nY A

TUBERCULOSIS BACKGROUND About Agent

yr old
4Mar 18sED p bcobacterium Tuberculosis (Mtb) intra
proad TAbs of Mtycobacteria (Human,
direct&Oropi acutatve ect

ANAL OUoeLINESoa AND ongen wonmental, atenuated of BCG vacen iCMI)

nemunity (
aMEOCAL COLLEGE SHHOSPHTAL nuntan beiengs and produce cell medialea

193099 PASTI
10-15peryed
9calyve pevalent case infect
NTC
Right treatment reduces
oath ebaue ND E A R T8 colnscd wth ivADS
90N% intectior
cucatm perod n 3 to 5 weAs
1997 RNTCP, DOh. hleimert Regaie
ea velop Ciseae

No eg0
AboutHost Abou Ervio nment Ingence
Age: is exempted Estimasee1oS09 SOCNLEActos.fa harometerlE- High burcon o l pooulabon s nlectec 1 wCrvelop c.aease in t
chidren (o-14yrs) Globat d tO of wthich iwst die of TB
countries are atricken with the
following'-
inereasing tend in adults and elderty (up to 9035) h ihda er day Fo.000s03hn newty pet inilechod
,Poverty, under-nutrntion
More preolent in males but more ceaths in
children
(250h) develcp TB& e n ) de of T
Early marmiage, migration Ciimated inose a s 1 Lakh in 1990, reducod
&female by 2015 n India
3. Poor housing, indoor air
pollutikon
inhented s.sceptibility is a risk facte ARTI annunl mk o T0
1ainutrition predisposes to Tuerculosis Overpoputaton, Overcrowding m e a r +ve
e 440
& 110

Smoking / alcohol 7
literacy revalence per Lakh perv
irmmunity a acquired through intuction / 6CG
6 Poor cough etiquete, open air spitling 1002

Prevalence Mortality
Esbmated mortaity tor 2015 was 14 iakha
L Co-morbidity
Prevalence of TB infection
o-3%ie. 900
per 30,000 nword Sih of he 10
pOpulaton of PHC, 990 per 3000 of SC, 330 per 1000 eading causes of death globaly & top among inlecoUs 51% HiV+ves
Ssease
HIV nave active TB.
Popuion
S7% TB Cases
Prevalence of TB cases was 465/L Population in 1990.
4.1 takhs (323) TB deaths were in lnda, of ths -000 wee
ve with HIV
reduced to 195/ Lakh J by 2015 [MDG achieved); , wd woe m i o n ooths
were averted betuee
Q40/L in 2012 2000 & 20
At any given time there will be 2 cases per AWc. 6 per SC h Inda TB deaths reduoed trom
43 n 1990 to 17100 000
PHC of both PTB/EPTB.
and 60 per
30000 population: by 2015
achievsdE 15100. 000 n 2016 -600 dealts per
MDG

Prevalence of
DRTB:3 n New cases and 1 2 i Cy, per hkBut 31t in 2013
2 Diabetes Malnutrition
MDRXOR TB
CRRamong DS TB is 10% and 50 to 70% in
 Success Story DE
National Strategic Plan-9 Thrust areas
The tnd 18
Shotegy
S Pinars and a principles Tes
w h y RNTCP- TUDerculosis is he eadng cause

diseases
top anong niectious
**
of doath workd wwde.

T8 doaths were averted betwoen 2000&

intes
54 milion
a
z01 cOVed the targot d of goal 6 MOG- 2000
ratkonal DST
oeneala 1990 2015
Foc
21
Incidenc 167 Aieto
Prevalence 455/L 195/1 2407
****** 043/L L 017 LY
Montaiyy-
*****"P ****

4NewIni
Bden of 31 SDG End TBTEliminationl Dy
F
Et s ot T9 Gtobal npnndia ppn ea 190201 0:0 907s
Burden (2018) 27 bil Giob 2 group -TB

CASCs 10Milion " 27 20% %s0 sme

High Poltical 4Performance Pre
Mln 2
Commitmant1. Case Noifcotion
* Pen
G1
PCr
Treatnent success
Pvealene 16 170 0 S
TE

