Brief overview of tuberculosis and it's relevance in india

This presentation highlights tuberculosis and it's relevance in india with treatment options available

1. TUBERCULOSIS A brief overview

2. Foreword This presentation aims to provide a brief insight into one of the oldest disease in the world, tuberculosis. It includes brief information on the history, epidemiology, morphology of the etiological agent, pathogenesis,signs and symptoms,lab diagnosis, treatment, prevention and the national programmes aimed towards its complete elimination. It has been made possible due to the contributions of my classmates mentioned in the next slide

3. What is tuberculosis? Tuberculosis (TB) is a contagious infection that usually attacks your lungs. It can also spread to other parts of your body, like your brain and spine. A type of bacteria called Mycobacterium tuberculosis causes it.

4. Insight into history Johann Schonlein coined the term “tuberculosis” in the 1834, though it is estimated that Mycobacterium tuberculosis may have been around as long as 3 million years
Tuberculosis (TB) was called “phthisis” in ancient Greece, “ tabes ” in ancient Rome, and “ schachepheth ” in ancient Hebrew. In the 1700s, TB was called “the white plague” due to the paleness of the patients. TB was commonly called “consumption” in the 1800s even after Schonlein named it tuberculosis. During this time, TB was also called the “Captain of all these men of death.”
During the Middle Ages, TB of the neck and lymph nodes was called “scrofula.” Scrofula was believed to be a different disease from TB in the lungs.

5. What’s responsible for TB? Mycobacterium tuberculosis (M. Tb), also known as Koch’s bacillus, is a species of pathogenic bacteria in the family Mycobacteriaceae and the causative agent of tuberculosis.On March 24, 1882, Dr. Robert Koch announced the discovery of Mycobacterium tuberculosis. The physiology of M. Tuberculosis is highly aerobic and requires high levels of oxygen. Primarily a pathogen of the mammalian respiratory system, it infects the lungs

6. Mycobacterium tuberculosis M. Tuberculosis is a small, rod-shaped, strictly aerobic, acid-fast bacillus The M. Tuberculosis bacillus is 0.2–0.5 µm wide and 2–4 µm long and so it is bioaerosols measuring 1–5 µm that may plausibly serve as vehicles of this pathogen, permitting infection of alveolar macrophages in distal portions of lungs

7. Structure of Mycobacterium tuberculosis

8. The magic in the cell wall

9. Epidemiology over the world About a quarter of the global population is estimated to have been infected with TB bacteria. About 5–10% of people infected with TB will eventually get symptoms and develop TB disease. TB occurs in every part of the world. In 2022, the largest number of new TB cases occurred in WHO’s South-East Asian Region (46%), followed by the African Region (23%) and the Western Pacific (18%). Around 87% of new TB cases occurred in the 30 high TB burden countries, with more than two-thirds of the global total in Bangladesh, China, Democratic Republic of the Congo, India, Indonesia, Nigeria, Pakistan and the Philippines.

10. Globally in 2022, there were 2.2 million new TB cases that were attributable to undernutrition , 0.89 million to HIV infection, 0.73 million to alcohol use disorders, 0.70 million to smoking and 0.37 million to diabetes. In 2022, about 167 000 people died of HIV-associated TB. The percentage of notified TB patients who had a documented HIV test result in 2022 was 80%, up from 76% in 2021. The WHO African Region has the highest burden of HIV-associated TB. Overall in 2022, only 54% of TB patients known to be living with HIV were on antiretroviral therapy (ART).

11. A total of 1.3 million people died from TB in 2022 (including 167 000 people with HIV). Worldwide, TB is the second leading infectious killer after COVID-19 (above HIV and AIDS).
In 2022, an estimated 10.6 million people fell ill with tuberculosis (TB) worldwide, including 5.8 million men, 3.5 million women and 1.3 million children. TB is present in all countries and age groups. TB is curable and preventable.
Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. Only about 2 in 5 people with drug resistant TB accessed treatment in 2022.
Global efforts to combat TB have saved an estimated 75 million lives since the year 2000.

