EPIDEMIOLOGY OF TUBERCULOSIS

DR.HARIVANSH CHOPRA
M.D.,DCH
PROFESSOR
DEPT.OF COMMUNITY MEDICINE
L.L.R.M.MEDICAL COLLEGE, MEERUT
harichop@gmail.com

OBJECTIVES
8/23/2018 DR. HARIVANSH CHOPRA 2
1. To study the epidemiology of
Tuberculosis.
2. To study its pathogenesis,
diagnosis, treatment, & prevention.

What is Tuberculosis?
 Tuberculosis is a
worldwide, chronic
communicable
bacterial disease.

TUBERCULOSIS
 Tuberculosis disease is
the out come of the
fight between
virulence of the
organism and
resistance of the
body

Historical Perspective
 1882-Robert Koch,a German
Scientist,discovered rod shaped
bacteriae causing tuberculosis on 24th
March 1882.So World TB Day is being
celebrated on 24th March every
year.From 2005 March,it is
called”World StopTB Day”.

 1921-French Scientists Calmette and
Guerin discovered vaccine against
tuberculosis.
 1944-Selman A.Waksman and his
Colleagues discovered
Streptomycin,an antibiotic,effective
against TB.
 1946-Drugs like INH and PAS were
introduced.

 1960-National Tuberculosis Institute
was established at Bangalore to
formulate a comprehensive National
TB control program.
 1962-Government of India launched
National TB Control Program(NTCP).
 1966-Rifampicin proved to be an
excellent drug against TB.

 1972-Wallace Fox and colleagues of
British Medical council showed that
addition of Rifampicin and
Pyrazinamide alongwith INH would
reduce the duration of treatment
from 11/2 years to hardly 6 months .Thus
Short Course Chemotherapy was
introduced.

 1993-WHO declared TB as
the”Global Emergency”.(Because of
emergence of HIV).Government of
India revised and intensified the
NTCP and renamed as “Revised
National TB Control
Program.”(RNTCP)

WORLD PROBLEM
10
10.4
1.8
0.4
TOTAL CASES DEATHS DEATHS DUE TO HIV
TB CASES
( IN MILLIONS)

DRUG RESISTANCE CASES
11
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
MDR TB RIFAMPICIN
RESISTANT
4.8
1
TB CASES IN LAKHS
MDR TB RIFAMPICIN RESISTANT

SEX WISE DISTRIBUTION
OF TB CASES : 2015
12
57%
34%
9%
TB CASES IN 2015
MALES FEMALES CHILDREN
SOURCE: TB INDIA 2017,
ANNUAL STATUS REPORT

TB : WORLD AND INDIA
13
73% 27%
TB CASES (2015)
REST OF WORLD
INDIA
SOURCE: TB INDIA 2017, ANNUAL
STATUS REPORT

TB DEATHS : INDIA
14
83% 17%
TB CASES (2015)
NO DEATHS DEATHS
SOURCE: TB INDIA 2017,
ANNUAL STATUS REPORT

INDIA PROBLEM
15
0
0.5
1
1.5
2
2.5
3
NEW CASES DEATHS HIV CASES
2.8
0.48 0.14
TB CASES IN MILLIONS
NEW CASES DEATHS HIV CASES

PROBLEM STATEMENT
 TB kills 5,000 people a
day – 2-3 million each
year
 One third of the world’s
population is infected
with TB
 TB kills more young
women than any other
disease

 India is the highest TB burden country in
the world and accounts for nearly one-fifth
of the global burden of tuberculosis and
2/3rd of cases in SEAR.
 Every year, approximately 1.8 million
persons develop tuberculosis, of which
about 0.8 million are new smear positive
highly infectious cases.

 Annual risk of becoming infected with
TB is 1.5% and once infected there is
10% lifetime risk of developing TB
disease.
 2 out of every 5 Indians are infected
with the TB bacillus.
 Everyday about 5000 people develop
the disease.

 Patients with infectious pulmonary
tuberculosis disease can infect 10-15
persons in a year.
 In India almost 0.37 million people die
every year.

 Today, India’s DOTS programme against
tuberculosis is recognized as the fastest
expanding programme.
 Launched in March 1997, it has covered
the whole country by March 2006.
 More than 7.3 million patients are on
DOTS treatment so far and about 1.4
million additional lives have been saved.

 Death rate under RNTCP have been cut 7-
folds from 29% to around 4% in smear
positive cases.
 In the year 2006, the programme had
achieved a case detection rate of 66% as
against the global target of 70%.
 Treatment success achieved consistently is
about 85%.

Daily Burden in India
 Everyday,more than 20,000 people
become infected with TB bacilli.
 More than 5,000 people develop the
disease.
 More than 1,000 people die of the disease.
 More than 2 persons die per
minute.(2880)
 About 80 working days are lost per year
per case.

AGENT
 Tuberculosis (TB) is a
disease caused by
bacteria called
Mycobacterium
tuberculosis.
commonly known as
“Koch’s bacillus” or
tubercle bacilli or Acid
Fast Bacillus (AFB).

Mycobacterium tuberculosis
 First identified in 1882
by Koch in Berlin
 Not immediately
recognized as the cause
of all forms of
tuberculosis
 Concept of ‘latent’
infection developed
in 1920s from studies in
Norway (Heimbeck).

SOURCE OF INFECTION
There are two sources of infection-
a) Human source- human case whose sputum
is positive for tubercle bacilli.
b) Bovine source- usually infected milk.

HOST FACTORS
 AGE - The data in India shows that the
tuberculin positivity rate increases steadily
with age
 At 0-14years prevalence of infection is 2%
 For age group 15-24years it is 20.9%

HOST FACTORS
 SEX- the disease is more
common in males
 NUTRITION- It has no
relationship with the
recovery from tuberculosis
in context of modern
drugs but can precipitate
malnutrition in children.

HOST FACTORS
 INCUBATION PERIOD –
VARIABLE .Time from
receipt of infection to the
development of positive
tuberculin test ranges
from- 3- 6 weeks.
 RESERVIOR - Human
case is chief reservoir.

HOST FACTORS
 PERIOD OF
COMMUNICABILITY - It is as
long as bacilli are excreted
in the sputum.
 Effective anti-tubercular
treatment reduces infectivity
by 90% within 48 hours.

SOCIAL FACTORS
 T.B is a social
disease with
medical aspects.
 Social factors include-
1. Poor quality of life,
2. Poor housing &
overcrowding,
3. Population explosion,

SOCIAL FACTORS
4. Undernutrition,
5. Lack of education,
6. Large families,
7. Lack of awareness of
causes of illness
8. Social stigma

TRANSMISSION
 Spreads through
the air when a
person with active
TB
1. Coughs
2. Speaks
3. Laughs
4. Sneezes
5. Sings
Another person breathes in
the bacteria and becomes
infected.

PULMONARY TUBERCULOSIS
The bacteria
usually
attack the
lungs.

