In this presentation: 3 sessions Tuberculosis / Mtb

Sessn 2: D ShaaihaaSessine2 Dr Ko tet

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DATE: 02 Feb to 22 Mar 2021 n a i t v e lo hest. sunlight and V rwditim

TB Infection TB
Transmission. Dynamics of Cough Risk of infection and disease
LTBrs are the reservoir of infection / Population infection (droplets5 microns)
Common source isa puimonay TB patien
(ruget) Tall t a s t
1
Asmear positive putmonary TB in general
ropets
Spread: Airborne- both droplet & droplet nuciel, also Small droplets-

g
population if left untreated may infact 19-15
Hematogenous-Congenital around tioating .. and remain infectious
otner persons in a year
Vuinerabity depends on duration and frequency of exposurs, .."crystallize" creatinga for 2-3years
load and virulence of bacilli and immune status of the nucleus
Or r e c t o u s mate f inside.. 10-15% of infected people deveiop disease in
naivioua
their life time
S u r v i v e witnin macrophages as phag0somes 1.0 micron droplets nuclei (Wells)
will
Atincreases to 10% by year among PLHIV
Usually takes 6-8 weeks for establishment and manifestation of eventually tall just 3 m. in 24 h.
infection Oiabetes, undernutrition, tobacco smoking and
use of alcohol also demote infection to disease
Presence of infection is indicated by skin tests Mantoux, C-Tb,
Diaskin or by IGRA-Q FT in Tube, T-Spot
Large droplets UPper Aiway trapping
1-5 droplet nuclei reach Alveoli & cause infection

s b 42 rec+t atd a-78 4cartmi and ther sites efmrstion Broader TB Determinants & Estimated Global and India TB burden:2020
Spectes Differentiated Treatment Approach
beegh nodes
M AViumcampies
Annually, -50% of 10 million TB cases EsimatedTGlobei190.000 ndia1000nOfthe 197; 157
attributable to five risk factors slobal ndia
FLaRn
inciedence of
Undernourishment 2.2 million ulkc
epoted and

407 lakh not

AIV Infection 0.8 million oHVTB) -S 0.69 detected
NE Marinum
16 CFR is -107
M Ahieslis Fulna1a. Alcohol Use Disorders 0.7 million
M. Che among DSTB

Pevale 85.000 1.000

and -50 to
Smoking9 0.7 million entTB

0%among

Diabetes 0.4 million MDR TB 000 6.1

DRTB
 LINE PROBE ASSAY
ycobacterial Growth Indicator Conventional culture[L)
Line p Tube Lowenstein Jensen m a
a y s are drug
epotytests that use MGIT) 960 4-6weeRS
PCR an
methodseonotation
or the
detection o raprc
utauons
assocated with drug
resistance

Prope 553ysare
desi
tuberca dentity M.
simulta
piexand
mutatione detect
ted with

drug resistance.

Operational process of specimen referral Considerations

in test
Any discordance results for Rfampicin between AAf and FLA
Epeat NnA wil be carried out at C0ST lab

Specimen handling Nikshay

De besed on consernsus of thet 3 lests 2AA 2nd

Specimen Two specimen in conical e na resut

tubes, collteo. p Generate lest LPAJ I 2of 3are K resistant then the final reut w
collectio
& transported in cocO
Centers resistance not detecte

Update NAAT ATeu be invalid, the sputum specimen is

cee o
TOuno to
ately, tf the culture result is found to be
snecimen will be POE, A tETCed out tof contirming MDR/RHR TB
aibpotetocrup DSTah

0ST to Lzd, Z. Cfa would be availabie as soorn as the profhciency testing

econd specimef w D
eerie compaetednd soq ano Dirm would be introduced soon

testedofL
PA and further D9

Pretreatment Adherence Evaluation

evaluation for DRTB
Pre-treatment
Why change in

Evaluation Patient understands the MDR treatment: About

Components of
Pre-treatment
of months
treatiment 20 or longer,
regime, lengeth
by doctor at least. possibie side efects, limitations,
Clinical
examination drugs-5 drugs
1. adherence follow up schedule.
radiograph (CXR)
2. Chest for treatment adherence

3. Blood tests
Patient ready care
involved in own

Patient actively
support
Family and/or social
4 . Urine tests
desirable

Other tests
like ECG etc Treatment supporter is
5. adherence have Deen addressed such as highly
Barriers to
needed
as
evaluation
drug heavy alcohol
6 Specialist

unstable social
situation, w
abuse,
tness, reigious beliefs,
health tacility/s serious psychiatric
be done at appropriate dependence,
needs to
Handle emergency plan
Evaluat n he done on out-patie
Evaluation
 Interim Outcomes
e C o n v e n i o n (to negative)
Moving from IP to CP Follow-up microscopy
J0 days All oral fonger MOR T8 mear exa
ettPeee aoart Run o be
Shorter MOR TB regimen mwards te guide the decison on m nf
l ess than 12 months Ra) 6 epmem and edension df tatment from 5 months 1o months and
ieda
the date of converslion ths Bul
Dabe of DT6 trest Detwee 12monts
*Smear at d month Monthly culture from3
*
negative, initiate CP month onwards to end of
* If positive, extend IP for
Curture Revenon (to
.
w ge /4t months culture
After an initial c o positive negative initiate For s h o r a M L 0
consecutie cultures, thie at least 30 days
a a r e found to be pouitive extended IP (6 months) If 574 months Culture t
o e PORDRODeOT DOn eatent faled, reverSAn 8 conicdered onty positive, e x t e n d 1P for o n e
olow-uptheculture will be
done at end of lP
end of extended iP and
more
month till corversion
of end of extended IP
Theterm microbiological conversion re end of treatment.
e t h e r for s m e a r o r cultsorm bhaga e e

