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ERD Major Contributions

MAJOR CONTRIBUTIONS OF EPIDEMIOLOGY AND RESEARCH DIVISION IN TUBERCULOSIS CONTROL PROGRAMME

EPIDEMIOLOGY

The National Tuberculosis Institute (NTI) was established in 1959 with the primary objective of developing a nationally applicable, scientifically valid and logistically viable TB (tuberculosis) control program. To promote this valuable task various sections were established, like Epidemiology, Control, Statistics, and Sociology, to facilitate all theses section in their field activities transport section was in function.

The epidemiology and its importance was to find the TB disease and risk factors that escalate its transmission. Therefore, it plays a pivotal role in the development of a program and monitoring it.

The epidemiology unit was headed by a renowned epidemiologist Dr. Raj Narain, who is called the father of TB epidemiology among the TB workers’ held great responsibility in developing scientific procedures, methods to estimate the epidemiological indicators and develop the control programme and its implication on TB control programme.

The newly incepted epidemiology unit at the National Tuberculosis Institute, Bangalore accrued the vast experience in the analysis and interpretation of large volume data in the surveys conducted anywhere else in the country, which makes the unit more stringent in the development of protocols, procedures, formats in regards to the surveys and nationwide TB control programme, going to be implemented in the community on behalf of government of India.

This unit is bestowed with efficient researchers and dedicated field staff who’s familiarize in conducting surveys, encourages in conducting various laudable studies to estimate the epidemiological indicators of TB. In view of this, performance of Epidemiology unit and the surveys conducted were broadly categorized in the following way:

  1. Disease prevalence/ Incidence surveys
  2. Fate of cases found during the Longitudinal survey
  3. Tuberculin surveys
  1. Disease prevalence/incidence surveys

The meticulous and sincere efforts of the researchers and the support of the government of India The first disease survey (1961-62) was conducted in the District Model (District Tumkur of Mysore state) by Raj Narain, apprising all the available tool to find the base line information on the prevalence of infection by radiological, bacteriological cases in a community, this study boost the morale of researchers at that time to plan for carrying out the project for estimating the TB indicators and see the trends, designing of Land mark Longitudinal survey Some aspects of a TB prevalence Survey in a South Indian District, Tumkur district, in Karnataka state (1961-68) was carried out.

This study was designed and protocol had been developed with the objectives to study various issues in disease determinants/ screening tools incorporating an time factor: the same population would be followed up, say, 4 times at regular/ specified time intervals: a population of 62,000 belonging to 119 villages in Bangalore district was followed up during the years 1961-1968. The study began yielding results, not only about prevalence of infection and morbidity of TB but also about fate of cases. The main objectives were to estimate the prevalence of infection, radiologically active pulmonary TB and bacteriologically confirmed disease. The results were, respectively: 38.3%; 1.86% and 0.41%. Both the infection and disease increased with age; and morbidity was higher among males. The prevalence of cases was not significantly different from survey to survey (varying from 3.96 to 4.92 per thousand).

In a chronic disease like TB, the exact levels of prevalence or incidence of infection and disease are of lesser importance than its time trend. Survey should be conducted repeatedly if possible.

Annual incidence rate of disease ranged from 79 to 132 per 100,000 population, highest being between first and second surveys and lowest between second and third surveys. The incidence rates in younger age groups below 35 years showed a decline during the study period. The annual incidence rate of bacteriologically confirmed disease in the three radiological groups of population:

(i) 185 per 100,000 with normal-rays,

(ii) 958 per 100,000 with abnormal shadows judged as inactive tuberculosis or non-tuberculosis and

(iii) 4530 per 100,000 with abnormal shadows judged as active or probably active tuberculosis but bacteriologically not confirmed.