 PREVALENCE OF INFECTION 30%
 INCIDENCE OF INFECTION 1-2%
 PREVALENCE OF DISEASE- 4/1000
 INCIDENCE OF DISEASE 1/1000

 PREVALENCE OF INFECTION CAN BE
FOUND OUT BY DOING TUBERCULIN
TEST WHILE,
 PREVALENCE OF DISEASE CAN BE FOUND
OUT BY DOING A SPUTUM
EXAMINATION FOR AFB.

 Tuberculin developed as a form of
treatment by Koch in 1891.
 Developed as a diagnostic test by von
Pirquet in 1907.
 Complex mix of antigens that cannot be
separated.
 Internationally standardized.

Testing for M. tuberculosis
Infection
Mantoux tuberculin skin test (TST)
Skin test that produces delayed-type
hypersensitivity reaction in persons with
M. tuberculosis infection.

Mantoux Tuberculin Skin Test
 Preferred method of skin testing for M.
tuberculosis infection
 TST is useful for
– Determining how many people in a group are
infected (e.g., contact investigation)
– Examining persons who have symptoms of TB
 Multiple puncture tests (e.g., Tine Test) are
inaccurate and not recommended

Administering the TST
 Inject 0.1 ml of 5
TU PPD tuberculin
solution
intradermally on
volar surface of
lower arm using a
27-gauge needle
 Produce a wheal 6
to 10 mm in
diameter

Reading the TST (1)
 Measure reaction in 48 to 72 hours
 Measure induration, not erythema
 Record reaction in millimeters, not
“negative” or “positive”
 Ensure trained health care
professional measures and
interprets the TST

Reading the TST (2)
 Positive TST reactions can be measured
accurately for up to 7 days
 Negative reactions can be read accurately
for only 72 hours

REACTIONS IN MONTOUX TEST
 < 5 mm – NEGATIVE
 5 – 9 mm – BORDERLINE
 > 10 mm - POSITIVE

TST Interpretation (1)
5-mm induration is interpreted as
positive in
1. HIV-infected persons
2. Close contacts to an infectious TB case
3. Persons with chest radiographs
consistent with prior untreated TB

5-mm induration is interpreted as
positive in (cont.)
4. Organ transplant recipients
5. Other immunosuppressed patients (e.g.,
those taking the equivalent of >15 mg/d
of prednisone for 1 month or those
taking TNF-α antagonists)

10-mm induration is
interpreted as positive which
means that the person is
exposed to tubercular
infection.
If it is positive below the age of
two years, then it is taken as
indirect evidence of
manifestation of disease.

Causes of False Negative Reaction
1. INFECTIONS – SEVERE TUBERCULAR
INFECTIONS LIKE Miliary tuberculosis,
mumps, measles, chicken pox, HIV etc.
2. Attenuated viral vaccinations (measles,
mumps, polio)
3. Protein energy malnutrition
4. Lymphoreticular disorders

Causes of False Negative Reaction
5. Intake of corticosteroids.
6. Faulty technique
7. Improper storage & dilution of
tuberculin.
8. Denatured/contaminated tuberculin.
9. Errors in reading.

PATHOGENESIS OF TB INFECTION
AND DISEASE
1. Droplet nuclei
containing tubercle
bacilli are inhaled,
enter the lungs,
and travel to the
alveoli.

AND DISEASE
2. Tubercle bacilli
multiply in the
alveoli.

AND DISEASE
PRIMARY COMPLEX
CONSTITUTE -
1. PRIMARY FOCUS,
2. LYMPHANGITIS,&
3. LYMPHADENITIS

AND DISEASE
 Fate of Primary
Focus :
 If resistance is
good, it will heal by
itself followed by
calcification.

AND DISEASE
 If the resistance is
poor, then the lesion
will progress and
may lead to cavity
formation.
 The lesion may
burst open into
pleura resulting in
pleural effusion.

AND DISEASE
 Fate of regional lymph
node :
 It may enlarge and
compress the bronchus
completely leading to
collapse.
 It may compress the
bronchus incompletely &
erode into the bronchus
thereby resulting in collapse
with consolidation.

AND DISEASE
 It may lead to
consolidation.
 The lymph node may
rupture into a blood
vessel leading to
MILIARY
TUBERCULOSIS.

AND DISEASE
 A small number of
bacilli via lymphatics
enter into the blood
stream and then they
are seeded into various
organs of the body like
brain, kidney, bone
and other organs.

AND DISEASE
 Depending upon the
virulence of organism
and the resistance of
the body, the bacilli
at these sites multiply
and result into
diseases like
tubercular meningitis
& renal tuberculosis.

Progression of TB
 People who are exposed to TB may or
may not develop TB infection.
 People with TB infection may or may
not develop TB disease.
 The risk of developing TB disease is
highest in the first 2 years after
infection.

Unhealthy person
– Bacilli overwhelm
immune system
– Bacilli break out of
tubercles in alveoli
and spread through
bloodstream
This is ≥active≤ TB

Healthy person
– Initial infection controlled by immune system
– Bacilli remain confined in tubercles for years
This is ≥ latent ≤ TB

A Person with Latent
TB Infection
A Person with Active TB
Disease
Has no symptoms Has symptoms that may
include:
Cough that lasts 3 weeks
or longer, pain in the
chest, coughing up blood
or sputum, weakness or
fatigue, weight loss, no
appetite chills, fever,
sweating at night.

A Person with Latent
TB Infection
A Person with Active
TB Disease
Does not feel sick
Cannot spread TB to
others
Usually has a positive
skin test.
May spread TB to others
Usually has a positive
skin test.
May have an abnormal
chest x-ray, or positive
sputum smear or culture

Cough>3weeks
Fever
Spit up Blood
(Hemoptysis)
Chest Pain

1) The prevalence of disease in
tuberculosis in India is
1. 1/ 1000 population
4. 6/1000 population
ANS 3

 2) The incidence of disease in
ANS 1

3) The prevalence of infection of
1. 20%
2. 30%
3. 40%
4. 50%
ANS 2

 4) The incidence of infection in
1. 1%
2. 3%
3. 5%
4. 10%
ANS 1

 5) Tubercle bacillus was discovered
by
 Koch
 Calmette
 Guerin
 None of the above
ANS 1

 Mantoux test is a
1. Prognostic test
2. Diagnostic test
3. Test which tells about exposure to
tubercular infection
4. All of the above
ANS 3

 Examine medical
history, X-rays, and
sputum.
 Tuberculin skin test.

SPUTUM EXAMINATION
 Three samples of sputum stained with Zeihl
Neelsen technique are examined under
microscope if his/her symptoms are suggestive
of TB.
 Samples are collected on two days:
SPOT OVERNIGHT/ SPOT
EARLY MORNING
First day Second day Second day

SPUTUM EXAMINATION
 Two samples of sputum stained with Zeihl
Neelsen technique are examined under
microscope if his/her symptoms are suggestive
of TB.
 Samples are collected on two days:
SPOT OVERNIGHT/ EARLY MORNING
First day Same day

SPUTUM EXAMINATION
 At least 100 fields should be examined before
giving the result. Smears have been graded
depending on the number of bacilli seen:
1+ when 3 - 9 bacilli are seen in the entire
smear.
2+ when 10 or more bacilli are seen in the
smear and
3+ when 10 or more bacilli are seen in most oil
emersion fields.

