Post on 28-Jan-2018
ALL INDIA INSTITUTE OF LOCAL SELF
GOVERNMENT
DELHI
“ REVISED NATIONAL TB CONTROL
PROGRAMME “
DR.P.P.SINGH
By
Dr. P.P.SINGH
Faculty AIILSGD
Ex Medical Superintendent Cum Consultant pathologist HRH Delhi
Ex. Director India Population Project 8 Delhi..
INTRODUCTION
Tuberculosis is an infective Disease caused by
Mycobacterium tuberculosis. ( Koch’s bacilli.)
Discovered By ROBERT KOCH of Germany on 24th
March 1882.
World TB day is celebrated on 24th March.
Main Types of Tuberculosis.
1. Pulmonary (most common0
2. Extra pulmonary (EP) – all organs except hair & nails.
It is an airborne spread of droplets and droplet nuclei
containing TB bacilli.
Untreated sputum positive can infect 10-15 persons each year.
Poorly treated develop drug resistance and it become
incurable.
GLOBAL Scenario.
In 2009 about 9.4 million new cases.
One fifth are in INDIA. Now Total cases = 1.4 cr. – 0.28 cr
INDIA
TB death total 13 Lakh – 4.23 Lakh in INDIA
Multi Drug Resistant Total 490000 --- 84000 in INDIA
80% 1.8 Million cases every year are in 22 high burden
countries and mostly Asia.
In 2007 it was estimated 4.9 % of new cases are HIV
positive in INDIA.
NATIONAL TB CONTROL PROGRAMME ( NTCP)
After significant research during 1950 – 1960 . NTCP
programme was launched in 1962 through District TB
centres.
OBJECTIVES of NTCP
A. Long Term objective ;- Prevalence rate in 14 years is
brought down less than 1%. By 2025 INDIA by 2030
World.
B. Short Term objective.:-
I. To detect maximum number of TB cases and
treated effectively.
II. Vaccinate new born and infants with BCG.
III. Undertake above objectives through integrated
manner of existing institutions.
STRATEGY
1. Passive Surveillance- Examination of patients.
2. Examination of Sputum.
3. X-ray of patients.
4. Tuberculin test ( MOUNTAX) and giving BCG
vaccine.
5. TB training centre in major states . National
tuberculosis institute in Bangalore 1959.
6. Ant TB drugs freely supplied to TB clinics by State
Gov.
7. BCG vaccination in UIP taken in1990.
NTCP unable to make an improvement therefore in 1992
Revised National TB control programme was launched.(
pilot study done during 1993-97)
The 1992 review by WHO revealed that:-a. Less than 30% completed Treatment.
b. Inadequate case detection
c. Microscopy of sputum exam is of poor quality.
d. Undue emphasis on X-rays
e. Multiplicity of treatment regimes of non standard and
ineffective,
f. Shortage of Drugs.
g. Budget provision is in adequate etc.
a. In public and private sector incomplete treatment.
RNTCP with DOTs strategy , globally recommended accepted
and implemented in year 1992 in phase manner to cover whole
of country by 2006.
Structure Of RNTCP.
1. Central TB division ( CTD) in MOHFW.
2. State level – STO ( state tuberculosis Officer) and State
Tuberculosis control Society ( STCS)
3. District level – DTC ( district tuberculosis Centre with
DTO ( district TB Officer ) for overall supervision
4. Under DTC a team of
Medical officer ( MO –TC)
Senior Treatment supervisor ( STS)
Senior Tuberculosis Laboratory Supervisor (
STLS)
Senior DOT plus supervisor.
5. Sub District level – covers a population of 5 lakh (
2.5lakh in hill and difficult area)
6. Designated Microscopic Centre ( DMC)= one per 1 Lakh
population ( in hilli area 0.5 Lakh population)
7. Peripheral Health institution ( PHI) – 1 MO. At each
centre .
