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Can we eradicate TB in India?

Mar 28 | 2:00 PM

Tuberculosis (TB) is one of humanity's oldest diseases, dating back over 17,000 years based on molecular evidence. Despite modern diagnostic and treatment approaches, people continue to suffer from tuberculosis, and it remains one of the top ten deadly infectious illnesses in the world, second only to HIV. TB is a worldwide pandemic, according to the World Health Organization (WHO). Let's hear from Dr. Bhavini Shah, a renowned microbiologist and Director of Neuberg Supratech Laboratories in Ahemdabad, on whether India can eradicate TB!

[Music] good evening everyone this is dr vrushali from team medflix and we welcome you all for today's session that's can we eradicate tb in india today we have with us dr bhavini shah she's the co-founder of the neuberg supratech labs in ahmedabad she has over 29 years of experience in medical microbiology and tuberculosis with her in extensive experience of 28 years she works in the field of clinical and molecular microbiology and is a researcher in tuberculosis she also looks after the infection prevention of tertiary care units and she's well versed and very familiar with the national and international accreditation along with the documentation for the same so i welcome you ma'am team medflix welcomes all of you for this session thank you so a very good evening to all of you uh i am dr bhavini shah and i think the little bit whatever was needed was already said by vrushali i hope i'm clear so but today i'm going to talk on can we eradicate tuberculosis in india it is a very sensitive heading but this relates only to diagnostics as of now there are tons of clinical aspects also but being a microbiologist this heading and this discussion is a challenge only for diagnostics so i would just quickly like to go i mean all of you who have joined relatively know what tuberculosis is all about it has been with us for a very long time a bacterial disease most of us at least 80 percent of us would think it is caused by mycobacterium tuberculosis let me give you a small peep into what diagnostics is all about today this is a graph with reference to tuberculosis that we have seen it has always gone higher and higher this was published in 2017 and 2019-20 have been covid but if you see data in literature the graph has gone higher with significant increase in drug resistance tb that is the drtb so now i have clinicians with me i have these quick questions you could answer it yourself and it's nice to be honest on a platform like this so that we exactly know what is the weakness and where we should work upon so whenever we send in a patient for diagnostics what is it that we ask do we request only for an afb smear if yes why i would say maybe my clinicians tell me it's the finance or they tell me that oh the patient has you know just a patch in the x-ray and we just want to rule it out the smear is positive now what what would you do would you treat the patient that oh it's primary Kochs you know let's begin with AKT or would you ask for other diagnosis so these are some bugs i've written all of you should go through this carefully it is mycobacterium chelonae fortuitum abscesses avium kansassii smegmatis and many many many more thousands of them so what are these bugs then these are ntm mott or atypical mycobacteria so this is one thing all of us who are here should know that these exist these are very much with us they are here to stay so what are these ntm just to give you a small brief so that we could understand the difference when it is pathogenic and when it is not they are normal colonizers of the respiratory tract normal inhabitants of water and soil today they are commonly isolated as pathogens from pulmonary and extrapulmonary specimens they are commonly addressed as atypical mycobacteria by clinicians and surgeons so these are a few guidelines you should just keep it in mind because they are normally respiratory tract colonizers so how would you call it relevant these are ats guidelines which very clearly define when would you call a isolated ntm a pathogen suppose you are sending a sputum sample or a bile sample or a trans-bronchial biopsy when would you say that this isolated ntm is a pathogenic organism these are ats guidelines very freely available you could always google also and download it if this is not something you could write down so fast so now that we have ntm before we go into the details we just need to know a basic concept of ntm mott or atypical mycobacteria i will call them ntm so that we save some time on that ntm have different species like candida if i have microbiologists here they would relate to what i'm saying candida we need to speciate if they are non-albicans because the treatment depends on the species the same is the case with ntm treatment is species specific so if i as a microbiologist was to report on a specimen saying that this is an ntm it is very difficult to begin with ntm therapy in the broad spectrum because as it is we know we are going into amr even in case of tuberculosis so if we start using the drugs left and right it's going to be difficult so speciation of ntm is mandatory so please it's a request for you and all your colleagues who are not here that if you get an atypical bacteria whether you are going to treat it or not it should be documented as to what species that ntm was so you could just go through this i have some rapid growers here which i see are abcessesus chelonae fortuitum kansassii mycobacterium avium complex and you can see very easily there what is the drug regimen which is