Journal of Mahatma Gandhi Institute of Medical Sciences

LETTER TO THE EDITOR
Year
: 2014  |  Volume : 19  |  Issue : 2  |  Page : 164--165

Revised national tuberculosis control program: Progress in the diagnostic front


Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy 
 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India

Correspondence Address:
Saurabh R Shrivastava
Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, 3rd Floor, Thiruporur-Guduvancherry Main Road, Ammapettai village, Kancheepuram - 603 108, Tamil Nadu
India




How to cite this article:
Shrivastava SR, Shrivastava PS, Ramasamy J. Revised national tuberculosis control program: Progress in the diagnostic front.J Mahatma Gandhi Inst Med Sci 2014;19:164-165


How to cite this URL:
Shrivastava SR, Shrivastava PS, Ramasamy J. Revised national tuberculosis control program: Progress in the diagnostic front. J Mahatma Gandhi Inst Med Sci [serial online] 2014 [cited 2020 Aug 13 ];19:164-165
Available from: http://www.jmgims.co.in/text.asp?2014/19/2/164/138446


Full Text

Sir,

World Health Organization (WHO) has revealed that in the year 2011 alone, 11.7 million new cases of tuberculosis (TB) have been reported worldwide, of which India contributed to almost one-quarter of the cases. [1] Considering the global distribution, magnitude of the problem, impact on the quality of life, life-threatening complications, mortality rates, and above all unrestricted nature of the disease, TB in today's world is the biggest public health disease of an infectious nature. [1] Further, the best way to combat the disease is to diagnose the sputum-positive TB cases at the earliest by the quality assured laboratory test (namely sputum microscopy) and then to initiate the patient immediately on WHO/Revised National TB Control Program (RNTCP) approved regimens. [2]

In India, the National TB Control Program was launched in the year 1962 to counter TB, which was later on replaced by the RNTCP (1992) on account of multiple flaws identified at the diagnostic/ treatment/administrative levels. [2] Subsequently, the program has been geographically scaled up and has incorporated various elements within its umbrella to take care of the menace such as adoption of newer diagnostic tools; treatment regimens for drug resistant forms of TB; public-private partnership projects; involvement of multiple stakeholders; and national and international collaboration; etc. [2],[3]

For making a diagnosis of sputum-positive TB, sputum microscopy has been identified as the gold standard tool, as it is simple to perform with highly specific, reliable and reproducible results, being inexpensive, an indicator of infectiousness, a comprehensive tool for diagnosis/monitoring progress/defining cure, and being feasible even in the remote/tribal places. [2] As per the RNTCP diagnostic algorithm, due importance has been given to chest-x-ray/laboratory tests/radiological investigations for diagnosing sputum-negative and extra-pulmonary TB cases. [3] On a serious note, WHO has negatively recommended the use of serological tests/tuberculin skin test/interferon gamma release assay in either diagnosing TB or in initiating antituberculosis treatment. [4] The government of India has imposed ban on three different levels - doctor, manufacturing, import of the diagnostic kits, to discourage the serological tests. [4] To fast track the process of microscopy/reduce the burden on laboratory technicians in high workload settings (>25 slides per day), RNTCP has piloted the use of light-emitting diode-based fluorescent microscope (LED-FM) services in 200 medical colleges distributed across the country under project LIGHT (LED Fluorescent Microscopy In Gaining TB Cases in High workload Teaching Hospitals). [5] It has been revealed that employment of LED-FM has aided in the detection of 5495 more new sputum smear-positive TB cases in 2012 compared to that in 2011. [5]

However, maximum development and progress have been observed in diagnosing drug-resistant TB (DR-TB) using culture and drug-sensitivity testing (C and DST). Although solid culture is still considered the gold standard for detecting DR-TB, because of the length of time required for obtaining the results (9-12 weeks), it has gradually been replaced by liquid culture (3-5 weeks). [2] As even the liquid culture results are obtained after more than 1 month, chances of loss to follow-up of TB patients cannot be ruled out. In order to overcome this time barrier and the operational hurdles in smooth execution of the program by the program managers, RNTCP adopted a newer tool based on amplification of deoxyribosenucleic acid of mycobacterium tuberculosis bacilli, named line probe assay (LPA) which provides a confirmatory diagnosis of MDR-TB within 1-2 days. [6] Subsequently, RNTCP has also approved the cartridge-based nucleic acid amplification test (CBNAAT or GeneXpert) as a pilot project in 18 districts of country. The initial results of the CBNAAT pilot project has been quite encouraging and thus it is now extended to 70 districts of the country, mainly because of the availability of MDR-TB results within 2 hours and hence patients can be immediately put on appropriate treatment without any unnecessary delay/risk to the susceptible members of the community. [7]

The strengthening of the program on the diagnostic front has not been limited to the adoption of newer diagnostic tools but has also been extended to formulation of standard guidelines and time-bound training of the technicians and the program managers. [2],[3] Revised guidelines have been released for obtaining appropriate specimens from the presumed site of involvement for microscopy/culture in diagnosing extra-pulmonary cases of multi-/extremely DR-TB. In addition, it has been strictly proposed that only those culture and DST results done in a RNTCP-certified laboratory should be considered as confirmatory evidence to begin the treatment. [8] Further, to lessen the burden on the three existing national reference laboratories (NRLs) in New Delhi, Bangalore, and Chennai, two additional NRLs have been proposed in Bhopal and Bhubaneswar. [8] In addition, based on the framework of International Standards for TB Care, the Central TB Division has formulated Standards for TB Care in India, in which six standards have been mentioned for diagnosis of TB.

To conclude, the Revised National TB Control Program has remained the most flexible program in the country and in order to make the services more accessible and user-friendly, it has progressed remarkably on the diagnostic front to promote timely and accurate diagnosis of different forms of TB.

References

1World Health Organization. Global Tuberculosis Control Report 2012. Geneva: WHO press; 2012.
2TBC India. Managing the RNTCP in your area - A training course (Modules 1-4). Available from: http://tbcindia.nic.in/documents.html. [Last accessed on 2013 Sep 22].
3TBC India. Managing the RNTCP in your area - A training course (Modules 5-9). Available from: http://tbcindia.nic.in/documents.html. [Last accessed on 2013 Sep 22].
4World Health Organization. Commercial serodiagnostic tests for diagnosis of tuberculosis, 2011. Geneva: WHO Press; 2011.
5International Union against Tuberculosis and Lung Disease. Project LIGHT increases the number of TB cases diagnosed at test sites. Available from: http://www.theunion.org/index.php/en/newsroom/news/item/2350-project-light-increases-the-number-of-tb-cases-diagnosed-at-test-sites. [Last accessed on 2013 Sep 25].
6Albert H, Bwanga F, Mukkada S, Nyesiga B, Ademun JP, Lukyamuzi G, et al. Rapid screening of MDR-TB using molecular line probe assay is feasible in Uganda. BMC Infect Dis 2010;10:41.
7RNTCP-FIND-WHO CBNAAT Project. Available from: http://www.finddiagnostics.org/export/sites/default/media/events/2012/pdf/Flyer_CBNAAT_India.pdf. [Last accessed on 2013 Sep 16].
8TBC India. Guidelines for PMDT in India, 2012. Available from: http://tbcindia.nic.in/documents.html. [Last accessed on 2013 Sep 16].