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EPIDEMIOLOGY OF TUBERCULOSIS

Tuberculosis infection is very common in the world and the disease manifest when ever either the virulence of the organism increases or the resistance of the host goes down.it can affect any part of the body.the best method of control of tuberculosis is early diagnosis and treatment.despite international cooperation the problem of resistance in tuberculosis is increasing and great efforts are being made to tackle this problem both in diagnostic tools as well as in treatment modalities. the social factors also play a big role in the causation as well as emergence of resistance is concerned . a participatory approach is required to combat the problem.

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EPIDEMIOLOGY OF TUBERCULOSIS

  1. 1. DR.HARIVANSH CHOPRA M.D.,DCH PROFESSOR DEPT.OF COMMUNITY MEDICINE L.L.R.M.MEDICAL COLLEGE, MEERUT harichop@gmail.com
  2. 2. OBJECTIVES 8/23/2018 DR. HARIVANSH CHOPRA 2 1. To study the epidemiology of Tuberculosis. 2. To study its pathogenesis, diagnosis, treatment, & prevention.
  3. 3. What is Tuberculosis? 8/23/2018 DR. HARIVANSH CHOPRA 3  Tuberculosis is a worldwide, chronic communicable bacterial disease.
  4. 4. TUBERCULOSIS 8/23/2018 DR. HARIVANSH CHOPRA 4  Tuberculosis disease is the out come of the fight between virulence of the organism and resistance of the body
  5. 5. Historical Perspective  1882-Robert Koch,a German Scientist,discovered rod shaped bacteriae causing tuberculosis on 24th March 1882.So World TB Day is being celebrated on 24th March every year.From 2005 March,it is called”World StopTB Day”.
  6. 6.  1921-French Scientists Calmette and Guerin discovered vaccine against tuberculosis.  1944-Selman A.Waksman and his Colleagues discovered Streptomycin,an antibiotic,effective against TB.  1946-Drugs like INH and PAS were introduced.
  7. 7.  1960-National Tuberculosis Institute was established at Bangalore to formulate a comprehensive National TB control program.  1962-Government of India launched National TB Control Program(NTCP).  1966-Rifampicin proved to be an excellent drug against TB.
  8. 8.  1972-Wallace Fox and colleagues of British Medical council showed that addition of Rifampicin and Pyrazinamide alongwith INH would reduce the duration of treatment from 11/2 years to hardly 6 months .Thus Short Course Chemotherapy was introduced.
  9. 9.  1993-WHO declared TB as the”Global Emergency”.(Because of emergence of HIV).Government of India revised and intensified the NTCP and renamed as “Revised National TB Control Program.”(RNTCP)
  10. 10. WORLD PROBLEM 10 10.4 1.8 0.4 TOTAL CASES DEATHS DEATHS DUE TO HIV TB CASES ( IN MILLIONS)
  11. 11. DRUG RESISTANCE CASES 11 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 MDR TB RIFAMPICIN RESISTANT 4.8 1 TB CASES IN LAKHS MDR TB RIFAMPICIN RESISTANT
  12. 12. SEX WISE DISTRIBUTION OF TB CASES : 2015 12 57% 34% 9% TB CASES IN 2015 MALES FEMALES CHILDREN SOURCE: TB INDIA 2017, ANNUAL STATUS REPORT
  13. 13. TB : WORLD AND INDIA 13 73% 27% TB CASES (2015) REST OF WORLD INDIA SOURCE: TB INDIA 2017, ANNUAL STATUS REPORT
  14. 14. TB DEATHS : INDIA 14 83% 17% TB CASES (2015) NO DEATHS DEATHS SOURCE: TB INDIA 2017, ANNUAL STATUS REPORT
  15. 15. INDIA PROBLEM 15 0 0.5 1 1.5 2 2.5 3 NEW CASES DEATHS HIV CASES 2.8 0.48 0.14 TB CASES IN MILLIONS NEW CASES DEATHS HIV CASES
  16. 16. PROBLEM STATEMENT 8/23/2018 DR. HARIVANSH CHOPRA 16  TB kills 5,000 people a day – 2-3 million each year  One third of the world’s population is infected with TB  TB kills more young women than any other disease
  17. 17. 8/23/2018 DR. HARIVANSH CHOPRA 17  India is the highest TB burden country in the world and accounts for nearly one-fifth of the global burden of tuberculosis and 2/3rd of cases in SEAR.  Every year, approximately 1.8 million persons develop tuberculosis, of which about 0.8 million are new smear positive highly infectious cases.
  18. 18. 8/23/2018 DR. HARIVANSH CHOPRA 18  Annual risk of becoming infected with TB is 1.5% and once infected there is 10% lifetime risk of developing TB disease.  2 out of every 5 Indians are infected with the TB bacillus.  Everyday about 5000 people develop the disease.
  19. 19. 8/23/2018 DR. HARIVANSH CHOPRA 19  Patients with infectious pulmonary tuberculosis disease can infect 10-15 persons in a year.  In India almost 0.37 million people die every year.
  20. 20. 8/23/2018 DR. HARIVANSH CHOPRA 20  Today, India’s DOTS programme against tuberculosis is recognized as the fastest expanding programme.  Launched in March 1997, it has covered the whole country by March 2006.  More than 7.3 million patients are on DOTS treatment so far and about 1.4 million additional lives have been saved.
  21. 21. 8/23/2018 DR. HARIVANSH CHOPRA 21  Death rate under RNTCP have been cut 7- folds from 29% to around 4% in smear positive cases.  In the year 2006, the programme had achieved a case detection rate of 66% as against the global target of 70%.  Treatment success achieved consistently is about 85%.
  22. 22. Daily Burden in India  Everyday,more than 20,000 people become infected with TB bacilli.  More than 5,000 people develop the disease.  More than 1,000 people die of the disease.  More than 2 persons die per minute.(2880)  About 80 working days are lost per year per case.
  23. 23. AGENT 8/23/2018 DR. HARIVANSH CHOPRA 23  Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis. commonly known as “Koch’s bacillus” or tubercle bacilli or Acid Fast Bacillus (AFB).
  24. 24. Mycobacterium tuberculosis 8/23/2018 DR. HARIVANSH CHOPRA 24  First identified in 1882 by Koch in Berlin  Not immediately recognized as the cause of all forms of tuberculosis  Concept of ‘latent’ infection developed in 1920s from studies in Norway (Heimbeck).
  25. 25. SOURCE OF INFECTION 8/23/2018 DR. HARIVANSH CHOPRA 25 There are two sources of infection- a) Human source- human case whose sputum is positive for tubercle bacilli. b) Bovine source- usually infected milk.
  26. 26. HOST FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 26  AGE - The data in India shows that the tuberculin positivity rate increases steadily with age  At 0-14years prevalence of infection is 2%  For age group 15-24years it is 20.9%
  27. 27. HOST FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 27  SEX- the disease is more common in males  NUTRITION- It has no relationship with the recovery from tuberculosis in context of modern drugs but can precipitate malnutrition in children.
  28. 28. HOST FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 28  INCUBATION PERIOD – VARIABLE .Time from receipt of infection to the development of positive tuberculin test ranges from- 3- 6 weeks.  RESERVIOR - Human case is chief reservoir.
  29. 29. HOST FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 29  PERIOD OF COMMUNICABILITY - It is as long as bacilli are excreted in the sputum.  Effective anti-tubercular treatment reduces infectivity by 90% within 48 hours.
  30. 30. SOCIAL FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 30  T.B is a social disease with medical aspects.  Social factors include- 1. Poor quality of life, 2. Poor housing & overcrowding, 3. Population explosion,
  31. 31. SOCIAL FACTORS 8/23/2018 DR. HARIVANSH CHOPRA 31 4. Undernutrition, 5. Lack of education, 6. Large families, 7. Lack of awareness of causes of illness 8. Social stigma
  32. 32. TRANSMISSION 8/23/2018 DR. HARIVANSH CHOPRA 32  Spreads through the air when a person with active TB 1. Coughs 2. Speaks 3. Laughs 4. Sneezes 5. Sings Another person breathes in the bacteria and becomes infected.