The third group constituted 1% of the total population and contributed 34% of the total incidence cases. In each of the above three radiological groups, the incidence of disease was highest among those with tuberculin test indurations of 20 mm or more to 1 TU RT 23 with Tween 80. The resurvey of the district again perform in the year 1972-73 by Gothi et al.,

The prevalence survey in Nelamangla during 1975 was carried out in randomly selected 55 villages, a total of 12,105 persons >15years of age were screened for pulmonary symptoms as well as by MMR. a spot and an early morning sputum sample were collected from those with symptoms and/or any abnormal shadow on MMR.. The crude prevalence of culture positive PTB using symptom screening alone was 311 per 100,000 populations.

In developing the operationally feasible surveys to be carried out by the state officials to monitor the program implementation and its effectiveness, in the year 1994: Epidemiology unit has developed the protocol and demonstrated that screening of population by chest symptoms, subjected them to MMR followed by sputum examination among the suspects. The main objective of the study, to find out the prevalence of bacillary cases by screening the population through identification of Persons with Pulmonary Symptoms: PPS (chest symptomatic) compared to that by MMR. Prevalence rates by MMR, culture positive as well as smear positive cases were similar by any of the three methods 0.18%, 0.23% and 0.25% respectively.

In the last end of the decade, epidemiology was again played pivotal role in conducting community based: A Disease prevalence survey at Nelamangala (2007-2010) using all the available tools to screen the population The objective of the study to estimate point prevalence of bacteriologically positive pulmonary TB in a rural area, and implication of control program on epidemiological indicators where TB program DOTS strategy implemented since 2002.

Methodology of the study follows, person > 15 yrs of age were screened for chest symptoms, persons with pulmonary symptoms (PPS) were subjected for two sample of sputum examination by smear and culture.

All the eligible persons were screened with MMR at six clusters, abnormal shadow on X-ray were eligible for sputum examination in addition to those with symptoms. Of the screened population with various methods using screening alone, prevalence of smear, culture and bacteriologically positive PTB in persons >15 years of age was 83, 152 and 196 per 100,000 population respectively. Prevalence corrected for non screening by X- ray was 108, 198 and 254 respectively. Observed prevalence suggests further strengthening of TB control program

Table I: Disease prevalence survey conducted from the inception of Epidemiology Unit upto 2010

Year Study area Examined popul, and age group Method and investigation Tuberulosis infection (>_10mm Radiogically +ve, Bacteriologically+ (per 100000)
1960-61 Tumkur District (rural and semi urban area 31,967 a.House to house surveyb. MMR 10+

c.Tubeculin testing all with 1 TU RT 23

sputum examined from eligibles.

38.3% 1.9% 0.44
1961-68 Bangalore (3 Taluk ) of peri urban area 66,000 House to house to surveya).House to house census

b).Tuberculin test to all with 1 TU RT 23

c). MMR 5+ age

 

ARTI: 1%30% S- I 0.40

S- II 0.37

S- III 0.33

S- IV 0.39

1975 Nelamangala study 15,243
  1. House to house survey
  2. Chest symptomatic screening
  3. MMR 15+

a) One specimen of sputum culture eligible by B &C hour

0.32 0.32
1979 Tumkur District (rural and semi urban area 41,390 

24,785

x-rayed

a.House to house surveyb. MMR 10+

c.Tubeculin testing all with 1 TU RT 23

sputum examined from x-ray +ves, PPS

? 14mm14.3% 1.1% 0.41
1984-86 LS follow up Fresh sample in 2 of the above 3 taluks 30,000 a)Tuberculin 0-44 yrs.b)Chest symptomatics 15+yrs

c) 2 speciments from PPS/ tuberculin reactors;

 

31.29% 0.49
1986-89 Bangalore peri-urbanRandom sample of villages in the 5 km radius, 19 km from city urban 56,000
  1. House to house survey

b Chest symptomatic screening

c. MMR 15+

d. One specimen of sputum culture eligible by B &C

2.50
2007-2010 Nelamangala 63,362 a) a) House to house censusb) Chest symptomatic screening

c) MMR 15+

d)Two specimen of sputum culture eligible by B &C hour

1.3% 2.54

 

Table II: Prevalence bacteriological cases at surveys 1-V (1961-84)

