Revised National Tuberculosis Control Programme Guidelines Research Articles

Treatment Practices in Pulmonary Tuberculosis by Private Sector Physicians of Meerut, Uttar Pradesh

Majority of the qualified medical practitioners in the country are in the private sector and more than half of patients with tuberculosis (TB) seek treatment from them. The present study was conducted with the objective of assessing the treatment modalities in pulmonary tuberculosis by the private physicians in Meerut City, Uttar Pradesh, India. A cross-sectional study was carried out covering all the private physicians (graduates and postgraduates in Medicine and Chest Diseases) registered under the Indian Medical Association, Meerut Branch (n = 154). The physicians were interviewed by a pre-designed and pre-tested questionnaire about the treatment modalities practiced by them. Only 43.5% private physicians had attended any Revised National Tuberculosis Control Programme (RNTCP) training in the past five years. Only 33.1% of them were aware of the International Standards of Tuberculosis Care (ISTC). Fifty-three different regimens were used to treat the patients. Majority of physicians (76%) prescribed daily regimens while 24% administered both daily and intermittent treatment. None of the private physicians prescribed exclusive intermittent regimen. Eighty-seven different treatment regimens were used for the treatment of multidrug-resistant TB (MDR-TB) with none of them prescribing standard treatment under RNTCP. As majority of private practitioners do not follow RNTCP guidelines for treating TB, there is an urgent need for their continued education in this area.

Improved Diagnosis of Pulmonary Tuberculosis using Bleach (Sodium hypochlorite) Concentration Technique at Tertiary Care Hospital

Introduction: In the Revised National Tuberculosis Control Program (RNTCP), microscopic examination of sputum for acid-fast bacilli (AFB) is currently the backbone for the diagnosis of pulmonary tuberculosis. Studies have shown liquefaction and concentration of sputum by 5% sodium hypochlorite is useful in providing increased sensitivity and safety for the handling of specimens. Objective: To assess the utility of the 5% Sodium hypochlorite concentration method in increasing the sensitivity of smear microscopy for detection of AFB for diagnosis of pulmonary tuberculosis. Methods: The study included a total of 1000 sputum samples from 500 patients with suspected pulmonary tuberculosis. Direct smears were prepared from the sputum samples as per RNTCP guidelines. The remaining sputum was used for bleach concentration and smears prepared from the concentrated material. Both smears were stained by Ziehl-Neelsen staining and screened for acid-fast bacilli and graded according to the RNTCP guidelines. Results: A total of 158 samples (15.8%) from 89 patients were positive by a routine direct method whereas by concentration method 236 samples (23.6%) from 143 patients were found positive diagnosing additional 54 patients. The gain in sputum smear positivity of 7.8% over the routine method is highly significant (p=0.0000, χ2= 270) with a 10.8% increase in case detection. Conclusions: Improvement in the sensitivity of smears microscopy will be useful in case detection of tuberculosis especially in resource-poor countries. The increased positivity of microscopy by bleach method indicates that would prove useful if included in the RNTCP to improve case detection. Keywords: Concentration; smear positivity; sodium hypochlorite; tuberculosis.

Implementation of revised national tuberculosis control program guidelines: Practitioner's perspective and awareness-a questionnaire based study

BackgroundStrengthening public health services, setting up directly observed therapy short course Centres, introduction of Revised National tuberculosis Control Program (RNTCP) are aimed to eradicate tuberculosis by 2025. The aim of this study was to assess physician's awareness, and perspectives about the recent RNTCP guidelines. MethodsThis was a cross-sectional, opinion deriving, study through a tested, validated, standardized questionnaire that covered the role of physician in the diagnosis or treatment of tuberculosis, and tested their awareness about various aspects of RNTCP guidelines. Descriptive statistics was used. ResultsOf the 96 participants, 61.5% were involved in diagnosis and management, 15.6% in diagnosis only, three in treatment aspect of tuberculosis, 19 (19.8%) were not involved in any activity. Awareness regarding RNTCP guidelines was high (90.6%). Forty-five (46.9%) opined that revised Indian program was different from the World Health Organization End Tuberculosis Strategy. Understanding the definitions of diagnosis (DoD) (92.7%), guideline (92.7%), implementation of revised DoD (89.6%), guidelines ((82.3%) was considered simple. Awareness regarding the implementation of revised DoD (86.5%) and guidelines (78.1%) was below expectation. Participants wereless aware (80.2%) of reporting adverse drug reactions to the deputy drug controller; 41.7% each responded that the treating physician or any of the listed persons can report. Reporting ADR to the supervising committee was not clear as >50% did not answer. Awareness about Nikshay (86.5%), procedure for procuring Nikshay ID (46.9%), Institute's Nikshay ID (53.1%) was less. ConclusionsKnowledge about RNTCP guidelines is satisfactory among participants. Extensive training, continued medical education programs are required to increase awareness.

