Control of tb
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  • 1. by Dr. Sridhar.D 2nd year PGDepartment of Community Medicine Osmania Medical College Hyderabad
  • 2. OVERVIEWGlobal and Indian scenarioControl of tuberculosisRNTCP
  • 3. Estimated TB incidence rates 2010
  • 4. Global TB disease burden 8.8 million incident cases of TB (range, 8.5million-9.2 million) globally in 2010 1.1 million deaths (range, 0.9 million-1.2 million) among HIV- negative cases of TB and An additional 0.35 million deaths (range, 0.32million-0.39 million) among people who were HIV positive In 2009 There were an estimated 9.7 million (range, 8.5-11 million) children who were orphans as a result of parental deaths caused by Tuberculosis.The WHO Global TB Report 2011
  • 5. Global estimation of burden of HIV positive incidentTB cases is 10,00,000 (11,00,000-12,00,000) while theestimates of HIV positive incident TB cases in India is75,000 (1,10,000 - 1,60,000), HIV prevalence amongst incident TB cases is estimated to be 3.3% (5%-7.1%). Globally, about 1 million cases of paediatric TB are estimated to occur every year accounting for 10-15% of all TB; with more than 100,000 estimated deaths every year, it is one of the top 10 causes of childhood mortality.The WHOs Global TB Report of 2011
  • 6. Estimated burden of tuberculosis in India Number (Millions)(95%CI) Rate Per 100000 persons(95 CI)IncidenceAll cases(2009 WHO 2.0(1.6-2.4) 168estimates)Period Prevalence (2000GoI estimate)AFB positive 1.7 (1.3-2.1) 165 (126-204)Bacillary 3.8 (2.8-4.7) 369 (272-457)Prevalence, all cases (2009 3.0 (1.3-5.0) 249WHO estimate)
  • 7. India is the highest TB burden country in the worldaccounts 20% of global burden of TB and 2/3rd of casesin SEAR.Every year approximately 1.8million persons developtuberculosis, of which about 0.8 million are new cases.Annual risk of becoming infected with tb is 1.5% andonce infected there is 10% life time risk of developingTB disease.Patients with infectious pulmonary tuberculosis diseasecan infect 10-15 persons in a year.
  • 8. Case notification 2010 in IndiaNew cases Number(thousand Retreatment cases Number(thousand s)& % s)& % %Smear +ve 630165(51) relapse 110691(38)Smear -ve 366381(30) Treatment after 18463(6) failureSmear unknown Treatment after 72110(25) defaultextrapulmonary 231121(19) other 91708(31)other 1508(<1)Total new 1229175 Total rertretment 292972Total <15 years 13415 Total new and relapse 1339866 88% of total Total notified cases 1522147
  • 9. The estimated MDR TB cases emerging annually in India are reported to be 99,000 among incident total TB cases in India in 2008 (range 79,000 - 1,20,000). As per the WHO Global TB Report 2011, Estimated number of MDR-TB cases out of notified Pulmonary TB cases in India is 64,000 (range 44,000 to 84,000) emerge annually.WHO Global TB Report 2010 and Multidrug andextensively drug-resistant TB (M/XDR-TB) - 2010 GlobalReport on Surveillance and Response
  • 10. TB India annual report 2012.
  • 11. The control of tuberculosisTuberculosis control means reduction in the prevalenceand incidence of the disease in the community.The WHO defines that tuberculosis “control” is said tobe achieved when the prevalence of natural infection inthe age group 0-14 years is of the order of 1 %. This isabout 40% in India.The control measures consists of a curative component-namely case finding and treatment and prevention.
  • 12. Case findingA “case” is defined by WHO as a patient whose sputumis positive for TB bacilli and such cases are the target ofcase finding.All other possible sufferers from TB whose sputum isnegative but who show suggestive shadows in chest x-ray’s are reckoned as “suspects”.Park’s text book of Preventive and Social Medicine 21steditionAFMC Text book of Public Health and Community Medicinewww.WHO.int
  • 13. Target group-pulmonary TB patients because pulmonary TB is most common and causes pool of infection every year. Case finding tools:-{1}sputum examination: direct microscopyCollection of samples- 2samples day1 sample1 Patient provides an “on the spot “ sample day2 sample2 Patient brings an early morning sample
  • 14. Slide reportingNumber of bacilli Results reportedNo AFB per 100 oil 0 Slide reporting immersion fields1-9 AFB per 100 oil Scanty( number AFB immersion fields seen)10-99 AFB per 100 oil +(1+) immersion fields1-10 AFB oil immersion fields ++(2+)>10 AFB oil immersion fields +++(3+)
  • 15. RNTCP Laboratory Network 4 NRLs 27 IRLs>12,000 DMCs(one per 50,000-100,000 population)
  • 16. Quality Assurance (QA) External Quality Internal Quality QualityAssessment (EQA) Assurance Improvement (Quality Control) (QI)1. On Site Evaluation (OSE) 1. Instrument 1. Data checks2. Panel Testing Collection 2. Reagent3. Random Blinded 2. Data Analysis quality check Rechecking 3. Solving (RBRC) problems
  • 17. One specimen out two is enough to declare positive TB.Patients in whom both specimens are smear negativeshould be prescribed symptomatic treatment and broadspectrum antibiotic for 10-14 days.If symptoms persists after treatment repeat sputum smear .if one smear is positive label as smear positive and none ofthe repeated smear positive take chest x-ray if it suggestspulmonary TB label as sputum negative pulmonary TB .
