Study of different methods of susceptibility testing of M. tuberculosis.

This communication is on a multi-centre collaborative study carried out by New Delhi Tuberculosis (NDTB) Centre, Delhi, to compare the different methods of drug susceptibility testing (DST) of Mycobacterium tuberculosis for Streptomycin, Rifampicin, Isoniazid and Ethambutol in various accredited laboratories 40 samples (selected by simple random sampling technique) from sputum positive out-patients presenting between December 2004 and January 2005 were collected at New Delhi Tuberculosis Centre from 24 males and 16 females (age ranging from 18 to 55 years) were taken up for culture and susceptibility testing. The proportion method of DST done at NDTB Centre was taken as standard for comparing the other methods after it was found to have a good agreement with the proportion method performed at Tuberculosis Research Centre, Chennai (Kappa coefficient 0.75 to 1). All 40 sub-cultures were processed for DST by the resistance ratio and proportion methods at NDTB Centre. Also, the 40 sub-cultures were sent to Central JALMA Institute for Leprosy (JALMA), Agra that used the resistance ratio method and 25 sub-cultures were transported to National Institute of Communicable Diseases (NICD), Delhi for performing the Bactec 460TB method. The resistance ratio and proportion methods were compared both intra-laboratory (NDTB Centre) and inter-laboratory (NDTB Centre and JALMA). The sensitivity and specificity of the resistance ratio method compared to the proportion method both inter and intra-laboratory, were very high for all the drugs (except Ethambutol inter-laboratory). This was corroborated by the good agreement between the resistance ratio performed at the two centres. Bactec 460TB method, on the other hand, did not have acceptable measures of validity (sensitivity and specificity) compared to the proportion method for Streptomycin and Ethambutol. Both resistance ratio method & proportion method are comparable and either can be used for making clinical decisions. But Bactec 460 method, despite yielding early results loses out on validity.

Acquired drug resistance pattern in tuberculosis cases at the State Tuberculosis Centre, Delhi, India.

SETTING: State TB Demonstration Centre, Delhi, India. OBJECTIVE: To obtain a baseline estimate of the prevalence of multidrug-resistant tuberculosis (MDR-TB) among previously treated tuberculosis (TB) cases at the State Tuberculosis Centre in 2006. DESIGN: A retrospective study. Drug susceptibility data of 5252 previously treated patients tested at this centre were analysed. RESULTS: Of 2880 Mycobacterium tuberculosis isolates from previously treated cases, 1498 (52%) were resistant to one or more anti-tuberculosis drugs, of which 47.1% were MDR. Resistance to isoniazid was observed in all resistant isolates, followed by resistance to rifampicin in 1357 (47.1%), streptomycin in 403 (14.2%) and ethambutol in 107 (3.72%). A significantly higher rate of resistance, including MDR, was observed among treatment failures compared to relapses and defaulters. CONCLUSION: A very high proportion of drug-resistant cases had MDR besides resistance to two or more drugs. This proportion was significantly higher among treatment failures compared to relapses and treatment after default cases, underlining the need for early identification of treatment failure by early referral for culture and drug susceptibility testing, and initiation of appropriate treatment.

Tuberculosis of the ilium: a case report.

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

Knowledge, attitude and practices regarding tuberculosis and dots among interns in delhi, India.

OBJECTIVE: To assess the knowledge, attitude and practices regarding tuberculosis (TB) and DOTS among young medical graduates (interns). DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Lady Hardinge Medical College and Maulana Azad Medical College, New Delhi, India, during November and December 2002, simultaneously. SUBJECTS AND METHODS: A pre-tested semi-structured questionnaire consisting of 30 items was administered to the young medical graduates/interns posted in different departments. The questions covered mode of transmission, symptoms of pulmonary TB, investigations, short course chemotherapy including DOTS as well as conventional anti-tubercular treatment, special situations, health education and chemoprophylaxis. RESULTS: A total of 287 interns were surveyed. Majority of the study subjects (92.7%) ranked DOTS strategy as more successful for treating tuberculosis in comparison to self-administered therapy. However, a mere 4.2% study subjects were aware of all modes of transmission. One hundred and eighty-nine (65.9%) correctly chose sputum examination for acid fast bacilli as the single most confirmatory test for diagnosing pulmonary TB. The rest either gave incorrect responses (including ELISA-17.0%, PCR-9.8%, X-ray chest-4.2%, ESR-1.7%) or did not respond (1.4%). Only 2.1% marked pyrazinamide and rifampicin as the agents to be avoided in patients with liver disease. One hundred and forty-one different treatment regimens were mentioned in the responses received and of those only 11(7.8%) were scientifically acceptable. CONCLUSION: TB is a major health problem in South-East Asian countries. There is a need for appropriate changes to be made in the undergraduate medical teaching/training curriculum in the concerned countries with regard to TB.

