WHAT IS NEW IN RNTCP ?

Dr. Surya Kant

M.D (Gold Medalist),
FAMS,FNCCP,FCCP,FCAI,FIAB,FICS,FIMSA,FUPDA,FIAMS,FIACM,FICP,FISEB,FCGP
Professor & Head
Dept. of Respiratory Medicine,
K. G. Medical University, Lucknow, U.P.
President, Indian College of Allergy Asthma and Applied Immunology (ICAAAI)
President, National College of Chest Physician (NCCP)
Past President, Indian Chest Society (2016-2017)
 Tuberculosis
• Whether we ourselves have escaped from
the scourge of tuberculosis or not, there is
probably hardly a family which has not had
to do something with this dreaded disease.

- Pt. Jawahar Lal Nehru

1st Prime Minister of India

5/2/2019 KGMU
 Tuberculosis
• Known since vedic era in India as
– Kshaya Roga (Kshaya = decay)
– Raj yakshma
• Similar description by Hippocrates (Father of
Medicine) as Phthisis (decay)
• Discovery of causative organism on 24th
March 1882 by Robert Koch – Koch’s
disease.
• 24th March – World TB Day
5/2/2019 KGMU
 Tuberculosis
• Prechemotherapeutic Era – before
1944.
• Basics of Treatment of TB
– Nursing care
– Good nutrition
– Fresh air
} described in
Ayurveda

Sanitaria treatment

5/2/2019 KGMU
Chemotherapy Era – Beginning in 1944
• Streptomycin 1944 (Wakesman)
PAS
Isoniazid 1950s
Thiacetazone 60s
Ethambutol 70s
Pyrazinamide
Rifampicin 80s

Bedaquiline 2012
Dalamanid

5/2/2019 KGMU
 Resurgence of TB in late 80s
– mainly due to HIV

• 1993 – “GLOBAL EMERGENCY”

by WHO:
– Rising problem – Globally
– Association with HIV
– Increasing drug resistance

5/2/2019 KGMU
 India is the Highest TB
Burden Country
HBC = High Burden
Country India
27%
Other countries
20%

Other 13 HBCs
16% China
12%

Phillipines
3% South Africa
Ethiopia 6%
3%
Nigeria Bangladesh Pakistan 5% Indonesia
3% 4% 5%

5/11/2016 WHO Geneva; WHO Report 2016

Global TB Burden -2017
Global India
1,04,00,000
27,90,000
Incidence (140/lakh)
(211/lakh)

16,74,000 4,35,000
Deaths
(22/lakh) (33/lakh)

HIV TB 10,30,000 87,000

cases (14/lakh) (6.6/lakh)

HIV TB 3,74,000 12,000

deaths (5.0/lakh) (0.9/lakh)

Estimated 6,01,000 1,47,000

MDR/RR (8.1/lakh (11/ lakh
cases population) population)
 Burden of TB in India
• ~ ½ of population infected
• 1/ th of the global annual new cases occur in India
4

• Prevalence – 3.2 Million

• 2.7 million new cases annually(Incidence)
– >6000 people develop TB every day
– >4 people develop TB every minute
• About 4 lakh 35 thousands deaths due to TB / year(Mortality)
– > 1000 deaths a day
– About 25 deaths an hour
– About 2 deaths every 5 minutes
– One child dies every day

WHO Geneva; Report 2017

 Case definitions
Presumptive pulmonary TB refer to a
person with any of the symptoms and
signs suggestive of TB including
cough > 2 week
fever >2 week
significant weight loss
hemoptysis
any abnormality in chest radiograph.
5/2/2019 KGMU
 Contd..
• Presumptive Extrapulmonary TB refers
to presence of organ specific symptoms and
signs like swelling of lymph node, swelling
and pain in joints, neck stiffness,
disoriented etc and/or constitutional
symptoms like significant weight loss night
sweats, persistent fever for ≥ 2 weeks

5/2/2019 KGMU
Definitions and classification of DR-TB
patients
Presumptive DR-TB: It refers to the
following patients in order of their risk:

– TB patients found positive on any follow-up sputum smear

examination during treatment with first line drugs including
treatment failures;
– Paediatric TB non-responders;
– TB patients who are contacts of DR-TB;
– Previously treated TB patients;
– New TB patients with HIV coinfection;
– All notified new TB patients.
 Classification and Definitions of DR-TB
• Mono-resistance TB (MR): A TB patient, whose biological
specimen is resistant to one first-line anti-TB drug only.

