Wabah TBC Di India
Wabah TBC Di India
Wabah TBC Di India
Abstract
Background: We conducted a survey to estimate point prevalence of bacteriologically positive pulmonary TB (PTB) in a
rural area in South India, implementing TB program DOTS strategy since 2002.
Methods: Survey was conducted among persons $15 years of age in fifteen clusters selected by simple random sampling;
each consisting of 512 villages. Persons having symptoms suggestive of PTB or history of anti-TB treatment (ATT) were
eligible for sputum examination by smear microscopy for Acid Fast Bacilli and culture for Mycobacterium tuberculosis; two
sputum samples were collected from each eligible person. Persons with one or both sputum specimen positive on
microscopy and/or culture were labeled suffering from PTB. Prevalence was estimated after imputing missing values to
correct for bias introduced by incompleteness of data. In six clusters, registered persons were also screened by X-ray chest.
Persons with any abnormal shadow on X-ray were eligible for sputum examination in addition to those with symptoms and
ATT. Multiplication factor calculated as ratio of prevalence while using both screening tools to prevalence using symptoms
screening alone was applied to entire study population to estimate prevalence corrected for non-screening by X-ray.
Results: Of 71,874 residents $15 years of age, 63,362 (88.2%) were screened for symptoms and ATT. Of them, 5120 (8.1%) 4681 (7.4%) with symptoms and an additional 439 (0.7%) with ATT were eligible for sputum examination. Spot specimen
were collected from 4850 (94.7%) and early morning sputum specimens from 4719 (92.2%). Using symptom screening
alone, prevalence of smear, culture and bacteriologically positive PTB in persons $15 years of age was 83 (CI: 57109), 152
(CI: 108197) and 196 (CI :145246) per 100,000 population respectively. Prevalence corrected for non-screening by X-ray
was 108 (CI: 82134), 198 (CI: 153243) and 254 (CI: 204301) respectively.
Conclusion: Observed prevalence suggests further strengthening of TB control program.
Citation: Chadha VK, Kumar P, Anjinappa SM, Singh S, Narasimhaiah S, et al. (2012) Prevalence of Pulmonary Tuberculosis among Adults in a Rural Sub-District of
South India. PLoS ONE 7(8): e42625. doi:10.1371/journal.pone.0042625
Editor: Madhukar Pai, McGill University, Canada
Received May 1, 2012; Accepted July 10, 2012; Published August 15, 2012
Copyright: 2012 Chadha et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: Survey was undertaken with available human and capital resources already available in the institute, supplemented by funding of 11700000 Indian
Rupees from World Health Organization (WHO) for supplies and additional manpower. Website of WHO India is whoindia.org/en. The funders had no role in study
design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: vineet2.chadha@gmail.com
Introduction
National Tuberculosis Programme (NTP) based on a cost
effective operational strategy was implemented all over India from
1962; after a nation-wide survey during 19551958 revealed that
tuberculosis (TB) was highly prevalent throughout the country [1].
Surveys carried out thereafter in geographically defined areas
revealed that the prevalence of TB continued to be high, though
varied, in different parts of the country [2]. Taking cues from a
review of NTP, Revised National tuberculosis Control Programme
(RNTCP) adopting DOTS (an internationally recommended
strategy for TB control) was launched in 1997 and expanded in
phases to cover the entire population by 2006 [3]. Implementation
of RNTCP lead to improvements in case detection and high
treatment success rates in most parts of the country [3,4]. Indeed,
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i.
ii.
iii.
iv.
Field Procedures
Field work was carried out during October 2008June 2010.
A planning visit was made to each Panchayat office and each
village to familiarize the officials, village leaders and the
community with the purpose and procedures of the survey and
to seek their cooperation. In each village, a rough sketch of lanes
and hamlets showing approximate number of houses in each was
drawn, after going around and in discussions with village leaders.
Survey in each village began on a mutually agreed date.
Enumerators went to each household and recorded the age, sex
and resident status of each individual. Each eligible person (15
years or more in age and residing for $6 months in the household
or in any other village in Nelamangala sub- division) was registered
into an individual card. Subsequently, a symptom elicitor queried
each eligible individual for presence of symptoms suggestive of
PTB (persistent cough for $2 weeks, fever or chest pain for $1
month, presence of blood in sputum any time during last 6
months) and history of ATT. Field supervisors re-interviewed 10%
of eligible individuals, as a quality control mechanism.