Follow up Follow up schedule Follow up schedule

Smear Microscopy moor

Cutture D5T and

E a t iP & 4 LA E a

cemes
mitarfC wdw

serurm creatimime

very&months
AudneY very 2 months
Me. Cal
As and when

atelets linicaly
SH &UT indicate

Outcomes schedule
Follow up schedule Long term follow uup

of treatment, the patients shOuld

Clncal + w
*After completion
h onerd to ond of 6 monha Ga e & 24
be followed up at the end of 6,12, 18
4month 5moeths 6mont 2
months. All oral H

eted
recurrence of TB, on
3 he tut 4 toue s
For timely detecting 14 mnes
uditety
of signs & symptoms, sputum
appearance 24 months
13 20 m
be
/ or culture sensifivity are to
a y usnd
microscopy and
end of ben esn ndcapd
considered
a
d e d wnd
s i Me Cal As andhen
ollaborations to address risk factors of TB Strengthening Case Finding in the Public Sector
Strengthening Case Finding in the Privates
AVEAPADACN TO CASE FINOHNG EAPRRONO O CAE T shedule Ht implementtioc No of chemist

O R n n e ror
NCO onaASCentrel Prograr
Ohet
natulying in 201l wat 2318 And 2103 in 201
Provsion ofGovt p h
Canee o

rdiovasctular Diseases oshan Abhiyaan

Stroke

ational Tobacco
ontrol Program R3SK ashtriya aeininse
e

Karyakram
ar estine
Ayushman Bharat
Heath and W- www

Centres

ational Guidelines on Airborne Infection Control in

Fundamentals of TB Infection Control
Healthcare Settings Triage
Hierarchy of Infection Control Measures
Screening ast-irack respiratory
Eolefinee

importance of AfC dentity people

with respiratory Symptomaeto
1Healthcae and Chher Sertins
Covers Administrative Controls symptoms
mlninize tlme in

health care tacilities

Managed rilit Reduce potertal opportiunities for eposure
AC nineorin
contre yEneerin8 Environmental Controls
Reduce curncentralion ef i t artiecks thet may b

Cold climates
Personat respiratory
protect
Risk Asessment and
Respiratory Protection
wonitotng >Y>ie

www.tbcindia.nic.in

Segregation and Spacing& Examples of waiting areas

Cough etiquette Minimum Air Changes

fectious or h e a t n care Minimum

t s away from ypo A ACH
vulnerable patien egstraonaitin9
6 ACH
g Whatever
5 AUH
Pproache Cupae panens
ments 25ACH

ndvioua 212 ACH

High-risk Settngs
Desg
Crowded waiting area

Spacious area tor

tpatient and a
favoring
maintaining social
Spread of Airborne
MOR-T s
Atnn infections distance
 Sorter MDR u e tor
TB AGuits (P18)
ured:A
nErobiolO8ICally regim
imen Daily Drug Dosage for Paediatric TB
eatment a
eatment idence
and
contirmed
of failit MOR/RR TB
on at patient who has all oral
reatment
oleted. n prevou
least one iqus completed Lured:
longer regimen for MDR B
uidelines
uidelines but
but cio Apatient who h ocao
On A
tmcrobiologically confimed MDRURR
does not
CK Of microbiological remeet the
he definition forc u r a t m e n t according to
delinition for consecutive cunwithout evidence of
T
patient whohas
patient wO
cure or
Treatment failed: Treatm treatment tailure due to Wards are negat E east 1 month apart fror
O nated or need
any anti-T8 deugs in CPp for reotment completed Anat
A r e at the end of treatrment

acROT
permanent reimen
hicrobioiogical conversion by th treta n Ecuidelines but does not e d treatment
Taure due to lack of microbiological0 r c u r e or
iP or
s o ni fter cor ed Trentes
dve a c u r e d resistance
Died: A patient w
for
drugs in
regimen d
EO eatment terminated
regimenchan
n n s onwards becauseo
or need for permanent
o o e ante10 orug Trom b
Recordingg
p: A
Y cuing Uhe course of anti T8 treatment COf mcrobologCalconversion by the end of the & morth c
and
e o n or fmoOre us al ra
reversion n the
Not evaluated:A Datientto
nciudes 10rmer
A
wono
transter-out&still ontreathent
treatmentoutcome
ts
855i6heo, Uhis
negative or
idenceot boditonal
acquired resistance
ba month or

for
later after converson to

drugs in
regimen or
Reporting
cng
A

e e pmnent
ocontinuation of esisting regimer DEGA patientwho dies tor any reason dunne the course of and 18
with change of at least one or more anti-TB
prior to being declared as failed drugs Lost to follow
on
month or more for any reaxons
orior t
Notevaluated:A patient for whom no treatm o

