Pre-treatment delay and out of pocket expenses by notified new tuberculosis patients in an Indian mega city

BACKGROUND

Study was carried out to find out delay from onset of symptoms and out of pocket expenditure (OOPE) until initiation of anti-TB treatment (ATT) by new Tuberculosis (TB) patients registered in public health facilities in Bengaluru.

METHODS

Notified patients (N = 228) selected purposively were interviewed at initiation of ATT regarding number and type of facilities visited and delay in initiating ATT. OOPE was elicited separately for in- and out-patient visits, towards consultation, purchase of medicines, diagnostic tests, transportation, hospitalization and food. Dissaving or money borrowed was ascertained.

RESULTS

Two-thirds of participants were 15-44 years of age and 56% were males, mean annual household income was $4357. About 75% first visited a private health facility; 68% and 87% respectively were diagnosed and started on ATT in public sector after visiting an average of three facilities and after a mean delay of 68 days; the median delay was 44 days. Of mean OOPE of $402, 54% was direct medical expenditure, 5% non-medical direct and 41% indirect. OOPE was higher for Extra-pulmonary TB compared to PTB and when number of health facilities visited before initiating treatment was >3 compared to those who visited ≤3 and when the time interval between onset of symptoms and treatment initiation (total delay) was >28 days compared to when this interval was ≤28 days. About 20% suffered catastrophic expenditure; 34% borrowed money and 37% sold assets.

CONCLUSION

Concerted efforts are needed to reduce delay and OOPE in pre-treatment period and social protection to account for indirect expenditure.

A descriptive study of tuberculosis case finding in private health care facilities in a South Indian district

SETTING

A South Indian district providing anti-tuberculosis services through the Revised National TB Control Programme (RNTCP) and private health care facilities.

OBJECTIVE

To ascertain the profile of tuberculosis (TB) patients diagnosed and/or treated in private health care facilities.

METHODS

Data on TB cases diagnosed and/or treated in all clinical departments of the medical college, 83 nursing homes and RNTCP health care facilities were collected prospectively.

RESULTS

About 83% of new TB cases recorded in the private medical college, 47% in nursing homes and 24.5% in RNTCP TB registers were extra-pulmonary. The proportion of retreatment cases was respectively 5.5%, 9.6% and 19.8%. The proportion of males and those in the economically productive age group were similar in the three data sources. About 94% of cases diagnosed in the medical college and 55% in nursing homes were registered for treatment under the RNTCP. About 11% of the smear-positive patients diagnosed in RNTCP were initial defaulters.

CONCLUSION

The proportion of extra-pulmonary cases was higher in the medical college and nursing homes and that of retreatment cases was lower than in the RNTCP.

Implementation efficiency of a diagnostic algorithm in sputum smear-negative presumptive tuberculosis patients

BACKGROUND

For the diagnosis of smear-negative pulmonary tuberculosis (PTB), India's Revised National Tuberculosis Control Programme (RNTCP) recommends a course of broad-spectrum antibiotics after negative smear on initial sputum examination, followed by repeat sputum examination and chest X-ray (CXR).

OBJECTIVES

1) To ascertain the proportion of presumptive PTB patients smear-negative on initial sputum examination who completed the diagnostic algorithm, and 2) to investigate barriers to the completion of the algorithm.

METHODS

In Karnataka State, India, 256 study participants were interviewed in 2012 to ascertain the number of days antibiotics had been prescribed and consumed, the number of re-visits to health centre(s), whether repeat sputum examinations had been performed, whether or not CXR had been performed and when, and whether PTB had been diagnosed. In-depth interviews were conducted with 19 medical officers.

RESULTS

The diagnostic algorithm was completed in 13 (5.1%) of 256 participants; three were diagnosed with PTB without completing the algorithm. Most medical officers were unaware of the algorithm, had trained 5-10 years previously, prescribed antibiotics for <10 days and advised CXR without repeat sputum examination, irrespective of the number of days of antibiotic treatment. Other main reasons for non-completion of algorithm were patients not returning to the health centres and a proportion switching to the private sector.

CONCLUSION

Refresher training courses, raising patient awareness and active follow-up of patients to complete the algorithm are suggested.

Health seeking and knowledge about tuberculosis among persons with pulmonary symptoms and tuberculosis cases in Bangalore slums

SETTING

Bangalore city slums, India.

OBJECTIVES

To ascertain 1) health-seeking behaviour patterns in persons with pulmonary symptoms; 2) pathways followed by pulmonary tuberculosis (PTB) cases until diagnosis and treatment; and 3) their knowledge about TB-symptoms, cause, mode of transmission, diagnosis and treatment.

METHODS

In selected slums, persons with pulmonary symptoms identified during house visits and residents with PTB were interviewed using pre-tested, semi-structured questionnaires. Visits to relevant health centres were made to obtain information regarding their treatment.

RESULTS

About 50% of the 124 persons with pulmonary symptoms interviewed had taken action for relief; of these, three quarters had first approached private health facilities. About 19% had undergone sputum microscopy and 27% chest X-ray. Of 47 PTB cases interviewed, 72% first approached private health facilities; about 50% visited two health facilities before diagnosis and 87% visited two or more facilities before initiating treatment; 42 initiated treatment at government health facilities and five who initiated treatment at private health facilities were later referred to government health facilities. The majority of persons with pulmonary symptoms and PTB cases had poor knowledge about TB, and most of those with pulmonary symptoms were not aware of the availability of free anti-tuberculosis services at government health facilities.

