Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Professor and Head
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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
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Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : LC15 - LC20 Full Version

A Study of Tuberculosis among Patients Visiting Regional Tuberculosis Centre in Central India- A Cross-sectional Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52284.16356
Vikrant Singh Chauhan, Manoj Bansal, Vikash Sharma, Rajesh Gupta

1. Medical Officer, Department of Community Medicine, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India. 2. Associate Professor, Department of Community Medicine, Gajra Raja Medical College, Gwalior, Madhya Pradesh, India. 3. Demonstrator, Department of Community Medicine, Government Medical College, Ratlam, Madhya Pradesh, India. 4. District Health Officer, Department of Community Medicine, Gajra Raja Medical College, Shivpuri, Madhya Pradesh, India.

Correspondence Address :
Vikrant Singh Chauhan,
No 3, Ladanbagh, Near Maharshi School,
Balakot Road, Gwalior, Madhya Pradesh, India.
E-mail: drvikrantsinghc@gmail.com

Abstract

Introduction: Number of Drug-Resistant Tuberculosis (DRTB) patients has increased. Determination of the causes of delay in timely diagnosis and treatment is one of the most important steps for complete cure. Delay in diagnosis and treatment of disease are important factors and these may arise from patients and by the healthcare system.

Aim: To study factors contributing to Tuberculosis (TB) patients , visiting a regional DRTB centre in central India.

Materials and Methods: A cross-sectional study was conducted at DRTB centre, Lashkar, Gwalior, Madhya Pradesh, India, from January 2019 to June 2019. Purposive sampling technique was used for data collection. Patients who visited the centre were requested to fill the performa regarding their TB status. Total 371 patients, who visited and filled the form, participated in the study. Patients were divided into drug resistant and drug sensitive patients. For the significant independent variables adjusted odds ratio and p-values were calculated. The p-values <0.05 was considered to be significant.

Results: Total 227 (61.2%) drug-resistant and 144 (38.8%) drug-sensitive patients were included in the study. Education played a significant role with only 5.7% and 6.9% of drug resistant and sensitive patients, respectively, developed disease. Overall, 186 (81.9%) participants took more than 6 months of treatment prior to final initiation of Proper Anti-Tubercular Treatment (ATT) were DRTB cases.

Conclusion: Delay in proper diagnosis and multiple visits to health facility and further delay in initiation of definitive treatment poses threat for emergence of drug resistance.

Keywords

Delay, Drug-resistant tuberculosis, Drug-sensitive tuberculosis, Government, Private, Reporting centre, Symptoms

Mankind has evolved with the development of latest technologies and has conquered many communicable diseases but is now facing epidemiological transition with the evolution of non communicable diseases. Mutations at genetic level are also responsible for drug resistance among mycobacterium like, KatG and InhA (genes determining isoniazid susceptibility) (1). Among the total Tuberculosis (TB) cases, 10% develops clinical disease (2). For the year 2017 World Health Organization (WHO) report estimates that 1.3 million deaths have been reported from multiple Drug-Resistant Tuberculosis (DRTB) without Human Immunodeficiency Virus (HIV), while 3,00,000 deaths from TB with Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) cases (2).

If not totally missed, delayed identification and diagnosis of TB plays a vital role in the transmission of the disease in the community. Many people with active TB do not experience typical symptoms during the first stages of the disease and may not seek care early and tested for TB (3). If the interval between presentation of the first symptoms of disease, diagnosis and treatment of disease is prolonged, the risk of TB transmission increases. With progression of pulmonary lesions, the likelihood of bacterial resistance and mortality is increased (4).

Determination of the causes of delay in timely diagnosis and treatment is one of the most important steps that must be taken for implementing the National TB Programme (NTP). Much of the delay in diagnosis and treatment of disease are due to two reasons, delays by the patients and delay by the health care system in proper initiation of treatment (5). Hence, the present study was undertaken to find out the factors contributing to Tuberculosis (TB) patients visiting Drug-Resistant Tuberculosis (DRTB) centre in district Gwalior, Madhya Pradesh, which is the biggest TB centre in central India.

Material and Methods

A cross-sectional, hospital-based study was conducted at Government DRTB centre, Lashkar, Gwalior, Madhya Pradesh, India, which caters patients from all the districts of Gwalior-Chambal division. Data was collected from January 2019 to June 2019. For data collection the primary researcher visited the DRTB centre three times a week from morning 10 am to 1 pm.

Permission was granted from the Department of Community Medicine, Gajra Raja Medical College, Gwalior and District TB officer prior to conducting the study. Purposive sampling technique was used for data collection.

