How Do Urban Indian Private Practitioners Diagnose and Treat Tuberculosis? A Cross-Sectional Study in Chennai

Setting

Private practitioners are frequently the first point of healthcare contact for patients with tuberculosis (TB) in India. Inappropriate TB management practices among private practitioners may contribute to delayed TB diagnosis and generate drug resistance. However, these practices are not well understood. We evaluated diagnostic and treatment practices for active TB and benchmarked practices against International Standards for TB Care (ISTC) among private medical practitioners in Chennai.

Design

A cross-sectional survey of 228 practitioners practicing in the private sector from January 2014 to February 2015 in Chennai city who saw at least one TB patient in the previous year. Practitioners were randomly selected from both the general community and a list of practitioners who referred patients to a public-private mix program for TB treatment in Chennai. Practitioners were interviewed using standardized questionnaires.

Results

Among 228 private practitioners, a median of 12 (IQR 4–28) patients with TB were seen per year. Of 10 ISTC standards evaluated, the median of standards adhered to was 4.0 (IQR 3.0–6.0). Chest physicians reported greater median ISTC adherence than other MD and MS practitioners (score 7.0 vs. 4.0, P<0.001), or MBBS practitioners (score 7.0 vs. 4.0, P<0.001). Only 52% of all practitioners sent >5% of patients with cough for TB testing, 83% used smear microscopy for diagnosis, 33% monitored treatment response, and 22% notified TB cases to authorities. Of 228 practitioners, 68 reported referring all patients with new pulmonary TB for treatment, while 160 listed 27 different regimens; 78% (125/160) prescribed a regimen classified as consistent with ISTC. Appropriate treatment practices differed significantly between chest physicians and other MD and MS practitioners (54% vs. 87%, P<0.001).

Conclusion

TB management practices in India’s urban private sector are heterogeneous and often suboptimal. Private providers must be better engaged to improve diagnostic capacity and decrease TB transmission in the community.

Below:  Mean annual volume of patients with tuberculosis (TB) in the past year according to practitioner training among private practitioners in Chennai

Below:  Distribution of aggregate practitioner-reported adherence scores to ten of the International Standards for TB Care by practitioner training in the private sector in Chennai

Full article at:   http://goo.gl/ikN7R1

By:  

Liza Bronner Murrison, David W. Dowdy

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America

Liza Bronner Murrison, David W. Dowdy

Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, United States of America

Ramya Ananthakrishnan, Sumanya Sukumar, Sheela Augustine, Nalini Krishnan

REACH, Chennai, India

Madhukar Pai

McGill International TB Centre & Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, Quebec, Canada

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The Prevalence of Tuberculosis in Zambia: Results from the First National TB Prevalence Survey, 2013–2014

Background

Tuberculosis in Zambia is a major public health problem, however the country does not have reliable baseline data on the TB prevalence for impact measurement; therefore it was among the priority countries identified by the World Health Organization to conduct a national TB prevalence survey.

Objective

To estimate the prevalence of tuberculosis among the adult Zambian population aged 15 years and above, in 2013–2014.

Methods

A cross-sectional population-based survey was conducted in 66 clusters across all the 10 provinces of Zambia. Eligible participants aged 15 years and above were screened for TB symptoms, had a chest x-ray (CXR) performed and were offered an HIV test. Participants with TB symptoms and/or CXR abnormality underwent an in-depth interview and submitted one spot- and one morning sputum sample for smear microscopy and liquid culture. Digital data collection methods were used throughout the process.

Results

Of the 98,458 individuals who were enumerated, 54,830 (55.7%) were eligible to participate, and 46,099 (84.1%) participated. Of those who participated, 45,633/46,099 (99%) were screened by both symptom assessment and chest x-ray, while 466/46,099 (1.01%) were screened by interview only. 6,708 (14.6%) were eligible to submit sputum and 6,154/6,708 (91.7%) of them submitted at least one specimen for examination. MTB cases identified were 265/6,123 (4.3%). The estimated national adult prevalence of smear, culture and bacteriologically confirmed TB was 319/100,000 (232-406/100,000); 568/100,000 (440-697/100,000); and 638/100,000 (502-774/100,000) population, respectively. The risk of having TB was five times higher in the HIV positive than HIV negative individuals. The TB prevalence for all forms was estimated to be 455 /100,000 population for all age groups.

Conclusion

The prevalence of tuberculosis in Zambia was higher than previously estimated. Innovative approaches are required to accelerate the control of TB.

Below:  Reported signs and symptoms among presumptive TB participants

Full article at:   http://goo.gl/zy0Fjg

By:  Kapata N1,2, Chanda-Kapata P3,2, Ngosa W3, Metitiri M3, Klinkenberg E4,5, Kalisvaart N4, Sunkutu V6, Shibemba A6, Chabala C6, Chongwe G7, Tembo M8,Mulenga L9, Mbulo G6, Katemangwe P6, Sakala S3, Chizema-Kawesha E3, Masiye F10, Sinyangwe G11, Onozaki I12, Mwaba P13, Chikamata D3, Zumla A14,Grobusch MP2.

• 1National TB and Leprosy Control Program, Lusaka, Zambia.
• 2Centre for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
• 3Ministry of Health Headquarters, Lusaka, Zambia.
• 4KNCV Tuberculosis Foundation, The Hague, the Netherlands.
• 5Department of Global Health, Academic Medical Centre, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands.
• 6University Teaching Hospital, Lusaka, Zambia.
• 7Department of Public Health, University of Zambia, Lusaka, Zambia.
• 8Tropical Diseases Research Centre, Ndola, Zambia.
• 9Chest Diseases Laboratory, Ministry of Health, Lusaka, Zambia.
• 10Department of Economics, School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.
• 11United States Agency for International Development, Country Mission, Lusaka, Zambia.
• 12Global Tuberculosis Programme, World Health Organisation, Geneva, Switzerland.
• 13Ministry of Home Affairs headquarters, Lusaka, Zambia.
• 14Division of Infection and Immunity, Department of Infection, University College London, London, United Kingdom. 