7.4 1,00, 00 3. Cases detected in

1 population ACF

36% % Ptye. HR Vacancy

ghallendes 5Pioritesto eliminatekE

Key Changes6.
Modality
of Treatment Under detoction, Undor reporting and Uncertain care
1. Reaching tho "missed" cases (3.6 million.
1. Oagnoelic algorithm ( o , Famy Do
of TB patients in privato sectot. -36% not in the system-globally:
Defintion 7.OR TB-Shortor e
BDa bST Guided
Roaching the unroBchod- Marginaized and of whlch 26% live in India).
Type/ Classification Regimen,
Valnerabio populalilon Address DR-TB as crisis.
Outcome
8t
8. Active Case Seoreh
In high rdsk groups
3.Diagn
Registrnton ine ACS
9. Revised recording nd
D r u g Rosistant TB

3. Accolerate response to TB/HIV.

HIV, Diobe:es
-

Notilication Register) Co-mofbiditios 4. Increase financing to close resource gaps

roporing
4. Long term foow up

for al t6
10. Supervislon and Under-nutntion, overcrowaing S. ntensity research and ensure rapld uptake or

5. Datly Regimen
'
Vkdo goOgropnlcal variation in the epidemic

Cases |Monitoring innovations.

 Delhi End TU Sunmlt 13.03-2018 umplivo Extra Pulmonary
Preumptive Pulmonary T0-Adult

dwrerdel

' ga
* ** P****
t

Psur Pedlatric 15 1Ts nciro y

altack ""
a'c 40 to 70%,
Less of
weyk wy
ga omary
adults
20
2 0 to 40% ife time nsk ef active disease,
w a y beatet 1 t c a e
islwy o cntact wth wlectous Th case h in adults
" resistance - 12%. R resntance- 8

g O Oeveoping
ared Ts

BLGrenatonprevents TB in'ecton 50%-J

Gaso Dofinltion,1 Chsp Definltions.2
CChease elwre ***F * s * r ***** *a

CLINICALLY DAGNONLO Tn CASE

eunptw T0 palent not mcoblokogwaly confimed but
agnoed an actve 1Tl by a clinkian en the bash of

ve Mycobacterial infection ************v*o* ***unin

Hatapathok
TBi (Manoua lest}. Dingnoslic aid,
Treat patient with full course of Anti 78 drug
 Classiffcation of TB cases based on Classification of TB casos based on Classification of TB cases based on Resistance
Anatomical sites BMnoresstnce(MR) Reustart b ** ine
Poly drg are(PpR) Resstart ta 1 ine drua oer
me PaEVCcusLY TREATED PATIENTSs &Rtrpon

Drg Revstari(MOR)
ncah dagnne * ti t a e e n e tnd moeegay ei M Resvstart
to NH & Rtampon
Eta Pnonary tberaioas (EPTE
o/ rer ine arugs
H a T o HebsartRR) HeaartBRarpan wtho
* RRa t o
*

MDR
e re drg o n tan IN
be treated
Ceer rvieut) twatd patients-P e a y t a tar Ts
vOR
eterse Dvg RessarD) reustant
6 . to
t 6 *PiB ** castsd*TO ndoumeed outcome

PFTC ndorsed Diagn tiTools Quality-sstua spu

Ueemrting cugde uorescentmiros
croseiogcal confiimaton ct iu
uorescent Mcrocopyl
Aers b e undertaxen to 9C ZN/ acid-f:t staining 373ining with fluorescent Cyes, >
(OrI. S a r
senrte than 2*
read a lower
Sputum Smear
pecitcity. can

Rapid 10,000 AFB/m requirea

icroscoPy
AE
Culire olccula S e n s i t v i t y = 50%
Conventional FM cost, darkroom,
livtedlamp life, health t1:ards of
- Zei
LED Lechnologyess ex,
e Pr: b
Cht sourte. da
LP 2P oom
ble
Fluore c CENAAT to run on batter es, longer ife of
n bu'bs, no toac productsbroien

n ampe Sol Sulturo &DSTN euid Cülture&DST

A3bie niay as in-
Suboptimal Quality Sensitive (10-100 bacall/mil)
Optimal Quality onven TE tem
ST is ser
Automated MGlt so
dentification tests