Cough 3 weeks
AFB X 3
Broad-spectrum antibiotic 10-14 days
If symptoms persist, repeat AFB smears, X-ray
If consistent with TB
Anti-TB Treatment
If 1 positive,
X-ray and
evaluation
If 2/3 positive:
Anti-TB Rx
If negative:

Cough 2 weeks
AFB X 2
Broad-spectrum antibiotic 10-14 days
If symptoms persist, repeat AFB smears, X-ray
If consistent with TB
Anti-TB Treatment
If 2 negative
X-ray and
evaluation
If 1/2/ positive:
Anti-TB Rx
If negative:

PLHIV Presumptive TB Patient
Smear Examination CXR
Smear Positive And
CXR Suggestive Of TB
Smear Positive , But
CXR Not Suggestive Of
TB
Smear Negative But
CXR Suggestive Of TB
Smear Negative Or
Not Available &
CXR Not Suggestive Of
Or Not Available
Clinical
Suspicion
High
PMDT Criteria , High
MDR Settings
CBNAAT
MTB Detected MTB Not Detected Or CBNAAT
Result Not Available
Consider
Alternate
Diagnosis
And Refer To
Specialist
Clinically
Diagnosed
TB
Alternate
Diagnosis
Rif Sensitive Rif Indeterminate Rif Resistant Refer To
Management
Of
Rif Resistance
Microbiologically
Confirmed TB
Repeat CBNAAT On
2nd Sample
Indeterminate On 2nd Sample ,
Collect Fresh Sample For Liquid Culture / LPA
DIAGNOSTIC ALGORITHM

MOST SUSCEPTIBLE
People at higher risk of TB infection
– Close contacts with people with
infectious TB
– People born in areas where TB is
common
– People with poor access to health care

MOST SUSCEPTIBLE
4. People who inject illicit drugs
5. People who live or work in residential
facilities
6. Health care professionals
7. The elderly

MOST SUSCEPTIBLE
People at higher risk of active TB disease
1. People with weak immune systems
(especially those with HIV or AIDS)
2. People with diabetes or silicosis
3. People infected within the last 2 years
4. People with chest x-rays that show previous
TB disease
5. Illicit drug and alcohol abusers

TUBERCULOSIS CONTROL
 The WHO defines that tuberculosis
"control" is said to be achieved when the
prevalence of natural infection in the age
group 0-14 years is of the order of 1 per
cent.

 The control measures
consist of a curative
component - namely
case finding and
treatment; and a
preventive component
- namely BCG
vaccination.

CASE FINDING-
a. THE CASE - The first step
in a tuberculosis control
programme is early detection
of sputum-positive cases.

b. TARGET GROUP - The
chest symptoms such as
persistent cough and fever
often develop early, that is
before the disease has gone
on to an advanced stage. This
is the most fertile group for
case finding.

 c. CASE
FINDING
TOOLS-
Sputum smear
examination by
direct microscopy
is now
considered the
method of
choice.

CHEMOTHERAPY
 Chemotherapy is indicated in every case of
active tuberculosis.
 The objective of treatment is cure - that is,
the elimination of both the fast and slowly
multiplying bacilli (including the persisters)
from the patient's body.

TREATMENT : CHEMOTHERAPY
88
RIFAMPICIN
ISONIAZIDE
PYRAZINAMIDE
ETHAMBUTOL
STREPTOMYCIN
FLUROQUINOLONES
ETHIONAMIDE
CAPREOMYCIN
KANAMYCIN
AMIKACIN
CYCLOSERINE
THIOACETAZONE
MACROLIDES
BEDAQUILINE
1st LINE DRUGS
2nd LINE DRUGS

LONG TERM CHEMOTHERAPY
89
DAILY REGIMEN
BI WEEKLY OR
INTERMITTENT REGIMEN
18
MONTHS

SHORT TERM CHEMOTHERAPY
90
RAPID BACTERIOLOGICAL CONVERSION
LOWER FAILURE RATES
REDUCTION IN EMERGENCE OF DRUG
RESISTANT BACILLI
PATIENT COMPLIANCE IMPROVES AND
THEY BECOMES NON INFECTIOUS EARLY

DIRECTLY OBSERVED
TREATMENT SHORT COURSE
(DOTS)
91
 DOTS is a strategy to ensure cure by providing the most
effective medicine and confirming that it is taken.
 Under DOTS patients were divided into categories
– CATEGORY 1
– CATEGORY 2

DOTS CHEMOTHERAPY
92
CATEGORY TYPE OF PATIENT INTENSIV
E PHASE
CONTINUATION
PHASE
CATEGORY I NEW SPUTUM SMEAR
POSITIVE
NEW SPUTUM SMEAR
NEGATIVE
NEW EXTRA PULMONARY
NEW OTHER
2 (HRZE)3 4 (HR)3
CATEGORY II SPUTUM SMEAR POSITIVE
RELAPSE
SPUTUM SMEAR NEGATIVE
FAILURE
2
(HRZES)3
+
1 (HRZE)3
5 (HR)3

DAILY DOSE REGIMEN
93
Standards for TB Care in India, 2014 based on
available evidences and WHO treatment of TB
Guidelines state that all patients should be given daily
regimen.
The National Technical Working Group on TB / HIV has
recommended use of daily regimen using Fixed Drug
Combination first line TB treatment for PLHIV patients.

CHANGES FROM DOTS
REGIMEN
94
 INTENSIVE PHASE WILL NOT CONTINUE EVEN IF
AFTER 2 MONTHS THE PATIENT COMES POSITIVE.
 AFTER 2 MONTHS CONTINUATION PHASE WILL
BEGIN IRRESPECTIVE OF SPUTUM RESULTS

CHANGES IN TREATEMENT POLICY
95
TYPE OF TB CASE TREATMENT
REGIMEN
INTENSIVE PHASE
TREATMENT
REGIMEN
CONTINUATION
PHASE
NEW 2 HRZE 4 HRE
PREVIOUSLY
TREATED
2 HRZES + 1 HRZE 5 HRE

DAILY DOSAGE SCHEDULE
FOR ADULTS
96
WEIGHT
CATEGORY
NUMBER OF TABLETS TO BE CONSUMED Inj.
Streptomyci
n
INTENSIVE PHASE CONTINUATION PHASE
H R Z E H R E
75 / 150 / 400 / 275
Mg per tab
75 / 150 / 275
Mg per day
25 – 39 kg 2 2 0.5 gm
40 – 54 kg 3 3 0.75 gm
55 – 69 kg 4 4 1.0 gm
≥ 70 kg 5 5 1.0 gm

