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.

Prevalence of pulmonary tuberculosis among the tribal populations in India

Importance

There is no concrete evidence on the burden of TB among the tribal populations across India except for few studies mainly conducted in Central India with a pooled estimation of 703/100,000 with a high degree of heterogeneity.

Objective

To estimate the prevalence of TB among the tribal populations in India.

Design, participants, setting

A survey using a multistage cluster sampling design was conducted between April 2015 and March 2020 covering 88 villages (clusters) from districts with over 70% tribal majority populations in 17 States across 6 zones of India. The sample populations included individuals ≥15 years old.

Main outcome and measures

Eligible participants who were screened through an interview for symptoms suggestive of pulmonary TB (PTB); Two sputum specimens were examined by smear and culture. Prevalence was estimated after multiple imputations for non-coverage and a correction factor of 1.31 was then applied to account for non-inclusion of X-ray screening.

Results

A total of 74532 (81.0%) of the 92038 eligible individuals were screened; 2675 (3.6%) were found to have TB symptoms or h/o ATT. The overall prevalence of PTB was 432 per 100,000 populations. The PTB prevalence per 100,000 populations was highest 625 [95% CI: 496–754] in the central zone and least 153 [95% CI: 24–281] in the west zone. Among the 17 states that were covered in this study, Odisha recorded the highest prevalence of 803 [95% CI: 504–1101] and Jammu and Kashmir the lowest 127 [95% CI: 0–310] per 100,000 populations. Findings from multiple logistic regression analysis reflected that those aged 35 years and above, with BMI <18.5 Kgs /m², h/o ATT, smoking, and/or consuming alcohol had a higher risk of bacteriologically positive PTB. Weight loss was relatively more important symptom associated with tuberculosis among this tribal populations followed by night sweats, blood in sputum, and fever.

Conclusion and relevance

The overall prevalence of PTB among tribal groups is higher than the general populations with a wide variation of prevalence of PTB among the tribal groups at zone and state levels. These findings call for strengthening of the TB control efforts in tribal areas to reduce TB prevalence through tribal community/site-specific intervention programs.

Training strategies practiced for TB elimination

Training is the backbone of any public health program and it is true for a vast program like TB. It is urgent when the program is aiming to End TB. The strategy that is followed in India for capacity building of TB workers is presented in this article. Various types of trainings that are needed are described in detail. Also enlisted are the different trainings undertaken at NTI for the last five years. Recent times the effect of Covid-19 has resulted in the acceleration of the effort of going for digital platforms and onlinetrainings and is described.

Active tuberculosis case finding in India - The way forward

Community based active case finding (ACF) for tuberculosis (TB) has seen resurrection in the current armamentarium of many TB managers in their fight toward eliminating TB. This article explores the accuracy and approximate cost of various ACF algorithms currently in vogue in India or those which could be useful, while inputting the sensitivity and specificity of screening and diagnostic tools as estimated from recently conducted community based surveys. This analysis informs that ACF may be prioritized to higher prevalence settings and the diagnostic algorithm for specific setting may be chosen taking into account the expected prevalence, estimated accuracy of the algorithm and resource availability. Further, chest X-ray cannot be used alone as a diagnostic tool and can be relied upon for this purpose when at least one of the three sputum specimen is smear positive. Accuracy of Xpert MTB/RIF as a diagnostic tool in community situations needs to be investigated further. The review brings out significant proportions of initial default and default during treatment among cases detected through ACF thus emphasizing the need for heightened efforts toward preventing the same. The article rounds off emphasizing priority to addressing barriers to speedy scale up of more sensitive diagnostic tools for health center based case finding including in private sector and ACF in high risk clinical groups for early and efficient case detection. It concludes by putting forth certain research areas that would strengthen future efforts.

Constructing care cascades for active tuberculosis: A strategy for program monitoring and identifying gaps in quality of care

The cascade of care is a model for evaluating patient retention across sequential stages of care required to achieve a successful treatment outcome. This approach was first used to evaluate HIV care and has since been applied to other diseases. The tuberculosis (TB) community has only recently started using care cascade analyses to quantify gaps in quality of care. In this article, we describe methods for estimating gaps (patient losses) and steps (patients retained) in the care cascade for active TB disease. We highlight approaches for overcoming challenges in constructing the TB care cascade, which include difficulties in estimating the population-level burden of disease and the diagnostic gap due to the limited sensitivity of TB diagnostic tests. We also describe potential uses of this model for evaluating the impact of interventions to improve case finding, diagnosis, linkage to care, retention in care, and post-treatment monitoring of TB patients.

Operational research within a Global Fund supported tuberculosis project in India: why, how and its contribution towards change in policy and practice

BACKGROUND

The Global Fund encourages operational research (OR) in all its grants; however very few reports describe this aspect. In India, Project Axshya was supported by a Global Fund grant to improve the reach and visibility of the government Tuberculosis (TB) services among marginalised and vulnerable communities. OR was incorporated to build research capacity of professionals working with the national TB programme and to generate evidence to inform policies and practices.