Bilateral diffuse tuberculosis of the parotid gland.

Tuberculosis of the parotid gland is an unusual occurrence. We describe here a case of bilateral parotid gland tuberculosis showing diffuse involvement, which is even more rare. The patient was diagnosed on fine needle aspiration cytology and treated with WHO-approved Directly Observed Treatment Short Course (DOTS) category III regimen under Revised National Tuberculosis Programme with effective remission.

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

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

Effect of bovine horn cancer serum on E-rosetting capacity of peripheral blood lymphocytes from normal unaffected animals.

The effect of serum from horn cancer affected bullocks and cows on E-rosetting capacity of peripheral blood lymphocytes (PBL) from unaffected control animals was examined. The E-rosette counts were made using 2-aminoethyl isothiouronium bromide (AET) treated sheep red blood cells. A significant decrease in the percentage of EAET rosette forming cells was noticed when PBL were incubated with 50 per cent serum from animals affected with horn cancer. However, no such effect was noticed when PBL were treated with 50 per cent serum from unaffected control animals. A linear relationship was observed between percentage of EAET rosette forming cells of animals affected with horn cancer and E-rosette inhibitory activity of the corresponding serum on PBL from control animals.

Restoration of E-rosette formation by levamisole and its abrogation by autochthonous serum from cattle with squamous cell carcinoma of horn.

The effect of levamisole on the erythrocyte rosette (E-rosette) forming capacity of peripheral blood lymphocytes from eight horn cancer affected and an equal number of unaffected control animals was studied in vitro. There was an appreciable increase (from 38.75 +/- 2.91 to 56.90 +/- 2.37) in the number of E-rosette forming cells when peripheral blood lymphocytes from horn cancer affected animals were treated with levamisole. However, no significant variation in E-rosette values was noticed when peripheral blood lymphocytes from control animals were treated with this drug. This restorative effect of levamisole on E-rosetting capacity of peripheral blood lymphocytes was abrogated (mean value 39.50 +/- 3.07) when peripheral blood lymphocytes were first treated with levamisole and then incubated in the presence of 50 per cent autochthonous horn cancer serum.

Demonstration of acid alpha naphthyl acetate esterase activity in bovine lymphocytes and monocytes or macrophages.

Nonspecific acid alpha naphthyl acetate esterase (ANAE) activity has been demonstrated in bovine lymphocytes and monocytes-macrophages. The lymphocytes exhibited a solitary reddish brown globular reaction adjacent to the cell membrane (T-pattern) whereas the monocytes-macrophages revealed a diffuse reddish brown cytoplasmic reaction (M-pattern) product. Cytocentrifuge smears of lymphocytes forming rosettes with sheep erythrocytes also revealed T-pattern ANAE reaction in the majority of the cells. Similar T- and M-patterns of ANAE activity were observed in cryostat sections of biopsies collected from normal bovine lymph nodes and horn cancer tissue sections from bullocks.

Rosette forming T-lymphocyte levels in the peripheral blood of cattle affected with squamous cell carcinoma of horn.

The level of thymus-derived lymphocytes was assessed by determining the per cent of cells which formed non-immune rosettes with 2-Aminoethyl isothiouronium bromide treated sheep erythrocytes in the peripheral blood of 20 (14 bullocks and 6 cows) histopathologically confirmed cases of bovine squamous cell carcinoma of horn (horn cancer) and an equal number of age-matched control animals. A significantly marked (P less than 0.01) depression in the per cent erythrocyte-rosette forming cell count was observed in horn cancer affected bullocks and cows as compared to the values in unaffected control animals. The decrease in the level of these cells was comparatively more marked in animals which were clinically in advanced stages of the disease.

Health care seeking pattern of tuberculosis patients attending an urban TB clinic in Delhi.

