|Year : 2020 | Volume
| Issue : 1 | Page : 56-60
Estimation of the burden of bacteriologically positive Tuberculosis among Adults in Kashmir: A baseline for future surveys in the Valley
Saleem-ur- Rehman1, Rehana Kausar2, Syed M Kadri2, Nasreen Jan3, Bilal Bhat4, S Najar2, Vijay K Chattu5
1 Director of Health Services, Kashmir, Jammu and Kashmir, India
2 Directorate of Health Services, Kashmir, Jammu and Kashmir, India
3 Division of Epidemiology and Public Health, Directorate of Health Services, Jammu, Jammu and Kashmir, India
4 Department of Statistics, Faculty of Fisheries, Sher-e-Kashmir University of Agricultural Sciences and Technology of Jammu, Jammu, Jammu and Kashmir, India
5 Department of Psychiatry, Faculty of Medicine, University of Toronto, Canada
|Date of Submission||01-Mar-2019|
|Date of Decision||12-Dec-2019|
|Date of Acceptance||16-Dec-2019|
|Date of Web Publication||28-Jan-2020|
Dr. Vijay K Chattu
Department of Psychiatry, Faculty of Medicine, University of Toronto, ON M5S 1A8
Source of Support: None, Conflict of Interest: None
Background: India has the highest burden of both Tuberculosis and MDR-Tuberculosis based on estimates reported in the Global Tuberculosis Report 2016. The estimates have been revised upwards based on the newer evidence, and the current study was done to estimate the prevalence of bacteriologically positive pulmonary Tuberculosis among the adult population and to provide baseline information for future measurements of Tuberculosis burden and trends. Methods: A cluster-based sampling design was adopted in 10 districts of Kashmir valley in India. Assuming a prevalence of 217 per lakh population, a design effect of 2.5, a relative precision of 0.25% and the expected participation rate of 80%, a sample size of 49,716 was achieved. A total of 67 clusters were identified where each cluster had 750 subjects aged ≥15 years, and eligible individuals were questioned for pulmonary symptoms suggestive of Tuberculosis. Results: Of the total 42,805 that were interviewed, 3.85% had pulmonary Tuberculosis symptoms. A total of 1539 sputum samples were collected from symptomatic and 1351 chest X- rays were done. Cartridge based nucleic acid amplification test (CBNAAT) tests were done on individuals with suspicious X-ray findings. The prevalence of bacteriologically positive pulmonary Tuberculosis was found to be 147 per 100,000 population. Females are affected more than males, and the age of female Tuberculosis patients is less than that of males. Conclusion: The study is the first survey of its kind providing a baseline for further research in the state. CBNAAT is going to be game-changer which surmounts the drawbacks of sputum smear microscopy.
Keywords: CBNAAT, cluster sampling, north India, prevalence, pulmonary tuberculosis, sputum examination
|How to cite this article:|
Rehman Su, Kausar R, Kadri SM, Jan N, Bhat B, Najar S, Chattu VK. Estimation of the burden of bacteriologically positive Tuberculosis among Adults in Kashmir: A baseline for future surveys in the Valley. J Family Med Prim Care 2020;9:56-60
|How to cite this URL:|
Rehman Su, Kausar R, Kadri SM, Jan N, Bhat B, Najar S, Chattu VK. Estimation of the burden of bacteriologically positive Tuberculosis among Adults in Kashmir: A baseline for future surveys in the Valley. J Family Med Prim Care [serial online] 2020 [cited 2020 Feb 27];9:56-60. Available from: http://www.jfmpc.com/text.asp?2020/9/1/56/276737
| Introduction|| |
Globally, India accounts for one-fourth of the global Tuberculosis (TB) burden, and around 4.8 lakh people died due to TB of the estimated 28 lakh cases in 2015. Global health is considered critical for national and international security, domestic and global economic well-being. A country over 1.2 billion people, with over 500 million latent infections of TB and weaknesses in the available estimates are disappointing and limit effective policy-making. Achieving the global targets of 'End TB 2035' is feasible only with a dramatic decline in TB deaths and cases, and elimination of the economic and social burden of TB.
The first ever Tuberculosis prevalence study in Kashmir was conducted by Mayurnath et al. in 1978. Since then there is no relevant data from Kashmir regarding TB prevalence. National Tuberculosis Control Programme was started in Kashmir in 1964, and the Revised National Tuberculosis Programme (RNTCP) was implemented 40 years later, in 2004.