12. TB prevalence in the world

13. What about India? India accounts for about 25% of global TB burden, with an estimated TB incidence of 2.77 million in 2022 In 2020, India accounted for 26% of the incident TB cases across the globe. India has incidence rate of 192 cases per 100,000 of population. India accounted for 38% of global TB deaths among HIV-negative people and for 34% of the combined total number of TB deaths in HIV-negative and HIV-positive people. Further in 2020, India accounted for 24% of global gap between estimated TB incidence and the number of people newly diagnosed with TB and reported.[6]

14. India and TB

15. Virulence factors of MTB Non protein virulence factors of MTB include- • Phthiocerol Dimycocerosates •Mycolic acid •1-tuberculosinyladenosine •Phenolic glycolipid •Sulfolipid-1 • Lipomannan • Mannosylated Lipoarabinomannan • Phosphatidyl inositol mannosides • Arabinomannan •α- glucan

16. Protein virulence factors of MTB include- PE proteins: PE-PPE and PE-PGRS Lipoproteins- LpqH (19 kDa protein),P27 lipoprotein,RpfB multidomain lipoprotein and LprN PtpA and SapM are two phosphatases that contribute with the phagosome arresting.

17. Pathogenesis of tuberculosis

18. Can TB be classified? Classification based on anatomical site of disease Pulmonary TB (PTB) refers to any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or the tracheobronchial tree Extrapulmonary TB (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

19. Pulmonary tuberculosis Pulmonary tuberculosis accounts for 60-90% of all cases of tuberculosis. It can be further classified into primary and post primary types. Primary pulmonary tuberculosis results due to initial exogenous infection with tubercle bacilli. Commonly affects children. However recent cases show increased prevalence in adults Post primary pulmonary tuberculosis results due to exogenous reinfection or reactivation of latent primary lesion after a brief period of latency

20. Extra pulmonary tuberculosis EPTB results from hematogenous dissemination of tubercle bacilli to various organs. Constitutes about 10-40% of all cases of TB,in HIV positive patients, the frequency is much higher accounting up to two thirds of all cases of TB. Common types include- tuberculous lymphadenitis, pleural tuberculosis, genitourinary tuberculosis, skeletal tuberculosis, tuberculous meningitis, gastrointestinal tuberculosis, tuberculous pericarditis, cutaneous tuberculosis and miliary tuberculosis.

21. Can you recognise a TB patient? •Patients with primary pulmonary tuberculosis usually are asymptomatic. Symptoms can include mild or progressive dry cough, low-grade fever, fatigue, weight loss, and night sweats. The most common manifestations of primary pulmonary tuberculosis in children consist of unilateral hilar or paratracheal lymph node enlargement, which is seen in 90% to 95% of cases

22. •Post primary pulmonary TB is the most common form of reactivation TB. The typical findings consist of the insidious onset of a productive cough, night sweats, anorexia, and weight loss. Fever is present in approximately half of those affected. •Physical examination may show dullness to percussion, low-pitched amphoric (hollow sounding) breath sounds, and occasionally crepitations that may be post- tussive

23. Tuberculous lymphadenitis Tuberculous lymphadenitis typically involves a gradual and usually painless swelling of the affected lymph nodes (termed lymphadenitis).Duration of symptoms can vary, and ranges between weeks to months following initial onset. Unilateral lymph node involvement accounts for the majority of cases, and involvement of the cervical lymph nodes is the most common.

In addition to swollen lymph nodes, the person may experience mild fevers, decreased appetite, or weight loss.Pulmonary tuberculosis infection may co-occur with tuberculous lymphadenitis and account for additional symptoms such as cough.

24. Pleural tuberculosis Tuberculous pleurisy usually presents as an acute illness. The most common presenting symptoms are non-productive cough and pleuritic chest pain. Other symptoms include fever, night sweats, weight loss, malaise, and dyspnea varying in severity according to the size of effusion.

25. Genitourinary tuberculosis The most common symptoms of GUTB, in descending order of frequency, include increased frequency of urination (during the day initially but at night later in the disease course), dysuria, frank pain, suprapubic pain, blood or pus in the urine, and fever.