OBJECTIVES

To describe how Project Axshya facilitated building OR capacity within the country, helped in addressing several TB control priority research questions, documented project activities and their outcomes, and influenced policy and practice.

METHODS

From September 2010 to September 2016, three key OR-related activities were implemented. First, practical output-oriented modular training courses were conducted (n = 3) to build research capacity of personnel involved in the TB programme, co-facilitated by The Union, in collaboration with the national TB programme, WHO country office and CDC, Atlanta. Second, two large-scale Knowledge, Attitude and Practice (KAP) surveys were conducted at baseline and mid-project to assess the changes pertaining to TB knowledge, attitudes and practices among the general population, TB patients and health care providers over the project period. Third, studies were conducted to describe the project's core activities and outcomes.

RESULTS

In the training courses, 44 participant teams were supported to develop research protocols on topics of national priority, resulting in 28 peer-reviewed scientific publications. The KAP surveys and description of project activities resulted in 14 peer-reviewed publications. Of the published papers at least 12 have influenced change in policy or practice.

CONCLUSIONS

OR within a Global Fund supported TB project has resulted in building OR capacity, facilitating research in areas of national priority and influencing policy and practice. We believe this experience will provide guidance for undertaking OR in Global Fund projects.

Tuberculosis preventive treatment: the next chapter of tuberculosis elimination in India

The End TB Strategy envisions a world free of tuberculosis—zero deaths, disease and suffering due to tuberculosis by 2035. This requires reducing the global tuberculosis incidence from >1250 cases per million people to <100 cases per million people within the next two decades. Expanding testing and treatment of tuberculosis infection is critical to achieving this goal. In high-burden countries, like India, the implementation of tuberculosis preventive treatment (TPT) remains a low priority. In this analysis article, we explore potential challenges and solutions of implementing TPT in India. The next chapter in tuberculosis elimination in India will require cost-effective and sustainable interventions aimed at tuberculosis infection. This will require constant innovation, locally driven solutions to address the diverse and dynamic tuberculosis epidemiology and persistent programme monitoring and evaluation. As new tools, regimens and approaches emerge, midcourse adjustments to policy and practice must be adopted. The development and implementation of new tools and strategies will call for close collaboration between local, national and international partners—both public and private—national health authorities, non-governmental organisations, research community and the diagnostic and pharmaceutical industry. Leading by example, India can contribute to global knowledge through operational research and programmatic implementation for combating tuberculosis infection.

Sensitivity and specificity of screening tools and smear microscopy in active tuberculosis case finding

SETTING

Community based five pulmonary tuberculosis (PTB) surveys among adults.

OBJECTIVES

Estimate sensitivity and specificity of screening tools for PTB and sputum microscopy.

METHODS

For each survey site, we estimated sensitivity and specificity of different screening criteria and microscopy against culture; pooled estimates were obtained using Random Effects Model.

RESULTS

Sensitivity of cough alone, screening for any symptom (persistent cough ≥2 weeks, fever or chest pain ≥1 month, hemoptysis), any symptom or history of anti-TB treatment (h/o ATT) were 56.2%, 66% and 71.2% respectively; specificities were 95.3%, 93.8% and 92.7% respectively. X-ray when used alone for primary screening had sensitivity and specificity of 76.6% and 97.3% respectively. When used along with screening for cough, these figures were 94.3% and 93.1%, and 100% and 97.3% when used with any symptom and h/o ATT. When used for secondary screening, sensitivity and specificity of X-ray was 66.8% and 87.8% respectively after primary screening for cough, 65.0% and 89.8% after screening for any symptom, and 67.1% and 86.7% when used after screening for any symptom or h/o ATT. Pooled sensitivity and specificity of smear was 46.2% and 99.3% respectively.

CONCLUSION

Program managers may use these estimates while evaluating algorithms for active case finding.

Estimating tuberculosis incidence from primary survey data: a mathematical modeling approach

BACKGROUND:

There is an urgent need for improved estimations of the burden of tuberculosis (TB).

OBJECTIVE:

To develop a new quantitative method based on mathematical modelling, and to demonstrate its application to TB in India.

DESIGN:

We developed a simple model of TB transmission dynamics to estimate the annual incidence of TB disease from the annual risk of tuberculous infection and prevalence of smear-positive TB. We first compared model estimates for annual infections per smear-positive TB case using previous empirical estimates from China, Korea and the Philippines. We then applied the model to estimate TB incidence in India, stratified by urban and rural settings.

RESULTS:

Study model estimates show agreement with previous empirical estimates. Applied to India, the model suggests an annual incidence of smear-positive TB of 89.8 per 100 000 population (95%CI 56.8–156.3). Results show differences in urban and rural TB: while an urban TB case infects more individuals per year, a rural TB case remains infectious for appreciably longer, suggesting the need for interventions tailored to these different settings.

CONCLUSIONS:

Simple models of TB transmission, in conjunction with necessary data, can offer approaches to burden estimation that complement those currently being used.

