Tuberculosis: Prevention & Control

1. Tuberculosis:

Prevention and Control
Dr Prabir Ranjan Moharana
MD(Community Medicine),PGDHHM.

2. Disease Burden
• 9.4 million new tuberculosis cases(Incidence rate-139
cases per 100,000 population) The 22 high burden countries account
for 80% of all estimated cases world wide. India (1.98 million), China
(1.3 million), South Africa(0.47 million), Nigeria (0.45 million) and
Indonesia(0.43million).
•India and China alone account for an estimated 35% of TB cases
worldwide.
•1.7 million(3.2%) tuberculosis deaths in 2009.
•Kills more adults & 80% of died from TB belong to age
group(15-49).
• 33% of global population are infected asymptomatically with
Tuberculosis Bacilli and 5-10% of them will develop clinical
disease.

3. Disease Burden(India)
• 21% of global incidences of new TB cases occur in India
and India tops the list of 22 High Burden Countries (HBC) in the
world followed by China.
• 1.98 million develop TB and 0.276 million die every year.
•Prevalence 185 per lakh(2009) from 312(2004) and568 per
lakh(1990)
•Incidence 168 per lakh(2009) in India.
•24 per lakh population(2009) from 42 lakh population(1990).

4. Disease Burden
• Annual Risk of Infection : 1.5% in India(15 million)
•40% of Indian population are infected with TB.
•Untreated pulmonary TB patients infects 10-15 persons every
year.
•2 Indians die in every 3 minutes from TB.
•Kills more women of 15-49 age group.

5. Disease Burden
•Kills more women than all causes of maternal mortality
combined.
• Create more orphans than any other infectious disease.
•Causes of one third of female infertility in India.
•More than 1,00,000 women are abandoned by their families.
•One-fifth of children of TB patients leave school/take up
employment to support family.
•Untreated pulmonary TB patients infects 10-15 persons every
year.
•Kills more women of 15-49 age group.

6. Natural History of Tuberculosis: Agent
•Rod-shaped, non motile, non capsulated, non-spore-forming, thin
aerobic bacterium measuring 0.5 µm by 3 µm.
• Mycobacteria neutral on Gram's staining. However, once stained,
the bacilli cannot be decolorized by acid alcohol; this
characteristic
justifies their classification as acid-fast bacilli (AFB).

7. AFB in sputum under microscope

8. Natural History of Tuberculosis: Agent
•Mycobacterium tuberculosis( Human and Bovine strain)
•Atypical Mycobacteria
•i. Photochromogen: M.kansasii,M.marinum.
•ii. Scotochromogen: M.scrofulaceum,M.gordonae
•iii. Non-photochromogen: M.avium,M.intracellulare
•iv. Rapid Growers: M.fortuitum

9. Source of Infection
An untreated/incompletely treated Pulmonary
Tuberculosis patient(Open Case).
Sputum positive cases are more infective.
Bovine Source: Infected Milk
Mode of Transmission: Air Borne droplet nuclei
released during coughing/sneezing/speaking.
Not transmitted by fomites/articles used by a patient.
Extra-pulmonary/Sputum negative cases minimally
transmit.

10. Host
• Age- No age escapes.(In India1% in Under-5 age group,
30% < 15 years).
•Sex: Males suffer more.
•Heredity: Susceptibility to infection is inheritable.
•Nutrition: Under nutrition increases susceptibility.
•Immunity: Natural infection/ BCG vaccination produces acquired
immunity.
•Socio-economic Status: poor quality of life, poor housing, large
families, overcrowding, illiteracy, lack of awareness are inter
related contribute to occurrence & spread of disease.