To Assess the Knowledge and Awareness of Interns Regarding the Management of Tuberculosis as per Recent RNTCP (2017-2025) Guidelines – A Cross Sectional Study

India has been engaged in Tuberculosis control activities for more than 50 years as India is the highest TB burdened country in the world. One such initiative is Revised National Tuberculosis Control Programme (RNTCP) which has been rechristened as National Tuberculosis Elimination Programme (NTEP). The change in name is in line with the larger goal of eliminating the disease by 2025. Objective: The aim of this cross-sectional study is to assess the knowledge and awareness of interns regarding the management of tuberculosis as per recent RNTCP guidelines. Materials & Methods: A structured questionnaire was provided to 111 interns to be filled in a stipulated time. The data collected was analyzed using descriptive statistical parameters and expressed in percentage. Result: Out of a total of 111 interns, 48 (43.24%) were males and 63 (56.75%) were females. Good knowledge was seen among the interns regarding the cardinal symptoms of TB as well as definition of MDR-TB. 92.79% of the participants responded rightly about two sputum samples being taken for diagnosis of TB. Only 76.57% of interns knew the principle of treatment of TB as daily administration of fixed-dose combination of first-line anti-tubercular drugs as per appropriate weight bands and 61.27% of interns were unfamiliar of chemoprophylaxis of tuberculosis according to the recent RNTCP guidelines. Only 71.17% of the participants were updated about the follow-up procedure according to new guidelines. But only 36.93% of participants could answer Cotrimoxazole as the effective drug used in HIV-TB co-infection apart from routine TB drugs to reduce mortality. Conclusion: This survey is providing valuable information that there is deficiency of knowledge among the interns regarding management of tuberculosis according to recent RNTCP guidelines which can lead to treatment failure and thereby causing a hindrance to elimination of TB from our country by 2025

Adverse drug reaction prevalence and mechanisms of action of first-line anti-tubercular drugs

PurposeUnderstanding the appearance of anti-tubercular drug-related adverse drug reactions (ADRs) in patients receiving tuberculosis (TB) treatment is important, and may be related to morbidity and mortality if not recognized early. Here, we aimed to characterize the mechanisms underlying adverse drug reactions due to combination anti-tuberculosis therapy of the Revised National Tuberculosis Control Program (RNTCP). MethodsThis was a prospective observational study conducted in 9 DOTS centers of New Delhi, India. All enrolled TB patients receiving first-line tuberculosis treatment as per RNTCP guidelines were monitored for ADRs. All ADRs that appeared during the treatment were recorded and analyzed. ResultsThe study included 1011 TB patients on anti-TB treatment under DOTS. According to Naranjo’s probability scale, of a total 351 (34.72%) reported adverse events, 102 (10.09%) were definite, 59 (5.83%) probable, 123 (12.17%) possible, and 67 (6.63%) doubtful. On the Hartwig severity scale, of the 351 adverse drug events, 225 (22.26%) were mild, 105 (10.38%) were moderate, and 21 (2.08%) were severe. Out of 102 reported adverse drug reactions, 81 (79.41%) were moderate and 21 (20.59%), while 65.28% did not experience any ADRs. ConclusionsDirectly Observed Treatment (DOT) is effective and safe compared to daily treatment regimens. Patients receiving DOTS therapy needed close monitoring for adverse events. Therefore, a pharmacovigilance program should be added at the National level to accesses the adverse event incidence.