  33. 33. PULMONARY TUBERCULOSIS 8/23/2018 DR. HARIVANSH CHOPRA 33 The bacteria usually attack the lungs.
  34. 34. 8/23/2018 DR. HARIVANSH CHOPRA 34  PREVALENCE OF INFECTION 30%  INCIDENCE OF INFECTION 1-2%  PREVALENCE OF DISEASE- 4/1000  INCIDENCE OF DISEASE 1/1000
  35. 35. 8/23/2018 DR. HARIVANSH CHOPRA 35  PREVALENCE OF INFECTION CAN BE FOUND OUT BY DOING TUBERCULIN TEST WHILE,  PREVALENCE OF DISEASE CAN BE FOUND OUT BY DOING A SPUTUM EXAMINATION FOR AFB.
  36. 36. 8/23/2018 DR. HARIVANSH CHOPRA 36  Tuberculin developed as a form of treatment by Koch in 1891.  Developed as a diagnostic test by von Pirquet in 1907.  Complex mix of antigens that cannot be separated.  Internationally standardized.
  37. 37. Testing for M. tuberculosis Infection 8/23/2018 DR. HARIVANSH CHOPRA 37 Mantoux tuberculin skin test (TST) Skin test that produces delayed-type hypersensitivity reaction in persons with M. tuberculosis infection.
  38. 38. Mantoux Tuberculin Skin Test 8/23/2018 DR. HARIVANSH CHOPRA 38  Preferred method of skin testing for M. tuberculosis infection  TST is useful for – Determining how many people in a group are infected (e.g., contact investigation) – Examining persons who have symptoms of TB  Multiple puncture tests (e.g., Tine Test) are inaccurate and not recommended
  39. 39. Administering the TST 8/23/2018 DR. HARIVANSH CHOPRA 39  Inject 0.1 ml of 5 TU PPD tuberculin solution intradermally on volar surface of lower arm using a 27-gauge needle  Produce a wheal 6 to 10 mm in diameter
  40. 40. Reading the TST (1) 8/23/2018 DR. HARIVANSH CHOPRA 40  Measure reaction in 48 to 72 hours  Measure induration, not erythema  Record reaction in millimeters, not “negative” or “positive”  Ensure trained health care professional measures and interprets the TST
  41. 41. Reading the TST (2) 8/23/2018 DR. HARIVANSH CHOPRA 41  Positive TST reactions can be measured accurately for up to 7 days  Negative reactions can be read accurately for only 72 hours
  42. 42. REACTIONS IN MONTOUX TEST 8/23/2018 DR. HARIVANSH CHOPRA 42  < 5 mm – NEGATIVE  5 – 9 mm – BORDERLINE  > 10 mm - POSITIVE
  43. 43. TST Interpretation (1) 8/23/2018 DR. HARIVANSH CHOPRA 43 5-mm induration is interpreted as positive in 1. HIV-infected persons 2. Close contacts to an infectious TB case 3. Persons with chest radiographs consistent with prior untreated TB
  44. 44. TST Interpretation (2) 8/23/2018 DR. HARIVANSH CHOPRA 44 5-mm induration is interpreted as positive in (cont.) 4. Organ transplant recipients 5. Other immunosuppressed patients (e.g., those taking the equivalent of >15 mg/d of prednisone for 1 month or those taking TNF-α antagonists)
  45. 45. TST Interpretation (3) 8/23/2018 DR. HARIVANSH CHOPRA 45 10-mm induration is interpreted as positive which means that the person is exposed to tubercular infection. If it is positive below the age of two years, then it is taken as indirect evidence of manifestation of disease.
  46. 46. Causes of False Negative Reaction 8/23/2018 DR. HARIVANSH CHOPRA 46 1. INFECTIONS – SEVERE TUBERCULAR INFECTIONS LIKE Miliary tuberculosis, mumps, measles, chicken pox, HIV etc. 2. Attenuated viral vaccinations (measles, mumps, polio) 3. Protein energy malnutrition 4. Lymphoreticular disorders
  47. 47. Causes of False Negative Reaction 8/23/2018 DR. HARIVANSH CHOPRA 47 5. Intake of corticosteroids. 6. Faulty technique 7. Improper storage & dilution of tuberculin. 8. Denatured/contaminated tuberculin. 9. Errors in reading.
  48. 48. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 48 1. Droplet nuclei containing tubercle bacilli are inhaled, enter the lungs, and travel to the alveoli.
  49. 49. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 49 2. Tubercle bacilli multiply in the alveoli.
  50. 50. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 50 PRIMARY COMPLEX CONSTITUTE - 1. PRIMARY FOCUS, 2. LYMPHANGITIS,& 3. LYMPHADENITIS
  51. 51. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 51  Fate of Primary Focus :  If resistance is good, it will heal by itself followed by calcification.
  52. 52. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 52  If the resistance is poor, then the lesion will progress and may lead to cavity formation.  The lesion may burst open into pleura resulting in pleural effusion.
  53. 53. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 53  Fate of regional lymph node :  It may enlarge and compress the bronchus completely leading to collapse.  It may compress the bronchus incompletely & erode into the bronchus thereby resulting in collapse with consolidation.
  54. 54. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 54  It may lead to consolidation.  The lymph node may rupture into a blood vessel leading to MILIARY TUBERCULOSIS.
  55. 55. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 55  A small number of bacilli via lymphatics enter into the blood stream and then they are seeded into various organs of the body like brain, kidney, bone and other organs.
  56. 56. PATHOGENESIS OF TB INFECTION AND DISEASE 8/23/2018 DR. HARIVANSH CHOPRA 56  Depending upon the virulence of organism and the resistance of the body, the bacilli at these sites multiply and result into diseases like tubercular meningitis & renal tuberculosis.
  57. 57. Progression of TB 8/23/2018 DR. HARIVANSH CHOPRA 57  People who are exposed to TB may or may not develop TB infection.  People with TB infection may or may not develop TB disease.  The risk of developing TB disease is highest in the first 2 years after infection.
  58. 58. 8/23/2018 DR. HARIVANSH CHOPRA 58
  59. 59. 8/23/2018 DR. HARIVANSH CHOPRA 59 Unhealthy person – Bacilli overwhelm immune system – Bacilli break out of tubercles in alveoli and spread through bloodstream This is ≥active≤ TB
  60. 60. 8/23/2018 DR. HARIVANSH CHOPRA 60 Healthy person – Initial infection controlled by immune system – Bacilli remain confined in tubercles for years This is ≥ latent ≤ TB
  61. 61. 8/23/2018 DR. HARIVANSH CHOPRA 61
  62. 62. 8/23/2018 DR. HARIVANSH CHOPRA 62 A Person with Latent TB Infection A Person with Active TB Disease Has no symptoms Has symptoms that may include: Cough that lasts 3 weeks or longer, pain in the chest, coughing up blood or sputum, weakness or fatigue, weight loss, no appetite chills, fever, sweating at night.