26. Skeletal tuberculosis •Severe back pain
•‌Inflammation in back or joints
•‌Stiffness
•Trouble moving or walking, especially in children
•‌Spinal abscess
•‌Soft tissue swelling
•‌Neurological disorders
•‌Muscle weakness
•Paralysis from the waist down (paraplegia) or of all four limbs and sometimes in specific organs (tetraplegia)
•‌Kyphosis, also known as hunchback

27. Tuberculous pericarditis The predominant symptoms of tuberculous pericarditis are cough, dyspnea , and chest pain. Night sweats, orthopnea , weight loss, and ankle edema are also common. As for signs, the most frequent are cardiomegaly, pericardial rub, fever, and tachycardia.

28. Cutaneous tuberculosis Lesions appear as friable, painful, erythematous-to-yellowish papules and nodules, measuring 1 to 3 cm in diameter, which can lead to painful ulcers with fibrinous bases in the skin near bodily orifices. Edema and inflammation are evident in perilesional tissue.

29. Tuberculous meningitis Typical symptoms and signs of meningitis including headache, fever, and stiff neck, although meningeal signs may be absent in the early stages.

30. Miliary tuberculosis Symptoms of miliary tuberculosis can be vague and difficult to identify. They include weight loss, fever, chills, weakness, general discomfort, and difficulty breathing. Infection of the bone marrow may cause severe anemia and other blood abnormalities, suggesting leukemia .

31. How do laboratories diagnose TB? It involves – Specimen collection Staining and microscopy Culture and identification Molecular diagnosis Radiodiagnosis Other specific tests Serology is not preferred as WHO found that commercial serological tests for TB provide inconsistent and imprecise findings that result in highly variable values for sensitivity and specificity. This can seriously jeopardize patient safety.

32. Specimen collection SPUTUM (EXPECTORATED)
Three early morning specimens obtained on different days should be submitted. A volume of 5 to 10 mL is adequate and there is no advantage in collecting a larger volume. The sample should contain recently discharged material from the bronchial tree with minimal saliva content.
SPUTUM (INDUCED)
If the patient has difficulty producing a sputum specimen, then induction should be considered. Sputum production may be induced by the inhalation of a warm aerosol of sterile 5-10% sodium chloride in water produced by a nebulizer.
The specimen should be clearly marked “INDUCED” on the request slip since nebulized sputa is watery in consistency and could be mistaken for saliva.

33. GASTRIC LAVAGE
This procedure can be employed where sputum production is unsuccessful. This technique requires professional attention and should only be attempted in the hospital. Gastric lavage is performed early in the morning before eating and at least 8 hours after the patient has eaten or taken oral drugs. A specimen volume of 5-10mL is required and must be neutralized with 100 mg of sodium carbonate.
URINE
An early morning midstream specimen should be collected. Send entire specimen. Multiple specimens over several days may be required to obtain a positive specimen. Due to contamination and deterioration, 24 hour urine specimens are NOT acceptable. Keep specimen refrigerated until transport.
BLOOD
Specimens should be collected in Isolator tubes available from the kit room of this laboratory on request. Check expiration date prior to drawing blood. Store tubes at room temperature. Transport the same day of collection.

34. FLUIDS
Body fluids (spinal, pleural, pericardial, synovial, ascitic , blood, pus, and bone marrow) must be aseptically collected and submitted in sterile containers. Keep refrigerated until transport.
TISSUE
Any tissue to be cultured must be collected aseptically into sterile a container without fixatives or preservatives. If the specimen may dry, add sterile saline to keep moist. Do not place tissue specimen for culture into formalin. Keep refrigerated until transport.

35. Direct microscopy Brightfield sputum smear microscopy requires simple laboratory facilities and is a much cheaper alternative to the complex and costly process of TBculture . However, to be effective staff must be trained, follow correct standard operating procedures, be provided with good quality equipment, consumables and reagents, and be part of a Quality Assured network of laboratories.The Ziehl-Neelsen (ZN) technique has been the primary diagnostic technique for over 100 years. It is easier to learn to recognise ZN stained AFB compared with fluorescence microscopy. The detection of one AFB in a smear is sufficient to declare a positive result. Viewed with an oil immersion lens, AFB are red, slender rods, sometimes with one or more granules •Tubercle bacilli may occur singly, as V-shaped forms, or as clumps of bacilli • Report fragments of bacilli – often seen during treatment