Integration and decentralisation of TB-HIV services increases HIV testing of TB cases in Rajasthan, India

The proportion of tuberculosis (TB) patients tested for the human immunodeficiency virus (HIV) in the state of Ra-jasthan, India, is limited by the availability of HIV testing facilities. Rajasthan implemented a policy of initiating TB-HIV diagnosis at all health institutions in July 2013. The number of TB diagnostic facilities increased from 33 to 63 in Banswara District and from 22 to 68 in Jhunjhunu District, while the number of HIV testing facilities in these districts increased from 1 to 53 and from 10 to 81, respectively, after the policy implementation. The proportion of TB patients tested for HIV increased by respectively 27% and 19%.

Counting the lives saved by DOTS in India: a model-based approach

BACKGROUND

Against the backdrop of renewed efforts to control tuberculosis (TB) worldwide, there is a need for improved methods to estimate the public health impact of TB programmes. Such methods should not only address the improved outcomes amongst those receiving care but should also account for the impact of TB services on reducing transmission.

METHODS

Vital registration data in India are not sufficiently reliable for estimates of TB mortality. As an alternative approach, we developed a mathematical model of TB transmission dynamics and mortality, capturing the scale-up of DOTS in India, through the rollout of the Revised National TB Control Programme (RNTCP). We used available data from the literature to calculate TB mortality hazards amongst untreated TB; amongst cases treated under RNTCP; and amongst cases treated under non-RNTCP conditions. Using a Bayesian evidence synthesis framework, we combined these data with current estimates for the TB burden in India to calibrate the transmission model. We simulated the national TB epidemic in the presence and absence of the DOTS programme, measuring lives saved as the difference in TB deaths between these scenarios.

RESULTS

From 1997 to 2016, India's RNTCP has saved 7.75 million lives (95% Bayesian credible interval 6.29-8.82 million). We estimate that 42% of this impact was due to the 'indirect' effects of the RNTCP in averting transmission as well as improving treatment outcomes.

CONCLUSIONS

When expanding high-quality TB services, a substantial proportion of overall impact derives from preventive, as well as curative, benefits. Mathematical models, together with sufficient data, can be a helpful tool in estimating the true population impact of major disease control programmes.

Relationship between Nutritional Support and Tuberculosis Treatment Outcomes in West Bengal, India

Introduction

Poverty and poor nutrition are associated with the risk of developing tuberculosis (TB). Socioeconomic factors may interfere with anti-tuberculosis treatment compliance and its outcome. We examined whether providing nutritional support (monthly supply of rice and lentil beans) to TB patients who live below the poverty line was associated with TB treatment outcome.

Methods

This was a retrospective cohort study of sputum smear-positive pulmonary TB patients living below the poverty line (income of <$1.25 per day) registered for anti-tuberculosis treatment in two rural districts of West Bengal, India during 2012 to 2013. We compared treatment outcomes among patients who received nutritional support with those who did not. A log-binomial regression model was used to assess the relation between nutritional support and unsuccessful treatment outcome (loss-to-follow-up, treatment failure and death).

Results

Of 173 TB patients provided nutritional support, 15 (9%) had unsuccessful treatment outcomes, while 84 (21%) of the 400 not provided nutrition support had unsuccessful treatment outcomes (p < 0.001). After adjusting for age, sex and previous treatment, those who received nutritional support had a 50% reduced risk of unsuccessful treatment outcome than those who did not receive nutritional support (Relative Risk: 0.51; 95% Confidence Intervals: 0.30 - 0.86).

Conclusion

Under programmatic conditions, monthly rations of rice and lentils were associated with lower risk of unsuccessful treatment outcome among impoverished TB patients. Given the relatively small financial commitment needed per patient ($10 per patient per month), the national TB programme should consider scaling up nutritional support among TB patients living below the poverty line.

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models

BACKGROUND

The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.

METHODS

We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.

FINDINGS

Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.

INTERPRETATION

Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.

FUNDING

Bill & Melinda Gates Foundation.

Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models

Background

The post-2015 End TB Strategy proposes targets of 50% reduction in tuberculosis incidence and 75% reduction in mortality from tuberculosis by 2025. We aimed to assess whether these targets are feasible in three high-burden countries with contrasting epidemiology and previous programmatic achievements.

Methods

11 independently developed mathematical models of tuberculosis transmission projected the epidemiological impact of currently available tuberculosis interventions for prevention, diagnosis, and treatment in China, India, and South Africa. Models were calibrated with data on tuberculosis incidence and mortality in 2012. Representatives from national tuberculosis programmes and the advocacy community provided distinct country-specific intervention scenarios, which included screening for symptoms, active case finding, and preventive therapy.

Findings

Aggressive scale-up of any single intervention scenario could not achieve the post-2015 End TB Strategy targets in any country. However, the models projected that, in the South Africa national tuberculosis programme scenario, a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care could achieve a 55% reduction in incidence (range 31–62%) and a 72% reduction in mortality (range 64–82%) compared with 2015 levels. For India, and particularly for China, full scale-up of all interventions in tuberculosis-programme performance fell short of the 2025 targets, despite preventing a cumulative 3·4 million cases. The advocacy scenarios illustrated the high impact of detecting and treating latent tuberculosis.