Puruiant
-12 weeks for DsT AMore relia
abie iytem 0
fime tested, roDUST DST than u
of DSI
MOst newer methods
to this as
compared Need lor n e g e
presiure emronment
gold standard
Mucoid Dloooy
 Line Probe y&Specificity of CB-NAA
molecular ests endorsed Cartridge based NAAT
Assay [LPA dentde pd (CE-NAAD O n respiratory specime
o o n o DNANA directly trom Snge use dsposable Canmoge contanng S p e e c y

pamen/quMure isolates
3 (70-99)
abon
Aulomaied ample preparabon. amplilcation MA
0eiecson
formutaoa tal 0 ProWOes resulls Nom
cormo

osed ona nitrocelulose urprocessed sputum 34(24-44]

nuld
sinp
Other uld samples ercardia
Dgtal
nad outs wn 2 hours 67 -100
detected by moleoa
rapd dagnosis of TB
p
p e c n e n nnding& blosafety

utomated system based on

o
ATT can e started promptly .
o b e s on pe srn does mot alwaysru i e a f
rost
en uTRRIE U LOOof 10-100 CFU m ve fion
.CE-NAAT Should not be used for folow Dp ca
ecion trahspac processihg o
dlupiEOApertg RNTC CrentPolicy for oofce-NÁAT Priority .CRNAATs
Nacessary instructions are to be given to the Diagnosis of RR in Presun1piive MDR TB Optmum utlizsian of all tochnologies

concerned staff for sending the biopsy cases -

LPA (Smear Positve)

specimen in normal saline and NOT IN

Prioritize CBNAAT to detect Mtb in C8-NAAT (PLHN, Pedatnc,
EPaTB
-

Presumptive TB cases among:

FORMALIN or CPC as it will kill the Optrmum utlzation of CB-NAAT (10-12 tost pet day)
bacilji. -People living with HTV/ADS Compeon c' CB NAT site upzrades at par CTD
istopathological examination is required rEVES

o specimen should be collected -Pacdiatric cases

Rorout plan for CB NAAT St8s including lnk3geCs of

SOPs: Annexure 5, page 151-157 -Extra Pulmonary TB diStritt induc ng regional vainung

pima,
os y putnonarysonomety n chertracograoh nech ffr.4edentation andalutanto
wwght kos, Persislant lerer for2 2aeks, nighi aweata.

i
 Diagnosticalgorithm for DR-TB Integrated Dlagnostic Algorithm Rsa case based, woo Dased, recdag &
lopoling
NIksliay:
edR yten tor 0 palent managerod and care
in

L
Unded nterfaco lor pubic and puwale sector a t h care

providers
ndegrates all adherence technologies such as 99 DOTS
L
nd MERM
Undied DSTU and DRTB data onuy o u s

PHI level e i

**

ACGURATEMONITORING
AVERYLOWST
WID Ron

by onung
relapso fred cure.
2.To minimlze
mer ncee

Hunan joservoh

Oporationarguidelines for treatmont Initlatlon.

CirclarsChangesin troatimont
MoH-Gol daed 1812 2018. NTEG on TB Ca Hdscontirum
Infomation lor Initiation: STANDARDS FOR TB CARE IN INDIA
1.Drug Sensitivity patorn- DS 2.Hislory of ATT
e r4REr DS cases
History of
treatment " Or regimen
26standards developed after a
E R m d a l o n y lox
morobioiogcay condmed
Drug scnsitive or o Ggnien ioe new
National Workshop
New
Cases

24.17:*013:
ERZE4HRE Diagnosis (1-6)
2 MoH-Gof dswd
(4 Km LtREZNELAEZ epme for Hmonopoy dh resstan p es "eginefor new tase Treatment (7-11)
TB patent is prospecvey changed to injøction fhee negime 2HRZE+4HREJ
(d) LhREZ
Mewor previously Regimen bated on
Public Health (12-20)
org rest
Do not use Levolozacin used tor veabng DR TB #or reatng non 0ST paue Social inclusion (21-26)
lP
B intections NO Bxtension of
 AduIs
tine and screenina+ sagefor
Dally Drug bands 4
Siendar 3Ta o
Daily Drug Dosage for Paediatric TB 5 por we N u m b e r o ft a b l e t s