Comparison of front-loading versus spot morning sputum microscopy approach among suspected pulmonary tuberculosis cases in tertiary care centre in Uttarakhand

PurposeComparative evaluation of front loading sputum microscopic approach versus standard Revised National Tuberculosis Control Programme (RNTCP) spot morning approach for diagnosis of pulmonary tuberculosis. MethodsAll cases coming to the designated microscopy centre, Microbiology in this tertiary care centre with presumptive diagnosis of pulmonary tuberculosis were enrolled for the study population after taking informed consent. The sputum sample collection, staining and reporting were done according to standard RNTCP guidelines. ResultsThis study shows the probable non-inferiority of the frontloading sputum smear microscopy over the standard RNTCP approach. ConclusionThe front loading smear microscopy could be considered a suitable alternate to standard RNTCP approach in an area with high drop out during diagnostic testing pathway.

Management of pulmonary tuberculosis in private health sector: is it according to revised national tuberculosis control programme guidelines?

Background: As private sector is dominant tuberculosis (TB) care provider in India, to realize the vision of TB free India, it is crucial that public and private sector follow uniform standard of TB care. This can be achieved when private health sector adopts TB management methodology of Revised National Tuberculosis Control Programme (RNTCP) of India. The present study was conducted to estimate whether or not TB management practices of allopathic private practitioners (PPs) conform to RNTCP guidelines by assessment of their knowledge and practice about new pulmonary TB (PTB).Methods: A cross-sectional study conducted using a semi-structured questionnaire among PPs practicing in urban areas of five of the six districts of Kumaon Division of Uttarakhand State of India between October 2013 to November 2014.Results: Of 71 PPs included in the study, almost 66% did not suspect pulmonary TB unless cough was associated with other symptoms. For diagnosis and follow up, sputum AFB microscopy alone was used by only 10% and 8.4% PPs respectively. Of the 71 PPs, 67 PPs who prescribed treatment for new PTB, used 20 diverse anti-TB regimens, and 10.5% of them included levofloxacin in the regimen.Conclusions: Majority PPs didn’t follow the RNTCP’s TB management guidelines for new PTB.

Clinical Spectrum of Central Nervous System Tuberculosis and the Efficacy of Revised National Tuberculosis Control Program in its Management.

Introduction:Tuberculosis (TB) is a major global problem and poses a threat which is of considerable magnitude, with an estimated one-third of the population infected with TB bacillus.Aim:The aim of this study is to study the treatment outcomes in patients with various forms of neurological TB treated with the standardized Revised National TB Control Program (RNTCP), directly observed treatment short-course (DOTS).Materials and Methods:Patients diagnosed to have TBM, tuberculoma with or without spinal arachnoiditis (central nervous system tuberculosis-TB [CNS-TB]) were categorized as per the RNTCP guidelines and received DOTS Category I or Category II thrice-weekly intermittent treatment as deemed appropriate.Results:The outcome of management with the standard RNTCP DOTS regimen was that a success rate (treatment completed) of 75%, the default rate of 6.6%, and a mortality of 3.3%. The target fixed by the RNTCP is to achieve a cure rate of 85%. We were able to document successful completion of treatment in 75% which is close to the target fixed by RNTCP. The default rate is 6.6% which quite negligible when compared to the unsupervised therapy which has a default rate of 50%.Conclusion:The most important factor in predicting the outcome of treatment in CNS-TB is early diagnosis and the timing of initiation of antituberculous treatment. Early initiation of treatment is associated with better treatment outcomes.

Diagnosis and treatment of pulmonary tuberculosis in one day: Way forward for END TB Strategy 2015.

Background:According to Revised National Tuberculosis Control Program (RNTCP), diagnosis of pulmonary tuberculosis (TB) in India requires examination of two sputum samples collected over 2 days, that is, “spot” and next day “morning” samples.Objective:To assess the feasibility of diagnosing pulmonary TB by examining two spot sputum samples in 1 day and to compare this approach with the current RNTCP protocol.Materials and Method:A total of 375 subjects having cough >2 weeks were enrolled into the study. Three sputum samples were collected from each of the study participant; first spot (S1), second extra-spot (S2) sample 1 h after collection of the first sample, and third morning (M) sample collected next day morning. These specimens were subjected to standard sputum smear microscopy for acid-fast bacilli as per RNTCP guidelines. For 1-day protocol, results of “S1 and S2” samples and for 2-day protocol results of “S1 and M” samples were considered.Results:The number of sputum-positive pulmonary TB cases diagnosed with standard 2-day protocol was 119, whereas the experimental 1-day protocol diagnosed 120 cases (P = 0.7). Comparing with standard 2-day protocol, this new 1-day protocol had sensitivity 98.32%, specificity 100%, positive predictive value 100%, and negative predictive value 99.17%.Conclusion:Single-day method can be adopted as the standard diagnostic approach for pulmonary TB after large-scale multicenter randomized controlled trials.