Age Survey I(1962) Survey II(1963) Survey III(1965) Survey IV(1967) Survey V(1977) Survey VI(1984)
No examined 43889 40633 40405 41213 21924
No of cases 178 151 136 162 96
Sm + 83 71 61 95 15
P sm+cases(per 100,000) 189 175 151 230 492 68

A. Incidence of infection

Incidence of tuberculous infection was studied in a series of 4 surveys of longitudinal study carried out in the same population of Bangalore district for 5 years. The incidence rate was found to be 1% per year between surveys I and II in those aged 0-14 yrs. This had declined to 0.72% per year between surveys III and IV.

B. Fate of incidence cases

During the period of longitudinal surveys, sustainable tuberculosis program had not been implemented and developmental activities in the community were at very slow pace. This gave an opportunity to study the fate of cases and study the contributory forces that possibly determine the natural history of TB.

Out of the 178 cases found at the first survey of longitudinal study conducted in1961-68, 126 could be followed up at the three subsequent surveys during the study period. The death rate and cure rate were highest during the first 1 ½ yrs: by the end of this period, 30.2 of 126 patients were dead, 27.8% had been cured, and 42% were still excreting bacilli.

By the end of the second 1 ½ yr periods, the corresponding proportions were 40.5%, 34.9% and 24.6%.

Two years later at the end of the 5 year period -62 patients 49.2% were dead, 41(32.5%) cured and 23 (18.3% remained sputum positive 9 sensitive to drugs and 14 drug resistant).

Table III: Fate of TB cases during the Longitudinal survey(1961-68)

Incidence cases between Total No followed up (1 /1/2 , and 2 yrs) Cured Dead Remained bacillary
Survey I and II 70 63 33 (52.4%) 9 ( 14.3%) 21 (33.3%)
Survey II and III 40 39 11(28.2%) 15 (38.5%) 13 (33.3%)

C. Tuberculin surveys

In view of the findings of the previous studies conducted by the unit, it is felt that the simple method of periodic tuberculin testing of the population in younger age groups could be developed into a method of tuberculosis surveillance. This would appear to be the cheapest, less time consuming, practicable and technically appropriate method for studying the overall tuberculosis situation. This data can be used for calculating annual risk of infection as well as trend of transmission of infection.

The first ever tuberculin survey conducted in India was in 1920s. Even though the survey design was poor, it still pointed out to the government that tuberculosis infection was high wherever the survey was conducted.

The first survey was conducted in and around Bangalore using tuberculin as a tool: Tuberculin sensitivity in young children (0-4 yrs) as an index of the tuberculosis in the community conducted in 1960 by NL Bordia et al., The purpose of the this study, was to find out whether the prevalence of infection in young children might be used as an index of the TB problem in a population. It was found that prevalence of infection in the cantonment and city area was higher (1.6%-4.1%) and rural it was about 2%.

Several tuberculin allergy related studies were conducted during the next decade: effect of BCG engineered sensitivity following vaccination, infection with Mycobacterium other than M.tuberculosis (M.TB), effect of malnutrition, techniques of interpretation and utilizing tuberculin sensitivity as a measure for estimating disease burden leading to the surveillance of TB. Intensive work in all these fields, yielded rich dividends culminating in developing the basic factors and inputs that are required to develop protocol for estimating risk of tuberculous infection on the model developed by K. Styblo in the 90’s. Entitled the annual risk of tuberculous infection, ARTI (Previously ARI) is defined as the probability of acquiring new infection with M TB during the course of one year.

It was a historic moment when the NTI, Epidemiology unit in particular was given the responsibility of conducting zonal level tuberculin surveys 2000-03, that covered the nation as a whole. For the purpose of the survey the country was divided into 4 geographical zones: north, east, south and west-each having about a fourth of the country’s population. An elaborate, district based, random stratified design to take care of both urban and rural populations as extant during the period and to estimate the average ARTI facilitating inter-zonal comparison.