Number of tablets
nAd 7 Treatruant weght contunuato
ih Rrst i n
drg (dpersDE
Statndad Drug RestantTE maranener ntensive phase ontinuation Welghtensive phase (P)Phas
Phase

tandard.111Treatment adterenER
6 phae nir
Per tablet ormg
Per tablet of HRZE
Gtandard 13 Pubio heaith rmsponibiMs
nta
tategones 2eptOmycin Band
tandard1sContaet intigaton 5OS/150 00 0S/100 discontinueo 751150/400/275 mg
since
stere 11 25-39 kg
Standard-20 eath ouEatton
) VECE018.
40-54 kg
nirditon io ttandards

4
fo 0Cia

yrvces
inctusi04. o
***ing 55-69 ka
taa.32 * ne is not recomimeo
Standad-25 CaI and ppen *ovg* ***** re
-
AAsult 1DC (ORZE 75/15a/4c0/275, MRE 75/150/275/
tment.

Dosage ioPadpits E Integrate prig ResistanfTBOrn

DUg
4 FD 3FDC

a**

**

Rodien foTEreatmaitandits
d.
tutatiph Saraini resin with orwtbout neied
wwww
Regimen designing is aprerogstive of the DR-TB Center Commitee
At District DR TB Center
1 AMDFURR-TB
oer
2HMonoPoly Drug-Resistant TB

ilstmin A1 Nodal DR TU Center

ERRR 18 wth addtonal resstance to F SLI
Prin**
1.
2
r

*
e isenar eern tevsant TE
Delamal
hes 4 1 anttsan * -ot 1 Hmong FQ/'sLMLzO rEsu
MO *n

1, In DSTB, NO extension ot IP 3 O e r paterits who reeg carety teg men devgnng

2. In DRTB, No extension of CP
 Principles ot Designing a WHO
Pre-treatment evaluation Isoniazid Preventive Therapy{IP
tor DR-1B patients
ocommended DRaERegimen (THUMB rule) Deiled Nistory
dir d (incudng sreening
g or mental less.
ess.
menal
we sezer

Ateast 5 efectve TB
medicines during the IP For all HiV indected choen wo e t t e
hd
snoep
cuding Pyrazinamide and B ase o are Tubercin
aniniecOs
ebmm indurabon) buf have no scbve TB daease
sin

4core second line T8 medicines Blood Cound wm plaelets count

Dabetes Mels M TSTeve chren
One ftrom group A o ga een for who **
recelving whmunosuppres
cbon lest rerapy (e9 Chgren w nephroee syndrume,
one om g e Nney ncon an
TEM ekemia, etc

yUoen o assess the yrod urncton of the patien) chld borm to mother who was
disgnosed to have TB
owe nes cannot be Une amsbon Rovene sd Mcrosaoge
*egnancy wih no congental TB BCG vacciraton can be
Eedaçuilin / Detamanie] and uthet r e * * * e gNp)
11
Chest XRay e n at Dh en Hprevertve herapy
tcGeMorocan s io be use
s plonned
D3may e a23ed io bring the total to fve *mEectrolyes (f Caeomyon b be used)
Pyridoxine is recommended

er
d Prefent hereyIP
chdren who
EFollpefreatment.1 Eollow ofTreatment.2
are in dlose contact wth TB
paten; oponents of follow up: aboratory investigations
uvg na atve i8, shoud be
gvEn PT
Sputu
NTEspectve o Laboratov foe and CP eative
of IP

ner BCG or nutrtonal status go0o

Clinical follow up PIOgnosis
The dese of INH Tor preeventve therapy is 10 af least
mgg body monthly (Pabent visils the clinical lacility nical deterioralion during CP consider
* * 2dminstered Caiy 1or
e eEvews dug ome
O
a
minimum penod e v
On
en n chest symplorns, increase in completon of treatment, a sputum smear
or cuture for
pro no every patient is mandatory.
e

tBes should Contrel of co-morbid conditions lke HIV

be coiecte on monthy bass diabetes. FOT O n e v e r required.