MULTI DRUG RESISTANT
TUBERCULOSIS TREATMENT
97
TYPE OF TB CASE TREATMENT REGIMEN
(IP)
TREATEMENT REGIMEN (CP)
RIFAMPICIN
RESISTANT +
ISONIZIDE
SENSITIVE
6 – 9 MONTHS
KANAMYCIN,
LEVOFLOXACIN
ETHIONAMIDE,
CYCLOSERINE
ETHAMBUTOL,
PYRAZINAMIDE
ISONIAZIDE
18 MONTHS
LEVOFLOXACIN,
ETHIONAMIDE
CYCLOSERINE,ETHAMBUTOL
(E)
ISONIAZIDE (H)
MDR TB 6 -9 MONTHS
LEVOFLOXACIN
ETHIONAMIDE
CYCLOSERINE
ETHAMBUTOL
PYRAZINAMIDE
18 MONTHS
LEVOFLOXACIN
ETHIONAMIDE
CYCLOSERINE
ETHAMBUTOL

XTENSIVE DRUG RESISTANT
TUBERCULOSIS
TREATMENT
98
TYPE OF
TB
TREATMENT REGIMEN IN IP TREATMENT REGIMEN IN
CP
XDR 6 – 12 MONTHS
INJ. CAPREOMYCIN
MOXIFLOXACIN
PAS
HIGH DOSE ISONIAZIDE
CLOFAZAMINE
LINEZOLID
AMOXY – CLAV
18 MONTHS
PAS
MOXIFLOXACIN
HIGH DOSE
ISONIAZIDE
CLOFAZAMINE
LINEZOLID
AMOXY – CLAV

ALOGRITHM OF TB TREATMENT
99
CONFIRMED TB
CASE
START ATT
INTENSIVE PHASE
CONTINUATION
PHASE
ADDITIONAL 1
MONTH INTENSIVE
PHASE
SPUTUM
NEGATIVE
SPUTUM
POSITIVE

ALOGRITHM OF MDR TB
TREATMENT
100
CONFIRMED DR TB CASE
START ATT
INTENSIVE PHASE
CONTINUATION PHASE
ADDITIONAL 1
MONTH INTENSIVE
PHASE
SPUTUM
NEGATIVE
SPUTUM
POSITIVE
4T
H
5T
H
6T
H

PEDIATRIC TUBERCULOSIS
101
 Tuberculosis is one of the major
cause of childhood mortality and
morbidity
 Constitutes 6-8% of all new cases
of TB
 Common in children aged 1-4 years

DIAGNOSIS OF PEDIATRIC
TUBERCULOSIS
102
 SPUTUM MICROSCOPY IS BEST METHOD TO DETECT
TUBERCULOSIS
 IN CASES WHERE SPUTUM IS NOT AVAILABLE:
– GASTRIC LAVAGE
– INDUCED SPUTUM
– BRONCHO ALVEOLAR LAVAGE

TREATEMENT OF PEDIATRIC
TUBERCULOSIS
103
DRUG DOSE
ISONIAZIDE 10 mg/kg (max 300 mg/day)
RIFAMPICIN 10 – 15 mg/kg (max 600
mg/day)
PYRAZINAMIDE 30 – 35 mg/kg (max 2000
mg/day)
ETHAMBUTOL 20 -25 mg/kg (max 1500
mg/day)
STREPTOMYCIN 15mg/kg (max 1 gm/day)

104
BOXES COMPOSITION
YELLOW BOX
(PC 13)
ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg
PYRAZINAMIDE : 250 mg, ETHAMBUTOL :
200 mg
ISONIAZIDE : 75
mg
RIFAMPICIN : 75
mg
ORANGE BOX
(PC 14)
ISONIZIDE : 150 mg, RIFAMPICIN : 150
mg
400 mg
ISONIAZIDE : 150
mg
RIFAMPICIN :
150 mg
PURPLE BOX
(PC 15)
ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg
200 mg
GREY BOX
(PC 16)
ISONIZIDE : 150 mg, RIFAMPICIN : 150
mg
400 mg

BOX WISE TREATMENT FOR
CHILDREN
105
AGE GROUP NUMBER OF BOXES
6 – 10 kg 1 YELLOW BOX
11 – 17 kg 1 ORANGE BOX
18 – 25 kg 1 YELLOW AND 1 ORANGE
BOX
26 – 30 kg 2 ORANGE BOX

WAY FORWARD… FIXED DRUG
COMBINATIONS
106
AGE NO. OF TABLETS IN
INTENSIVE PHASE
RHZ (75mg / 50mg /
150mg)
NO. OF TABLETS IN
CONTINUATION PHASE
RH (75mg / 50mg)
4 KG – 7 KG 1 1
8 KG – 11 KG 2 2
12 KG – 15 KG 3 3
16 KG – 24 KG 4 4
≥ 25 KG ADULT DOSE ADULT DOSE

.
The DOTS strategy
represents the most
important public health
breakthrough of the decade,
in terms of lives which will be
saved."
— Director General
World Health Organization
March 24,1997
DOTS

DOTS
 DOTS is Directly Observed Treatment,
Short-course.
 DOTS was developed by the WHO as a
means to directly observe patients taking
their medications to ensure their TB is
cured and not allowed to mutate into
multi-drug resistant TB.

Treatment
groups
Type of patient
Regimen
Intensive
Phase (IP)
Continuat
ion Phase
(CP)
New (Cat I)
New Sputum smear-positive
New Sputum smear-negative
New Extra-pulmonary
New Others 2H3R3Z3E3 4H3R3
Previously
Treated (Cat II)
Smear-positive relapse
Smear-positive failure
Smear-positive treatment
after default
Others
2H3R3Z3E3S3
/ 1H3R3Z3E3
5H3R3E3

Category IV(DOTS PLUS)
Treatment for MDR-TB
 The diagnosis is made at the Intermediate
Reference laboratory..
 Treatment is initiated at designated DOTS-
Plus sites , established in tertiary care
centers at least one in each state.
 Qualified staff available to manage patient
using second line drugs.

TREATMENT REGIMEN:
6(9) Km Ofx Eto Cs ZE+18Ofx Eto CsE
(Km-Kanamycin;
Ofx-Ofloxacin;Eto=Ethionamide;
Cs-cyclosporine;Z-Pyrazinamide;E-
Etambutol)

DOTS Plus regimen: Dosages
The average body weight of the MDR TB patient
in India is 40 kgs. So two weight bands are
recommended:
Drugs < 40 kg body wt. > 40 kg body wt.
Kanamycin 500 mg 750 mg
Ofloxacin 600 mg 800 mg
Ethionamide 500 mg 750 mg
Ethambutol 800 mg 1200 mg
Pyrazinamide 1500 mg 1750 mg
PAS 10 gm 12 gm
Cycloserine 500 mg 750 mg

IP regimen- Duration
 The group came to the consensus that
the intensive phase should be given for
a minimum duration of 6 months, upto
9 months.
 Monthly sputum smear examination and
sputum culture would be conducted to
monitor response to therapy
IP regimen would be given till at
least three consecutive negative smears
AND last available culture is negative.

