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