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1. Vijay S, Kumar P, Chauhan LS, Narayan Rao SV, Vaidyanathan P; Treatment Outcome and Mortality at One and Half Year Follow-Up of HIV InfectedTB Patients Under TB Control Programme in a District of South India; PLoS ONE, 2011, 6(7): e21008.doi:10.1371/journal.pone.0021008

Background: There is paucity of data from India on the impact of HIV related immuno-suppression in response to TB treatment and mortality among HIV infected TB patients. We assessed 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.
Methodology/ Findings: Among 3798 TB patients registered for treatment in Mysore district from July 2007 to June 2008, 281 HIV infected patients formed the study group. The socio-demographic and treatment related data of these patients was obtained from TB and HIV programme records and patient interviews 19 months after TB treatment initiation by field investigators. Treatment success rate of 281 patients was 75% while in smear positive pulmonary tuberculosis cases it was 62%, attributable to defaults (16%) and deaths (19%). Only 2 patients had treatment failure. Overall, 83 (30%) patients were reported dead; 26 while on treatment and 57 after TB treatment. Association of treatment related factors with treatment outcome and survival status was studied through logistic regression analysis. Factors significantly associated with ‘unfavourable outcome’ were disease classification as Pulmonary [aOR-1.96, CI (1.02–3.77)], type of patient as retreatment
[aOR-4.78, CI (2.12–10.76)], and non initiation of ART [aOR-4.90, CI (1.85–12.96)]. Factors associated with ‘Death’ were non initiation of ART [aOR-2.80, CI (1.15–6.81)] and CPT [aOR-3.46, CI (1.47–8.14)].
Conclusion: 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 as a high risk factor for unfavourable 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.
Keywords:Tuberculosis, HIV, Co-infection, DOTS, Mortality, Follow-up
Citation: PLoS ONE, 2011, 6(7): e21008.doi:10.1371/journal.pone.0021008

2. Vijay S, Kumar P, Chauhan LS, Vollepore BH, Kizhakkethil UP: Risk Factors Associated with Default among New Smear Positive TB Patients Treated Under DOTS in India; PLoS ONE, 2010, 5(4): e10043. doi:10.1371/journal.pone.0010043

Background: Poor treatment adherence leading to risk of drug resistance, treatment failure, relapse, death and persistent infectiousness remains an impediment to the tuberculosis control programmes. 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.
Methodology & Principal Findings: Twenty districts selected from six states were assigned to six strata formed, considering the geographic, social-cultural and demographic setup of the area. 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 presence and degree of association between default and determinant factors was computed through univariate and multivariate logistic regression analysis. Data collection was through patient interviews using pretested semi structured questionnaire and review of treatment related records. Information on a wide range of social demographic and patient related factors was obtained. Among the 687 defaulted and equal numbers of patients in completed group, 389 and 540 patients respectively were satisfactorily interviewed. In the logistic regression analysis, factors independently associated with default were alcoholism [AOR-1.72 (1.23–2.44)], illiteracy [AOR-1.40 (1.03–1.92)], having other commitments during treatment [AOR-3.22 (1.1–9.09)], inadequate knowledge of TB [AOR-1.88(1.35–2.63)], poor patient provider interaction [AOR-1.72(1.23–2.44)], lack of support from health staff [AOR-1.93(1.41–2.64)], having instances of missed doses [AOR-2.56(1.82–3.57)], side effects to anti TB drugs [AOR-2.55 (1.87–3.47)] and dissatisfaction with services provided [AOR-1.73 (1.14–2.6)].
Conclusion: 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.
Keywords: New Smear Positive, Tuberculosis, Patients, DOTS, India
Citation: PLoS ONE, 2010, 5(4): e10043. doi:10.1371/journal.pone.0010043

3. Hans L Rieder, Vineet K Chadha, Nico JD Nagelkereke, Frank Van Leth; Guidelines for conducting tuberculin skin test surveys in high-prevalence countries; Int J Tuberc Lung Dis, 2011, 15(1), 51-525