The study of pattern of health care seeking of tuberculosis patients is important for identification of factors which might influence delayed reporting of tuberculosis cases, especially the open pulmonary cases. Consecutive 301 pulmonary TB patients, belonging to any of the categories under RNTCP, diagnosed at New Delhi Tuberculosis Centre or its sub-centres over a six-month period were assessed for health care seeking pattern. "Delay" was defined as the time over 3 weeks that a case took to report to the area TB facility. 43.2% patients reported to the TB health facility on their own and others were referred by government hospitals (34.9%) and general practitioners (21.9%). Median delay over 3 weeks was 2.69 weeks for all three categories combined, with a significantly higher delay (3.41 weeks) for retreatment cases as compared to new cases (2.13 weeks). No significant differences were observed in health seeking delay in relation to sex, income, literacy status and source of referral and sputum status. Extensive health education activities can reduce this period of delay in health seeking and result in reduction of transmission of tuberculosis to healthy members of the family and community.

Adverse drug reactions observed during DOTS.

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

Prevalence of initial drug resistance to M. tuberculosis in new sputum positive RNTCP patients.

There is an increased prevalence of drug resistant M. tuberculosis strains and of these, multi drug resistant organisms are of particular concern. With the implementation of Revised National Tuberculosis Control Programme (RNTCP) allover the state of Delhi, Initial drug resistance (IDR) to Isoniazid and Rifampicin assumes great importance and needs to be monitored on a regular basis. We undertook to study the IDR against the first line essential drugs i.e. Isoniazid (H), Rifampicin (R), Ethambutol (E) and Streptomycin (S) from April 1999 to March 2000 in newly diagnosed sputum positive cases of pulmonary tuberculosis attending TB clinics under RNTCP in Delhi. A total of 157 consecutive new smear positive patients attending TB clinics under RNTCP were taken into the study. All sputum samples were subjected to culture and drug sensitivity tests on LJ medium after decontamination of samples by Petroff's method. Resistance was expressed as the percentage of colonies that grow on critical concentration of the drugs. To determine the proportion of resistance, the number of colonies on the control and the number of colonies on the drug medium were determined. A total of 94.77% samples were sensitive to the four first line essential drugs and IDR to any drug was 5.22%. The resistance to Rifampicin alone was nil but the resistance to Isoniazid alone was 2.24%. Combined resistance to both Rifampicin and Isoniazid was 2.98 %. The incidence of resistance to first line drugs in tuberculosis is not very high among new sputum positive patients attending TB clinics under RNTCP.

A sociological study on stigma among TB patients in Delhi.

SETTING: The study was carried out at Delhi State, New Delhi. OBJECTIVES: 1. To assess the effect of social stigma in TB patient's treatment, their personality, emotions, feelings, changes in their thinking process and behaviour of their family members, friends. 2. To study the relationship of gender and to what extent social stigma affects their lives. DESIGN: It was a prospective study. A total of 1977 newly diagnosed and registered cases under Revised National TB Control Programme for treatment during the period of March 2009 to May 2009 were included in the study. Out of a total population of 170 lacs, a proportion of 31 lacs of Delhi, distributed among five chest clinics of Delhi, comprised the study population. All the patients were interviewed according to a pre-designed & pre-tested questionnaire after taking informed consent of the patients. The data was collected and analysed after processing into MS excel sheets for statistical analysis. RESULTS: There was an immense stigma observed at society level with 60% of the patients hiding their disease (p<0.05) from friends and neighbours. Stigma was observed more among middle and upper middle class when compared to lower middle class and lower class (p<0.05). Gender-wise further it was observed that stigma was more among females (p<0.05) than in males. CONCLUSION: The study has demonstrated that despite good performance of Revised National TB Control Programme the stigma in tuberculosis still remains a problem and we need to supplement the efforts in advocacy, communication and social mobalization for reducing the stigma problem among TB patients in effective control of tuberculosis.

Efficacy of repeat sputum examination in RNTCP.