f 9u be
ciesely r h c n t E d tor 1B h i y keievant
symptoTS Symp:on1s and signs ot adverse reactions to
drugs
should be nvestigations may be t
spocificaly asked

Long term follow up Contacts -

-
*****

fter completion of treatment, the

Screen all close contacts for TB,
.

atients should be followed up at the end of

mandatorily <6 yrs.
12, 18 & 24 months. .
Reverse contact tracing For pediatric TB Ready reckonor 1or display in the department
r timely detecting recurrence of TB, on
cases
pearance of signs & symptoms, sputum
Screen persons with co-morbidity for TB - 11
croscopy and / or culture sensitvity are to
considered antection
Deaes in RTCP Dely Regimen Outcomes of treatment
1
Cured Microbiologically confimed, negalive on
completion of treatment
a Ds
conti
2 Treatment complieted ica cop
10r the
3 Treatment success Cured I completed treatment
Keagy recKOner display in dopartment 4 Failure Microbiologically positive at tho end of
treatment
T

Lost to folow up Treatment

interrupted for
consecutive month or more

A Ded ded during the course of treatment

Pharmacovigilapce Management of comvnon Adrere Dovg"

heat
suvetance etwty to ntm anng
t
a

nanertal publc *
rans ement of patent satety meanu/esin heath care
sthe
wio definltion: "science and actvites relating to the
detec tion, asses smont nderntand ng and preventon or dted

Preventionand Management of adverte efects or any oher d r g elated probem

gm ds anana, Antiev Antch

Adversez reaction [ADRI namacovigiiance includes: " ***

& noring o ea"r dead *****

uCony enot ed AD gens ut

al situation ateges w matg at gADA

DcuTentato

Common AdVersa Reacion

Tinging and Numbness
INH (
Hepato-toxC R1tampicicn (R)
Visual Impairment Ethambutol (E)
Psychosis Cycloserine (Cs)
Flu-ike Syndrome Rifampic1n (R)
Jointpain Pyrazinamide 1e

Ready reckoner for display in t o dar

arten
 MDR-TB patients with pregnang
Management of

Treatmentin special sítuations Duratien of pre

women
1 T8 in Pregnant and Lactating
1.TB
cootraceptive pllipatients
of TB in
r with liver witn iver
L
3. Management
disorderss renal
renal fanlure and severe

---EH- T patient with M L

insulticieney with seizure disorders
i npatients
n patients with psycho5s
. Hospitalization
3. EP TB
Latent TB Infection (LTBl)
9.
reatment of Nontuberculous Mycobactera
(NTM) Lung Diseas8
Recdy rockone rO Cisplay in the departmont
DR-TB in patiens wilh repail ld 2

msototi3 in P htswith liverdisonie EDR-TEInpatients withpre-eistinglverdise2se,

Ethionamide are
ef all Pyrazinamide, PAS and
csis ing iver disease sheutd be perfonmed during treatment otentially hepatotoxe the uoroquinolones.
v e the nalon of keatmend, the 6ena reonens shodd he Hepatits OcCurs rarey with

is
increased
C he potential for fhepatotoxicity
and in patients with pre-
s ot inosapd and ntampan, pla etarno n elderly, alcoholicS
existing liver disease.
be
totowed by 7 monte of tona?d and nfamp s*
R
In
genera, most of second line drugs can
safely used P are relatively less
2 monts of isonazid. eamtul and septoyn, y
hepatotoxic than the first-line orog
Containing ao an shouia etliionamide
HoweveI, pyrazinamide and
be avoided in such patients.