If the above two results are not available, IP
will be extended till such result is obtained;
upto a maximum of 9 months
Decision to stop IP and start CP will be ratified
by the hospital’s DOTS Plus Committee
In rare cases where the patient remains
sputum positive by culture at 9 month and
patient is tolerating injectable drugs, injectable
will continue till sputum conversion???

CP- Duration
 The group recommends that the continuation
phase should be:
-for at least 18 months after culture conversion
CP- Drugs
The three drugs are: Ethionamide, Ofloxacin,
Ethambutol
 These are to be given as daily doses for 6 days a
week; all doses would be DOT
 Intolerance to any drug in CP: offending drug may be
replaced by PAS/ Cycloserine

TB Control:
The 5 components of DOTS
Political commitment
Diagnosis by microscopy
Adequate supply of SCC
drugs
Directly observed
treatment
Accountability
TB Register

Directly Observed Treatment
 Treatment observer must be accessible and
acceptable to the patient and accountable
to the health system
 Observation is a service to patients and
providers
 Many patients do not take medicines regularly,
even if excellent health education is provided
 Impossible to predict which patient will take
medicine

Advantages of DOTS
 DOTS produces cure rate high as 95
percent.
 DOTS guarantees quicker and surer relief
from the disease.
 DOTS has changed the lives of 17 lakh
patients in India.

Advantages of DOTS
 DOTS is a strategy for alleviating poverty.
Saving lives, reducing the duration of
illness, and preventing new infectious
cases would mean fewer years of
employment lost.

Advantages of DOTS
 DOTS prolongs survival of HIV-Infected TB
patients.
 DOTS prevents treatment failure and the
emergence of multi-drug resistant
tuberculosis by ensuring patient
compliance and uninterrupted supply of
anti-TB drug.

Advantages of DOTS
 DOTS increases the reach of health
services. The DOTS strategy has been
remarkably successful in promoting the
development of peripheral health services.
 DOTS is available for free at all Health
Centres.

TB and HIV: A Deadly Combination
 TB is the leading killer of people with
HIV.
 Up to half of the people living with
HIV/AIDS will develop active TB.
 HIV positive people are 30 times more
likely to have their latent TB turn
active because of their compromised
immune systems.

TB and HIV: A Deadly Combination
 Active TB in an HIV positive person if
left untreated will end their life in 5
to 6 weeks.
 Treating an HIV positive person for
active TB can extend their life by 5
years.

TB and AIDS
10%
60%
0%
10%
20%
30%
40%
50%
60%
70%
PPD+/HIV-negative PPD+/HIV+
Lifetime Risk
of TB

1) The best method of control of
tuberculosis in a community is -
1. B.C.G. vaccination
2. Early diagnosis & treatment
3. Chemoprophylaxis
4. All of the above
ANS. 2

 2) Which of the following is not a
cardinal sign of tuberculosis -
1. Cough
2. Fever
3. Weight loss
4. Haemoptysis
ANS 3

IMMUNOPROPHYLAXIS
BCG vaccination
AIM: The aim of BCG vaccination is to
induce a benign, artificial primary
infection which will stimulate an acquired
resistance to possible subsequent
infection with virulent tubercle bacilli, and
thus reduce the morbidity and mortality
from primary tuberculosis among those
most at risk.

IMMUNOPROPHYLAXIS
VACCINE: BCG is the
only widely used live
bacterial vaccine.
TYPES OF VACCINE:
There are two types
of BCG vaccine - the
liquid (fresh) vaccine
and the freeze-dried
vaccine.

IMMUNOPROPHYLAXIS
 DOSAGE: For vaccination, the usual
strength is 0.1 mg in 0.1 ml volume, and
dose is 0.1 ml.

IMMUNOPROPHYLAXIS
 ADMINISTRATION: The standard
procedure recommended by WHO is to
inject the vaccine intradermally using a
"Tuberculin" syringe (Omega microstat
syringe fitted with a 1 cm steel 26 gauge
intradermal needle).

IMMUNOPROPHYLAXIS
 AGE: In countries where tuberculosis is
prevalent and the risk of childhood
infection is high (as in India), the national
policy is to administer BCG very early in
infancy either at birth (for institutional
deliveries) or at 6 weeks of age
simultaneously with other immunizing
agents such as DPT and polio.

IMMUNOPROPHYLAXIS
 PHENOMENA AFTER VACCINATION: Two
to three weeks after a correct intradermal
injection of a potent vaccine, a papule
develops at the site of vaccination. It
increases slowly in size and reaches a
diameter of about 4 to 8 mm in about 5
weeks.

IMMUNOPROPHYLAXIS
 PHENOMENA AFTER VACCINATION
CONT..: It then subsides or breaks into a
shallow ulcer, rarely open, but usually
seen covered with a crust.
 Healing occurs spontaneously within 6 to
12 weeks leaving a permanent, tiny, round
scar, typically 4-8 mm in diameter. This is
a normal reaction.

The National TB Control
Programme (NTCP)
 Formulated in 1962 and implemented
throughout the country
STRATEGIES:
1. Early detection and treatment.
2. Diagnosis through radiology & sputum
microscopy.

The National TB Control
Programme (NTCP)
STRATEGIES cont..
3. Free domiciliary treatment through PHC
Services.
4. Establishing District Tuberculosis Center
in every district.
5. Extend coverage under Short Course
Chemotherapy.
6. Strengthen state TB training &
demonstration centres.

The result of NTP
 Case finding in NTP was only about 30% of the
expectation and
 Treatment completion was about 35% with
standard drug regimens and 45% to 50% with
SCC.
 There was no significant change in the
epidemiological situation inspite of having NTP in
place for more than 30 years, and with
increasing cases of drug resistance,
compounded by the advent of HIV infection.

Revised national Tuberculosis
Programme – RNTCP
The main pillars of the revised strategy are:
(1) Achievement of not less than 85% cure
rate amongst infectious cases of
tuberculosis, through short course
chemotherapy involving peripheral health
functionary.

(2) Detecting 70 per cent of the estimated
cases through quality sputum microscopy.
(3) Involvement of NGOs.
(4) Direct Observed Therapy Short-term
(DOTS) a community-based TB treatment
and care strategy.