Individuals having pulmonary symptoms suggestive of PTB or a
positive history of ATT were eligible for sputum examination. A
spot sputum specimen was collected at a temporarily setup sputum
collection centre within the village, after briefing by the laboratory
technician (LT) on how to bring out good sputum sample and spit
into a pre-numbered sterilized screw capped sputum cup. After a
satisfactory extraction of spot specimen, a pre-numbered empty
bottle was given for collecting another sample next morning.
Sputum containing bottles marked with ID of each patient were
transported in a sputum box on day of collection to the accredited
laboratory of the institute.
In six of the clusters, each registered person was also screened
by X-ray. A 70 mm photofluorography film of the chest was taken
at the temporarily setup centre using a mobile mass miniature
radiography (MMR unit); pregnant women and bed ridden
individuals were excluded (screening by X-ray could not be
undertaken in other clusters due to breakdown of equipment
during the middle period of the survey). After processing of
exposed MMR rolls in X-ray laboratory of the Institute, each film
was read and classified by two trained independent X-ray readers
into one of the categories - N (normal)/TI (technically inadequate)/A (lung pathology other than tuberculosis)/B (tuberculosis
inactive)/C (tuberculosis active). Persons with their films labeled as
TI/A/B/C by any of the two X-ray readers were eligible for
sputum examination, in addition to those having symptoms
suggestive of PTB or history of ATT.
Study population
Persons $15 years of age residing in Nelamangala sub-division
for $6 months comprised the study population.
Sampling
Simple random sampling (SRS) was adopted for selection of
clusters. Each cluster corresponded to a group of villages in the
jurisdiction of a Gram Panchayat a local self government
consisting of elected members of the community and having
responsibility to implement rural development programs. Office
bearers of the Panchayats visited during planning phase of the
study insisted for political reasons to cover all the villages in their
jurisdiction. There were altogether 25 panchyats in Nelamangala
sub-division.
Since the exact count of adult population in individual clusters
was not known, fifteen (arbitrarily decided number) clusters were
selected and the survey was planned to start in the first selected
cluster covering all eligible persons and proceed to subsequent
clusters in order of their selection till the required sample size was
achieved.
Sample size
Sample size was originally calculated at 47,828 to estimate the
prevalence within 20% of the true value at 5% level of significance
considering a design effect of 2 to account for cluster sampling.
Expected prevalence of bacteriologically positive PTB (positive for
AFB on microscopy and/or culture) while using both screening
tools symptom screening and chest X-ray, was arbitrarily
considered at 400 per 100,000 population. During the earlier
survey in the area in 1975, prevalence of culture positive PTB in
the age group of $15 years while using both screening tools was
480 per 100,000 population [6]; prevalence of bacteriologically
positive PTB was not reported.
Since the mobile X-ray equipment broke down during the
course of the survey, sample size was revised during the course of
the survey to 68,400 for an expected prevalence of 280 per
100,000 population assuming that 30% of PTB cases would be
missed due to non-screening by X-ray. This assumption was based
from the data of the previous survey in the same area [6].
Key variables
Key study variables were: age, sex, presence of pulmonary
symptoms, history of anti-TB treatment (ATT), presence of
abnormal shadow on X-ray, result of sputum smear microscopy
spot & early morning specimen and result of culture - spot &
early morning specimen.
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Laboratory procedures
Sputum specimens were subjected to smear microscopy for acid
fast bacilli (AFB) and culture for M. tuberculosis following standard
Statistical methods
Digitized data was verified and analyzed using SPSS version
17.0 and STATA version 12.0.
Point prevalence was estimated by three different approaches
[9]:
i)
ii)
Study investigators
iii)
Ethical considerations
Survey was approved by the Institutional Ethics Committee.
Written consent for participation was sought from each
individual, after explaining procedures of the survey and its
benefits to the individuals and community, through material
printed in local language and also personally by field staff. No one
was compelled to participate.
TB cases detected during the survey were counseled and
facilitated to initiate ATT at the nearest RNTCP facility. For the
patients who failed to reach the RNTCP facility, repeated visits
(upto a maximum of nine) were made to their households by the
field staff to persuade them and also some times to accompany
them to RNTCP facility in order to initiate ATT. Follow up
during treatment was the responsibility of routine staff of RNTCP.