,this imcludes former transtfer out'&"stll on treatment

S No
Active Screening of Contacts
RNTCP Reques torm tor examinationot Biologica 19A

5pecimen fortTtB DS TB R TB
RNTCP laboratory Register for Culture, CBNAAT and 15L
DST referral for treatment form 9 E 9roap idren s b years
PMDT (Annexure V) 15H
Initiatives to Strengthen the All age groups
PMDT treatinentcaro 15 E All
15 Status ncivicua5
T8 notificabon register Ymptcms Ony SYmplormat irrespective of

PMDT Treatmente t
booklet 15 M
Programme symptom
8 15 N Prophylaxs NH prophylauis inc5
Patient counseling register of Second
years and in imimuno Under
Stock Report for Stocks & Indenting
9 Monthiy
n e onugs at DRATB Centre
supressed contacts consideration
from State For pediatnic TB cases.
Monthly StoCK Statement of
S e c o n d line dnugs Reverse contact tracing
Drsn Store

Incentives
NIKSHAY Poshan Yojana
Incentive for Incentive
tav
Nikshay- is to monitor and Rs. 500/- per month support in
Nikshay track services and
status gven to every 18 patent
cSHAY S
Treatment
Supporter
or
Informant Tribal blocks
Rs. 750- ass
diagnosis,
related to screening. through D8T for Patient Drug sensitive T8 An Infomant
treatment and follow-up
of
duration of treatment
Rs. 1000- is eligible tof
Tuberculosis cases. ank completion of treatme
Scheme roled out fron Drug Resistant Case. S,
Online Tool For Rs.5000/-duning Conimed Tb
regardin8 April 2016 treatmen
Monitoring TB Alerts to TB patient kh
alerts to ne Rs.9 Cr.
follow-up
medication, RS. 20.6
Rs.866.5 Cr amount Period-April
Control the patients
and providers etc

Programme..
disbursed to
2018 till date
16
beneficiaries from Apr
 Daily Drug Dosage 2e0
Adverse Drug Reaction & Pharmaco vigilance
is a fundamental public health surveilance activity to inform he Severity Criteria
manogenent oi patent safeety measures in health care

WHO definition: science and activities

relating to the evere: Etene dities esing s g e
detection, a5sesSnent, uindestanng ano poimenof fnctong d c t t
D oC
acverse erects or any other
Prets normal ever rdey ctt
drug-related problem"
ADR/SAE seriousness
Pharmaco vigilance includes: Death

Monitoning for early detection of ADR reatening

tion required
a Commonly erncountered ADRs wh regimers used Permanent disability
S t r a t e g e s tor managing and reportin9 ADR Birth detect
Require intervenbion to prevent

permanent damage
Docurnentabon and reporting oftADR

TB- HIV
Treatment in Special Situations 99 DOTS: Pill-in-hand monitoring
te be dame?

sk of TB h a t needs
women
21umess tugher CF: edt
T5 m Women Pregnant and Lactatin and 25% ot deaths
1 DCFJa CtTC.Artf or
ot T5 in
patents with
Lver clisorders among PLHIV s due to
2. Management CAIC:Ar ome recona
tasiure and Severe renal insutficiency
pathent wn Henal
35
in patients with Setzure disorders 2018: Among total aassionHy
4.T8
notified cases of HIV PT p i t a i o n of honisca
eDn
patens wtn ychosis evertive trnament (
tara

18 tntection (oB)
TB-PLHIV-KA 10.3
5. Hospitalization/ EP T5/Latent LHIW OART
India3.4% [Notification
ycobacterial (NTM) Lung
-Treatment of Nontubercuious
rate-80]
Diseases

Diagnosis of Non Tubercular Mycobacterium (NTM)

Mycobacterium (NTM)
Non Tubercular Follow Up
Environmental Mycobacterum.
s o called Positive smear for AFB andjor hety99 C a
indniduals &
seen in i m m u n o suppressed
tore commonty i deshres or Culture of NTM EOTh b y
torm
Chuidt en

attects-
Dseminated
skin, soft tissues, L, implants devices
pecimens:
and
Usually

Medications
Treatment Ritampicin-450mgeomg oo Outcomes
intensive nase
for 3 months Ethambutol-boo-1200mgOu

