Rifampicin-induced renal toxicity during retreatment of patients with pulmonary tuberculosis

Rifampicin is a crucial component of treatment regimens for tuberculosis and has been in use since the early 1970’s. It is usually considered safe. Rarely life-threatening complications like acute renal failure or acute thrombocytopaenia may manifest during treatment with rifampicin. In our experience at the Tuberculosis Research Centre of treating more than 8000 pulmonary and extrapulmonary tuberculosis patients with rifampicin-containing regimens over the last 30 years, we are reporting 3 cases of probably rifampicininduced acute renal failure. Despite extreme therapeutic safety of this drug the clinician must be aware of this rare complication, which if detected early is completely reversible

Impact of improved treatment success on the prevalence of TB in a rural community based on active surveillance.

Objective: To study the impact of improved treatment outcome of a cohort of patients treated under DOTS strategy on the prevalence of pulmonary tuberculosis (TB) in the community. Design: The data from TB register of one Tuberculosis Unit (TU) in Tiruvallur district of Tamilnadu, and two TB disease surveys conducted in the same area during 1999-2003 were analysed. The successful treatment outcome was compared to the prevalence of TB in the subsequent cohort. Results: The proportion of patients who completed treatment successfully was 75.3% in the first cohort period. This higher proportion of treatment success among patients treated under DOTS in the first cohort period (1999-2001) compared to the 51-55% reported during SCC, resulted in a lower prevalence of smear-positive cases, irrespective of culture results observed in the survey conducted during 2001-2003 compared to that in the survey conducted during 1999-2001 (252 vs. 323 per 100,000; annual decline of 9%). Similarly, a decline in culture-positive cases, irrespective of smear results, was also observed (443 vs. 605; annual decline 11%). Conclusion: The higher proportion of successful completion of treatment after DOTS implementation was associated with a substantial decline in the prevalence of TB. These findings showed that we are in the direction towards achieving the Millennium Development Goals (MDGs)

Status of Re-registered Petients for Tuberculosis Treatment Under DOTS Programme

Objective: To assess the proportion of patients re-registered after default, failure or successful treatment, completion and evaluate their treatment outcome. Setting: Tuberculosis patients diagnosed were registered for treatment under DOTS in rural area, South India. Patients reregistered during 1999-2004 identified from the TB register were considered for analysis. Results: Among 273 Category-I patients ‘defaulted’ 23% and among 112 ‘failure’ cases 68% were re-registered. After ‘successful treatment completion’ of 1796 cases 6.5% were re-registered as relapse. Corresponding figures for Category II were 20% of 281 defaulters; 23% of 60 failures; 12.9% of 302 ‘successful treatment completion’ patients. Among patients re-registered as ‘default’, subsequent default was also high (57% vs 37%). Failure in Category II treatment was similar among patients who were re-registered for Category II and initially registered in it for treatment. Median delay for reregistration was >200 days for ‘defaulters’ and 18 days for ‘failures’. Conclusion: Our findings emphasise the need for continuing motivation and prompt defaulter retrieval action to reduce default at all stages of treatment. ‘Defaulters’ need to be contacted so that they can be started on treatment without delay. Patients declared as ‘successful treatment completion’ should be encouraged to report if chest symptoms recur

Sputum examination at 2-months into continuation phase - How much does it contribute to define treatment outcome?

Objective: To assess the usefulness of sputum examination at 2-months into Continuation Phase (CP) to declare treatment outcome. Methodology: It is a retrospective study conducted in one tuberculosis unit, Tiruvallur district of Tamilnadu among smear positive patients treated with Category I and Category II regimens from May, 1999 – December, 2003. Results: Sputum was collected at 2-months into CP from 70% of 1551 Category I and 74% of 292 Category II patients declared cure, failed or treatment completed. Result at 2-months CP was used for giving outcome in 112 (10.3%) of 1088 Category I patients and 37 (17%) of 217 Category II patients. Conclusion: In practice, sputum needs to be collected for 7.8% of the patients with smear positive at the end of Intensive Phase. By doing so, there will be a delay of 1 month for 3.6% of the patients in declaring ‘failure’. By deferring the sputum examination at 2 months into CP, workload of laboratory technicians can be reduced by about 30%

Feasibility of utilising address card system for obtaining accurate address of patients under programme conditions

An addresscard, one on which patient's home address is asked to be recorded by a person knowing for sure the patient's address, was investigated for acceptability and efficiency, in two Government hospitals located in semiurban areas and six Primary Health Centres located in rural areas in North Arcot district. In all 394 address-cards were given to the patients from the eight centres, of which 374 were returned with the address filled in, showing an acceptability rate of 95%. In all, 373 Type A letters were then posted to these addresscard addresses in respect of which acknowledgment cards were received back from 306 (82%) patients. For 140 patients, the recorded addresses were found to be the same as on the addresscard and the treatment card: In the remaining 233, there was some difference between the two addresses. Type B letters were then posted to the 233 patients at their treatment card address. No definite information was available regarding the receipt of one or both types of letters in respect of 80 patients; so, an attempt was made to visit these patients in their homes to find out the fate of these letters. Of these, no information could be collected in 9 patients. Out of 224 patients for whom information regarding the receipt of letter was available, 143 (64%) patients received both letters and 16 (7%) received neither Type A nor Type B letter. Twenty one (9%) had probably or definitely not received the Type A letter, but had received the Type B letter. Forty four (20%) had definitely or probably not received the Type B letter, but had received the Type A letter