Definitions of tuberculosis cases and
treatment outcomes under RNTCP
 CASE OF TUBERCULOSIS- A case of TB which
has been bacteriologically confirmed, or has
been diagnosed by a clinician.
 DEFINITE CASE- Patient with positive culture
for the Mycobacterium tuberculosis complex. In
countries where culture is not routinely available
a patient with two sputum smears positive for
acid-fast bacilli (AFB+) is also considered a
definite case.

treatment outcomes
 PULMONARY CASE A case of TB disease
involving the lung parenchyma.
 SMEAR-POSITIVE PULMONARY CASE
1. At least two initial sputum smear examinations
(direct smear microscopy) AFB+; or
2. one sputum examination AFB+ and
radiographic abnormalities consistent with
active pulmonary tuberculosis as determined by
a clinician; or
3. one sputum specimen AFB+ and culture
positive for M. tuberculosis.

treatment outcomes
 SMEAR-NEGATIVE PULMONARY CASE
Pulmonary tuberculosis not meeting the above
criteria for smear positive disease.

Diagnostic criteria should include:
1. 2 sputum smear examinations negative for AFB; and
radiographic abnormalities consistent with active
pulmonary TB;
2. and no response to a course of broad-spectrum
antibiotics;
3. and decision by clinician to treat with full course of
ATT;
4. or positive culture but negative AFB sputum
examinations.

 Sputum positive tuberculosis-At least
one initial sputum smears positive for AFB
in a well functioning EQA system.
 Sputum negative tuberculosis-At least
two negative smears,but tuberculosis
suggestive symptoms and X-Ray
abnormalities or positive culture.

treatment outcomes
 EXTRAPULMONARY CASE- Patient with
tuberculosis of organs other than the
lungs e.g. pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones,
meninges.
 Diagnosis should be based on one culture-
positive specimen, or histological or strong
clinical evidence consistent with active
extrapulmonary disease.

DEFINITIONS OF TREATMENT
OUTCOMES
 CURED- Initially smear-positive patient who
was smear-negative in the last month of
treatment, and on at least one previous occasion
 COMPLETED TREATMENT- Patient who
completed treatment but did not meet the
criteria for cure or failure.

DEFINITIONS OF
TREATMENT OUTCOMES
 DIED- Patient who died for any reason
during treatment.
 FAILED- Smear-positive patient who
remained smear-positive at five months
or later during treatment.

 Treatment completed-Initially smear
negative patient who received full course
of treatment , or smear positive who
completed treatment , with negative
smear at the end of initial phase , but no
or only one negative smear during
continuation and none at treatment end.

DEFINITIONS OF TREATMENT
OUTCOMES
 DEFAULTED Patient whose treatment was
interrupted for two consecutive months or more.
 TRANSFERRED OUT Patient who transferred
to another reporting unit and for whom the
treatment outcome is not known.
 SUCCESSFULLY TREATED Patients who were
cured and those that completed treatment.

Case definitions
• A BACTERIOLOGICALLY CONFIRMED TB
CASE : is one from whom a biological
specimen is positive by smear microscopy,
culture or WRD (such as Xpert MTB/RIF). All
such cases should be notified, regardless of
whether TB treatment has started.

 A CLINICALLY DIAGNOSED TB CASE : is
one who does not fulfil the criteria for
bacteriological confirmation but has been
diagnosed with active TB by a clinician or
other medical practitioner who has
decided to give the patient a full course of
TB treatment.

CLASSIFICATION BASED ON
ANATOMICAL SITE OF DISEASE
 PULMONARY TUBERCULOSIS (PTB) :
refers to any bacteriologically confirmed or
clinically diagnosed case of TB involving
the lung parenchyma or the
tracheobronchial tree. Miliary TB is
classified as PTB because there are lesions
in the lungs.

 EXTRAPULMONARY TUBERCULOSIS
(EPTB) : refers to any bacteriologically
confirmed or clinically diagnosed case of
TB involving organs other than the lungs,
e.g. pleura, lymph nodes, abdomen,
genitourinary tract, skin, joints and bones,
meninges.

CLASSIFICATION BASED ON HISTORY
OF PREVIOUS TB TREATMENT
(PATIENT REGISTRATION GROUP)
 NEW PATIENTS : have never been
treated for TB or have taken anti-TB drugs
for less than 1 month.
 PREVIOUSLY TREATED PATIENTS : have
received 1 month or more of anti-TB drugs
in the past.

 RELAPSE PATIENTS : have previously been treated for
TB, were declared cured or treatment completed at the
end of their most recent course of treatment, and are
now diagnosed with a recurrent episode of TB (either a
true relapse or a new episode of TB caused by
reinfection).
 TREATMENT AFTER FAILURE PATIENTS : are those
who have previously been treated for TB and whose
treatment failed at the end of their most recent course
of treatment.

 TREATMENT AFTER LOSS TO FOLLOW-UP
PATIENTS have previously been treated for TB
and were declared lost to follow-up at the end of
their most recent course of treatment. (These
were previously known as treatment after
default patients.)
 OTHER PREVIOUSLY TREATED PATIENTS
are those who have previously been treated for
TB but whose outcome after their most recent
course of treatment is unknown or
undocumented.

HIV STATUS
 HIV-POSITIVE TB PATIENT : refers to any
bacteriologically confirmed or clinically
diagnosed case of TB who has a positive result
from HIV testing conducted at the time of TB
diagnosis or other documented evidence of
enrolment in HIV care, such as enrolment in the
pre-ART register or in the ART register once ART
has been started.

 HIV-NEGATIVE TB PATIENT REFERS : to
any bacteriologically confirmed or clinically
diagnosed case of TB who has a negative result
from HIV testing conducted at the time of TB
diagnosis. Any HIV-negative TB patient
subsequently found to be HIV-positive should be
reclassified accordingly.

 HIV STATUS UNKNOWN TB PATIENT :
refers to any bacteriologically confirmed or
clinically diagnosed case of TB who has no result
of HIV testing and no other documented
evidence of enrolment in HIV care. If the
patient’s HIV status is subsequently determined,
he or she should be reclassified accordingly.

DRUG RESISTANCE
 MONORESISTANCE : resistance to one
first-line anti-TB drug only.
 POLYDRUG RESISTANCE: resistance to
more than one first-line anti-TB drug
(other than both isoniazid and rifampicin).
 MULTIDRUG RESISTANCE: resistance
to at least both isoniazid and rifampicin.

 EXTENSIVE DRUG RESISTANCE: resistance to any
fluoroquinolone and to at least one of three second-line
injectable drugs (capreomycin, kanamycin and
amikacin), in addition to multidrug resistance. •
 RIFAMPICIN RESISTANCE: resistance to rifampicin
detected using phenotypic or genotypic methods, with or
without resistance to other anti-TB drugs. It includes any
resistance to rifampicin, whether mono resistance,
multidrug resistance, poly drug resistance or extensive
drug resistance.

OBSTACLES TO TB CONTROL
The treatment
1. At least six months
2. Multiple medicines
3. Relatively expensive
4. No effective vaccine
5. No new drugs on the horizon

Control programmes
1. Require government coordination
2. Require prolonged effort and funding on
part of government

 CLINICAL
 A) History of symptoms like –
1. Irregular fever
2. Chronic cough
3. Recurrent bronchitis with poor response
to bronchodilators.
4. Loss of weight
5. Poor appetite over 2 weeks or more.

