Medical Officers PHI Training_NTEP_V2.pptx

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1. Medical Officers Training National Tuberculosis Elimination Programme

2. Tuberculosis – The Disease

3. 2023 – Tamil Nadu 95,792 Patients were diagnosed with TB 23 . 2 Lakhs TB symptomatic were tested for TB 4,430 Drug Resistant TB Patients were diagnosed 2683 TB HIV coinfected patients were diagnosed 24,338 TB patients with Diabetes comorbidity identified 6000 (around) patients with TB died (among the 82,683 notified DSTB pts in 2021) Every hour, 11 TB patients are being diagnosed in Tamil Nadu 1 out of 55 TB patients have Drug resistant TB 1 out of every 4 TB patient has been diagnosed with Diabetes

4. Drivers of the epidemic India* *Global TB Report, 2022 – Interim report for India

5. Sustainable Development Goals 80% reduction 0% patient have catastrophic expenditure due to TB treatment from 2020 onwards

6. National Tuberculosis Elimination Programme Sustainable Development Goals for Tuberculosis SDG Goal 3.3.2 To End TB Epidemic by 2030 Sustainable Development Goals – Targets Reduction in TB incidence rate compared with 2015 (%) 80% Reduction in number of TB deaths compared with 2015 (%) 90% TB-affected families facing catastrophic costs due to TB (%) 0% Sustainable Development Goals – Tamil Nadu 2015 (Baseline) 2025 (Target) Reduction in TB incidence rate compared with 2015 (per lakh population) 191 38 Reduction in number of TB deaths compared with 2015 (per lakh population) 33 3 TB-affected families facing catastrophic costs due to TB (%) 35% 0% Tamil Nadu Committed to achieve SDG Targets by 2025 “TB Free Tamil Nadu”

7. Strategic Plan for TB Elimination India Tamil Nadu

8. STRENGTHS OF GOVERNMENT TAMIL NADU HEALTH CARE DELIVERY SYSTEM- Tertiary Care DME   Secondary Care DM&RHS   Primary Care DPH&PM

9. Sub National certification for TB Free disease status awards Year TB Free Gold Silver category Bronze Category 2020 Tiruvannamalai 2021 The Nilgiris Kanniyakumari , Namakkal, Karur, Sivagangai , Nagapattinam, Villupuram 2022 The Nilgiris Tiruchirapalli , Thiruvarur Madurai, Thoothukudi, Tiruvannamalai, Kanniyakumari, Karur Krishnagiri

10. Tuberculosis Case Finding Tuberculosis Case Finding

11. Case finding

12. Presumptive TB Cases

13. Latent TB vs. Active TB In LTBI, M. tuberculosis , the tubercular bacteria is present in the body of the person and the same can be diagnosed by the recommended tests, but the person does not have any clinical evidence of TB. It is estimated that the lifetime risk of an individual with LTBI for progression to Active TB is 5–10%. An Active TB case is a case which is either microbiologically confirmed for M. Tuberculosis or clinically diagnosed, and has sign and symptoms such as cough for more than two weeks, fever, weight loss and blood in sputum.

14. Identification of Presumptive TB Cases Presumptive Pulmonary TB; TB, including: cough for 2 weeks or more F ever for 2 weeks or more Signicant weight loss, Haemoptysis Any abnormality in chest radiograph. Note: In addition, contacts of microbiologically-conrmed TB Patients, PLHIV, diabetics, malnourished, cancer patients, patients on immune-suppressants or steroid should be regularly screened for sign and symptoms of TB The following are also to be investigated as presumptive PTB a. Contacts of Microbiologically conrmed TB patients having cough of any duration b. Presumptive / conrmed extra-pulmonary TB having cough of any duration c. HIV positive patient having cough of any duration

15. Identification of Presumptive TB Cases Presumptive Extra Pulmonary TB refers to the presence of organ-specic symptoms and signs Swelling of lymph node P ain and swelling in joints N eck stiffness, disorientation, etc., and/or constitutional symptoms like signicant weight loss, persistent fever for 2 weeks or more, night sweats.

