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Abstract Background India, China and Russia account for more than 62% of multidrug resistant tuberculosis (MDRTB) globally. Within India, locations like urban metropolitan Mumbai with its burgeoning population and high incidence of TB are suspected to be a focus for MDRTB. However apart from sporadic surveys at watched sites in the country, there has been no systematic attempt by the Revised National Tuberculosis Control Programme (RNTCP) of India to determine the extent of MDRTB in Mumbai that could feed into national estimates. Drug susceptibility testing (DST) is not routinely performed as a part of programme policy and public health laboratory infrastructure, is limited and poorly equipped to cope with large scale testing. Methods From April 2004 to January 2007 we determined the extent of drug resistance in 724 {493 newly diagnosed, previously untreated and 231 first line treatment failures (sputum-smear positive at the fifth month after commencement of therapy)} cases of pulmonary tuberculosis drawn from the RNTCP in four suboptimally performing municipal wards of Mumbai. The observations were obtained using a modified radiorespirometric Buddemeyer assay and validated by the Swedish Institute for Infectious Disease Control, Stockholm, a supranational reference laboratory. Data was analyzed utilizing SPSS 10.0 and Epi Info 2002. Results This study undertaken for the first time in RNTCP outpatients in Mumbai reveals a high proportion of MDRTB strains in both previously untreated (24%) and treatment-failure cases (41%). Amongst new cases, resistance to 3 or 4 drug combinations (amplified drug resistance) including isoniazid (H) and rifampicin (R), was greater (20%) than resistance to H and R alone (4%) at any point in time during the study. The trend for monoresistance was similar in both groups remaining highest to H and lowest to R. External quality control revealed good agreement for H and R resistance (k = 0.77 and 0.76 respectively). Conclusion Levels of MDRTB are much higher in both previously untreated and first line treatment-failure cases in the selected wards in Mumbai than those projected by national estimates. The finding of amplified drug resistance suggests the presence of a well entrenched MDRTB scenario. This study suggests that a wider set of surveillance sites are needed to obtain a more realistic view of the true MDRTB rates throughout the country. This would assist in the planning of an adequate response to the diagnosis and care of MDRTB.

Improved molecular diagnostic techniques have resulted in increased reporting of nontuberculous mycobacterial infections. A 40-year-old male immunocompetent individual presented with cough and fever of 2-week duration. His chest X-ray showed cavities in the left upper zone and fibrosis in the right upper zone. His sputum was positive for AFB on Ziehl-Neelsen staining and showed slow-growing mycobacteria in mycobacteria growth indicator tube. The isolate was identified as Mycobacterium interjectum using GenoType® Mycobacterium CM assay (Hain Lifescience, GmBH, Nehren, Germany). At the end of a year's treatment, this first case from India has shown good progress. [ABSTRACT FROM AUTHOR]

Background: Characteristics and treatment outcomes of patients with drug-resistant tuberculosis (DR TB) before introduction of directly observed treatment strategy (DOTS) plus are infrequently reported. Aims: To study clinical characteristics and treatment outcomes of drug-resistant TB patients. Setting: A TB unit in Mumbai. Materials and Methods: A retrospective analysis of DR TB patients attending a TB unit and taking treatment at NGOs was performed. Of the 34 cases, 5 (14%) had mycobacterium other than tuberculosis, 24 were pulmonary TB, 4 extra-pulmonary TB, and one both. Three were HIV-infected, two had diabetes. Two cases were treatment naive. Of the 29 cases studied, 3 (11%) were mono-resistant, 20 (69%) were multidrug-resistant (MDR) TB with E/Z/EZ resistance; 4 were pure MDR TB. One case had XDR TB, 13 (44.8%) had resistance to at least one conventional second-line drug. Seven cases had adverse drug reaction, four requiring drug substitution. Two patients are on treatment; 14 of the remaining 27 (51%) were successfully treated, 5 (18%) died, 2 (7%) failed treatment, 5 (18%) were lost to follow-up, one migrated. Conclusion: DST profiles suggest high levels of drug resistance due to amplification which leads to poor outcomes. There is an urgent need for Indian Revised National TB Control Program to introduce daily DOTS for susceptible cases, DST for all new cases, and scaling up DST for second-line drugs. There is also a need to use individualized treatment for DR TB. [ABSTRACT FROM AUTHOR]

Background: India, China and Russia account for more than 62% of multidrug resistant tuberculosis (MDRTB) globally. Within India, locations like urban metropolitan Mumbai with its burgeoning population and high incidence of TB are suspected to be a focus for MDRTB. However apart from sporadic surveys at watched sites in the country, there has been no systematic attempt by the Revised National Tuberculosis Control Programme (RNTCP) of India to determine the extent of MDRTB in Mumbai that could feed into national estimates. Drug susceptibility testing (DST) is not routinely performed as a part of programme policy and public health laboratory infrastructure, is limited and poorly equipped to cope with large scale testing. Methods: From April 2004 to January 2007 we determined the extent of drug resistance in 724 {493 newly diagnosed, previously untreated and 231 first line treatment failures (sputum-smear positive at the fifth month after commencement of therapy)} cases of pulmonary tuberculosis drawn from the RNTCP in four suboptimally performing municipal wards of Mumbai. The observations were obtained using a modified radiorespirometric Buddemeyer assay and validated by the Swedish Institute for Infectious Disease Control, Stockholm, a supranational reference laboratory. Data was analyzed utilizing SPSS 10.0 and Epi Info 2002. Results: This study undertaken for the first time in RNTCP outpatients in Mumbai reveals a high proportion of MDRTB strains in both previously untreated (24%) and treatment-failure cases (41%). Amongst new cases, resistance to 3 or 4 drug combinations (amplified drug resistance) including isoniazid (H) and rifampicin (R), was greater (20%) than resistance to H and R alone (4%) at any point in time during the study. The trend for monoresistance was similar in both groups remaining highest to H and lowest to R. External quality control revealed good agreement for H and R resistance (k = 0.77 and 0.76 respectively). Conclusion: Levels of MDRTB are much higher in both previously untreated and first line treatment-failure cases in the selected wards in Mumbai than those projected by national estimates. The finding of amplified drug resistance suggests the presence of a well entrenched MDRTB scenario. This study suggests that a wider set of surveillance sites are needed to obtain a more realistic view of the true MDRTB rates throughout the country. This would assist in the planning of an adequate response to the diagnosis and care of MDRTB. [ABSTRACT FROM AUTHOR]