The study aimed to gain an understanding of the burden of TB in Kashmir and to identify ways in which TB control can be improved. The specific objectives are to measure the prevalence of bacteriologically positive pulmonary TB among the adult population and provide baseline information for future measurements of the TB burden.
| Methods|| |
After acquiring formal approval from the institutional ethical Committee of Director Health Services Kashmir, this cross-sectional study was conducted in 10 districts of Kashmir valley from June to August 2017. People who were older than 15 years were eligible to be enrolled for the study after getting due consent. The sample size of 49,716 was estimated based on World Health Organization's (WHO) guidelines  on the expected prevalence of pulmonary TB.
Cluster-based sampling design as per WHO guidelines  and a sample was designed assuming an expected prevalence of 217 per 100,000 population, a design effect of 2.5, a relative precision of 0.25% and expected participation rate of 80%. Study sites, i.e. districts were selected as the primary sampling units, and the blocks within these districts were the secondary sampling units. Within each block, the villages were enumerated and finally selected and sampled. The block formed the cluster and there were 67 clusters in total, where each cluster consisted of 750 subjects.
The survey tool consists of patient's socio-demographic details, X-ray film number, sputum smear number, CBNAAT number, and their results. Any respondent having cough >2 weeks, chest pain, hemoptysis, fever more than two weeks, history of previous ATT use, diabetes and age >65 years were eligible for sputum examination and were asked to provide two sputum samples. The staff collected one spot sputum sample in a pre-numbered sterilized sputum cup. A second bottle was provided for morning sample collection. For people living in difficult terrain, two spot samples were taken one hour apart and transported to the nearest DMC. X-ray examinations were done at the nearest facility and subjects with suspicious X-rays were tested using CB-NAAT.
Patients found positive were started on treatment at the nearest Directly Observed Treatment Short-course (DOTS) provider. The flowchart showing the study population, coverage by sputum examination, X-ray and CBNAAT is shown in [Figure 1].
|Figure 1: Flowchart depicting study population, coverage by sputum examination, X-ray and CBNAAT|
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| Results|| |
Case Definition: A case of TB for the study was defined as having a positive sputum smear microscopy or a positive CBNAAT test (Xpert MTB/RIF) with or without an abnormal X-Ray result consistent with tuberculosis.
[Table 1] depicts the demographic profile of the surveyed population. Out of a total screened population of 42,805, a majority 75% of the surveyed population were from rural areas and 25% population from urban areas with 51.33% males and 48.72% females. The majority of the population screened belonged to age group 15-24 (23%), with 21.14% males and 26.03 females.
In [Table 2] above, active TB was reported in 42 cases (3.11%) and inactive TB in 153 cases (11.32%) on X-ray findings. Out of 1351X-Rays done, 71.8% were normal, 8.66% technically inadequate. Active TB was reported in 42 cases. Lesions other than TB were reported for 68 films and inactive TB in 153 cases.
Presenting symptoms among participants
Cough alone or with any other symptom was found in 67.41% of the symptomatic individuals. The remaining 23% of the subjects had symptoms other than cough, and hemoptysis alone was the least common presenting symptom (1.15%) [Table 3].
|Table 3: Distribution of study participants according to their presenting symptoms|
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Participants based on smear and CBNAAT results
The distribution of patients by Smear and CBNAAT is shown in [Figure 2]. The [Table 4] shows that a maximum number of cases were found in the age groups 15-24 years with cases spread almost equally in other age groups. This difference is statistically significant.
|Table 4: Age & sex wise distribution of the surveyed population with positive laboratory findings (sputum smear &CBNAAT)|
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Geographical distribution of TB cases
The number of positive cases was highest in North Kashmir followed by Central and least in South Kashmir (P = 0.41); however, this finding is not statistically significant.
Prevalence of pulmonary TB among the study population
To account for missing cases, we doubled the cases found by sputum smear examination and CB-NAAT by culture, and the calculated prevalence was 112.13/100,000 population. To account for the cases were missing by not using X-Ray as an initial screening tool, we used a multiplication factor 1.13 to obtain a prevalence of 146.72/100,000 population.
| Discussion|| |
The current community study was the first of its kind on TB prevalence with a sample size of 49716, of which 42,805 (86%) subjects were interviewed. Among those, 1539 were symptomatic who were subjected to sputum smear examination, and 1351X-ray films were studied. The prevalence of sputum positive TB by Sputum smear examination and CBNAAT was 147 per 100,000. A study conducted by Mayurnath et al. used PPD, bacteriological examination of sputum and X-ray as survey tools. This study which was conducted on 18,000 subjects across all age groups found the prevalence of Culture Positive TB patients as 3 per 1000, and that of bacillary X-ray positive patients was 14 per 1000. The present survey shows a 50% decline in the prevalence of sputum positive TB.