• Poly-Drug Resistance TB (PDR): A TB patient, whose

biological specimen is resistant to more than one first-line anti-
TB drug, other than both H and R.

• Rifampicin Resistance (RR): A TB patient, whose biological

specimen is resistant to R, detected using phenotypic or
genotypic methods, with or without resistance to other anti-TB
drugs. It includes any resistance to R, in the form of mono-
resistance, poly-resistance, MDR or XDR.
 Classification and Definitions of DR-TB

• Multi Drug Resistance (MDR) : A TB patient, whose

biological specimen is resistant to both H and R with
or without resistance to other first line drugs. MDR-
TB patients may also have additional resistance to
any/all FQ OR any/all SLI anti-TB drug.

• Extensive Drug Resistance (XDR) : A MDR TB

patient, whose biological specimen is additionally
resistant to a fluoroquinolone (Ofx, Lfx, or Mfx) and a
second-line injectable anti TB drug (Km, Am or Cm).
 SUCCESSFUL TREATMENT OF
TUBERCULOSIS

• Correct diagnosis

• Correct categorization

4Cs • Correct prescription

• Compliance/adherence to treatment

5/2/2019 KGMU
 Correct Diagnosis
• Molicular Diagnosis : CBNAAT
LPA
• Bacteriological Diagnosis :
Sputum smear for AFB, sputum for AFB culture

• Histo-Pathological Diagnosis:
FNAC/Biopsy

• Clinico-Radiological Diagnosis:
5/2/2019 KGMU
 TB Molecular Diagnostics
NAAT

GeneXpert MTB/RIF
Automated NAAT
TB Molecular Diagnostics

Hains Rapid MDR/XDR TB

Manual NAAT / LPA
Choice of diagnostic technology

DR-diagnostic
Choice
technology

CBNAAT/LPA First
Liquid culture isolation
Second
and LPA DST
Liquid culture isolation
Third
and liquid DST
 Turnaround (Testing) time

Solid LJ media- of up to 84 days(12 weeks).

Liquid Culture (MGIT) up to 42 days(6weeks).

LPA up to 72 hours.

 CBNAAT - 2 hours.
 CHEST RADIOGRAPHY
• High inter and intra reader variation

• No shadow is characteristic of TB

• Jaise – Har Chamakti Cheez ‘SONA’ nahin hoti

Vaise hi – Har X-ray ka Dhabba ‘TB’ nahin hoti

Dr. SURYA KANT, (since 1996)

• 10-15% culture positive cases remain undiagnosed (under reading)

• 50%patients diagnosed as having TB by X-ray alone might not have

TB(over reading)
 TB SEROLOGY

• From 2012,serological tests for

diagnosis of TB have been banned by
WHO as well as Govt. of India.

5/2/2019 KGMU
Diagnostic algorithm for pulmonary
tuberculosis
5/2/2019 KGMU
 Investigation in EPTB
Site of extra-pulmonary tuberculosis Investigation

Node (excluding abdominal)
Intra-abdominal (excluding renal)
Pleural
FNAC, LN biopsy, AFB smear, culture and histology,
molecular tests
FNAC, Biopsy, Excision and culture, Guided procedures,
molecular tests
Pleural aspirate, AFB smear,
total lymphocyte count and differential, biochemistry,
Culture, Biopsy and HPE, molecular tests

