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epidemiology of Tuberculosis

The document discusses the epidemiology and advances in the treatment of tuberculosis (TB), highlighting its historical context, clinical features, diagnosis methods, and treatment strategies, including the Revised National Tuberculosis Control Programme (RNTCP) in India. It emphasizes the global public health impact of TB, particularly in India, where socio-economic burdens and drug-resistant strains pose significant challenges. The document also outlines current strategies to detect, treat, and reduce TB incidence and mortality rates as part of the national strategic plan and the End TB strategy.

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EPIDEMIOLOGY AND RECENT ADVANCES OF TUBERCULOSIS WITH RNTCP BY : ABHISHEK AGARWAL 1
A small thought… If you want to practice medicine in India never under estimate the possibility of Malaria and Tuberculosis in Patients… 2
INDEX HISTORY OF TUBERCULOSIS INTRODUCTION AND PROBLEM STATEMENT EPIDEMILOGICAL TRIAD OF TUBERCULOSIS CLINICAL FEATURES & DIAGNOSIS OF TUBERCULOSIS TREATMENT OF TUBERCULOSIS RNTCP END TB STRATEGY & NATIONAL STRATEGIC PLAN BEDAQUILINE AND 99DOTS STRATEGY 3
WHAT IS TUBERCULOSIS ? Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB) 4
9000 BC 3000 BC 1500 BC 1882 1906 FROM THE PAGES OF PAST … 5
FROM THE PAGES OF PAST … TILL 20TH CENTURY COLLAPSING THE LUNG 1ST ANTI TUBERCULAR DRUG 1ST ORAL ANTI TUBERCULAR DRUG : 1952 MAJOR REVOLUTION : 1970 ANTIBIOTIC RESISTANCE : 1980 1994 6
INTRODUCTION  Tuberculosis is a global public health problem.  Tuberculosis is the leading cause of death world wide along side HIV.  It has been declared Public Health Emergency in 1993. 7
WORLD PROBLEM TB CASES 10.4 1.8 0.4 TOTAL CASES DEATHS DEATHS DUE TO HIV 8
DRUG RESISTANCE CASES 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 9
SEX WISE DISTRIBUTION OF TB CASES : 2015 57% 34% 9% TB CASES IN 2015 MALES FEMALES CHILDREN 10 SOURCE: TB INDIA 2017, ANNUAL STATUS REPORT
TB : WORLD AND INDIA 73% 27% TB CASES (2015) REST OF WORLD INDIASOURCE: TB INDIA 2017, ANNUAL STATUS REPORT 11
TB DEATHS : INDIA 83% 17% TB CASES (2015) NO DEATHS DEATHSSOURCE: TB INDIA 2017, ANNUAL STATUS REPORT 12
INDIA PROBLEM 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 13
80% 20% DALY LOST DUE TO TUBERCULOSIS PREMATURE DEATHS OTHER CAUSES 3 LAKH CHILDREN LEAVES SCHOOL 1 LAKH WOMEN LOSE STATUS OF WIFE AND MOTHER 14SOCIO ECONOMIC BURDEN OF TUBERCULOSIS
SOCIO ECONOMIC BURDEN OF TUBERCULOSIS TB causes loss of Rs 13000 crore annually in India 17 crore days are lost to TB Category 1 treatment : Rs 13462 Category 2 treatment : Rs 13654 ICMR 2005 15
AGENT FACTOR Mycobacterium tuberculosis non motile, non spore forming, rod shaped bacilli Acid and Alcohol fast bacilli on ZN staining Sensitive to heat (killed at 60 degree) Cultured on : LJ Medium 16
SOURCE OF INFECTION HUMAN: MOST COMMON SOURCE OF INFECTION FROM 1 CASE 10 – 15 PERSONS ACQUIRES THE INFECTION BOVINE USUALLY INFECTED MILK AGENT FACTOR 17
CONSTITUTIONAL FACTORS HORMONAL FACTORS AGE SEX IMMUNITY SOCIO ECONOMIC FACTORS PERSONAL FACTORS HOST FACTORS 18
ENVIRONMENT FACTORS OVERCROWDING POOR SANITATION MALNUTRITION POVERTY SILICA EXPOSURE 19
CLINICAL FEATURES FOR PULMONARY TUBECULOSIS Cough > 2 weeks Fever > 2 weeks Hemoptysis Significant Weight loss 20
CASE DEFINITION A bacteriologically confirmed TB case is one from whom a biological specimen is positive by smear microscopy or culture. 21
CLINICAL DEFINITION 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 practioner who has decided to give the patient a full course of TB treatment. 22
DIAGNOSIS : MICROBIOLOGICAL EXAMINATION  METHOD OF CHOICE  2 samples taken “ON THE SPOT” sample Early morning sample 23
SLIDE REPORTING NUMBER OF BACILLI RESULTS NO AFB PER 100 OIL IMMERSION FIELDS 0 1 - 9 AFB PER 100 OIL IMMERSION FIELDS SCANTY 10 – 99 AFB PER 100 OIL IMMERSION FIELDS + (1+) 1 – 10 AFB PER OIL IMMERSION FIELDS ++ (2+) > 10 AFB PER OIL IMMERSION FIELDS +++ (3+) 24
DIAGNOSIS : CHEST X RAY CONSOLIDATION CAVITARY LESION NODULE WITH POOR DEFINED MARGINS PLEURAL EFFUSION HILAR OR MEDIASTINAL LYMPHADENOPATHY 25
DIAGNOSIS : CULTURE Very Sensitive test Can detect as low as 10 – 100 bacilli per ml Media used : Solid Media: Lowenstein Jensen (LJ Medium) Liquid Media: Middle Brook, Dubos, Proskauer and Beck’s Combination of Solid and Liquid Media is now a days gold standard 26
DIAGNOSIS : GENOTYPIC AND PHENOTYPIC METHODS POLYMERASE CHAIN REACTION TRANSCRIPTION MEDIATED AMPLIFICATION AND NUCLEIC ACID AMPLIFICATION CARTRIDGE BASED NUCLEIC ACID AMPLIFICATION TEST (CB NAAT) FAST PLAQUE TB TEST 27
TUBERCULIN TEST  Discovered in 1907 by Von Pirquet  A positive test represents past or present infection with Mycobacterium tuberculosis  It is used as means of estimating Tuberculosis infection in the population. 28
TUBERCULIN TEST  TUBERCULIN TEST: 5 TUBERCULIN UNIT OF PPD-S IS USED AS 0.1ML INTRADERMALLY AND RESULTS ARE READ AFTER 48 TO 96 HOURS (72 HOURS IS BEST)  IN MANTOUX TEST : PPD-RT 23 IS USED AS 1 TUBERCULIN UNIT AS 0.1 ML  INTERPRETATION :  INDUARTIONS : < 6 mm : negative 6 – 9 mm : doubtful ≥ 10 mm : positive 29
BAN ON TB SEROLOGY  The serological tests are based on antibody response, which is highly variable in TB and may reflect remote infection rather than active disease  Currently available serological tests are having poor specificity and should not be used for the diagnosis of pulmonary or extra pulmonary TB 30
