Tuberculosis



 TUBERCULOSIS 

Definition:

Tuberculosis is a chronic infectious disease caused by tibercle bacilli (Mycobacterium tuberculosis).The disease primarily affects lungs and causes pulmonary tuberculosis. It can also affect intestine, meninges, bones and joints, lymph glands, skin and other tissues of the body.The disease also affects animals such as cattle; this is known as " bovine tuberculosis " which may sometimes be communicated to man. Pulmonary tuberculosis, the most important form of tuberculosis which affects man, will be considered here.


Tuberculosis Problem:

(A) WORLD:

Tuberculosis  remains a worldwide public health problem  despite the fact that highly effective  drugs and vaccine are available  making tuberculosis a preventable and curable disease.

  During  the 2013, there were an estimated  9.0 million incident cases of tuberculosis globally, 1.1 million cases of HIV associated  with tuberculosis   ; and 1.5 million  deaths including  0.36 million  deaths in HIV_ positive patients. In the same year, there were an estimated  0.48 million  cases of multidrug _ resistant  tuberculosis  ( MDR_ TB) and about 0.2 million deaths associated  with MDR_ TB, and about 9 per cent cases of MDR_ TB  were  cases  of extensively drug resistant  ( XDR) tuberculosis . Drug resistant strains of tuberculosis  including   XDR_ TB, have been found in every country where they have been sought. As in previous years, 85 per cent of all tuberculosis cases occur in WHO region of South_ East Asia ( 39 per cent ), Afruca ( 27 per cent ) and Western Pacific ( 19 per cent).

  It  is  estimated that about one_ third of the current global population  is infected asymptomatically with tuberculosis , of whom 5_ 10 per cent will develop  clinical disease during their lifetime. Most new cases and deaths occur in development  countries  where infection is developing countries where infection is often acquired in childhood. The annual risk of tuberculosis  infection  in high Burden countries is estimated  to be 0.5__ 2 per  cent.


  In  many  developing  countries  particularly in Asia, acquired drug resistance  remains high, because national tuberculosis  control programmes in these countries have  not been able to achieve a high cure rate over a very long period of time, even after the introduction of short __ course chemotherapy . Poverty, economic  recession,  malnutrition,  overcrowding, indoor air pollution, tobacco,  alcohol  abuse and diabetes make populations more vulnerable to tuberculosis. Increase in human migration has rapidly mixed infected with uninfected communities.  To make global situation  worse, tuberculosis has formed a lethal combination with HIV.

  People who are infected with both HIV and tuberculosis are 25__ 30 times more likely to develop  tuberculosis   disease, than people infected  only  with TB. This is because HIV stops the immune system working effectively  and tuberculosis bacilli are able to multiply  rapidly. In developing countries  HIV associated tuberculosis is very common.


  Globally , th  DOTS strategy  has been recognized as the best cost _ effective  approach  to tuberculosis  control which is now presented  as Stop TB Strategy 

The advantage  of DOTS  are :

(a) Accuracy of TB diagnosis  is more than double.

(b) Treatment success rate is up to 95 per cent.

(c) Prevent th spread of the tuberculosis  infection, thus reducting the incidence and prevalence of tuberculosis. 

(d) Improves quality  of health  care and removes stigma  associate  with TB.

(e) Prevents  failure   of treatment and the emergence of MDR_ TB by ensuring  patient adherence and uninterrupted  drug supply.

(f) Helps alleviate  poverty  by saving lives, reducing duration of illness  and presenting spread of infection.

(g) Lends credibility  to TB control efforts.

 

  The target of  DOTS  programme is successful treatment  or cure rate  of 85 per cent of new smear positive cases, and detection  of  70  per  cent of  such cases.

 The WHO has set International Standards for tuberculosis  care.These standards are intended to facilitate the effective engagement  of all care for patients of all ages, including those with smear_ positive, smear __ negative , extrapulmonary tuberculosis , drug _ resistant  tuberculosis, and tuberculosis  combined  with HIV infection. 



(B) INDIA: 

India  is the highest TB burden country in the world  and accounts for nearly one_ fifth of global Burden of tuberculosis. 

  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 11 million patients are on DOTS treatment  so far, and about 2 million additional lives have been cut 7_ folds from 29 per cent to around 4 per cent in smear positive cases.

