective pragmatic non-randomised controlled trial in Karnataka state, India

IntroductionSputum smear microscopy is the cornerstone of tuberculosis (TB) diagnosis under the Revised National Tuberculosis Control Programme (RNTCP) in India. Instructions on how to produce a good sputum sample are...

Household food insecurity among patients with pulmonary tuberculosis and its associated factors in South India: a cross-sectional analysis

ObjectivesFood insecurity is ‘the limited or uncertain availability of nutritionally adequate, safe foods or inability to acquire foods in socially acceptable ways’. Majority of tuberculosis (TB) cases of resource-poor settings...

Health care seeking behaviour of pulmonary tuberculosis patients in Jabalpur district, Madhya Pradesh

Background: Successful tuberculosis control requires specific behaviors from patients and health providers. Therefore, understanding behaviors is fundamental to design interventions to strengthen tuberculosis control programs, including communication interventions. The aim of this study was to assess the healthcare-seeking behavior of pulmonary tuberculosis (PTB) patients in Jabalpur district.Methods: Cross-sectional study was conducted among category I new sputum positive PTB patients identified from nine designated microscopy centres from November 2013 to October 2014. Calculated sample size of 135 with a multistage random sampling method was used. Student’s t-test and Chi-square test were used along with descriptive statistics.Results: Mean age of patients was 33.87 (14.3) years, males constituted 66.7%, 72.5% patients belonged to below class IV socioeconomic status. Cough was experienced by 91.1% subjects, followed by fever (69.6%). First action was consulting a health care provider (HCP) in 41.5% followed by self-medication (21.5%). It took two attempts for 76% of patients to reach a formal health care provider. Private health care providers were consulted as first choice among HCPs by 86.7% patients, initial diagnosis was made by them in 25.9% cases. Sixty-three percent of patients were not satisfied with care at government hospitals, 41.5% had not heard of tuberculosis before their diagnosis, 59.5% of patients got information about tuberculosis from their relatives suffering from it.Conclusions: Cough is the most common and earliest symptom responsible for seeking care in pulmonary tuberculosis. Government health facilities contribute maximum to diagnosis but private health facility is the first choice for initial consultation. Patients’ perception of suggestive symptoms needs to be changed.

Universal health coverage and tuberculosis care in India in the times of Covid-19: Aligning Ayushman Bharat (National Health Assurance Scheme) to improve case detection, reduce deaths and catastrophic health expenditure.

India has the largest global burden of new cases of tuberculosis (TB) and deaths due to TB. These occur predominantly in the poor who suffer catastrophic costs during diagnosis and treatment. The National Tuberculosis Elimination Programme has ambitious goals of 80% reduction of incidence of TB, 90% reduction in mortality due to TB by 2025 and 0% occurrence of catastrophic costs to households affected by TB by 2020. The Covid-19 pandemic and the resulting disruption to TB services are expected to worsen the situation. There are gaps in case finding at the peripheral level and access to care at the higher level for patients with TB. An estimated 32% patients with active TB do not access diagnostic services, while catastrophic costs associated with hospitalization are a barrier to access for seriously ill patients. Deaths due to TB in India occur largely at home and not in medical facilities, and are preventable with appropriate inpatient care. The Ayushman Bharat scheme with its Health and Wellness Centres (HWCs) and coverage for inpatient care under the Pradhan Mantri Jan Arogya Yojana (PM-JAY) can facilitate, the achievement of the goals of TB elimination. The HWCs provide an opportunity to close the case-finding gap as first point of contact by enabling sputum transport services to the designated microscopy centres. This will facilitate case detection, reduce diagnostic delays, and decrease community transmission and the incidence of TB. The benefit package of PM-JAY can cover patients with pulmonary TB, inpatient evaluation for other forms of TB, enhance the allocation for treatment and cover management of comorbid conditions such as severe undernutrition, anaemia, HIV and diabetes.

HIV positivity in presumptive tuberculosis cases in a tertiary respiratory care institute in New Delhi, India

Background: Routine screening of presumptive tuberculosis (TB) patients for HIV was advised by the Treatment and Operational Guidelines of TB in India in 2016. This was in contrast to the earlier policy in which only diagnosed TB cases underwent HIV screening. Keeping this in mind, our study was carried to look at the prevalence of HIV in presumptive TB cases in a tertiary respiratory disease hospital in New Delhi, India. Materials and Methods: This prospective observational study was carried out from 2015 to 2017 in which patients (>18 years of age) attending the outpatient department diagnosed as presumptive TB were enrolled. They underwent sputum examination in Revised National TB Control Programme Designated Microscopy Centre by fluorescence microscopy/Ziehl–Neelsen staining technique for the diagnosis of PTB, and they were taken to Integrated Counselling and Testing Centre in our hospital. Fine-needle aspiration cytology from lymph nodes and pleural or ascitic fluid studies were also done as per requirement for the diagnosis of extrapulmonary tuberculosis. Pretest counseling and HIV test were performed after informed consent. Results: Forty out of 1020 enrolled patients were HIV positive (3.9%). Fifteen out of 617 patients who were not suffering from TB came out to be HIV positive (2.4%). Our strategy led to an enhanced case finding of 15/25 (60%) new HIV-positive patients. Conclusion: Routine HIV screening in presumptive TB patients is a viable model to increase the case finding of HIV patients.