recommended so if you just treat it as atypical mycobacteria we would lead to resistance and a failure of clinical management so now getting back to our core that is tuberculosis what are the modalities that are available today we have smear for afb we all know about that it could be a zn smear it could be a fluorescent strain but it is smear study which was tell you it is smear positive or smear negative now please note here that a stain will not be able to tell you whether the bacteria is life or dead so this should be taken with a pinch of salt when you are seeing smears for those patients who are already on treatment they are just showing you presence or absence not the viability of the bug second is naat testing cb naat somebody had written your yes cb naat should be mentally mandatory it is an excellent modality a quick modality genexpert or naat testing for mtb we now have mdr and xdr both while i'm talking about this let me share with all of you i don't know how many of you are using cb naat if you are microbiologists right please remember there are two things available one is for rifampicin that is mdr the xdr naat that is available gives you second line injectables [Music] very very careful here that mdr the ultra naat testing that you get will detect 13 bacilli per ml 13 cfu per ml 1 3 the xdr will detect 135 cfu per ml see the difference 1 3 and 135 so if you are going to request for a patient cb naat ultra the first only rifampicin if you get a positive you would say okay go ahead with xdr but the xdr may come negative because if mtb is low very low trace it is give you going to give you xdr negative so please think before you request could save a little bit of patience money which could be used for the gold standard of afb culture the line probe assay is a molecular method just like mac testing remember molecular methods of naat testing and line probe assay again will not show the viability of the bacteria whether they are live or dead even genexpert positive does not mean that the bacteria is live so genexpert and line probe assay both are molecular methods mdr xdr are both available naat testing is rapid line probe assay could take 48 to 72 hours the gold standard remains afb culture and of course dst liquid medium which has MGIT and it has the biomedical equipment also lj medium which is the solid medium could be helpful only in case of some species of ntm in our personal experience lj medium does not help a lot in the final conclusion of tb so we use it only as a parallel second methodology now when you speciate ntm what are the modalities that are available to speciate ntms the line probe assay which has ntm cm cm stands for common mycobacterium and ntmas that stands for additional species so both cm and as both of them have limited number of species so if the species falls in that database then you would be able to detect it in case of line probe assay the best modality is the maldi tof the maldi tof is a laser-based mass spec which has a huge database for indians so it saves money it is quick and it is reliable lpa otherwise have bands so interpretation skills are also important maldi tof is one of the gold standards for identification or speciation of any bacteria any fungus any mycobacteria then comes the mic of ntm just like how we have mic for bacteria we also have technologies by which we can give drug sensitivity for emptiness that is also readily available by microbroth dilution the latest the last is pyro sequencing and whole genome sequencing we have been doing i think we have done about 250 whole genome sequencings and i think we need a whole talk on whole genome sequencing as to how it will revolutionize and change the practice of tb drug workup i would just like all of you i have some questions here maybe if uh dr vrushali could help me i could take it in the end if she could just list down the questions yes yes ma'am so this is a very nice graph all of you could just quietly go through this i will give you a minute to grow through this these are three things that are available today the smear the culture and the molecular method on the smear if you see it is zn and fluorescence remember fluorescence you will pick up easily even if fewer in number because you see it under high power so if you want yes somebody's written you could pinch it to you know zoom it if you want to read it better in case of culture as i discussed lj and automated cultures lj in our opinion has a little low sensitivity depends on the infrastructure of the lab could come in with a lot of contamination so we use it only as a secondary method in case of automated cultures what is the advantage it helps you to grow both mtb and ntm dst also happens on the same speciation i gave you the different methodologies of lpa and maldi tof culture will always remain the gold standard for tb as of now in case of moleculars there could be tb pcr it is a home brew test lbt and ivd approved please remember all clinicians if we are here quality comes with a price if somebody is giving you a test which is 200 rupees cheaper for tb pcr the sensitivity also will be 200 times cheaper so for the patient for the sake of the lungs of the patient for the same sake of clinical failure please see what you're getting your patient tested for ask for the methodology if it is an ivd approved test it is definitely a good test if it is a home brew test you need to remember what is the sensitivity of the test when we talk about naat testing remember naat testing is also a molecular pcr there it is going to give you a quick result it is a closed system it is a who approved system there are limitations