Renal/urinary tract Urine for AFB smear &culture

Biopsy and HPE, molecular tests
Tuberculous meningitis CSF - AFB smear,
total lymphocyte count and differential, Culture and
biochemistry, molecular tests
Bone/joint Tissue and / or synovial biopsy, and histology, molecular
tests
Pericarditis Pericardial aspirate, AFB smear, total lymphocyte count
and differential, biochemistry, Culture, Biopsy and HPE,
molecular tests
Cold Abscess anywhere Pus AFB smear and culture
Tissue biopsy, and histology and culture, molecular tests
5/2/2019 KGMU
 Differential Diagnosis
• URTI
• Chronic Bronchitis
• Bronchiectasis
• Pneumonia
• Lung abscess
• Fungal infection, ABPA
• Parasitic infection
• Eosinophillia
• Atypical mycobacteria
• Neoplasm
• Sarcoidosis
• Interstitial Lung Disease
 DR-TB Diagnostic Algorithm
Presumptive All diagnosed TB
TB patients

Key/Vulnerable • Non responders to

populations CBNAAT treatment
• Paediatric age group • DR-TB contacts
• People living with HIV • Previously treated
• EPTB site TB
• TB-HIV co-infection
For discordance on LPA for • New TB patients $
RR TB RR-TB – repeat CBNAAT at RS TB
LPA lab

SL - FL-LPA*
LPA**

FQ and SLI FQ and/or SLI H Resistant H Sensitive

Sensitive Resistance
 Correct Categorization
Pre-requisites
• Site of disease – Pulmonary / Extra pulmonary

• Severity of disease – Severe / Less severe

• AFB positivity – AFB +ve / AFB –ve

• Previous history of treatment – New case / Old case

5/2/2019 KGMU
 Correct Categorization
Tuberculosis

New Case/Previously treated

(relapse, failure, treatment after
loss to follow up) XDR TB
MDR TB

Cat. IV Cat. V
Cat. I
CAT III Removed in 2010
CAT II Removed in 2018
Daily Regimen introduced in 2016
5/2/2019 KGMU
 Treatment Drug sensitive TB
Type of TB Intensive Continuation Total duration
cases Phase Phase
(IP) (CP)

New/Previously 2 (RHEZ) 4 (HRE ) 6 months

treated(relapse,
failure,
treatment after
loss to follow
up)

5/2/2019
 Note
• There is no need to extend IP
• CP in both new and previously treated
cases may be extended by 3-6 months
in certain form of TB like
 CNS TB
 Skeletal TB
 Disseminated TB
5/2/2019 KGMU
 Weight band for daily dose
regimen
• New (2016) guidelines by Govt. of India
Central TB Division provides number of
FDCs according to weight bands.
• 4 weight bands for Adults, 7 for children.
• This is to prevent further drug resistance
and assured bioavailability by increasing
drug compliance.

5/2/2019 KGMU
 Weight bands for Adults

5/2/2019 KGMU
 Weight bands for children

5/2/2019 KGMU
 Follow up evaluation in drug
sensitive patients
Type of case Follow up Extension of Action on Long term
treatment follow up follow up

New and Microbiologi Extension of DST should Clinical and/or

Previously cal: Smear IP is not be done if any sputum
treated TB examination required follow up examination
cases at the end of sputum at the end of
IP and end of comes 6,12, 18 and
treatment(CP) positive 24 months
Weight:
monthly
Chest x-ray:
if required

