SettingPrivate medical practitioners in Visakhapatnam district, Andhra Pradesh, India.ObjectivesTo evaluate self-reported TB diagnostic and treatment practices amongst private medical practitioners against benchmark practices articulated in the International Standards of Tuberculosis Care (ISTC), and factors associated with compliance with ISTC.DesignCross- sectional survey using semi-structured interviews.ResultsOf 296 randomly selected private practitioners, 201 (68%) were assessed for compliance to ISTC diagnostic and treatment standards in TB management. Only 11 (6%) followed a combination of 6 diagnostic standards together and only 1 followed a combination of all seven treatment standards together. There were 28 (14%) private practitioners who complied with a combination of three core ISTC (cough for tuberculosis suspects, sputum smear examination and use of standardized treatment). Higher ISTC compliance was associated with caring for more than 20 TB patients annually, prior sensitization to TB control guidelines, and practice of alternate systems of medicine.ConclusionFew private practitioners in Visakhapatnam, India reported TB diagnostic and treatment practices that met ISTC. Better engagement of the private sector is urgently required to improve TB management practices and to prevent diagnostic delay and drug resistance.

BackgroundThough internationally recommended, provider initiated HIV testing and counseling (PITC) of persons suspected of tuberculosis (TB) is not a policy in India; HIV seroprevalence among TB suspects has never been reported. The current policy of PITC for diagnosed TB cases may limit opportunities of early HIV diagnosis and treatment. We determined HIV seroprevalence among persons suspected of TB and assessed feasibility and effectiveness of PITC implementation at this earlier stage in the TB diagnostic pathway.MethodsAll adults examined for diagnostic sputum microscopy (TB suspects) in Vizianagaram district (population 2.5 million), in November-December 2010, were offered voluntary HIV counseling and testing (VCT) and assessed for TB diagnosis.ResultsOf 2918 eligible TB suspects, 2465(85%) consented to VCT. Among these, 246(10%) were HIV-positive. Of the 246, 84(34%) were newly diagnosed as HIV (HIV status not known previously). To detect a new case of HIV infection, the number needed to screen (NNS) was 26 among ‘TB suspects’, comparable to that among ‘TB patients’. Among suspects aged 25–54 years, not diagnosed as TB, the NNS was 17.ConclusionThe seroprevalence of HIV among ‘TB suspects’ was as high as that among ‘TB patients’. Implementation of PITC among TB suspects was feasible and effective, detecting a large number of new HIV cases with minimal additional workload on staff of HIV testing centre. HIV testing of TB suspects aged 25–54 years demonstrated higher yield for a given effort, and should be considered by policy makers at least in settings with high HIV prevalence.

BackgroundIndia accounts for one-fifth of the global TB incidence. While the exact burden of childhood TB is not known, TB remains one of the leading causes of childhood mortality in India. Bacteriological confirmation of TB in children is challenging due to difficulty in obtaining quality specimens, in the absence of which diagnosis is largely based on clinical judgement. While testing multiple specimens can potentially contribute to higher proportion of laboratory confirmed paediatric TB cases, lack of high sensitivity tests adds to the diagnostic challenge. We describe here our experiences in piloting upfront Xpert MTB/RIF testing, for diagnosis of TB in paediatric population in respiratory and extra pulmonary specimens, as recently recommended by WHO.MethodXpert MTB/RIF testing was offered to all paediatric (0–14 years) presumptive TB cases (both pulmonary and extra-pulmonary) seeking care at public and private health facilities in the project areas covering 4 cities of India.ResultsUnder this pilot project, 8,370 paediatric presumptive TB & presumptive DR-TB cases were tested between April and–November 2014. Overall, 9,149 specimens were tested, of which 4,445 (48.6%) were non-sputum specimens. Xpert MTB/RIF gave 9,083 (99.2%, CI 99.0–99.4) valid results. Of the 8,143 presumptive TB cases enrolled, 517 (6.3%, CI 5.8–6.9) were bacteriologically confirmed. TB detection rates were two fold higher with Xpert MTB/RIF as compared to smear microscopy. Further, a total of 60 rifampicin resistant TB cases were detected, of which 38 were detected among 512 presumptive TB cases while 22 were detected amongst 227 presumptive DR-TB cases tested under the project.ConclusionXpert MTB/RIF with advantages of quick turnaround testing-time, high proportion of interpretable results and feasibility of rapid rollout, substantially improved the diagnosis of bacteriologically confirmed TB in children, while simultaneously detecting rifampicin resistance.