Induction of rifampicin metabolism during treatment of tuberculous patients with daily and fully intermittent regimens containing the drug

Self-induction of rifampicin metabolism during daily and intermittent chemotherapy was studied by monitoring the changes in the serum half-life of the drug over a 4-week period in patients with pulmonary tuberculosis. Rifampicin 450 mg was administered to 8 patients who received treatment daily, 7 on thrice-weekly and 7 others on twice-weekly treatment. Serum half-life was computed from concentrations of the drug determined at 3, 4½ and 6 hours after drug administration, on admission and at 1, 2 and 4 weeks after start of treatment. In the daily series, the mean serum half-life decreased from 4.9 hours on admission to 3.6 hours at 1 week (P = 0.02), and treatment beyond this had no further effect. In the thrice-weekly series, maximal induction was observed at the 2nd week, the mean values on admission and at 2 weeks being 5.8 and 3.7 hours, respectively (P < 0.01). In the twiceweekly series, maximal induction was observed only at the 4th week, the mean values on admission and at 4 weeks being 4.9 and 3.7 hours, respectively (P < 0.01). Serum activity of gamma glutamyl transferase was not found to be a suitable in vivo marker to monitor induction of the hepatic microsomal enzymes as no significant changes were observed in the activity of this enzyme in any of the 3 series during the 4-week period

Is mirgration a factor leading to default under RNTCP?

Objective: To study the contribution of migration to treatment default among tuberculosis patients treated under RNTCP Methods: Retrospective study by interviewing the defaulters using semi-structured interview schedule to elicit the reasons for default including migration. Results: Of the 531 patients registered under TB programme in 3rd and 4th quarters of 2001, 104 (20%) had defaulted for treatment. Among defaulters, 24% had migrated. The reasons for migration were: occupational (48%), returning to the native place (28%), domestic problems (12%) and other illnesses (12%). Conclusion: After initiation of treatment, patients should be encouraged to report to the provider, if they are leaving the area, to transfer treatment to the nearest centre to ensure continuity of treatment. These measures will help to reduce default on account of migration and achieve the desired outcome in RNTCP. Availability of treatment under the DOTS strategy should be popularized among patients, providers and community

DOTS Reaches Socially Marginalized Population in the Community : A Study from a Rural Area of South India

We report here that the Directly Observed Treatment, Short course (DOTS) is reaching all tuberculosis patients in the community irrespective of social classification based on the analysis from the tuberculosis prevalence survey and programme performance during 1999-2003 from a rural area in Tamilnadu, South India. New smear- positive cases treated under a DOTS programme were classified in two groups namely; scheduled caste living in colony and other population. The prevalence of smear- positive cases among the scheduled caste population was 1.9 times higher than the other population and this was reflected in the notification also. The successful treatment outcome was also similar in these two groups (75% and 78% respectively; overall 77%). From these findings it is concluded that people living in colony have equal access to DOTS as those in the village

Estimation of burden of tuberculosis in India for the year 2000

Background & objectives: Data on the burden of tuberculosis (TB) in India are vital for programme planners to plan the resource requirements and for monitoring the nation-wide TB control programme. There was a need to revise the earlier estimate on the burden of TB in India based on the increase in population and current epidemiological data. This study estimates the burden of disease for the year 2000 based on recent prevalence of TB and annual risk of tuberculosis infection (ARTI) estimates. Methods: Data on prevalence generated among adults by the Tuberculosis Research Centre (TRC), Chennai, among children by National Tuberculosis Institute (NTI), Bangalore, and the ARTI estimates from the nation-wide sample survey by NTI and TRC were used for the estimation. The prevalence of disease corresponding to 1 per cent ARTI was extrapolated to different parts of the country using the estimates of ARTI and the population in those areas and added together to get the total cases. Abacillary cases that required treatment were estimated from X-ray abnormals. The estimates of bacillary, abacillary and extrapulmonary cases were then combined to get the national burden. Results: The estimated number of bacillary cases was 3.8 million (95% CI: 2.8 - 4.7). The number of abacillary cases was estimated to be 3.9 million and that for extrapulmonary cases was 0.8 million giving a total burden of 8.5 million (95% CI: 6.3-10.4) for 2000. Interpretation & conclusion: The present estimate differs from the earlier estimates because we have included the disease burden of X-ray cases that are likely to breakdown to bacillary cases in a one year period, and extrapulmonary TB cases. The current estimates provided baseline information for advocacy and planning resource allocation for TB control activities. Also, these estimates can be compared with that in future years to measure the long term impact of TB control activities in India

Status of smear-positive TB patients at 2-3 years after initiation of treatment under a DOTS programme

Objective: To describe the status of cases 2-3 years after the initiation of treatment under DOTS. Setting: After DOTS implementation in Tiruvallur district, south India, we followed up a cohort of smear-positive TB patients registered during 2002-03 after initiation of treatment. Results: The overall mortality rate was 15.0% and among the remaining 18.6% had active disease. In multivariate analysis, a higher mortality rate was independently associated with age, sex, occupation, treatment outcome and initial body weight of patients. Conclusion: The mortality and morbidity rates are still high during follow-up and needs to be curtailed by addressing these issues effectively in TB control programm