Our study was an effort to look at the TB situation in Kashmir to provide an accurate and realistic picture of disease burden in a valley. In a large country like India, many sub-national surveys are required to give a practical view of the burden of disease. Different surveys have shown the prevalence varying from 311/100,000 in rural South India, 255.3/100,000 in Central India (Madhya Pradesh) 390/100,000 in Gujarat, Western India, 254 per 100,000 in South India, 101.4 per 100,000 in Haryana, North India  24.5/100,000 in Mohali, North India  and 387 among tribal population of Central India., Importantly, the percentage of symptomatic in the present study was 3.85%, whereas in other sites it ranged from 8.3% in Jabalpur Central India  to 3.4% in Mohali, North India. Our estimate was less than other parts but more than urban Mohali.
The present survey has covered urban, rural as well as tribal population Kashmir – which is the most important strength of the survey covering a population of 7.1 million. We utilized the RNTCP staff for the study who were well versed with the symptom screening, technique of sputum collection, microscopy and transport techniques without any additional burden on the state exchequer. The prevalence of sputum positive Tuberculosis was highest in the 15-24 age group followed by 45-54-year-olds in contrast to reports by other surveys.,, In younger age groups, the prevalence was skewed in favor of females. The male: female ratio was 1:8 in this age group, despite the number of males and females surveyed being roughly equal. Overall, the male: female ratio is 1:2.4 in this study which is opposite to that observed in the rest of the country. It was reported that the prevalence of culture-positive cases and abacillary X-ray positive cases among males in Kashmir was similar to those seen among females, contrary to the usual experience that the prevalence of the disease is 2-4 times higher in males than females in the rest of the country. Various studies have demonstrated clear-cut male preponderance in TB with a male: female ratio ranging from 6:1 in South India to 2.37:1 in Central India. In India, the RNTCP detects nearly three times more male than female TB cases, although the extra-pulmonary disease has been reported more commonly in women. RNTCP data from Kashmir over the last 10 years shows a male: female ratio of nearly 1:1 (range 0.96:1 to 1.06:1). The difference could be because of a different ethnicity since the same pattern of nearly equal male: female ratio is seen in neighboring Afghanistan.
Another significant finding was that the prevalence of TB was higher in North Kashmir (Kupwara, Baramulla) and less in South Kashmir (Anantnag, Pulwama). Although there is no statistically significant difference, the same regional difference was reported by Mayurnath et al. in 1978.
The decline in Tuberculosis from 1978 to 2017 (present study) can be attributed to the strengthening of TB-control activities through RNTCP and implementation of Rifampicin-based DOTS regime. The programme has consistently shown a treatment success rate of more than 90% hence a reduction in case load has emerged. The India State-Level Disease Burden Initiative also documents a reduction in TB as a cause of death and disability from number 6 to number 15 over 16 years. In 1990, 4% of the total DALYs were contributed by TB, and this reduced to 1.9% in 2016 for the state of Jammu and Kashmir. The same study also documents that the range of per capita disease burden due to TB among the states of India varies nine fold.
Role of family physicians and general physicians
The role of family physicians and general practitioners in the control of TB in India is very significant as 50% of the population access private care, and they become the first point of care for the suspected cases. Since RNTCP is saturated with 100% coverage, the general practitioners could contribute to the success of the programme by timely referral of patients to DOTS centers, avoiding development of drug resistance due to irrational practices and by adhering to the “Standards of TB Care in India” developed by Government of India and WHO. The strategies such as orienting the private practitioners, networking of private practitioners with patients and with DOTS providers, follow up and sensitization of patients by GPs on treatment adherence will have an enormous impact through these public-private partnerships.
