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BACKGROUND In most developing countries, sputum smear microscopy for acid-fast bacilli remains the front line and often the only diagnostic tool for the diagnosis of tuberculosis (TB), making quality assurance of smear microscopy an important activity. OBJECTIVE To evaluate the results of a pilot study, where the random blinded rechecking for the entire state of Delhi was conducted at a reference laboratory. METHODOLOGY Slides from 25 Revised National Tuberculosis Control Programme designated districts (200 peripheral microscopy centres) in Delhi were re-read after proper coding by all the Senior Tuberculosis Laboratory Supervisors (STLS) at an intermediate reference laboratory under proper supervision. RESULTS Of 12,162 re-read slides, 204 discrepant results were found. Of these, 150 (73.5%) errors were attributed to the peripheral microscopy centres and 54 (26.5%) to STLS. High false-positive errors were observed at a frequency of 12/150 (8%), and high false-negative errors at a frequency of 38/150 (25%). Minor errors, i.e., low false-negative, low false-positive and quantification errors, were observed at frequencies of respectively 68/150 (45.3%), 17/150 (11.3%) and 15/150 (10.0%). CONCLUSION Greater stringency in the supervision of random blinded rechecking at the district level is essential to make smear rechecking more efficient and effective.

Background Direct sputum smear microscopy is commonly used for diagnosing tuberculosis (TB). The objectives of the study were first, to determine the recovery of Mycobacterium tuberculosis in smear-negative sputum samples through liquid culture (using MGIT 960) and solid culture (using LJ slant) and second, to screen multidrug-resistant isolates through line probe assay and further third, to identify XDR isolates through MGIT second-line DST from these positive MDR cultures in Delhi region. Methods In this study, the sample size was 717 (sputum smear AFB negative and culture positive for M. tuberculosis complex by both solid and liquid culture methods) MDRTB suspects who were enrolled from January 2014 to December 2014 at the Intermediate Reference Laboratory in New Delhi Tuberculosis Centre, New Delhi. Rapid line probe assay was performed on all culture-positive samples, which were direct smear-negative specimens, and LPA-confirmed MDR samples were tested on MGIT 960 second-line DST for identification of XDR strains. Results An overall increase in the culture positivity (9.4%) among these smear-negative cases shows a good sign of recovery from M. tuberculosis infection in these samples. 717 (9.4%) positive cultures (MGIT + LJ) were subjected to line probe assay. Out of these 717 cultures, 9 (1.2%) were confirmed as NTM, 50 (7%) were MDR, 4 (0.6%) were mono-rifampicin resistant and 654 (91.2%) cultures were sensitive to both drugs Rif and Inh, respectively. Out of these 54 (50 MDR +4 mono-RIF resistant) cultures as screened by LPA, 1 (1.8%) was XDR, 10 (18.6%) were mono-ofloxacin resistant and 1 (1.8%) was mono-Kanamycin resistant. Sensitivity to both drugs KAN and OFX was seen in 42 (77.8%) cultures. Conclusions Since the bacterial load in direct smear-negative suspected MDR samples is less, it is important to recover mycobacteria by rapid liquid culture method in such samples. Initial screening for MDRTB is to be done in such cases by performing rapid molecular genotypic drug susceptibility test such as LPA. Baseline second-line DST is also done to rule out the XDR cases among them for rapid and better management of XDRTB patients.

Fluoroquinolones are among the most promising antibiotic drugs for Tuberculosis treatment. Although high levels of fluoroquinolone resistance have been detected among many common bacterial pathogens, little is known about the fluoroquinolone resistance of M. tuberculosis especially at the baseline. The present study was thus aimed at determining the profile of resistance against two newer generation fluoroquinolones-Moxifloxacin and Levofloxacin in MDR-TB isolates with baseline resistance to ofloxacin. A total number of 65 isolates (4 XDR and 61 pre-XDR) were subjected to susceptible testing against levofloxacin and two (higher and lower) concentrations of moxifloxacin. 72.3% in addition to being resistant to ofloxacin were also resistant to levofloxacin and lower concentration of moxifloxacin. The increasing use of FQs for the treatment of other bacterial infections has led to increasing resistance to these antimicrobials. Newer generation FQs are promising drugs in the treatment of drugresistant Tuberculosis but care should be taken regarding the rationale use of these drugs for the treatment of other diseases especially when other drugs are available.