Persistence of AFB after ant-TB weatment tor twe f

t h CBNAAT Or
may extend up toCarmomycin 1gmoD (splh to tac ora detecting M 70
6 month
ni Amikacin-750mg-oma
oes Smear positive, CBNAAT negatve, LP Dr Kriti Bhat
De
g o e s
atbo need
to
Continuous Rfannpa

phase
For 1e montns

Clarithro7
 terta
Tor
patients to receive standard DR
TB
regimen
Shorter Regimen: Packaging Newer anti-TB drugs
Based Patient
eg eraen l y wh any
g d
on
weight band, loose drugs to be ro-pacKoG
YDe A
&1Ype B patient wine bOx ( Monmly hox After almost five decades of discovery of
atier
ype A (Core oral drug box) Type B(1P Plus box)
hk mte
Tab Moxifloxacin (Mfx)
Rifampicin, the two new drug5 named
shorter
MDR TB pulmonary o Cap Clofazimine (Cfz) Inj Kanamycin (Km)
regimen extra pulmonary Tab
Tab lsoniazid (H) Bedaquilineand Delamanid with anti-TB effect
TB
Pyrazinamide (2) Tab Ethionamide- (Eto) were approved for treatment of multidrug
Tab Ethambutol (E)
Tab Pyridoxine (Pdx)
resistant TB by The Central Drugs Standard
egie
PType A box+
Type B box of same
weight band Control Organization (CDSCO).
CP= Type A box of same weight band

Bedaquiline: Dosage All Oral

Week
0-2:BDQ 400 mg (4 tablets of 100 mng) daily (7 All
Regimen- BDQ Delamanid First Representative of
days per week)+ OBR oral regimen consist of 4 drugs with B00 and
New Class of anti-TB
no Injectables
drugs
Duration of Treatment 18-20 months
Week 3-24: 200 mg (2
BDQ
d n
of 100
a est48 hours between
tablets
mg) 3 Levofloxacin (Lfx) Moxifloxacin
Mfx) high dose (it * actS Dy mhibrting the synthesd of mmycobacteral
doses) for a total dose of b00 mg per week + OBR
s required)
modification 2 0
cel wall
AetOrtnycolic acd
BDO
Week 25 (start of month 7) to
end of treatment:
Linezolid (Lzd) #
(Sedaquiline courte
Conunue other Secono-lne dntebdrugsS Only as per will be handed e terss
RNTCP r e c o m i i e n d a t o n s Clofazimine (Ctz) ove
to the patient) reactve intermediate metabolte
e ooa0Ce y weonound wle thC 306.9e of and desnitro-imidacooaoie derivative
Cycloserine (Cs)
p e h e inhibition of mycalic acid

All Oral Regimen DLM Inclusion criteria for new drugs (Bdq/Dim) Exclusion criteria for new drugs (Bdq/Dim)
Alloral regimen cosist of 4 drugs with DLM and no
njectables Bdq/ Dim can be provided to the
Pregnancy & lactating mother
yrs Uncontrolled cardac arthythmia
Duration of Treatment 18-20 months tratreqdiesh
Dim can be provided to age 9oup b to yoars. QTcF 2 500 at baseline & nomal electrolytes
Levofloxacin (Lfx)/ Moxifloxacin (Mfx) high Use of Bdq for B to 17 yrs and Dim for 3 to 6 ys may be o y ODOoo1a s Tactos for os.ade oe Poinles, eg

dose (ifmodification is required)

Consioered only ater approval of DCG
yp
syndrome ea. amily hastory of long Q7
Linezolid (Lzd) # resuts oT the serum chermisty haernatoiogY or unnalysis
Non-pregrnant emaes or femaies not onDhormonal birth contro are outside the nomail reference
range based om
Clofazimine (Cf2) a c t c i n g tDirth control

Cycloserine (Cs) YpoRaaeha, nypomagneslena and nypocae

Snould be cofrecle p r o r to a patient f e c e v i n g any Q1c

Delamanid (DIm) atients wth control ind state arhyihmia. can be considered ater
C t a i i 9 CraroiaC consitabion
prolonging drugs
Bdq/Dim is notadded to a tailing regmen in a n
MDRIRR TE patient
Extension of
treatment in Shorter MDR TB
Pshould De gven for at
regimen
nitiated ater least four months, then CP should be
Longer MDR Regimen Drugs to be used Extension of treatment in All oral
sputum conversion longer MDR TB
regimen
t
sputum smear Levofloacin / Minofloacin
1s not Drugs not to be used Bedaqualin >6years of bgr Lzd (600 mg)- The dose of Lzd wi be tapered to 300
negative by the fourth month of mg i
treatment subject the Linezolid he 4th or Stm month Culture resut s negative
patient to FL LPA and SL LPA and Kanamycin/ Capreomycin
f the 4th or 5th month cuiture resuit remains positive,
culture 0ST f no additional resistance is detected anic Acid Clofamizine/ Cycioserine the
the 1P e ot Lzd 1op mg) and ihe regimen is extended by 1 - 2
should be prolonged untl EthambutO
sputum smear converts maximum bil
5 months. where Delarmanide > 3years of age
he
injectabie is Drugs to be used only if Howver, the duration of new drugs (Bdq or Dlim) s limited
only given three times a to 24 weeks only
week Bdq, Liz, Clof, Del is not e
he pabent contmues to cue
f the Used remann posaie e
patent remains smear positive at the end of otn month of back to culture positve ater 8 months of treatment, the
Amikacin 18 years age, f

treatment he patent will bee decared as Treatment Ehionamide/ PAS not available Streptomyc patient is declared as Treatment failed",- revaluate the
Failure patient
re-evaluated as per integrated DR TB algornthm and initiated on Fo R E 5 patents he duraion ofal oral longer MDR T5
an
Duration of Treatment
apprOprate modihed regimen based on the extended DST egimen wOud be tor 0menns
15-17 months after conversion culture conversion