Individuals with symptoms but not having TB were advised to
seek treatment at the local health center; however no active
intervention was undertaken by survey team for referral or
otherwise.
Village leaders were informed of the findings of the study
emphasizing their role in raising awareness regarding symptoms of
TB and availability of quality services under RNTCP.
Definitions
Smear Positive case: An individual with at least one sputum
specimen found to be positive for AFB on smear microscopy,
irrespective of culture result.
Study participants
1524 (32.6)
544 (11.6)
Symptoms
No.
Cough alone
2365 (50.5)
Fever alone
47 (1.0)
Haemoptysis alone
91 (1.9)
110 (2.3)
Total
4681 (100.0)
Results
I. Prevalence of PTB based on symptom screening
followed by sputum examination
Of the persons interviewed, 4681 (7.4%) were found to have
symptoms. Of them, about 83% had cough of 2 weeks or moreeither alone or in combination with one or more of the other
symptoms- chest pain, fever, haemoptysis. The remaining 17%
had one or more of the other symptoms (table 2).
Previous history of ATT was present in 653 (1.0%) persons and
56 (0.09%) were currently on ATT. Of the total of 709 persons
with history of ATT, 270 had symptoms at the time point of the
survey while 439 (0.7% of the total interviewed) did not have
symptoms.
Of 5120 persons (4681 with symptoms and an additional 439
with history of ATT) eligible for sputum examinations, spot
specimen were collected from 4850 (94.7%), of which 28 were
positive for AFB on smear microscopy and 65 on culture.
Age group
1524
Male
No. registered
No. participated
9324
7506
1818
(80.5)
(19.5)
6506
2036
(76.2)
(23.8)
5147
1420
(78.4)
(21.6)
3825
743
(83.7)
(16.3)
2534
8542
3544
6567
4554
5564
65+
Total
Female
No. not
participated
4568
3326
4079
36406
2973
353
(89.4)
(10.6)
3806
273
(93.3)
(6.7)
29763
6643
(81.8)
(18.2)
No. registered
No. participated
No. not
participated
P value*
8728
8159
569
0.009
(93.5)
(6.5)
7446
502
(93.7)
(6.3)
7948
6181
4839
3937
3835
35468
5911
270
(95.6)
(4.4)
4645
194
(96.0)
(4.0)
3766
171
(95.7)
(4.3)
3672
163
(95.7)
(4.3)
33599
1869
(94.7)
(5.3)
0.002
,0.001
0.32
,0.001
,0.001
,0.001
Table 3. Prevalence of PTB per 100,000 population, by method of estimation, all clusters-using screening by symptoms alone.
Method of Analysis
Type of PTB
Crude Prevalence
81 (62100) N = 62959
74 (44103) N = 62959
83 (57109) N = 71874
Discussion
No.
Prevalence
Odds ratio
Age group
(Yrs)*
1524
15602
57.7 (25.989.5)
1.00
2534
13866
108.2 (62.0154.4)
3544
10971
182.3 (115.0249.6)
4554
8388
154.9 (83.9225.9)
5564
6648
420.2 (288.8551.6)
7.33 (3.31,16.7)
65+
7366
339.4 (227.6451.2)
Female
33403
50.9 (30.671.2)
1.00
Male
29438
315.9 (261.8370.0)
Sex**
Acknowledgments
Authors are thankful to Umadevi, Jameel Ahmed, Ramesh Srivastav,
Narayana Prasad (Field Investigators), Dr. Alpana Mishra (Bacteriologist);
Surendra, Hemalatha, VijayLakshmi, Shivashankari, Raghunandan,
Manjunath (LTs); Ravindra, Padmesh, Anandababu (X-ray Technicians),
Dr L Suryanarayana, Dr (Mrs.) Sophia Vijaya (X-ray readers), Venkatachallappa, Nagaraja (Statistical Assistants) and Babis Sisimandis (for
guidance in statistical analysis).
Author Contributions
Conceived and designed the experiments: VKC SMA SS MVJ. Performed
the experiments: SS SN JG L MV SP VKC. Analyzed the data: SMA JR
MVJ VKC SB. Contributed reagents/materials/analysis tools: HK. Wrote
the paper: VKC SMA JR. Final approval, provision of resources and funds:
PK.
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