Tuberculosis (TB) remains the major cause of mortality and morbidity throughout the world and has been cited by World Health Organisation (WHO) as the single most important fatal infection. In 2013 alone an estimated 9.0 million cases TB and 1.5 million deaths from this disease were reported. Of these 9.0 million cases, India alone accounted for 24% of the total cases [1]. In most developing countries including India, sputum smear microscopy remains the basis of diagnosis of TB.Correct reading of sputum smears is thus critical in initiating treatment in those who truly do have a disease, and to avoid unnecessary and sometimes costly treatment among those who do not. Keeping this in view, the International Union Against Tuberculosis and Lung Disease (IUATLD) and WHO recommend that quality control of smear microscopy be an essential part of an effective national TB control program [2,3]. In 2002 international working group recommended the lot quality assurance sampling (LQAS) for external quality assessment (EQA) of AFB microscopy which was adapted by Revised National Tuberculosis Control Program (RNTCP) of India in 2008 [4,5]. In India random blinded rechecking (RBRC) of routine smears after LQAS is done every month at district level by senior tuberculosis laboratory supervisors (STLS). Blinded rechecking of smears by STLS read at the periphery by the laboratory technicians yields a realistic view of daily routine performance of the laboratory technicians and allows identification of laboratories with problems that need to be solved. The STLS therefore plays an important role in EQA and is regarded as the controller in RBRC.The only limitation in the RNTCP EQA guidelines is that during RBRC only the performance of the laboratory technicians is assessed while the errors committed by the STLS are ignored and unreported. In order to assess the performance of STLS during RBRC we conducted a study where in RBRC of the entire Delhi state for one quarter of the year was conducted at reference laboratory instead of the districts. The study was conducted at New Delhi Tuberculosis Centre (NDTC) for the period of 3 months, i.e., from October 2014 to December 2014. NDTC serves as an intermediate reference laboratory (IRL) for Delhi state. The Centre is going through regular rounds of proficiency testing for smear microscopy and culture and drug susceptibility testing by the National reference laboratory; National Institute of Tuberculosis and respiratory diseases, New Delhi, India. A total of 12,162 slides were reread by STLS during the study period as per the EQA guidelines [6]. 204 discrepant results were obtained in this study and 54 (26.5%) of these discrepant results were attributed to STLS. Among the major errors, High false positive (HFP) errors were reported at a frequency of 8/54 (14.8%) and High False negative (HFN) errors were observed at a frequency of 10/54 (18.5%). Minor errors i.e. Low false negative (LFN), low false positive (LFP) and quantification errors (QE) were observed at a frequency of 11/54 (20.3%), 23/54 (42.59%) and 2/54 (3.7%) respectively. Significantly high number of errors committed by the STLS in this study is a major concern especially when RBRC is used as the method of choice for assessing the overall performance of the smear microscopy and STLS is the controller of the procedure. Although there seems to be no obvious reason for such high number of errors, careless work by the STLS and lack of motivation could be the possible reasons. Unfortunately no study till this date has been done to highlight the need of reporting errors committed by the STLS as RBRC is thought to be the method of assessing the performance of Laboratory technicians and not the STLS. The method for assessing the performance of STLS as per the EQA guidelines is the panel testing done once in a year during the Onsite evaluation (OSE) visit by the IRL team to the district.It is worth mentioning that panel testing is considered to be the weakest method of EQA and it gives an indication of capability rather than of true performance.STLS may score extremely well in this test because they know their work is being evaluated, but their daily work may remain unsatisfactory because of carelessness. The study therefore highlights the importance of having an in-built system to assess and monitor the performance STLS along with of the technicians of the periphery microscopy centers. The observation of the current study indicates that significant numbers of errors are committed by the controllers during RBRC and as per the existing reporting formats these errors are never reported. RBRC at a reference centre can provide a method for assessing the performance of STLS and laboratory technicians simultaneously. This however may not be possible in all the states owing to the distance between the districts and reference centre. We however do recommend that more stringency in the supervision of RBRC at district level should be made in order to make the rechecking more effective. A thought may also be given to the improvement of the current reporting format of RBRC and a column for errors committed by the STLS may be included so that necessary actions can be taken in due time.