    In  the year 2013, the programme has achieved  case detection rate of 67 per cent as against target of 70 per cent. Treatment success achieved consistently is  about 87 per cent .Tuberculosis  estimates in the country. The Indian scenario about DOTS programme has been discussed in detail *



Epidemiological indices :

  Indices or Parameters are needed to measure  the tuberculosis  problem in a community as well as for planning  and evaluation of control measures. Indices are also required for international comparison. The following used in tuberculosis  problem measurements and programme strategy : 


(a) Prevalence of infection: It is the percentage of individuals who show a positive  reaction to the standard tuberculin test. When the test is done in defined age_ groups, it yields age_ specific prevalence. 


(b)  Incidence  of Infection  : ( Annual Infection Rate)  : It is the percentage of population  under study who will be newly infected by Myco. tuberculosis among the non__ infected  of the  preceding  survey  during the course of one year. It reflects  the annual  risk of being infected ( or  reinfected ) in a given community. 

(c) Prevalence of disease or case  rate : It is the percentage of individuals whose sputum is positive for tubercle bacilli on microscopic examination. It is the best available practical index to estimate the number of infectious cases or " case load" in a community. 

(d) Incidence of new cases : It is the percentage of new tuberculosis cases ( confirmed by bacteriological examination) per 1,000 population  occurring during one year.

(e) Prevalence of drug _ resistant cases : It is the prevalence of patient excreting  tubercle bacilli resistant to anti __ tuberculosis drugs . This index is directly related to chemotherapy.

(f) Case detection rate : The case detection  rate is calculated as the number of  notifications of new  and relapse cases in a year, divided by the estimated incidence of such cases in the same year.

(g) Mortality  rate: The number of deaths from tuberculosis  every year per 1,000 or 100,000 population. 



Some definitions of tuberculosis cases and treatment:

Case of Tuberculosis: A patient in whom tuberculosis has been confirmed by bacteriology or diagnosed by a clinician. 

 Sputum smear examination __ Laboratory technique  to screen sputum for tuberculosis, where Acid Fast Bacilli  ( AFB) are stained red by the Ziehl Neelsen method, and then identified and counted using microscope. 

  Smear positive tuberculosis __ At least one initial sputum smears positive for AFB  in  a well  functioning  external quality assessment ( EQA) system.


  Smear negative  tuberculosis __ At least two negative  smears, but tuberculosis  suggestive symptoms and X__ ray abnormalities or positive culture.


  Adherence __ Person takes appropriate drug regimen for required time ( also known  as compliance).

 New case __ A patient  with sputum positive pulmonary tuberculosis who has never had treatment for tuberculosis or has taken anti_ tuberculosis drugs  for less than 4 weeks.


Relapse __ A patient  who returns smear positive having previously  been treated for tuberculosis  and declared cured after the completion of his treatment. 

Failure case__ A patient who was initially smear positive, who began treatment and who remained or  became smear positive again at five months or later  during the course of treatment. 

Return after default __ A patient who returns sputum smear positive,  after having left treatment  for at least two months.

Transfer in __ A patient recorded in  another administrative area register and transferred into another area register and treatment ( treatment  results should be reported to the district where the patient was initially  registered).


Transfer out _ A patient who has been transferred to another  area register and treatment results are not known.

Cured __ Initially smear positive patient who completed treatment and has negative smear result on at least two occasions ( one at treatment completion).


  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 bend.

 Cohort __ A group of patient in whom TB has been diagnosed,  and who were registered for treatment during a specified time period ( e.g., the cohort of new smear _ positive cases registered in the calendar year 2010). This group  forms the denominator for calculating treatment  outcomes.The sum of the treatment  outcomes, plus any case for which no outcome is recorded ( e.g., still on  treatment) should equal the number of cases registered. 








Tuberculosis causes: 


Tuberculosis, also known as TB, is caused by a bacterium called Mycobacterium tuberculosis. This bacterium is spread through the air when an infected person coughs, sneezes, speaks, or sings or talks, tiny droplets containing the bacteria can be inhaled by others and infect their lungs. TB can also spread to other parts of the body, such as the brain, spine, or kidneys, through the bloodstream. Tuberculosis is a highly contagious disease and is one of the leading causes of death worldwide. It is primarily transmitted through close contact with an infected person, prolonged exposure in crowded places, or living in unsanitary conditions. Weakened immune systems, such as those caused by HIV infection, increase the risk of developing active tuberculosis.  It can be contracted when someone inhales the bacteria from the air.