Depends on response to thenpy

for trestment of DR-TB
Classes oft Anti Ts Drugs recommended
Weight bands for DR-TB treatment Dosage of DR-TB drugs for adults
m
All oral H mono/poly regimen, Standardized ebui

onthly
Shorter MDR-TB regimen, treatment
boxes will be

All oral longer MDR TB

regimen prepared at 1 Ethm le t
wwg1 430n

kad ts compen e e
State/District m e d c n s roG A and

ed in A
Lewid
tasoas Care KanayO

16-29 30-45 46-70 70

<16 ke Kgs
e Kgs KgS Kgs Clvulanac
M e wd
DR C
and District
Patieet wise boves &loose drugs w ed to Nodal
Caution to be exercised in choosing Keynotes
recommended
WHO drugs
Principles of
designing a
(WHO-2019)
other group A and B >"f the intensve phase 1s prolonged. the njectabve

MDR TB regimen ümes a week in the

all oral longer agent is gven only three

on longer
regimens, all three GroupA DrugsAnaemia, thrombocytopenia extended intenisve phuse
months
In MDR/RR TB patients
one Group
B agent (Cfz &Cs) neuriis # Reduce Lzd to 300 mg
/ day after 6 to 8
(L/ M, Bdq &Lto)
and
are
inciuded
for the
Lza peripheral neuritis and optic
agents agents as
at least three
given to alf DR TB patients
Pyridoxin to be
that
four B, and
1.e
after Bdq is
stoPped.
sezure
disorders not
treatmernt

st of the
est In pre-exIsting
control with medication. per weght band
Group B
used,
both
Cs adequately
agents
are fhere 1s intensive
only if injectables are given
A
two Group severe depression
one or
if only
to be
incuded.
discoloration of the skin
phase (P) in the treatment
Dark brown
are
agents

agents
from Groups Cfz
with
be composed
if tthe
If h e rekimen can
regimen
cannot
nte are added to complete
Components of Pre-treatment evaluation for Pulmonary Rehabilitation
for DRTB Support Measures in Palliative care

Dlood Ter
DR TB Patients.
Cout patet eo

Blood sugar DebAle # needed) Respiratory rehabilitation Preventive measures for-

bed sore, muscle
bumen Gha
Painrelef contractures

Infection control- N 95
nec & Thyreld hundieg2
Cliicak ec e
L 14 nee
mask for care givers Treatment of fatigue,
Breathiessness, cachexia
m est
Nutritional support
Valu or lie crisis-
Regular medical visits
tCG Specalist evaliathon respiratory failure,
Vocational rehabilitation
assesame Jurgeon
CLNEC amxiety.
e
sychosocial support
ehthamol

Paradigm shift in management of

Drug Resistant TB
Guidelines for PMDT Treatment in India 2019
Treatment
Ragumen c a ation

Moving towards Injection Free

Why? Treatment All oral H mono-poly DR
() L RE
Risk of Previously Isoniazid (INH) TB regimen
Treated Mono/Poly
Resistance MDRIRR TB
20,000
1. Potential Co-infection patients) (100,000) Shortar D R TB r e g i m e n
(5) MtCt 2E
EtoCte ZHE
MDR/RR-TB All oral fonger MOR T8
2. Potential Drug Resistance (All oral longer -31,000) 9ne
(t8-20) Bdq(6) Ltx Lad" ct Cs

Extension of treatment in H mono/poly DR TB regimens

Shorter MDR TB Regimen
/ poly DR-TB Regimen
H mono
till 9 months
Standardized shorter regimen consist of 7 drugs
Treatment may be extended
Duration of Treatment 9-11 months

T r e a t m e n t duration:
6 months n patients with extensive disease,
Toeatrmant Cost Appros 1,161 INR per Patbent aa
*Uncontroedco-o
morbidity, compared to 56,903 INRFer Patent unof
Levofloxacin (Lfx) *Extra-pulmonary T8 and Phase Durapo Drugs
is found positive; based on
month
f snear at the end of 4 anamyCIh
Ethambutol (E) smear microscopy and clinical
montoring -6 Montths High dose Moxifloxacin,
to a
ntesi (2 monthsEhio0amce. n
treatment may be given up
and rmiliary T8, Phase prolonged P yrataamoe, gh dose
Pyrazinamide (Z) In CNS, skeletal

