Revised National TB control Progrramme

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1. 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..

2. INTRODUCTION Tuberculosis is an infective Disease caused by Mycobacterium tuberculosis. ( Koch’s bacilli.) Discovered By ROBERT KOCH of Germany on 24 th March 1882. World TB day is celebrated on 24 th March. Main Types of Tuberculosis. Pulmonary (most common0 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.

3. 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 .

4. OBJECTIVES of NTCP Long Term objective ;- Prevalence rate in 14 years is brought down less than 1%. By 2025 INDIA by 2030 World. Short Term objective .:- To detect maximum number of TB cases and treated effectively. Vaccinate new born and infants with BCG. Undertake above objectives through integrated manner of existing institutions.

5. STRATEGY Passive Surveillance- Examination of patients. Examination of Sputum. X-ray of patients. Tuberculin test ( MOUNTAX) and giving BCG vaccine. TB training centre in major states . National tuberculosis institute in Bangalore 1959. Ant TB drugs freely supplied to TB clinics by State Gov. 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)

6. The 1992 review by WHO revealed that:- Less than 30% completed Treatment. Inadequate case detection Microscopy of sputum exam is of poor quality. Undue emphasis on X-rays Multiplicity of treatment regimes of non standard and ineffective, Shortage of Drugs. Budget provision is in adequate etc. 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.

7. Structure Of RNTCP . Central TB division ( CTD) in MOHFW. State level – STO ( state tuberculosis Officer) and State Tuberculosis control Society ( STCS) District level – DTC ( district tuberculosis Centre with DTO ( district TB Officer ) for overall supervision 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 .

8. 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 RNTCP To 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.

9. COMPONENTS of DOTS Political and administrative commitment. Good quality diagnosis , primarily by Sputum Microscopy. Uninterrupted supply of good quality drugs, Directly observed treatment ( DOTs). Systematic Monitoring and accountability,

10. 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%

11. 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 ;- Cure the patient. Prevent death from active disease or from late effects. Prevent the emergence of drug resistant organism. Minimize relapse. Protect the community from continue transmission of infection.

12. 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.

13. PHASES of TREATMENT Initial intensive phase (IP) --- 2/3 months for rapid killing the bacilli. 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).

14. Classification of Tuberculosis cases. Pulmonary Tuberculosis Extra pulmonary Tuberculosis. Pulmonary Tuberculosis Smear Positive cases.--- + at least one. 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 .

15. 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 known.

16. 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)

17. 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,ofloxacin , 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 )

18. 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

19. 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

20. 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.

21. 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.

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. 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. 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 .

28. 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.

29. HOW to CONFIRM – MDR. LPA – Line Probe Assay. Liquid Culture or Solid Culture test. Drug Sensitivity Test LJ – Lowenstein Jensen medium Cartridge- Basic Nucleic Acid Amplification Testing ( results are in 2 hrs)

30. 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

31. THANKS