Interpretation

Major reductions in tuberculosis burden seem possible with current interventions. However, additional interventions, adapted to country-specific tuberculosis epidemiology and health systems, are needed to reach the post-2015 End TB Strategy targets at country level.

Funding

Bill and Melinda Gates Foundation

Drug-Induced Hypothyroidism during Anti-Tuberculosis Treatment of Multidrug-Resistant Tuberculosis: Notes from the Field

We followed 188 euthyroidic persons undergoing treatment for multidrug resistant tuberculosis (MDR-TB) in the state of Karnataka, India to determine the incidence of hypothyroidism during anti-tuberculosis treatment. Overall, among MDR-TB patients with valid thyroid stimulating hormone (TSH) values, about 23% developed hypothyroidism (TSH value ≥10 mIU/ml) during anti-tuberculosis treatment; the majority (74%) occurring after 3 months of treatment. Among 133 patients who received a regimen that contained ethionamide, 42 (32%) developed hypothyroidism. Among 17 patients that received a regimen that contained para-aminosalicylate sodium, 6 (35%) developed hypothyroidism. Among 9 HIV positive patients on anti-retroviral treatment, 4 (44%) developed hypothyroidism. These results differ from previously reported 4% incidence of hypothyroidism amongst patients who passively reported thyroidal symptoms during treatment, suggesting routine serologic monitoring of TSH throughout the course of treatment for MDR-TB is warranted.

Cost analysis of different diagnostic algorithms for pulmonary tuberculosis varying in placement of Xpert MTB/RIF

BACKGROUND

We undertook cost analysis for diagnosis of pulmonary tuberculosis (PTB) using present algorithm under Revised National Tuberculosis Control programme and using Xpert MTB/RIF (Xpert) as frontline test or in conjunction with smear microscopy and/or chest radiography.

METHODS

Costs were estimated for different strategies: (A) present algorithm involving sputum smear examination followed by antibiotic trial in smear negative patients, repeat smear examination (RE) if symptoms continue and chest radiography if RE negative; (B) direct Xpert; (C) smear microscopy followed by Xpert in smear negative patients; (D) radiography followed by Xpert in those having abnormal pulmonary shadows; and (E) smear examination followed by radiography among smear negative patients and Xpert in presence of abnormal pulmonary shadow.

RESULTS

Cost to program was estimated lowest with Strategy A and highest with Strategy B. Compared to the latter, program cost reduces by 7%, 4.5%, and 17.4% by strategies C, D, and E, respectively. Cost to the group of individuals with presumptive PTB and their attendants is significantly higher for Strategy A compared to other four strategies. Among the latter, the patients' cost was minimum with Strategy B and maximum with Strategy C. Program cost per case diagnosed was lowest by Strategy A and highest by Strategy B. Patient cost per case diagnosed was highest by Strategy A and lowest by Strategy B. Using Xpert, Strategy E had the lowest program as well as overall cost per case diagnosed.

CONCLUSION

Strategy E may be chosen for diagnosis of PTB. When resources would no longer be a constraint, direct Xpert would reduce costs incurred by the patients.

Impact of awareness drives and community-based active tuberculosis case finding in Odisha, India

India's Revised National Tuberculosis Control programme employs passive case detection. The new sputum smear-positive case detection rate is less than 70% in Odisha State. During April-June 2012, active case finding (ACF) was conducted through awareness drives and field-based tuberculosis (TB) screening in select communities with the lowest case detection rates. During the campaign, 240 sputum smear-positive TB cases were detected. The number of smear-positive cases detected increased by 11% relative to April-June 2011 in intervention communities compared to an 0.8% increase in non-intervention communities. ACF brought TB services closer to the community and increased TB case detection.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS

Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Tuberculosis case notification by private practitioners in Pune, India: how well are we doing?

SETTING

Pimpri Chinchwad Municipal Corporation area, Pune, India.

OBJECTIVE

To assess the proportion of private practitioners (PPs) who notified tuberculosis (TB) patients during February-April 2013 and their contribution to the overall number notified, and to determine their perceived challenges in reporting TB cases.

DESIGN

Mixed-method study including an analysis of notification data, followed by in-depth interviews with PPs. Interviews were transcribed and inductive content analysis was performed to derive themes.

RESULTS

Of 831 PPs, 533 (64%) participated in case notification; of these 87 (16%) notified at least one TB case during the study period. In all, 138 TB cases were notified by PPs, accounting for 20% of the total TB cases notified. Emerging themes among perceived challenges and barriers were lack of complete knowledge about TB notification, fear of a breach of patient confidentiality, lack of a simplified operational mechanism of notification, and lack of trust and coordination with the government health system.

CONCLUSION

About two thirds of PPs participated in case notification and contributed significantly to the overall TB cases notified. India's national TB programme should focus on training PPs and targeted media communication campaigns, and establish alternative mechanisms for notification, such as the internet and mobile telephones, to overcome perceived barriers.

Are registered sputum smear-negative tuberculosis patients in Karnataka, India, diagnosed by national algorithm?

SETTING

Four districts of Karnataka State, India, that have implemented the National Tuberculosis Control Programme (RNTCP).