Certain factors can increase the risk of developing tuberculosis, including:

1. Weakened immune system: People with weakened immune systems, such as those with HIV/AIDS, malnutrition, or certain medical conditions, are more susceptible to tuberculosis.

2. Close contact with an infected person: Spending time with someone who has active TB increases the risk of infection.

3. Living in crowded or unsanitary conditions: Poor living conditions and close quarters with infected individuals can contribute to the spread of TB.

4. Traveling or living in areas with high TB rates: TB is more common in certain regions, especially in sub-Saharan Africa, India, China, and Southeast Asia.

5. Substance abuse: Intravenous drug use and excessive alcohol consumption can weaken the immune system, making individuals more vulnerable to TB.

It's important to note that not everyone infected with the bacteria will develop active tuberculosis disease. In some cases, the bacteria can remain dormant in the body for years without causing symptoms. This is known as latent tuberculosis infection. However, if the immune system weakens, the infection can become active and lead to tuberculosis disease.





Epidemiological Factors:

1): Agent : Of importance to man is the " human strain" of M.tuberculosis which is responsible  for the vast majority of cases. The " bovine" strain affects cattle and other animals.

2):Source of infection : There are two source of infection _ human and bovine. 

(i) Human source : The main source of infection  is the patient whose sputum is positive for tubercle bacilli.Their  early diagnosis is essential in any tuberculosis control programme. 

(ii) Bovine source : The bovine source of infection is usually infected milk and milk products. 

3): Age : Tuberculosis  can occur at any age. The disease prevalence was found  to be more in the 15_54 years age groups  than in the younger age groups. 

4): Sex : The disease is prevalent  more in males than in females.

5): Rural and urban areas: Occurrence of tuberculosis  is equal in urban and  rural areas. 

6): Social factors:Tuberculosis  is more likely  to occur in persons :_

(i) Who are malnourished 

(ii) Who live in overcrowded houses, and 

(iii) Where strandeds of hygiene are poor.

7): Period of infectivity: Tuberculosis is infectious as long as the bacilli are excreted  in the sputum by the human host. This may be form several months to a few years, if the case is not adequately treated.

8): Immunity : Man has no inherent immunity against tuberculosis. It is acquired as a result of national infection  or BCG vaccination. 

Mode of transmission:

(a) Droplet infection: Tuberculosis  is spread mainly by droplet infection by an infectious case. Coughing generates the  largest number of droplets .

(b) Other ways  : Pulmonary tuberculosis is also transmitted by inhalation of infected  dust.

Incubation period :

This may be weeks or months, depending  upon the host_ parasite relationship  and the dose of infection. 

Clinical Features:

The  commonest  signs and symptoms  which are likely  to bring the patient to medical  care institutions are :

 a .    Chronic  cough 

b.    Continuous low grade fever

c.   Chest pain

d. Haemoptysis 

e. loss of weight.

 These are referred  to as " symptomatics" or symptoms suggestive of pulmonary  tuberculosis. 

Tuberculosis  testing :

The tuberculosis  ( Mantous)  test was developed in 1907. By this test, we can find out those people who are " infected" by the tubercle bacilli  and those who are not .( It should be noted that in tuberculosis " infection " does not mean " disease "). Only 2 to 4 per cent of the infected population develop active tubercular disease  during their life.


  The tuberculin test is carried out by injecting intradermally one tuberculosis  unit ( TB) of purified protein derivative of tuberculin ( PPD) into the forearm. The result is read on the third day ( 72 hours).The test is  read as " positive" if there is swelling of at least 10 mm in diameter at the  site  of injection; the redness of the skin is not taken into consideration. Reactions under 5 mm are considered " negative". Those between  6 and 9 mm are considered  " doubtful ". A positive test indicates that the person is infected by tubercle bacilli. Those who are negative should be given BCG vaccine. 

