Registered with the Registrar of Newspapers of India under No. 655/57 Indian Journal of Tuberculosis Published quarterly by the Tuberculosis Association of India Vol. 57 : No. 2 April 2010 Editor-in-Chief Contents R.K. Srivastava EDITORIAL Editors M.M. Singh Expanding DOTS - New Strategies for TB Control? Lalit Kant - D. Behera 63 V.K. Arora Joint Editors ORIGINAL ARTICLES G.R. Khatri D. Behera Detection of circulating free and immune-complexed antigen in pulmonary tuberculosis using cocktail of Associate Editors antibodies to Mycobacterium tuberculosis excretory S.K. Sharma secretory antigens by peroxidase enzyme immunoassay L.S. Chauhan - Anindita Majumdar, Pranita D. Kamble and Ashok Shah B.C. Harinath 67 J.C. Suri V.K. Dhingra Can cord formation in BACTEC MGIT 960 medium be used Assistant Editor as a presumptive method for identification of M. K.K. Chopra tuberculosis complex? - Mugdha Kadam, Anupama Govekar, Shubhada Members Shenai, Meeta Sadani, Asmita Salvi, Anjali Shetty Banerji, D. and Camilla Rodrigues 75 Gupta, K.B. Katiyar, S.K. Randomized, double-blind study on role of low level Katoch, V.M. nitrogen laser therapy in treatment failure tubercular Kumar, Prahlad lymphadenopathy, sinuses and cold abscess Narang, P. - Ashok Bajpai, Nageen Kumar Jain, Sanjay Avashia Narayanan, P.R. and P.K. Gupta 80 Nishi Agarwal Status Report on RNTCP Paramasivan, C.N. 87 Puri, M.M. CASE REPORTS Radhakrishna, S. Raghunath, D. Pelvic Tuberculosis continues to be a disease of dilemma - Rai, S.P. Case series Rajendra Prasad - S. Chhabra, K. Saharan and D. Pohane 90 Sarin, Rohit Vijayan, V.K. Hypertrophic Tuberculosis of Vulva - A rare presentation of Wares, D.F. Tuberculosis - Punit Tiwari, Dilip Kumar Pal, Dhrubajyoti Moulik Journal Coordinators and Manoj Kumar Choudhury Kanwaljit Singh 95 R. 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The Publisher, Editor-in-Chief and its Editorial Board Members and Prevalence of pulmonary tuberculosis amongst the baigas: employees disown all responsibility for any A primitive tribe of Madhya Pradesh, Central India - R. Yadav, V.G. Rao, J.Bhat, P.G. Gopi, N. Selvakumar injury to persons or property resulting from and D.F. Wares any ideas or products referred to in the 114 articles or advertisements contained in this Book Review 117 journal. Abstracts 118 Obituary 121 Reproduction of any article, or part thereof, published in the Indian Journal of Tuberculosis, without prior permission of the Tuberculosis Association of India is prohibited. Bibliographic details of the journal available in ICMR-NIC Centre's IndMED data base (http://indmed.nic.in). Full-text of articles from 2000 onwards are available online in medIND data base (http://medind.nic.in). IJT is indexed in MEDLINE of National Library of Medicine, USA. Published and printed by the Secretary General, on behalf of the Tuberculosis Association of India, 3, Red Cross Road, New Delhi-110001 Phone: 011-23711303; 23715217 and printed at Cambridge Printing Works, B-85, Naraina Industrial Area-II, New Delhi-110 028 Phone : 45178975. Indian Journal of Tuberculosis Vol. 57 New Delhi, April, 2010 No. 2 Editorial EXPANDING DOTS – NEW STRATEGIES FOR TB CONTROL? [Indian J Tuberc 2010; 57:63-66] Tuberculosis continues to be a major public health problem in the world, particularly in the developing countries. The updated WHO report reveals that about 9.4 million (8.9–9.9 million) new TB cases occurred in 2008 (3.6 million, of whom are women) including 1.4 million cases among people living with HIV. The prevalence of the disease was about 11.1 million (9.6–13.3 million prevalent cases). There were about 1.3 million (1.1–1.7 million) deaths from TB among HIV-negative people and an additional 0.52 million (0.45–0.62 million) TB deaths among HIV-positive people1. India is the highest TB burden country in the world, accounting for 21% of the global incidence and 2/3rd of the cases in South East Asia. In the year 2008, the incidence of tuberculosis was reported to be 1.982 million (1.586-2.379 million) with prevalence of 2.186 million (1.044 – 3.739 million) with mortality due to TB being 2, 76, 512. The percentage of HIV positivity in that year was 6.7% with a range of 5.5 – 7.9%.1-3. The WHO declared TB a global emergency in 1993 realizing its growing importance as public health problem. It developed the DOTS strategy (Directly Observed Treatment, Short Course) in 1994 as the new frame work for effective TB control4-7 with five components. The strategy has been adopted in many countries with flexibility and adaptation to the existing needs of the community8,9. The global targets for TB control, adopted by the World Health Assembly, are to cure 85% of the newly detected sputum smear positive TB cases and to detect 70% of the estimated incidence of sputum smear-positive TB case10. Although many countries have achieved this target, the case detection rate was 63% globally in 2007 through the DOTS programmes and the same for all cases was 56%. 