year
at the emd of S

Rifampicin (R) In patients

who remain sputum
smear positve
as
Continuation 5 Monits Pytaziramioe,
decoed
wnl De
the outcome
month or
r Ortres ,
is of 6
DR TB regimen t r e a t m e n t failure.
mono/poly
All oral H
no separate IP/CP.
months
with
 Classification and Definitions of DR-TB
Classification and Definitions of DR-TB DR-TB Diagnostic Algorithm
Mono-resista nce TB (MR) A TB patient, whose
biological specimen is resistant to one first-line anti-TB Multi
drug o
Drug Resistance (MDR) A TB patient, whose
is resistant to both H and B with
Poly-Drug Resistance TB (PDR) A TB patient, whose pecimen
resistance to other first line
w t drugs. MOR
OiOlogical specimen is resistant t t h a n one
first have additional resistance to
ine anti-TB
line anti-T5 druß, Other than
drug, other than both tand h. e may aso
Y/olraOR any/all SUl anti-TB drug
Rifampicin Resistance (RRJ: AT5 patient, whose
Diological specimen is resistant to R. detected using Extensive Drug Resistance (XOR):A MOR T6 patient
phenotypIc or gernotypic methods, with or without whose biological specimen is additionally resistant to
resistance to other ant-Ts drugs. It ncludes any a fhuoroquinolone (Ofx, th, or M) and second
resistance to R, in the torm of mono-resistance. poly ine injectable anti TB drug (Km, Am or Cm)
resistance, MDR or XDR.

Definitions and classification of DR-TB patients Drug-susceptibility testing VS Figure 4.1 Technical Specifications of Transport Box
Drug resistance testing forSputum specimen transportation in Cool natn
Universal DST reles to raprd DST
among all notised TB patients (prelerably betfore initation ot
at least rtampiain Growth-based phenotypic drug d mdar dg wetanee
estng
treatment o maumum within 15 days diagnosis) and turther
of susceptibility testing
DSTDr Dunoones and c o n d n e inectaoes
*Cuture though highil
among all TB pasients weth nitampicin resstance enstve and specific method

O T6 diagnosis, requires 2- a ys res 7hos

Drug-susceptibility testing (0ST) reters 1o in-vetO g
y O
A 1O y e d r e s u t NAAT provdes acciurs ndrod
autormated Liqud uture
geno.9p yslems eg 5ACTEC MGIT
60, BacTAlert or Versatrek ete pertomes n bom res
sting and sold (Lowenstein Jensen) run fenpe pecmers
autar techniques) to determine
eictance
2 h a u

media

Sensitivity& Specificity of CB-NAAT

Integrated automated CBNAAT
to labs
Specimen collection and transportation in Non respiratory specimen
GeneXpert platform
Two tresh specimen neeo to Co
Specene
RIT test
ymph Node Siopy
collection centres n0 t a *Kpert MtD / ymph Node FNAC
atients in work tlow
day to the nearet
ChraA aDo
e p *Major advantages
with 1-step external sample ue
*Tuly automated
34 (24-44)
on results o RReT6
or FST8,
the
ALCBA E a s e d ansported to 1% h (walk away
test n d sampies (Pericardiak
cecond specimen nep for SL-LPA FA *time-to-result1
Ascitic, Synovial)
the RN
an * t h r o u g h p u t : up to 10 tests 7 m o d u e 7 r u
a% (58-8)
alon8 with the upoated H Preguestfo
tespectvely n o bio-safety cabunel

contamination risk) nce [Goldl Standard Liguid cu

C-DS5 *Closed system (no
All spe wthin ed to be delivered to the inRNTCP cool chain
1. A positive test provides useful c o n i a t n o
within 48-72hours of c o l l e c t i o n *scalable technoioEY ATTcan be started prompty
laboratory
*Perfomance:specinic rorMTB
carrers need silaf to curture hon
or human sensitvity
(counef/speed post unny to
pou
a9ency
Anontifed from the health system of
iresstance
detection
to be condifons
ranspo
t h e ss p e c i m e n n
tme
Djo-5ale
 Doses in NTEP
Daily Regimen Daily Dose Schedule for Adults (>18Y) Daily Drug Dosage for
Paediatric TB
Type of TB
Case
.aClo
Doses irñ IP Doses in CP Number of tablets Number of tabilets

e FDCs

2HRZE 4 HRE 5 (Five)

Weight band
e phase
Continuation pha5e
Weight
ntensre Phase Contirmuation Inj
New or 56 doses HRZE
112 doses
Previously (8 weeks x7
(16 weeks x 7 75/150/400/275 mg 75/150/279me 6 HRZ E HRE
Streptomycin
treated SOTS/150 100 50/75/100 discontinued
cases days /week) days/ week)
or 25-34 kg
or 28x2 4-7Ng since
"CP can be extended
28x4 35-49 kg
8-11 g Dec 2018.
by 12 to 24 weeks in 50-64 kg 12-15 ke
certain forms like CNS TB, Skeletal TB and 16-24ig
Disseminated TE, based on clinical decision of 64-75 kg 25-29 3+1A 3-1A
thetreating physician 2/5 Kg 30-39 kg 2-2A 2 2-2A
A-Adult FDC (HRZE = 75/150/400/275; HRE = 75/150/275)