Antigen 85 (mol. wt 30,000) (30 kD), secreted by actively growing mycobacteria under axenic conditions, and mol. wt 65,000 (65 kD), a cytoplasmic antigen released during mycobacterial lysis, were used to monitor the efficacy of chemotherapy in previously untreated pulmonary tuberculosis (UPTB) patients using enzyme-linked immunosorbent assay. Sera from 125 UPTB patients were examined for each of the 2 antigens individually and for the ratio of secretory (30 kD) to cytoplasmic (65 kD) antigen (SCR), before commencement of treatment, after intensive phase (IP), completion of optimum period of treatment (COPT) and 6 months post-COPT. 116 controls (normals and contacts) were also checked for these antigens. The detection of 30 kD and 65 kD antigens in UPTB patients had a sensitivity ranging from 50-57% (mean 30 kD value: 0.64±1.24 ngs/ml) to 20-22% (mean 65 kD value: 0.51±1.87 ngs/ml), respectively, whereas in controls it ranged from 2-8% (0.05±0.28 ngs/ml) to 14-47% (0.09±0.22 ngs/ml), respectively. Although the decline in 30 kD positivity was more evident at COPT, computation of the SCR denoted efficacy of chemotherapy more readily at IP. Similarly, SCR resolved the ambiguity between individual antigen levels and the clinical status of a patient. Since significant numbers of patients demonstrated 30 kD at IP it may be computed that the lifespan of circulating 30 kD in serum could be at least 2 months after the start of treatment, declining gradually thereafter. Although seromonitoring for secretory antigen generally reflects the efficacy of chemotherapy, the interpretation of findings clearly requires further elucidation. [ABSTRACT FROM AUTHOR]

The article focuses on the Programmatic Management of Drug-Resistant Tuberculosis (PMDT) implemented in India for multi-drug resistant tuberculosis (MDR TB) patients. The author mentions that the PMDT has alternative drug available in cases where patients cannot tolerate oral medications to avoid placing their lives at risk. He states that medical ethics demands that patients should be provided the best available care to avoid violating the basic human right of an individual.

Background: Co-infection with tuberculosis adversely affects the quality of life of HIV infected individuals and additionally, HIV testing among TB patients gives an opportunity for prevention and treatment of HIV infection. TB-HIV coordination activities are therefore a good public health intervention., Methods: It was a three-year Public Private Partnership Project, implemented in four districts of Maharashtra, to improve access to public health facilities through community awareness and motivating referrals. Outreach workers were engaged to motivate patients attending Integrated Counselling and Testing Centres (ICTCs) and Designated Microscopy Centres (DMCs) for cross referrals and adherence to services. Community leaders and private health providers were sensitized to issues around TB and HIV/AIDS., Observations: 357 outreach workers referred 17,200 individuals for HIV testing and 32,549 TB suspects were referred for testing. An average of 18% TB cases (13% to 26%) and 7% (4% to 13%) HIV infected cases were identified. Involvement of PLHA and cured TB patients can better motivate symptomatics to avail of diagnostic services. Erratic funding affects smooth implementation of programmes., Conclusion: Public Private Partnerships improve access to care. Constant dialogue between all stake holders is essential for successful implementation of such partnerships.

Background: The private medical sector is an important source of healthcare in India. Increasingly, concerns have been raised about its role in the care of patients with HIV/AIDS. Evidence about private practitioners' existing management practices will help to create policies addressing this sector., Methods: A central urban area of Pune city was selected for its high density of healthcare facilities. Private practitioners in the area were interviewed using a structured interview schedule. Based on a 1-year recall period, the schedule covered different aspects of the practitioners' HIV/AIDS management practices including diagnosis, treatment and referral., Results: Of the 215 practitioners interviewed, 66% had tested and diagnosed HIV infection. Fifty-four per cent had been consulted by HIV-infected clients 'shopping' for alternative diagnoses or treatment. Overall, 75% of the respondents had been consulted by HIV-infected clients for treatment. Of these, 14% had prescribed antiretroviral drugs, sometimes without adequate knowledge of the guidelines for their use. Other supportive and symptomatic treatments were also frequently prescribed. Private practitioners commonly referred HIV-infected clients for management to other private doctors, or to public hospitals. There were variations in respondents' practices by sex and system of medicine., Conclusion: Private practitioners are actively involved in diagnosing and managing patients with HIV/AIDS. Some of their management practices are inappropriate and need to be remedied. There are also concerns about gaps in the continuity of care of HIV-infected persons, for which networks between providers need to be strengthened. Public-private partnerships must be created to improve the flow of information to private practitioners, and Include them in the national health framework.