11. Risk Factors for development of Active TB
• Recent infection (<1 year) :12.9
•Fibrotic lesions (spontaneously healed) :2–20
• Comorbidity HIV infection: 100
•Silicosis : 30
•Chronic renal failure/hemodialysis :10–25
•Diabetes: 2–4
• Intravenous drug use: 10–30
•Immunosuppressive treatment: 10
•Gastrectomy :2–5, Jejunoileal bypass:30–60
•Posttransplantation period (renal, cardiac): 20–70
•Undernutrition and severe underweight: 2

12. Pathogenesis
• Ghon focus: Primary tuberculosis usually occurs in
young children. In them the bacilli are engulfed by alveolar
macrophages multiply and give rise to sub-pleural pneumonia in
the lower lobe or lower part of the upper lobe.
•Primary complex: Ghon focus together with the enlarged hilar
lymph node.This occurs about 3-8 weeks after the infection.In
the majority of cases this spontaneously heals in 2-6 months
leaving behind a calcified nodule.
•However a few bacilli may survive in the healed lesion and
remain latent for years. In a few children with impaired immunity
and other risk factors the primary lesion may enlarge and cause
milliary, meningeal and other forms of disseminated
tuberculosis

13. Pathogenesis
• Post-primary (secondary or adult) tuberculosis:
Reactivation of previous latent infection(post-primary
progression, endogenous reactivation) or exogenous
reinfection and differs from primary type in many respects. It
affects usually the upper lobes of the lungs, the lesions
undergoing necrosis and tissue destruction, leading to
cavitation. Lymph node involvement is usually unusual. The
necrotic tissue materials break out into the airways, leading to
expectoration of bacteria laden sputum which is the main
source of infection to contacts. In the immuno-deficient persons
cavity formation is unusual, instead they suffer from
widespread lesions in the lungs and other organs .

14. Organs Involved
•Pulmonary TB: 2/3
rd
Cases.
•Extrapulmonary TB- 1/3
rd
Cases
•
Lymphnodes(40%), Pleura(20%),
Genito-urinary(15%), Bone(10%),
Brain & Meninges(5%), GI tract(3.5%),

Eye, Skin, Larynx, Pericardium, Peritoneum etc.

15. Clinical Features
• Fever(Evening rise of temperature)
•Loss of appetite(Anorexia) & Weight(cachexia)
•Cough more than 2 weeks not relieved by empirical broad
spectrum antibiotics.
•Productive cough with Muco-purulent sputum.
•Haemoptysis
•Sub-pleuritic chest pain

16. •Malignancy Lymphoma
•Leukemia
•Other neoplasm
•
Infections Human immunodeficiency virus
•Tuberculosis
•Mycobacterium avium complex
•Infectious mononucleosis
•Fungal infections (histoplasmosis, coccidioidomycosis)
•Lung abscess
•Endocarditis
•Other infection
•Endocrine Ovarian failure Rheumatologic
•Hyperthyroidism Takayasu's Diabetes mellitus
(nocturnal hypoglycemia)
•Endocrine tumors (pheochromocytoma, carcinoid tumor)
•OrchiectomyarteritisTemporal arteritis
•

17. •Other Obstructive sleep apnea
•Gastroesophageal reflux disease
•Chronic fatigue syndrome
•Granulomatous disease
•Chronic eosinophilic pneumonia
•Lymph node hyperplasia
•Diabetes insipidus
•Prinzmetal's angina
•Anxiety
•Pregnancy
•
Drugs Antipyretics (salicylates, acetaminophen)
•Antihypertensives
•Phenothiazines
•Substances of abuse: alcohol, heroin

18. Diagnosis of Active Tuberculosis
•A-(i) AFB Microscopy(Ziehl-Neelsen basic fuchsin dyes)
•(ii) Chest Radiography:
•(iii) Biochemical Markers for Diagnosis
•(iv) Immunodiagnosis
•(v) Nucleic Acid Amplification Assay
•(vi) Mycobacterial Growth Indicators Tubes(MGIT)
•

(vii) Radiometric Method (BACTEC)
•(viii) Mycobacterial Culture
•B- Mantoux Test (Tuberculin Skin Test:TST) for Latent TB Infection