  63. 63. 8/23/2018 DR. HARIVANSH CHOPRA 63 A Person with Latent TB Infection A Person with Active TB Disease Does not feel sick Cannot spread TB to others Usually has a positive skin test. May spread TB to others Usually has a positive skin test. May have an abnormal chest x-ray, or positive sputum smear or culture
  64. 64. 8/23/2018 DR. HARIVANSH CHOPRA 64 Cough>3weeks Fever Spit up Blood (Hemoptysis) Chest Pain
  65. 65. 8/23/2018 DR. HARIVANSH CHOPRA 65
  66. 66. 8/23/2018 DR. HARIVANSH CHOPRA 66 1) The prevalence of disease in tuberculosis in India is 1. 1/ 1000 population 2. 2/ 1000 population 3. 4/ 1000 population 4. 6/1000 population ANS 3
  67. 67. 8/23/2018 DR. HARIVANSH CHOPRA 67  2) The incidence of disease in tuberculosis in India is 1. 1/ 1000 population 2. 2/ 1000 population 3. 4/ 1000 population 4. 6/ 1000 population ANS 1
  68. 68. 8/23/2018 DR. HARIVANSH CHOPRA 68 3) The prevalence of infection of tuberculosis in India is 1. 20% 2. 30% 3. 40% 4. 50% ANS 2
  69. 69. 8/23/2018 DR. HARIVANSH CHOPRA 69  4) The incidence of infection in tuberculosis in India is 1. 1% 2. 3% 3. 5% 4. 10% ANS 1
  70. 70. 8/23/2018 DR. HARIVANSH CHOPRA 70  5) Tubercle bacillus was discovered by  Koch  Calmette  Guerin  None of the above ANS 1
  71. 71. 8/23/2018 DR. HARIVANSH CHOPRA 71  Mantoux test is a 1. Prognostic test 2. Diagnostic test 3. Test which tells about exposure to tubercular infection 4. All of the above ANS 3
  72. 72. 8/23/2018 DR. HARIVANSH CHOPRA 72  Examine medical history, X-rays, and sputum.  Tuberculin skin test.
  73. 73. SPUTUM EXAMINATION 8/23/2018 DR. HARIVANSH CHOPRA 73  Three samples of sputum stained with Zeihl Neelsen technique are examined under microscope if his/her symptoms are suggestive of TB.  Samples are collected on two days: SPOT OVERNIGHT/ SPOT EARLY MORNING First day Second day Second day
  74. 74. SPUTUM EXAMINATION 8/23/2018 DR. HARIVANSH CHOPRA 74  Two samples of sputum stained with Zeihl Neelsen technique are examined under microscope if his/her symptoms are suggestive of TB.  Samples are collected on two days: SPOT OVERNIGHT/ EARLY MORNING First day Same day
  75. 75. SPUTUM EXAMINATION 8/23/2018 DR. HARIVANSH CHOPRA 75  At least 100 fields should be examined before giving the result. Smears have been graded depending on the number of bacilli seen: 1+ when 3 - 9 bacilli are seen in the entire smear. 2+ when 10 or more bacilli are seen in the smear and 3+ when 10 or more bacilli are seen in most oil emersion fields.
  76. 76. 8/23/2018 DR. HARIVANSH CHOPRA 76 Cough 3 weeks AFB X 3 Broad-spectrum antibiotic 10-14 days If symptoms persist, repeat AFB smears, X-ray If consistent with TB Anti-TB Treatment If 1 positive, X-ray and evaluation If 2/3 positive: Anti-TB Rx If negative:
  77. 77. 8/23/2018 DR. HARIVANSH CHOPRA 77 Cough 2 weeks AFB X 2 Broad-spectrum antibiotic 10-14 days If symptoms persist, repeat AFB smears, X-ray If consistent with TB Anti-TB Treatment If 2 negative X-ray and evaluation If 1/2/ positive: Anti-TB Rx If negative:
  78. 78. PLHIV Presumptive TB Patient Smear Examination CXR Smear Positive And CXR Suggestive Of TB Smear Positive , But CXR Not Suggestive Of TB Smear Negative But CXR Suggestive Of TB Smear Negative Or Not Available & CXR Not Suggestive Of Or Not Available Clinical Suspicion High PMDT Criteria , High MDR Settings CBNAAT MTB Detected MTB Not Detected Or CBNAAT Result Not Available Consider Alternate Diagnosis And Refer To Specialist Clinically Diagnosed TB Alternate Diagnosis Rif Sensitive Rif Indeterminate Rif Resistant Refer To Management Of Rif Resistance Microbiologically Confirmed TB Repeat CBNAAT On 2nd Sample Indeterminate On 2nd Sample , Collect Fresh Sample For Liquid Culture / LPA DIAGNOSTIC ALGORITHM
  79. 79. MOST SUSCEPTIBLE 8/23/2018 DR. HARIVANSH CHOPRA 79 People at higher risk of TB infection – Close contacts with people with infectious TB – People born in areas where TB is common – People with poor access to health care
  80. 80. MOST SUSCEPTIBLE 8/23/2018 DR. HARIVANSH CHOPRA 80 4. People who inject illicit drugs 5. People who live or work in residential facilities 6. Health care professionals 7. The elderly
  81. 81. MOST SUSCEPTIBLE 8/23/2018 DR. HARIVANSH CHOPRA 81 People at higher risk of active TB disease 1. People with weak immune systems (especially those with HIV or AIDS) 2. People with diabetes or silicosis 3. People infected within the last 2 years 4. People with chest x-rays that show previous TB disease 5. Illicit drug and alcohol abusers
  82. 82. TUBERCULOSIS CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 82  The WHO defines that tuberculosis "control" is said to be achieved when the prevalence of natural infection in the age group 0-14 years is of the order of 1 per cent.
  83. 83. TUBERCULOSIS CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 83  The control measures consist of a curative component - namely case finding and treatment; and a preventive component - namely BCG vaccination.
  84. 84. TUBERCULOSIS CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 84 CASE FINDING- a. THE CASE - The first step in a tuberculosis control programme is early detection of sputum-positive cases.
  85. 85. TUBERCULOSIS CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 85 b. TARGET GROUP - The chest symptoms such as persistent cough and fever often develop early, that is before the disease has gone on to an advanced stage. This is the most fertile group for case finding.
  86. 86. TUBERCULOSIS CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 86  c. CASE FINDING TOOLS- Sputum smear examination by direct microscopy is now considered the method of choice.
  87. 87. CHEMOTHERAPY 8/23/2018 DR. HARIVANSH CHOPRA 87  Chemotherapy is indicated in every case of active tuberculosis.  The objective of treatment is cure - that is, the elimination of both the fast and slowly multiplying bacilli (including the persisters) from the patient's body.
  88. 88. TREATMENT : CHEMOTHERAPY 88 RIFAMPICIN ISONIAZIDE PYRAZINAMIDE ETHAMBUTOL STREPTOMYCIN FLUROQUINOLONES ETHIONAMIDE CAPREOMYCIN KANAMYCIN AMIKACIN CYCLOSERINE THIOACETAZONE MACROLIDES BEDAQUILINE 1st LINE DRUGS 2nd LINE DRUGS
  89. 89. LONG TERM CHEMOTHERAPY 89 DAILY REGIMEN BI WEEKLY OR INTERMITTENT REGIMEN 18 MONTHS
  90. 90. SHORT TERM CHEMOTHERAPY 90 RAPID BACTERIOLOGICAL CONVERSION LOWER FAILURE RATES REDUCTION IN EMERGENCE OF DRUG RESISTANT BACILLI PATIENT COMPLIANCE IMPROVES AND THEY BECOMES NON INFECTIOUS EARLY
  91. 91. DIRECTLY OBSERVED TREATMENT SHORT COURSE (DOTS) 91  DOTS is a strategy to ensure cure by providing the most effective medicine and confirming that it is taken.  Under DOTS patients were divided into categories – CATEGORY 1 – CATEGORY 2
  92. 92. DOTS CHEMOTHERAPY 92 CATEGORY TYPE OF PATIENT INTENSIV E PHASE CONTINUATION PHASE CATEGORY I NEW SPUTUM SMEAR POSITIVE NEW SPUTUM SMEAR NEGATIVE NEW EXTRA PULMONARY NEW OTHER 2 (HRZE)3 4 (HR)3 CATEGORY II SPUTUM SMEAR POSITIVE RELAPSE SPUTUM SMEAR NEGATIVE FAILURE 2 (HRZES)3 + 1 (HRZE)3 5 (HR)3
  93. 93. DAILY DOSE REGIMEN 93 Standards for TB Care in India, 2014 based on available evidences and WHO treatment of TB Guidelines state that all patients should be given daily regimen. The National Technical Working Group on TB / HIV has recommended use of daily regimen using Fixed Drug Combination first line TB treatment for PLHIV patients.