Impact of Refresher Training on Knowledge Regarding Tuberculosis among Health Workers of West Bengal

Background: Tuberculosis(TB) is one of the leading causes of morbidity and mortality in India. Peripheral health workers in rural areas come in contact with TB suspects regularly during their home visits. The success of the Revised National Tuberculosis Control Programme (RNTCP) depends largely upon the involvement of these workers particularly Auxiliary Nurse Midwives (ANMs). Materials and Methods: All the ANMs and Health Assistants attached to a block primary health center (BPHC) of West Bengal were called for a refresher training on tuberculosis and RNTCP. Medical Officer – Tuberculosis Unit of the area impacted the training along with Senior Treatment Supervisor (STS) and Senior Tuberculosis Laboratory Supervisor (STLS) of the concerned Tuberculosis Unit (TU). The training was of one full day duration and conducted at the BPHC. The resource persons told them about the diagnosis and management of TB cases according to RNTCP guidelines. A pre-test questionnaire having 20 multiple choice and true/ false type questions were given to the participants. The same questionnaire was given to them after the training. The score of post-tests was compared with the pre-test questionnaire. Results: In total 34 health workers participated in the training. 44.1% of the participants were ANM and 38.2% were Health Assistants (Female). Rest were Health Assistants (Male). The mean (SD) duration of their service was 17.79 (1.8) years. 35.3% of them had a graduate degree. The mean (SD) post-test score was significantly better than the mean (SD) pre-test score, 16.53 (1.73) vs 9.76 (1.71). There was a significant improvement in score for 12 questions. Conclusion: With time the knowledge regarding TB and RNTCP is fading in health workers. Regular refresher training is required for the health workers to remain updated about tuberculosis.

Prospective 1-year follow-up study of all cured, new sputum smear positive tuberculosis patients under the Revised National Tuberculosis Control Program in Hyderabad, Telangana State, India.

Background:Tuberculosis (TB) is one of the leading causes of mortality in India. The Revised National Tuberculosis Control Program (RNTCP) is a robust public health system to deal with TB in India. Unless the treated patient comes back to the system with signs and symptoms of TB due to relapse or re-infection, there is no mechanism of follow-up or any method to know the relapse rate in the population. We attempted to follow the patients declared as “Cured” as per the RNTCP guidelines for 1–2 years to identify the health status of the index cases and their household contacts in posttreatment phase.Materials and Methods:In this prospective cohort study, 187 index cases, who were declared “Cured” in six randomly selected TB units of Hyderabad district, were followed up for 1–2 years through home visits by trained staff with structured data collection forms. Data were analyzed using SPSS v20.0.Results:The mean age of the index cases was 33.64 (±16.10) years, and there were 75 females and 112 males. The study sample was homogenous for gender, age, smear grade, religion, marital status, smoking status, alcohol consumption, and human immunodeficiency virus status, etc., At 1-year posttreatment follow-up of 187 index cases, 143 (76.47%) were healthy and working without any symptoms of TB. Symptoms of TB were present in 26 (13.90%) cases, and seven index cases (4.06%) were re-diagnosed with TB. The 2-year posttreatment survival was 92%.Conclusion:Long-term follow-up of cured, new smear-positive TB cases reinforce the effectiveness of anti-TB treatment under the RNTCP as assessed by improved health outcomes in more than two-thirds of cases and posttreatment survival of 92% of index cases. We recommend continuing such follow-up for all TB cases treated under the RNTCP for effective end-TB strategy.