The survey in each zone was conducted following a uniform methodology. Using appropriate statistical techniques, 26 districts from the 4 zones were selected for the survey – 6 each from the north, south and west zones and eight from east zone. The survey was conducted in rural and urban clusters of the selected districts. From each cluster, 85 children, 1-9 years of age were registered for tuberculin testing with 1 TU PPD RT23 with Tween 80 and the maximum transverse diameter of the reactions were read about 72 hours later.

The data analyzed among children without BCG Scar, pertained to 85,218 children – 25,816 from north zone 17,811 from south zone, 22,259 from west zone and 19,332 from east zone. The prevalence of infection was calculated both by the cut-off point method (Method I) and mirror image technique (Method II). The modes of tuberculin reactions attributable to tuberculous infection were observed at 20 mm in north, west and east zones and 19mm in south zone. The anti-modes varied from 14 to 16 mm in rural areas and 12 to 16 mm in urban areas of the four zones.

Keeping in view the importance of tuberculin surveys and its significance, epidemiology unit has evolved a generic protocol to be followed by the any state in the India, in order to develop the capacity building at the state level to monitor tuberculosis control programme.

Following this, 3 state level ARTI surveys were undertaken: Orissa (2003-04), Andhra Pradesh (2005-06) and Kerala. District level surveys were undertaken in Khammam tribal district (2000-02).

Again the Epidemiology unit was abide by the responsibility of drafting the protocol and work procedures of repeat zonal ARTI surveys (2009-2011). In-order to bring about changes and sharing of experience with different institutions of repute, the NTI became the nodal centre and the study was completed in collaboration with 5 institutions.

At the national level, the estimated ARTI rates at Surveys I and Surveys II were 1.4% (CI: 1.3-1.5) and 1.0% (CI: 0.9-1.1) respectively, which translated into an average decline of about 3.7% (C.I: 5.1 – 2.4) per year between the years 1998 and 2007 approximately. The computed ARTI rates among children without BCG scar were 1.5% (CI: 1.4-1.6) and 1.0% (CI: 0.8-1.1) with the computed decline at 4.5% (C.I: 6.3 – 2.8) per year in the intervening period.

Table IV: Tuberculin survey conducted since the inception of Epidemiology unit

Year Author Sample size Age Findings Remark

1961

Bordia NL

2,589

0-4

1.6-4.1( 14mm)

Bangalore city, cantonment

(urban settings)

4,090

0-4

2.0 (14mm)

In and around 59 villages of Bangalore(Rural settings)

1963 Raj Narain 26,032 0-60+ 38.3( 10mm) Tumkur district
1972 Gothi GD 9,847 0-19 14.3(14 mm) Resurvey of tumkur district
1961-68 NTI WHO,1974 66,000 0-60+ 30 (20mm) ARTI 1% Bangalore peri urban areas
1984-86(LS follow up ) AKChakraborthy 30,000 0-14 31.29 Vth survey
1977 IJTB Gothi GD 0-9 5.5
1980 AKChakraborthy 12,535BCG- 6045 test read 0-9 4.9(10-12mm)0-4-(2.6)

5-9-(8-9)

 

Doddaballapura
1985 Kurthkoti 12,535 0-9 0-4(2.46)5-9(12.3) Doddaballapura follow up
1997 Chadha etal 4,575 1-9 yrs 5%
1999 L.suryanarayana et al 1,645 <14 yrs 34.5 Bangalore rural
2000 Chadha et al 11,132 0-9 BCG-8.08BCG+8.06

ARTI- 1.12 and 1.19

Bangalore city 

 

2001 Chadha et al 9,738 6-7 11.1ARTI 1.67% Bangalore city school, govt, govt aided, private schools.(161) 
2003 Chadha et al 8,637 5-9 BCG-11.8% ARTI 1.6%BCG+10.6% ARTI 1.5% Khammam district
2004 Shashidhar et al 10,191 1-9 9.2% (7.2–11.1)ARTI 1.6%

Urban 12.9 %(6.8–18.9)

ARTI 2.5%

Eight selected districts of Orissa state
2005 Chadha et al 85,218(BCG-) 1-9 ARTI 1.5% Four defined zones of india
2007 Chadha et al 3,636 5-9 Prevalence 9.6%ARTI 1.4% Andhrapradesh ARTI survey
2013 Chadha et al 69,496 1-9 ARTI 1.0%  Repeat ARTI survey in India.