5/2/2019 KGMU
 Treatment Drug
resistant TB

5/2/2019 KGMU
 Pre-treatment evaluation

# HBsAg at baseline
Pre-treatment evaluation
 Classes of Anti TB Drugs recommended for treatment of DR-TB
New Grouping of Drugs
A. Fluoroquinolones Levofloxacin Lfx
Moxifloxacin Mfx
Gatifloxacin Gfx
B. Second-line injectable Amikacin Am
agents Capreomycin Cm
Kanamycin Km
(Streptomycin) (S)
C. Other second-line Ethionamide / Prothionamide Eto/Pto
agents Cycloserine / Terizidone Cs/Trd
Linezolid Lzd
Clofazimine Cfz
D. Add-on agents (not part D1 Pyrazinamide Z
of the core MDR-TB Ethambutol E
regimen) High-dose isoniazid Hh
D2 Bedaquiline Bdq
Delamanid Dlm
D3 p-aminosalicylic acid PAS
Imipenem-cilastatin Ipm/Cls
Meropenem Mpm
Amoxicillin-clavulanate Amx-Clv
(Thioacetazone) (T)
 Treatment Drug resistant TB
Type of TB Intensive Continuation Total duration
cases Phase Phase
(IP) (CP)
Regimen for (6-9) Lfx (18) Lfx Eto Cs E 24-27months
MDR/RR-TB Km
Eto Cs Z E

Isoniazide (6-9) LfxREZ 6-9 months

(mono)
resistance

5/2/2019
 Treatment Drug resistant TB
Type of TB Intensive Continuation Total duration
cases Phase Phase
(IP) (CP)
XDR-TB (6-12) (18) Mfx(high 24-30 months
Mfx(high dose)Cm dose) Eto Cs Lzd
Eto Cs Z Lzd Cfz E Cfz E

Shorter MDR (4-6) Mfx(high (5) Mfx(high 9-11months

regimen (R dose)Km Eto Cfz Z dose) Cfz Z E
resistance + H H(high dose) E
sensitive/
unknown or
MDR TB)

5/2/2019
Features of Shorter MDR-TB Regimen

• Treatment duration: 9-11 months

• Indicated for pulmonary & extra pulmonary case
(plural effusion and lymph nodes) RR-TB or MDR-TB
patients regardless of patient age or HIV status
• Exclusion criteria:
– Second-line drug resistance (FQ and/or SLI drugs)
– Pregnancy
– Extra pulmonary case (other than plural effusion and
lymph nodes)
– Previous exposure for >1 month to a fluoroquinolone or a
second-line injectable medicine.
 Dosage of DR-TB drugs for adults
S.No Drugs 16-29 Kgs 30-45 Kgs 46-70 Kgs >70 Kgs
1 Rifampicin(R)1 300mg 450mg 600mg 600mg
2 High dose H (Hh) 300 mg 600 mg 900 mg 900 mg
3 Ethambutol(E) 400 mg 800 mg 1200 mg 1600 mg
4 Pyrazinamide(Z) 750 mg 1250 mg 1750 mg 2000 mg
5 Kanamycin(Km) 2 500 mg 750 mg 750 mg 1000 mg
6 Capreomycin (Cm) 500 mg 750 mg 750 mg 1000 mg
7 Amikacin (Am) 500 mg 750 mg 750 mg 1000 mg
8 Levofloxacin(Lfx) 4 250 mg 750 mg 1000 mg 1000 mg
9 Moxifloxacin (Mfx) 4 200 mg 400 mg 400 mg 400 mg
10 High Dose Mfx (Mfxh) 4 400mg 600mg 800mg 800mg
11 Ethionamide(Eto) 4 375 mg 500 mg 750 mg 1000 mg
12 Cycloserine(Cs)4 250 mg 500 mg 750 mg 1000 mg
13 Na-PAS (60% weight/vol) 3,4 10 gm 14 gm 16 gm 22 gm
14 Pyridoxine(Pdx) 50 mg 100 mg 100 mg 100 mg
15 Clofazimine (Cfz) 50 mg 100 mg 100 mg 200 mg
16 Linezolid (Lzd) 300 mg 600 mg 600 mg 600 mg
17 Amoxyclav(Amx/Clv) 875/125 mg 875/125 mg 875/125 mg 875/125
(In child: WHO 80mg/Kg in 2 BD BD (2 morning +1 (2 morning +1
evening) evening)
divided doses)
18 Bedaquiline (Bdq) Week 0–2: Bdq 400 mg daily
Week 3–24: Bdq 200 mg 3 times per week
1For H mono/poly resistant TB; 2For adult more than 60 yrs of age, dose of SLI should be reduced to 10mg/kg (max up
to 750 mg) 3In patient of PAS with 80% weight/volume the dose will be changed to 7.5gm (16-29Kg); 10 gm (30-45 Kg);
12 gm (46-70 Kg) and 16 gm (>70 Kg) 4 drugs can be given in two divided doses in a day in the event of intolerence
 Dosage of DR-TB drugs for children*
(< 30 kg body weight)
Drug Daily Doses*
Kanamycin / Capreomycin 15-30 mg/kg (SM 20-40 mg/kg)
Levofloxacin / Moxifloxacin Lfx <5 yrs: 15-20 mg/kg split dose
Lfx >5 yrs: 10-15 mg/kg once day
Mfx 7.5-10 mg/kg
Mfxh 12 mg/ kg
Ethionamide 15-20 mg/kg
Cycloserine 10-20 mg/kg
Ethambutol 15-25 mg/kg
Pyrazinamide 30-40 mg/kg
(Na-PAS ) <30 kg: 200-300 mg/kg
High dose H (h) 15-20 mg/kg*
Clofazimine (Cfz) 1 mg/kg (max. 200 mg / day) limited data
Linezolid (Lzd) 10 mg/kg TDS (max. 600mg /day) with pyridoxine
Amoxyclav(Amx/Clv) 80 mg/kg (based on the amoxicillin component) in
two divided doses (max. 4gm Amox+0.5gm clav)
* as per Companion handbook to the WHO guidelines for the programmatic management of drug-resistant
TB 2014
# till the time data are available, adult dose is used
Follow up evaluation in
DR-TB patients