16. Identification of Presumptive TB Cases Presumptive Paediatric TB refers to children with P ersistent fever and/ or cough for 2 weeks or more L oss of weight/ no weight gain History of contact with infectious TB cases History of unexplained weight loss or no weight gain in past 3 months; Loss of weight is dened as loss of more than 5% body weight as compared to highest weight recorded in last 3 months. In a symptomatic child, contact with a person with any form of active TB within last 2 years may be signicant

17. TB Diagnosis Health & Wellness Center Sub Center PHC CHC District Hospital

18. Tuberculosis

19. Basis of diagnosis and identification of bacilli Microbiologically confirmed TB: –presumptive TB patient with biological specimen positive for AFB, or positive for MTB on culture, or positive for TB through Quality Assured Rapid Diagnostic molecular test. Clinically diagnosed TB case: A presumptive TB patient who is not microbiologically confirmed, but diagnosed with active TB by a clinician on the basis of X-ray, histopathology or clinical signs with a decision to treat the patient with a full course of Anti-TB treatment. In children, this is based on the presence of abnormalities consistent with TB on radiography, history of exposure to an infectious case, evidence of TB infection (positive TST) & clinical  ndings suggestive of TB in the event of negative or unavailable microbiological results

20. Disease Classification Pulmonary Disease: microbiologically confirmed or clinically diagnosed case of TB involving lung parenchyma or tracheo -bronchial tree. Extra Pulmonary Disease: microbiologically confirmed or clinically diagnosed case of TB involving organs other than lungs e.g. pleura, lymph nodes, intestine, genitourinary tract, joint and bones, meninges of the brain etc. Sites – Lymph Node, Bone, TB Meningitis, Spine, Bone, abdomen etc All EPTB cases to be offered Chest X-ray. In a case initially diagnosed as extra pulmonary TB, sample obtained from lung becomes positive in microscopy or NAAT tests, it shall be called as Pulmonary TB only. Miliary TB also belongs to Pulmonary TB

21. 32% Gender Distribution 0.05% Age Distribution Tamil Nadu 68% Pulmonary TB patients – 75% Extra - Pulmonary TB patients – 25% Site of Disease Extra Pulmonary site TB – Age Gender Distribution and category

22. Type of patient New case – A TB patient who has never had treatment for TB or has taken anti-TB drugs for less than one month. Previously treated patients have received 1 month or more of anti-TB drugs from any source in the past. Recurrent TB case - A TB Patient previously declared as successfully treated (cured/treatment completed) and is subsequently found to be microbiologically confirmed TB case. Treatment After failure- those patients who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. Treatment after lost to follow-up - A TB patient previously treated for TB for 1 month or more and was declared lost to follow-up in their most recent course of treatment and subsequently found microbiologically confirmed TB case. Other previously treated patients are those who have previously been treated for TB but who cannot be classified into any of the above classication .

23. DSTB Regimen

24. Drug Regimen for Adult TB Patients All TB patients with age more than 18 years shall be considered as an adult. All patients are given FDCs ( F ixed D ose C ombinations). Each tablet is a combination of the following anti TB Drugs: Isoniazid – (H) – 75 mg Rifampicin – (R) – 150 mg Pyrazinamide – (Z) – 400 mg Ethambutol – (E) – 275 mg HRZE – H (75 mg) + R (150 mg) + Z (400 mg) + E (275 mg) HRE – H (75 mg) + R (150 mg) + E (275 mg) Weight Band Intensive Phase – HRZE (75/150/400/275) Continuation Phase – HRE ((75/150/275) 25 – 34 Kg 2 2 35 – 49 Kg 3 3 50 – 64 Kg 4 4 65 – 75 Kg 5 5 > 75 Kg 6 6

25. Drug Regimen for Pediatric TB Patients Isoniazid – (H) – 50 mg Rifampicin – (R) – 75 mg Pyrazinamide – (Z) – 150 mg Ethambutol – (E) – 100 mg Dispersible FDC, Flavoured: HRE - Isoniazid 50 mg + Rifampicin 75 mg + Pyrazinamide 150 mg HR - Isoniazid 50 mg + Rifampicin 75 mg Dispersible Loose drugs: Ethambutol 100 mg Isoniazid 100 mg Ethambutol is combined with the FDC - HRZ in Intensive Phase and FDC - HR in the Continuation phase. Weight Band Intensive Phase Continuation Phase Number of Pills HRZ (50/75/150) Ethambutol (100 mg) HR (50/75) Ethambutol (100 mg) 4 – 7 Kg 1 1 1 1 2 8 – 11 Kg 2 2 2 2 3 12 – 15 Kg 3 3 3 3 4 16 – 24 Kg 4 4 4 4 5 25 – 29 Kg 3 + 1A* 3 3 + 1A 3 7 30 – 39 Kg 2 + 2A 2 2 + 2A 2 6 All TB patients with age less than 18 years shall be considered as a child (Paediatric). All adolescents up to 18 years of age and weighing less than 39 kg, are to be treated using paediatric weight bands and children weighing more than 39 kg with adult weight bands.