  94. 94. CHANGES FROM DOTS REGIMEN 94  INTENSIVE PHASE WILL NOT CONTINUE EVEN IF AFTER 2 MONTHS THE PATIENT COMES POSITIVE.  AFTER 2 MONTHS CONTINUATION PHASE WILL BEGIN IRRESPECTIVE OF SPUTUM RESULTS
  95. 95. CHANGES IN TREATEMENT POLICY 95 TYPE OF TB CASE TREATMENT REGIMEN INTENSIVE PHASE TREATMENT REGIMEN CONTINUATION PHASE NEW 2 HRZE 4 HRE PREVIOUSLY TREATED 2 HRZES + 1 HRZE 5 HRE
  96. 96. DAILY DOSAGE SCHEDULE FOR ADULTS 96 WEIGHT CATEGORY NUMBER OF TABLETS TO BE CONSUMED Inj. Streptomyci n INTENSIVE PHASE CONTINUATION PHASE H R Z E H R E 75 / 150 / 400 / 275 Mg per tab 75 / 150 / 275 Mg per day 25 – 39 kg 2 2 0.5 gm 40 – 54 kg 3 3 0.75 gm 55 – 69 kg 4 4 1.0 gm ≥ 70 kg 5 5 1.0 gm
  97. 97. MULTI DRUG RESISTANT TUBERCULOSIS TREATMENT 97 TYPE OF TB CASE TREATMENT REGIMEN (IP) TREATEMENT REGIMEN (CP) RIFAMPICIN RESISTANT + ISONIZIDE SENSITIVE 6 – 9 MONTHS KANAMYCIN, LEVOFLOXACIN ETHIONAMIDE, CYCLOSERINE ETHAMBUTOL, PYRAZINAMIDE ISONIAZIDE 18 MONTHS LEVOFLOXACIN, ETHIONAMIDE CYCLOSERINE,ETHAMBUTOL (E) ISONIAZIDE (H) MDR TB 6 -9 MONTHS LEVOFLOXACIN ETHIONAMIDE CYCLOSERINE ETHAMBUTOL PYRAZINAMIDE 18 MONTHS LEVOFLOXACIN ETHIONAMIDE CYCLOSERINE ETHAMBUTOL
  98. 98. XTENSIVE DRUG RESISTANT TUBERCULOSIS TREATMENT 98 TYPE OF TB TREATMENT REGIMEN IN IP TREATMENT REGIMEN IN CP XDR 6 – 12 MONTHS INJ. CAPREOMYCIN MOXIFLOXACIN PAS HIGH DOSE ISONIAZIDE CLOFAZAMINE LINEZOLID AMOXY – CLAV 18 MONTHS PAS MOXIFLOXACIN HIGH DOSE ISONIAZIDE CLOFAZAMINE LINEZOLID AMOXY – CLAV
  99. 99. ALOGRITHM OF TB TREATMENT 99 CONFIRMED TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE
  100. 100. ALOGRITHM OF MDR TB TREATMENT 100 CONFIRMED DR TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE 4T H 5T H 6T H
  101. 101. PEDIATRIC TUBERCULOSIS 101  Tuberculosis is one of the major cause of childhood mortality and morbidity  Constitutes 6-8% of all new cases of TB  Common in children aged 1-4 years
  102. 102. DIAGNOSIS OF PEDIATRIC TUBERCULOSIS 102  SPUTUM MICROSCOPY IS BEST METHOD TO DETECT TUBERCULOSIS  IN CASES WHERE SPUTUM IS NOT AVAILABLE: – GASTRIC LAVAGE – INDUCED SPUTUM – BRONCHO ALVEOLAR LAVAGE
  103. 103. TREATEMENT OF PEDIATRIC TUBERCULOSIS 103 DRUG DOSE ISONIAZIDE 10 mg/kg (max 300 mg/day) RIFAMPICIN 10 – 15 mg/kg (max 600 mg/day) PYRAZINAMIDE 30 – 35 mg/kg (max 2000 mg/day) ETHAMBUTOL 20 -25 mg/kg (max 1500 mg/day) STREPTOMYCIN 15mg/kg (max 1 gm/day)
  104. 104. 104 BOXES COMPOSITION YELLOW BOX (PC 13) ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg PYRAZINAMIDE : 250 mg, ETHAMBUTOL : 200 mg ISONIAZIDE : 75 mg RIFAMPICIN : 75 mg ORANGE BOX (PC 14) ISONIZIDE : 150 mg, RIFAMPICIN : 150 mg PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg ISONIAZIDE : 150 mg RIFAMPICIN : 150 mg PURPLE BOX (PC 15) ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg PYRAZINAMIDE : 250 mg, ETHAMBUTOL : 200 mg GREY BOX (PC 16) ISONIZIDE : 150 mg, RIFAMPICIN : 150 mg PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg
  105. 105. BOX WISE TREATMENT FOR CHILDREN 105 AGE GROUP NUMBER OF BOXES 6 – 10 kg 1 YELLOW BOX 11 – 17 kg 1 ORANGE BOX 18 – 25 kg 1 YELLOW AND 1 ORANGE BOX 26 – 30 kg 2 ORANGE BOX
  106. 106. WAY FORWARD… FIXED DRUG COMBINATIONS 106 AGE NO. OF TABLETS IN INTENSIVE PHASE RHZ (75mg / 50mg / 150mg) NO. OF TABLETS IN CONTINUATION PHASE RH (75mg / 50mg) 4 KG – 7 KG 1 1 8 KG – 11 KG 2 2 12 KG – 15 KG 3 3 16 KG – 24 KG 4 4 ≥ 25 KG ADULT DOSE ADULT DOSE
  107. 107. . 8/23/2018 DR. HARIVANSH CHOPRA 107 The DOTS strategy represents the most important public health breakthrough of the decade, in terms of lives which will be saved." — Director General World Health Organization March 24,1997 DOTS
  108. 108. DOTS 8/23/2018 DR. HARIVANSH CHOPRA 108  DOTS is Directly Observed Treatment, Short-course.  DOTS was developed by the WHO as a means to directly observe patients taking their medications to ensure their TB is cured and not allowed to mutate into multi-drug resistant TB.
  109. 109. 8/23/2018 DR. HARIVANSH CHOPRA 109 Treatment groups Type of patient Regimen Intensive Phase (IP) Continuat ion Phase (CP) New (Cat I) New Sputum smear-positive New Sputum smear-negative New Extra-pulmonary New Others 2H3R3Z3E3 4H3R3 Previously Treated (Cat II) Smear-positive relapse Smear-positive failure Smear-positive treatment after default Others 2H3R3Z3E3S3 / 1H3R3Z3E3 5H3R3E3
  110. 110. Category IV(DOTS PLUS) Treatment for MDR-TB 8/23/2018 DR. HARIVANSH CHOPRA 110  The diagnosis is made at the Intermediate Reference laboratory..  Treatment is initiated at designated DOTS- Plus sites , established in tertiary care centers at least one in each state.  Qualified staff available to manage patient using second line drugs.
  111. 111. 8/23/2018 DR. HARIVANSH CHOPRA 111 TREATMENT REGIMEN: 6(9) Km Ofx Eto Cs ZE+18Ofx Eto CsE (Km-Kanamycin; Ofx-Ofloxacin;Eto=Ethionamide; Cs-cyclosporine;Z-Pyrazinamide;E- Etambutol)
  112. 112. DOTS Plus regimen: Dosages The average body weight of the MDR TB patient in India is 40 kgs. So two weight bands are recommended: Drugs < 40 kg body wt. > 40 kg body wt. Kanamycin 500 mg 750 mg Ofloxacin 600 mg 800 mg Ethionamide 500 mg 750 mg Ethambutol 800 mg 1200 mg Pyrazinamide 1500 mg 1750 mg PAS 10 gm 12 gm Cycloserine 500 mg 750 mg
  113. 113. IP regimen- Duration  The group came to the consensus that the intensive phase should be given for a minimum duration of 6 months, upto 9 months.  Monthly sputum smear examination and sputum culture would be conducted to monitor response to therapy IP regimen would be given till at least three consecutive negative smears AND last available culture is negative.