Inclusion criteria: All the diagnosed drug-resistant and drug-sensitive TB cases Cartridge Based Nucleic Acid Amplification Tests (CBNAAT)/Line Probe Assay (LPA), and who were willing to participate in the study were included.

Exclusion criteria: Those who were terminally ill and did not want to participate in the study, were extra pulmonary TB cases, and cured from TB were excluded from the study.

Procedure

Each CBNAAT/LPA report or report from other institutions of study participants were counter checked for verification of the drug-resistant/ drug-sensitive TB status. A self-designed questionnaire was used to gather information from the study participants. The confidentiality of the study participants were maintained throughout the study. The first reporting centre was the centre which was visited by the TB patients for their symptoms for the first time, thereafter their second visit for his/her complaints either resolved or not at first reporting centre. For study purpose authors have divided Tuberculosis patients into drug resistant and drug sensitive cases on the basis of CBNAAT/LPA reports. Overcrowding was assessed using a simple ratio between numbers of people in the household and rooms-maximum persons recommended were one room two person (not overcrowded if they are in relationship), two rooms three persons, three rooms five persons, four rooms seven persons, five rooms ten persons. Above that was considered as overcrowding (6).

Statistical Analysis

Statistical analysis was performed with Statistical Package for the Social Sciences (SPSS) version 16.0. Simple frequency format was used for categorical variables. Standard deviation with 95% confidence interval was applied to percentages and quantitative and numerical variables. Proportions, Pearson Chi-square and p-values were calculated for the variable. Logistic regression analysis was used to describe the possible association between independent variables and the outcome variable as TB which is further divided into drug-resistant and drug-sensitive cases. For the significant independent variables adjusted Odds Ratio (OR) and p-values were calculated. The p-values <0.05 was considered to be significant.

Results

A total of 371 TB patients were included in the study, among them 227 (61.2%) were drug-resistant cases while rest 144 (38.8%) were drug-sensitive. Postdetection of the initial symptoms, 74 patients visited Government setup, where 32 (43.2%) patients diagnosed as TB and received ATT. While 151 visited private clinic/hospital, among them 61 (40.4%) diagnosed and initiated on ATT. Sequence of events, from initial symptoms to subsequent visit by the patients (Table/Fig 1), (Table/Fig 2).

Mean age of the participants was 35.7±15.1 years for DRTB patients, while for drug-sensitive cases it was 37.4±17.6. Mean BMI of the participants was 15.91, which is in underweight category. After the onset of symptoms, DRTB patients took mean 2.6±4.2 months of treatment at the 1st reporting centre, while for drug-sensitive cases it was 1.8±1.5 months. DRTB patients took mean 12.8±9.7 months of treatment, while for drug-sensitive patients it was 10.6±2.3.The socio-demographic variables of the participants are presented in (Table/Fig 3).

Majority 96 (66.7%) of the drug-sensitive patients had no history of TB, while 82 (36.1%) DRTB cases were drug defaulters as shown in (Table/Fig 4). Overall, 137 (60.4%) of the DRTB patients had taken more than 6 months of treatment with rifampicin/isoniazid in past. A 105 (72.9%) drug-sensitive TB patients were living in overcrowded places.

Fever with cough was the initial symptoms among 116 (51.1%) of the DRTB patients. Total 151 (66.5%) visited the private centre and 190 (80%) patients subsequently visited the Government centre for further treatment (Table/Fig 5), (Table/Fig 6). Contributing factors for TB, like diabetes mellitus, smoking, alcohol intake, HIV status are presented in (Table/Fig 7).

Logistic regression analysis of the independent variables was performed for the outcome variable as a case of drug-resistant DRTB or drug-sensitive TB patients. Forward stepwise (likelihood ratio) was used for regression model. Hosmen Lemeshow test was conducted to check the p-value, which was 0.72, which was non significant hence the adequacy of regression model was accepted and is fit. Negelkerkes R2 was 0.574 which suggests that 57.4% of the variance can be explained by the independent variables. Significant findings from regression model are presented in (Table/Fig 8).

Discussion

As per the present study, majority of the participants were of age group 21-30 years i.e., 78 (34.6%) for drug-resistant, while 34 (23.6%) for sensitive cases. Similar finding was reported by Kanungo S et al., and Shiferaw MB and Zegeye AM, (7),(8). The study by Rizvi SMS et al., from Bangladesh has shown that 22.2% of the drug-sensitive and 39.5% of drug-resistant cases were 21-30 years age group (9). A 51% of DRTB patients in study by Venkatesh U et al., from Gorakhur were of age range 21-30 years (5). It was found that 153 (67.4%) for drug resistant and 108 (75.0%) for drug sensitive patients were male. In Ernakulum study by Nirupa C et al., had 68.0% males among DRTB cases (10). The study by Rizvi SMS et al., in Bangladesh has shown that 55.6% were male in drug-sensitive category while 81.6% in drug-resistant patients (9). This shows that prevalence was higher among younger male participants.