Setting:Ten peripheral health institutions of a tribal t uberculosis unit, Saluru, Vizianagaram District, South India. Objective: To assess among tuberculosis (TB) patients: 1) the feasibility of screening for diabetes mellitus (DM), 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to find one new case of DM. Design: Cross-sectional study: all TB patients registered from January to September 2012 were screened for DM using a screening questionnaire and random blood glucose, followed by fasting blood glucose (FBG) measurements using a glucometer. DM was diagnosed if FBG was ⩾126 mg/dl. Results: Of 381 patients, 374 (98%) were assessed for DM, suggesting feasibility of screening, and 19 (5%) were found to have DM (12 were newly diagnosed and 7 had a previous diagnosis of DM). The only characteristic associated with DM was age ⩾40 years. The NNS to detect a new case of DM among all TB patients was 31; among those aged ⩾40 years, the NNS was 20, and among current smokers it was 21. Conclusion: Screening of TB patients for DM was feasible and effective, and this should inform national scaleup. Other key considerations include the continued provision of free TB-DM screening, with co-location and integration of services. showed that of 8109 TB patients who were assessed for DM, 1084 (13%) were found to have DM, based on fasting blood glucose (FBG) measurements. Based on these data, a policy decision was made by India's Revised National TB Control Programme (RNTCP) to implement countrywide screening of TB patients for DM. 11 One limitation of this study, however, was that it published only aggregate data from all sites, and may have missed site-specifi c variations, and other socio-demographic and clinical factors affecting the effectiveness and feasibility of the screening programme. AFFILIATIONSWe therefore analysed individual patient data and described the effectiveness of screening all TB patients for DM in one tribal TU. The tribal area is remote and diffi cult to access due to poor connectivity and lack of other basic infrastructure. Indicators relating to literacy, economic status, social status and access to health care services are poor among tribes compared to the general population. 12 The tribes are in transition from a forest-centred way of life to a rural, settled farming lifestyle. Given the different lifestyle, more access to unprocessed, fi brerich foods, including fruit and vegetables in their diet and greater daily physical activity, we hypothesized that the prevalence of DM would be considerably lower in tribal areas when compared with the rest of the country. The specifi c objectives of the study were to assess, among a cohort of TB patients: 1) the feasibility of screening for DM, 2) the prevalence of DM, 3) the demographic and clinical features associated with DM, and 4) the number needed to screen (NNS) to fi nd one new case of DM among TB patients. 13,14 METHODS Study designThis was a descriptive study of all TB patie...

BackgroundMulti drug resistant and rifampicin resistant TB patients in India are treated with the World Health Organization (WHO) recommended standardized treatment regimens but no guidelines are available for the management of isoniazid (INH) resistant TB patients. There have been concerns that the standard eight-month retreatment regimen being used in India (2H3R3Z3E3S3/1H3R3Z3E3/5H3R3E3; H-Isoniazid; R-Rifampicin; Z-Pyrazinamide; E-Ethambutol; S-Streptomycin) may be inadequate to treat INH resistant TB cases and leads to poor treatment outcomes. We aimed to assess if INH resistance is associated with unfavorable treatment outcomes (death, default, failure and transferred out) among a cohort of smear positive retreatment TB patients registered in three districts of Andhra Pradesh, India.MethodsWe conducted a retrospective record review of all smear positive retreatment TB patients without rifampicin resistance registered during April–December 2011.ResultsOf 1,947 TB patients, 1,127 (58%) were tested with LPA—50 (4%) were rifampicin resistant, 933 (84%) were sensitive to INH and rifampicin and 144 (12%) were INH resistant. Of 144 INH resistant cases, 64 (44%) had poor treatment outcomes (25 (17%) default, 22 (15%) death, 12 (8%) failure and 5 (3%) transfer out) as compared to 287 (31%) among INH sensitive cases [aRR 1.46; 95%CI (1.19–1.78)].ConclusionOur study confirms that INH resistance is independently associated with unfavorable treatment outcomes among smear positive retreatment TB patients, indicating that the current treatment regimen may be inadequate. These findings call for an urgent need for randomized controlled trials to discover the most effective treatment regimen for managing INH resistant TB.

This cross-sectional multi-centric study compared the yield of and potential benefit for detecting smear-positive pulmonary tuberculosis (PTB) by bleach sedimentation (2% sodium-hypochlorite) versus direct microscopy under programme conditions in India. Among 3168 PTB suspects, 684 (21.6%) were detected by bleach sedimentation vs. 625 (19.7%) by direct microscopy, with a proportional overall agreement of 96% (κ = 0.88). While 594 patients were smear-positive with both methods, 31 patients detected by direct microscopy were missed and an additional 90 patients were detected by bleach sedimentation. Overall, bleach sedimentation increased the yield of smear-positive TB detection; however; it also increased the time to results.

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SettingSeven districts in Andhra Pradesh, South IndiaObjectivesTo a) determine treatment outcomes of patients who fail first line anti-TB treatment and are not placed on an multi-drug resistant TB (MDR-TB) regimen, and b) relate the treatment outcomes to culture and drug susceptibility patterns (C&DST).DesignRetrospective cohort study using routine programme data and Mycobacterium TB Culture C&DST between July 2008 and December 2009.ResultsThere were 202 individuals given a re-treatment regimen and included in the study. Overall treatment outcomes were: 68 (34%) with treatment success, 84 (42%) failed, 36 (18%) died, 13 (6.5%) defaulted and 1 transferred out. Treatment success for category I and II failures was low at 37%. In those with positive cultures, 81 had pan-sensitive strains with 31 (38%) showing treatment success, while 61 had drug-resistance strains with 9 (15%) showing treatment success. In 58 patients with negative cultures, 28 (48%) showed treatment success.ConclusionTreatment outcomes of patients who fail a first-line anti-TB treatment and who are not placed on an MDR-TB regimen are unacceptably poor. The worst outcomes are seen among category II failures and those with negative cultures or drug-resistance. There are important programmatic implications which need to be addressed.