  114. 114. 8/23/2018 DR. HARIVANSH CHOPRA 114 If the above two results are not available, IP will be extended till such result is obtained; upto a maximum of 9 months Decision to stop IP and start CP will be ratified by the hospital’s DOTS Plus Committee In rare cases where the patient remains sputum positive by culture at 9 month and patient is tolerating injectable drugs, injectable will continue till sputum conversion???
  115. 115. CP- Duration  The group recommends that the continuation phase should be: -for at least 18 months after culture conversion CP- Drugs The three drugs are: Ethionamide, Ofloxacin, Ethambutol  These are to be given as daily doses for 6 days a week; all doses would be DOT  Intolerance to any drug in CP: offending drug may be replaced by PAS/ Cycloserine
  116. 116. TB Control: The 5 components of DOTS 8/23/2018 DR. HARIVANSH CHOPRA 116 Political commitment Diagnosis by microscopy Adequate supply of SCC drugs Directly observed treatment Accountability TB Register
  117. 117. Directly Observed Treatment 8/23/2018 DR. HARIVANSH CHOPRA 117  Treatment observer must be accessible and acceptable to the patient and accountable to the health system  Observation is a service to patients and providers  Many patients do not take medicines regularly, even if excellent health education is provided  Impossible to predict which patient will take medicine
  118. 118. Advantages of DOTS 8/23/2018 DR. HARIVANSH CHOPRA 118  DOTS produces cure rate high as 95 percent.  DOTS guarantees quicker and surer relief from the disease.  DOTS has changed the lives of 17 lakh patients in India.
  119. 119. Advantages of DOTS 8/23/2018 DR. HARIVANSH CHOPRA 119  DOTS is a strategy for alleviating poverty. Saving lives, reducing the duration of illness, and preventing new infectious cases would mean fewer years of employment lost.
  120. 120. Advantages of DOTS 8/23/2018 DR. HARIVANSH CHOPRA 120  DOTS prolongs survival of HIV-Infected TB patients.  DOTS prevents treatment failure and the emergence of multi-drug resistant tuberculosis by ensuring patient compliance and uninterrupted supply of anti-TB drug.
  121. 121. Advantages of DOTS 8/23/2018 DR. HARIVANSH CHOPRA 121  DOTS increases the reach of health services. The DOTS strategy has been remarkably successful in promoting the development of peripheral health services.  DOTS is available for free at all Health Centres.
  122. 122. TB and HIV: A Deadly Combination 8/23/2018 DR. HARIVANSH CHOPRA 122  TB is the leading killer of people with HIV.  Up to half of the people living with HIV/AIDS will develop active TB.  HIV positive people are 30 times more likely to have their latent TB turn active because of their compromised immune systems.
  123. 123. TB and HIV: A Deadly Combination 8/23/2018 DR. HARIVANSH CHOPRA 123  Active TB in an HIV positive person if left untreated will end their life in 5 to 6 weeks.  Treating an HIV positive person for active TB can extend their life by 5 years.
  124. 124. TB and AIDS 8/23/2018 DR. HARIVANSH CHOPRA 124 10% 60% 0% 10% 20% 30% 40% 50% 60% 70% PPD+/HIV-negative PPD+/HIV+ Lifetime Risk of TB
  125. 125. 1) The best method of control of tuberculosis in a community is - 1. B.C.G. vaccination 2. Early diagnosis & treatment 3. Chemoprophylaxis 4. All of the above ANS. 2 8/23/2018 DR. HARIVANSH CHOPRA 125
  126. 126. 8/23/2018 DR. HARIVANSH CHOPRA 126  2) Which of the following is not a cardinal sign of tuberculosis - 1. Cough 2. Fever 3. Weight loss 4. Haemoptysis ANS 3
  127. 127. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 127 BCG vaccination AIM: The aim of BCG vaccination is to induce a benign, artificial primary infection which will stimulate an acquired resistance to possible subsequent infection with virulent tubercle bacilli, and thus reduce the morbidity and mortality from primary tuberculosis among those most at risk.
  128. 128. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 128 VACCINE: BCG is the only widely used live bacterial vaccine. TYPES OF VACCINE: There are two types of BCG vaccine - the liquid (fresh) vaccine and the freeze-dried vaccine.
  129. 129. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 129  DOSAGE: For vaccination, the usual strength is 0.1 mg in 0.1 ml volume, and dose is 0.1 ml.
  130. 130. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 130  ADMINISTRATION: The standard procedure recommended by WHO is to inject the vaccine intradermally using a "Tuberculin" syringe (Omega microstat syringe fitted with a 1 cm steel 26 gauge intradermal needle).
  131. 131. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 131  AGE: In countries where tuberculosis is prevalent and the risk of childhood infection is high (as in India), the national policy is to administer BCG very early in infancy either at birth (for institutional deliveries) or at 6 weeks of age simultaneously with other immunizing agents such as DPT and polio.
  132. 132. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 132  PHENOMENA AFTER VACCINATION: Two to three weeks after a correct intradermal injection of a potent vaccine, a papule develops at the site of vaccination. It increases slowly in size and reaches a diameter of about 4 to 8 mm in about 5 weeks.
  133. 133. IMMUNOPROPHYLAXIS 8/23/2018 DR. HARIVANSH CHOPRA 133  PHENOMENA AFTER VACCINATION CONT..: It then subsides or breaks into a shallow ulcer, rarely open, but usually seen covered with a crust.  Healing occurs spontaneously within 6 to 12 weeks leaving a permanent, tiny, round scar, typically 4-8 mm in diameter. This is a normal reaction.
  134. 134. The National TB Control Programme (NTCP) 8/23/2018 DR. HARIVANSH CHOPRA 134  Formulated in 1962 and implemented throughout the country STRATEGIES: 1. Early detection and treatment. 2. Diagnosis through radiology & sputum microscopy.
  135. 135. The National TB Control Programme (NTCP) 8/23/2018 DR. HARIVANSH CHOPRA 135 STRATEGIES cont.. 3. Free domiciliary treatment through PHC Services. 4. Establishing District Tuberculosis Center in every district. 5. Extend coverage under Short Course Chemotherapy. 6. Strengthen state TB training & demonstration centres.
  136. 136. The result of NTP 8/23/2018 DR. HARIVANSH CHOPRA 136  Case finding in NTP was only about 30% of the expectation and  Treatment completion was about 35% with standard drug regimens and 45% to 50% with SCC.  There was no significant change in the epidemiological situation inspite of having NTP in place for more than 30 years, and with increasing cases of drug resistance, compounded by the advent of HIV infection.
  137. 137. Revised national Tuberculosis Programme – RNTCP 8/23/2018 DR. HARIVANSH CHOPRA 137 The main pillars of the revised strategy are: (1) Achievement of not less than 85% cure rate amongst infectious cases of tuberculosis, through short course chemotherapy involving peripheral health functionary.
  138. 138. 8/23/2018 DR. HARIVANSH CHOPRA 138 (2) Detecting 70 per cent of the estimated cases through quality sputum microscopy. (3) Involvement of NGOs. (4) Direct Observed Therapy Short-term (DOTS) a community-based TB treatment and care strategy.
  139. 139. Definitions of tuberculosis cases and treatment outcomes under RNTCP 8/23/2018 DR. HARIVANSH CHOPRA 139  CASE OF TUBERCULOSIS- A case of TB which has been bacteriologically confirmed, or has been diagnosed by a clinician.  DEFINITE CASE- Patient with positive culture for the Mycobacterium tuberculosis complex. In countries where culture is not routinely available a patient with two sputum smears positive for acid-fast bacilli (AFB+) is also considered a definite case.
  140. 140. Definitions of tuberculosis cases and treatment outcomes 8/23/2018 DR. HARIVANSH CHOPRA 140  PULMONARY CASE A case of TB disease involving the lung parenchyma.  SMEAR-POSITIVE PULMONARY CASE 1. At least two initial sputum smear examinations (direct smear microscopy) AFB+; or 2. one sputum examination AFB+ and radiographic abnormalities consistent with active pulmonary tuberculosis as determined by a clinician; or 3. one sputum specimen AFB+ and culture positive for M. tuberculosis.