36. Fluorescence microscopy In 2011, WHO released a new policy on Light Emitting Diode (LED) based Fluorescent Microscopy (FM) for diagnosing TB. FM is equally accurate, at least 10% more sensitive and has qualitative, operational, cost and workload advantages for all laboratories performing sputum smear microscopy. WHO recommended a phased approach to change from brightfield microscopy to LED-based FM across the microscopy network.LED FM offers considerable advantages over conventional FM, which requires a darkened room to read smears. Conventional FM relies on expensive mercury vapour lamps that have a limited life span, generate large amounts of heat, and are a safety hazard if broken

37. The typical appearance of AFB is a long, slender, slightly curved rod,but variable in shape and staining intensity They may be uniformly stained or may contain one or more gaps, or have a granular appearance. AFB occur singly, in small groups containing a few bacilli, or more rarely,as large clumps.

38. Culture and identification Egg-base media such as Lowenstein–Jensen (LJ) and Ogawa have been the primary culture media for both diagnostic specimens and specimens from tuberculosis (TB) patients receiving anti-TB therapy. More recently agar-base media such as Middlebrook 7H10 and 7H11 have been used instead. Advantages are agar-base media avoid the need for drug-free eggs and an inspissator , growth appears sooner, easy to visualize and separate individual colonies with a larger transparent surface, and their larger surface area makes it easier to recover MTB in the presence of contaminants. Furthermore, antibiotics which do not inhibit the growth of MTB can be incorporated into the agar media to suppress contaminant growth and make the media selective for MTB.

39. Rough , tough and buff colonies on lowenstein Jensen media indicate positive cultural growth of Mycobacterium tuberculosis

40. Molecular diagnosis The majority of molecular tests have been aimed at the detection of MTB specific nucleic acids, both in DNA and RNA, by using amplification techniques such as polymerase chain reaction (PCR), and detection of genes mutation that are related with the resistance to anti-TB drugs by sequencing or nucleic acid hybridization.

41. NAAT? A nucleic acid amplification test, or NAAT, for tuberculosis (TB) is a molecular test used to detect the DNA (deoxyribonucleic acid) of Mycobacterium tuberculosis complex (MTBC) in a sputum or other respiratory sample. Because the amount of DNA in a sample is very small, NAA testing includes a step that amplifies (or copies) the genetic material. Polymerase Chain Reaction (PCR) is a common form of NAAT used in laboratory diagnosis. GeneXpert ® MTB/RIF test is a PCR that simultaneously detects MTBC and the genetic mutation that confers rifampin (RIF) resistance.

42. Is NAAT the future? •A NAAT can detect MTBC genetic material even when very small amounts are present in the sample tested. NAAT results are typically available in 24 to 48 hours. • Rapid results enable earlier diagnosis of TB, earlier initiation of treatment, a reduced period of infectiousness, and improved patient outcomes. • The GeneXpert MTB/RIF NAAT also provides rapid identification of RIF resistance, a predictor of multi-drug resistant TB. In most cases, patients resistant to RIF are also resistant to isoniazid (INH).

43. A NAAT does not replace the need for an acid-fast bacilli (AFB) smear or culture. Culture remains the gold standard for laboratory confirmation of TB and is required for drug-susceptibility testing and genotyping.

44. Radio diagnosis of TB Chest radiographs are used to stratify for risk and to assess for asymptomatic active disease. Sequelae of previous tuberculosis that is now inactive manifest characteristically as fibronodular opacities in the apical and upper lung zones. Stability of radiographic findings for 6 months distinguishes inactive from active disease. Nontuberculous mycobacterial disease can sometimes mimic the findings of active tuberculosis, and laboratory confirmation is required to make the distinction. Familiarity with the imaging, clinical, and laboratory features of tuberculosis is important for diagnosis and management.

45. The most common radiographic findings in primary pulmonary TB by recent infection in previously healthy adolescents are upper lung lesions, which were thought to be radiographic findings of reactivation pulmonary TB by remote infection

46. Young male patient with fever and cough has a focal opacity in the left lower lobe that looks like a pneumonia. This is a case of primary tuberculosis in an adult.

47. Primary pulmonary tuberculosis in 18-year-old boy with typical radiographic findings. Chest radiograph shows patchy consolidation, nodules, and cavities (arrows) in bilateral upper lung zones.