SCREENING OF TUBERCULOSIS  COMMUNITY BASED: Who have had recent closed contact with person suffering from Tuberculosis  INSTITUTIONAL BASED: In health care facilities: Active screening of vulnerable individuals in hospitals In congregate Settings: Active screening of vulnerable individuals in shelters, old age homes, refugee camps and other locations such as work place. 31
VULNERABLE GROUPS HIV PATIENTS DIABETICS CANCER PATIENTS PATIENTS ON IMMUNOSUPPRESSANTS HEALTH CARE WORKERS MALNOURISHED PERSONS ANTENATAL WOMEN 32
VULNERABLE GROUPS PRISONERS OCCUPATIONS WITH RISK FOR DEVELOPING TUBERCULOSIS PEOPLE IN : NIGHT SHELTERS, DE ADDICTION CENTERS, OLD AGE HOMES 33
TREATMENT 34
TREATMENT : CHEMOTHERAPY RIFAMPICIN ISONIAZIDE PYRAZINAMIDE ETHAMBUTOL STREPTOMYCIN 35 FLUROQUINOLONES ETHIONAMIDE CAPREOMYCIN KANAMYCIN AMIKACIN CYCLOSERINE THIOACETAZONE MACROLIDES BEDAQUILINE 1st LINE DRUGS 2nd LINE DRUGS
LONG TERM CHEMOTHERAPY DAILY REGIMEN BI WEEKLY OR INTERMITTENT REGIMEN 36 18 MONTHS
SHORT TERM CHEMOTHERAPY RAPID BACTERIOLOGICAL CONVERSION LOWER FAILURE RATES REDUCTION IN EMERGENCE OF DRUG RESISTANT BACILLI PATIENT COMPLIANCE IMPROVES AND THEY BECOMES NON INFECTIOUS EARLY 37
DIRECTLY OBSERVED TREATMENT SHORT COURSE (DOTS)  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 38
DOTS CHEMOTHERAPY CATEGORY TYPE OF PATIENT INTENSIVE 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 39
DAILY DOSE REGIMEN 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. 40
CHANGES FROM DOTS REGIMEN  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 41
CHANGES IN TREATEMENT POLICY 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 42
DAILY DOSAGE SCHEDULE FOR ADULTS WEIGHT CATEGORY NUMBER OF TABLETS TO BE CONSUMED Inj. Streptomycin 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 43
MULTI DRUG RESISTANT TUBERCULOSIS TREATMENT 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 44
XTENSIVE DRUG RESISTANT TUBERCULOSIS TREATMENT 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 45
ALOGRITHM OF TB TREATMENT 46 CONFIRMED TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE
ALOGRITHM OF MDR TB TREATMENT 47 CONFIRMED DR TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE 4TH 5TH 6TH
PEDIATRIC TUBERCULOSIS  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 48
DIAGNOSIS OF PEDIATRIC TUBERCULOSIS  SPUTUM MICROSCOPY IS BEST METHOD TO DETECT TUBERCULOSIS  IN CASES WHERE SPUTUM IS NOT AVAILABLE: GASTRIC LAVAGE INDUCED SPUTUM BRONCHO ALVEOLAR LAVAGE 49
TREATEMENT OF PEDIATRIC TUBERCULOSIS 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) 50
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 PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg ISONIAZIDE : 150 mg RIFAMPICIN : 150 mg PURPLE BOX (PC 15) ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg PYRAZINAMIDE : 250 mg, ETHAMBUTOL : 200 mg GREY BOX (PC 16) ISONIZIDE : 150 mg, RIFAMPICIN : 150 mg PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg 51
BOX WISE TREATMENT FOR CHILDREN 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 52
WAY FORWARD… FIXED DRUG COMBINATIONS 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 53
BCG VACCINE AIM : TO REDUCE MORTALITY AND MORBIDITY FROM PRIMARY TUBERCULOSIS LIVE ATTENUATED VACCINE DANISH 1331 STRAIN IS USED FOR VACCINE PRODUCTION LIQUID AND FREEZE DRIED VACCINE ARE AVAILABLE 54
BCG VACCINE DILUENT : NORMAL SALINE DOSAGE : 0.05ML UPTO 1 MONTH AND 0.1 ML UPTO 1 YEAR PROTECTION UP TO 15 TO 20 YEARS COMPLICATIONS : SUPPURATIVE LYMPHADENITIS, OSTEOMYELITIS, ULCERATION, BCG INFECTION AND DEATH 55
RNTCP 56 NTP - 1962 RNTCP - 1997 RNTCP - 2006
NTP RNTCP OBJECTIVE EARLY DIAGNOSIS AND TREATMENT BREAKING THE CHAIN OF TRANSMISSION OPERATION AL TARGETS NOT DEFINED 1. CURE RATE 85% 2. CASE FINDING 70% OF ESTIMATED CASES STRATEGY 1. SHORT COURSE CHEMOTHERAPY 2. CONVENTIONAL : LONG TERM DOMICILLIARY TREATMENT WITH INZ + THIACETAZONE 1. DOTS 2. UNINTERRUPTED DRUG SUPPLY DIAGNOSIS 1. MORE EMPHASIS ON x RAYS 2. 2 SPUTUM SMEARS 3. ONE SPUTUM POSITIVE IS CONSIDERED AS A CASE 1. MAINLY SPUTUM MICROSCOPY 2. TWO SPUTUM SMEARS 3. ONE SMEAR POSITIVE / CLINICALLY POSITIVE IS A CASE 57
RNTCP : ORGANOGRAM 58 CENTRAL TB DIVISION STATE TB CELL DISTRICT TB CENTRE TUBERCULOSIS UNIT DESIGNATED MICROSCOPY CENTRE PERIPHERAL HEALTH INSTITUTIONS 1 PER LAC POPULATION 1 PER BLOCK DR TB CENTRES C & DST LAB NATIONAL INSTITUTES
LABORATORY NETWORK UNDER RNTCP NATIONAL REFERENCE LABORATORY (6) IRL (28) & CULTURE AND DRUG SUSCEPTIBILITY CENTRE (37) CB NAAT (628) DESIGNATED MICROSCOPY CENTERS (13888) 59
QUALITY ASSURANCE PROGRAM  The components of a quality assurance programme are:  Quality control  Quality improvement  Proficiency testing 60
RNTCP I STRENGTHENIN G OF TB CELLS STRENGTHENING OF TRAINING INSTITUTES FOR TB GRADUAL IMPLEMENTATION OF STRATEGY STRENGTHENIN G OF NTCP UNINTERRUPTE D SUPPLY OF ANTI TB DRUGS 61
RNTCP II Case detection with microscopy Un interrupted supply of drugs Direct observation by health worker Systematic evaluation and monitoring Political and administrative commitment STRENGTHEN THE QUALITY OF DOTS DECENTRALIZED THE DOTS SERVICES PUBLIC PRIVATE ACTIVITIES TO INCREASE REACH TO DOTS RATIONALIZED USE OF 1ST AND 2ND LINE DRUGS GENERATE AWARENESS AND DEMAND FOR QUALITY SERVICES 62