19. Ziehl-Neelsen Staining of Sputum Smear
• Sputum is spread on the slide by a broomstick and slide is allowed
to air dry for 15-30 minutes.
•Fixation of Slides by passing over flame 3-5 times for 3-4 seconds each time.
•
•Flooding with Carbol fuchsin followed by gentle heating until vapours rise.
Slides are left with vapouring carbol fuchsin for 5 minutes. Rinsing gently
with tap water to wash away all free carbol fuchsin.
•Treating with 25% Sulphuric acid and allowing to stand for 2-4 minutes .
After that the slide is rinsed with tap water.
•0.1% Methylene blue is applied to slide and kept for 30 seconds. The slide is
rinsed with water and allowed to dry up.
•The slide is examined under X40 lens for suitable area and then under X100
using a drop of immersion oil.

20. Result of Sputum Smear Examination
Examination Result GradingNo. of fields to
be examined
More than 10 AFB per Oil Immersion
Field
Positive 3+ 20
1-10 AFB per Oil Immersion Field positive 2+ 50
<1 AFB per Oil Immersion Field
(10-99 AFB per 100 Oil Immersion Field)
positive 1+ 100
1-9 AFB per 100 Oil Immersion FieldscantyExact
number
is recorded

200
No AFB in 100 Oil Immersion Field Negative 0 100

21. Chest Radiography:
• (i) Opacity mainly in upper zone.
• (ii)Patchy or nodular opacities.
•
•(iii)Presence of cavities or activities.
•(iv)Presence of calcification.
•
•(v)Bilateral opacities especially in upper zones.
•(vi)Opacities which persist after several weeks of antibiotic
therapy.

22. Radiometric Method (BACTEC)
•BACTEC radiometric assay uses fatty acids like palmitic acid
and formic acid labeled with radioactive carbon. As the
mycobacteria metabolise these fatty acids radioactive carbon
dioxide is released which is measured as a marker of bacterial
growth.

23. Mycobacterial Growth Indicators Tubes
(MGIT)
•MGIT is another rapid method for detection of mycobacterial
growth consisting of round buttom tubes.
•
•Each tube contains 4 ml of modified Middlebrook 7Hq broth
which has an oxygen sensitive fluorescent sensor on the
buttom.
• When mycobacteria grow,they deplete the dissolved oxygen in
the broth and allow the indicator to flourish brightly in 365nm UV
light.
•Clinical samples having bacilli give positive signal within 10-12
days of growth.

24. Biochemical Markers for Diagnosis
•Adenosine Deaminase Activity(ADA) is an aminohydrolase
enzyme that catalyses the deamination of adenosine to inosine.

Its biological activity is related to proliferation and differentiation
of lymphocytes.
Elevated ADA enzyme level has been detected in
pleural, pericardial and peritoneal effusion due to tuberculosis.

25. Mycobacterial Culture

•Solid Media: Lowenstein- Jehnsen Medium, Dorset & Petragnini
(egg based), and Pawlowsky (potato based) take about 6-8
weeks to allow colonies to appear.
•Liquid media Like Middlebrooks Medium(agar based), Sula’s
medium and Proskaure etc colonies take 2-6 weeks to appear.

26. Nucleic Acid Amplification Assay
• These assays are both highly sensitive & specific and
use polymerase chain reaction (PCR) to amplify nucleic acid
targets which uniquely identify M. tuberculosis in clinical
specimens.
(b)PCR for DNA: DNA-PCR is so sensitive which can also
detect the presence of a fraction of bacillus in the specimen. It
is used to cross check whether a smear positive sample is
really due to M. tuberculosis or some other non-tuberculous
Mycobacteria.
(b) PCR for RNA: Since r-RNA is an integral part of bacterial
ribosome, its presence would naturally indicate the presence of
multiplying bacteria hence active disease. Results of PCR are
available in three days compared to culture which takes six
weeks.
(viii)

