International Journal of Current Research and Review
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IJCRR - 6(10), May, 2014

Pages: 45-50

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SPOT AND EARLY MORNING SPUTUM REPORT STUDY FOR DIAGNOSIS OF PULMONARY TUBERCULOSIS AT DMC OF MEDICAL COLLEGE VADODARA, GUJARAT: A RETROSPECTIVE ANALYSIS

Author: Meghna M. Patel, Apurv N. Patel, Jitendra A. Sisodia, K. R. Patel, Kalpita Shringarpure

Category: Healthcare

Abstract:Tuberculosis, caused by Mycobacterium Tuberculosis is a major public health problem. India is the highest tuberculosis burden country across the globe. Under the Revised National Tuberculosis Control Programme (RNTCP) diagnosis of pulmonary tuberculosis is done by sputum smear microscopy using Zeil-Nelson staining method. For sputum microscopy, two sputum (spot and early morning) samples are collected. Spot sample is collected at the time of first visit of patient to laboratory and early morning sputum is collected the next day. This study is based on retrospective analysis of spot and early morning sputum microscopy samples tested in the year 2012 and 2013 at Designated Microscopy Center (DMC) of Government Medical College, Vadodara, Gujarat. This study showed that the observed difference in sputum sample positivity in the two groups, viz. spot sample and morning sample in diagnosis of TB is statistically insignificant (Chi-square value 1.703 and 0.00584 respectively, P value 0.191 and 0.939 respectively).

Keywords: Tuberculosis, Sputum microscopy, Spot sputum, Early morning sputum

Full Text:

INTRODUCTION

Tuberculosis (TB) is an infectious disease caused by Mycobacterium Tuberculosis. It typically affects the lung but also affects the other systems as well (Extra-pulmonary TB). In 2012 there were an estimated 8.6 million incidents case of TB and 1.3 million people died from the disease globally1 . India is the highest TB burden country with WHO statistics giving the total incidence of 2.2 million case of TB out of a global incidence of 8.7 million cases and an estimated TB prevalence of 3.1 million (2011). It is estimated that 40% of Indian population is infected with TB2 . Infectious sputum-positive TB patients with pulmonary disease produce droplet nuclei through coughing, sneezing and talking. It is estimated that one infectious case, on an average, infects about 10 -15 new cases every year. The concentration of bacilli in the sputum of a TB case correlates well with the infectivity of the TB patient. This is the reason why smear microscopy is a sensitive tool for identifying infectious cases and it is used as the mainstay diagnostic tool for tuberculosis control in India3 . In 2011, the new sputum positive (NSP) case detection rate was 71% and treatment success rate was 87%. Quality assured sputum smear examination facilities are available through more than 13,000 Designated Microscopy Centers (DMCs) across the country. The new vision of

RNTCP under the next five year plan (2012-2017) is of a TB free India and for achieving this vision, one of the targets is early detection and treatment of at least 90% estimated TB cases in the community including HIV-associated TB4. The older RNTCP guidelines required examination of three sputum specimen (spot-early morning -spot) by Zeil-Nelson (Z-N) stain for acid fast bacilli over two consecutive days. From 1st April 2009, under RNTCP two sputum specimens are collected over one, or two consecutive days. Of the two sputum specimens, one is collected on the spot and the other is an early morning specimen collected at home by the patient5 . The spot sample is collected at the first visit at laboratory and for the second early morning sample, sputum container is given to the patient, who collects the sputum early in the morning and submits it to the laboratory. Microscopy services currently require patients to make repeat visits to the healthcare facility. This is associated with considerable patient costs and patient drop-out during diagnosis. The new WHO definition of a smear positive case does not require confirmatory smears. This allows patients to be diagnosed on the basis of a single smear6 . A two day visit of patients to the health facility affects patients’ daily wages. Many patients do not come for submitting second early morning sputum sample due to cost, job related issues or due to some other reasons. Patients have to spend time and money behind it. Because of this, many patients remained undiagnosed and untreated. Undiagnosed and untreated sputum positive TB cases are the source of infection in community3 . If two sputum examinations are done on the first day of visit, it will reduce the number of visits and patient dropout rate. Objective To compare the sensitivity and specificity of spot and morning samples versus spot+ morning sample.

MATERIALS AND METHOD

This retrospective analytic study was carried out in Department of Pulmonary Medicine, based on sputum samples collected at DMC of Medical College, Baroda. In this study retrospective analysis of spot and early morning sputum sample result was done. At DMC, Sputum sample examination is done by Z-N stain for AFB and laboratory register is maintained as per RNTCP guidelines7 . Data of sputum examination results was collected from laboratory register of DMC for calendar year 2012 and 2013. In the laboratory records, spot sample is registered as sample A and early morning sample as sample B. As per RNTCP guide line if one sample out of two is positive then it is labeled as sputum positive5 . Inclusion Criteria: Data of sputum examination of both spot and early morning samples was collected from register. Exclusion Criteria: Record of sputum examination in which either spot or early morning result was missing were excluded in data collection. Statistical methods The sensitivity, specificity, positive predictive value, negative predictive value of two samples was calculated. Test of association between spot and early morning sample was done using ChiSquare test.

