RNTCP Updates

forDr.Medical Officers
K.A.Mohamed Salim,
District TB Center, Alappuzha.

LOGO CHANGE
Paediatric

TREATMENT REGIMEN

Type of Regimen in Treatment

Type of Case IP Regimen CP
New 2HRZE 4HRE
Previously Treated 2HRZES+1EHRZ 5HRE

Type of Regimen in Treatment

Type of Case IP Regimen CP
New 2HRZE 4HRE
Previously Treated 2HRZES+1EHRZ 5HRE
 ➢ No separate regimen for Re treatment cases.
➢ The drugs are given daily
➢ The dose of drugs are according to body weight
➢ Fixed Dose Combination (FDC) tablets are used
➢ Loose Drugs would be needed as substitutions in case of
adverse drug reaction or with co-morbid conditions.
➢ No need for extension of IP
➢ CP may be extended by 12-24 weeks in certain forms of TB
like CNS TB, Skeletal TB, Disseminated TB etc. based on
clinical decision of the treating physician.
➢ Extension beyond 12 weeks should only be on recommendation
of experts of the concerned field.

Treatment Change of Drug Sensitive TB -

Weight
Adult
Number of tablets Inj. Weight Number of tablets (FDCs)
band Streptom category Intensive Continuation
ycin
phase phase
Intensive Continuat HRZE HRE
phase ion phase
75/150/400/2 75/150/275
HRZE HRE 75
75/150/400/ 75/150/27 gm 25-34 kg 2 2
275 mg 5 mg 35-49 kg 3 3
25-39 kg 2 2 0.5 gm 50-64 kg 4 4
40-54 kg 3 3 0.75 gm 65-75 kg 5 5
55-69 kg 4 4 1 gm ≥75 6 6
≥70 5 5 1 gm
Weight category Number of tablets
(dispersible FDCs)
Intensive phase Continuation phase
HRZ E HR E
50/75/150 100 50/75 100

4-7 kg 1 1 1 1
8-11 kg 2 2 2 2
12-15 kg 3 3 3 3
16-24 kg 4 4 4 4

DR-TB Diagnostic Algorithm

Presumptive All diagnosed TB
TB patients

Key/Vulnerable • Non responders to

populations
• Paediatric age group
• People living with HIV
• EPTB sites
• Smear negative/NA with
X-ray suggestive of TB
CBNAAT
For discordance on LPA for RR-
RR TB TB – repeat CBNAAT at LPA lab
treatment
• DR-TB contacts
• Previously treated TB
• TB-HIV co-infection
• New TB patients $
RS TB

SL - LPA** FL-LPA*

FQ and SLI
FQ and/or SLI Resistance H Resistant H Sensitive
Sensitive
*Offer molecular testing for H mono/poly resistance to TB patients prioritized by risk as per the available lab
capacity
**LC DST (Mfx 2.0, Km, Cm, Lzd) will be done only for patients with any resistance on baseline SL-LPA. DST to
Z, Cfz, Bdq & Dlm would be considered for policy in future, whenever available, standardized & WHO endorsed.
$ States to advance in phased manner as per PMDT Scale up plan for universal DST based on lab capacity and
policy on use of diagnostics
Criteria for patients to receive standard DR TB regimen
Standard DR TB
Inclusion criteria Exclusion criteria
regimen
All oral H mono/poly Isoniazid-resistant TB with No specific criteria except drug interaction/intolerability with any
regimen confirmed result for Rifampicin- other drug used concomitantly
resistance not detected (RS)
Shorter MDR TB Patient with Rifampicin-resistant DST based criteria:
regimen pulmonary or extra pulmonary TB • If DST/DRT result for FQ or SLI is resistant or
• presence of InhA mutation (for Eto) or
• Resistance to Z (whenever available)
• History of use for > 1 month/intolerance to Mfx(h), Km, Eto
or Cfz
Non-DST based criteria:
• Pregnancy
• Any extrapulmonary disease in PLHIV
• Disseminated, meningeal or central nervous system TB
• Intolerance to any drug in the shorter MDR TB regimen or
risk of toxicity from a drug in the shorter regimen (e.g. drug–drug
interactions)
All oral longer Patients in whom shorter MDR TB None
regimen for MDR/ regimen cannot be considered due to
RR TB any reason