27. Immunodiagnosis

:
•Enzyme Linked Immuno Sorbent Assay(ELISA) :Very
useful in the diagnosis of tuberculosis.
•Monoclonal antibodies to 35KDa, M. tuberculosis
antigen(73% cases of extra pulmonary TB and 70%
smear negative pulmonary TB cases diagnosed).
•Anti P32 antibodies in pleural fluid of patients with
tubercular pleural effusion.
•Detection of IgG antibodies to lipoarabinomenon
antigen were clinically very useful for the early diagnosis
of tuberculous meningitis.

28. Prevention & Control of TB
•1.Elimination of Reservoir
•2.Breaking the chain of transmission
•3.Protection of susceptible

29. 1.Elimination of Reservoir
• Early detection of cases from cardinal features of cough
more than 2/3 weeks, intermittent fever, loss of appetite and
weight , chest pain, hemoptysis .
•Prompt treatment by effective chemotherapy:
•To make infectious case non-infectious.
•To prevent development of complications like resistance &
relapse.
•To prevent further spread and deaths from TB.

30. Anti-TB Drugs
•First Line Drugs:
•Bacteriocidal: Isonicotinic acid hydrazide (INH-H),
Pyrazinamde (Z), Streptomycin (S).
•Bacteriostatic: Ethambutol(E), Thioacetazone
•Second Line Drugs:
•Ethionamide, Prothionamide, Cycloserine, Capreomycin,
• Amikacin, Kanamycin, Fluoroquinolones.

31. RNTCP & DOTS
• 1962: National Tuberculosis Control Program(NTCP)
•1972- SCC(Short Course Chemotherapy) was introduced.
•1985: Mass BCG vaccination under UIP.
•Case Detection Rate-30-50%, Cure Rate- <30% of diagnosed.
•Revised National Tuberculosis Control Program: 1992(Target-
Case Detection Rate-70% of total new smear positive TB cases
present in the country & Cure Rate-85% of cases detected.)

32. NTCP Failures
•1. Low quality microscopy
•2. Over reliance on clinical & radiological diagnosis.
•3.More emphasis on case detection rather than cure.
•4.Poor response from patients to come and collect drugs.
•5.Inadequate budget for drugs & logistics.
•6.No standardized treatment.
•7.Emergence HIV pandemic and increased incidence of MDR-
TB.

33. RNTCP & DOTS
•DOTS(Directly Observed Treatment Short-course):
•Treatment is directly observed & Drug administration is
•thrice in a week unlike daily administration in
• conventional treatment.
•RNTCP shifts the responsibility for cure from patients to
the health system

34. 5 Principles of DOTS
•1. Political Commitment (No financial constraint)
•2. Good Quality Sputum Microscopy.
•3.Directly Observed Treatment (accountable person).
•4.Uninterrupted Supply of good quality Drugs.
•5.Accountability.

35. Diagnostic Algorithm
Cough for 2weeks/more
2 sputum smears
1 +ve Both --ve
Smear +ve TB
Retreatment Case
Cat-I Cat-II
New Case
Antibiotic (10-14days)
Cough Persists
Repeat 2 sputum smears
1 +ve 2 --ve
TB Case Chest X--Ray
Non Suggestive of TB
Non-TB
Suggestive of TB
Cat-I / Cat --III

36. Phases of Chemotherapy
•Intensive Phase(IP): 2-3 months of
intensive & aggressive treatment using 3
or more drugs
•Continuation Phase(CP): 6-8 months with
2-3 drugs.