when mycobacteria is very very low in load that is if it is trace we did have a lot of issues if you have it please don't shy away from publishing it because people need to know as a country as india our weakest challenge is publishing so very important if you find a problem if you find that you are having a trace and the culture is growing ntm please remember it is important to publish so a lot of people can come on the same page because when the genetic material is less it fails to identify rifampicin mutation and at times ntms are also identifies as mtb trace so please keep this in mind when you are sending your patients for line probe as i told you you have mtc you have rifampicin you have inh together line probe assay gives you both mdr and xdr are of course from lpa speciation of ntm your tat would be 48 to 72 hours depending on the lab whole genome sequencing is a superb modality it will give you everything from first line to second line to all the mutations that are present but as i said it is something we need to talk about for an hour alone so we will skip that just letting you know that there is a modality like this so this as i said try and see the statistics this can detect 10 000 bacilli per ml okay 10 000 nine to ten thousand bacilli now when you're looking at naat testing it can detect thirteen bacilli one three this is nine thousand to ten thousand bacilli so you can see the difference if you're seeing a smear a smear negative can one million times be a naat positive this is i'm relatively explaining it to you that why naat testing is so important that even if you have 13 bacilli per ml it is going to give you positive so afb smear positive is not always mtb is the learning lesson here ntms will also be smear positive now if you are going to do a smear which is two plus right and your genexpert on naat testing is negative this is a clear indirect evidence that this is an ntm because smear positive should 100 percent be naat positive for mtb so if mtb is negative you should immediately be able to tell your clinician this is an ntm for sure please proceed with treatment if it is a pus sample if is it if it is a sputum sample you must understand it could be a normal respiratory flora even in case of a bowel sample these are just some pictures for people who are clinicians and not microbiologists if you see if you pinch here you will see in the second slide i have tons of patients coming to me from rural areas who have been diagnosed as smear positive afb and they are on akt for a very long time not responding these are nocardia when small fragments of nocardia just spill away they look like afb so for those who have been unable to see nocardia or cannot appreciate nocardia everybody has to learn it once for people who have not been able to see nocardia they could very easily report this as afb the patient would be on att and would not respond and then would come to tertiary units like others and find out that this is nocardia so the damage is done to a large extent so this as i said automated system both for mdr and xdr ultra as i said 13 bacilli 13 colony forming units per ml while the xdr has 133 so please keep this always in mind though it is the validation is not for all extra pulmonary specimens i think the whole world is using it and it gets good results also remember in the indirect evidence of help from naat testing if your smear is positive genexpert negative it definitely is an ntm so this is how the graph shows the clinicians might not have a lot of fun but for microbiologists it is very important to look at the graphs errors are very visible in the graphs this is the line probe assay as i said directly from smears smear positive and negative it is a genotypic method for both naat testing and line probe assays remember they are they could be that bacilli too the viability is not tested these are all different types of mutations not important when we do whole genome sequencing maybe sometime we could discuss these mutations this is a small picture of the line probe assay it comes like this see what is the challenge between naat and line probe assay we have tons and tons and tons of lab across the country who do this and covid has actually made everybody do this whether skilled or not now this is a very skilled test because interpretation becomes very important the first three bands are control bands the next bands that you see are of rif and the last two that you see are of inh now a light band missing a wild type band no mutant and missing a wild band there are tons of interpretations so if the lab or the reporting head is not very familiar with interpretations it's a learning curve for everybody then there could be an issue of results which would eventually affect your clinical management so it should be very clearly understood the clinicians actually need to know what they are sending for the test and what results they could question the results so very important for the clinicians also to understand this because of a lab is reporting without understanding the interpretation what happens is the clinician is only going to look at the report not understanding the sensitivity the specificity the interpretation so very important for the clinician to say i want this trip also with my result so he or she himself can look at this strip so this is for xdr we can skip that this is a quick comparison for the clinicians this is all readable and i've already discussed this so this is all as i was telling you common mycobacteria you could again pinch and see at the bottom you can see all the species and this is how the bands appear when you do a line probe