CONCLUSION

Educational interventions targeted at slum dwellers and their health providers are needed.

Annual risk of tuberculous infection in Andhra Pradesh, India

BACKGROUND

There is paucity of information on epidemiological situation of Tuberculosis (TB) in Andhra Pradesh. The DOTS strategy under the Revised National Tuberculosis Control Programme (RNTCP) was introduced in the year 2000 to cover the entire State by 2005.

OBJECTIVES

To estimate the prevalence of tuberculous infection among children 5-9 years of age and to compute the average Annual Risk of Tuberculosis Infection (ARTI) from the estimated prevalence.

METHODS

A cluster-sample house-based tuberculin survey was carried out in a representative sample of children between 5-9 years of age. The clusters were selected by a two-stage sampling procedure. At first stage, five districts were selected by probability proportional to population size (PPS) method. Depending upon child population ratio, 32 clusters allocated to each district were further sub-divided into rural and urban clusters selected by simple random sampling. A total of 3636 children, irrespective of their BCG scar status, were tuberculin tested using one TU PPD RT23 with Tween 80 and the maximum transverse diameter of induration was measured about 72 hours later.

RESULTS

The prevalence of infection estimated by mirror-image technique using observed mode of reactions attributable to infection with tubercle bacilli at 20mm was 9.6% (95% CI: 8.0-11.2). The ARTI was computed at 1.4% (95% CI: 1.1-1.6).

CONCLUSION

Survey findings indicate a fairly high rate of transmission of tubercle bacilli.

Modulation of TCA cycle enzymes and electron transport chain systems in experimental lung cancer

The modulatory effect of Withania somnifera along with paclitaxel on tricarboxylic acid (TCA) cycle key enzymes and electron transport chain complexes were investigated against lung cancer induced by benzo(a)pyrene in Swiss albino mice. Decreased activities of TCA cycle key enzymes such as isocitrate dehydrogenase (ICDH), succinate dehydrogenase (SDH), malate dehydrogenase (MDH) and alpha-ketoglutarate dehydrogenase (alpha-KGDH) in lung cancer bearing animals were observed. Upon W. somnifera along with paclitaxel administration the above biochemical changes were inclined towards normal control animal values. Activities of mitochondrial enzymes and electron transport complexes were analyzed in the experimental groups to determine the efficiency of energy production. This study further confirms the chemotherapeutic effect of W. somnifera along with paclitaxel which is found to be more effective in the treatment of lung cancer. Thus these results are consistent with our hypothesis that the combination chemotherapy of W. somnifera along with paclitaxel as a promising chemotherapeutic agent.

Preliminary study on inhibition of genotoxicity by piperine in mice

A significant suppression (33.9-66.5%) in the micronuclei formation induced by benzo(a)pyrene and cyclophosphamide was reduced following oral administration of piperine at doses of 25, 50 and 75 mg/kg in mice.

The annual risk of tuberculous infection in the eastern zone of India

SETTING

Rural and urban areas of eight selected districts in the eastern zone of India.

OBJECTIVES

To estimate the annual risk of tuberculous infection (ARTI).

STUDY DESIGN

A community-based, cross-sectional tuberculin survey was conducted among children aged 1-9 years residing in a sample of rural and urban areas. Stratified two-stage cluster sampling was adopted for selection of rural and urban clusters. A total of 40964 children in 515 clusters underwent tuberculin testing and reading with 1TU PPD RT23 with Tween 80; the maximum transverse diameter of induration was measured about 72 h after the test.

RESULTS

A bacille Calmette-Gúerin (BCG) scar was observed in 51.5% of the test-read children. The frequency distribution of tuberculin reaction size among 19332 children without BCG scar was found to be bimodal, with the mode of reactions attributable to infection with tubercle bacilli at 20 mm. The prevalence of infection was estimated as 6.9%. The ARTI computed from the estimated prevalence was 1.3%. Children residing in the urban areas were found to be at a significantly higher risk of infection than those residing in rural areas.

CONCLUSION

The high rate of ARTI in the eastern zone of India suggests a need for committed, sustained action in provision of quality tuberculosis control services.

Modulatory effect of Piperine on mitochondrial antioxidant system in Benzo(a)pyrene-induced experimental lung carcinogenesis

Chemoprevention has emerged as a very effective preventive measure against carcinogenesis. Many bioactive compounds present in edible as well in herbal plants have revealed their cancer chemopreventive potential. In the present study, our goal was to investigate the impact of piperine, a principle ingredient of pepper, on alterations of mitochondrial antioxidant system and lipid peroxidation in Benzo(a)pyrene (B(a)P) induced experimental lung carcinogenesis. Oral supplementation of piperine (50 mg/kg body weight) effectively suppressed lung carcinogenesis in B(a)p induced mice as revealed by the decrease in the extent of mitochondrial lipid peroxidation and concomitant increase in the activities of enzymatic antioxidants (superoxide dismutase, catalase and glutathione peroxidase) and non enzymatic antioxidant (reduced glutathione, vitamin E and vitamin C) levels when compared to lung carcinogenesis bearing animals. Our data suggests that piperine may extent its chemopreventive effect by modulating lipid peroxidation and augmenting antioxidant defense system.