ESULTS

In 2012, total 5331 TB suspects were examined and amongst them 1017 were found to be positive and 4314 were negative. Out of total 1017 positive cases , total number of patients with both spot and early morning positive sputum report were 924, only spot positive were 20 in number and only early morning positive were 73 in number [Table 1 and 2]. Spot sample when compared with spot plus early morning sample gave sensitivity of 92.67%, specificity 100.16%, positive predictive value 97.88%, negative predictive value 98.33%. While early morningsample when compared with spot plus early morning sample gave sensitivity of 97.88%, specificity 98.33%, positive predictive value 92.67%, negative predictive value 99.53%. In 2013 total 5495 TB suspects were examined and amongst them 937 patients were found to be sputum positive and 4541 patients were sputum negative. Out of total 954 positive cases , total number of patients with both spot and early morning positive sputum report were 902, only spot positive were 24 in number and only early morning positive were 28 in number [Table 3 and 4]. Spot sample when compared with spot plus early morning sample gave sensitivity of 96.98%, specificity 99.47%, positive predictive value 97.40%, negative predictive value 99.38 %. While early morning sample when compared with spot plus early morning sample gave sensitivity of 97.40%, specificity 99.38%, positive predictive value 96.98% negative predictive value 99.47 %. There is no significant difference in sputum positivity as detected using spot or morning sample alone for sample collected in 2012 and 2013 (P value 0.191 and 0.939 respectively). [Table 5 and 6]

DISCUSSION

In 1993, the WHO declared tuberculosis to be a global health emergency.8 The most common and widely used diagnostic method for diagnosis is sputum smear microscopy in which bacteria are observed in sputum sample under microscope1,9 . The current RNTCP guideline recommends two sputum examinations, one is spot and other is early morning sputum5 . It requires two days visit to health facility, thereby increasing chances of patient drop out. If sputum examination is done on the first day of visit then patient will save the cost of travelling and daily wages, reduce chances of transmission of tuberculosis while travelling and reduce the number of visit and thereby the patient dropout rate.

Statistical analysis for association between positivity of samples in present study showed that spot sample is as good as early morning sample for diagnosis of sputum positivity and difference between two samples is by chance. Few studies by T. Jaya Chandra, Dr. Shafiyabi S. et al and Yassin MA et al showed that one day method test approach was equally effective as two days method in identifying cases10, 11, 12 . However, cross-sectional study conducted by Priyakanta et. al. showed that same day sputum microscopy method missed 17% of smear positive cases in their study13 . A pilot study conducted by Myneedu VP et.al. concluded that same day sputum microscopy does not seem to be a promising step towards improving quality of sputum14 . If result of one sputum turns out to be positive, the second sputum sample examination may not be much helpful without compromising quality of sputum. Examination of first day two sputum specimens taken one hour apart is much more convenient to the patient and as well as for operational purpose in RNTCP. Diagnosis of smear negative pulmonary tuberculosis can be increased by doing Chest X- ray examination on same day.

CONCLUSION

From this study, it may conclude that spot sample is as good as early morning sample sputum sample for diagnosis of sputum positive pulmonary tuberculosis. Same day two spot specimen examination one hour apart will be helpful for early diagnosis and reduce patients’ dropout rate for follow up visit on next day. Because of patient friendly strategy, diagnosis of smear negative Pulmonary Tuberculosis cases may increase indirectly and it will possible to implement it on operational grounds under programmatic condition. However, multi-centric large scale studies are required to effectively implement this strategy under RNTCP. This provides furtherscope for studies for diagnosis based on two spot and one overnight or same day versus routine protocol for sputum examination.

ACKNOWLEDGEMENT

We would like to express our gratitude to Dean and Medical Superintendent of Medical College Vadodara for their constant encouragement and guidance for research publication. We authors are very much thankful to District TB officer and all staff members at Designated Microscopy center at Medical College, Vadodara for their constant and valuable support. Our heartfelt thanks especially to laboratory technicians of DMC who gives their valuable guidance in collecting data for study. The authors would like to acknowledge all authors whose cited articles guided us in conducting this retrospective study and provided very much insight in preparing this research article. The authors are very much thankful to editors and publishers of books and of journal from where we got literature for making this article successful. Last but not least we are very much thankful to our residents doctors for their support and enthusiasm.