  CONTROL OF TUBERCULOSIS:

The basic principles of tuberculosis control are:

  a.  Early case finding

b. Chemotherapy 

c. BCG vaccination 

d. Health  education. 

a. Early case finding :

  The first step in a tuberculosis control programme is early detection of all " cases" in the community.  The WHO defines a " case" of Pulmonary tuberculosis as a person whose sputum is positive for tuberculosis  bacilli. 


  Sputum examination  : Sputum examination  by direct microscopy is now considered the method of choice for early detection of cases. The reliability, cheapness,  and ease of direct sputum examination has over the world.It enables us to discover the epidemiologically most important cases of tuberculosis, i.e., those excreting  tubercle bacilli in their sputum.This is the group which contributes most of the new cases to the " pool of infection" in the community. Sputum should be examined from any patient presenting one or more of the following symptoms of respiratory disease:

(i) Cough  lasting more than two weeks;

(ii) Continuous fever; 

(iii) Chest pain, and 

(iv) Haemoptysis or spitting  of blood.

      Under the National Tuberculosis  Control Programme,  case_ finding is an important activity. In order to improve  case finding, the Government  of India in the Mjnistry of Health and Family Welfare  have fixed targets of case detection. Two sputum smears are collected for microscopy. Sample one is provided by the patient " on the spot". Next day patient  brings early morning  sputum sample ( sample 2). Secretions are built up in the airways overnight . So an early morning  sputum sample is more likely  to contain tuberculosis  bacilli than one taken later in the day.


  One specimen out of the two is enough  to declare a patient as smear positive TB. Smear positive TB  is further classified   as a new or retreatment case based on previous treatment history, and appropriate therapy is prescribed. Patients in  whom both  specimens are smear negative should be prescribed symptomatic treatment and broad_ spectrum antibiotics such as fluoroquinolones ( ciprofloxacin, ofloxacin, etc). rifampicin or streptomycin, which are active against TB, should not be used . Most patients are likely to improve with antibiotics if they are not  suffering from TB. If the symptoms persist after a course of broad_ spectrum antibiotic, repeat sputum smear examination ( 2 samples) must be done  for such patients. If one or more smear are positive, the patient is diagnosed as having  smear_ positive Pulmonary TB. If none of the repeat sputum  specimen is positive, a chest X _  ray are consistent with pulmonary  TB, the patient is diagnosed as a case of sputum _ negative  pulmonary  TB. 


b. Chemotherapy:

          Chemotherapy has completely revolutionized the treatment  of pulmonary tuberculosis. The objective  of chemotherapy is to achieve " bacterial cure" rapidly. Current chemotherapy is based on multiple drugs ( short _ course chemotherapy) with the addition of rifampicin, ethambutol and pyrazinamide to conventional drugs ( i.e., streptomycin and INH). The potent regiments of short_ course chemotherapy have reduced the direction of treatment  from  18 months to 6__ 8 months. 
    
     The drugs are provided in patient _ wise boxes for alternate day treatment . The cases are divided into three types of categories  __ Category  I , Category  II  and  Category  III. The type of cases included in each category , the treatment  regimen and duration  of treatment regimen  and  duration of  treatment. 










   Every patient diagnosed  by sputum examination  should be put on multi _ drug treatment. If treatment  is  irregular or interrupted, the patient may develop drug resistance and it becomes more difficult  to treat the patient.

  Each Health  Worker ( male) keeps a list of TB patients  on treatment  in his area. During his  home visits, he verifies whether the patient is consuming  the prescribed drugs. Chemotherapy requires patients full cooperation. 


DOTS:

Every since WHO declared tuberculosis  a global emergency in 1993 DOTE ( direct observed treatment, short _ course) is the recommended  strategy for global  tuberculosis control. During the intensive phase of chemotherapy all the drugs are administered under direct supervision.  DOTS is a community based tuberculosis  treatment and care strategy which combines the benefits of supervised treatment, and the benefits of  community based care and support. It ensures high cure rates through its three components: appropriate medical treatment, supervision and motivation by a health or non_ health services.  DOTS will be given by peripheral health staff such as MPWs, or through voluntary workers such as teachers,  anganwadi workers, dais, ex_ patients, social workers etc. They are known as DOT " Agent" and are paid incentive / honorarium of Rs. 150 per patient completing the treatment. 

c.  BCG vaccination 

          BCG vaccine ( Bacille Calmette Guerin) is a " live" vaccine.It is prepared from living attenuated bovine strain of tubercle bacilli. In all countries,  freeze_ dried vaccine is used. The does of the vaccine  is 0.1 ml. For infants below the age of one month thr dose is 0.05 ml. The vaccine is administered intradermally  using a " tuberculin" syringe. The usual site of injection is just above the insertion of the  deltoid of the left arm. 