Overall, 172 (75.8%) of drug-resistant and 102 (70.8) sensitive participants were married. Similar were the findings by Sajith M et al., Bhawalkar J et al., while more than 90.0% were married as per study done by Sairam A et al., (11),(12),(13). Venkatesh U et al., in Gorakhpur had 55.4% married participants among DRTB cases (5). If a marital partner contracts TB, there are higher chances of the counterpart to get infected which shows the heightened risk of transmission of TB among married individuals.

Illiteracy was seen in 80 (35.2%) of the drug-resistant cases, while it was among 70 (48.6%) for drug-sensitive patients. Almost similar was the findings in the studies by Raza AKMM et al., and Chakraborty AK (14),(15). The study by Sidharta SD et al., in Mayanmar found a lower literacy rate of 17% and is contradictory to the present study (16). Lower education status is also a significant factor for spread of TB, as is reflected in the current study.

There was a substantial positive history of TB among the drug-resistant and drug-sensitive patients (62.6% and 33.3%, respectively). Rizvi SMS et al., in their study from Bangladesh, found that 16.7% drug-sensitive patients had history of TB, while it was 7.9% for drug-resistant cases (9). Study in Ethiopia by Awoke N et al., found 8.5% patients with history of TB (17). A study in Patna by Mistry N et al., has shown that 23% patients had history of TB (18). Sinha R and Umashankar H in Bareilly have shown that 23.3% patients were defaulters for past TB treatment (19). Inappropriately, treated TB patients in past contributes in the development of drug-resistant cases. High number of cases in the present study may be because the study centre caters to an overall larger number of cases from Gwalior-Chambal division, with adjoining districts of UP and Rajasthan.

Total 137 (60.4%) drug-resistant cases received more than 6 months of ATT/rifampicin for history of TB, while it was 4 (2.8%) for drug-sensitive cases. Total 38.9% drug-sensitive and 10.5% drug-resistant patients in a Bangladesh-based (8) study had received ATT in past. A study in Gorakhpur by Venkatesh U et al., has shown that 74.5% of DRTB patients had received insufficient duration of ATT in past (5). This concludes that history of ATT intake significantly affects TB drug status. Investigation of drug resistance status is utmost important for appropriate TB diagnosis and treatment initiation.

Total 116 (51.1%) DRTB cases visited health facility for cough and fever as 1st symptoms. Djouma FN et al., had 96.5% patients with cough as 1st symptom (20). Paramasivam S et al., Sahu R et al., had reported cough in almost 93% patients, and 98% drug-resistant cases reported fever in another study from Bangladesh (21),(22),(23). The difference might be due to segregation of symptoms in the index study as cough, fever separately and cough+fever together as 1st reporting symptoms.

Patients visiting government facilities for initial symptoms were reported by 74 (32.6%) and 61 (42.4%) among the drug-resistant and sensitive patients respectively. Overall, 23.8% visited a public facility as reported by a study in Cameroon (20). A 60-70% patients from study by Nair N et al., had patients visiting private health clinic for their symptoms (24). This reflects that majority of the patients prefer a private health facility for the initial symptoms. That might be due to easy availability of doctors in private sector.

In the current study, 93 (41%) and 77 (53.3%) received ATT at the 1st reporting centre itself for drug-resistant and drug-sensitive cases respectively. Paramasivam S et al., reported that 18.5% were started on ATT at the 1st visit (21). A study from Jabalpur by Sahu R et al., revealed that 86.7% visited private facility but 25.0% were diagnosed as TB and given ATT at 1st visit, while13.3% visited government facility and among them 74.0% were diagnosed and initiated on ATT (22). A study on MDR from coastal southern India found that 57.5% of the total patients, who visited a health facility, were diagnosed and initiated on ATT (25). A study in Surat by Yadav SK et al., has revealed that 76.1% of DRTB cases were put on ATT at 1st visit as compared to 81.6% of drug sensitive cases (26). This suggests that there is lack in proper and timely diagnosis of TB in India whether they visit government sector or private sector, and is one of a bigger reason for emergence of DRTB apart from other factors. Drug sensitivity testing should be done on every high-risk patient of TB.

