Tuberculosis: a Persistent Health Challenge for India

Impact of fine needle aspiration cytology strategy implemented at the microscopy center level for diagnosis of tuberculous lymphadenitis

INTRODUCTION

In India, EPTB accounts for about 50% of TB cases especially in people living with HIV/AIDS. Microbiological confirmation is present in only about 15% of EPTB cases. Tuberculous Lymphadenitis is the most common form of EPTB in India, accounting for around 35% of EPTB cases. Fine needle aspiration cytology has been found to be highly sensitive and specific in the diagnosis of tuberculous lymphadenitis with 83-94% accuracy. The procedure of AFB detection is exactly the same for the FNAC obtained smears as for the presently examined sputum smears at the DMCs. The aim of the present study was to determine the feasibility and effectiveness of FNAC strategy implemented at DMC level for detection of tuberculous lymphadenitis cases.

METHODS

The present study was a randomized cluster trial with one control and one intervention arm. At the intervention units (DMCs) all suspected tuberculous lymphadenitis cases was subjected to FNAC of the suspected superficial lymph nodes by the trained Medical Officers. The control group was free from any such intervention. Effectiveness and feasibility of FNAC strategy in the intervention group was determined by relevant indicators.

RESULTS

At the seven intervention DMCs, FNAC was performed on a total number of 1298 suspected cases of Tuberculous Lymphadenitis. Among them 294 cases were selected in the intervention arm and 196 cases in the control arm. Intervals between advice of FNAC and performance of FNAC as well as start of therapy was significantly low in the intervention arm. Complication was insignificant. The concordance between FNAC reports generated at the DMCs and that at Medical College estimated by agreement measurement kappa (0.970) suggested a high level of agreement.

CONCLUSION

Implementation of FNAC strategy at the DMC level for detection of tuberculous lymphadenitis cases was found to be feasible as well as effective.

Impact of cartridge-based nucleic acid amplification test (CBNAAT) introduction on the detection of pulmonary and extra-pulmonary tuberculosis in Bhubaneswar, Odisha

Background

Compared to conventional microscopy, the cartridge-based nucleic acid amplification test (CBNAAT, Xpert MTB/RIF, Cepheid, USA) has the dual advantage of higher sensitivity to detect Mycobacterium tuberculosis (M. tb), and the ability to detect rifampicin resistance.

Aim

To evaluate the impact of the CBNAAT on the detection of pulmonary and extra-pulmonary tuberculosis from private and public healthcare facilities in Bhubaneswar, Odisha.

Materials and Methods

The study included specimens received between June 2015 to February 2017 from public and private health sectors for tuberculosis diagnosis at a national reference laboratory for tuberculosis in Bhubaneswar, where the CBNAAT was initiated in February 2016. We retrospectively collected the patients' socio-demographic characteristics from their test request form, CBNAAT results from the CBNAAT register and PMDT culture and drug susceptibility testing (DST) register and validated the data by comparing the patient details and test results from the CBNAAT software.

Results

From June 2015 to January 2016, 106 samples were received from Bhubaneswar at the reference laboratory, of which there were zero referrals from the private sector and zero referrals of extra-pulmonary tuberculosis (TB) samples. After initiation of the CBNAAT, from February 2016 to February 2017, 1262 specimens were received, of which 55.2% (696/1262), 17.8% (225/1262), 17.2% (217/1262), and 9.8% (124/1262) were from government hospitals and medical colleges, private hospitals, private practitioners, and district TB centers, respectively.

Conclusion

The availability of TB diagnostics at public sector facilities to patients from private sectors and the rollout of the CBNAAT increased the referral of patients from private health facilities and the referral of paucibacillary non-sputum samples.

Prevalence of diabetes mellitus amongst hospitalized tuberculosis patients at an Indian tertiary care center: A descriptive analysis

Background

India has a high prevalence of tuberculosis (TB) as well as diabetes mellitus (DM). DM is a chronic disease caused by deficiency of insulin production by the pancreas. The risk of TB amongst DM patients is three times higher than those without. The estimated national prevalence of DM is 7.3%. Despite the growing burden of DM, there are limited studies describing the prevalence of TB-DM in India.

Objective

Our study estimated the prevalence of DM amongst adult hospitalized TB patients at Kasturba Hospital, Manipal and determined factors associated with the likelihood of DM-TB co-prevalence.

Methods

We conducted a retrospective cohort study at Kasturba Hospital, Manipal Academy of Higher Education. All hospitalized adult patients diagnosed with pulmonary TB (PTB) and extrapulmonary TB (EPTB) between June 1^st 2015 and June 30^th 2016 were eligible for inclusion. Pediatric and pregnant TB patients were excluded from our study. Data were extracted from medical charts. Descriptive and multivariate analyses were performed in R. Multivariate analysis adjusted for age, gender, type of TB, history of TB, and nutrition (body mass index (BMI)) status.

Results

A total of 728 patients met the eligibility criteria, 517 (71%) were male, 210 (29%) female, 406 (56%) had PTB and 322 (44%) had EPTB. Amongst those with a nutritional status, 36 (30%) patients were underweight (BMI <18.4 kg/m²), 73 (40%) had a normal BMI (18.5kg/m²–24.9 kg/m²), 15 (8%) were overweight (BMI 25.0 kg/m²–29.9 kg/m²) and 9 (5%) were obese (BMI >30.0 kg/m²). A total of 720 (98.9%) of TB patients had at least one blood sugar test result. The overall prevalence of DM (n = 184) amongst TB patients was 25.3% (95% CI 22.2%, 28.6%). When stratified, it was 35.0% (30.4%, 39.9%) and 13.0% (9.7%, 17.3%) amongst PTB and EPTB patients respectively. TB patients aged 41–60 years had 3.51 times higher odds (aOR 3.51 (2.08, 6.07)) of having DM than patients 40 years or younger. Patients aged 60 years or older had 2.49 times higher odds (aOR 2.49 (1.28, 4.85)) of having DM than younger patients (<40 years). Females had lower odds (aOR 0.80 (0.46, 1.37)) of developing DM than male TB patients and patients with a history of TB had lower odds (aOR 0.73 (0.39, 1.32)) than newly diagnosed TB patients. Additionally, EPTB patients had significantly lower odds (aOR 0.26 (0.15, 0.43)) compared to PTB patients. Underweight patients also had significantly lower odds (aOR 0.25 (0.14, 0.42)) of having DM than normal weight patients.

Conclusion

Our study found a higher prevalence of TB-DM than the national average. TB-DM co-prevalence was significantly associated with age, type of TB and undernutrition. As India’s DM prevalence is expected to rise, TB-DM will become an increasingly important part of the TB epidemic requiring specialized study and care.