Goal of RNTCP
To decrease the Mortality and Morbidity ,
To cut transmission of infection of TB.
By DOTs ( Directly Observed Treatment Short
course chemotherapy)
Objectives of RNTCPTo achieve 90% notification.
To achieve 90% success rate for all new cases
and 85% for previously treated cases.
To significantly improve successful outcome of
treatment of MDR cases.
To achieve decreased morbidity and Mortality of
HIV associated TB.
To Improve outcomes of tB cases in Private
sector.
COMPONENTS of DOTS
1. Political and administrative
commitment.
2. Good quality diagnosis , primarily by
Sputum
3. Microscopy.
4. Uninterrupted supply of good quality
drugs,
5. Directly observed treatment ( DOTs).
6. Systematic Monitoring and
accountability,
SCIENTIFIC BASIS of DOTs.Sputum smear microscopy. --- easy & cost effective.
X-ray examination – it is sensitive but not specific.
ESR ( Erythrocyte sedimentation Rate ) --- not
specific and not reliable.
Culture of Sputum – highly sensitive and specific
but take long time
EFFECTIVENESS of DOTs.
Cure rate >90%
Sputum conversion more than 90%
Death Rate < 5%
Treatment Failure < 5%
Defaulter <5%
Domiciliary Chemotherapy--- Effective as Sanatoria
TT. Effective Economic but risk of infection to contacts.
Intermittent Chemotherapy--- Most effective ,
convenient for DOTs provider and patients. Less drugs so
less adverse reactions. Cost effective.
Currently recommended treatment aims ;-
1. Cure the patient.
2. Prevent death from active disease or from
late effects.
3. Prevent the emergence of drug resistant
organism.
4. Minimize relapse.
5. Protect the community from continue
transmission of infection.
DOT gives to Patients.
Service to patients & communities.
It ensure that patient take the medicine in
right dose at right intervals and completes
the treatment.
It offers a platform for building a human
bond between health provider and the
patients.
This helps in winning the confidence of
patient.
Patient can tell any problem while taking
treatment.
PHASES of TREATMENT
1. Initial intensive phase (IP)--- 2/3 months for rapid killing the
bacilli.
2. Continuous phase, ( CP) -- one week packet is given with
one dose given in front of provider.
Tuberculosis suspects All persons with cough more than 2 or more weeks.
Weight loss.
Chest pain .
Tiredness .
Shortness of breath.
Fever - evening rise.
Blood in sputum.
Loss of appetite.
Night sweating.
All such patients should have 2 Sputum Examination for
AFB ( Acid Fast Bacilli).
Classification of Tuberculosis cases.A. Pulmonary Tuberculosis
B. Extra pulmonary Tuberculosis.
Pulmonary Tuberculosisa. Smear Positive cases.--- + at least one.
b. Sear Negative cases. – Negative 2 smears
and even after 2 repeat after 10 -14 days of
antibiotic treatment.
Extra pulmonary Tuberculosis.– Patient
have symptoms of Fever- evening rise., Loss of
appetite, Night sweating., Swelling of Lymph
nodes., Joints or stiffness of neck in TB
meningitis .
TYPES OF TB PATIENTS.
New TB case – who had no treatment or had
treatment less than one month.
After treatment failure – ATT failed at the end of
treatment.
Treatment after lost to follow up. --- for one or more
month
Transferred in – from other unit.
Transfer out – Sent to other unit.
Recurrent Tuberculosis --- patient cured of
completed treatment but now positive.
Other previously treated patients– outcome is not
TREATMENT OF TUBERCULOSIS.
For treatment patients are divided in to Categories.
Treatment is always as Intensive phase and Continuous
phase.
2( HREZ) 3 == Number out side & front means for months, where
as outside and small number below means times in week.
H- ISONIAZID 600mg
R- RIFAMPICIN 450mg
Z- PYRAZINAMIDE 1500mg
E-ETHEMBUTOL 1200mg
S-STREPTOMYCIN 750mg.