26. Drug Dosages

27. Role

28. All Presumptive TB Cases Enrol in Nikshay Conduct HIV testing Conduct Diabetes testing Document in Lab Register/ sample referral register

29. TB Patients notification

30. TB Patients notification – Private Sector

31. Screening for Severe illness – Differentiated TB care (Tamil Nadu – Kasanoi Erapilla Thittam TNKET) Body mass index (BMI) ≤ 14 kg/m2 BMI ≤ 16 kg/m2 with pedal oedema Respiratory rate >24/min Oxygen saturation on pulse oximetry <94% Unable to stand without support Refer to identified centre for further evaluation Medical Officer to comprehensively assess for severe illness and plan for admission

32. Public Health action Conduct HIV testing Conduct Diabetes testing Field staff to visit the house of the patient – Contact tracing Screening of all household members for TB Nutritional advice Personal/ cough Hygiene Identify Treatment Supporter for patients. Awareness Nikshay Poshan Yojana – Collect Bank account details

33. Follow Up * - wherever available

34. UDST Universal DST . Refers to universal access to rapid DST for at least rifampicin, and further DST for at least fluoroquinolones among all TB patients with rifampicin resistance (preferably before initiation of treatment to maximum within 15 days of diagnosis).

35. Treatment Outcome Cured : Microbiologically confirmed TB patients at the beginning of treatment who was smear or culture negative at the end of the complete treatment Treatment completed : A TB patient who has completed treatment without evidence of failure or clinical deterioration BUT with no record to show that the smear or culture results of biological specimen in the last month of treatment was negative, either because test was not done or because result is unavailable. Failure : A TB patient whose biological specimen is positive by smear or culture at end of treatment. Lost to follow up : A TB patient whose treatment was interrupted continuously for ONE month or more. Not Evaluated - A TB Patient for whom no treatment outcome is assigned. This includes former “transfer-out” Treatment Regimen Changed - A TB patient who is on  rst line regimen and has been diagnosed as having DRTB and switched to drug resistant TB regimen prior to being declared as failed. Died : A patient who has died during the course of anti-TB treatment. Treatment Success : TB patients either cured or treatment completed are accounted in treatment success. It is an indicator and not an outcome.

36. Benefits to the patient

37. Incentives to ASHA/ Women Health Volunteer/ Community Volunteer Incentive for Informant Incentive for TB Preventive Treatment support Incentive for Bank account seeding of patients An Informant is eligible for incentive of Rs. 500/- for a confirmed TB case (new module launched) DSTB – Rs. 1000/- DRTB – Rs. 5000/- TPT – Rs. 250/- Provision of incentive at rate of Rs. 50/- ASHA/Community volunteer for facilitating seeding of bank account information of notified TB patient in Ni-kshay portal within 15 days of treatment initiation for enabling DBT payments under NTEP

38. Incentives to the Private facilities for Notification

39. Program Monitoring

40. The Process

41. Ni-kshay Enrolment: Identify a person in each health facility (SC/ HWC/ PHC/ Urban PHC/ CHC/ District Hospital etc) All presumptive TB cases to be enrolled Add Test Make LTs responsible to add the test and the result. The Chest X-ray findings need to be added. Notification

42. Recording - NIKSHAY A person is entered in Nikshay – Enrollment – Generates an ID – Patient ID. Adding investigations/ tests done in the Nikshay portal – shall identify them as presumptive TB. Entry of any test with a positive result - TB is diagnosed It may be smear positive, NAAT positive or Chest X-ray showing abnormalities suggestive of TB If the patient is diagnosed, they automatically becomes notified. Once a patient is diagnosed, his patient ID will now become his episode ID. – Unique ID

43. Enroll a case

44. Add sputum Test

45. Add X ray result

46. View the list of persons with NO TEST ADDED

47. View the list of patients diagnosed but NOT initiated on treatment

48. Patient Summary

49. Monitoring Indicators

50. Monitoring Indicators

51. Monitoring Indicators

52. Thank You