6. Chronic or recurrent abdominal pain
7. Ascites
8. Abdominal mass with no other
detectable cause.

B) Contact with sputum positive
pulmonary tuberculosis patient
presently or in recent past.

 C) PROLONGED ILLNESS OF
6-8 WEEKS AFTER AN
ATTACK OF MEASLES OR
PERTUSSIS.

 Positive tuberculin test 2 or
5 TU PPD, RT 23 with
Tween 80 or 1:000 old
tuberculin.
 Tuberculin test which gives
an indurations of 10mm or
more even in a BCG
vaccinated child.

 Positive chest X-ray
findings like
mediastinal lymph
node with or without
parenchymal lesion.

 In sputum or secretions obtained
by laryngeal stimulation, possible
mainly in older children with
pulmonary T.B.
 This can be done in district
tuberculosis centre where ever
possible.

 CONCLUSION
 SCORE <3 – PROBABLY NEGATIVE AND
T.B. IS UNLIKELY.
 SCORE BETWEEN 3 – 4 – PROBABLY
POSITIVE TUBERCULOSIS AND NEEDS
FURTHER EVALUATION.

 SCORE BETWEEN 5-6 – PROBABLY T.B. &
NEEDS CHEMOTHERAPY WITH 3 DRUGS.
 SCORE 7 & ABOVE – ESTABLISHED T.B.,
NEEDS FULL COURSE OF A.T.T. AND IN
SERIOUS CASES, STEROIDS.

Guidelines for Preventive chemotherapy in Children under 6
years of age who were in contact with a smear-positive
case
8/23/2018 DR. HARIVANSH CHOPRA
IF AND THEN
If the child has symptoms of TB An MO determines
(Preferably in
consultation with a
Paediatrician) that the
child has TB.
A full course of ATT(CAT
III)should be given.
The child does not have
Symptoms of TB
A tuberculin test is not
available
The child should receive
preventive chemotherapy
for six months (INH
daily-5mg/Kg body
weight)
A tuberculin test is
available
A child should receive 3
months of INH
preventive chemotherapy
and a tuberculin test
should be done

IF THEN
The child’s induration to the
tuberculin test is<6mm in diameter
Stop the preventive chemotherapy and
give BCG vaccination (if previously not
given)
The child’s induration to the tuberculin
test is 6mm or more in diameter
Continue INH preventive
chemotherapy for another 3 months

 TB bacteria can attack any part of the body
such as the kidney, spine, and brain.
 If not treated properly, TB disease can be fatal.

 In general, long-
term contact with
an infected person
is needed— as
much as eight
hours a day for up
to six months — to
become infected.

 A person with active
TB who's been
effectively treated for
at least two weeks is
no longer contagious
and can't spread the
bacteria to others.

 1) The meaning of a case of tuberculosis
is -
1. Patient is excreting tubercle bacilli in his
sputum
2. Sputum is positive for A.F.B.
3. At least 2 initial sputum smears positive
for A.F.B. or one A.F.B. positive smear
and one positive culture
4. All of the above
ANS.4

2) Smear negative tuberculosis means -
1. At least 3 negative sputum smears + cardinal
sign of tuberculosis
signs of tuberculosis + X-ray abnormality
signs of tuberculosis + X-ray abnormality or
positive culture
4. All of the above ANS 3

3) The difference between treatment
completed & cure of tuberculosis is in -
1. The duration of treatment
2. The no. of drugs taken during treatment
3. Sputum examination at the beginning of the
treatment
4. Sputum examination at the end of the
treatment
ANS 4

4) Tubercle bacilli was discovered in the
year -
1.1796
2.1882
3.1921
4.1900
ANS 3

 5) In India B.C.G. vaccination
programme was started in the year
1. 1951
2. 1962
3. 1948
4. 1960
ANS 2

6) The dose of B.C.G. in all age group
is -
1.0.1 ml
2.0.05 ml
3.Both of the above
4.None of the above
ANS.1

 7) The reconstituted B.C.G. vaccine
should be used within
1. 1 hr.
2. 2 hr.
3. 3 hr.
4. 4 hr.
ANS 3

REVISED NATIONAL TB CONTROL
PROGRAMME(RNTCP)
 On the recommendations of an expert committee ,
a revised strategy to control TB was pilot tested in
1993 and launched as a national program in 1997.
 The RNTCP applies the WHO recommended
DOTS(Directly Observed Treatment, Short course)
strategy.
 The programme was expanded in a phased manner
to cover the entire country in 2005.

 By 24 March 2006, the entire country was covered
under DOTS covering 1114 million people.
 the majority of TB patients have pulmonary TB, with
the sputum smear-positive pulmonary TB patients
constituting the infectious pool in the community.
 Early diagnosis and cure of these patients can break
the chain of transmission of TB infection in the
community.

 Since the inception of RNTCP and up to June
2005, more than 4.5 million patients were
initiated on treatment and about 750,000
additional lives were saved.
 Each month more than 100,000 patients are
initiated on treatment.

STRUCTURE OF THE RNTCP
 The RNTCP is lead by Central TB Division (CTD)
in the Ministry of Health and Family Welfare,
Govt. of India in Delhi.
 The state, district and sub-district levels and
peripheral health institutions implement the
programme.

National
level
Deputy director
general
Natioanl TB
Institutions
State
Level
State TB officer
State tuberculosis
control society
District
level
District tuberculosis
center
District TB control
society
District Tuberculosis
officer

Sub district level
Medical officer-tuberculosis
control(MO-TC)
Senior treatment
supervisor(STS)
Senior TB laboratory
supervisor
Tuberculosis Unit
PHIs
TB center
CHC/PHC

CENTRAL TB DIVISION
 At the Ministry of Health and Family Welfare, the
Central TB Division is responsible for TB control
in the entire country.
 The Deputy Director General (DDG-TB) is the
national programme manager.
 The main functions of the CTD are to formulate
technical policy, plan, implement, monitor and
coordinate the programme at the national level.

STATE LEVEL
 At the state level, a State TB Officer (STO) is
responsible for planning, training, implementing,
monitoring and coordinating the programme.
 A State Tuberculosis Control Society (STCS) has
been established for increased state ownership
and accountability and also for the smooth
transfer of funds from CTD to the state and then
to districts.

DISTRICT LEVEL
 The District Tuberculosis Centre (DTC) is
the nodal point for TB control activities in
the district and also functions as a
specialized referral centre.
 There is a District TB Control Society
(DTCS) in every RNTCP district. It is
responsible for budgeting and providing
financial resources and also for monitoring
the programme implementation.

-1 District Tuberculosis Officer (DTO)
-1 Second medical officer
-2 Laboratory technicians
-2 Treatment organizer/Health visitor
-1 X-ray technician
-1 Non-medical team leader
-1 Statistical assistant
-1 Pharmacist
REVISED NATIONAL TB CONTROL
PROGRAMME(RNTCP)

 It also arranges necessary logistics such as
transport, hiring of contractual staff and
procurement of materials including laboratory
consumables.