5/2/2019 KGMU
 Clinical monitoring
• After initiation of Rx from the DR-TB Centre,
MO District/Nodal-DR TB center
– at monthly intervals during the IP, and
– at 3-monthly intervals during the CP until the end
of treatment
• Assess clinical, microbiologic, and radiologic
response to treatment
• Measure weight
• Assess possible adverse drug reactions
(ADR)
• Encourage the patient to continue treatment
• Verify treatment card
 Correct Prescription
Pre-requisites
• Weight of patient
• Financial condition of patient
• Health education regarding disease, infectiousness,
toxicity of drugs and social behaviour
• Motivation for regular and complete treatment
• Prescription according to category

5/2/2019 KGMU
 Compliance / Adherence to Treatment
• Key issue in the success of treatment
• Require involvement of
– Doctor / Health worker
– Patient
– Peer / Family
– Society
– Government / NGO
– Media
– Pharma Industry

5/2/2019 KGMU
 NEWER DRUGS FOR MDR-TB

• FDA APPROVED:
– BEDAQUILINE
– DELAMANID

• UNDER CLINICAL TRIALS:

– PRETOMANID
– SQ109 (SEQUELLA)
– PNU100480 (SUTEZOLID)
5/2/2019 KGMU
 BEDAQUILINE
• A diarylquinoline which inhibits ATP synthase.
• Bedaquiline is effective in shortening duration
of treatment without any increased risk of
relapse.
• Effective against both dividing and non-
dividing bacteria.
• Extensive tissue distribution up to 5.5 months post
stopping BDQ

KGMU
• Approved by the US FDA in 2012 for the
treatment of MDR-TB in adults with limited
options.
• In March 2016, RNTCP introduced BDQ
through CAP at six DR-TB centres
• Expansion of access to BDQ has been
initiated in all states in early 2017.
5/2/2019 KGMU
 Inclusion criteria