ACHIEVEMENTS 63 1998 2010 500000 322000 TB MORTALITY / PER ANNUM 1998 2010
2000 2001 - 03 2007 - 10 1.70% 1.50% 1.10% ANNUAL RISK OF TUBERCULOSIS INFECTION 2000 2001 - 03 2007 - 10 64 ACHIEVEMENTS
ACHIEVEMENTS 2000 2005 2010 2013 216 209 185 171 INCIDENCE OF TUBERCULOSIS SINCE LAUNCH OF RNTCP PER LAKH POPULATION 2000 2005 2010 2013 65
TARGETS UNDER RNTCP Detection and treatment of about 87 lakh tuberculosis patients during the 12th five year plan. Detection and treatment of at least 2 lakh MDR TB patients during 12th five year plan. Reduction in delay in diagnosis and treatment of all types of TB cases Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups. 66
END TB STRATEGY : VISION “To have a world Free of Tuberculosis with Zero Deaths, disease and sufferings due to TB and End the Global epidemic of TB” 67
END TB STRATEGY : TARGETS 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 % 68
3 PILLARS OF END TB STRATEGY INTEGRATED PATIENT CENTERED TB CARE AND PREVENTION BOLD POLICIES AND SUPPORTIVE SYSTEMS INTENSIFIED RESEARCH AND INNOVATIONS 69
NATIONAL STRATEGIC PLAN FOR TUBERCULOSIS ELIMINATION 2017 - 2025 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 % 70
STRATEGY UNDER NSP 2017 - 2025 DETECT TREAT PREVENT BUILD 71
BEDAQUILINE (BDQ)  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 72
SCHEDULE FOR BEDAQUILINE 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 73
TREATMENT SCHEDULE 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 74
99 DOTS STRATEGY  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 75
NIKSHAY  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. 76
NIKSHAY: COMPONENTS MASTER MANAGEMENT USER DETAILS TB PATIENT REGISTRATION AND DETAILS OF DIAGNOSIS DOT PROVIDER HIV STATUS FOLLOW UP CONTACT TRACING 77
NIKSHAY: COMPONENTS 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 78
PUBLIC PRIVATE MIX DOTS IN INDIA  RNTCP launched the PPM DOTS Model for additional TB case detection with good quality treatment success rates in 2003.  Impact of this model : 79 Reduced financial burden on patient and society Reached the people from lower socio economic groups Helped in treatment observations
PUBLIC PRIVATE MIX DOTS IN INDIA  PRESENT STATUS NGOs : 2500 PRIVATE PRACTIONERS : 25000 MEDICAL COLLEGES : 260 CORPORATE HOUSES: 150 80
TB ADVOCACY, COMMUNICATION AND SOCIAL MOBILIZATION SCHEME SPUTUM COLLECTION CENTRES SPUTUM PICK UP AND TRANSPORT SCHEME DESIGNATED MICROSCOPIC CENTRE SCHEME LABORATORY TECHNICIAN SCHEME CULTURE DST SCHEME TREATMENT ADHERENCE SCHEME 81PUBLIC PRIVATE MIX DOTS IN INDIA
SUMMARY  Tuberculosis is caused by Mycobacterium tuberculosis, which spread by either human or bovine routes.  Clinical features include cough, fever and weight loss and is diagnosed by microscopic examination followed by Chest X ray and other genotypic and phenotypic tests.  Tuberculosis is treated by DOTS strategy, with the recent launch of fixed drug combinations. 82
SUMMARY  RNTCP was launched as a continuation program of NTP in 1997 followed by launch of second phase of RNTCP in 2006.  With the achievements under MDG goals and launch of sustainable goals, END TB STRATEGY was launched with the objective to reduce incidence of TB Prevalence. 83
REFERENCES  K PARKS TEXTBOOK OF SOCIAL AND PREVENTIVE MEDICINE, 24TH EDITION  JUGAL KISHORE’S TEXT BOOK OF NATIONAL HEALTH PROGRAMS, 11TH EDITION  WHO DOCUMENT ON STRATEGY TO CONTROL TUBERCULOSIS IN INDIA  NATIONAL STRATEGIC PLAN TO END TUBERCULOSIS 2017 – 22 , MOHFW 84
85
HIGH RISK CASES OF TUBERCULOSIS PLHIV DIABETES CANCER PATIENTS PERSONS ON IMMUNOSUPPRESANTS 86
DIAGNOSIS : TUBERCULIN TEST AND INTERFERON GAMMA RELEASE ASSAY  NOT RECOMMENDED FOR THE DIAGNOSIS OF ACTIVE TUBERCULOSIS  STANDARDIZED TUBECULIN SKIN TEST MAY BE USED AS COMPLIMENTARY TEST IN CHILDREN 87
DIAGNOSIS : CB NAAT  CARTIDGE BASED NUCLEIC ACID AMPLIFICATION TEST  FIRST DIAGNOSTIC TEST AMONG CHILDREN AND PL-HIV 88
NATIONAL RESEARCH LABORATORY 89 NATIONAL REFERENCE LABORATORY
ZIEHL NELSON ACID FAST STAINING 90 FIX THE SMEAR ON SLIDE BY PASSING THE SLIDE THROUGH FALME 3 TIMES COVER WITH CARBOL FUSCHIN AND STEAM FOR 5 MIN AND WASH WITH WATER DECOLORIZE WITH 3 % ACID ALCHOHAL AND WASH WITH WATER COUNTER STAIN FOR 1 MIN WITH LOEFFLER’S METHYLENE BLUE WASH IT WITH DE IONIZED WATER
INTERMEDIATE REFERENCE LABORATORY ONE IRL HAS BEEN DESIGNATED TO EACH STATE TUBERCULOSIS TRAINING AND DEMONSTRATION CENTRES / PUBLIC HEALTH LABORATORY / MEDICAL COLLEGES 91
CERTAIN DEFINITIONS NEW PATIENTS: “Patient who have never been treated for TB or taken anti TB drugs for less than 1 month” PREVIOUSLY TREATED TB PATIENT “Patient who received 1 month or more of anti TB drugs in past” 92
 RELAPSE PATIENTS: patients who were 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.  TREATMENT AFTER FAILURE: patients who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. 93 CERTAIN DEFINITIONS
MULTIDRUG RESISTANCE : resistance to both Rifampicin and Isoniazid at least EXTENSIVE DRUG RESISTANCE : Resistance to any fluoroquinolone and at least one of the three 2nd 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. 94 CERTAIN DEFINITIONS
PREVENTION  Cough etiquettes not being followed  Indiscriminate spitting  Sneezing without covering face  Alcoholics and mentally challenged patients  Delay in reaching health facility for specific diagnosis 95