37. Classification of Tuberculosis cases
• Case of Tuberculosis: A patient in whom tuberculosis has
been confirmed by positive culture or sputum positivity for AFB
or diagnosed by a clinician.
•Pulmonary Case: A patient with tuberculosis involving the lung
parenchyma.
•Smear-Positive Pulmonary Case: A patient with at least two
initial sputum smear examination (direct microscopy) positive
for AFB
•or TB in a patient with one sputum smear examination +ve for
AFB and radiographic abnormalities are consistent with active
pulmonary TB as determined by treating MO
•or TB in patient with one sputum smear specimen +ve for AFB
and culture +ve for M.tuberculosis.

38. Classification of Tuberculosis cases
• Smear-Negative Pulmonary Case: Diagnostic criteria
include: (i) At least two sputum smear examinations negative for
AFB;
(ii) Radiographic abnormalities consistent with active pulmonary
tuberculosis;
(iii) No response to a course of broad spectrum antibiotics
(except in a case of proven HIV +ve patient);
(iv)Positive in culture but negative in sputum for AFB &

(v)Decided by a clinician to treat with a full course of anti-
tuberculosis chemotherapy.

39. Classification of Tuberculosis cases
• Extra-Pulmonary Case: A patient with tuberculosis of any
organ other than the lungs (eg.pleura, lymph nodes, abdomen,
genitourinary tract, meninges of brain, skin, bones and joints).
•Diagnostic criteria include: (i) one culture positive specimen
(ii) histological/radiological or strong clinical evidence consistent
with active extra-pulmonary tuberculosis
(iii) Decided by a clinician to treat with a full course of anti-
tuberculosis chemotherapy.

40. Types of TB Patients under DOTS(RNTCP)
• New Case: A patient who has never had treatment for
tuberculosis or taken anti-tuberculosis drugs for less than one
month.
•Re-treatment case: A patient previously treated for TB, who is
started on a re-treatment regimen after previous treatment has
failed (treatment after Failure)
or
•A patient whose treatment was interrupted for two consecutive
months or more after taking the treatment for more than 1 month
(treatment after Default)
or
•A patient who was previously declared cured or treatment
completed and is again diagnosed to be bacteriologically
positive (Sputum Smear/Culture +ve) tuberculosis (Relapse).

41. Types of TB Patients under DOTS(RNTCP)
• Failure: Any TB patient who is smear positive at 5
months or more after starting treatment. Failure also includes a
patient who was treated with category III regimen but who
becomes smear positive during the course of treatment.
•Chronic: A TB patient who remains smear positive after
completing a re-treatment regimen.
•Others: TB patients who do not fit into the above mentioned types.
Reasons for putting a patient in this type must be specified.
•Transferred in: A TB patient who has been received for anti-TB
treatment into a Tuberculosis Unit, after starting treatment in
another TU where she/he has been registered.
•Transferred out: A patient who was transferred to another
reporting unit and for whom the treatment outcome is not known.

42. Drugs Under DOTS(RNTCP)
H:Isoniazid(5 mg/kg/day: 600mg- for intermittent therapy ),
R:Rifampicin(10mg/kg/day:450 mg- for intermittent therapy),

S:Streptomycin(750mg).
E:Ethambutol(15 mg/kg/day:1200mg for Intermittent
therapy)
Z:Pyrazinamide(30 mg/kg/day:1500 mg for intermittent
therapy)

43. Categories of Treatment under DOTS
(RNTCP)
Category of
Treatment
Type of Patient Regimen
Category-I
(6 months)
New sputum smear-positive
Seriously ill new sputum smear-negative
Seriously ill new extra-pulmonary
2H
3
R
3
Z
3
E
3
(IP)
+4H
3
R
3
(CP)

44. •Extra-pulmonary TB are classified as
“seriously ill”:
•1.Menigitis, 2.Pericarditis, 3.Peritonitis, 4.Bilateral/ Extensive
Pleural Effusion,5.Spinal TB with neurological involvement,
6.Intestinal, 7.Genito-urinary ,8.Co-infection with HIV, 9.All forms
of paediatric extra-pulmonary TB other than lymph node TB and
unilateral pleural effusion are considered to be seriously ill.\
•The following forms of smear negative pulmonary TB are
classified as seriously ill:
•1. Milliary TB, 2. Extensive Parenchymal Infiltration, 3. Co-
infection with HIV 4. Cavitary disease, 5. All forms of paediatric
sputum smear negative pulmonary TB except primary complex.