Light-emitting diode-fluorescent microscopy: Determining its sensitivity and specificity in diagnosis of pulmonary tuberculosis in a high-burden tuberculosis region and resource-limited country like India

Background: Tuberculosis (TB) remains a major global health problem. India accounts for the one-fourth of the global TB burden. For resource-limited countries like India having high burden of TB, smear microscopy is the most commonly used method for microbiological diagnosis. Although culture being highly sensitive and specific method, it is time-consuming. Under Revised National TB Control Program (RNTCP), Ziehl–Neelsen (ZN) stain-based microscopy and light-emitting diode-based fluorescent microscopy (LED-FM) are being recommended. Aim: The present study was done to determine the sensitivity and specificity of ZN stain-based microscopy and FM (LED-FM) keeping solid culture as gold standard. Materials and Methods: A total of 1503 sputum samples were collected from suspected cases of pulmonary TB (new or previously treated). They were processed and subjected to ZN (conventional light microscopy), Auramine-O (AO) staining (LED-FM) and solid culture on Lowenstein–Jensen medium for detection of acid-fast bacilli. Positive smears were graded according to RNTCP guidelines. Results: Sensitivity, specificity, positive predictive value, and negative predictive value of ZN staining technique were 84.93%, 95.74%, 96.50%, and 82.16%, respectively, and that of FM was 95.25%, 91.33%, 93.81%, and 93.31%, respectively. Conclusion: LED-FM being more sensitive, especially in detecting the paucibacillary cases and less time-consuming, has advantage over ZN method. Nation-wide implementation will lead to improved diagnosis, thus better control of TB.

Impact of drug susceptibility on treatment outcome in sputum smear positive pulmonary tuberculosis patients receiving category-II regimen in RNTCP under field conditions in an urban setting

Background: The study was conducted with the aim to evaluate the pre-treatment drug susceptibility profile and to assess the influence of drug resistance on treatment outcome among patients treated with category- II (cat- II) regimen under programme conditions.Methods: This study was conducted on 58 smear positive patients with history of previous anti-tuberculosis treatment for more than one month, comprising cases of ‘Failure’, ‘Treatment after Default’ (TAD) and ‘Relapse’. They received cat- II regimen in Chennai Corporation, RNTCP (revised National tuberculosis control programme) centers from July 2006 to September 2006 and they were monitored upto July 2007 as per RNTCP guidelines to assess the outcome of cat-II treatment by sputum smear status.Results: Male dominance (n=40) was seen in the study participants. Most common age group affected was 35-44 years (n=20). Out of 57 cases, 50.9% cases come under ‘Relapse’, 26.3% arises from ‘TAD’ and 22.8% cases were from ‘Failure’. After completion of treatment with cat-II regimen, out of 57 patients 33 patients were cured and 11 cases were into the category of failure, 10 patients were defaulted during treatment and 3 were died.Conclusions: Besides, the low treatment efficiency in MDR-TB cases, cat- II regimen was effective in sensitive and INH resistant cases.

Management of multidrug resistant tuberculosis (MDR-TB) – Monitoring is the key to successful outcome

ContextTreatment of multidrug resistant tuberculosis (MDR-TB) is challenging. In India, standard treatment regimen is established by Revised National Tuberculosis Control Programme (RNTCP). Adequate follow-up of patients during the treatment period is a challenging task under programmatic conditions. We did a retrospective analysis of patients enrolled and treated under the national programme to study the outcome. AimsTo study the treatment outcome of MDR-TB and the factors affecting it. Settings and designRetrospective analysis of 69 patients treated with standard regimen for MDR-TB, as per RNTCP guidelines. Methods and materialRetrospective analysis of 69 MDR-TB patients for the clinical and demographic profile. Treatment outcome is defined as cure rate, default rate, death rate and failure. The factors affecting this outcome are also studied. ResultsSputum culture conversion rate was 33.9% and 62.5% at 3rd and 6th month of treatment respectively. Cure rate was 47.8%, death rate 27.5%, default rate 14.5% and failure 7.3%. ConclusionsThe major hindrance in achieving a good cure-rate was a high death rate and default. Early diagnosis of MDR-TB and adequate clinical monitoring during treatment is essential. Identifying adverse drug reactions, other co morbidities and their optimal management is the key to success.