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In this document
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Presentation introduces Tuberculosis and its epidemiology, discusses its historical context from ancient times to modern treatment.

Highlights the global public health problem of TB, statistics from 2015 show that TB is a leading cause of death alongside HIV.

Discusses drug resistance in TB, socio-economic burdens due to TB, and its impact on society including financial losses.

Defines Mycobacterium tuberculosis and explores various host and environmental factors that increase TB risks.

Presents symptoms and diagnosis methods for TB, including clinical features, case definitions, and laboratory tests.

Outlines screening strategies, focuses on community and institutional level screenings, and identifies high-risk and vulnerable groups.

Describes different treatment regimens for TB, including first and second line therapies, and protocols for multidrug-resistant TB.

Explains treatment algorithms for TB and pediatric TB, emphasizing the importance of adherence to treatment and diagnosis methods.

Discusses the BCG vaccine and the evolution of the RNTCP highlighting its objectives and strategies for reducing TB incidence.

Summarizes achievements of RNTCP and sets targets for detection and treatment of TB patients in the upcoming years.

Details the vision and milestones set under the End TB Strategy, aiming to eradicate TB and reduce death rates significantly.

Introduces Bedaquiline, the 99 DOTS strategy, and the Nikshay surveillance system to improve TB treatment adherence.

Discussions on public-private mix strategies in India, aiming at enhancing TB case detection and treatment success rates.

Summarizes TB causes, templates for diagnosis, definitions for treatment responses, and challenges in TB management.