DR-TB in patients with psychosis

SeZúre disoriers. Selzure disO iers:2 Treatment with psyehiatric mediatlon, includes
mant far DM ha pa@ e ent meda
The use
of
sonlazid and ilampcan
may
teriere wmanY o y be
anery of e i u e daeser
anaee the patient suffering from a
re andt Meent takine antiswilue medcaen checke . .. psychiatric condition or advese psychiatric effect due to
also carries a high risk ot
a

seiunen
. cenarel aten er dv should be avoided in patients with »ctrve seture oeooes an be
medrcation.
oPo ( an s Group therReYhas been very see p
eserin Ca, Eeneoe at efets of sonazid or C hefoful foe patients with or without psychiatric conton
soniazid ntection is* Snoud "
t a r r es he
suggested prophyactc d o e for
at
rSA
patenls on
fadequate measures to prevent
10 to on s " o *g o
oup herdpy.
dedi patinnts wln acthe seewn dnerders that are is 25 me/day and or patens
Fluoroquinolones and Ethiono mide have been
a5s0at
dose of
pyridoxine for children has not

dacse
dcati d t r d as needrd a entrol the seien
been estableshed, nonetheless 1-2 mg/kg/day has been ritovine
praphyt.axis may munirnize risk of neurgig
range ol 10-s0 me
reports wHth usua
a
sonie
ecommended in psychiatric adver3e reactio5
_/day for Rardiatex patienls at tot lor neuroOg SU
 ts
TB& Diabetes TB-DM: Service
delivery "I"'s to
roduco
burden

A
People with a weak aimune coordination PLHIV Throo
finding (
system as resut ot chrowc a Activities to reduce burden of Diabetes among
ntensified
(TB)
case

- t s 0abetes, are
TB patients: ICTC,ART centres
and

of all registered TB patents for DM IC-AIC: Air-borne infection col

om latont to active TB
Eope wn dabetes nave 2
ScreeningDM
Mo 0 B compared
Ensuring management among TB measures foratprevention o
rans Hiv care s e t y
A E O u t 10% o TH cases giobaiy
Activitias to recuce burden of TB among DM IPT:
Implementation O
ANAN are ned to diabeles infected individuals: or all PLHIV
fOr
diatvetcs as vell as TR preventivetreatment (1P1)
S go os oi3nosed too
amcng DM patients
Ensuning TB infection control measures in
(On ART +Pre-ART)
1B
HIV infected
heaith care setungs where D1 is managed Provision of ART for
Ensuring effective ATT in comorbid patients patients

SDptom cComple0
ningamong obacco AStatistics ETOEtat robaeöb.onTB
risk of TB infection and disease.
Adult Chilcie Increased
milliondeaths
Current cough Affect clinical manifestations and increase
Current cough
Fever Fever 2nd targest risk of relapse

Weght ioss F o o r weight gan consumer

Affect microbiological conversion and
Nght Sweats Contact wih T6 case largest producer 275 mllion adult totbacca users
treatment outconies
wn Het bertulos
neta b e t canartieEeing e uereu
data meta
nalyna cf eervatonal tudes Pics *edieine,
2011. ElL)
Srmokeless tobtco use 1wice Increased TB mortality and drug
han smoking tobacco
esistance

ole osurgerpnmadaiementorMDR-TE E Sualiaica TBnoRficationsystempubloS5t00

tn DR TB patients with localzed disease, surgery s an adjunct to urvelance Information for action involves

surgeons and excellent post operative care are

availabie Once a TB patient is diagnosed, s/he
deriving the indic ators >> Interpretation >> taking appropriate imely
present. surgery should be
when unilatrralrezectable.diseases
onsicrea 0

Absence or c a c a o
e
owg EE t "
action >> foedback >> feed forward..
will be notified in peripheral health
a

Prompt notiication to the public hoailn sysilens an tnpoane

igh risà ofalre or relapse due to hugh degree of resitance or extense
component of the survedance proce ss facility TB notification registor (PHC).
parencnymavemE
Morbid complc atoniotparenhymai dee neop. Public health objeclves: The notification is to be done on the
Aerurrence of positive culture status during course o reatment, and
dentilies patient need follow up Enabie contact Investigotion
Relapse after completion ot ant- tubercuDi remen same day of diagnosis.
urgical opion is under consideratron at east Six t o n i n e
Measure dlsease a Taret
o n t h s or chemotherpy s recommended prior to surgery. Detec
E M trend ouocoStreatment services