Trend of tuberculous infection

Tuberculin surveys seemed also to hold the key for evaluating epidemiological trends of the disease in the community. The choice of demarcation level arbitrarily made on the basis of the distributions and these varied from survey to survey; between 10mm at survey I and 16 mm at survey IV. The infection rates showed more or less declining trend in 0-4yrs, 5-9 yrs and 10-14 yrs age groups. Trend of 23 years after the intake phase of the longitudinal study, an estimate of the annual decline in the risk of infection for the area was calculated at 3.2%. Further, the efficiency of the programme was estimated to be an average 33% during the nearly 3 decades of its existence, which had resulted in an annual declining trend of the following extent: 1.4% in case rate, 2.0% in smear positive rate, and 3.2% in ARTI.

The results obtained from the first nationwide ARTI survey India conducted by NTI (2000-2003) estimated the average ARTI from the country was as 1.5% after pooling the data for the four zones. Applying Karl Styblo’s parametric relationship between the ARTI and incidence of smear positive cases, it was expected that there would be 95, 55, 90 and 65 smear positive TB cases per 100,000 population for the north, south, west and east zones respectively. The high ARTI is largely due to the unsatisfactory performance of the erstwhile NTP. However, the introduction of the RNTCP in the country has raised hopes of controlling TB.

In a resurvey carried out among randomly selected schools of Bangalore, the average annual decline in ARTI of about 4% was observed between the two surveys. But it cannot be stated with certainty whether this trend was achieved by the RNTCP program or changes in the population pattern or effects of overall socio-economic improvements that is occurring in that area.

Repeat ARTI survey in the same districts, computed ARTI which varies between 1.1% and 1.9% in Survey I and 0.6% and 1.2% in Survey II. The ARTI declined by respectively 6.1% and 11.7% per year in the north and west zones; no decline was observed in the south and east zones. National level estimates were respectively 1.5% and 1.0%, with a decline of 4.5% per year in the intervening period. Although a decline in ARTI was observed in two of the four zones and at national level, the current ARTI of about 1% in three zones suggests that further intensification of TB control activities is required.

TableV: Annual risk rates among 0- and 14 yrs old children over a period of 23 yrs(1985-86)

Survey Midpoint of observation ARI on observed prevalence rates (based on 4.6% annual decrease in risk b/w surv1-5 (15.67yrs) Based on 3.2%annual decrease in risk between survey 1- present survey (22.8) Standardized rates

I

Mar1962

1.03

1.12

1.12

II

Oct 1963

1.03- 0.85

1.12

1.12

III

May 1965

0.79

0.92

0.99

IV

June 1967

0.51

0.86

0.92

V

Nov 1977

0.55

0.80

Re-survey

June 1985

0.55

0.61

 

Prevalence of Tuberculous infection and ARTI among the children age 1-9 yrs in NSS survey 2000-2003 and repeat survey in 2009-2011

Zone Surveys I Surveys II

Prevalence

%

ARTI

%

Prevalence

%

ARTI

%

North

10.1

(9.1-11.1)

1.9

(1.7-2.1)

5.0

(4.0-5.9)

0.9

(0.7-1.1)

South

6.1

(5.4-6.7)

1.1

(1.0-1.2)

6.3

(5.5-7.1)

1.2

(1.0-1.3)

East

6.2

(5.5-7.0)

1.2

(1.0-1.3)

5.9

(4.4-7.4)

1.1

(0.8-1.4)

West

8.7

(7.7-9.6)

1.7

(1.5-1.9)

3.8

(3.0-4.6)