36 million people with TB are cured and up to 8 million lives are saved through 15 years of DOTS programmes, confirming that DOTS as the most cost effective approach in the fight against tuberculosis but millions still unable to access high quality care1,11. While the global incidence of TB appears to have been declining slowly since 2004, and treatment success was as per the target in 2006, the case detection rate for sputum smear-positive TB is stagnating at 64% in 200712. Many countries at the global level including India has achieved the initial set target of 70% of case detection rate and 85% cure rate13. Is this strategy enough to control TB? In a simple mathematical calculation, out of 100 cases of TB, the current programme is detecting 70 cases and with a success rate of treatment under DOTS being 85%, in fact out of these 100 patients, only 59.5 patients are actually being cured. This means that a large chunk is still not being covered/cured/treated. 70% of case detection still leaves behind a gap of 30% of cases yet to be detected. The issues of HIV, drug resistant tuberculosis like MDR and XDR-TB complicated matters further. For such a large programme, huge amount of funding is required. The drugs are still old and in the recent past there is no new drug discovery. Vaccines are still a distant dream. The Stop TB strategy has adopted seven key areas and the Stop TB Partnership’s seven key approaches are: DOTS expansion; DOTS-Plus for multidrug resistant TB; TB/HIV Collaborative activities; Newer TB diagnostics; Discovery of new TB drugs; New TB vaccines, Advocacy and of course adequate funding. All these factors need to be taken into account before we dream of a TB-free Indian Journal of Tuberculosis 64 EDITORIAL world or to achieve the million development goals even if, there are indications that there is some progress towards this. Then how can we achieve such goals? Besides maintaining and sustaining the current achievements, quality DOTS expansion has to be made which is perhaps the key factor. To increase the case detection and to have wider access of TB services to each and every body in the community, we need to develop newer strategies. An action framework for higher and earlier TB case detection has been proposed by the DOTS Expansion Working Group of the Stop TB Partnership. Several possible reasons for low case detection rate and delay treatment have been identified. They include poor understanding of TB and its symptoms in the general population, poor knowledge where to seek care, poor health service infrastructure with limited out reach, barriers to access, poor diagnostic quality, limited human resource for health, poor TB knowledge amongst health providers, perverse incentive systems for providers that foster us of inappropriate medical technologies, poor coordination of health services and poor information systems including notification and referral routines. These factors may be different in different settings and they need to be identified by analyzing the gaps and barriers for early case detection. Some of the priority actions may include intensifying the case finding strategies in health care facilities. The diagnostic algorithm should go beyond the current passive case finding strategies i.e. unexplained cough for two weeks or more. Any cough of any duration may be used as a screening indication in a high burden setting. Although this will maximize sensitivity, more tests will be performed on people who do not have TB and will unnecessarily burden the resources. Fluorescent microscopy using LED microscopes will improve the case identification. The earlier mass radiology may be used in selective cases, particularly those who are sputum negative but having a high index of suspicion.