OBJECTIVE

To assess the proportion of patients diagnosed according to the nationally recommended algorithm among new smear-negative (NSN) PTB cases registered under the RNTCP.

METHODS

Information on 201 registered NSN-PTB patients as regards date of initial sputum examination, repeat sputum examination and chest X-ray (CXR) if undertaken, treatment initiation and number of days of antibiotic treatment after initial sputum examination, were collected through record review and patient interviews. In patients with negative or unknown human immunodeficiency virus (HIV) status, the algorithm was considered completed if the patient underwent initial sputum examination, antibiotic trial for ⩾10 days, repeat sputum examination ⩾10 days after initial sputum examination, CXR after repeat sputum examination and anti-tuberculosis treatment ⩾10 days after initial sputum examination. In HIV-positive patients, the algorithm was considered completed if CXR was performed after or at the same time as initial sputum examination.

RESULTS

Complete information was available for 170 patients. Of these, the algorithm was completed in 14 (8.2%, 95%CI 0.9-15.5): 1/140 patients with negative or unknown HIV status and 13/30 HIV-positive patients.

CONCLUSION

The algorithm was not completed in most patients registered for treatment. Measures are needed to improve the diagnostic process for smear-negative PTB.

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.

Role of pre-Xpert® screening using chest X-ray in early diagnosis of smear-negative pulmonary tuberculosis

In a sub-district level hospital in South India, the proportion of patients with abnormal chest X-ray (CXR) was evaluated among smear-negative, Xpert® MTB/RIF (Xpert) positive individuals with pulmonary tuberculosis (PTB) symptoms; 384 smear-negative PTB individuals with PTB symptoms and without a history of anti-tuberculosis treatment underwent CXR and Xpert testing of one sputum specimen. Of 378 individuals with both Xpert and CXR results available, 14 were positive for Mycobacterium tuberculosis. Of these, 13 (92.9%) had an abnormal CXR and one was normal. This study highlights the usefulness of CXR before Xpert testing, which needs further validation.

Prevalence of pulmonary tuberculosis in Wardha district of Maharashtra, Central India

A house based survey was conducted during 2007–2009 in a representative sample of population in Wardha district implementing Directly Observed Treatment Short Course strategy for tuberculosis (TB) control since 2001. The objective was to estimate prevalence of bacillary pulmonary TB (PTB) in individuals aged 15 years or above, and to estimate trends in prevalence when compared to a previous survey carried out in mid 1980’s. Two sputum samples (one spot, one early morning) collected from individuals having symptoms suggestive of PTB, history of previous anti-TB treatment (ATT) or abnormal pulmonary shadow on Mass Miniature Radiography (MMR) consistent with possibly or probably active tuberculosis were subjected to Ziehl–Neelsen microscopy and culture on Lowenstein–Jensen medium.

Of 55,096 individuals registered into the survey, 50,332 (91.4%) were screened by interview for symptoms and history of ATT and/or by MMR. Of them, 4805 were eligible for sputum collection; both specimens were collected in 4285 (89.2%) and only one specimen in 27 (0.6%).

A total of 86 bacillary cases were detected during the survey. Prevalence of bacillary PTB was estimated at 188.7 (140.3–236.9) per 100,000 populations. There was a decline of 61% in the prevalence of PTB over a period of 22 years.

Prevalence of pulmonary tuberculosis among adults in a north Indian district

Background

Recent population prevalence estimates of pulmonary tuberculosis (PTB) are not available for several areas in India. We conducted a field-based population survey at a north Indian district to estimate point prevalence of bacteriologically positive PTB.

Methods

A stratified cluster sampling design was used to conduct the survey in both urban and rural areas within the district. All adults aged more than 15 years, in 18 rural and 12 urban clusters of 3000 subjects each, were interviewed using a symptom card. Two sputum samples were collected from all persons having symptoms suggestive of PTB, or history of antitubercular treatment, for smear microscopy for acid-fast bacilli and mycobacterial culture. Those having at least one sputum specimen positive on microscopy and/or culture were categorized as having PTB. Prevalence was estimated after adjusting for cluster sampling and incomplete data (through individual level analysis with robust standard error).

Results

Of 91,030 eligible adult participants (47,714 men and 43,316 women), 85,770 (94.2%) completed the symptom cards. Of them, 2,898 persons were considered eligible for sputum examination and 2,839 (98.0%) provided at least one sample. Overall, 21 persons had bacteriologically positive PTB, and cluster level prevalence was estimated at 24.5 per 100,000 population (95% CI 12.8–36.2). Individual level analysis with robust standard error yielded a prevalence estimate of 24.1 per 100,000 populations (95% CI 12.8–35.4).

Conclusion

The observed prevalence of bacteriologically positive PTB in this district is lower than empiric national estimates, probably as a result of successful implementation of tuberculosis control measures in the area.

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.

METHODS

To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

FINDINGS

Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

INTERPRETATION

Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

FUNDING

Bill & Melinda Gates Foundation.