assay which helps you to conclude as to what species it is but only these many species will come in the common mycobacteria so if you do an lpa for cm it is very much possible that you will have none of these and the lab would report as recommended to do additional species so you are going to pay for this so please don't get upset with the lab you know that oh we have paid for it and how can you say microbacterium species you need to know that this has limitations and it is only these number of bugs if present it will be able to identify same for additional species this remains the gold standard personally i prefer the automated system at any point of time positive cultures can directly be processed for genexpert and lpa and whole genome sequencing please remember if a culture is positive you have an xdr patient or an mdr patient for that then from the isolate you can immediately run on naat testing if sometimes what happens practically that a surgeon sends a lymph node and he does not request for an naat testing because they're not used to it they would say oh do just an afb culture so the lymph node goes into biopsy and goes into afb culture it's later on that the patient is referred maybe to medicine id pulmonologist and he says oh i want an naat testing but now everything is gone the specimen is no longer there but the patient has a suspicion of xdr he is not responding so the clinician can request that oh the culture is positive please from the positive culture please run an naat for me so on the same day you would get a rif now you could get an xdr also from that because it would have lots of bugs in that so mdr xdr naat testing both could be done within 2-3 hours from the positive culture you could also do a lpa a whole genome sequencing will give you everything first line second line etc but it would take time more than a week for whole genome sequencing one more takeaway learning here is that 60 percent of the global and around 38 of the indian population has monoresistance to inh please remember this this goes with my heading of my topic today will india eradicate tuberculosis because if you are going to do only naat testing mdr and start treating the patient with att that he is sensitive you are missing out on 38 of the population which could have more no resistance to inh i report one almost every day so please be cautious only if sensitive does not mean that inh will also be sensitive so this is just a quick look at the machines that's the so this we would talk later sometime maybe these are all the molecular sequencers that are available on which we run technology in sequencing changes or i think every two months so you know it's a whole whole new topic on its own so we take sequencer in our pockets the nano sequencer is so small it's like an ac remote see this is the nano sequencer it's actually smaller than an ac remote i put my office ac remote here and i put the nano there just so that relatively you could know how fast technology is growing and in my opinion success of clinical management comes from current knowledge you know because as microbiologists or as people from diagnostics we are a total failure if we are unable to convince the clinician of the modalities that we are using so it is very important to for clinicians also to work hand in hand and understand the technology that is available so this is a humble request to all clinicians who are online today walk into your lab see what is available see how you can grow see what you need and i think it will be a great communication so these are all different generations of sequencing so as i rightly said technology has no value if the clinician is not convinced of its benefits now when i show you this again you would understand it better i'll again give you half a minute to go through this now you would understand better as to if a patient is coming to you how will you go ahead with it and if you miss out something what's going to go wrong if you're seeing a smear positive and beginning with att what is going to happen it could be an ntm it could be an ntm and it's only we have tons of patients coming to us after you know maybe a year maybe a year and a half of taking the drugs and then getting diagnosed as ntm because they have not been responding to the first line and the second line we have tons of patients who get ntms even from cesarean sections or let's say their laparoscopic wounds but in centers rural centers specifically only a smear is seen which is afb positive and they begin with att the drug is taken for more than a year the patient gets tired and then the patient is referred to other tertiary units when the specimen comes to us so very very important if a smear is positive it is not necessary that it could be mtb so please keep this in mind and go ahead if nothing else of the patient is non-affording request your lab to do an afb culture by an automated liquid system please don't rely on lj medium it is actually very harsh your lab would do it free of cost if the patient really needs it but the money that you're spending on the drugs you're not going to spend 100 on a culture and i think all the government organizations give free cultures and free therapy so please use that it's the gold standard this is some data this is uh this is my data which is now already published i've written under publication but it's already published in the indian journal of tuberculosis all of you would be able to see it online if your members there so this is a data of almost eight nine thousand patients if you see here you will see negative smear with genex positive right negative smear with genex positive