45. Categories of Treatment under DOTS
(RNTCP)
Category of
Treatment
Type of Patient Regimen
Category-IISputum smear-positive Relapse
Sputum smear-positive Failure
Sputum smear-positive Treatment After
Default
Others
2H
3
R
3
Z
3
E
3
S
3
+
1H
3R
3Z
3E
3
(IP)
+
5H
3
R
3
E
3
(CP)

46. Categories of Treatment under DOTS
(RNTCP)
Category of
Treatment
Type of Patient Regimen
Category-IIINew Sputum smear-negative & not
seriously ill
New Extra-pulmonary & not seriously ill
2H
3
R
3
Z
3
(IP)
+
4H
3
R
3
(CP)

47. Drugs Under DOTS(RNTCP)
Adult Dosage(30-60 kg Body Weight)
H:Isoniazid(600 mg), R:Rifampicin(450 mg),
Z:Pyrazinamide(1500 mg), E:Ethambutol(1200 mg),
•S:Streptomycin(750mg).
•Patients who weigh 60 kg more receive additional Rifampicin
150 mg .
•Patients who are more than 50 years old, receive Streptomycin
500 mg.
•Patients who weigh less than 30 kg receive drugs as per body
weight.

48. 2.Breaking the chain of transmission
•Careful collection of patient’s sputum in sputum cup, half
filled with 5% cresol/ 8% bleaching powder.
•Sputum is collected in tissue paper handkerchief and
disposed of by burning and burial.
•Untreated Patients are advised to avoid indiscriminate
spitting sputum here & there.

49. 3.Protection of susceptible
•
General Measures:
•Health Promotion: Improvement of living condition with
healthful housing, personal hygiene, good food & nutrition,
exercise, healthy lifestyles(no to smoking & alcohol).
•Health Education: BCG immunization in early
childhood(protects from TB-meningitis & Miliary TB
Immunity starts from 15 days and lasts for 15 years)
And specific treatment of patients with regular follow-up

50. Recent Developments in RNTCP
•Public Private Mix (PPM)
•Multidrug-resistant Tuberculosis (MDR-TB)
•RNTCP and DOTS-Plus Services for MDR-TB
•Pediatric TB
•HIV Co-infection among TB Patients

51. Public Private Mix (PPM)
•Partnerships between government, private, corporate and
NGO health care sectors.
•Increase TB case detection rate, reduce diagnostic delays,
improve patient adherence, reduce cost to the patients,
provide quality RNTCP services to the patient.
•Guidelines for collaboration with NGOs (2001) and private
practitioners (2002) were developed and revised in 2008.

52. RNTCP provides:
•Technical training
•Laboratory consumables
•Registers and forms
•Health education materials
• Free drugs in patient-wise boxes

53. partners of RNTCP can take up
p

Referral for diagnosis (sputum collection and
transportation centres)
t Diagnosis
D Referral for treatment
R Treatment initiation
T Provision of Directly Observed Treatment Short-course
(DOTS)
( Health education and related activities
H Management and supervision of diagnostic and treatment
activities at the sub-district level

54. Multidrug-resistant Tuberculosis
(MDR-TB)
•Bacilli are resistant to Isoniazid (H) and Rifampicin (R) with or
without resistance to other drugs.
•Irregular consumption and frequent interruption in taking
treatment for TB is the most common cause of acquiring
multidrug resistance.
•In India, MDR-TB amongst new cases are estimated at 2- 3%
and amongst re-treatment cases at 14-17%.

55. Providers
•Absence of guidelines/inappropriate
guidelnes
•Non-compliance with guidelines
•Inadequate training of cre providers
•No monitoring of treatment.
•Poorly organized control program.

