Dots plus

LECTURE ON DOTS PLUS, CHILDHOOD TB TB-HIV CO-INFECTION AND BCG VACCINE

1. DR RAGHURAM V, MD PROFESSOR AND HEAD DEPT OF COMMUNITY MEDICINE DOTS-PLUS

2. INTRODUCTION It is a regimen included under RNTCP programme for treating cases of drug resistant TB Involves use of second line anti-tubercular drugs Duration of treatment longer.

3. WHAT IS DOTS -PLUS

4. DOTS –PLUS REGIMEN The regimen should usually comprise 6 drugs Pyrazinamide , Ethambutol , a later generation Fluoroquinolone (such as high dose Levofloxacin ) and a parenteral agent (such as Kanamycin or Amikacin ), Ethionamide (or Prothionamide ), and either Cycloserine or PAS (P- aminosalicyclic acid), if Cycloserine cannot be used.

5. CONTD.. This regimen should be used during six to nine months of the intensive phase. Four drugs usually Levoflaxacin , Ethionamide , Ethambutol and Cycloserine , should be used during the 18 months of the continuation phase.

6. CHILDHOOD TB Prevalence of the disease in India 15-25 per 1000 population 15 million infected, 25% sputum positive 3 to 4 million infected are children

7. Portal of entry for tuberculosis Inhalation of Tubercle bacilli in >95% (M.TB) Ingestion of milk containing Bovine Tubercle bacilli (M. bovis ) Contamination of superficial skin or mucous membrane lesion with tubercle bacilli Congenital infection when mother has lymphohematogenous spread during pregnancy

8. Primary infection- Children vs. Adults Adult primary infection tends to be more local and pulmonary. In children the disease tends to be more disseminated .

9. Symptoms of childhood tuberculosis Failure to thrive } & Intermittent fever } are the commonest symptoms Pleural effusion Ascites Abdominal mass (Painless) Limp / Arthritis Painless lymphadenopathy Persistent skin ulcer Sterile pyuria Meningitis

10. Diagnosis of TB Z-N staining AFB culture on L-J Medium PCR amplification of targeted mycobacterial DNA sequences BACTEC radiometric assay Septichek AFB system MGIT – mycobacterial growth indicator tube system

11. Mantoux test For establishing diagnosis of TB in children Delayed type hypersensitivity reaction 0.1 ml of 5 TU PPD is injected intradermally into the volar aspect of the forearm (or 2 TU of PPD RT 23) A wheal of 5 mm should be raised Reaction is read after 48 – 72 hrs Look for induration and erythema

12. Interpretation 48-72 hours later diameter of induration is measured transversely to the long axis of the forearm. Induration > 10mm is suggestive of natural infection. 5-10 mm - borderline; considered positive in immunocompromised host <5mm - Negative mantoux test does not rule out TB

13. Positive Mantoux

14. Treatment for TB Isoniazid (INAH) 5 mg/kg/day H Rifampicin 10 mg/kg/day R Pyrazinamide 25 mg/kg/day Z Ethambutol 20 mg/kg/day E Streptomycin 20mg/kg/day S

15. 2nd Line drugs Drug resistant cases or when first line drugs cant be used Eg . Cycloserine , ethionamaide , PAS, kanamycin Other drugs Strictly for drug resistant cases Eg . Quinolones , rifamycin , amikacin , imipenem , ampicillin

16. Phases of Treatment Intensive Phase Eliminate bacterial load Prevent emergence of drug resistant strains Atleast 3 Bactericidal Drugs used Continuation Phase Continue and complete therapy Atleast 2 Bactericidal drugs used

17. BCG VACCINE

18. Introduction BCG ( Bacille Calmette Guerin) prepared from Mycobacterium bovis DANISH 1331 strain which is closely related to Mycobacterium tuberculosis, the agent responsible for tuberculosis. It prevents development of more severe forms of TB, particularly TB meningitis in children .

19. Contd.. It is freeze-dried and need to be mixed with the correct diluent from the same manufacturer before administration Dose: a vial with 20doses, dose for new born is 0.05ml. Route: ID into the Rt. upper arm. BCG vaccine vials must be discarded 6hrs after mixing. BCG can be given up to 1 year .

20. Adverse reactions

21. Contd..

22. Contraindications

23. TB- HIV CO INFECTION

24. Problem statement As per NACO sentinel surveillance report of 2007, the prevalence of HIV infection is estimated to be 0.34 % of the population, which translates to 2.31 million people living with HIV/AIDS in India. Tuberculosis (TB) continues to be a public health challenge in India and is estimated that 1.9 million new cases of TB occur in India annually. Active TB disease is the commonest opportunistic infection amongst HIV-infected individuals.

25. TB –HIV COLLABORATION TB-HIV collaborative activities between RNTCP and NACP started initially in the year 2001, in the six states with high prevalence of HIV/AIDS i.e. Andhra Pradesh ,Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu. The collaborative activities were extended to 8 additional states in 2004.

26. OBJECTIVES To strengthen the mechanisms for coordination between RNTCP and NACP at National, State and District levels. To decrease morbidity and mortality due to tuberculosis among persons living with HIV/AIDS. To decrease the impact of HIV in tuberculosis patients and provide access to HIV related care and support to HIV- infected TB patients

27. SPECIFIC TB/HIV COLLABORATIVE ACTIVITIES Establish / Strengthen NACP-RNTCP coordination mechanisms at national, state and district level. Scaling up of Intensified TB/HIV Package of Services across the country. Joint Monitoring and Evaluation including standardized reporting shared between the two programmes . Training of the programme and field staff on TB/HIV TB and HIV service delivery coordination

28. THANK YOU