so which is 513 that is 9.37 patients they had genexpert positive now think about this if they did only an afb smear and did not do naat testing you would have missed out on 10 of the population who had tb this is what i am trying to explain i have not put in all my data negative smear with genexpert negative both are negative but culture was positive so if you didn't do a culture you would have 60.41 of the patients who would go home saying i don't have tb and at 40th day you would have afb culture positive so you are missing out on 13.72 of the population who has tb think about this these patients are going to come back again with a bad lung how diagnostics plays such an important role in being able to eradicate tb and not eradicate tb smear is positive and genexpert is negative right so i had 71 patients like these which is 1.30 percent so this population only from this number only at my center had ntms now if it was only smear positive and it was treated the patient was never respond to att no smear with genex that is 188 positive and 644 were negative now genexpert negative 644 think about this they could have been smear positive they could have means smear positive and genexpert was negative you could have saved time for the patient you could have started treating the patient with ntm therapy till the culture came positive these were no cultures were requested in these patients you could see this this is the second slide negative smear with genex positive and afb culture see afb culture negative were 27.29 i've highlighted what is important negative smear genexpert was positive they requested for afb culture also but 27.29 that is almost 28 percent of the population has dead bacilli right so only for genexpert is positive and you keep on treating it it is again irrational use of the precious drugs that we are using again negative smear and genexpert negative had how many positive 2.78 percent three percent of the population was culture positive all treated patients all on treatment patients so that means if you do a negative smear and a genex negative and stop treatment you have three percent of the population which comes back after six to eight months becoming symptomatic positive smear and genex also positive where culture was negative again it is almost nine percent positive smear with genex negative this is ntms as i said but afb culture was positive which was 47.8 that means almost 48 so this is something to think about for all the clinician why the whole workup is important for each and every patient so i have a case here 15 year old female may 2018 low grade fever with occasional cough patient was already elsewhere started on treatment no improvement october the patient came to us with high grade fever cough and hemoptysis sputum afb smear was negative what should be the immediate step in the management of this patient immediately start with second line because patient was not responding genexpert naat testing mdr or xdr lpa on bal or tb mgit culture and dst you could think about it as a clinician as a microbiologist what would be the first thing that you would do earliest diagnosis of dr tb should be the dictum in management of tb very very important to remember that time it's not that i mean patients have been with that for years but earliest diagnosis of dr tb should be the dictum if we want to eradicate tb from india so this has been it is a recommended summary since 2011 but somehow i don't know where the gap is but somehow the clinicians fail to request and my fraternity fails to convince them that this is the need of the hour today these are references which you know re-emphasize that this is very important so molecular assays can rapidly diagnose mdr-tb they are also useful if smears are negative the diagnosis of mdr should be based on history and dst for h and r so this is case 2 45 year old female again presented to the opd with dorsal spine pain no past history of akt mri there was a large abscess and cord compression surgery was done to remove pus pus was sent for routine bacterial culture which was negative post surgery there was deterioration patient deteriorated only grade one power akt was started without any tubercular investigations there could be people here with me in the team who would feel oh my god does this still happen and there could be 50 percent who would say oh yes i would do the same thing with my experience of 30 years with physicians and surgeons surgeons tend to rely on the physicians or their anesthetist for sampling and sending over tests i talk about this in a general mode patient partially improved over a period of three four months but there was persistent non-healing wound multiple bacterial cultures sent for the wound which was negative after six months the implant was removed and the doctor found granulation tissue everywhere all over the implant but no pus at all please remember just like bacterial infections even for tb source control is the first thing that needs to be done without source control any bacterial infection especially with implants is never ever going to heal removal of implant has to be done orthopedicians shy away from that because i understand absolutely it's a lot of counseling to the relatives it's a lot of issues it's a lot of expense but knowing microbiology knowing the bugs knowing how brilliant they are with an implant in it is very difficult to clear away the infection implant was sent for afb culture sonication genexpert and lpa correct requests for diagnostics mtb very low rif sensitive line probe assay rifampicin was sensitive and look here again isoniazid was resistant the doctor had already