Abstract:This Supplement provides an update on guidelines first published in 1996 on conducting a tuberculin skin test survey and analyzing the resulting data. The updated guidelines add experiences gained from community surveys, revisit the proposed sampling strategies, and provide additional information on ethical considerations.
Keywords:Tuberculin skin test, tuberculin surveys, sampling, sample size, budgeting, training, field work organization, data recording, data management, data interpretation, reaction reading, analysis, community based survey,ethical considerations

4. Chadha, V. K. and Sarin, R. and Narang, P. and John, K. R. and Chopra, K. K. and Jitendra, R. and Mendiratta, D. K. and Vohra, V. and Shashidhara, A. N. and Muniraj, G. and Gopi, P. G. and Kumar, P. (2013)Trends in the annual risk of tuberculous infection in India Int J Tuberc Lung Dis, 17 (3). pp. 312-319

SETTING:Twenty-four districts in India.
OBJECTIVES:To evaluate trends in annual risk of tuberculous infection (ARTI) in each of four geographically defined zones in the country.
STUDY DESIGN:Two rounds of house-based tuberculin surveys were conducted 8-9 years apart among children aged 1-9 years in statistically selected clusters during 2000-2003 and 2009-2010 (Surveys I and II). Altogether, 184,992 children were tested with 1 tuberculin unit (TU) of purified protein derivative (PPD) RT23 with Tween 80 in Survey I and 69,496 children with 2TU dose of PPD in Survey II. The maximum transverse diameter of induration was measured about 72 h after test administration. ARTI was computed from the prevalence of infection estimated using the mirror-image method.
RESULTS:Estimated ARTI rates in different zones varied 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.
CONCLUSION: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

5. Bipra B, Sudipto B, Ajaykumar MV, Dewan P, Chadha VK, et al. (2013) What Are the Reasons for Poor Uptake of HIV Testing among Patients with TB in an Eastern India District? PLoS ONE 8(3): e55229. doi:10.1371/journal.pone.0055229

Background:National policy in India recommends HIV testing of all patients with TB. In West Bengal state, only 28% of patients with TB were tested for HIV between April-June, 2010. We conducted a cross-sectional survey to understand patient, provider and health system related factors associated with low uptake of HIV testing among patients with TB.
Methods:We reviewed TB and HIV program records to assess the HIV testing status of patients registered for anti-TB treatment from July-September 2010 in South-24-Parganas district, West Bengal, assessed availability of HIV testing kits and interviewed a random sample of patients with TB and providers.
Results:Among 1633 patients with TB with unknown HIV status at the time of diagnosis, 435 (26%) were tested for HIV within the intensive phase of TB treatment. Patients diagnosed with and treated for TB at facilities with co-located HIV testing services were more likely to get tested for HIV than at facilities without [RR=1.27, (95% CI 1.20–3.35)]. Among 169 patients interviewed, 67 reported they were referred for HIV testing, among whom 47 were tested. During interviews, providers attributed the low proportion of patients with TB being referred and tested for HIV to inadequate knowledge among providers about the national policy, belief that patients will not test for HIV even if they are referred, shortage of HIV testing kits, and inadequate supervision by both programs.
Discussion:In West Bengal, poor uptake of HIV testing among patients with TB was associated with absence of HIV testing services at sites providing TB care services and to poor referral practices among providers. Comprehensive strategies to change providers’ beliefs and practices, decentralization of HIV testing to all TB care centers, and improved HIV test kit supply chain management may increase the proportion of patients with TB who are tested for HIV.

6.Lungten, Chadha VK. Annual risk of tuberculous infection in Bhutan. Accepted for publication. Int J Tuberc Lung Dis. 2013. 17( 4): 468-472