  141. 141. Definitions of tuberculosis cases and treatment outcomes 8/23/2018 DR. HARIVANSH CHOPRA 141  SMEAR-NEGATIVE PULMONARY CASE Pulmonary tuberculosis not meeting the above criteria for smear positive disease.
  142. 142. 8/23/2018 DR. HARIVANSH CHOPRA 142 Diagnostic criteria should include: 1. 2 sputum smear examinations negative for AFB; and radiographic abnormalities consistent with active pulmonary TB; 2. and no response to a course of broad-spectrum antibiotics; 3. and decision by clinician to treat with full course of ATT; 4. or positive culture but negative AFB sputum examinations.
  143. 143. 8/23/2018 DR. HARIVANSH CHOPRA 143  Sputum positive tuberculosis-At least one initial sputum smears positive for AFB in a well functioning EQA system.  Sputum negative tuberculosis-At least two negative smears,but tuberculosis suggestive symptoms and X-Ray abnormalities or positive culture.
  144. 144. Definitions of tuberculosis cases and treatment outcomes 8/23/2018 DR. HARIVANSH CHOPRA 144  EXTRAPULMONARY CASE- Patient with tuberculosis of organs other than the lungs e.g. pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, meninges.  Diagnosis should be based on one culture- positive specimen, or histological or strong clinical evidence consistent with active extrapulmonary disease.
  145. 145. DEFINITIONS OF TREATMENT OUTCOMES 8/23/2018 DR. HARIVANSH CHOPRA 145  CURED- Initially smear-positive patient who was smear-negative in the last month of treatment, and on at least one previous occasion  COMPLETED TREATMENT- Patient who completed treatment but did not meet the criteria for cure or failure.
  146. 146. DEFINITIONS OF TREATMENT OUTCOMES 8/23/2018 DR. HARIVANSH CHOPRA 146  DIED- Patient who died for any reason during treatment.  FAILED- Smear-positive patient who remained smear-positive at five months or later during treatment.
  147. 147. 8/23/2018 DR. HARIVANSH CHOPRA 147  Treatment completed-Initially smear negative patient who received full course of treatment , or smear positive who completed treatment , with negative smear at the end of initial phase , but no or only one negative smear during continuation and none at treatment end.
  148. 148. DEFINITIONS OF TREATMENT OUTCOMES 8/23/2018 DR. HARIVANSH CHOPRA 148  DEFAULTED Patient whose treatment was interrupted for two consecutive months or more.  TRANSFERRED OUT Patient who transferred to another reporting unit and for whom the treatment outcome is not known.  SUCCESSFULLY TREATED Patients who were cured and those that completed treatment.
  149. 149. Case definitions 8/23/2018 DR. HARIVANSH CHOPRA 149 • A BACTERIOLOGICALLY CONFIRMED TB CASE : is one from whom a biological specimen is positive by smear microscopy, culture or WRD (such as Xpert MTB/RIF). All such cases should be notified, regardless of whether TB treatment has started.
  150. 150.  A CLINICALLY DIAGNOSED TB CASE : is one who does not fulfil the criteria for bacteriological confirmation but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment. 8/23/2018 DR. HARIVANSH CHOPRA 150
  151. 151. CLASSIFICATION BASED ON ANATOMICAL SITE OF DISEASE  PULMONARY TUBERCULOSIS (PTB) : refers to any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or the tracheobronchial tree. Miliary TB is classified as PTB because there are lesions in the lungs. 8/23/2018 DR. HARIVANSH CHOPRA 151
  152. 152.  EXTRAPULMONARY TUBERCULOSIS (EPTB) : refers to any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs, e.g. pleura, lymph nodes, abdomen, genitourinary tract, skin, joints and bones, meninges. 8/23/2018 DR. HARIVANSH CHOPRA 152
  153. 153. CLASSIFICATION BASED ON HISTORY OF PREVIOUS TB TREATMENT (PATIENT REGISTRATION GROUP)  NEW PATIENTS : have never been treated for TB or have taken anti-TB drugs for less than 1 month.  PREVIOUSLY TREATED PATIENTS : have received 1 month or more of anti-TB drugs in the past. 8/23/2018 DR. HARIVANSH CHOPRA 153
  154. 154.  RELAPSE PATIENTS : have previously been treated for TB, were declared cured or treatment completed at the end of their most recent course of treatment, and are now diagnosed with a recurrent episode of TB (either a true relapse or a new episode of TB caused by reinfection).  TREATMENT AFTER FAILURE PATIENTS : are those who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. 8/23/2018 DR. HARIVANSH CHOPRA 154
  155. 155.  TREATMENT AFTER LOSS TO FOLLOW-UP PATIENTS have previously been treated for TB and were declared lost to follow-up at the end of their most recent course of treatment. (These were previously known as treatment after default patients.)  OTHER PREVIOUSLY TREATED PATIENTS are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented. 8/23/2018 DR. HARIVANSH CHOPRA 155
  156. 156. CLASSIFICATION BASED ON HIV STATUS  HIV-POSITIVE TB PATIENT : refers to any bacteriologically confirmed or clinically diagnosed case of TB who has a positive result from HIV testing conducted at the time of TB diagnosis or other documented evidence of enrolment in HIV care, such as enrolment in the pre-ART register or in the ART register once ART has been started. 8/23/2018 DR. HARIVANSH CHOPRA 156
  157. 157.  HIV-NEGATIVE TB PATIENT REFERS : to any bacteriologically confirmed or clinically diagnosed case of TB who has a negative result from HIV testing conducted at the time of TB diagnosis. Any HIV-negative TB patient subsequently found to be HIV-positive should be reclassified accordingly. 8/23/2018 DR. HARIVANSH CHOPRA 157
  158. 158.  HIV STATUS UNKNOWN TB PATIENT : refers to any bacteriologically confirmed or clinically diagnosed case of TB who has no result of HIV testing and no other documented evidence of enrolment in HIV care. If the patient’s HIV status is subsequently determined, he or she should be reclassified accordingly. 8/23/2018 DR. HARIVANSH CHOPRA 158
  159. 159. CLASSIFICATION BASED ON DRUG RESISTANCE  MONORESISTANCE : resistance to one first-line anti-TB drug only.  POLYDRUG RESISTANCE: resistance to more than one first-line anti-TB drug (other than both isoniazid and rifampicin).  MULTIDRUG RESISTANCE: resistance to at least both isoniazid and rifampicin. 8/23/2018 DR. HARIVANSH CHOPRA 159
  160. 160.  EXTENSIVE DRUG RESISTANCE: resistance to any fluoroquinolone and to at least one of three second-line injectable drugs (capreomycin, kanamycin and amikacin), in addition to multidrug resistance. •  RIFAMPICIN RESISTANCE: resistance to rifampicin detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to rifampicin, whether mono resistance, multidrug resistance, poly drug resistance or extensive drug resistance. 8/23/2018 DR. HARIVANSH CHOPRA 160
  161. 161. OBSTACLES TO TB CONTROL 8/23/2018 DR. HARIVANSH CHOPRA 161 The treatment 1. At least six months 2. Multiple medicines 3. Relatively expensive 4. No effective vaccine 5. No new drugs on the horizon
  162. 162. 8/23/2018 DR. HARIVANSH CHOPRA 162 Control programmes 1. Require government coordination 2. Require prolonged effort and funding on part of government
  163. 163. 8/23/2018 DR. HARIVANSH CHOPRA 163
  164. 164. 8/23/2018 DR. HARIVANSH CHOPRA 164  CLINICAL  A) History of symptoms like – 1. Irregular fever 2. Chronic cough 3. Recurrent bronchitis with poor response to bronchodilators. 4. Loss of weight 5. Poor appetite over 2 weeks or more.
  165. 165. 8/23/2018 DR. HARIVANSH CHOPRA 165 6. Chronic or recurrent abdominal pain 7. Ascites 8. Abdominal mass with no other detectable cause.
