Tuberculosis

INTRODUCTION Tuberculosis is an infectious disease caused by a bacterium Mycobacterium tuberculin spread through air by an infected person. TB is most prevalent in India compared to other developing countries due to HIV infection, low socioeconomic status and unhygienic living conditions

About 0.5 million people die of TB every year . To control tuberculosis NATIONAL TUBERCULOSIS PROGRAMME [NTP] has been in operation since 1962

OBJECTIVES OF NTP LONG TERM OBJECTIVES:  To reduce TB in the community to that level when it causes to be a public health problem i.e. *when one case infects less than one new person annually *the prevalence of infection in age group below 14 is brought down to less than 1 

OPERATIONAL/SHORT TERM OBJECTIVE:

*To detect maximum number of TB cases among the outpatient attending any hospital with symptoms of TB an treat them effectively *To vaccinate newborns and infants with BCG *To undertake the above objectives in an integrated manner through all the existing health institutions in the country

DISTRICT TUBERCULOSIS PROGRAMME NTP operates through DTP which is the backbone of NTP  Over 600 TB clinics have been set up in the country out of which 390 have been upgraded as DISTRICT TUBERCULOSIS CENTRE [DTC]  DTC is the nucleus of DTP  The function of DTC is to plan, organize and implement DTP in entire district 

The health institutions available for inclusion in DTP are government general hospitals and community health centres,TB clinics  Only such peripheral health institutions [PHI’s] are selected for implementation of the program which are under the charge of qualified medical officers these are called implement able PHI’s 

The activities of DTC inclde case finding and treatment. The treatment is free and is offered on domiciliary bases from all health institution  It is organized in such a manner that patients are expected to collect drugs once a month on fixed dates from the nearest treatment centers .When the patient fails to collect his drug on the due date a letter is written to him [first action] and in event of no response for 7 days a home visit is paid [second action] by the 

health staff

ACTIVITIES OF DTC Case finding and case holding  Microscopic examination of sputum  Radiological examination  BCG vaccination  Monitoring and evaluation  Supervision and follow up  Involvement of PHC, subcentres and private practitioners 

ORGANIZATION OF DTP A DTP consists of 1 DTC and on an average 50 PHI’s To implement the DTP a specially trained team of key program personnel is posted at each DTC .The team is trained at national TB institute, Bangalore for a period of 13 weeks. The team consists of  1 district TB officer  1second medical officer  2 lab technician  2 treatment organizer or health visitor

1 X-ray technician  1 non-medical team leader  1 statistical assistant  1 pharmacist Not only PHI’s but also cadres of health workers and MPW’s are all involved in the program of case detection treatment NTP is a centrally sponsored scheme. Anti TB drugs for free treatment are being supplied to TB clinics run by state Govt’s on 50-50 basis between central and state 

REVISED NATIONAL TB CONTROL PROGRAM  The Govt of India, WHO and world bank together reviewed the NTP in the year 1992. Based on this a revised strategy for NTP was evolved. The salient features of this strategy are * achievement of at least 85% cure rate of infectious cases through supervised short course chemotherapy involving health functionaries

* augmentation of case finding activities through quality sputum microscopy to detect at least 70% of cases *Involvement of NGO’s, information, education, communication and research

Under RNTCP case finding is not pursued. Case finding is passive. Patients presenting themselves with symptoms suspicious of TB are screened through 3 sputum smear examinations. Such microscopic examination is done in designated RNTCP MICROSCOPY CENTRE

CRITERIA OF DIAGNOSIS AND INITIATION OF TREATMENT

Cough for 3 weeks or more

3 sputum smears

2 or 3 +ve

1 +ve

3-ves

3 or 2 +ves

Smear +ve TB

Anti TB treatment

1 +ve X-ray

+ve Smear +ve TB Anti TB treatment

-ve Non TB

3 -ves Antibiotics for 1-2 weeks Symptoms persists

X-ray -ve for TB Non TB

+ve for TB Smear +ve TB

Anti TB treatment

All patients are provided short course chemotherapy free of charge. All the drugs are administered under direct supervision called DIRECT OBSERVED THERAPY SHORT COURSE [DOTS