The criterion for patients to receive BDQ as approved

by the Apex Committee is:
• Adults aged > 18 years having pulmonary MDR-TB.
Additional requirements
• Non pregnant females or females not on effective
hormonal birth control methods are eligible
• Willing to continue practicing birth control methods
throughout the treatment period or
• have been post-menopausal for the past 2 years.
• Patients with controlled stable arrhythmia can be
considered after obtaining cardiac consultation.
 Exclusion criteria
• Currently having uncontrolled cardiac arrhythmia that
requires medication
• Has any of the following QT/QTc interval characteristics at
screening:
- A marked prolongation of QT/QTc interval, e.g.
repeated demonstration of QTc interval > 450 ms.
– A history of additional risk factors for Torsade de
Pointes, e.g. heart failure, hypokalaemia, family
history of long QT syndrome;
– has evidence of chorioretinitis, optic neuritis, or
uveitis at screening which precludes long term linezolid
(Lzd) therapy;
 Eligibility for Bedaquiline
Bdq is indicated in adult MDR-TB patients not eligible for the
newly WHO-recommended shorter regimen.
These may include:
• MDR/RR-TB patients with resistance to any/all FQ OR to
any/all SLI
• XDR-TB patients
• Mixed pattern resistant TB patients
• Treatment failures of MDR-TB + FQ/SLI resistance OR
XDR-TB
• MDR/RR-TB patients with extensive pulmonary lesions,
advanced disease and others deemed at higher baseline
risk for poor outcomes
 Bedaquiline: Dosage
• Week 0–2: BDQ 400 mg (4 tablets of 100 mg) daily (7
days per week) + OBR

• Week 3–24: BDQ 200 mg (2 tablets of 100 mg) 3 times

per week (with at least 48 hours between doses) for a
total dose of 600 mg per week + OBR

• Week 25 (start of month 7) to end of treatment: Continue

other second-line anti-TB drugs only as per RNTCP
recommendations

The dosage of BDQ would apply to all weight bands while the dosage of other
drugs in the OBR would be as per the weight bands in accordance to the RNTCP
PMDT guidelines.
Bedaquiline: Administration
 Delamanid(DLM)
• Bactericidal with Half-life of 36 hours.
• First approved drug in the class of nitro-dihydro-imidazo-
oxazoles for the treatment of MDR-TB.
• Developed by Otsuka Pharmaceutical Ltd,Japan.
• Dlm achieved culture conversion on average six to 13 days
earlier than the conventional regimen.
• Dlm may have a protective role in preventing the
emergence of additional drug resistance.

5/2/2019 KGMU
 Contd…
• First approved by the European Medicines Agency (EMA)
in November 2014.
• On 14 June 2017 Ministry of Health and Family Welfare in
its 34th meeting has approved the use of Dlm under
RNTCP PMDT through conditional access.
• Seven states (Punjab, Chandigarh, Rajasthan, Karnataka,
Odisha,Kerala,Lakshadweep) have been identified as initial
sites for the introduction of DLM under the RNTCP PMDT
through conditional access

5/2/2019 KGMU
 Criteria for patients to receive
Delamanid
Inclusion Criteria: All Adults ≥18 yrs, including people
living with HIV (PLHIV) with;

 MDR/RR-TB with resistance to any/all FQ OR any/all SLI

 XDR-TB
 Mixed Pattern DR-TB including patients who are failing any DR-
TB regimen or have drug intolerance or contraindications or who
return after interruption or emergence of any exclusion criteria
for shorter MDR-TB regimen or with extensive or advanced
disease.

5/2/2019 KGMU
 Contd…
Special caution: HIV+ (in consultation with ART centres), 65yrs+,
patients with diabetes, hepatic or severe renal impairment, those with
serum albumin <2.8 g/dL or those who use alcohol or substances.

Exclusion Criteria:
 Children under 6 years.
 Pregnant & breastfeeding women.
 Patients with repeated demonstration of a QT interval >500 ms,
history of torsades de pointes or cardiac ventricular arrhythmias
 Hypersensitivity to the active substance or to any of the excipients

5/2/2019 KGMU
 Doses Of Delamanid
• Week 0–24: Delamanid 100 mg (two tablets of 50 mg)
orally twice a day + OBR.
• Week 25 (start of month 7) to end of treatment:
Continue other second-line anti-TB drugs only as per
RNTCP recommendations.