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Screening for TB by Sputum Culture in High-Risk Groups in Copenhagen, Denmark: A Novel & Promising Approach

INTRODUCTION:

Evidence on screening high-risk groups for TB by mobile X-ray in low-incidence countries is building, but knowledge on other possible screening methods is limited. In this retrospective study we report results from a community based programme screening for TB by spot sputum culture.

METHODS:

On seven occasions, from September 2012 through June 2014, we offered TB screening to all persons present at 11 locations where socially marginalised people gather in Copenhagen. Spot sputum samples from participants were examined by smear microscopy and culture. Genotype, nucleic acid amplification test and chest X-ray were done if TB was found.

RESULTS:

Among 1075 participants, we identified 36 cases of TB. Twenty-four cases (66.7%) were identified at the first screening of each participant, that is, the prevalence of TB was 2233/100 000. Thirty-five (97%) of the TB cases were culture-positive and seven (19.4%) were smear-positive. Twelve out of 21 (57.1%) cases tested were nucleic acid amplification test positive. Twenty-eight (77.8%) had chest X-ray suggestive of TB. All patients with TB started treatment, 30 (83.3%) had a successful outcome.

DISCUSSION:

Screening for TB by spot sputum culture is possible and a promising alternative to mobile X-ray in a community based screening programme. 22.2% did not have chest X-ray suggestive of TB and would not have been identified using mobile X-ray. Most of the TB cases were smear-negative, suggesting that they were identified at an early, less infectious stage, which is essential in order to prevent transmission and gain infection control.

Purchase full article at:   http://goo.gl/jwDskp

By:   Jensen SG1, Olsen NW1, Seersholm N1, Lillebaek T2, Wilcke T1, Pedersen MK2, Kok-Jensen A2.

• 1Department of Respiratory Medicine, Gentofte Hospital, Hellerup, Copenhagen, Denmark.
• 2International Reference Laboratory of Mycobacteriology, Statens Serum Institut, Copenhagen, Denmark. 

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Evaluating the Diagnostic Accuracy of Xpert MTB/RIF Assay in Pulmonary Tuberculosis

Pulmonary tuberculosis still remains a major communicable disease worldwide. In 2013, 9 million people developed TB and 1.5 million people died from the disease. India constitutes 24% of the total TB burden. 

Early detection of TB cases is the key to successful treatment and reduction of disease transmission. Xpert MTB/RIF, an automated cartridge-based molecular technique detects Mycobacterium tuberculosis and rifampicin resistance within two hours has been endorsed by WHO for rapid diagnosis of TB. 

Our study is the first study from India with a large sample size to evaluate the performance of Xpert MTB/RIF assay in PTB samples. The test showed an overall sensitivity and specificity of 95.7% (430/449) and 99.3% (984/990) respectively. In smear negative-culture positive cases, the test had a sensitivity of 77.7%. The sensitivity and specificity for detecting rifampicin resistance was 94.5% and 97.7% respectively with respect to culture as reference standard. However, after resolving the discrepant samples with gene sequencing, the sensitivity and specificity rose to 99.0% and 99.3% respectively. 

Hence, while solid culture still forms the foundation of TB diagnosis, Xpert MTB/RIF proposes to be a strong first line diagnostic tool for pulmonary TB cases.

Full article at: http://goo.gl/X54bXP

By:

Surendra K Sharma, Mikashmi Kohli, Raj Narayan Yadav, Jigyasa Chaubey, Dinkar Bhasin, Rohini Sharma, Binit K Singh

Department of Internal Medicine, All India Institute of Medical Sciences, New Delhi, India

Vishnubhatla Sreenivas

Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India

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Accuracy of QuantiFERON-TB Gold Test for Tuberculosis Diagnosis in Children

To evaluate the accuracy of the QuantiFERON-TB Gold assay (QFT-IT) in children with suspected active or latent TB infection (LTBI).

A retrospective study was conducted on 621 children (0–14 years old) evaluated for TB infection or disease. Following clinical assessment, children were tested with the QFT-IT assay.

Among the 140 active TB suspects, we identified 19 cases of active disease. The overall sensitivity for active TB was 87.5%, ranging from 62.5% in children 25–36 months old to 100% in children older than 49 months. The overall specificity for active TB was 93.6%. Among the 481 children tested for LTBI screening, 38 scored positive and all but 2 had at least one risk factor for TB infection. Among the 26 children with indeterminate results, bacterial, viral or fungal pneumonia were later diagnosed in 11 (42.3%) cases and non-TB related extra-pulmonary infections in 12 (46.1%).

Our results indicate that the children's response to QFT-IT associates to active TB and risk factors for LTBI. Moreover, we show that mitogen response is also found in children of 1 year of age, providing support for QFT-IT use also in young children.

Below:  Quantitative response to QuantiFeron TB Gold-In Tube in relationship to age

Full article at: http://goo.gl/D8TAhz

By: 

Michela Sali, Pamela D’Alfonso, Antonella Zumbo, Giovanni Fadda, Maurizio Sanguinetti, Giovanni Delogu

Institute of Microbiology, Università Cattolica del Sacro Cuore, Rome, Italy

Danilo Buonsenso, Piero Valentini

Institute of Pediatrics, Università Cattolica del Sacro Cuore, Rome, Italy

Delia Goletti

Translational Research Unit, Department of Epidemiology and Preclinical Research, "Lazzaro Spallanzani" National Institute for Infectious Diseases (INMI), IRCCS, Rome, Italy

  

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