  166. 166. 8/23/2018 DR. HARIVANSH CHOPRA 166 B) Contact with sputum positive pulmonary tuberculosis patient presently or in recent past.
  167. 167. 8/23/2018 DR. HARIVANSH CHOPRA 167  C) PROLONGED ILLNESS OF 6-8 WEEKS AFTER AN ATTACK OF MEASLES OR PERTUSSIS.
  168. 168. 8/23/2018 DR. HARIVANSH CHOPRA 168  Positive tuberculin test 2 or 5 TU PPD, RT 23 with Tween 80 or 1:000 old tuberculin.  Tuberculin test which gives an indurations of 10mm or more even in a BCG vaccinated child.
  169. 169. 8/23/2018 DR. HARIVANSH CHOPRA 169  Positive chest X-ray findings like mediastinal lymph node with or without parenchymal lesion.
  170. 170. 8/23/2018 DR. HARIVANSH CHOPRA 170  In sputum or secretions obtained by laryngeal stimulation, possible mainly in older children with pulmonary T.B.  This can be done in district tuberculosis centre where ever possible.
  171. 171. 8/23/2018 DR. HARIVANSH CHOPRA 171  CONCLUSION  SCORE <3 – PROBABLY NEGATIVE AND T.B. IS UNLIKELY.  SCORE BETWEEN 3 – 4 – PROBABLY POSITIVE TUBERCULOSIS AND NEEDS FURTHER EVALUATION.
  172. 172. 8/23/2018 DR. HARIVANSH CHOPRA 172  SCORE BETWEEN 5-6 – PROBABLY T.B. & NEEDS CHEMOTHERAPY WITH 3 DRUGS.  SCORE 7 & ABOVE – ESTABLISHED T.B., NEEDS FULL COURSE OF A.T.T. AND IN SERIOUS CASES, STEROIDS.
  173. 173. Guidelines for Preventive chemotherapy in Children under 6 years of age who were in contact with a smear-positive case 8/23/2018 DR. HARIVANSH CHOPRA IF AND THEN If the child has symptoms of TB An MO determines (Preferably in consultation with a Paediatrician) that the child has TB. A full course of ATT(CAT III)should be given. The child does not have Symptoms of TB A tuberculin test is not available The child should receive preventive chemotherapy for six months (INH daily-5mg/Kg body weight) A tuberculin test is available A child should receive 3 months of INH preventive chemotherapy and a tuberculin test should be done
  174. 174. 8/23/2018 DR. HARIVANSH CHOPRA 174 IF THEN The child’s induration to the tuberculin test is<6mm in diameter Stop the preventive chemotherapy and give BCG vaccination (if previously not given) The child’s induration to the tuberculin test is 6mm or more in diameter Continue INH preventive chemotherapy for another 3 months
  175. 175. 8/23/2018 DR. HARIVANSH CHOPRA 175  TB bacteria can attack any part of the body such as the kidney, spine, and brain.  If not treated properly, TB disease can be fatal.
  176. 176. 8/23/2018 DR. HARIVANSH CHOPRA 176  In general, long- term contact with an infected person is needed— as much as eight hours a day for up to six months — to become infected.
  177. 177. 8/23/2018 DR. HARIVANSH CHOPRA 177  A person with active TB who's been effectively treated for at least two weeks is no longer contagious and can't spread the bacteria to others.
  178. 178. 8/23/2018 DR. HARIVANSH CHOPRA 178  1) The meaning of a case of tuberculosis is - 1. Patient is excreting tubercle bacilli in his sputum 2. Sputum is positive for A.F.B. 3. At least 2 initial sputum smears positive for A.F.B. or one A.F.B. positive smear and one positive culture 4. All of the above ANS.4
  179. 179. 8/23/2018 DR. HARIVANSH CHOPRA 179 2) Smear negative tuberculosis means - 1. At least 3 negative sputum smears + cardinal sign of tuberculosis 2. At least 3 negative sputum smears + cardinal signs of tuberculosis + X-ray abnormality 3. At least 3 negative sputum smears + cardinal signs of tuberculosis + X-ray abnormality or positive culture 4. All of the above ANS 3
  180. 180. 8/23/2018 DR. HARIVANSH CHOPRA 180 3) The difference between treatment completed & cure of tuberculosis is in - 1. The duration of treatment 2. The no. of drugs taken during treatment 3. Sputum examination at the beginning of the treatment 4. Sputum examination at the end of the treatment ANS 4
  181. 181. 8/23/2018 DR. HARIVANSH CHOPRA 181 4) Tubercle bacilli was discovered in the year - 1.1796 2.1882 3.1921 4.1900 ANS 3
  182. 182. 8/23/2018 DR. HARIVANSH CHOPRA 182  5) In India B.C.G. vaccination programme was started in the year 1. 1951 2. 1962 3. 1948 4. 1960 ANS 2
  183. 183. 8/23/2018 DR. HARIVANSH CHOPRA 183 6) The dose of B.C.G. in all age group is - 1.0.1 ml 2.0.05 ml 3.Both of the above 4.None of the above ANS.1
  184. 184. 8/23/2018 DR. HARIVANSH CHOPRA 184  7) The reconstituted B.C.G. vaccine should be used within 1. 1 hr. 2. 2 hr. 3. 3 hr. 4. 4 hr. ANS 3
  185. 185. REVISED NATIONAL TB CONTROL PROGRAMME(RNTCP) 8/23/2018 DR. HARIVANSH CHOPRA 185  On the recommendations of an expert committee , a revised strategy to control TB was pilot tested in 1993 and launched as a national program in 1997.  The RNTCP applies the WHO recommended DOTS(Directly Observed Treatment, Short course) strategy.  The programme was expanded in a phased manner to cover the entire country in 2005.
  186. 186. 8/23/2018 DR. HARIVANSH CHOPRA 186  By 24 March 2006, the entire country was covered under DOTS covering 1114 million people.  the majority of TB patients have pulmonary TB, with the sputum smear-positive pulmonary TB patients constituting the infectious pool in the community.  Early diagnosis and cure of these patients can break the chain of transmission of TB infection in the community.
  187. 187. 8/23/2018 DR. HARIVANSH CHOPRA 187  Since the inception of RNTCP and up to June 2005, more than 4.5 million patients were initiated on treatment and about 750,000 additional lives were saved.  Each month more than 100,000 patients are initiated on treatment.
  188. 188. STRUCTURE OF THE RNTCP 8/23/2018 DR. HARIVANSH CHOPRA 188  The RNTCP is lead by Central TB Division (CTD) in the Ministry of Health and Family Welfare, Govt. of India in Delhi.  The state, district and sub-district levels and peripheral health institutions implement the programme.
  189. 189. 8/23/2018 DR. HARIVANSH CHOPRA 189 National level Deputy director general Natioanl TB Institutions State Level State TB officer State tuberculosis control society District level District tuberculosis center District TB control society District Tuberculosis officer
  190. 190. 8/23/2018 DR. HARIVANSH CHOPRA 190 Sub district level Medical officer-tuberculosis control(MO-TC) Senior treatment supervisor(STS) Senior TB laboratory supervisor Tuberculosis Unit PHIs TB center CHC/PHC
  191. 191. CENTRAL TB DIVISION 8/23/2018 DR. HARIVANSH CHOPRA 191  At the Ministry of Health and Family Welfare, the Central TB Division is responsible for TB control in the entire country.  The Deputy Director General (DDG-TB) is the national programme manager.  The main functions of the CTD are to formulate technical policy, plan, implement, monitor and coordinate the programme at the national level.
  192. 192. STATE LEVEL 8/23/2018 DR. HARIVANSH CHOPRA 192  At the state level, a State TB Officer (STO) is responsible for planning, training, implementing, monitoring and coordinating the programme.  A State Tuberculosis Control Society (STCS) has been established for increased state ownership and accountability and also for the smooth transfer of funds from CTD to the state and then to districts.