epidemiology of Tuberculosis

  • 1.
    EPIDEMIOLOGY AND RECENTADVANCES OF TUBERCULOSIS WITH RNTCP BY : ABHISHEK AGARWAL 1
  • 2.
    A small thought… Ifyou want to practice medicine in India never under estimate the possibility of Malaria and Tuberculosis in Patients… 2
  • 3.
    INDEX HISTORY OF TUBERCULOSIS INTRODUCTIONAND PROBLEM STATEMENT EPIDEMILOGICAL TRIAD OF TUBERCULOSIS CLINICAL FEATURES & DIAGNOSIS OF TUBERCULOSIS TREATMENT OF TUBERCULOSIS RNTCP END TB STRATEGY & NATIONAL STRATEGIC PLAN BEDAQUILINE AND 99DOTS STRATEGY 3
  • 4.
    WHAT IS TUBERCULOSIS? Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB) 4
  • 5.
    9000 BC 3000 BC 1500BC 1882 1906 FROM THE PAGES OF PAST … 5
  • 6.
    FROM THE PAGESOF PAST … TILL 20TH CENTURY COLLAPSING THE LUNG 1ST ANTI TUBERCULAR DRUG 1ST ORAL ANTI TUBERCULAR DRUG : 1952 MAJOR REVOLUTION : 1970 ANTIBIOTIC RESISTANCE : 1980 1994 6
  • 7.
    INTRODUCTION  Tuberculosis isa global public health problem.  Tuberculosis is the leading cause of death world wide along side HIV.  It has been declared Public Health Emergency in 1993. 7
  • 8.
    WORLD PROBLEM TB CASES 10.4 1.8 0.4 TOTALCASES DEATHS DEATHS DUE TO HIV 8
  • 9.
    DRUG RESISTANCE CASES 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 MDRTB RIFAMPICIN RESISTANT 4.8 1 TB CASES IN LAKHS MDR TB RIFAMPICIN RESISTANT 9
  • 10.
    SEX WISE DISTRIBUTIONOF TB CASES : 2015 57% 34% 9% TB CASES IN 2015 MALES FEMALES CHILDREN 10 SOURCE: TB INDIA 2017, ANNUAL STATUS REPORT
  • 11.
    TB : WORLDAND INDIA 73% 27% TB CASES (2015) REST OF WORLD INDIASOURCE: TB INDIA 2017, ANNUAL STATUS REPORT 11
  • 12.
    TB DEATHS :INDIA 83% 17% TB CASES (2015) NO DEATHS DEATHSSOURCE: TB INDIA 2017, ANNUAL STATUS REPORT 12
  • 13.
    INDIA PROBLEM 0 0.5 1 1.5 2 2.5 3 NEW CASESDEATHS HIV CASES 2.8 0.48 0.14 TB CASES IN MILLIONS NEW CASES DEATHS HIV CASES 13
  • 14.
    80% 20% DALY LOSTDUE TO TUBERCULOSIS PREMATURE DEATHS OTHER CAUSES 3 LAKH CHILDREN LEAVES SCHOOL 1 LAKH WOMEN LOSE STATUS OF WIFE AND MOTHER 14SOCIO ECONOMIC BURDEN OF TUBERCULOSIS
  • 15.
    SOCIO ECONOMIC BURDENOF TUBERCULOSIS TB causes loss of Rs 13000 crore annually in India 17 crore days are lost to TB Category 1 treatment : Rs 13462 Category 2 treatment : Rs 13654 ICMR 2005 15
  • 16.
    AGENT FACTOR Mycobacterium tuberculosis nonmotile, non spore forming, rod shaped bacilli Acid and Alcohol fast bacilli on ZN staining Sensitive to heat (killed at 60 degree) Cultured on : LJ Medium 16
  • 17.
    SOURCE OF INFECTION HUMAN: MOSTCOMMON SOURCE OF INFECTION FROM 1 CASE 10 – 15 PERSONS ACQUIRES THE INFECTION BOVINE USUALLY INFECTED MILK AGENT FACTOR 17
  • 18.
    CONSTITUTIONAL FACTORS HORMONAL FACTORS AGE SEX IMMUNITY SOCIOECONOMIC FACTORS PERSONAL FACTORS HOST FACTORS 18
  • 19.
  • 20.
    CLINICAL FEATURES FORPULMONARY TUBECULOSIS Cough > 2 weeks Fever > 2 weeks Hemoptysis Significant Weight loss 20
  • 21.
    CASE DEFINITION A bacteriologicallyconfirmed TB case is one from whom a biological specimen is positive by smear microscopy or culture. 21
  • 22.
    CLINICAL DEFINITION A clinicallydiagnosed 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 practioner who has decided to give the patient a full course of TB treatment. 22
  • 23.
    DIAGNOSIS : MICROBIOLOGICALEXAMINATION  METHOD OF CHOICE  2 samples taken “ON THE SPOT” sample Early morning sample 23
  • 24.
    SLIDE REPORTING NUMBER OFBACILLI RESULTS NO AFB PER 100 OIL IMMERSION FIELDS 0 1 - 9 AFB PER 100 OIL IMMERSION FIELDS SCANTY 10 – 99 AFB PER 100 OIL IMMERSION FIELDS + (1+) 1 – 10 AFB PER OIL IMMERSION FIELDS ++ (2+) > 10 AFB PER OIL IMMERSION FIELDS +++ (3+) 24
  • 25.
    DIAGNOSIS : CHESTX RAY CONSOLIDATION CAVITARY LESION NODULE WITH POOR DEFINED MARGINS PLEURAL EFFUSION HILAR OR MEDIASTINAL LYMPHADENOPATHY 25
  • 26.
    DIAGNOSIS : CULTURE VerySensitive test Can detect as low as 10 – 100 bacilli per ml Media used : Solid Media: Lowenstein Jensen (LJ Medium) Liquid Media: Middle Brook, Dubos, Proskauer and Beck’s Combination of Solid and Liquid Media is now a days gold standard 26
  • 27.
    DIAGNOSIS : GENOTYPICAND PHENOTYPIC METHODS POLYMERASE CHAIN REACTION TRANSCRIPTION MEDIATED AMPLIFICATION AND NUCLEIC ACID AMPLIFICATION CARTRIDGE BASED NUCLEIC ACID AMPLIFICATION TEST (CB NAAT) FAST PLAQUE TB TEST 27
  • 28.
    TUBERCULIN TEST  Discoveredin 1907 by Von Pirquet  A positive test represents past or present infection with Mycobacterium tuberculosis  It is used as means of estimating Tuberculosis infection in the population. 28
  • 29.
    TUBERCULIN TEST  TUBERCULINTEST: 5 TUBERCULIN UNIT OF PPD-S IS USED AS 0.1ML INTRADERMALLY AND RESULTS ARE READ AFTER 48 TO 96 HOURS (72 HOURS IS BEST)  IN MANTOUX TEST : PPD-RT 23 IS USED AS 1 TUBERCULIN UNIT AS 0.1 ML  INTERPRETATION :  INDUARTIONS : < 6 mm : negative 6 – 9 mm : doubtful ≥ 10 mm : positive 29
  • 30.
    BAN ON TBSEROLOGY  The serological tests are based on antibody response, which is highly variable in TB and may reflect remote infection rather than active disease  Currently available serological tests are having poor specificity and should not be used for the diagnosis of pulmonary or extra pulmonary TB 30
  • 31.
    SCREENING OF TUBERCULOSIS COMMUNITY BASED: Who have had recent closed contact with person suffering from Tuberculosis  INSTITUTIONAL BASED: In health care facilities: Active screening of vulnerable individuals in hospitals In congregate Settings: Active screening of vulnerable individuals in shelters, old age homes, refugee camps and other locations such as work place. 31