    BCG vaccine can  be given soon  after birth. The  national  immunization policy is to given BCG when  the infant is 6 weeks old along with DPT ( but in different arms) and oral polio. BCG can be  given directly  without a prior tuberculin  test to those below 20 years of prior tuberculin test to those below 20 years  of age. After the age of 20 years, BCG is given  only to those who are tuberculin _ negative. 

     BCG does not give  100 per  cent protection  against  tuberculosis;  the protection  is about 80 per cent .The immunity after  BCG vaccination lasts for about 15__ 20 years. 

Contraindications:Unless  specifically indicated, BCG should not be given to patients suffering from generalized  eczema, infective dermatosis, hypogammaglobulin_ aemia, to those  with a history of deficient  immunity ( symptomatic  HIV  infection, known or suspected congenital immunodeficiency, leukaemia, lymphoma or generalized malignant diseases), patients under immuno _ suppressive treatment  ( corticosteroids, alkhlating agents, antimetabolites, radiation), and in pregnancy. The effect of BCG may be exaggerated  in these patients. 

Drug resistance:

Drug resistance means that certain strains of tuberculosis bacilli are not killed by the anti_ tuberculosis drugs given during the  treatment. Some strains can be resistant to one or more drugs.

Definitions : 

(a) MULTI_ DRUG RESISTANT TUBERCULOSIS:

   WHO defines a multi_ drug resistant ( MDR) strain as one that is at least resistant to isoniazid  and rifampicin. 


(b) EXTENSIVELY DRUG RESISTANT  TUBERCULOSIS: 

   Cases of TB that are resistant  to almost all second_ line drugs are extensively  drug resistant  tuberculosis  ( XDR_ TB) and are defined as occurring  when M. tuberculosis  is resistant  to:_ 

1): At least rifampicin  and isoniazid  ( i.e. MDR_ TB)

2): Resistant to a fluoroquinolones, 

3): Resistant  to one or more of the following  second line injectable drugs: amikacin, capreomycin, kanamycin.

    Drug resistance  is caused by inadequate  treatment and poor tuberculosis  control Programmes. The most common reasons for the development of resistant are :

(a)  Incorrect prescription;

(b) Irregular  supply of drugs ; 

(c)  Non_ compliance of  treatment , 

(d) Lack of supervision  and follow _ up.

Tuberculosis and HIV:

Worldwide the number of people  infected with  both HIV and tuberculosis  is rising. To make the global situation  worse, tuberculosis has formed a lethal Partnership with HIV. The HIV virus damages the body's  natural defence  _  the immune system  _ and  accelerates the speed at which tuberculosis  progresses from a  harmless infection to life_ threatening conditions. The estimated 10per  cent activation of  dormant tuberculosis  infection  over the life span of an infected  person, is increased  to 10 per cent activation in one year,  if  HIV  infection is  superimposed. Tuberculosis  is already  the opportunistic infection  that most frequently  kills  HIV __ positive people.

      Even in HIV positive cases, tuberculosis  can be cured if diagnosed in time and treated properly. Good TB control  programme ( DOTS) is the best thing that can be done to  cure   and  extend the lives of HIV positive individuals.  With  correct TB treatment,  the HIV positive person having tuberculosis can gain, on an average  two additional  years  of life. 


(d)  Health  education  :

   No anti__ tuberculosis  programme  can  have a lasting effect unless coupled  with health  education.  TThe health education  programme should  be  directed  to motivating patients  for undergoing  regular  treatment  and follow _ up  disposal of sputum  and cooperation  with agencies with agencies   administering  the programme.


Nursing  care :

   Admission  to hospital  confers no benefit  for most patients.  There are some situations where admission  to hospital  may be considered  __ ill patients  who need nursing  care and those who develop  drug reactions.  There is rarely any need for isolation,  because  infection will have spread  in   the  weeks and months  before diagnosis.