Treatment outcome of tuberculosis patients in a clinic of Bangalore

A total of 112 cases (New = 101, previously treated = 11) were diagnosed as suffering from tuberculosis (TB) at a private clinic in Bangalore city. The clinic identified TB suspects, established diagnosis of TB, administered direct observation of treatment (DOT), maintained treatment cards and undertook defaulter retrieval actions as and when required. The Revised National Tuberculosis Control Programme (RNTCP) provided support in terms of sputum microscopy supply of patient-wise drug boxes and registration of patients. Ninety six (95.1%) of new cases and 10 (90.9%) of previously treated cases had successful treatment outcome. Most patients completed treatment within the prescribed period. No TB deaths were reported during the period of treatment.

Annual risk of tuberculous infection among schoolchildren in Bhutan

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%.

Trends in the annual risk of tuberculous infection in India

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.

Trend in annual risk of tuberculous infection in north India

Setting

Six selected districts in Northern India.

Objectives

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.

Prevalence of pulmonary tuberculosis--a baseline survey in central India

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.

Guidelines for conducting tuberculin skin test surveys in high-prevalence countries

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.

High risk of tuberculous infection in North Sulawesi Province of Indonesia

SETTING

Of all the provinces in Indonesia, the highest tuberculosis (TB) case notification rates are reported from North Sulawesi Province.

OBJECTIVE

To estimate the annual risk of tuberculous infection (ARTI) among schoolchildren in the 6-9 year age group.

METHODS

A cross-sectional survey was carried out in 99 schools selected by a two-stage sampling process. Children attending grades 1-4 in the selected schools were administered intradermally with 2 tuberculin units (TUs) of purified protein derivative RT23 with Tween 80, and the maximum transverse diameter of induration was measured about 72 h later. A total of 6557 children in the 6-9 year age group were satisfactorily test-read, irrespective of their bacille Calmette-Guérin (BCG) vaccination status.

RESULTS

Based on the frequency distribution of reaction sizes obtained among satisfactorily test-read children (without and with BCG scar), the estimated ARTI rates when estimated by different methods (anti-mode, mirror-image and mixture model) varied between 1.9% and 2.5%. BCG-induced tuberculin sensitivity was not found to influence the ARTI estimates, as the differences in estimates between children without and with BCG scar were not statistically significant.

CONCLUSION

TB control efforts should be further intensified to reduce the risk of tuberculous infection.

Relationship of nutritional status with tuberculin sensitivity

OBJECTIVE

To estimate the prevalence of under-nutrition among school children and to find out the relationship between nutritional status and tuberculin sensitivity.

METHODS

A cross sectional study was carried out among 3335 children between 5-8 years of age attending 60 schools in Bangalore city selected by stratified random sampling. The nutritional anthropometric indices were calculated using reference median as recommended by World Health Organization, classified according to standard deviation units termed as Z-scores. The nutritional status of the children was assessed by Weight for age, Height for age and Bio-mass-index (BMI).

RESULTS

Depending upon the method for classifying nutritional status, the prevalence of under-nutrition (including mild and severe under-nutrition) varied between 14.9-29.8%. The prevalence of severe under-nutrition varied from 2.9-6.7%. The frequency distributions of reaction sizes were found to be similar among children classified by nutritional status. The differences in proportions of significant reactions (=10 mm) and mean tuberculin reaction sizes between children classified by nutritional status were not found to be statistically significant.

CONCLUSION

Tuberculin sensitivity was not influenced by nutritional status among apparently healthy school children.

Utilization of RNTCP services in rural areas of Bellary District, Karnataka, by gender, age and distance from health centre

BACKGROUND

Knowledge on utilization pattern of RNTCP shall provide important inputs towards its strengthening in rural areas.

AIMS

To find out the utilization of RNTCP services by age, sex and distance from residence to designated microscopy centres and treating health centres.

METHODS

The study was carried out in Sandur TU of Bellary District, Karnataka. Information on age, sex and residence of persons with pulmonary symptoms and detected new sputum smear positive cases during third quarter 2003 to second quarter 2004; and their treatment outcome was obtained from the respective RNTCP records. Age and sex distribution of out-patients was collected from OPD registers of one randomly selected DMC and its PHCs.

RESULTS

A lesser number of males accessed the health care services. However, larger number of males with pulmonary symptoms and new sputum smear positive cases utilized RNTCP services than females in the ratio of 1.6:1 and 2.5:1 respectively. This was due to higher prevalence of persons with pulmonary symptoms and sputum positivity rate among males. Sputum positivity rates were also lower among the elderly. Male symptomatics and cases were on an average older than females. About 70% symptomatics and 53% cases resided at more than four kilometers from the respective DMCs and treating health centres. Treatment outcome was poorer among males with higher proportion of initial defaulters and among those residing at more than 20 kms.

CONCLUSION

There is need to make health services available to the male working population at convenient hours and to be more vigilant to screen persons with pulmonary symptoms among the elderly. Collection of sputum specimen from eligible persons may be undertaken at PHCs which may later be transported to DMC. Supervision and motivation of treatment for male TB cases and those residing more than 20 kms from the treating health centres requires to be strengthened.