  • 32.
    VULNERABLE GROUPS HIV PATIENTS DIABETICS CANCERPATIENTS PATIENTS ON IMMUNOSUPPRESSANTS HEALTH CARE WORKERS MALNOURISHED PERSONS ANTENATAL WOMEN 32
  • 33.
    VULNERABLE GROUPS PRISONERS OCCUPATIONS WITHRISK FOR DEVELOPING TUBERCULOSIS PEOPLE IN : NIGHT SHELTERS, DE ADDICTION CENTERS, OLD AGE HOMES 33
  • 34.
  • 35.
  • 36.
    LONG TERM CHEMOTHERAPY DAILYREGIMEN BI WEEKLY OR INTERMITTENT REGIMEN 36 18 MONTHS
  • 37.
    SHORT TERM CHEMOTHERAPY RAPIDBACTERIOLOGICAL CONVERSION LOWER FAILURE RATES REDUCTION IN EMERGENCE OF DRUG RESISTANT BACILLI PATIENT COMPLIANCE IMPROVES AND THEY BECOMES NON INFECTIOUS EARLY 37
  • 38.
    DIRECTLY OBSERVED TREATMENTSHORT COURSE (DOTS)  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 38
  • 39.
    DOTS CHEMOTHERAPY CATEGORY TYPEOF PATIENT INTENSIVE 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 39
  • 40.
    DAILY DOSE REGIMEN Standardsfor 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. 40
  • 41.
    CHANGES FROM DOTSREGIMEN  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 41
  • 42.
    CHANGES IN TREATEMENTPOLICY 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 42
  • 43.
    DAILY DOSAGE SCHEDULEFOR ADULTS WEIGHT CATEGORY NUMBER OF TABLETS TO BE CONSUMED Inj. Streptomycin 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 43
  • 44.
    MULTI DRUG RESISTANTTUBERCULOSIS TREATMENT 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 44
  • 45.
    XTENSIVE DRUG RESISTANTTUBERCULOSIS TREATMENT 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 45
  • 46.
    ALOGRITHM OF TBTREATMENT 46 CONFIRMED TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE
  • 47.
    ALOGRITHM OF MDRTB TREATMENT 47 CONFIRMED DR TB CASE START ATT INTENSIVE PHASE CONTINUATION PHASE ADDITIONAL 1 MONTH INTENSIVE PHASE SPUTUM NEGATIVE SPUTUM POSITIVE 4TH 5TH 6TH
  • 48.
    PEDIATRIC TUBERCULOSIS  Tuberculosisis 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 48
  • 49.
    DIAGNOSIS OF PEDIATRICTUBERCULOSIS  SPUTUM MICROSCOPY IS BEST METHOD TO DETECT TUBERCULOSIS  IN CASES WHERE SPUTUM IS NOT AVAILABLE: GASTRIC LAVAGE INDUCED SPUTUM BRONCHO ALVEOLAR LAVAGE 49
  • 50.
    TREATEMENT OF PEDIATRICTUBERCULOSIS 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) 50
  • 51.
    BOXES COMPOSITION YELLOW BOX (PC13) 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 PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg ISONIAZIDE : 150 mg RIFAMPICIN : 150 mg PURPLE BOX (PC 15) ISONIZIDE : 75 mg, RIFAMPICIN : 75 mg PYRAZINAMIDE : 250 mg, ETHAMBUTOL : 200 mg GREY BOX (PC 16) ISONIZIDE : 150 mg, RIFAMPICIN : 150 mg PYRAZINAMIDE : 500 mg, ETHAMBUTOL : 400 mg 51
  • 52.
    BOX WISE TREATMENTFOR CHILDREN 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 52
  • 53.
    WAY FORWARD… FIXEDDRUG COMBINATIONS 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 53
  • 54.
    BCG VACCINE AIM :TO REDUCE MORTALITY AND MORBIDITY FROM PRIMARY TUBERCULOSIS LIVE ATTENUATED VACCINE DANISH 1331 STRAIN IS USED FOR VACCINE PRODUCTION LIQUID AND FREEZE DRIED VACCINE ARE AVAILABLE 54
  • 55.
    BCG VACCINE DILUENT :NORMAL SALINE DOSAGE : 0.05ML UPTO 1 MONTH AND 0.1 ML UPTO 1 YEAR PROTECTION UP TO 15 TO 20 YEARS COMPLICATIONS : SUPPURATIVE LYMPHADENITIS, OSTEOMYELITIS, ULCERATION, BCG INFECTION AND DEATH 55
  • 56.
    RNTCP 56 NTP - 1962 RNTCP- 1997 RNTCP - 2006
  • 57.
    NTP RNTCP OBJECTIVE EARLYDIAGNOSIS AND TREATMENT BREAKING THE CHAIN OF TRANSMISSION OPERATION AL TARGETS NOT DEFINED 1. CURE RATE 85% 2. CASE FINDING 70% OF ESTIMATED CASES STRATEGY 1. SHORT COURSE CHEMOTHERAPY 2. CONVENTIONAL : LONG TERM DOMICILLIARY TREATMENT WITH INZ + THIACETAZONE 1. DOTS 2. UNINTERRUPTED DRUG SUPPLY DIAGNOSIS 1. MORE EMPHASIS ON x RAYS 2. 2 SPUTUM SMEARS 3. ONE SPUTUM POSITIVE IS CONSIDERED AS A CASE 1. MAINLY SPUTUM MICROSCOPY 2. TWO SPUTUM SMEARS 3. ONE SMEAR POSITIVE / CLINICALLY POSITIVE IS A CASE 57
  • 58.
    RNTCP : ORGANOGRAM58 CENTRAL TB DIVISION STATE TB CELL DISTRICT TB CENTRE TUBERCULOSIS UNIT DESIGNATED MICROSCOPY CENTRE PERIPHERAL HEALTH INSTITUTIONS 1 PER LAC POPULATION 1 PER BLOCK DR TB CENTRES C & DST LAB NATIONAL INSTITUTES
  • 59.
    LABORATORY NETWORK UNDERRNTCP NATIONAL REFERENCE LABORATORY (6) IRL (28) & CULTURE AND DRUG SUSCEPTIBILITY CENTRE (37) CB NAAT (628) DESIGNATED MICROSCOPY CENTERS (13888) 59
  • 60.
    QUALITY ASSURANCE PROGRAM The components of a quality assurance programme are:  Quality control  Quality improvement  Proficiency testing 60
  • 61.
    RNTCP I STRENGTHENIN GOF TB CELLS STRENGTHENING OF TRAINING INSTITUTES FOR TB GRADUAL IMPLEMENTATION OF STRATEGY STRENGTHENIN G OF NTCP UNINTERRUPTE D SUPPLY OF ANTI TB DRUGS 61
  • 62.
    RNTCP II Case detection with microscopy Un interrupted supplyof drugs Direct observation by health worker Systematic evaluation and monitoring Political and administrative commitment STRENGTHEN THE QUALITY OF DOTS DECENTRALIZED THE DOTS SERVICES PUBLIC PRIVATE ACTIVITIES TO INCREASE REACH TO DOTS RATIONALIZED USE OF 1ST AND 2ND LINE DRUGS GENERATE AWARENESS AND DEMAND FOR QUALITY SERVICES 62
  • 63.
  • 64.
    2000 2001 -03 2007 - 10 1.70% 1.50% 1.10% ANNUAL RISK OF TUBERCULOSIS INFECTION 2000 2001 - 03 2007 - 10 64 ACHIEVEMENTS
  • 65.
    ACHIEVEMENTS 2000 2005 20102013 216 209 185 171 INCIDENCE OF TUBERCULOSIS SINCE LAUNCH OF RNTCP PER LAKH POPULATION 2000 2005 2010 2013 65