SETTING:School-based survey in the mountainous nation of Bhutan.
OBJECTIVE:To estimate the annual risk of tuberculous infection (ARTI) among children aged 6-8 years.
DESIGN:A national-level tuberculin survey was carried out among children attending 64 schools selected by two-stage cluster sampling. The study population was comprised of children without and with bacille Calmette-Guérin (BCG) scar. Tuberculin testing was performed using 2 tuberculin units of purified protein derivative RT23. The maximum transverse diameter of induration was measured at 48-72 h.
RESULTS:Of 6087 satisfactorily test-read children, 82% had a BCG scar. The frequency distribution of tuberculin reaction sizes in all children (with and without BCG scar) did not reveal the mode for tuberculous reactions. The mode seen at 17 mm among children without BCG scar was applied to estimate the prevalence of infection among all children using the mirror-image method. Estimation was also undertaken by shifting the mode by 1 mm on either side. The ARTI computed from the prevalence thus estimated varied between 0.2% and 0.7%. There was no difference in the prevalence of infection by BCG scar status, implying that the estimated ARTI was not influenced by BCG-induced tuberculin sensitivity.
CONCLUSION:The ARTI has declined in Bhutan compared to the 1991 survey estimate of 1.9%.

7. Chopra K, Chadha VK, Ramachandra J, Aggarwal N (2012) Trend in Annual Risk of Tuberculous Infection in North India. PLoS ONE 7(12): e51854. doi:10.1371/journal.pone.0051854

SETTING:Six selected districts in Northern India.
OBJECTIVE:To find out the trend in Annual risk of tuberculous infection (ARTI) in north India.
STUDY DESIGN:Two rounds of community level surveys were conducted during 2000-2001 and 2009-10 respectively. Representative samples of children 1-9 years of age were tuberculin tested and maximum transverse diameter of induration was recorded in mm at about 72 hours. ARTI was computed from the estimated Prevalence of infection using mirror-image technique and anti-mode method.
RESULTS:ARTI was found to decline from 1.9% (confidence interval: 1.7-2.1) at round I to 1.1% (confidence interval: 0.8-1.3) at round II at the rate of 8% per year during the intervening period.
CONCLUSION:A significant reduction in the risk of tuberculous infection among children was observed between two rounds of surveys carried out at an interval of about 9 years.

8. Vineet K. Chadha, Prahlad Kumar, Sharada M Anjinappa, Sanjay Singh, Somashekar Narasimhaiah, Malathi V. Joshi, Joydev Gupta, Lakshminarayana, Jitendra Ramchandra, Magesh Velu, Suganthi Papkianathan, Suseendra Babu, Hemalatha Krishna: Prevalence of Pulmonary Tuberculosis among Adults in a Rural Sub-District of South India; PLoS ONE, 2012, 7(8): e42625. doi:10.1371/journal.pone.0042625

Background:We conducted a survey to estimate point prevalence of bacteriologically positive pulmonary TB (PTB) in a rural area in South India, implementing TB program DOTS strategy since 2002.
Methods:Survey was conducted among persons $15 years of age in fifteen clusters selected by simple random sampling; each consisting of 5–12 villages. Persons having symptoms suggestive of PTB or history of anti-TB treatment (ATT) were eligible for sputum examination by smear microscopy for Acid Fast Bacilli and culture for Mycobacterium tuberculosis; two sputum samples were collected from each eligible person. Persons with one or both sputum specimen positive on microscopy and/or culture were labeled suffering from PTB. Prevalence was estimated after imputing missing values to correct for bias introduced by incompleteness of data. In six clusters, registered persons were also screened by X-ray chest. Persons with any abnormal shadow on X-ray were eligible for sputum examination in addition to those with symptoms and ATT. Multiplication factor calculated as ratio of prevalence while using both screening tools to prevalence using symptoms screening alone was applied to entire study population to estimate prevalence corrected for non-screening by X-ray.
Results:Of 71,874 residents $15 years of age, 63,362 (88.2%) were screened for symptoms and ATT. Of them, 5120 (8.1%) – 4681 (7.4%) with symptoms and an additional 439 (0.7%) with ATT were eligible for sputum examination. Spot specimen were collected from 4850 (94.7%) and early morning sputum specimens from 4719 (92.2%). Using symptom screening alone, prevalence of smear, culture and bacteriologically positive PTB in persons $15 years of age was 83 (CI: 57–109), 152 (CI: 108–197) and 196 (CI :145–246) per 100,000 population respectively. Prevalence corrected for non-screening by X-ray was 108 (CI: 82–134), 198 (CI: 153–243) and 254 (CI: 204–301) respectively.
Conclusion:Observed prevalence suggests further strengthening of TB control program.