  Barrier  nursing, disinfection of materials and special disinfection  procedures are  totally  unnecessary . Urine and  stool and  would  discharges  are  all non_ infectious. 

Revised National  TB Control Programme:

  National Tuberculosis  programme  ( NTP) has been in operation  since 1962.

  The revised strategy was introduced  in the country  as pilot  project in   1993, and large scale  implementation  began in late 1998 .The RNTCP has expanded  rapidly over the years and now covers  the  whole country . The RNTCP has now entered  into it's  second  phase in  which  the programme  aims  to consolidate  the gains made  to date, to widen services  in terms of activities, and access, and to sustain the achievements.The new initiatives  and the wider collaboration with  other  sectors  aim to provide standardized treatment  and  diagnostic  facilities  to all TB patients  irrespective  of the health  care facility it also envisages improved  access  to marginalized  groups such as  urban slum dwellers  and tribal  groups etc.

        RNTCP phase II is built upon infrastructure already  established by the previous  national  tuberculosis  programme, while incorporating  the elements  of the internationally   recommended  DOTS.

   The salient features  of this  strategy  are : 

(1) Achievement  of  at least 85 per cent cure rate of infectious  cases through  supervised  Short Course  Chemotherapy  involving peripheral  health  functionaries;


(2):  Augmentation  of  case finding activities through  quality  sputum microscope  to detect  at  least 70 per cent estimated  cases; 

(3) : Investment  of NGOs; Information, Education  and  Communication and improved operational  research. 


ORGANIZATION 

     The profile of RNTCP in a state is as follow :

State Tuberculosis        _        State
     Office                                     Tuberculosis 
                                                      Officer

State Tuberculosis      _    Director 
Training  and 
Demonstration Centre 

District  Tuberculosis   _   District 
Centre                                  Tuberculosis  
                                                 Officer

Tuberculosis  Unit       _   Medical 
                                               Officer _ TB
                                                  Control
                                          _  Senior
                                                      Treatment 
                                                    Supervisor 
                                            _  Senior TB
                                               Laboratory 
                                             Supervisor 

Microscope  Centres, treatment Center 

DITS providers 

LABORATORY NETWORK 

   A nation_ wide network of  RNTCP  quali assured  designated sputum  smear  microscopy laboratories  has  been set up, providing  appropriate,  available, affordable and accessible diagnostic services for TB suspects and cases.

Initiation  of treatment:

  Under the RNTCP active case finding  is not  pursued. Case finding is  passive.Patients  presenting themselves with symptoms suspicious of tuberculosis  are screened through  two sputum  smear  examinations. Sputum  microscopic  examination is  done  in  designated   RNTCP microscope centres. Microscopy  centres are established in  the districts  for  every one  lakh population. They are located either in  the CHC, PHC, Taluka Hospitals or in  the  TB  dispensary . Each centre has  a skilled  technician to ensure quality control, a senior  TB laboratory  supervisor  is appointed for every 5 microscopy centres.The senior  TB laboratory  supervisor re_ checks all the positive slides and  10 per  cent of  the negative  slides  of  these five microscope  centres. Thus the error  in  diagnosing  a patient is   minimized. It is  essential   to examine  2  sputum   sample  is  not sufficient  for  diagnosis  as the chance  of detecting  smear positive case  is  only 80 per cent.  Sputum microscopy not only confirms the diagnosis, but also indicates the degree of infectivity  and  response to treatment. The criteria  of  diagnosis and  initiation of treatment. 



        Diagnosis of tuberculosis in RTCP

  All patients are provided  short _ course chemotherapy free of charge. During  the intensive phase  of  chemotherapy all the  drugs are administered under direct  supervision called  Direct Observed Therapy  Short _ term ( DOTS).DOTS  is  a community _ based tuberculosis treatment  and care strategy which  combines the benefits of supervised treatment, and the  benefits of community _ based care and support. It ensures high cure rates through its  three components: appropriate medical treatment, supervision and  motivation by a health  or non_ health worker, and  monitoring  of disease status by the health  services. DOTS is  given  by  peripheral  health  staff  such  as MPWs, or through  voluntary workers such as teachers, anganwadi workers, ASHA, dais, ex_ patients, social  workers etc. They are  known  as DOT  ' Agent' and  paid incentive/ honorarium of Rs 150 per  patient  completing  the  treatment. 