  • 66.
    TARGETS UNDER RNTCP Detectionand treatment of about 87 lakh tuberculosis patients during the 12th five year plan. Detection and treatment of at least 2 lakh MDR TB patients during 12th five year plan. Reduction in delay in diagnosis and treatment of all types of TB cases Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups. 66
  • 67.
    END TB STRATEGY: VISION “To have a world Free of Tuberculosis with Zero Deaths, disease and sufferings due to TB and End the Global epidemic of TB” 67
  • 68.
    END TB STRATEGY: TARGETS 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 % 68
  • 69.
    3 PILLARS OFEND TB STRATEGY INTEGRATED PATIENT CENTERED TB CARE AND PREVENTION BOLD POLICIES AND SUPPORTIVE SYSTEMS INTENSIFIED RESEARCH AND INNOVATIONS 69
  • 70.
    NATIONAL STRATEGIC PLANFOR TUBERCULOSIS ELIMINATION 2017 - 2025 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 % 70
  • 71.
    STRATEGY UNDER NSP2017 - 2025 DETECT TREAT PREVENT BUILD 71
  • 72.
    BEDAQUILINE (BDQ)  TargetsMycobacterial 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 72
  • 73.
    SCHEDULE FOR BEDAQUILINE 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 73
  • 74.
    TREATMENT SCHEDULE 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 74
  • 75.
    99 DOTS STRATEGY 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 75
  • 76.
    NIKSHAY  TB surveillanceusing 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. 76
  • 77.
    NIKSHAY: COMPONENTS MASTER MANAGEMENT USERDETAILS TB PATIENT REGISTRATION AND DETAILS OF DIAGNOSIS DOT PROVIDER HIV STATUS FOLLOW UP CONTACT TRACING 77
  • 78.
    NIKSHAY: COMPONENTS DETAILS OFSOLID 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 78
  • 79.
    PUBLIC PRIVATE MIXDOTS IN INDIA  RNTCP launched the PPM DOTS Model for additional TB case detection with good quality treatment success rates in 2003.  Impact of this model : 79 Reduced financial burden on patient and society Reached the people from lower socio economic groups Helped in treatment observations
  • 80.
    PUBLIC PRIVATE MIXDOTS IN INDIA  PRESENT STATUS NGOs : 2500 PRIVATE PRACTIONERS : 25000 MEDICAL COLLEGES : 260 CORPORATE HOUSES: 150 80
  • 81.
    TB ADVOCACY, COMMUNICATIONAND SOCIAL MOBILIZATION SCHEME SPUTUM COLLECTION CENTRES SPUTUM PICK UP AND TRANSPORT SCHEME DESIGNATED MICROSCOPIC CENTRE SCHEME LABORATORY TECHNICIAN SCHEME CULTURE DST SCHEME TREATMENT ADHERENCE SCHEME 81PUBLIC PRIVATE MIX DOTS IN INDIA
  • 82.
    SUMMARY  Tuberculosis iscaused by Mycobacterium tuberculosis, which spread by either human or bovine routes.  Clinical features include cough, fever and weight loss and is diagnosed by microscopic examination followed by Chest X ray and other genotypic and phenotypic tests.  Tuberculosis is treated by DOTS strategy, with the recent launch of fixed drug combinations. 82
  • 83.
    SUMMARY  RNTCP waslaunched as a continuation program of NTP in 1997 followed by launch of second phase of RNTCP in 2006.  With the achievements under MDG goals and launch of sustainable goals, END TB STRATEGY was launched with the objective to reduce incidence of TB Prevalence. 83
  • 84.
    REFERENCES  K PARKSTEXTBOOK OF SOCIAL AND PREVENTIVE MEDICINE, 24TH EDITION  JUGAL KISHORE’S TEXT BOOK OF NATIONAL HEALTH PROGRAMS, 11TH EDITION  WHO DOCUMENT ON STRATEGY TO CONTROL TUBERCULOSIS IN INDIA  NATIONAL STRATEGIC PLAN TO END TUBERCULOSIS 2017 – 22 , MOHFW 84
  • 85.
  • 86.
    HIGH RISK CASESOF TUBERCULOSIS PLHIV DIABETES CANCER PATIENTS PERSONS ON IMMUNOSUPPRESANTS 86
  • 87.
    DIAGNOSIS : TUBERCULIN TESTAND INTERFERON GAMMA RELEASE ASSAY  NOT RECOMMENDED FOR THE DIAGNOSIS OF ACTIVE TUBERCULOSIS  STANDARDIZED TUBECULIN SKIN TEST MAY BE USED AS COMPLIMENTARY TEST IN CHILDREN 87
  • 88.
    DIAGNOSIS : CBNAAT  CARTIDGE BASED NUCLEIC ACID AMPLIFICATION TEST  FIRST DIAGNOSTIC TEST AMONG CHILDREN AND PL-HIV 88
  • 89.
    NATIONAL RESEARCH LABORATORY89 NATIONAL REFERENCE LABORATORY
  • 90.
    ZIEHL NELSON ACIDFAST STAINING 90 FIX THE SMEAR ON SLIDE BY PASSING THE SLIDE THROUGH FALME 3 TIMES COVER WITH CARBOL FUSCHIN AND STEAM FOR 5 MIN AND WASH WITH WATER DECOLORIZE WITH 3 % ACID ALCHOHAL AND WASH WITH WATER COUNTER STAIN FOR 1 MIN WITH LOEFFLER’S METHYLENE BLUE WASH IT WITH DE IONIZED WATER
  • 91.
    INTERMEDIATE REFERENCE LABORATORY ONEIRL HAS BEEN DESIGNATED TO EACH STATE TUBERCULOSIS TRAINING AND DEMONSTRATION CENTRES / PUBLIC HEALTH LABORATORY / MEDICAL COLLEGES 91
  • 92.
    CERTAIN DEFINITIONS NEW PATIENTS: “Patientwho have never been treated for TB or taken anti TB drugs for less than 1 month” PREVIOUSLY TREATED TB PATIENT “Patient who received 1 month or more of anti TB drugs in past” 92
  • 93.
     RELAPSE PATIENTS:patients who were 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.  TREATMENT AFTER FAILURE: patients who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. 93 CERTAIN DEFINITIONS
  • 94.
    MULTIDRUG RESISTANCE :resistance to both Rifampicin and Isoniazid at least EXTENSIVE DRUG RESISTANCE : Resistance to any fluoroquinolone and at least one of the three 2nd 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. 94 CERTAIN DEFINITIONS
  • 95.
    PREVENTION  Cough etiquettesnot being followed  Indiscriminate spitting  Sneezing without covering face  Alcoholics and mentally challenged patients  Delay in reaching health facility for specific diagnosis 95