put the patient on first line empirically without even testing for tb when the patient had first come in had the exercise been done at that time all this would have been saved so please remember isoniazid resistance is here it has to be cleared before you start treating 72-year male patient presented with complaints of low-grade fever full course medication history without any laboratory investigation no productive cough bal was done which was sent for microbiological investigations afb smear was strongly positive so nothing was done and patient was put on second line think about this ask yourself all of you who are with me i don't know vrushali you must tell me how many people were there because you have to remember that how many patients did you see smear was positive plus three and you began with att this patient was already on the drug because it was still strongly positive he was put on the second line this is criminal so continue with second line do genexpert mtb wait for afb culture to be positive do lpa do whole genome sequencing any other suggestions think about this i have discussed all that is available this patient was already on first line so we are strongly positive when he came back immediately put on second line was it the right thing to do afb smear is a screening test please remember it is not a confirmatory test a positive smear does not mean mtb afb smear is a screening test which does not tell you which is mtb which does not tell you whether the bacteria is live or dead if it is on treatment it could be a paradoxical reaction at times when a second thing develops ordering correct test at the correct time is the need of the hour this is bible this is gita this is whatever who believes in but ordering the correct test at the correct time and understanding the relevance of the test is the need of the hour please understand the indirect evidence of genexpert 27 year old female patient presented with lymph nodes in june 2021 pus was aspirated and sent for afb smear and naat testing smear was negative genexpert positive for mtb low rif resistance was not detected patient was put on first line the patient developed a new node full of pus after a month that lymph node was removed we all know all of us here know that patients become so apprehensive i have tons of them coming to me every 20 days at times with a lymph node even though they are rif is sensitive their inh is sensitive the lymph node was removed by biopsy and sense for extensive workup genex lpa mdr afp culture they also write down whole genome sequencing now afb smear was negative genexpert was rif sensitive lpa showed both sensitive but still oral linezolid and oral levofloxacin was added to the regimen afb's culture stands negative at 22 days today a third node developed and the patient is back with me yesterday with a syringe full of pus for whole genome sequencing what do you think it was what do you think i'll get rich with so many whole genome sequencings but what do you think let's understand what is a paradoxical reaction everybody needs to know what is a paradoxical reaction you could have fever also along with the lymph node there understanding need for whole genome sequencing just like you cannot use drugs irrationally diagnostics also should not be used irrationally otherwise the patient thinks that the doctor is just making us do tests for no reasons talk to your microbiologist understand the relevance and what are you going to get out of whole genome sequencing understanding the clinical treatment regimens i mean bedaquiline all of you know what is the rate of success if you have to begin with second line adding Bedaquiline to the regimen hugely helps in total cure of br tb so what do we say stay current stay current you have no other options interact with your microbiologist or your lab understanding mtb ntm and their workups for therapy is mandatory if we want to give justice to my heading today using and understanding technology is a vision for the future of eradication of tb with the help of diagnostics it is good to keep in mind heteroresistance i cannot go into detail of explaining what is heteroresistance but we do find two to two point eight percent of heteroresistance in our day to day practice and if you don't differentiate that the clinician will never be able to treat the patient inh resistance monoresistance please keep in mind let's also learn to understand accept and convince our colleagues regarding advantages and limitations in new diagnostic techniques so now you yourself are the right person why don't you write down in your question columns that can we eradicate tb in india what do you think now after the text that i've shown you do you think we can say yes or no vrushali could use it sometime yes yes so this is a slide which is one of my favorite slides for all those who are about 30. would know the story of the crow who was thirsty and wanted to drink water there was very little water so he put in pebbles and stones so the water could come up this was what was today you have straws to drink that water you have technology to help you you have technology to treat your patient you have literature available online to read it is very very important to understand that a patient of tuberculosis comes to you with a lot of faith this is an infection which might spread in his family if not treated if not diagnosed correctly it could affect the whole family and the community so the clinician and the lab is equally responsible to convince each other to use technology so that we could stand up strong with the government and tell them that we are with you hand in hand to