BACKGROUND: The guidelines of repeat sputum smear examination in initial smear negative patients (ISN), who also fail the antibiotic trial of three samples have been incorporated in the RNTCP diagnostic algorithm in India in 2005. This study was conducted to assess the utility of repeat sputum smear examination in symptomatic initial smear negative patients to detect new smear positives in the state of Delhi. MATERIAL AND METHODS: The monthly records of the laboratory abstracts for the six quarters for all the 24 districts of Delhi were analysed w.e.f. first of January 2006 to 30th June 2007. RESULTS: A total of 243,244 TB suspects were examined for diagnosis during the six quarters w.e.f. January 2006. Of these, 37,666 were found positive on sputum smear microscopy giving a positivity rate of 15.4%. During the same period, a total of 2,195 (1% of ISN ) TB suspects underwent repeat sputum examination, of which 272 were found positive giving a mean positivity of 12.3%. CONCLUSION: A significant number of apparently smear negative TB cases may in fact be smear positive due to various reasons and can be detected by a simple repeat sputum examination. Yield of sputum positive cases in sputum reexamination is almost the same as in initial sputum examination i.e. 10-15%. Therefore, the policy of repeat sputum examination in symptomatic initial sputum negative cases failing the antibiotic trial should be meticulously followed as advocated in the RNTCP diagnostic algorithm.

Tuberculosis mortality trends in Delhi after implementation of RNTCP.

OBJECTIVES: To study the impact of Revised National TB Control Programme on mortality among tuberculosis patients in Delhi and to correlate mortality trends with programme indicators. METHODS: Record based evaluation of mortality trends from TB registers of all chest clinics of Delhi after implementation of Revised National TB Control Programme. RESULTS: The study showed a statistically significant decline in tuberculosis mortality among new smear positive cases after the implementation of Revised National TB Control Programme (z = 4.478 p < 0.05). The mortality among new smear negative and extra pulmonary cases also showed reduction, though not statistically significant. CONCLUSION: Mortality due to tuberculosis has been considerably reduced in Delhi over the years with the Revised National TB Control Programme implementation since 1997.

Study of relapse and failure cases of CAT I retreated with CAT II under RNTCP--an eleven year follow up.

OBJECTIVE: To analyse the treatment outcome of Cat I smear positive relapse and failure cases and their fate when treated with Cat II regimen under RNTCP. METHODS: All Cat I smear positive relapse and failure TB patients treated with Category II regimen from 1994 to 2005 in a chest clinic of Delhi were analysed in this retrospective study. The re-treatment outcome data for relapse and failure cases of Cat I when treated with Cat II regimen was reviewed. RESULTS: The study population included 5576 registered as Cat I sputum positive cases in Gulabi Bagh chest clinic from 1994 to 2005. A total of 190 (3.4%) failed on Cat I regimen. Further out of 4905 (87.9%) successfully treated Cat I patients, 442 (9%) presented as relapses. The treatment success rate for relapse and failure cases of Cat I when subsequently treated with Cat II regimen were 76.4% and 48.8% respectively, with a significantly higher failure rate (27.6%) among Cat I failures subsequently treated with Cat II regimen. CONCLUSION: The failure cases of Cat I subsequently treated with Cat II were observed to have a significantly lower success rates (p < 0.05) as compared to relapse cases. The need for reappraisal of Cat II re-treatment regimen for failure cases among Cat I is suggested.

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

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

DOTS in drug addicts with TB : Delhi experience.

BACKGROUND: Drug abuse is on the rise. Drug addiction lowers the general immunity of the body. Tuberculosis is known to be one of the major infectious diseases with a high incidence among drug addicts. Treatment of drug addicts suffering from tuberculosis is a challenge to the treating physician. METHODS: An interventional prospective study which involved free de-addiction drugs and motivation along with free anti tubercular drugs under Revised National Tuberculosis Programme was undertaken among drug addicts. Sixty drug addicts suffering from tuberculosis, registered under RNTCP in SPM marg TB Clinic (Pili Kothi) between 2002-2007 and treated under DOTS along with de-addiction treatment by an NGO (Sharan) formed the study sample. OBJECTIVES: Objectives of the study were: a) To study the profile of drug addicts with tuberculosis, b) To assess the success results of DOTS in drug addicts with tuberculosis (along with de-addiction treatment). RESULTS: Extensive counselling for de-addiction and motivation of the study patients along with nutritional food supplements improved the compliance and adherence to treatment with equal success rates as in non-addict tuberculosis patients. The overall success rate in drug addicts was 83.3%. The default rate of 3.3% and failure rate of just 1.7% among study group were also within the permissible range of RNTCP (< 4%). CONCLUSION: DOTS along with supplementary intervention was observed to be quite effective in drug addicts with TB.