Post ATT Status of Patients who had Category II ATT: A Follow up study

INTRODUCTION : Outcome surveillance is an essential tool to determine the effectiveness of the national effort to control Tuberculosis. It provides an insight into the proportion of patients who complete treatment, experience complications, lose follow up or die. The main purpose of treatment outcome monitoring is to determine the outcome of potentially infectious cases and thus it provides information about the likely transmission of infection. The Revised National Tuberculosis Control Programme (RNTCP), adopting the DOTS strategy advocated by World Health Organization (WHO), was implemented in 1993 in the country and has been scaled up rapidly since mid 1998. Based on a stringent diagnostic algorithm and history of previous TB treatment, the diagnosed cases under RNTCP are classified as ‘New’ and ‘Re-treatment’ cases for allotting an appropriate drug regimen to them. Retreatment cases i.e. those who give history of previous TB treatment of more than one month, are put on Category II regimen. This category comprises smear positive ‘Failures’, ‘Relapses’, ‘Treatment after Default (TAD)’ and ‘Others’. The question often posed by clinicians is regarding effectiveness of Cat II regimen for re-treatment cases, especially those with failures. It has been suggested that they may be treated with a stronger regimen since such cases are likely to harbor drug resistant organisms. We conducted a retrospective study to evaluate the outcome of category II retreatment cases in a DOTS programme in Chennai city to examine if these concerns had any basis. AIM OF THE STUDY : To evaluate the present status of a cohort of retreatment cases started on Category II ATT in the year 2002 in three tuberculosis units of Chennai city and to evaluate the effectiveness of Category II. DESIGN OF THE STUDY: Descriptive study. MATERIALS AND METHODS : The study was conducted in the Institute of Thoracic Medicine, Chennai in the period from July 2005 to February 2006 .The study population is selected from three tuberculosis units of Chennai city, namely Pulianthope TU , Thanthai periyar TU and Saidapet TU. All the patients who received Category II anti-tuberculosis treatment in the year 2002 in those tuberculosis units were included for study. The indications for Category II were being relapse or treatment after default or failure or for other reasons. The details regarding treatment details, sputum status and treatment outcome at the end of Category II were collected from the tuberculosis register (T.R) available in the respective tuberculosis units. Postal cards were sent to the patient’s addresses, requesting them to come to the institute for evaluation. The non responders were traced personally with the help of staff available at the concerned TUs and were interrogated at their door steps. The patients were asked regarding their present symptoms with duration, past anti-tuberculosis treatment in a questionnaire. Then their sputum was collected in sputum cups and culture bottle. Sputum smear was examined using Ziehl-Neelsen method for the presence of acid fast mycobacteria. All the culture specimens were collected in a sterile culture bottle containing trisodium citrate. The specimens were processed with sodium hydroxide ( for decontamination) and then centrifuged. The inoculum is then inoculated in Lowenstein –Jensen medium. Chest skiagram was taken to all the patients. For those whose culture was positive for M.tuberculosis that specimen was sent to culture & sensitivity testing at Tuberculosis Research Centre. CONCLUSIONS : The purpose of the present study is to address the often-posed query regarding effectiveness of Category II regimen for re-treatment. In Our study the cure rate is 53% and overall successful treatment completion rate is 58%. Since that was the early days of implementation of the programme and the number of staff exclusively available were less, the outcome of the patients who had Category II is acceptable. 46.3 % of Category I defaulters again defaulted in Category II. Recommendations to be formulated concerning management of TB patients with respect to the risk of treatment default. In the three year follow up it is found that five of the cured patients of Category II now found to be positive by culture. This stresses the importance of prompt evaluation of patients who have completed the treatment in the presence of recurrent chest symptoms. Out of the 83 patients subjected for culture examination, only five patients showed drug resistance and among the five patients only two were having multi drug resistant tuberculosis. With this low incidence of drug resistance , Category II will be adequate under programme conditions for the management of re-treatment cases