5/2/2019 KGMU
NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS
ELIMINATION
2017–2025

VISION: TB-Free India with zero deaths, disease

and poverty due to tuberculosis

GOAL: To achieve a rapid decline in burden of

TB, morbidity and mortality while working towards
elimination of TB in India by 2025.

5/2/2019 KGMU
 TB notification
Govt. of India declared Tuberculosis a
notifiable disease on 7th May 2012

All public and private health providers

shall notify TB cases diagnosed and/or
treated by them to the nodal officers for
TB notification.

5/2/2019 KGMU
 Contd..
• As per MCI code of Ethics – Rules & regulations 2002,
Chapter 7, Point 7.7, a registered medical practitioner giving
incorrect information on his name and authority about
Notification is liable for deregistration

• As per gazette notification of MOHFW dated 16 march

2018(published on 19th march) ,clinical establishment –
doctors, laboratories, pharmacists, chemists and druggists
,that fails to notify tuberculosis patients will be booked under
Sections 269 and 270 of the Indian Penal Code that carries a
jail from six months to two years or a fine or both.

5/2/2019 KGMU
5/2/2019 KGMU
5/2/2019 KGMU
5/2/2019 KGMU
5/2/2019 KGMU
 Nikshay Poshan Yojana
• Launched by Govt. of India in march 2018

• Main aim to provide incentives (Rupees

500 per months for the duration of
treatment) for nutritional support to TB
patients.

5/2/2019 KGMU
5/2/2019 KGMU
 99DOTS

5/2/2019 KGMU
 Contd…
• 99DOTS is a low-cost approach for monitoring and
improving TB medication adherence.
• Using 99DOTS, each anti-TB blister pack is wrapped in a
custom envelope, which includes hidden phone numbers
that are visible only when doses are dispensed.
• After taking daily medication, patients make a free call to
the hidden phone number, yielding high confidence that
the dose was “in-hand” and has been taken.

5/2/2019 KGMU
 Contd…

5/2/2019 KGMU
 Key Benefits of 99DOTS
• Instead of traveling to a center for every dose,
patients can provide evidence of dosing from
their home.
• It improves the efficiency of care providers.
• Instead of mandating that all patients receive
frequent counseling, adherent patients can
proceed with less supervision, while limited
program resources are focused on cases that
need the most attention
5/2/2019 KGMU
 Recent changes in TB
Management
• Category 3 of RNTCP abolished 2010
• Introduction of CBNAAT/Gene expert for TB diagnosis 2010
• Ban on serological test for TB diagnosis 2012
• TB declared as a Notifiable disease 2012
• Category 2 abolished 18/12/2018
• Withdrawal of Kanamycin from H mono/poly DR TB
Regimen 24/12/2018
• Non declaration of TB made punishable 2018
• Daily regimen introduction 2016

5/2/2019 KGMU
 Contd…
• Newer definition and diagnostic algorhythm for TB
(pulmonary,extrapulmonary, pediatric TB, TB-HIV) 2016
• Nutritional support for TB patients (500/month) 2018
• Incentive for private doctors 1000 per patient at completion
of treatment
• Introduction of Bedaquiline for DR-TB patients 2016
• Introduction of Dalamanid for DR-TB patient 2018
• And above all historical and landmark decision of our PM
modified END TB BY 2025 ON 13TH MARCH 2018

5/2/2019 KGMU
 Delhi End TB Summit 13 March
2018, To END TB By 2025

5/2/2019 KGMU
TB Free Lucknow campaign

5/2/2019 KGMU
 Conclusion
• Tuberculosis is a major health problem in our country and
globally too

• TB is over diagnosed and misdiagnosed in our country

• Every shadow on X- ray is not TB

• Drug resistance is a man made problem and can only be

dealt by education and awareness.

• Inadequate and irregular treatment is the most important

cause of drug resistance.

5/2/2019 KGMU
 Conclusion
• Drug resistance is a bacteriological diagnosis.

• Follow treatment guidelines

• Newer diagnostic advances and new drugs

promise a situation of TB control.

5/2/2019 KGMU
THANK YOU