0.7

(0.6-0.9)

( ): 95% Confidence Intervals

Role of X-rays in TB case findings

X-ray examination having sensitivity of 92% and specificity of 88%, is a good screening tool. Sputum smear examination having sensitivity of 82% and specificity of 99% is a good confirmatory tool. Their predictive value, which is another important attribute for considering the use of a tool, is dependent on the prevalence of the disease besides sensitivity and specificity. when the disease prevalence goes down, the predictive values also go down and the same tools acquire high false positivity. The case yield can be increased by applying one or two screening tools in order to increase the efficiency of the combination of the tests In the Revised National Tuberculosis Control Programme (RNTCP), the methodology adopted is that the self reporting chest symptomatics are subjected to two sputum smear examinations. And, if one or no smear is positive then only the X-ray examination is done.

The rationale of this methodological change is mart at present 70% or more patients are being treated in NTP on the basis of X-ray result alone, leading to over-diagnosis and unnecessary treatment.

In 1956, a nation-wide survey using screening by MMR followed by sputum examination by smear and culture among those with abnormal shadow on X-ray film revealed the prevalence of bacteriologically positive PTB at 400 per 100,000 population ]. During subsequent surveys in different geographical locations at different points of time, prevalence of bacteriologically positive TB varied between 182–1270 per 100,000 ]. These surveys not strictly comparable due to variations in definition of symptoms, screening tools (symptoms and/or MMR), case definition and analytical methods, nonetheless revealed that TB continued to be a high burden disease in India. Male to female ratio in these surveys has been found to vary between 2:1 to 5:1 . It was 6:1 during the recently concluded disease prevalence survey at nelamangala (Bangalore rural district)

Table VI:

Year Study area Population screened MMR positive Bacteriologically positive/1000
1960-61 Tumkur 21,021 314(1.9%): 10+ age group 4.1
1972-73 Tumkur resurvey 24,785 250(1.1%): 10 + age group 4.4
Longitudinal Study Bangalore periurban area 4388940633

40405

41213

406372

337

393

1975 Nelamangala study 15,243 320/ 10000049 (0.32%) 3.2
1979 Follow up after twelve yrs 24785 399 4.4
1984-86 L S study after 23 yrs 21924 438
1986-89( AKC, IJTB 1994,46,17) BangalorePeri urban study 27,400 69 (0.25%) :15+ age group 3.1
2007-2010 Bangalore rural 26,429 389(1.3%) 2.54

 

TB-HIV

The HIV epidemic augmenting the incidence of TB in community resulting in the new approach with NACP to integrate the counseling and treatment of the TB cases at the earliest to contain the morbidity and mortality among TB cases. in view of this, the first study to estimate the prevalence of HIV infection among pulmonary TB patients taking into account all the Designated Microscopy centers ( DMCs) in a district in the sampling frame was under taken by National Tuberculosis Institute, Bangalore in 2005 in Mandya District of Karnataka. The sero-prevalence of HIV infection among new smear positive pulmonary TB cases was estimated to be 4.6%.

Patients not willing for HIV testing or sharing their HIV test result should not be forced to take the test or disclose information pertaining to their HIV status. It is important that patients with tuberculosis be provided the opportunity to know their HIV status as it would facilitate appropriate HIV care interventions such as Co-trimoxazole Prophylactic Treatment (CPT) and Anti-retroviral Therapy (ART) which would reduce suffering and death.