56. Drugs
•Non-availability of drugs/stock outs/non
delivery
•Poor quality
•Poor storage condition
•Wrong dosage/combinaion

57. Patients
•Lack of information
•Poor DOTS
•Non availability of free drugs.
•Adverse Drug Reaction
•Socio-economic barriers
•Mal-absorption
•Substance abuse like alcoholism.

58. Extensively Drug Resistant TB (XDR–
TB)
•A subset of MDR-TB(2-28% of MDR also have XDR)
•The bacilli, in addition to being resistant to R and H, are also
resistant to fluoroquinolones and any one of the second-line
injectable drugs(namely Amikacin, Kanamycin,
Capreomycin).
•Magnitude of XDR-TB remains undetermined due to the lack
of laboratories being capable of conducting quality assured
second line Drug Susceptibility Testing(DST).
•Existing unregulated availability, injudicious and irrational
use of first and second line anti-TB drugs for ARI/TB
suspect.

59. DOTS-Plus
•It is better not to produce MDR-TB rather than
giving incomplete/inappropriate treatment.
•Timely identification and diagnosis of MDR-TB cases
at designated RNTCP DOTS-Plus sites by quality
assured Culture & Drug Susceptibility Testing.
•
•Adequately administration of Cat-IV regimen.

60. MDR Suspect
•Any TB patient who fails an RNTCP Cat-I or III
treatment(T/t Failure Cases).
•Patient on Cat-II regimen who is sputum smear positive
at the end of 4 months of treatment.
•Patient not included- <15 years of age
•Being treated with any 2
nd
line anti-TB drugs over a
period of 1 month.

61. Categories of Treatment under DOTS
(RNTCP)
Category of
Treatment
Type of Patient Regimen
Category-IVA confirmed MDR-TB patient: An
MDR-TB suspect who is sputum
culture positive for M.tuberculosis
which is resistant to at least
Rifampicin & Isoniazid
with/without resistance to other
anti-tubercular drugs based on
culture and DST results from
RNTCP accredited laboratory.
6(9) ZEECsKmOfx

(IP) +
18EECsOfx

(CP)

62. Pediatric TB & PWB
•Children in the first five years of their life are likely to suffer from
serious and fatal forms of TB, more so, if not vaccinated with BCG.
• Globally, it is estimated that about 1.1 million(out of 9.9 million).
•new cases are reported and 1,30,000 deaths(out of 1.7 million
deaths) occur annually due to TB among children.
•Pediatric Patient Wise Boxes (PWB)are available with different
dosages as two product codes to be used under four weight bands
for children weighing 6 to 10 kg, 11 to 17 kg, 18 to 25 kg and 26 to
30 kg.

65. Patient Wise Boxes

67. HIV Co-infection among TB Patients
•In India, it is estimated that 2.31 million individuals are living
with HIV infection(0.34% of the adult population of the
country).
•6.7% of new adult TB patients in India are HIV positive.
•Tuberculosis is the most common opportunistic infection
amongst HIV-infected individuals.
• In India,55-60% of AIDS cases reported had TB, and TB is one
of the leading causes of death in People living with HIV/AIDS
(PLHA).
•Intensified TB Case Finding at ICTCs, ART and Community
Care Centres (CCCs) should be done.

68. Pulmonary TB Suspect is defined as:
• An individual having cough of 2 weeks or more.
•Contacts of smear-positive TB patients having cough of any
duration.
•Suspected/confirmed extra-pulmonary TB having cough of
any duration.
•HIV positive patient having cough of any duration.
•Persons having cough of 2 weeks or more, with or without
other symptoms are referred to as Pulmonary TB
suspect(other symptoms include: weight loss, tiredness,
fever with evening rise of temperature, night sweats, chest
pain, shortness of breathe, anorexia & haemoptysis