48. The most common radiographic manifestation of post-primary tuberculosis is a focal or patchy, heterogeneous consolidation involving the apical and posterior segments of the upper lobes and the superior segments of the lower lobes. Other common findings are small nodules and linear opacities (i.e., fibronodular pattern of tuberculosis) and single or multiple cavities. The most common CT findings are centrilobular nodules and branching, linear and nodular opacities (i.e., tree-in-bud pattern, which is a characteristic finding of endobronchial spread); patchy or lobular areas of consolidation; and cavitation.

49. Post primary pulmonary TB FINDINGS
PA chest radiography shows multiple bilateral fibronodular opacities and ill-defined pulmonary nodules with an upper lung lobes predominance. Some cavitary lesions can also be observed.

50. Multiple axial CT images through the lungs demonstrate multiple thick-walled pulmonary cavities predominantly in the apical and posterior segments of the upper lobes, as well as the superior segments of the lower lobes. There are multiple areas of nodularity and partial consolidation in a bilateral and peripheric distribution, forming a tree-in-bud pattern in some locations. Apical architectural distortion, fibrotic bronchiectasis and upper lung volume loss can additionally be observed. There are also small mediastinal lymphadenopathies.

51. Mantoux test The Mantoux test or Mendel– Mantoux test (also known as the Mantoux screening test, tuberculin sensitivity test, Pirquet test, or PPD test for purified protein derivative) is a tool for screening for tuberculosis (TB) and for tuberculosis diagnosis. It is one of the major tuberculin skin tests used around the world, largely replacing multiple-puncture tests such as the tine test

52. Older interpretation The results of this test must be interpreted carefully. The person’s medical risk factors determine at which increment (5 mm, 10 mm, or 15 mm) of induration the result is considered positive. A positive result indicates TB exposure. 5 mm or more is positive in- An HIV-positive person
Persons with recent contacts with a TB patient
Persons with nodular or fibrotic changes on chest X-ray consistent with old healed TB
Patients with organ transplants, and other immunosuppressed patients 10 mm or more is positive in Recent arrivals (less than five years) from high-prevalence countries
Injection drug users
Residents and employees of high-risk congregate settings (e.g., prisons, nursing homes, hospitals, homeless shelters, etc.)
Mycobacteriology lab personnel
Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia , end-stage renal disease, chronic malabsorption syndromes, low body weight, etc.)
Children less than four years of age, or children and adolescents exposed to adults in high-risk categories 15 mm or more is positive in Persons with no known risk factors for TB

53. Latest interpretation According to the guidelines published by Centers for Disease Control and Prevention in 2005, the results are re-categorized into 3 parts based on their previous or baseline outcomes:
Baseline test: ≥10 mm is positive (either first or second step); 0 to 9 mm is negative
Serial testing without known exposure: Increase of ≥10 mm is positive
Known exposure:
≥5 mm is positive in patients with baseline of 0 mm
≥10 mm is positive in patients with negative baseline or previous screening result of >0 mm

54. Let’s treat Tuberculosis If you have a TB infection, your health care provider may begin drug treatments. It is important to take every dose as instructed. And you must complete the full course of treatment. This is important for killing the bacteria in your body and preventing new drug-resistant bacteria. Common medications used to treat tuberculosis include:
Isoniazid. Rifampin Pyrazinamide Ethambutol .

55. There are three categories of treatment: Categories I, II and III and each has an Intensive Phase and Continuation Phase.During the Intensive Phase, you must directly observe the patient swallowing every dose of medicine. During the Continuation Phase, at least the first dose of medicine every week must be taken by the patient under your direct observation, while the other two doses are taken by the patient himself. The patient must bring the previous week’s blister pack when coming to collect the next week’s blister pack.

56. During the intensive phase, medicines are to be taken thrice weekly (three times a week) on alternate days. Thrice-weekly treatment is as effective as daily treatment. If a patient does not receive treatment on the scheduled day, you should trace the patient and give him treatment on that day or the following day. But the next dose should be given as scheduled. Upon completing 22 doses of the Intensive Phase (Category I and III patients) and 34 doses of the Intensive Phase (Category II patients), the patient should give 2 samples of his sputum for testing, so that, when his full Intensive Phase doses are completed the results of these tests are available. If sputum is negative, the patient begins drugs for the Continuation Phase. If sputum is positive, the Medical Officer may extend the patient’s Intensive Phase of treatment.