DOTS DOTS is a strategy to ensure cure by providing the most effective medicine and confirming that it is taken DOTS is a community based TB treatment and care strategy that combines the benefits of supervised treatment and benefits of community based care and support

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DOTS regimen recommended a short course regimens for 6 months for newly diagnosed patient It starts with an intensive phase of 4 drugs [isoniazid, rifampicin, pyrazinamide, ethambutol] for 2 months followed by continuation phase of [rifampicin,isoniazid] for 4 months all given under DOT

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When DOTS is not feasible through out the treatment periods the dots strategy recommends continuation phase for 6 months i.e. total 8 months of treatment

DOSAGE OF DRUGS *ETHAMBUTOL-800mg E *ISONIAZID-300mg H *RIFAMPICIN-450mg R *PYRAZINAMIDE-1.5g Z *STREPTOMYCIN-0.75mg S 

TREATMENT CATEGORIES IN DOTS CHEMOTHERAPY

C A T

TYPE OF PATIENT

New sputum smear +ve



2[HRZ E]3

Seriously ill sputum smear 4[HR]3 –ve Seriously ill extra pulmonary 

1

REG IMEN

C A T

TYPE OF PATIENT

Sputum smear +ve relapse



Sputum smear +ve failure

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2 Sputum smear +ve treatment after default 

REG IMEN 2[HRZ ES]3 1[HRZ E]3 5[HRE] 3

C A T

TYPE OF PATIENT

Sputum smear –ve not seriously ill 

3

Extra pulmonary not seriously ill 

REG IMEN 2[HRZ] 3

4[HR]3

HOW DOTS IS GIVEN In DOTS, during intensive phase of treatment a health worker or other trained person watches as the patient swallows the drug in his presence. During continuation phase, the patient is issued medicine for one week in a multiblister combipack, of which the first dose is swallowed by the patient in the presence of health worker or trained person..

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The consumption of medicine in the continuation phase is also checked by return of empty multiblister combipack, when the patient comes to collect medicine for the next week. The drugs are provided in patient wise boxes

5 ESSENTIAL COMPONENTS OF DOTS  POLITICAL COMMITMENT WITH INCREASED AND SUSTAINED FINANCING: *Clear and sustained political commitment by national government is crucial *adequate funding is essential. Current resources are inadequate and further effort is required to mobilize domestic as well as international resources

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CASE DETECTION THROUGH QUALITY ASSURED BACTERIOLOGY: *Bacteriology remains the good method of TB case detection first using sputum microscopy and then culture and sensitivity test *a wide network of properly equipped lab with trained personnel is necessary to ensure access to quality assured sputum smear microscopy

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STANDARDISED TREATMENT WITH SUPERVISION AND PATIENT SUPPORT:

*The mainstay of TB control is organizing

and administering treatment across the country for all adult and pediatric TB cases *Services of TB cases should identify factors that make patient interrupt or stop treatment

*DOTS helps patient to take drugs regularly and complete treatment, thus achieving cure and preventing development of drug resistance *supervision may be under taken at a health facility, in the work place, in community or at home. *locally appropriate measures should be undertaken to identify and address physical, financial, social and cultural barrier

AN EFFECTIVE DRUG SUPPLY AND MANAGEMANT: *An uninterrupted and sustained supply of quality assured anti TB drug is basis for TB control *A reliable system of distribution of all essential anti TB drug to all health facility should be in place and drugs should be provided free of cost for the patients *The TB recording and reporting system is designed to provide information needed to plan distribute and maintain adequate stock of drugs

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MONITORING AND EVALUATION SYSTEM AND IMPACT MEASUREMENT: *Establishment of reliable monitoring and evaluation system with regular communication between the central and peripheral levels of health system is vital. This requires standardized recording of individual patient data [name, address etc.] of sputum positive case in district TB index 

ADVANTAGES OF DOTS DOTS produces cure rates up to 95% even in poorest countries  DOTS prevent new infections by curing infectious patients completely  Prevent multi drug resistance by ensuring full course of treatment  This strategy has proven successful through out the world 

Patients need not be hospitalized  Dots prolong survival of HIV infected TB patients  DOTS helps more than double accuracy of diagnosis of TB  A DOT is cheap 