Importance of correct BCG vaccination Role of Medical Colleges Public Health Action
o t area of T5 prevention.
ECG is in use since 1921 20%% of TB diagnosed in Medical Colleges:) C ACton to De taxen by locat puubiic health staff
158 countries
included t g Se
More (44) EPTBdiagnosed in MedicalColleges
Centers of excellence (COEs) eg vG is TST trg centro
Patient Home Visit

Averts0necton, confers 1Bttee ite in pedatic age

Treatrment adherence ahd c w upP Suppot nsuro
alfeviate6 dissominatod TE5/ Miiary TB/TBM.
troatiment completon
intocton cotrol meanuros in heaith care tacilities in
h Bos more eticiont in mitigating <5 mortality ArDorne
Contact
dtcts tracing. sypoascreenng. ovalluation of B
Candidafe vaccines-122 for all ages preventing re-inlection
surveilance improverment support
Planning. and quality. to symptomatie
ane otenng Chemoprophylaxis to
E X t f a vaccinial property: Tropical Buruli ulcer. Eladder
destricts. aligible contacts,
cancet, elanotma. Tteotrment of Vwarts. Prvate Provdar agreenant
Offering HV
testing. Drug Suscaptibility Testing (OST,
Research
if eligible

h Ko
Le. dedS Th OOR) Magnitude of the DR-TB Problem in India
X DR-
Sest Excerpts from the Rapid
National survey 2014-15 communication-WHO
atients
treated (PT) APatients
High diagnostic accuracy as initial
ee Yg ulmonary 15 and mproved
test to diagnose
y ress patent outcomes conhrmed
Resistant TB
OJli for Xpert MED /RiP
Programmatic Management
of Drug as initial test to
diagnose pulmonary
aR+ FLD T5 (e. replacing smear
PMDT Streptomycin .9 microscopy) and to
Dr Shashikala N Erhaiibstol 5.9% 6.3% simultaneously cetec resstance
20 45 To
yriaiamide diagnose 18 and detect
R
SLD resistance in
children from
MOR sputum, stool,
244% 20.9% 21 5% nasopharyngeal and
gastric
Any Ta Specimens
TP-o ANIGdsoQ L drigs
Ka , Am, Crm
6.9% 2.27 3.58 To
diagnosa T8 and deteect R

data s Htu pagg l a . Tb 23 0919 .3ofMD resistance EPT8 in

adults
 Interferon Gamma Release Assays (ToNAS
Mantoux test- Tuberculin Skin Test
Blood test for TB intection...1
An adjunct test n diagnosing pediatrc T8 where it is difticult
O
diagnostic aid, whole blood testing
in diagnosing
to collect sputum GRAs are

Mantoux test is not relevarnt in diagnosing active To n ndection

adults in D o nct diferentiate between LTBI & Active TB like TST

a
country lke India
but trequently done in
Presumptve o s e whee sampie not available.
Tao GRAa drouantERO TE Goid ln uReiest (TGD
uberculin is an antigen(gold chain betweenac&9 TE PP.

and. SPOT TEst TSpa0 are approved by US FDA

2TU in 0.1mL for children and STU in 0.tmL for adults in one
tmeasresa person's imune.reocovty to Mtbjinfection in
stage test intradermally volar aspect of tore arm. Si ano
10TU in 2 stage test for children and bdults whiomV9creeee iniereron-gammsa EN-9
respectively vacoration wil nct grve taliseve rescton-unike 7ST
REad between 48& 72 hrs
a s no bocster efect or subsequent tsts, urnlike 7/ST/
vereaction hoicate yco enal tnection

Interferon Gamma Release Assays (IGRAs)

Blood test for TB intection...2
STANDARDS FOR TB CARE IN INDIA
Disadvantages: Vinole biood samples are 1o be processeo
26 standards developed after a National
wIinSi 0 ha whe Wecs are ssl alive
E r o r s in colecting or ansporting bliood
specimens or in running Workshop
lagnosiIs (1-6)
IGRAS cannaLpredict pro2soie e
u
nen o n whom fo use n plaoe of TS1, not both. fcortacts Heatment (7-11)
p g n a o y . e n i n g e a h wOn.ersj
Public Health (12-20)
<5yrs: TST is preferred over 1GRAs
Both TST & IGRAS not to be used in low risk group. Social inclusion (21-26))

Operational guidelines for treatment initiation.

Preventive Measures
BCG Vaccination ative services including
History of ATT
2 information tor initiation:
Drug Sensitivity pattern
4 FDC 3 FDC
LTBIPLHIV & 5 yr children in contactt with History o
Y eoepmen
microbiologically contirmeG PE CaseS
zAIntensified Case Finding [CF through Active Drut sensitive o r DST
Regimen for n e w
Case Finding [ACF] in vulnerable population. ew
unknown / awaited case
24 Personal Protection in work premises.
to DMC tor smear
2HRZE4HRE
Referring symptomatic sputum
2 Prevhosly Drug sensitve o s Regime for newSa
examinations. unknowmIawan L2HRZE+4HRE
24Eary detection ot all cases inciuding B follewup/ethe
2&Notification of al cases e w or previousY
Regimen based on
25Early and complete treatment ot all cases
ncluding LTB
treated oST9 tern
extension ot IP tn DS Cases
Promotes A F & 1CF No
Adequate ACSM
 Presumptive DR TB in children
TB in children [<15 yrs] LTBI&
Crose contact with a known case of DR T8,
TB Preventive Treatment [TPT]
Extent 20% of Gilobal pediatrc cases is ina Latent TB iifection coputation infection reservoir of intection
Close contact with a person who died whilst on TB 5 oftotal cases are pediatc n ino s-J0 of general population
treatment n e nsa o f C v e l o p i n g active TB is-10%%