help you to eradicate tb this is an original self-funded work no financial or other resources have been taken there is no conflict of interest here thank you so much for your patient listening and vrushali if there are any questions i would be happy to address that yes ma'am uh thank you so much for that amazing session and like you the way you have asked the questions we got many answers as yes that yes we can eradicate we have got one no from dr susayan connor he said that no it can't be eradicated it is a challenge i also sometimes sitting alone think about it you know whether it's it is a challenge but it's you know teams create magic so if everybody holds hands together i think we can do that uh dr sonam would like to ask that sometimes the cb naat result comes as indeterminate what does that mean yeah so as i said it's a molecular method so the amount of genetic material that is available is not enough to detect the mutation of rifampicin because for anybody who is doing molecular biology they would know that it is a sequence so sequence of mtb is stained inside of it there are mutants of rifampicin so the load is not enough for it to detect rifampicin but having said that sonam if you're a microbiologist i would also want to tell you that we have reported i think about 10 samples in the last one year which was mtb medium and mtb naive but they were unable to tell us why it happened like that but if you find something like this it is good to report it is good to give out as a case report so all the people know what this is about so when it is indeterminate you have to go for a line progress say so that you get rifampicin and inh okay uh dr sonam uh has another question uh can cb naat differentiate dead bacilli from the live ones no i told you no it's a molecular method it'll all it'll be presence of the molecular material so it will not be able to differentiate whether it is live on it and do we need to send the uh sample in some transport medium if we have to send it to some faraway lab no no unless it is going to dry out you know if it's trying to pass and if it's going to dry out you could always add saline there is no need to put any transport medium in plain saline you could push in the tissue so that you know it doesn't dry out though tb bacilli are found to survive for years together in the air in droplets so they are very sturdy [Music] uh dr bugs hiramat would like to ask that would you please elaborate a little about extra pulmonary tb so when we say extra pulmonary tb there are tons i mean everywhere tb can happen everywhere right the naat testing is does he want me to elaborate on where it is or what are the diagnostic modalities for extra pulmonary dr if you could just rephrase your question there's another question related to extra pulmonary tb by dr ramashankar is asking an extra pulmonary tb is culture a must culture is the gold standard you know this is like saying that if i take rifampicin and inh and you know is it okay if i avoid rifampicin see if the total cost the total pain of the patient is taken into consideration india is one of the most economical country for diagnostics you know so and if you're working with a lab all the time if you have one percent of the population who is not affording call up your lab and tell them that the patient is important he cannot pay money i'm also taking i'm not taking my consultation charges but that's not fair that you take two thousand rupees for consultation and then ask the lab to do free work so lab would be more than happy if you are not charging nobody is charging let's together get together and you know help the patient but gold standard is your tb culture you must do it because once you have pure growth of the bug there are 100 things you can do to save the patient i hope dr ramashankar that answered your question dr nishmita is asking how long will the culture take okay so culture we report the cultures 10 20 and 42 days okay with the liquid cultures the positivity depends on the load of the bug in the specimen with my experience i'll tell you that if it's a plus one you would get it positive anywhere between day 15 day 16 if it's a plus two you could get it positive anywhere between tenth eleventh day and if it's plus three we have reported positive as early as two to three days right so scanty hair it might take about let's say 30 days the only patients that go beyond 40 days are the ones that are on treatment so they have the bacteriostatic effect on the bacteria therefore they you know they are damaged bugs they are hurt bugs they take longer to grow so on treatment definitely at times grow after 40. i have recommended to a couple of forums to add in the guideline of tb you know in the ntcp guidelines that we need to extend afb testing to 56 days because we find at least about 1.7 of the population who comes positive between 42 and 56 days and they're all those patients who have been on treatment and that culture is you know to stop therapy now if you miss out on that two percent they're going to again come back so again as my heading says it will be a challenge to eradicate tb so i've requested them to extend it to 56 days because this 2 percent population should not be lost so positivity will depend on the load thank you so much for that answer ma'am uh dr sarvesh is asking uh the role of serum ada in extra pulmonary tb ada is never a stand-alone test you know like i remember when i was in my medical school and when i was doing my research on tb the topic was economical means to identify tb and the conclusion was that it has to be a package only an ada cannot tell you its tb so there are tons