 The District Collector (or Corporation
Commissioner, or District Magistrate) is the
Chairman and the District Tuberculosis Officer
(DTO) is the Member Secretary.
 The DTCS has representatives from government
and non-government sectors.
 The DTO has the overall responsibility to
implement the programme at the district level and
is assisted by medical Officer and other technical
and administrative staff.

SUB-DISTRICT LEVEL
 A team comprising of a designated Medical
Officer-Tuberculosis Control (MO-TC), a Senior
Treatment Supervisor (STS) and a Senior TB
Laboratory Supervisor (STLS) is based at the
Tuberculosis Unit (TU).
 This is the sub-district unit of TB control
activities and is usually based in health
institutions such as Community Health Centers
(CHC), Taluk Hospitals or Block PHCs.

 The sub-district covers a population of
approximately 5 lakh (2.5 lakh in hilly, tribal and
difficult areas) and is responsible for the TB
control activities at this level.
 The TU is also responsible for accurate
maintenance of the TB register and for
preparing quarterly reports.

DESIGNATED MICROSCOPY CENTRE
 Designated Microscopy Centers (DMC) are
usually situated at tertiary and secondary level
health care institutions and Block PHCs or other
equivalent institutions including private and NGO
facilities.
 Each usually caters to a population of 1 lakh (0.5
lakh in hilly, tribal and difficult areas).
 All DMCs should be included in the standard
RNTCP External Quality Assessment (EQA)
system.

 The DMC either must be covering a population of
1 lakh, or having about 60 -100 new adult
outpatient attendance per day.
 The laboratory technician must be examining an
average of at least 3 – 5 smears and not more
than 20 – 25 smears per day.
 there would be either a referral system to these
laboratories by the private practitioners for
sputum smear examination, and/or a referral
between the labs either of TB suspects or
samples.

PERIPHERAL HEALTH INSTITUTIONS
 For the purpose of RNTCP, a PHI is a health
facility which is manned by at least a medical
officer (even if the post Is currently vacant).
 At this level are the dispensaries,PHCs, CHCs,
referral hospitals, major hospitals, specialty
clinics / hospitals (including other health
facilities) / TB hospitals / Medical colleges within
the district.

 All health facilities in the private/NGO sector
participating in RNTCP are also considered as
PHIs under the programme.
 Some of these PHIs will also be DMCs.
 All PHIs with/without DMCs should submit a
monthly PHI level report to the respective TUs
and the district.

END TB STRATEGY : VISION
203
“To have a world Free of Tuberculosis
with Zero Deaths, disease and
sufferings due to TB and End the Global
epidemic of TB”

END TB STRATEGY : TARGETS
204
FACTOR MILESTONE TARGETS
2020 2025 2030 2035
REDUCTION IN NUMBER OF TB DEATHS
(IN COMPARISON TO 2015)
35 % 75 % 90
%
95
%
REDUCTION IN TB INCIDENCE RATE
(IN COMAPRISON TO 2015 )
20 % 50 % 80
%
90
%
TB AFFECTED FAMILY FACING
CATASTROPHIC COST DUE TO TB
0 % 0 % 0 % 0 %

3 PILLARS OF END TB STRATEGY
205
INTEGRATED PATIENT CENTERED TB CARE
AND PREVENTION
BOLD POLICIES AND SUPPORTIVE SYSTEMS
INTENSIFIED RESEARCH AND INNOVATIONS

NATIONAL STRATEGIC PLAN FOR
TUBERCULOSIS ELIMINATION
2017 - 2025
206
IMPACT INDICATORS BASELINE TARGET
2015 2020 2023 2025
TO REDUCE TB INCIDENCE RATE
(PER 100,000 )
217 142 77 44
TO REDUCE TB INCIDENCE RATE
(PER 100,000 )
320 170 90 65
TO REDUCE ESTIMATED MORTALITY DUE
TO TB
(PER 100,000 )
32 15 6 3
TO ACHIEVE ZERO CATASTROPHIC COST
FOR TB AFFECTED FAMILIES
35 % 0 % 0 % 0 %

BEDAQUILINE (BDQ)
207
 Targets Mycobacterial ATP Synthase
 Action is Bactericidal
 Extended Half life : can be present in
blood for another 5.5 months after the
therapy
 Contraindications :
– < 18 years
– Pregnancy
– Cardiac Arrhythmias

SCHEDULE FOR BEDAQUILINE
208
MDR / RR TB WITH RESISTANCE TO ALL FLUROQUINOLONES
MDR / RR TB WITH RESISTANCE TO ALL SECOND LINE INJECTABLES
XDR TB (ALL FQ AND SLI RESISTANT)
XDR TB (ANY FQ AND ALL SLI RESISTANT)
XDR TB (ALL FQ AND ANY SLI RESISTANT)
XDR TB (ANY FQ AND ANY SLI RESISTANT)
TREATMENT FAILURE MDR + FQ/SLI RESISTANT

TREATMENT SCHEDULE
209
WEEK 0 – 2 : 400 mg DAILY FOR 7 DAYS / WEEK
WEEK 3 – 24 : 200 mg THRICE A WEEK (ATLEAST
48 HOURS BETWEEN TWO DOSES)
WEEK 25 TO END OF TREATMENT : CONTINUE
ONLY 2ND LINE DRUGS AS PER RNTCP GUIDELINES

99 DOTS STRATEGY
210
 To improve the adherence to TB
treatment
 A number is printed on the back of
blister pack which will be revealed
only when the patient open the pack.
 The patient is made to call on that
number in order to make assure that
he has consumed the tablet

NIKSHAY
211
 TB surveillance using case based web based IT
system.
 Central TB Division in collaboration with National
Informatics Centre has undertaken the initiative to
develop a case based and web based application
called Nikshay.

NIKSHAY: COMPONENTS
212
MASTER MANAGEMENT
USER DETAILS
TB PATIENT REGISTRATION AND DETAILS OF DIAGNOSIS
DOT PROVIDER
HIV STATUS
FOLLOW UP
CONTACT TRACING

NIKSHAY: COMPONENTS
213
DETAILS OF SOLID AND LIQUID CULTURE AND DST, LPA,
CBNAAT DETAILS
DR – TB CASES REGISTRATION WITH DETAILS.
REFERRAL AND TRANSFER OF PATIENTS
PRIVATE HEALTH FACILITY REGISTRATION AND TB
NOTIFICATION
MOBILE APPLICATION FOR TB NOTIFICATION
SMS ALERT

CONCLUSION
 Tuberculosis is a silent, global emergency.
 The best method to control it is early
diagnosis & prompt treatment.
 DOTS ensures increased compliance &
cure.
 Generation of public awareness will go a
long way in the control of tuberculosis.

EPIDEMIOLOGY OF TUBERCULOSIS

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