ay attack rat, 201 # aduita, 40 to 701% 1 0 die due to T8

Close contact with a person who failed on TB in chuldren
e t n e risk of

treatment
developing active disease 107% in aduits R i s k s 7 3 0 times among house hold contacts

T chadiren NSP staeges to prevent ermergence of te

Failure of first-line regimen based on both dc12% Resistance- Treatnent of LTBI
gh nak of deveoprg
(TPT)in contacts
bacteriological and clinical definitions of tailure and
PEdressing socal determinants of TH mrough inter-sector
PrevioUs treatment with second-ine medications. minated TB,
B Mleningitis, Death
ch
Proper newborn vaccination with BcG prevents severe To o
SCaie up ar-bome intecon.como
childhood fuberculosis.

Treatment Options
ommendicns cNGo
3HR HR oie chMeicalcolfeges in TPT
Medicines Oniazid
Isoniazid Isoniazid
e r
RifampicinRifampicin
Duration

(Months)
nterva Dany Weeklyy DE ily
Doses 182 12
e
Pill Burden per
dose pills (108) Role of Medical is of
of 1 (182) 3 (252) College paramount
rotal number
pills for an
p i l s of
FDC (36)
importance for National Tuberculosis
average adult) Elimination Programme (NTEP)

NTEP Endorsed tests Sputum to be collected in the outdoor premises

Specimen Qualityy
Sputum Smear Examination
(ZNLE Ha
ood tsied

2 samples per case,

GeneXpert
2 per 1000
ruberculin Skin Test [Mantqux] Interferon Gama
ley
population
Release Assay (IGRA
FERo Ts 8 per month from the
hest X Ray [CXRITsfoT T field,
FNAC T dets LTS Mucoidd
2 per 100 OPD cases,.
Biopsy
CT Scan 1 sample per case

CS tests during the follow-up

B l clb tat
162
 he thrge g h u d h e End ou
r Ta
f the seried z0-a0 d hee a e h e yw principles

EN 2N et Pediatrse TE ndia
India-Committed to En 3 pillars
and 4

Hon tae PM deae

B
on Ncommliment to End t8

This boki commilment is of

l o t i a l importance s i n e i n t

ocounts for 26%

of the global
en
ENTCP was ipgraded to)
an 2020
MDR T8
BZHIV

Past/ current and the

future Revised terminologies & Case Definition Presumptive Pulmonary TB-Adult
Key
Indicators 0SO%22030 2035
TE ect-Presumptive TB; Relaptseitfection-Recurrant TB, Presumptve Pulmonary TB refer lo a perothany of the syenptoms
20% ots0s or B0 o
eul Treathent taiure
1990to 2035 2015 2015 2015 amd s g uggesthve of T5 rcaudng
Incidence 0 67A 27/ 13/L
ough or2
ndia2 1G7 142LK 2 11 197 Case Anatomical History ofA
OrecuceDy B y definition Slte AlT
ortd 31 16
5
ncdia 43L 17 11 S tobiologlcaty
174 137 RA H sonfirmad
revalence 267L
ndia 465/L 195 17 naatnarma.m.ches ndoangh
o in aanon, contacs n
a c r b s 9 y co
Catastropthic ed, t s pat
L India 36% 0%Sn2 Clinically Etra PLHIV, Dabetics, Mtatnourinhet, cancer patets, paneis on mmuno
ZERO TB= Plmonay
Achieving elimination targets
in the attached PHCs.
diagnosed suppressants or steroids anouild be regularty screened for sign and
sof TB

Presumptive Extra Pulmonary TB Presumptive DR-TB Presumptive Pediatric TB <15 yrs

organ specific local symptoms and signs: oaled reatment with 1 line drugs
Persistent fever and/ or cough for more than 2 weeks
swelling9 of lymph node, AB patient who are tound positive on any follow- up Koss of weight/no weight gain
p a i n and swelling in joints smear examination during treatment with 1 line drugs
andior

neck stiffness, disorientation, etc Previously treated TB case

Flistory ot contact with infectious TB
and 7 C TB patient with HiV co-infection
case
Hstory of unesplanecd weght 206s or no weght gain in
past 3 months
Constitutional symptoms: toss of wuignt s oeline0 0s
Pediatnc TB non-responders ioss
of5% bocy weghf ass
compared to
hghest wegnt recorced m ast d months
significant weight loss, contact of (Or Rit
TB patients who are
Mk-B
n a symptomabic ch c c
2persistent fever for 2 2 weeks, resistance)
i an om of actve
last 2 years

night sweats