of clinical conditions where ada would be elevated so it has to be a smear an ada a culture a naat testing that together will help you actually treat the patient so hard the first time the first time the patient comes to you if you do all that is necessary i'm sure we can eradicate tb next question is again by dr sonam what is the utility and cost effectiveness of igra in diagnosing latent tb igra and the mantoux test that we used in the past and still people are using it so igra is a modified test of mantouxs you know igra diagnosis latent tuberculosis so at this point of time we are more worried about active tuberculosis than latent tuberculosis so it is a good test like i still have clinicians asking me for tb igg you know which is actually a banned test rather you know people don't want to do it so igra is always a welcome test if it has to be done for latent tb uh dr ramashankar singh is asking the short course of att is it true or false so i mean the guidelines have very well defined it but i'm not a clinician i'm a microbiologist so i think it would not be right on this platform for me to discuss the regimens of tb all right dr jitendra shah is asking what is liquid culture and routine culture and the advantages of liquid culture so if i mean if there is a question in your mind that what are these types of cultures right then i would request number one if you read nothing like it right number two if you are not going to read please understand liquid MGIT culture is the gold standard so if you want to do tb and if you want to do only one test time is not a problem for you please request for a MGIT or automated liquid culture that is the gold standard dr suresh mittal is asking that in cases of genital tb in female is vaginal fluid to be signed for genexpert so a good question this is because the naat testing is not validated for all these samples right but we must remember in a country like ours that if the clinician is clear that validation of these samples have not been on because so many samples are not available for validation like we do tons of vaginal discharges or we do tons of endometrial tissues for naat testing the positivity rate is not as high as respiratory specimens because they are validated for respiratory specimens for sure but keeping that in mind that a negative genexpert is not necessarily tb negative but i am taking the opportunity if it's positive that is an advantage to my patient so there is no problem for that right doctor mother is asking they had a case they had a child with short history of fever for two days yellow csf sample the cb naat came positive neurologist is in favor of encephalitis so what is your opinion on the csf color in tb meningoencephalitis no so if your what was the result of the genexpert when i'm saying what was that means positive what was the load of tb uh dr mutter if you could just write down in the comments or if you want to comment stage you can raise hand and i would accept your request you will be able to ask the question better i think dr jitendra is asking which specimen is not suitable for cb naat or genexpert for afb so specimens that are very mucoid you know so even after putting in the buffer if they don't homogenize then it'll come an error in the genexpert the genexpert will not be able to handle it it needs a very clear specimen so even when we are doing biopsies you know we mince it we churn it and then we centrifuge and take the supernatant so if there is anything very mucoid or you know something that is interfering it will not give out the result it will abort the test it will give an error and abort the test okay uh thank you ma'am i hope dr jaten risha your question was answered uh dr mutto has that when you tap a csf you know and send it to the labs the mode of collection is very very important [Music] contamination number one should be ruled out xanthochromic csf is known in a lot of clinical conditions now if your smear of csf is positive and if your genexpert on naat test cb naat is giving you medium rifampicin sensitive then 100 it is tuberculosis there is no question but if it is trace you know then you have to because it could be the contaminated ntm which is actually giving you trace during collection of the csf right well those were the questions ma'am and i must say we've enjoyed this session and we've had some uh very positive comments uh i'll just uh read out one was what like you said that with the knowledge and experience and the technology we can eradicate tb when we have uh microbiologists like you packing up the clinicians uh i'm sure we will be able to eradicate and we should be able to eradicate looking at how forward we have come with the technology and today so i would say this was more of a we enjoyed the session the clinicians got the behind the scenes idea generally clinicians send the sample wait for the report and then go for the treatment today they got a great idea about what actually happens behind the scenes and how it actually the sample has been processed and done so i would like to thank you so much ma'am thank you for taking out the time to be on medflix for being a part of our women in medicine month and i would also like to thank our audience thank you so much for attending this session you

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dr. Bhavini Shah

Dr. Bhavini Shah

Director & Consultant Microbiologist | Neuberg Supratech Reference Laboratories, Ahmedabad

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dr. Bhavini Shah

Dr. Bhavini Shah

Director & Consultant Microbiologist | Neuber...

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