57. Standardized anti tb treatment guidelines

58. CATEGORY-I Treatment -6 months Intensive phase-months 1 and 2 Continuation phase-months 3 to 6 Sputum examination – at month 0 medicine is started Again at 2 months- If sputum is negative, continue medication and again have sputum examined at months 4 and 6 If sputum positive then intensive phase is extended again for 1 month with periodic sputum examination

59. CATEGORY -II Treatment (8 months)
Intensive Phase — Months 1, 2 and 3
Continuation Phase — Months 4 to 8
Sputum examination
At month 0 (time of detection of TB) Medicines started again at 3 months
If sputum is negative — Continue medicines and have sputum examined again at 5 and 8 months.
If sputum is positive — Intensive Phase is extended for 1 month and medicines for this period will be provided separately.— Ensure that sputum is examined again at 4, 6 and 9 months of treatment.

60. CATEGORY-III Treatment (6 months)
Intensive Phase — Months 1 and 2
Continuation Phase — Months 3 to 6
Sputum examination
At month 0 (time of detection of TB)
Medicines started
Again at 2 months
If sputum is negative — Continue medicines and have sputum examined again at 6 months. If sputum is positive — Refer the patient to the Medical Officer for change of treatment.

61. Side effects of anti TB drugs Unexplained loss of appetite, nausea or vomiting, brown urine*, or jaundice (yellowing of skin or eyes)
Persistent tingling, numbness, or burning of hands or feet
Persistent weakness, fatigue, fever, or abdominal tenderness
Easy bruising or bleeding
Blurred vision or changed vision

62. RIF and RPT decrease blood levels of many drugs including oral contraceptives, warfarin and some other anticoagulants (“blood thinners”), sulfonylureas (used for diabetes), and methadone
RIF and RPT are contraindicated in HIV-infected individuals being treated with protease inhibitors ( Pis ) and most nonnucleoside reverse transcriptase inhibitors (NNRTIs)

63. DOT and regimen for drug resistant TB DOTS programs focus on increasing patient adherence, the primary determinant in treatment success rates. DOTS is currently the WHO-recommended strategy for TB control. DOTS involves treatment with a four-drug regimen [INH, RIF, pyrazinamide (PZA), and ethambutol (EMB)] for 6–9 months. DOTS must be used throughout the entire course of therapy for best cure rates. The core intervention involves a health worker who observes the patient when s/he is swallowing each dose of anti-TB medication. DOTS also involves the regular collection of sputum specimens until two consecutive samples test negative for AFB.

64. The key change in the latest WHO recommendations is the addition and prioritization of a new all-oral 6-month regimen. For people with MDR/RR-TB, the regimen comprises bedaquiline (B), pretomanid (Pa), linezolid (L) and moxifloxacin (M), and is referred to as BPaLM ; for people who have pre-XDR-TB, the regimen can be used without moxifloxacin ( BPaL ). The shorter duration, lower cost, lower pill burden and high efficacy of this novel regimen should enable much better treatment and treatment outcomes for people with MDR/RR-TB or pre-XDR-TB, while also helping health systems to provide care for more people, even in the context of setbacks associated with the COVID-19 pandemic.

65. Prevention is better than cure Vaccines for tuberculosis prevention There’s only one vaccine used for the prevention of TB. It’s called the bacillus Calmette-Guérin (BCG) vaccine. It contains a live, weakened form of the bacteria that cases TB.
In many countries, BCG is part of the standard vaccine program for newborns . But it’s rarely used in the United States.
The BCG vaccine offers partial protection against severe forms of TB in infants and young children. But it doesn’tTrusted Source protect adolescents and adults from TB or prevent latent TB infections from progressing to active disease. It also doesn’tTrusted Source provide long-term protection, so booster doses are sometimes recommended for people at high risk of TB exposure.
People with compromised immune systems can’t take the BCG vaccine.
Recently, there have been several advances in TB vaccine development and research. For example, new experimental vaccines such as M72/AS01E have shown promise in clinical trials and may offer better protection than BCG. But more research is needed.