Editor's Notes

  • #6 History goes back to 9000 years Discovered in Mummies of Egypt dated back to 3000 BC Mentioned in Atharveda, Yajurveda and Sushruta Samita dated back to 1500 BC Many theories for disease transmission were given till 19th Century In 1882, Robert Koch discovered the Tubercle Bacilli during his discovery of Anthrax Bacilli. In 1906, BCG vaccine was discovered by Albert Calmitte and Camillee Gueirin
  • #7 Treatment history : Till 20th century Tuberculosis treatment was with pneumothorax with the view that collapse can rest lung and thus heals the disease In 1944, 1st antibiotic was discovered : Streptomycin In 1952, 1st oral anti tubercular drug discovered : isoniazid In 1970, major revolution in tuberculosis treatment with discovery of Rifampicin 1980s : Antibiotic resistant strains emerge 1990s : DOTS strategy to combat Tuberculosis was launched by WHO
  • #9 Total 10.4 million cases of TB were reported across the globe, with 1.8 million deaths including 0.4 million deaths among HIV positive patients
  • #12 2.8 MILLION NEW CASES ARE DETECTED ANNUALY IN INDIA IN 2015 CONSTITUTING 27% OF GLOBAL INCIDENCE OF TB
  • #15 Tuberculosis still one of the leading cause of global burden of disease in most developing countries 32.2 million years are lost annually DALY PREMATURE DEATH CONTRIBUTES 80% BURDEN OF TUBERCULOSIS IN TERMS OF DISABILITY ADJUSTED LIFE YEARS (DALY) 3 LAKH CHILDREN LEAVES SCHOOL BECAUSE THEIR PARENTS ARE SUFFERING FROM TB 1 LAKH WOMEN LOSE STATUS OF WIFE AND MOTHER BECAUSE OF SOCIAL STIGMA
  • #17 AGENTS : MYCOBACTERIUM TUBERCULOSIS MYCOBACTERIUM KANSASSI MYCOBACTERIUM AVIUM MYCOBACTERIUM SCROFULACEUM
  • #19 CONSTITUTIONAL FACTORS : GENETIC PREDISPOSING FACTORS, HLA IS RESPONSIBLE, DR2 GENE HORMONAL FACTORS : CORTICOSTEROIDS ACTIVATES LATENT TUBERCULAR LESIONS AND STIMULATE THE RATE OF MULTIPLICATION OF BACILLI AGE: MORE COMMON IN AGE GROUP OF 15 – 45 YEARS SEX : BOTH SEXES ARE EQUALLY EFFECTED
  • #24 DONE FOR ALL PATIENTS WHO ARE CAPABLE OF PRODUCING SPUTUM
  • #26 Use as screening tool Useful to detect sputum negative tuberculosis X rays are useful to detect pleural and pericardial effusion Essential for diagnosis of military tb
  • #30 IMPORTANCE OF TUBERCULIN TEST: ESTIMATION OF PREVALENCE OF INFECTION PROGNOSTIC IMPORTANCE
  • #37 THE CLASSICAL LONG TERM CHEMOTHERAPY WAS BASED ON ISONIZIDE WITH A BACTERIOSTATIC DRUG
  • #38 FOR A LONG TIME THE STANDARD DURATION OF TUBERCULOSIS CHEMOTHERAPY WAS 18 MONTHS . IN 1972 WALLACE FOX AND HIS COLLEAGUE MADE IT POSSIBLE TO REDUCE THE DURATION OF TREATMENT THE SHORT COURSE CHEMOTHERAPY PROVIDED FOLLOWING ADVANTAGES
  • #54 WORLD TB ALLIANCE HAS ANNOUNCED IN 2015 ABOUT THE FIXED DRUG COMBINATIONS TILL NOW ACCEPTED BY 18 COUNTRIES IN THE WORLD YET TO BE LAUNCHED BY INDIA
  • #61 Quality assurance with regard to tuberculosis bacteriology is a system designed to continuously improve the reliability, efficiency and use of the tuberculosis laboratory services
  • #62 EMPHASIS ON CURE OF INTECTIOUS AND SERIOUSLY ILL PATIENTS OF TUBERCULOSIS THROUGH ADMINISTRATION OF SUPERVISED SHORT COURSE CHEMOTHERAPY TO ACHIEVE A CURE RATE OF AT LEAST 85% AUGMENTATION OF THE CASE FINDING ACTIVITIES TO DETECT 70% OF THE ESTIMATED CASES, ONLY AFTER HAVING ACHIEVED THE DESIRED CURE RATE To ensure a systematic and speedy introduction of Revised National Tuberculosis Control Program without sacrificing quality control, a series of interventions are being introduced that has modified the functioning of NTCP these were:
  • #64 CURE RATE INCREASED FROM 25 % TO 88% WHILE DEATH RATE DECLINE 7 FOLD FROM 29 % TO 4% IN 2015
  • #68 END TB STRATEGY launched by World Health Organization in 2014, with the vision:
  • #69 WITH SUSTAINABLE GOALS AIMS TO END TB EPIDEMIC BY 2030, THE END TB STRATEGY AIMS FOR A WORLD FREE OF TUBERCULOSIS
  • #71 The NSP 2017-2025 builds on the success and learnings of the last NSP and encapsulates the bold and innovative steps required to eliminate TB in India by 2030. FOLLOWING TARGETS WERE SET UNDER NSP FOR 2017 - 25
  • #72 DETECT: Find all DS-TB and DRTB cases with an emphasis on reaching TB patients seeking care from private providers and undiagnosed TB in high-risk populations. TREAT: Initiate and sustain all patients on appropriate anti-TB treatment wherever they seek care, with patient friendly systems and social support. PREVENT : Prevent the emergence of TB in susceptible populations BUILD : Build and strengthen enabling policies, empowered institutions and human resources with enhanced capacities.
  • #90 Six national reference laboratories established in India NATIONAL INSTITUTE FOR RESEARCH IN TUBERCULOSIS, CHENNAI NATIONAL TUBERCULOSIS INSTITUTE, BANGALORE LALA RAM SWAROOP INSTITUTE OF TUBERCULOSIS AND RESPIRATORY DISEASES, NEW DELHI NATIONAL JAPANESE LEPROSY MISSION FOR ASIA (JALMA) INSTITUTE FOR LEPROSY AND OTHER MYCOBACTERIAL DISEASES REGIONAL MEDICAL RESEARCH CENTRE, BHUBNESHWAR BHOPAL MEMORIAL HOSPITAL AND RESEARCH CENTRE, BHOPAL MONITOR IRL’S, DST CENTRES, CBNAAT ACTIVITIES TRAINING MAINTAIN EQA WITH PERIODIC CHECKING OF IRL, C AND DST CENTRES