Prevalence of tuberculous infection among school children in Kerala

BACKGROUND

There is paucity of information on epidemiological situation of Tuberculosis (TB) in the State of Kerala. The DOTS strategy under the Revised National Tuberculosis Control Programme (RNTCP) was introduced in the year 1998 to cover the entire State by 2002.

OBJECTIVE

To estimate the prevalence of tuberculous infection among children attending 1-4th standard in a sample of selected schools in Kerala.

METHODS

A cluster-sample school-based tuberculin survey was carried out in 70 schools selected by a two-stage sampling procedure. A total of 4821 children (including those with and without BCG scar) in the age group of 5-9 years were tuberculin tested using 1 TU PPD RT23 with Tween 80 and the maximum transverse diameter of induration was measured about 72 hours later. About 81% of the children were found to have BCG scars. Analysis was also undertaken by mixture model.

RESULTS

While 67% of children without BCG scar and 62% with scar did not elicit any induration at the test site, the mode or anti-mode of reactions due to infection with tubercle bacilli could not be identified from the distribution graphs. Analysis by mixture model also did not provide the best fit thus precluding estimation of prevalence of infection. About 5% of children had reactions > or =10 mm, 3% had reactions > or =12 mm and 2% had reactions > or =14 mm.

CONCLUSION

Low proportion of reactors indicated a low level of transmission of infection in Kerala. Considering the problems in interpretation of tuberculin survey data, it may not be feasible to use ARTI as an epidemiological parameter to monitor future trends of TB situation in the state.

Annual risks of tuberculous infection in East Nusa Tenggara and Central Java Provinces, Indonesia

SETTING

East Nusa Tenggara (NTT) and Central Java Provinces, Indonesia.

OBJECTIVE

To estimate the average annual risk of tuberculous infection (ARTI) among school children aged 6-9 years in each province.

METHODS

Children attending Classes 1-4 in 65 schools in NTT and 79 in Central Java, selected by two-stage sampling, were intradermally administered 2 tuberculin units of purified protein derivative RT23 with Tween 80 on the mid-volar aspect of the left forearm. The maximum transverse diameter of induration was measured 72 h later. The analysis was carried out among 5479 satisfactorily test-read children in NTT and 6943 in Central Java. One hundred and fifty-five new sputum smear-positive pulmonary tuberculosis (PTB) cases (78 in NTT and 77 in Central Java) were also tuberculin tested. Based on the frequency distribution of reaction sizes among the children and PTB cases, the prevalence of infection was estimated by the mirror-image method using the modes of tuberculous reactions at 15 and 17 mm.

RESULTS

Using the 15 mm mode, ARTI was estimated at 1% in NTT and 0.9% in Central Java. Using the 17 mm mode, ARTI was estimated at 0.5% in NTT and 0.4% in Central Java.

CONCLUSION

Transmission of tuberculous infection may be further reduced by intensification of tuberculosis control efforts.

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.

Change in the risk of tuberculous infection over an 8-year period among schoolchildren in Bangalore City

SETTING

Bangalore City, South India.

OBJECTIVE

To estimate the trends in transmission of tuberculous infection.

METHODS

Two tuberculin surveys were carried out among children attending grades 1 and 2 of 60 selected schools at an interval of 8.3 years, corresponding to the period of DOTS expansion. Tuberculin testing was carried out using 1 tuberculin unit (TU) of purified protein derivative (PPD) RT 23 with Tween 80, and the maximum transverse diameter of induration was recorded about 72 h later. As the reactions due to infection with tubercle bacilli could not be clearly delineated from cross-reactions on the frequency distributions of tuberculin reaction sizes at either survey, the prevalence of tuberculin reactions > or = 10 mm, > or = 12 mm and > or = 14 mm in size were compared between the two surveys. The annual risk of tuberculous infection (ARTI) was computed from the estimated prevalence of reactions > or = 14 mm in size.

RESULTS

Estimates of prevalence of reactions at all chosen cut-off points were lower at Survey II compared to Survey I. These differences were statistically significant. An average per annum decline in ARTI of about 4% was observed between the two surveys.

CONCLUSION

Tuberculosis control measures should be further intensified to enhance the rate of decline in transmission of infection.

Annual risk of tuberculosis infection in West Sumatra Province, Indonesia

OBJECTIVE

To estimate the annual risk of tuberculosis infection (ARTI) among children attending elementary school Classes I-III in West Sumatra Province, Indonesia.

METHODS

The survey was designed to estimate ARTI among children, irrespective of BCG scar status. Fieldwork was carried out in 72 schools selected by two-stage sampling. Children were administered 2 TU of purified protein derivative RT23 with Tween 80 intradermally on the mid-anterior aspect of the left forearm. The maximum transverse diameter of induration was measured at about 72 h. Analysis was carried out among 5653 satisfactorily test-read children aged 6-9 years.

RESULTS

The estimation by mirror-image method among all children (without and with BCG scar) revealed an ARTI of between 1% and 1.3%. The estimated ARTIs among children without and with BCG scar varied between 0.8-1.3% and 0.9-1.4%, respectively, using the mirror-image method, anti-mode method and mixture model.

CONCLUSION

Tuberculosis control efforts need to be intensified to reduce the risk of transmission of infection.