66. Here are some tips for preventing TB infection: Avoid close contact with people who have active TB disease.
Wash your hands often and cover your mouth when coughing or sneezing.
Eat a nutritious diet and exercise regularly to keep your immune system strong.
If you work in a healthcare setting abroad, follow protocols for wearing protective gear such as masks and gowns.
If you have a latent TB infection, follow the entire treatment protocol.
If you’re traveling to a high risk area and you have a compromised immune system, talk with a doctor about preventive treatments.

67. National programmes aimed towards tuberculosis The National TB Control Programme was started in 1962 with the aim to detect cases earliest and treat them. In the district, the programme is implemented through the district Tuberculosis Centre (DTC) and the Primary Health Institutions. The District Tuberculosis Programme (DTP) is supported by the state level organization for the coordination and supervision of the programme. The Revised National Tuberculosis Control Programme (RNTCP), based on the Directly Observed Treatment, Short Course (DOTS) strategy, began as a pilot project in 1993 and was launched as a national programme in 1997 but rapid RNTCP expansion began in late 1998. The nation-wide coverage was achieved in 2006.

68. The Revised National TB Control Programme (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, was launched in 1997 expanded across the country in a phased manner with support from World Bank and other development partners. Full nation-wide coverage was achieved in March 2006. In terms of treatment of patients, RNTCP has been recognized as the largest and the fastest expanding TB control programme in the world. RNTCP is presently being implemented throughout the country.

Under the programme, diagnosis and treatment facilities are provided free of cost to all TB patients. For quality diagnosis, designated microscopy centers have been established for every one lac population in the general areas and for every 50,000 population in the tribal, hilly and difficult areas. More than 13000 microscopy centers have been established in the country. Free treatment services are available for TB at all Government hospitals, Community Health Centers (CHC), Primary Health Centers (PHCs). DOT centers have been established near to residence of patients to the extent possible. All public heatlh facilties , subs centres, Community Volunteers, ASHA, Women Self Groups etc. Also function as DOT Providers/DOT Centers .

69. In 2005, 1.29 million TB patients, in 2006, 1.39 million; in 2007, 1.48 million, in 2008, 1.51 million, in 2009, 1.53 million, in 2010, 1.52 million, in 2011, 1.51 million patients, in 2012, 1.46 million, in 2013, 1.44 million TB patients, in 2014 and 1.42 million TB patients have been registered for treatment. For the first time in 2015, the programme screened more than 9 million suspects for Tuberculosis.

Treatment success rates have tripled from 25% in pre-RNTCP era to 87% presently (2014) and TB death rates have been reduced from 29% to 4% during the same period.

Since 2007, RNTCP has achieved the NSP case detection rate of more than 70% in line with the global targets for TB control while maintaining the treatment success rate of >85%

70. Future plans? NSP( National strategic programme) India 2020–2025 identifies a number of goals which still need to be carried out for the elimination of TB from India. This plan intends to accelerate the national response to TB.

The recommended actions included:
•To mount a TB elimination campaign inspired by lessons gained from the eradication of Polio;
•Provide top priority reinforcements to the existing workforce;
•Scale up private provider engagement;
•Changes in approach from passive community involvement to full community participation and ownership;
•Investment in TB surveillance staff and systems for accurate, complete and timely information;
•Deployment of new precision diagnostic tools;
•Support patients comprehensively throughout treatment;
•Redesign and pursue targeted active case finding;
•Deploy and evaluate ambitious plans to implement TB preventive treatment in household and other close contacts, children, People living with HIV (PLHIV) and other locally defined “high risk” groups, using new and short regimens.

71. Tuberculosis Mukt Bharat Abhiyan The MoHFW along with various development partners of the Health Ministry launched the Tuberculosis (TB) Mukt Bharat Abhiyaan in 2021 under the NSP India 2020–25 for TB Elimination in a major mission activity for ending the epidemic of TB by 2025. It is a multi-dimensional approach which aims to detect all TB patients and emphasizes on reaching for patients who are seeking TB care from private practitioners and undiagnosed TB in high-risk populations.