  The success of DOTS depends on five components:

☆ Political commitment 

☆ Good quality sputum  microscopy 

☆Directly  observed treatment 

☆ Uninterrupted supply of  good  quality  drugs, and 

☆ Accountability 

   All  drugs are supplied  in patient _ wise boxes containing the full course of treatment, and  packaged in   blister   packs. For  the  intensive phase,  each blishter pack contains one day's  medication. For  the  continuation  phase, each  blister  pack contains  one weeks  supply  of  medicatio. The  combipack drugs for  extension  of   intensive phase are supplied  separately.  The boxes are coloured  according  to the category I  patients and blue  for  category II patients. 


Paediatric  Tuberculosis: 

  For  management  of   paediatric tuberculosis, treatment is based on  child's  body weight, and  there are two  generic paediatic  patient_  wise boxes  _ one  for   the 6_ 10 kg  weight   band,  and  the second  for  the  11_ 17  kg weight band. Children weighing  less than  6 kg are  to  be  treated with  losse anti__ TB  drugs. 

DOTS _ Plus :

DOTS_ Plus, conceived by the WHO and several  of  its  partners, is   a strategy for the management of multi_ drug  resistant TB ( MDR_ TB). The RNTCP  views the treatment of MDR_ TB patients as a  ' standard  of  care' issue  . Recognizing   that   the  treatment  of   MDR_ TB cases is  very  complex,  treatment  isto follow the internationally recommended DOTS_ plus  guidelines and  is  to be done in designated RNTCP  DOTS _ Plus  sites.

TB_ HIV  co _ ordination  :

HIV infection makes  an individual  more prone  to develop  Tb  diseas.The HIV epidemic has the potential to worsen  the TB situation  because  HIV increases the risk of disease re_ activation  in  people   with  latent  TB  infection. 


     RNTCP and  the  National  AIDS  Control  Organization ( NACO)  have   devised  a   joint Action   Plan    for   TB_ HIV  co_ ordination .The  objective of  TB_ HIV  co_ ordination   is    to  reduce   TB _  associated  morbidity  and  mortality in   people living  with  HIV/ AIDS  through  collaboration between NACP and RNTCP. The  basic  purpose of   the   Joint  Action  Plan  is  to ensure optimum synergy between the two national control of  both  diseases. 

Global  TUBERCULOSIS (TB) REPORT 

  World Health Organisation released Global Tuberculosis (TB) Report, 2023. 

Key findings:  



Global o Reported global number of people newly diagnosed with TB was 7.5 million in 2022.TB remained the world’s second leading cause of death in 2022 after COVID-19. o Net reduction of TB incidence from 2015- 2022 was 8.7% far from WHO End TB Strategy milestone of 50% reduction by 2025.  Only about 2 in 5 people with drug resistant TB accessed treatment in 2022. 

• India’s findings

  India, Indonesia and Philippines collectively account for nearly 60% of reduction in number of people newly diagnosed with TB in 2020- 2021.  India has 27% of world’s TB cases. 

TB is caused by bacillus Mycobacterium tuberculosis which most often affects lungs (pulmonary TB). Most common medications to treat TB include isoniazid, rifampin, ethambutol, pyrazinamide etc.  Currently, Bacillle Calmette-Guerin is only licensed vaccine available for TB prevention.  Spreads from person to person through air.  TB Risk factors: Diabetes, HIV infection, Undernutrition, tobacco use.

 • Steps taken to prevent Tuberculosis  National Strategic Plan for Tuberculosis Elimination 2017-2025. TB Mukt Panchayat Abhiyan Initiative. Nikshay Poshan Yojana for nutritional support to TB patients. 


  Drug-Resistant TB


 Mulmultidrug Resistance TB ( MDR :Resistant to at least isoniazid and rifampicin.

 Extensively  drug _ resistant  tuberculosis  ( XDR_ TB) : Resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs. 

 Totally   drug _  resistance  tuberculosis ( TDR TB):  Resistance  to all first- and second-line TB drugs. 
















Comments

Popular posts from this blog

Proteins

Cytoplasm

Nucleic Acids