Measuring tuberculosis burden, trends, and the impact of control programmes

The targets for tuberculosis control, framed within the United Nations' Millennium Development Goals, are to ensure that the incidence per head of tuberculosis is falling by 2015, and that the 1990 prevalence and mortality per head are halved by 2015. In monitoring progress in tuberculosis control, the ultimate aim for all countries is to count tuberculosis cases (incidence) accurately through routine surveillance. Disease prevalence surveys are costly and laborious, but give unbiased measures of tuberculosis burden and trends, and are justified in high-burden countries where many cases and deaths are missed by surveillance systems. Most countries in which tuberculosis is highly endemic do not yet have reliable death registration systems. Verbal autopsy, used in cause-of-death surveys, is an alternative, interim method of assessing tuberculosis mortality, but needs further validation. Although several new assays for Mycobacterium tuberculosis infection have recently been devised, the tuberculin skin test remains the only practical method of measuring infection in populations. However, this test typically has low specificity and is therefore best used comparatively to assess geographical and temporal variation in risk of infection. By 2015, every country should be able to assess progress in tuberculosis control by estimating the time trend in incidence, and the magnitude of reductions in either prevalence or deaths.

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.

Tuberculosis epidemiology in India: a review

High prevalence and incidence of disease and a high rate of transmission of infection characterise the tuberculosis (TB) situation in India. Disease surveys conducted in different parts of the country since the 1950s have reported prevalences of smear-positive pulmonary TB (PTB) of 0.6-7.6 per 1000 population, culture-positive TB of 1.7-9.8 and culture and/or smear-positive TB of 1.8-12.7. The incidence of smear-positive PTB has been observed in the range of 1.0-1.6/1000 and that of culture-positive PTB 1.0-2.5/1000 in the limited number of studies carried out. The annual risk of tuberculous infection (ARTI) had been estimated at 1-2% for most of the tuberculin surveys carried out in different areas over different time periods. During a nationwide study in 2000-2003, the average ARTI in the country was estimated at 1.5%. An increasing trend has been observed in human immunodeficiency virus (HIV) seropositivity among TB cases, which has been found to vary between 0.4% and 28.8% in different studies conducted mostly at tertiary health care centres. The proportion of new cases with multidrug resistance (MDR) was relatively low, at 0.5-5.3%. However, the proportion of MDR cases among previously treated cases varied between 8% and 67%.

Annual risk of tuberculous infection in four defined zones of India: a comparative picture

SETTING

Twenty-six selected districts in India.

OBJECTIVES

To estimate the average annual risk of tuberculous infection (ARTI) in four defined zones in the country.

STUDY DESIGN

A tuberculin survey was conducted in selected clusters of 26 districts in four defined zones of India. Children 1-9 years of age were subjected to tuberculin testing with ITU PPD RT23 with Tween 80, and the maximum transverse diameter of induration was measured 72 h later. Prevalence of infection was estimated using the cut-off point method (Method I) and the mirror-image technique (Method II) among children without bacille Calmette-Guérin scar. Results from individual zones have been reported earlier, and the results from all four zones are presented here as a consolidated summary.

RESULTS

The ARTI computed from estimated prevalence was found to be lowest in the southern zone (Method I: 1.1%, Method II: 1.0%). It was higher in the eastern zone (1.3% by both methods) and highest in the western (Method I: 1.8%, Method II: 1.6%) and northern zones (1.9% by both methods). The proportion of infected children was found to be significantly higher in urban than in rural areas in all zones.

CONCLUSION

The intensified tuberculosis control efforts need to be sustained for many years.

Average annual risk of tuberculous infection in India

Estimates of the prevalence of tuberculous infection among children 1-9 years of age were available for four defined zones of India from a recently concluded tuberculin survey. These were pooled together and the average annual risk of infection in the country was computed as 1.5%. It was higher in urban areas, at 2.2%, than in rural areas, at 1.3%. The results call for further intensification of tuberculosis control activities, especially in urban areas, greater involvement of private practitioners and information, education and communication (IEC) for high-risk groups, to reduce the diagnostic and treatment delay thereby reducing the transmission of infection in all settings.

Tuberculin sensitivity among children vaccinated with BCG under universal immunization programme

A tuberculin survey was conducted among 45988 children with BCG scar and 54227 children without BCG scar between 1-9 years of age and residing in selected rural areas of three defined zones of India. About 45-60% of the BCG-vaccinated children elicited reactions < 5 mm in size and about 70-80% had reactions < 10 mm. Therefore, in the majority of children (showing tuberculin reaction of < 10 mm), BCG-induced tuberculin sensitivity does not interfere with interpretation of tuberculin test. The study also revealed that a proportion of reactions among BCG vaccinated children in 5-9 mm, 10-14 mm and 15-19 mm range may be attributable to BCG vaccination. Therefore, reactions between 10-14 mm and especially 15-19 mm among the vaccinated children must be interpreted carefully. However, 19 mm was observed as the upper limit for BCG induced tuberculin sensitivity and all reactions >- 20 mm in size may be considered to be due to infection with tubercle bacilli, irrespective of the BCG vaccination status.