  193. 193. DISTRICT LEVEL 8/23/2018 DR. HARIVANSH CHOPRA 193  The District Tuberculosis Centre (DTC) is the nodal point for TB control activities in the district and also functions as a specialized referral centre.  There is a District TB Control Society (DTCS) in every RNTCP district. It is responsible for budgeting and providing financial resources and also for monitoring the programme implementation.
  194. 194. 8/23/2018 DR. HARIVANSH CHOPRA 194 -1 District Tuberculosis Officer (DTO) -1 Second medical officer -2 Laboratory technicians -2 Treatment organizer/Health visitor -1 X-ray technician -1 Non-medical team leader -1 Statistical assistant -1 Pharmacist REVISED NATIONAL TB CONTROL PROGRAMME(RNTCP)
  195. 195. 8/23/2018 DR. HARIVANSH CHOPRA 195  It also arranges necessary logistics such as transport, hiring of contractual staff and procurement of materials including laboratory consumables.
  196. 196. 8/23/2018 DR. HARIVANSH CHOPRA 196  The District Collector (or Corporation Commissioner, or District Magistrate) is the Chairman and the District Tuberculosis Officer (DTO) is the Member Secretary.  The DTCS has representatives from government and non-government sectors.  The DTO has the overall responsibility to implement the programme at the district level and is assisted by medical Officer and other technical and administrative staff.
  197. 197. SUB-DISTRICT LEVEL 8/23/2018 DR. HARIVANSH CHOPRA 197  A team comprising of a designated Medical Officer-Tuberculosis Control (MO-TC), a Senior Treatment Supervisor (STS) and a Senior TB Laboratory Supervisor (STLS) is based at the Tuberculosis Unit (TU).  This is the sub-district unit of TB control activities and is usually based in health institutions such as Community Health Centers (CHC), Taluk Hospitals or Block PHCs.
  198. 198. 8/23/2018 DR. HARIVANSH CHOPRA 198  The sub-district covers a population of approximately 5 lakh (2.5 lakh in hilly, tribal and difficult areas) and is responsible for the TB control activities at this level.  The TU is also responsible for accurate maintenance of the TB register and for preparing quarterly reports.
  199. 199. DESIGNATED MICROSCOPY CENTRE 8/23/2018 DR. HARIVANSH CHOPRA 199  Designated Microscopy Centers (DMC) are usually situated at tertiary and secondary level health care institutions and Block PHCs or other equivalent institutions including private and NGO facilities.  Each usually caters to a population of 1 lakh (0.5 lakh in hilly, tribal and difficult areas).  All DMCs should be included in the standard RNTCP External Quality Assessment (EQA) system.
  200. 200. 8/23/2018 DR. HARIVANSH CHOPRA 200  The DMC either must be covering a population of 1 lakh, or having about 60 -100 new adult outpatient attendance per day.  The laboratory technician must be examining an average of at least 3 – 5 smears and not more than 20 – 25 smears per day.  there would be either a referral system to these laboratories by the private practitioners for sputum smear examination, and/or a referral between the labs either of TB suspects or samples.
  201. 201. PERIPHERAL HEALTH INSTITUTIONS 8/23/2018 DR. HARIVANSH CHOPRA 201  For the purpose of RNTCP, a PHI is a health facility which is manned by at least a medical officer (even if the post Is currently vacant).  At this level are the dispensaries,PHCs, CHCs, referral hospitals, major hospitals, specialty clinics / hospitals (including other health facilities) / TB hospitals / Medical colleges within the district.
  202. 202. 8/23/2018 DR. HARIVANSH CHOPRA 202  All health facilities in the private/NGO sector participating in RNTCP are also considered as PHIs under the programme.  Some of these PHIs will also be DMCs.  All PHIs with/without DMCs should submit a monthly PHI level report to the respective TUs and the district.
  203. 203. END TB STRATEGY : VISION 203 “To have a world Free of Tuberculosis with Zero Deaths, disease and sufferings due to TB and End the Global epidemic of TB”
  204. 204. END TB STRATEGY : TARGETS 204 FACTOR MILESTONE TARGETS 2020 2025 2030 2035 REDUCTION IN NUMBER OF TB DEATHS (IN COMPARISON TO 2015) 35 % 75 % 90 % 95 % REDUCTION IN TB INCIDENCE RATE (IN COMAPRISON TO 2015 ) 20 % 50 % 80 % 90 % TB AFFECTED FAMILY FACING CATASTROPHIC COST DUE TO TB 0 % 0 % 0 % 0 %
  205. 205. 3 PILLARS OF END TB STRATEGY 205 INTEGRATED PATIENT CENTERED TB CARE AND PREVENTION BOLD POLICIES AND SUPPORTIVE SYSTEMS INTENSIFIED RESEARCH AND INNOVATIONS
  206. 206. NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS ELIMINATION 2017 - 2025 206 IMPACT INDICATORS BASELINE TARGET 2015 2020 2023 2025 TO REDUCE TB INCIDENCE RATE (PER 100,000 ) 217 142 77 44 TO REDUCE TB INCIDENCE RATE (PER 100,000 ) 320 170 90 65 TO REDUCE ESTIMATED MORTALITY DUE TO TB (PER 100,000 ) 32 15 6 3 TO ACHIEVE ZERO CATASTROPHIC COST FOR TB AFFECTED FAMILIES 35 % 0 % 0 % 0 %
  207. 207. BEDAQUILINE (BDQ) 207  Targets Mycobacterial ATP Synthase  Action is Bactericidal  Extended Half life : can be present in blood for another 5.5 months after the therapy  Contraindications : – < 18 years – Pregnancy – Cardiac Arrhythmias
  208. 208. SCHEDULE FOR BEDAQUILINE 208 MDR / RR TB WITH RESISTANCE TO ALL FLUROQUINOLONES MDR / RR TB WITH RESISTANCE TO ALL SECOND LINE INJECTABLES XDR TB (ALL FQ AND SLI RESISTANT) XDR TB (ANY FQ AND ALL SLI RESISTANT) XDR TB (ALL FQ AND ANY SLI RESISTANT) XDR TB (ANY FQ AND ANY SLI RESISTANT) TREATMENT FAILURE MDR + FQ/SLI RESISTANT
  209. 209. TREATMENT SCHEDULE 209 WEEK 0 – 2 : 400 mg DAILY FOR 7 DAYS / WEEK WEEK 3 – 24 : 200 mg THRICE A WEEK (ATLEAST 48 HOURS BETWEEN TWO DOSES) WEEK 25 TO END OF TREATMENT : CONTINUE ONLY 2ND LINE DRUGS AS PER RNTCP GUIDELINES
  210. 210. 99 DOTS STRATEGY 210  To improve the adherence to TB treatment  A number is printed on the back of blister pack which will be revealed only when the patient open the pack.  The patient is made to call on that number in order to make assure that he has consumed the tablet
  211. 211. NIKSHAY 211  TB surveillance using case based web based IT system.  Central TB Division in collaboration with National Informatics Centre has undertaken the initiative to develop a case based and web based application called Nikshay.
  212. 212. NIKSHAY: COMPONENTS 212 MASTER MANAGEMENT USER DETAILS TB PATIENT REGISTRATION AND DETAILS OF DIAGNOSIS DOT PROVIDER HIV STATUS FOLLOW UP CONTACT TRACING
  213. 213. NIKSHAY: COMPONENTS 213 DETAILS OF SOLID AND LIQUID CULTURE AND DST, LPA, CBNAAT DETAILS DR – TB CASES REGISTRATION WITH DETAILS. REFERRAL AND TRANSFER OF PATIENTS PRIVATE HEALTH FACILITY REGISTRATION AND TB NOTIFICATION MOBILE APPLICATION FOR TB NOTIFICATION SMS ALERT
  214. 214. CONCLUSION 8/23/2018 DR. HARIVANSH CHOPRA 214  Tuberculosis is a silent, global emergency.  The best method to control it is early diagnosis & prompt treatment.  DOTS ensures increased compliance & cure.  Generation of public awareness will go a long way in the control of tuberculosis.
  215. 215. 8/23/2018 DR. HARIVANSH CHOPRA 215

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