First and second line drug resistance among treatment naïve pulmonary tuberculosis patients in a district under Revised National Tuberculosis Control Programme (RNTCP) in New Delhi

There is limited information of level of drug resistance to first-line and second line anti-tuberculosis agents in treatment naïve pulmonary tuberculosis (PTB) patients from the Indian region. Therefore, the present prospective study was conducted to determine the antimicrobial susceptibility to first-line and second line anti-TB drug resistance in such patients. Sputum samples from consecutive treatment naïve PTB cases registered in Lala Ram Sarup (LRS) district, under RNTCP containing 12 Directly Observed Treatment Centre’s (DOTS), were enrolled using cluster sampling technology. A total of 453 samples were received from July 2011 to June 2012. All samples were cultured on solid medium followed by drug susceptibility to first and second line anti-tubercular drugs as per RNTCP guidelines. Primary multi-drug resistance (MDR) was found to be 18/453; (4.0%). Extensively drug resistance (XDR) was found in one strain (0.2%), which was found to be resistant to other antibiotics. Data of drug resistant tuberculosis among treatment naïve TB patients are lacking in India. The presence of XDR-TB and high MDR-TB in small population studied, calls for conducting systematic multi-centric surveillance across the country.

Efficacy and safety of anti-tuberculosis drugs in HIV-positive patients: A prospective study

Objectives:To assess the efficacy and safety of anti-tuberculosis drugs in HIV-positive patients at a tertiary care teaching hospital.Materials and Methods:As a part of an ongoing study of opportunistic infections (OIs) in HIV-positive patients, drug treatment in patients suffering from tuberculosis was assessed to determine its efficacy and safety. Based on prevalence data for last three years, a purposive sampling of study population was carried out in this observational, prospective, single centre study. Tuberculosis (TB) was the most common OI observed. The selected patients were followed up for a period of one year to evaluate the clinical course and outcome of OIs, and the efficacy and safety of drugs used was checked.Results:Tuberculosis was observed in 89 out of 134 enrolled patients. These included 79 adults and 10 children. Males (66.2%) were commonly affected. Extra pulmonary TB (73%) was the most common manifestation with abdominal TB observed in 55 (61.7%) patients. All patients were treated in accordance with the Revised National Tuberculosis Control Programme (RNTCP) guidelines as recommended by National AIDS Control Organization (NACO), India. Outcome of TB was assessable in 70 patients. Majority (82.8%) of the patients were cured, while 12 patients (17.1%) died during the course of treatment. A total of 149 ADRs were observed in 67 (75.2%) patients. Majority of ADRs (n = 147) were non-serious and did not warrant a change in therapy. Discoloration of urine was the most common ADR observed.Conclusion:TB is the most common opportunistic infection in HIV-positive patients with abdominal TB being the most common manifestation. RNTCP and NACO guidelines are adhered to in these patients. Anti-tuberculosis drugs are well tolerated and effective in majority of the patients.

Is One Sputum Specimen as Good as Two during Follow-Up Cultures for Monitoring Multi Drug Resistant Tuberculosis Patients in India?

BackgroundIn India, the Revised National Tuberculosis Control Programme (RNTCP) has adopted the strategy of examining two specimens during follow-up culture examinations to monitor the treatment response of multi-drug resistant tuberculosis (MDR-TB) patients.ObjectivesTo determine the incremental yield of the second sputum specimen during follow-up culture examinations among patients with MDR-TB and the effect on case management on changing from two to one specimen follow-up strategy.MethodsA cross sectional record review of MDR-TB patients registered during 2008–09 under RNTCP was undertaken in three MDR-TB treatment sites of India.ResultsOf 1721 pairs of follow-up sputum culture examinations done among 220 MDR-TB patients, 451(26%) were positive with either of the two specimens; 29(1.7%) were culture positive only on the second specimen indicating the incremental yield. To detect one additional culture positive result on the second specimen, 59 specimens needed to be processed. If we had examined only one specimen, we would have missed 29 culture-positive results. By current RNTCP guidelines, however, a single specimen policy would have altered case management in only 3(0.2%) instances, where patients would have missed a one month extension of the intensive phase of MDR-TB treatment. There is no meaningful advantage in using two specimens for the monitoring of MDR-TB patients. A single specimen policy could be safely implemented with negligible clinical effect on MDR-TB patients and favourable resource implications for RNTCP.

Directly observed treatment short course in immunocompetent patients of tuberculous cervical lymphadenopathy treated in revised national tuberculosis control programme.