The major weakness in the study was the absence of a culture of sputum samples which we have tried to overcome by doubling the number of cases. X-ray was available for 82% of the eligible population, and around 8.66% which had poor quality were discarded. We used a multiplication factor of 1.3 to overcome this deficiency. At the same time, 263X-rays were suggestive of TB, but only 19% were positive on CBNAAT, hence X-ray although useful, and cannot be relied upon for diagnosis. We could not screen for extra-pulmonary or pediatric TB as it is cumbersome to carry out the same under field conditions.
| Conclusion|| |
The study highlights the importance and rationale of adding CBNAAT as an essential diagnostic tool for suspected positive Tuberculosis cases. CBNAAT is going to be game-changer in TB programme by overcoming the deficiencies of sputum smear microscopy. Accurate estimates of the TB burden at country level guides national policy-making and also improves the control efforts.
The authors thank all the IDSP team members of Kashmir involved in the surveillance for their support to conduct the study.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
India TB. Revised National Tuberculosis Control Programme Annual Status Report; 2017.
Chattu VK. Global Health & Tuberculosis: A retrospective study. SAARC J Tuber Lungs Dis HIV/AIDS 2013;2:21-6.
Dye C, Bassili A, Bierrenbach AL, Broekmans JF, Chadha VK, Glaziou P, et al
. Measuring tuberculosis burden, trends, and the impact of control programmes. Lancet Infect Dis 2008;8:233-43.
Vijay Kumar C, Kumary S. Global health governance and the end TB strategy: An optimistic post-2015 development agenda. Global J Med Public Health 2015;4:1-3.
Mayurnath S, Anantharaman DS, Baily GV, Radhamani MP, Vallishayee RS, Venkataraman P, et al
. Tuberculosis prevalence survey in Kashmir valley. Indian J Med Res 1984;80:129-40.
WHO. Tuberculosis Prevalence Surveys: A Handbook. 2011.
Global Tuberculosis Report 2016, WHO, Updated and interim estimates of TB disease burden in India and plans for a national TB prevalence survey in 2017/2018, Box 3.3.
Subramani R, Radhakrishna S, Frieden TR, Kolappan C, Gopi PG, Santha T, et al
. Rapid decline in the prevalence of pulmonary tuberculosis after DOTS implementation in a rural area of South India. Int J Tuberc Lung Dis 2008;12:916-20.
Rao VG, Bhat J, Yadav R, Gopalan GP, Nagamiah S, Bhondeley MK, et al
. Prevalence of pulmonary tuberculosis-A baseline survey in central India. PLoS One 2012;7:e43225.
Chadha VK, Kumar P, Anjinappa SM, Singh S, Narasimhaiah S, Joshi MV, et al
. Prevalence of pulmonary tuberculosis among adults in a rural sub-district of South India. PLoS One 2012;7:e42625.
Sharma SK, Goel A, Gupta SK, Mohan K, Sreenivas V, Rai SK, et al
. Prevalence of tuberculosis in Faridabad district, Haryana State, India. Indian J Med Res 2015;141:228-35.
] [Full text]
Bhat J, Rao VG, Gopi PG, Yadav R, Selvakumar N, Tiwari B, et al
. Prevalence of pulmonary tuberculosis amongst the tribal population of Madhya Pradesh, central India. Int J Epidemiol 2009;38:1026-103.
Aggarwal AN, Gupta D, Agarwal R, Sethi S, Thakur JS, Anjinappa SM, et al
. Prevalence of pulmonary tuberculosis among adults in a north Indian district. PLoS One 2015;10:e0117363.
Rao VG, Bhat J, Yadav R, Gopi PG, Selvakumar N, Wares DF. Prevalence of pulmonary tuberculosis among the Bharia, a primitive tribe of Madhya Pradesh, Central India. Int J Tuberc Lung Dis 2010;14:368-70.
National Tuberculosis Institute Bangalore. Tuberculosis in a rural population of South India: A five-year epidemiological study. Bull World Health Organ 1974;51:473-88.
Central TB Division, Directorate General Health Services, Ministry of Health and Family Welfare, Government of India (2017) TB India 2017, Revised National Tuberculosis Programme Annual Status Report. Available from: http://www.tbcindia.gov.in
. [Last accessed on 2018 Nov 24].
Mukherji A, Saha I, Sarkar A, Chowdhury R. Gender difference in notification rates, Clinical forms and treatment outcome of tuberculosis patients under RNTCP. Lung India 2012;29:120-2.
Indian Council of Medical Research. India: Health of the Nation's States The India State-Level Disease Burden Initiative, published on 14th
Estimates of TB and MDR-TB burden are produced by WHO in consultation with countries. Generated: 2018-06-11.
Samal J. Ways and means to utilize private practitioners for tuberculosis care in India. J Clin Diagn Res 2017;11:LA01-4.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]