Abbreviations: DMC : Designated Microscopy Center TB : Tuberculosis AFB : Acid Fast Bacilli Z - N Stain : Zeil - Nelson Stain RNTCP : Revised National Tuberculosis Control Programme WHO : World Health Organization

References:

REFERENCES

1.Basic facts about TB .Global tuberculosis Report 2013, WHO. URL: http://apps.who.int/iris/bitstream/10665/91355/1 /9789241564656_eng.pdf. Access date: 04/02/2014

2. TB Facts. TB Statistics of India. URL : www.tbfact.org. Access date: 02/02/1014

3. Roy Dipanjan, Chauhan L.S. Epidemiology of Tuberculosis. Tuberculosis Control in India. Directorate General of Health Services, Ministry of Health and Family Welfare New Delhi: Elsevier 2005. URL: http://tbcindia.nic.in/pdfs/Tuberculosis%20Co ntrol%20in%20India-Final.pdf Access date:05/02/2014

4. Sachdeva KS, Ashok Kumar, Dewan Puneet, Kumar Ajay, Satyanarayana Srinath. New Vision for Revised National Tuberculosis Control Programme (RNTCP): Universal access-“Reaching the un-reached” Indian J Med Res May 2012;135:690-94. Access date:05/02/2014

5. Diagnosis of smear positive pulmonary TB New guidelines, effective from 1st April2009. URL:http://www.tbcindia.nic.in/pdfs/1b%20% 20Diagnosis%20of%20smear%20positive%20 pulmonary%20TB.pdf. Access date:06/02/2014

6. New laboratory diagnostic tools for tuberculosis control, stop TB partnership. URL:http://www.stoptb.org/assets/documents/ global/retooling/Diagnostic_Brochure_Print_2 009_Jan_29.pdf Access date:06/02/2014

7. Chauhan MM, Mahadev B, Balasangameshwara VH (Editors). Manual on isolation, identification and sensitivity testing of Myco. tuberculosis. National Tuberculous Institute Bangalore. Govt. of India Edition 2, 1998 . URL:http://ntiindia.kar.nic.in/cddistrictlevel/ie learn%5Ccategory%5CBooks%5CNMCMCH 98.pdf Access date:01/02/2014

8. Maru DS, Jason Andrews. Epidemiology: Global Perspective. In: Tuberculosis. India: Jaypee,2009; 6:103. Surendra K Sharma,Alladi Mohan(Editors).

9. Partnership Stop TB(2006): The global plan to stop TB,2006-2015. Action for life: towards aworld free of tuberculosis. Int J tuber Lung Dis 10: 240-241. Pubmed : 16562700. Access date:31/01/2014

10. T. Jaya Chandra. Same day sputum smear microscopy approach for the diagnosis of pulmonary tuberculosis in a microscopy center at Rajahmundry. Indian journal of Tuberculosis; 59:141-144. Access date:15/02/2014

11. Shafiyabi S., Ravikumar R., Ramaprasad, Krishna S. Study of same day sputum smear examination in diagnosis of Pulmonary Tuberculosis under RNTCP. Sch. Acad.J.Biosci.2013;1(7)):352-356. Access date: 28/02/2014

12. Yassin MA, Luis E. Cuevas. How many sputum smears are necessary for case findings in pulmonary tuberculosis? Tropical medicine and international health,2003;8(10):927-932. Access date: 15/02/2014

13. Nayak P ,Ajay M.V Kumar, Mareli Claassens, Donald A. Enarson, Srinath Satyanarayan, Debashish Kundu et al. Comparing same day sputum microscopy with conventional sputum microscopy for diagnosis of tuberculosisChhattisgarh, India. PLoS ONE 8(9): e74964. Access date:02/03/2014 14.

14. Myneedu VP,Verma Ak, Sharma PP,Beher D.A pilot study of same day sputum smear examination,its feasibility and usefulness in diagnosis of pulmonary TB. Indian J Tuberc.2011 Oct; 58(4):160-7. Access date:10/03/2014

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Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

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This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

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‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

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A Study by Manoj KP et al. entitled "A Randomized Comparative Clinical Trial to Know the Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block Against Multimodal Analgesia for Postoperative Analgesia Following Caesarean Section" is awarded Best Article Award of Vol 13 issue 23
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A Study by Sharipov R. Kh. et al. entitled "Interaction of Correction of Lipid Peroxidation Disorders with Oxibral" is awarded Best Article of Vol 13 issue 03
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
A Study by Habiba Suhail et al. entitled "Effect of Majoon Murmakki in Dysmenorrhoea (Usre Tams): A Standard Controlled Clinical Study" is awarded Best Article for Vol 12 issue 22
A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
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A Study by Jabbar Desai et al. entitled "Prevalence of Obstructive Airway Disease in Patients with Ischemic Heart Disease and Hypertension" is awarded Best Article for Vol 12 issue 17
A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
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A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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