If patient dose not take treatment he must be traced within 24 hrs.
PATIENT WISE BOXES (PWB) = RED for CAT I , BLUE for CAT II. (
DRUGS are in two pouches IP & CP blister pack)
CATEGORY I New sputum +
Seriously ill ASFB –ve
Seriously ill extra
Pulmonary.
2(HRZE)3
4(HR)3
If sputum is +ve after 2
month extend this phase
for One month
Every 2 month sputum
examination done. ( RED
BOX)
CATEGORY II Sputum –ve Relapse
Sputum +ve failure
Sputum +ve &default.
2(HRZES)3
1(HRZE)3
5(HRE)3
If sputum is +ve after3 month
extend this phase for One
month
(BLUE BOX)
CAT –IV (MDR) DOTS-PLUS IP -6-9
months
Kenamycin,of
loxacin, Z,E,
Ethonamide
& cycloserine
CP – 18months ofloxacine,
ethonamide ,E, Cycloserine,
Z ,E. ( with reserve substitute
drug – PAS ,
Moxifloxacin,Capreomycin)
Monthly boxex in 5 weight
band
CAT –V (XDR TB) IP – 6-12
MONTHS
AND CP= 18
MONTHS
IP- Capreomycin, PAS ,
Moxifloxacin, High doseof
INH, Clofizine,Linezolid,
Amoxyclav. ( 2 weight band
<45 &.>45 kgs)
SYMPTOMS DRUGS ACTION to be TAKEN
GI upset Any oral drug Reassured, Drug with less water
slowly in 20 minutes. Do not give
empty stomach
Itching Isoniazid or
any
Reassure and refer to Dr.
Burning in
hand & feet
Isoniazid Give Pyridoxine 100mg/day
Joint pain Pyrazinamide If sever refer to Dr.
Impaired
vision
Ethambutol Stop drug & refer
Side effects of Anti TB Drugs
DO Don't
Have 2 Sputum examination
if any cough of three weeks
or more.
Don’t avoid medical care if
there is cough.
Take all the medicines for
full period on regular basis
Don’t rely only on X-Ray for
diagnosis of TB
Understand TB can be cured Don’t stop treatment before
physician discontinued
them.
Cover your mouth while
coughing or sneezing.
Don’t discriminate against
TB patients.
Tuberculosis Do and Don’t
TUBERCULOSIS in CHILDREN
Sputum is difficult to collect so diagnosis is made
Clinical history.
Contact history.
X-ray
Tuberculin test
BCG
Treatment is given full course regardless of BCG status.
Preventive Treatment in children .
Child less than 6 years age are given 10 mg /KG weight for 6
Months.
Tuberculin Test( Mantoux test)1 TU injection intra dermal ( between layers of Skin) on fore
dorsal surface. And reading is take 48 hrs. about redness &
hardening of skin. The horizontal transverse diameter is measured.
Reading more than 10 mm == Positive.
6 mm; Negative.
6-9 mm – test is intermediate
Positive dose not suggest that person is suffering from
disease.
ROLE OF BCG
BCG is the only widely used Live Bacterial
Vaccine . Derived from attenuated strain of TB
bacilli.
There is a debate about usefulness of effect
of BCG vaccine. However it protect from
Milliary TB.
Dosage is 0.1mg in 0.1 ml volume given on
the left deltoid . For new born below 4 weeks
the dose is 0.05ml.
Who can be DOT provider?Any Body in Society or with the patient. He/ She
should;-
Be acceptable to patient.
Be available when patient needs.
Should take responsibility of patient.
Should follow the guidelines of RNTCP.
Should report time to time to DOT centre / Health
centre.
Should be accessible.
Should not get any pay from patient for transport
or treatment
Reasons for Discontinuance or interrupt of
treatment
When they improve symptomatically.
When they migrate to another place.