Besides regular work the section has also extended technical support to epidemiology studies in Indonesia, Bhutan and DPR Korea. It has also been providing support to research fellows, PG students, and workshops, training activities and South East Asia Regional Organization of the World Health Organization as and when warranted

Table VIII:

 

Study area Year Infection X-ray cases Bacillary cases
Prevalence Annual incidence Prevalence Annual incidence Prevalence Annual incidence
Tumkur 1961 38.3 2.0 1.9 - - -
Longitudinal study 1961-68 30.4 1.67 - - 0.39 0.14
Nelamangala study (GD gothi,ijmr 64,8,1974) 1975 0.32 0.32
Bangalore (LS follow up) AKC, Tubercle and lung disease 1992,73,213) 1984-86 44
Bangalore peri urban area(AKC Ind. J. Tub., 1994, 41, 17) 1986-89 69 31(0.11)
ARTI 2000-2003 1.5
Disease prevalence survey 2007-2010 389(1.3%) 2.54  
ARTIRepeat survey 2009-2011 1.0

Table III

Prevalence of tuberculous infection rates % of infection during longitudinal survey (1961-68)

Age Survey I(1962) Survey II(1963) Survey III(1965) Survey IV(1967) Survey V(1977) Survey VI(1985)
0-14 8.6 8.6 7.7 7.1 4.7 4.8
0-4 2.1 1.8 1.3 1.0 1.5 1.5
5-9 7.9 7.6 7.0 6.4 6.0 5.3
10-14 16.5 16.9 16.1 15.5 12.1 9.2

 

In none of the villages any association was seen between these two. In view of this finding, it is felt that the simple method of periodic tuberculin testing of the population in younger age groups could be developed into a method of tuberculosis surveillance even in areas where direct mass BCG vaccination is given This would appear to be the cheapest, practicable and technically appropriate method or studying the overall tuberculosis situation.

The study of changes in the prevalence rate of infection in the younger age group is simple, cheap, less time consuming. The data can be used for calculating annual risk of infection as well trend of transmission of infection.

In view of the difficultly of providing a single definition of a case of tuberculosis, four indices have been suggested

1 case definitely positive by direct smear

2. cases definitely positive by culture

3. All cases positive by culture (including less than twenty colonies)

4. Sputum positive cases which are radiologically active.

Incidence rate for males was nearly double that of females. More than half of the new male cases were 35 years of age.

 

OPERATIONS RESEARCH

  1. 1. Assessment of diagnosis of pulmonary tuberculosis by sputum microscopy in a District Tuberculosis programme: The study was conducted in Bangalore district covering 9 microscopy centres to assess the efficiency of smear examination carried out by paramedical personnel. Analysis of the results based on culture showed that barring a few centres where the performance was poor, the standard of examination was fairly good. The under and over diagnosis based on culture were 38.2% and 2.6% respectively, and these were within the limits as generally observed.
  1. 2. Persistent chest symptoms in smear Positive pulmonary tuberculosis Patients treated with standard and Short course chemotherapy regimens Under a district tuberculosis Programme-a five year follow –up : The study suggested that practice of prescribing specific subsequent anti-TB Treatment, should be based on the result of smear examination and not on symptoms, in treated cases.
  1. 3. Fate of pulmonary tuberculosis Patients diagnosed in a prevalence Survey- a socio epidemiological follow Up after 5 years: A socio-epidemiological study was carried out between August 1986 to October 1989 and repeated after an average interval of 5 years with an objective to study fate of ‘cases’ and ‘suspects’ in terms of disease status, deaths, their health seeking behavior between surveys and the current symptom status. Sociological enquiry revealed that cardinal symptoms of TB persisted even after 5 years in 65% of cases and 55% of suspects. Action taking behavior indicated that more than half the patients reported to government health centres for remedial measures.
  1. 4. Defaults among tuberculosis Patients treated under dots in Bangalore city – a search for solution The study was conducted in urban setup of Bangalore Mahanagara Palike and a retrospective analysis of defaulted patients of a cohort of 264 new (CAT I) and 219 retreatment (CAT II) bacteriologically positive patients treated under DOTS from March 1999 to September 2000 was undertaken. The objectives were to identify socio-demographic and treatment related risk factors predictive of default with DOT and to study the treatment regularity and final bacteriological profile of defaulted patients. More than half of the defaulted patients remained bacteriologically positive at the end of treatment period. The predictive risk factors of default with DOT in an urban setting are males and alcoholics. Those returning for treatment after default and having poor knowledge of disease are additional risk factors among re-treatment patients. Devoting attention to those at potential risk of defaults from the initiation of treatment with close supervision and repeated counseling would be a major input to minimize defaults and achieve desired goal of RNTCP.
  1. 5. Treatment outcome and two and Half years follow-up status of new Smear positive patients treated under RNTCP: This prospective study was undertaken in the city of Bangalore in a cohort of 271 new smear and culture positive patients initiated on Cat I regimen to evaluate the treatment outcome of new smear positive patients supported with pre and post-treatment bacteriological profile between April to December 1999 and followed up till treatment outcome and assessing their bacteriological and clinical status 2 ½ years thereafter. The development of drug resistance during treatment was seen in 1.3%. The proportion of bacteriological positivity and mortality during follow up was significantly higher among patients who defaulted from treatment. Relapses during the intervening period were 11.4%. The study findings underscore the importance of strict adherence to the programme guidelines for successful treatment completion and a lasting cure.
  1. 6. Treatment Outcome and Mortality at One and Half Year Follow-Up of HIV Infected TB Patients Under TB Control Programme in a District of South India:

The study was conducted to assess the TB treatment outcome and mortality in a cohort of HIV infected TB patients treated with intermittent short course chemotherapy under TB control programme in a high HIV prevalent district of south India. Among 3798 TB patients registered for treatment in Mysore district from July 2007 to June 2008, 281 HIV infected patients formed the study group.

Despite the treatment success of 75% the high mortality (30%) in the study group is a matter of concern and needs immediate intervention. Non initiation of ART has emerged has emerged as a high risk factor for unfarourable treatment outcome and mortality. These findings underscore the importance of expanding and improving delivery of ART services as a priority and reconsideration of the programme guidelines for ART initiation in HIV infected TB patients.

  1. 7. Risk Factors Associated with Default among New Smear Positive TB Patients Treated Under DOTS in India :

The objective of the study was to identify predictors of default among new smear positive TB patients registered for treatment to suggest possible interventions to set right the problems to sustain and enhance the programme performance.

New smear positive patients registered for treatment in two consecutive quarters during III quarter 2004 to III quarter 2005 formed the retrospective study cohort. Case control analysis was done including defaulted patients as “cases” and equal number of age and sex matched patients completing treatment as “controls”.

The study provided an insight into the various issues involved in delivery of DOT services and its utilization for maintaining treatment adherence to achieve the desired cure rate while keeping in view the regional diversities in the country. Majority of risk factors for default were treatment and provider oriented and rectifiable with appropriate interventions, which would help in sustaining the good programme performance.

  1. 8. Feasibility of Provider-Initiated HIV Testing and Counselling of Tuberculosis Patients Under the TB Control Programme in Two Districts of South India:

The study was conducted to evaluate provider-initiated HIV testing and counselling (PITC) of TB patients across two districts in India considered to have generalized HIV epidemics, Tiruchirappalli and Mysore.

Starting June 2007, healthcare providers in both districts were instructed to ascertain HIV status for all TB patients, and refer those with unknown HIV status to the nearest Integrated Counselling and Testing Centre (ICTC)—often in the same facility—for counselling and voluntary HIV testing. All TB patients registered from June 2007 to March 2008 were followed prospectively.

Among 5299 TB patients were registered in both study districts. Of the 4701 with unknown HIV status at the time of TB treatment initiation, 3368 (72%) were referred to an ICTC, and 3111 (66%) were newly tested for HIV. PITC implementation resulted in the ascertainment of HIV status for 3709/5299 (70%) of TB patients, and detected 200 cases with previously undiagnosed HIV infection. Overall, 468 (8.8%) of all registered TB patients were HIV-infected; 177 (37%) were documented to have also received any ART.

Previously undiagnosed HIV-infection was detected in 6.4% of those TB patients newly tested, enabling referral for life-saving anti-retroviral treatment. ART uptake, however, was poor, suggesting that PITC implementation should include measures to strengthen and support ART referral, evaluation, and initiation.