Sputum smear microscopy at two months into continuation-phase: should it be done in all patients with sputum smear-positive tuberculosis?
BACKGROUND
The Revised National Tuberculosis Control Program (RNTCP) of India recommends follow-up sputum smear examination at two months into the continuation phase of treatment. The main intent of this (mid-CP) follow-up is to detect patients not responding to treatment around two-three months earlier than at the end of the treatment. However, the utility of mid-CP follow-up under programmatic conditions has been questioned. We undertook a multi-district study to determine if mid-CP follow-up is able to detect cases of treatment failures early among all types of patients with sputum smear-positive TB.


METHODS
We reviewed existing records of patients with sputum smear-positive TB registered under the RNTCP in 43 districts across three states of India during a three month period in 2009. We estimated proportions of patients that could be detected as a case of treatment failure early, and assessed the impact of various policy options on laboratory workload and number needed to test to detect one case of treatment failure early.


RESULTS
Of 10055 cases, mid-CP follow-up was done in 6944 (69%) cases. Mid-CP follow-up could benefit 117/8015 (1.5%) new and 206/2040 (10%) previously-treated sputum smear-positive cases by detecting their treatment failure early. Under the current policy, 31 patients had to be tested to detect one case of treatment failure early. All cases of treatment failure would still be detected early if mid-CP follow-up were discontinued for new sputum smear-positive cases who become sputum smear-negative after the intensive-phase of treatment. This would reduce the related laboratory workload by 69% and only 10 patients would need to be tested to detect one case of treatment failure early.


CONCLUSIONS
Discontinuation of mid-CP follow-up among new sputum smear-positive cases who become sputum smear-negative after completing the intensive-phase of treatment will reduce the laboratory workload without impacting overall early detection of cases of treatment failure.
Office of World Health Organization Representative in India, New Delhi, India. gandhim@tbcindia.nic.in
Mohit Padamchand
MP
Gandhi
Ajay M V
AM
Kumar
Manoj Nandkishor
MN
Toshniwal
Raveendra H R
RH
Reddy
John E
JE
Oeltmann
Sreenivas Achuthan
SA
Nair
Srinath
S
Satyanarayana
Puneet Kumar
PK
Dewan
Shamim
S
Mannan
D000465:Algorithms; D000995:Antitubercular Agents / Q000627:therapeutic use; D005500:Follow-Up Studies; D006801:Humans; D007194:India / Q000453:epidemiology; D012042:Registries; D013183:Sputum / Q000382:microbiology*; D013997:Time Factors; D017211:Treatment Failure; D016896:Treatment Outcome; D014376:Tuberculosis / Q000175:diagnosis* / Q000188:drug therapy / Q000453:epidemiology
D000995:Antitubercular Agents