The HIV pandemic has had a profound impact on the health and economic conditions of individuals, and people living with HIV/AIDS are faced with the task of maintaining optimal health status despite an increasing insult to their immune status. The aim of the present study was to study the profile of direct walk-in and referred patients attending the Integrated Counselling and Testing Centre (ICTC) of a tertiary care hospital, which may provide important clues to understanding the epidemiology of the disease in a particular region. The study included all the attendees of the ICTC referred from the hospital or direct walk-in from January 2007 to December 2007. Three rapid HIV tests were used and the samples showing positive results in all the three tests were declared HIV positive. The results were analysed to correlate between HIV positivity, age, sex, route of transmission and direct walk-in/referred patients. A low proportion of ICTC attendees (27%) in our study were direct walk-ins. As regards HIV positivity, 312 (8.3%) out of 2440 males and 164 (4.3%) out of 1315 females were HIV positive. Among the referred HIV-positive patients 162 were males and 62 females, whereas among the direct walk-in HIV-positive patients, 150 were males and 102 females. Integrated counselling and testing is now seen as a key entry point for HIV prevention. In addition to scaling up ICTC services, it is also important to raise awareness by aggressive health education programmes and integration of ICTC into various community organizations.

Objective: GenoType MTBDR plus line probe assay (LPA) is developed for performing drug susceptibility testing (DST) for Rifampicin (RIF) and isoniazid in sputum specimens from smear-positive pulmonary tuberculosis (TB) patients and revised national TB control Programme (RNTCP) has endorsed LPA for the diagnosis of multi drug resistant TB (MDR-TB). This study was conducted to assess the potential utility of LPA for MDR-TB patient management. Methods: MDR-TB suspects under RNTCP PMDT criteria C referred from different districts in Delhi state were included in the study January 2013 to December 2014. Sputum specimens found acid-fast bacilli positive by fluorescent microscopy were processed for LPA. R esults: Out of 3062 specimens, 2055 (67.1%) MDR-TB suspects were read as positive and specimens from 1007 (32.9%) suspects were read as negative in sputum smear microscopy. Out of 2019 specimens valid LPA results, 1427 were found to be pan-sensitive, 280 were MDR-TB, 40 were RIF monoresistant, 183 were Isoniazid (INH) monoresistant, and 89 specimens were found negative for Mycobacterium tuberculosis . C onclusion: Routine use of LPA can substantially reduce the time to diagnosis of RIF and/or INH-resistant TB and can hence potentially enable earlier commencement of appropriate drug therapy and thereby facilitate prevention of further transmission of drug resistant strains. Ke ywords: Multi drug resistant tuberculosis, Line probe assay, Rifampicin, Isoniazid.

The aim of this study was to determine the clinical, immunological and virological status of newly diagnosed AIDS cases and to monitor their clinical and immunological response to HAART after a minimum period of three months. Forty three drug naive AIDS patients were enrolled. The most common presenting complaints were weight loss (74.4%), cough (72.1%) and diarrhoea (67.4%). Mean baseline CD4 cell count was 112 ± 60 cells/μL and mean baseline plasma viral load of 31 patients studied was 192,686 copies/mL. Baseline plasma viral load was higher among patients with lower baseline CD4 cell count. During follow-up, 80.8% patients showed clinical improvement, while a CD4 cell count increased by ≥50 cells/μL in 84.6% cases. Mean CD4 cell count increased from 126 ± 16.6 cells/μL at baseline to 278 ± 196.7 cells/μL.

Introduction: In developing countries the standard methods used to monitor HIV disease progression and therapy response are clinical assessment, CD4+ T lymphocyte count measurement, and plasma viral load (PVL) quantification. These tests require expensive equipment and skilled technicians, so monitoring HIV in resource-limited countries remains challenging as few laboratories can offer these tests free of cost. Methodology: Newly diagnosed HIV seropositive subjects (n = 130) were categorized into three study groups: CD4 counts 500 cells/µl (group C, 43 subjects). At recruitment, PVL estimation was performed for group A subjects only, who were then initiated on highly active antiretroviral therapy (HAART) and were followed up after six months for evaluation of response to HAART by measuring the CD4 counts and PVL. Groups B and C were followed up after six months to monitor disease progression by measuring only CD4 counts. Results: Among group A subjects, a rise in the median CD4 counts after six months of HAART was observed. At baseline, PVL ranged from 2636 to >750,000 copies/ml with a median PVL at baseline of 165,000 copies/ml. At follow-up, 90% of the study subjects had undetectable levels of viraemia. Among group B and C subjects, a fall in the CD4 counts at follow-up was observed. Conclusions: CD4 count is a powerful tool to determine response to antiretroviral therapy (ART) and monitor disease progression in HIV/AIDS. PVL is important to assess response to ART, especially in immunovirologic discordant responses.