Due to Alcoholism.
Due to side effects of drugs.
Inconvenient timing of DOT centre or Provider.
Other Socio – economic reasons.
TREATMENT OUTCOME CURED – Microbiological smear Negative after full
treatment.
Treatment Completed– Patient Completed
Treatment but smear test not done.
Treatment Failed --- Smear or Culture Positive after
end of treatment.
Lost to treatment -- Treatment interrupted more
than One Month.
Treatment regimen Changed --- Patient switched to
drug resistant.
Died – Death during treatment regardless the
cause.
Not evaluated.---Transferred out. Cases.
TB? HIV basic facts.
TB is the leading Killer of People infected with HIV.
Up to 50% of HIV/AIDS develop TB world wide.
Both can be treated successfully – 14 million has been
treated.
Treatment of TB can improve the quality of HIV +ve cases.
4.58 million are infected with HIV.
Over 1.8 million are co infected .
HIV leads to the progression of TB
HIV increases the MDR – TB
TB shorten the survival of HIV cases.
TB causes more deaths in HIV /AIDS cases.
Pulmonary TB is most common. In HIV cases.
Mantoux test may become Negative.
Even Sputum Smear may be negative in late phase of HIV
X-ray chest is required for diagnosis.
Side effects of DOTs are more in first 2 months of
treatment.
DOTs and Anti retroviral Therapy in TB & HIV.
Most effective
Drugs like Nucleoside Reserve Transcriptase Inhibitors
Zidovudine
Diadanosine
Zalcitabine
Stavudine
Lamivudine
Abacavir.
HEZ & S are drug of choice for TB + HIV.
Refampicin is contraindicated.
MDR –TB – CAT –IV. Treatment Programmatic Management
of Drug Resistance TB ( PMDT) ( DOTs-PLUS ) is to be
followed.
MULTI DRUG RESISTANCE
Definition :- Case resistant to Refampicin and
Isoniazide only in CAT –I & CAT –II are may not be
resistant to other drugs. Or if only resistant to Refampicin
but sensitive to Isonex. Will also be treated as MDR with
CAT –IV regimen.
Causes of drug Resistance.a. Providers /Programmes – Inadequate regimen.
Absence/ inappropriate of guidelines .
Non Compliance with guidelines.
Inadequate training of health staff.
No monitoring of treatment
Poor organized / funded TB control
programme.
B. Drugs – inadequate supply / quality. Non availability of drug.
Poor quality
Poor storage.
Wrong dosage or combination.
C. Patient – Inadequate drug intake.Poor adherence of DOTs.
Lack of information.
Adverse drug resistant
Social and economic barriers.
Mal absorption
SUSPECTING MDR cases.Any TB case on treatment on follow up smear positive .
All smear positive or negative who are previously treated
more than one month.
Any patient close contact of MDR case.
Any HIV – TB co-infected cases.
HOW to CONFIRM – MDR.
1. LPA – Line Probe Assay.
2. Liquid Culture or Solid Culture test.
3. Drug Sensitivity Test LJ – Lowenstein Jensen
medium
4. Cartridge- Basic Nucleic Acid Amplification
Testing ( results are in 2 hrs)
What is XDR TB ? ( CAT –V)An MDR TB cases recovered M Tuberculosis is at
least resistant to Ionized , Refampicin , a fluroquinolone (
Ofloxacin levo ofloxacine etc) and second line inject able
Ant TB drugs, certified culture and DST laboratory.
Treatment Intensive Phase – IP --- 6-12 months 7 drugs (
Capreomycin, PAS, Moxifloxcin, High dose of INH,
Clofazimine , Linezolid and Amoxyclav.)
Continuation phase – CP – 6 drugs.- 18 months.(PAS,
Moxifloxcin, High dose of INH, Clofazimine , Linezolid
and Amoxyclav.)
Change :- from IP to CP only after Negative = 2 culture at
least one month apart