Background:Prospective observation analysis to evaluate the cure in tuberculous cervical lymphadenopathy with directly observed treatment short course category III (DOTS CAT III) treatment as per revised national tuberculosis control program (RNTCP) at a tertiary care hospital in AP, India, from October 2007 to September 2009. These cases were followed up for period of 22 months.Materials and Methods:Total 1521 tuberculous cases were screened in KIMS both pulmonary and extra pulmonary cases out of which 146 cases were tuberculous lymphadenitis. Fifty cases of tuberculous cervical lymphadenopathy were included after diagnostic and treatment algorithm and fine needle biopsy or excision biopsy. Patients below 5 yrs, immunocompromised, having diabetes mellitus, pulmonary tuberculosis and with other co-morbid conditions were excluded from the study. All patients were put on DOTS CAT III as per RNTCP guidelines. Follow-up was done every 2 months till 6 months for 1) Constitution symptoms 2) Weight gain or loss 3) Appetite gain or loss 4) Regression of lymph nodes or increase 5) Compliance 6) Side effects 7) Failures by demonstration of organism by direct smear, culture or histopathological examination.Results:In this study, lymph node regression was found in 78% at the end of 2 months, 94% at the end of 4 months and 96% at the end of 6 months, 9 patients had regression in size though the nodes were palpable, 2 had no regression but fresh lymph nodes appeared on the same side and sinus discharge was present, culture was negative in these cases. Two cases had immune reconstitution syndrome, constitutional symptoms disappeared and showed clinical improvement. Four cases were subjected for surgical intervention.Conclusion:DOTS CAT III is effective in the treatment of tuberculous cervical lymphadenopathy. Compliance was good with minimal, minor side effects, only two had immune reconstitution syndrome and two had sinus formation; they were referred for surgical intervention, and follow-up of 22 months did not show any relapses.

Diagnostic defaulters: an overlooked aspect in the Indian Revised National Tuberculosis Control Program

The Revised National Tuberculosis Control Program (RNTCP) aims to achieve detection of 70% of new smear-positive patients in a community and to cure 85% of such patients.Though an elaborate recording and reporting system is in place to monitor the success of the program, no record of patients who do not complete the diagnostic process is currently maintained. The present study, performed in a tertiary care hospital, attempted to estimate the proportion of this group of patients, who were labeled "diagnostic defaulters. This prospective observational study was conducted over one year on consecutive patients presenting with cough of more than two weeks' duration. A total of two sputum samples were obtained from each patient, including a spot sample and a morning sample collected on the following day. Zeihl-Neelsen staining, reporting and external quality assessment of smear-microscopy was done per RNTCP guidelines. Of the 2,349 patients recruited, 175 defaulted on the second day. The positivity rates for the spot and morning samples were 18.3% and 18.9%, respectively (p > 0.001). Of the 175 defaulters, 31 were found to be smear-positive, thereby implying that the proportion of diagnostic defaulters was 17.7%. All 21 diagnostic defaulters contacted by telephone were found to be unaware of their smear-positive status. The high proportion of diagnostic defaulters, the majority of whom were unaware of their sputum-positive status, emphasizes the need to recognize the importance of this group of patients to better control tuberculosis.

Increased sensitivity of sputum microscopy with sodium hypochlorite concentration technique: A practical experience at RNTCP center

Background:In revised national tuberculosis control program (RNTCP), microscopic examination of sputum for AFB plays an important role in the initial diagnosis of tuberculosis. Bacillary concentration after decontamination and liquefaction by 5% sodium hypochlorite is useful in providing increased sensitivity and safety for handling of specimen.Materials and Methods:In this cross-sectional, prospective study, carried out at NKP Salve Institute of Medical Sciences and RC, Nagpur, patients were included according to RNTCP criteria. One set of smears was made according to the RNTCP guidelines while another set was prepared by concentration after decontamination with 5% sodium hypochlorite. Both set of smears were stained according to RNTCP method and were screened by two observers separately to remove observer’s bias and graded according to the RNTCP guidelines. A total of 591 sputum samples from 219 patients were included in the study with 168 males (76.71%) and 51 females (23.28%).Results:A total of 77 samples (13.02%) from 34 patients were positive by routine method whereas by concentration method 119 samples (20.13%) from 49 patients were found positive diagnosing 15 additional patients. This rise of 7.11% in sputum positivity over routine is highly significant (P=0.001021, χ2=10.78) with 44.11% increase in diagnosed cases.Conclusion:There is a statistically significant rise in smear positive cases after concentration with 5% sodium hypochlorite solution. Considering its low cost, decontaminating and liquefaction properties with better sensitivity, this method is safe and can be of vital importance; at least for smear negative cases.