9. Quazi TA, Sarkar S, Borgohain G, Sreenivas A, Harries AD, Srinath S, Khan K, Bishnu B, Tapadar S, Phukan AC, Kabir A, Chaddha V, Paul D, Dewan P. Are all patients diagnosed with tuberculosis in Indian medical colleges referred to the RNTCP? J Tuberc Lung Dis 2012; 16 (8):1083-1085.

To assess the proportion of tuberculosis (TB) patients diagnosed in three medical colleges in the states of West Bengal and Meghalaya who benefited from the services provided under the Revised National Tuberculosis Control Programme (RNTCP), a line list of patients with reports of investigations suggesting probable or confirmed TB was prepared from the records of the pathology, radiology and microbiology departments. This was com compared with another line list prepared using RNTCP records. Only 150 (36%) of 420 probable or confirmed TB patients were referred to the RNTCP services. This suggests a need for more intensive supervision and training of medical college faculty.

10. Rao VG, Bhat J, Yadav R, Gopalan GP, Nagamiah S, Bhondeley MK, Anjinappa SM, Ramchandra J, Chadha VK, Wares F (2012) Prevalence of Pulmonary Tuberculosis – A Baseline Survey In Central India. PLoS ONE 7(8):e43225. doi:10.1371/journal.pone.0043225

BACKGROUND:The present study provides an estimate of the prevalence of bacteriologially positive pulmonary tuberculosis in Jabalpur, a district in central India.
METHODOLOGY/PRINCIPAL FINDINGS:A community based cross-sectional survey was undertaken in Jabalpur District of the central Indian state of Madhya Pradesh. A stratified cluster sampling design was adopted to select the sample. All eligible individuals were questioned for pulmonary symptoms suggestive of TB disease. Two sputum samples were collected from all eligible individuals and were examined by Ziehl-Neelsen smear microscopy and solid media culture methods. Of the 99,918 individuals eligible for screening, 95,071 (95.1%) individuals were screened. Of these, 7,916 (8.3%) were found to have symptoms and sputum was collected from 7,533 (95.2%) individuals. Overall prevalence of bacteriologically positive PTB was found to be 255.3 per 100,000 population (95% C.I: 195.3-315.4). Prevalence was significantly higher (p<0.001) amongst males (355.8; 95% C.I: 304.4-413.4) compared with females (109.0; 95% C.I: 81.2-143.3). Prevalence was also significantly higher in rural areas (348.9; 95% C.I: 292.6-412.8) as compared to the urban (153.9; 95% C.I: 123.2-190.1).
CONCLUSIONS/SIGNIFICANCE:The TB situation in Jabalpur district, central India, is observed to be comparable to the TB situation at the national level (255.3 versus 249). There is however, a need to maintain and further strengthen TB control measures on a sustained and long term basis in the area to have a significant impact on the disease prevalence in the community.

11. Rieder HL, Chadha VK, Nakelkerke NJD, Van Leth F, Van der Werf MJ. Guidelines for conducting Tuberculin Test Surveys in high-prevalence countries. J Tuberc Lung Dis 2011, supplement 1: S1-S26.

This Supplement provides an update on guidelines first published in 1996 on conducting a tuberculin skin test survey and analyzing the resulting data. The updated guidelines add experiences gained from community surveys, revisit the proposed sampling strategies, and provide additional information on ethical considerations.

12. Chadha VK. Epidemiology of pulmonary tuberculosis In: Textbook of pulmonary and critical care medicine 2011, first edition. Jaypee Brothers medical publishers (P) Ltd, New Delhi, p.489-510.

This manuscript published as a chapter in this text book covers all aspects of TB Epidemiology including the natural course of the disease, risk factors, measurement of disease burden and progress towards control. All the epidemiological information generated in India since 1950’s has been provided. The global trends of the disease have been elucidated. The manuscript would serve as a useful resource material for TB workers and Medical students.
Last Updated Date : 11-11-2013 12:11:10