Summary of MDR TB regimen

Guidelines for PMDT in India 2019

Type of TB Regimen

Rif Sensitive, INH Resistant H Mono/Poly regimen

MDR TB Shorter MDR TB regimen

All Oral longer MDR TB

regimen
 Decision for initiating Regimen

First Line Regimen At PHC/CHC

1. MDR/RR-TB At the
1. Shorter MDR-TB Regimen DDR-TB
2. Conventional MDR- TB Regimen
Center
2. H Mono/Poly Drug-Resistant TB
3. MDR/RR-TB with additional resistance to any/all FQ or SLI
4. XDR-TB
5. Mixed pattern resistant TB At the
1. with H mono + FQ/SLI/Lzd resistance NDR-TB
2. with MDR/RR-TB + FQ/SLI ± Lzd resistance
Center
3. Other patients who need careful regimen designing
4. Non tuberculous mycobacterium (NTM)

Eligibility for Delamanid/ Bedaquiline

Bedaquiline or Delamanid is indicated in MDR-TB patients not
eligible for the newly WHO-recommended shorter regimen.
These may include:

• MDR/RR-TB patients with resistance to any/all Fluoroquinolones

OR to any/all Second Line Injectables
• 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
 Financial Support schemes to Patients
• Nikshay Poshan Yojana to All TB patients (Financial Support to Patients
@Rs.500/-month) as Direct Benefit Transfer
• Rs.1000/month for treatment duration from Revenue Department.
Eligibility Annual Income below 1 Lakh.

Financial Support schemes to Providers

Honorarium to Treatment Supporters
First line regimen/ H monopoly : Rs. 1000/- at completion of treatment
Drug Resistant Case: Rs. 2000/- at completion of intensive phase,
Rs.3000/- at completion of treatment

NIKSHAY Poshan Yojana

Beneficiary:
• All notified TB patients are the beneficiary of the scheme
Eligibility:
• All TB patients notified on or after 1st April 2018
Benefits:
• Rs. 500/- per month per TB patient till completion of treatment
Duration of benefit:
• Incentives will be extended to TB patients as long as the patient is on
anti-TB treatment
Arrangement for payment
• Payment will be made direct to bank account detail of patient, once s/he is
 Air borne Infection Control
AIC in hospitals/health
AIC kit to be given to all patients facilities

• All health facilities/hospitals to

undergo facility risk assessment
for air borne infection control

• Hospital Infection Control

committee to train/periodically
assess and correct risks for air
borne infection transmission

Airborne Infection Control in health facilities

1. Screening patients at reception for acute respiratory illness, or cough >2 weeks.
2. Cough etiquette: Providing face masks/tissues or educating persons with
respiratory symptoms, IEC materials at waiting area
3. Segregation: Placing respiratory suspects (including TB suspects) and cases in a
separate waiting area, if possible.
4. Fast tracking respiratory symptomatics to expedite their receipt of services in the
facility.
5. Environmental controls: Ensuring cross ventilation by routinely opening
windows and doors on both sides
6. N95 Respirators – for those in high-risk settings (bronchoscopy)
 Phases of Kerala TB Elimination
Mission
Phase Major Focus during the Phase Timeline

1 TB Vulnerability Mapping of the entire 1st January 2018-

individuals in the state 31st December 2018
II Active Surveillance for TB facilitating 1st January 2019 –
early case finding 31st December 2020
III Vulnerability Reduction at individual 1st April 2019-
and community level 31st December 2020
IV Detection and Management of Latent
TB Infection 1st June 2019 onwards

Mandatory Screening for TB Patients

➢ Diabetic Mellitus Bidirectional Screening.
➢ HIV Screening.
➢ Hepatic Function Assessment.
➢ Ophthalmic Evaluation.
➢ COVID 19 Bidirectional screening.
Fortnightly Clinical Review of all TB
patients
• All TB patients on ATT should
undergo clinical review by
Medical Officer PHC/CHC once
a fortnight.
• Ophthalmic evaluation by
optometrist at Block PHC
• Field staff to monitor any ADR
• Checklist to be attached to
treatment card by PHC MO

To Conclude ………………
● Rapid changes in Guidelines.
● Diagnosis strengthened DST based treatment.
● Current Regimen in India Best possible drugs & guided by best
available investigations.

Thank
You