Total 6-12 months of ATT was received by 106 (46.7%) drug-resistant patients prior to final definitive diagnosis as drug resistant cases, while it was 112 (77.8%) for drug-sensitive cases. Almost similar was the findings of study by Venkatesh U et al., in Gorakhpur MDR-TB patients. These drug sensitive patients later, converted into drug resistant cases as 77.8% patients received delayed treatment as per the current study (5). If drug sensitivity testing is done at early stages rather than 6-12 months later, patients will get definitive treatment at the start of disease. This will reduce the further spread of drug resistant mycobacterium to most of his contacts. The burden of DRTB in society will reduce in a significant way.

Diabetes was among 11 (4.8%) and 14 (9.7%) drug-resistant and sensitive patients, respectively, while a study in Bangladesh by Rizvi SMS et al., has shown Diabetes among 15% of drug resistant and 17% among drug sensitive TB patients (9). Mistry N et al., has revealed 7.8% diabetic patients (18). A 7% were diabetic among DRTB patients in Gorakhpur study by Venkatesh U et al., (5). Diabetes hampers the immunity of the patients which in turn increase the susceptibility for TB. Patients with TB and DM come with atypical features with increased lower lung field cavities, lymphadenopathy, pleural effusion, segmental and lobar consolidation, and the presence of multiple cavities. Diabetic patients with poor glycaemic control exhibit lower interaction between Mycobacterium Tuberculosis (M.TB) and monocytes resulting in a heightened susceptibility to infection (27).

The HIV positive patients were 17 (7.5) among DRTB cases, while 10 (6.9%) among drug-sensitive patients. Bhawalkar J et al., had 15.2% patients with TB and HIV (12). This relatively number may be because Maharashtra has a high prevalence of HIV. Study in Gorakhpur by Venkatesh U et al., reported a relatively low rate of 3.8% HIV positive patient among DRTB (5). The increased incidence of active TB in HIV-infected individuals can be attributed to at least two mechanisms: the increased reactivation of latent TB or increased susceptibility to M.TB infection (28). In India, a TB-endemic country, most recurrences after successful treatment of TB are attributable to exogenous re-infection in HIV infected persons but endogenous reactivation in HIV uninfected persons (29).

As per current study, 78 (34.4%) drug-resistant patients were smokers at any time and 70 (48.6%) were from drug-sensitive patients. Rizvi SMS et al., (Bangladesh) reported that 52.6% were smokers among drug-resistant patients, while it was 16.7% for drug-sensitive cases (9). A study from Gorakhpur reported 43.3% smokers among DRTB patients (5). Smoking damages the lungs and impacts the body’s immune system, making smokers more susceptible to TB infection. The occurrence of TB has been shown to be linked to altered immune response and multiple defects in immune cells such as macrophages, monocytes and CD4 lymphocytes. Other mechanisms, such as mechanical disruption of cilia function and hormonal effects (30).

Total 50 (22.0%) drug-resistant and 53 (36.8%) drug-sensitive patients had the habit of drinking alcohol. This data was 41.4% in another study by Venkatesh U et al., and 42.8% in a study conducted by Bhawalkar J et al., (5),(12). Consuming alcohol causes essential vitamin deficiency which in turn hampers the immunity and subsequently TB. Heavy alcohol use strongly influences both the incidence and the outcome of the disease, and was found to be linked to altered pharmacokinetics of medicines used in treatment of TB, social marginalisation and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB (31).

Limitation(s)

The familial, social and regional stigmas associated with TB were not covered in the study.

Conclusion

Initial symptom with fever and cough and inappropriate investigations and delayed diagnosis plays a significant role for the emergence of DRTB. Multiple visits to health facility and delay in proper diagnosis with further delay in initiation of definitive treatment are very important factors. All patients who came with a suspicion of TB should undergo drug-sensitivity testing and treatment should be initiated accordingly. The management aspect of anti-TB drive should include social and behavioural changes of treatment seeking patients and person providing treatment at every level apart from only treatment regime protocol as was accepted earlier. Further study needs to be done comparing normal cases with drug-resistant and drug sensitive pulmonary TB cases taking more subjects.

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DOI and Others

DOI: 10.7860/JCDR/2022/52284.16356

Date of Submission: Sep 06, 2021
Date of Peer Review: Nov 11, 2021
Date of Acceptance: Feb 12, 2022
Date of Publishing: May 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 07, 2021
• Manual Googling: Jan 31, 2022
• iThenticate Software: Mar 05, 2022 (9%)

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