  • 18. Sputum culture: it is only second in importance in case finding. Available at district and regional chest clinics Necessary for carrying out sensitivity tests and monitoring drug treatment.{2}mass miniature radiography : stopped as general measure of case finding due to lack of definitiveness, high cost , erroneous interpretation of films, very low yield of cases.{3}tuberculin test: invalidated as case finding tool.
  • 19. Treatment1st line drugs 2nd line drugsBactericidal Bacteriostatic FluroquinolonesRifampicin(RMP) Ethambutol EthionamideIsoniazide(INH) Thioacetazone CapreomycinStreptomycin Kanamycin and AmikacinPyraxinamide Cycloserine MacrolidesTwo phase chemo therapy: 1st is short , aggressive orintensive phase fo 1-3 months 2nd is continuation phase
  • 20. Long course regimens: daily regimens bi-weekly regimensShort course chemotherapy: 1972 Wallace Fox advantages- rapid bacteriological conversion, lowerfailure rates, and reduction in frequency of emergence ofdrug resistant bacilli. Patient compliance will improvedisadvantage- high cost of short –term chemotherapy.
  • 21. DOTS cost effective approach to tuberculosis control. (a) accuracy of diagnosis is more than doubled (b) treatment success rate is upto95% (c) prevents the spread of infection thus reducing the incidenceand prevalence of tb. (d)improves quality of health care and removes stigmaassociated with Tb (e) prevents failure of treatment and the emergence of MDR-TBby ensuring patient adherence and uninterrupted drug supply (f) helps alleviate poverty by saving lives , reducing duration ofillness and preventing spread of infection (g) lends credibility to TB control efforts
  • 22. 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
  • 23. Revised CategoriesTreatment groups Type of Patient Regimen Intensive Continuation Phase(IP) Phase(CP)New (Cat I) New Sputum smear-positive 2(HRZE)3 4(HR)3 New Sputum smear-negative New Extra-pulmonary New OthersPreviously Treated (Cat II) Smear-positive relapse 2 (HRZES)3/ 5(HRE)3 Smear-positive failure 1(HRZE)3 Smear-positive treatment after default OthersMDR-TB Cases(Cat IV) 6 (9) Km Ofx 18 Ofx (Lvx) Eto Cs Z (Lvx)Eto Cs E E
  • 24. MDR / XDRMDR-TB is defined as resistance to isoniazid and rifampicin,with or without resistance to other anti-TB drugs from anaccredited RNTCP LaboratoryXDR-TB is defined as resistance to at least Isoniazid andRifampicin (i.e. MDR-TB) with resistance to any of thefluoroquinolones and any one of the second-line injectable drugs(amikacin, kanamycin, or capreomycin).NTM is Non-Tuberculous Mycobacteria reported in the sputumspecimen by an accredited RNTCP Laboratory
  • 25. DOTS-plus It refers to DOTS programs that add components for MDR-TB diagnosis, management and treatment DOTS-plus strategy promotes full integration of DOTS and DOTS-plus activities under the RNTCP1. Sustained government commitment2. Accurate , timely diagnosis through quality assured culture and drug susceptibility testing3. Appropriate treatment utilizing second line drugs under strict supervision4. Uninterrupted supply of quality assured anti-TB drugs5. Standardized recording and reporting.
  • 26. Treatment during pregnancyin place of Streptomycin Ethambutol addedINH , RMP , Pyrazinamide and Ethambutol are safeEthionamide and Protionamide are teratogenic.
  • 27. Childhood tuberculosis10-20% of all tb casesUsally sputum smear –veChildren under 5years of age ae more prone to develop the disase mostlywith in 2years following infectionThe commonest age is 1-4 years. drugs dosage Isoniazide 10-15mg/kg Rifampicin 10mg/kg Pyrazinamide 35mg/kg Streptomycin 15mg/kg Ethambutol 30mg/kgEthambutol should not be given to children below 6years of age
  • 28. For infants if the mother or any other household member is smear positive then chemoprophylaxis should be given for 3 months then do mantoux test. If test is negetive stop chempprophylaxis and give BCG(if previously not vaccinated). If test is positive continue chemoprophylaxis for a total duration of 6months
  • 29. BCG vaccinationAim: to reduce morbidity mortality from primaryinfection.Vaccine: Danish 1331 strainTypes of vaccine: liquid(fresh) vaccine freeze dried vaccineDosage: 0.1mg in 0.1ml volumeadministration: tuberculin syringe intra dermal just above the insertion of deltoid
  • 30. Age: either at birth or at 6weeks of age (tuberculosis highprevalent countries) high risk groups ( low prevalent countries).Phenomena after vaccination: 2-3 wks - develops papule 5 weeks - 4-8mm diameter develops into shallow ulcer 6-12 weeks - permanent scarComplications: prolonged ulceration suppurative lymphadenitis osteomyelitis disseminated infection
  • 31. Protective value: 15-20 years protection offered by BCG varies from 0-80%. Because prior exposure to non tuberculous environmental mycobacteria.Contra indications: generalized eczema, infective dermatosis, hypogammaglobulinaemia, history of deficient immunity, patients under immuno suppressive treatment.
  • 32. Chemoprophylaxis (preventive treatment)With INH for 1year or INH + Ethambutol for 9monthsIt is costly exercise , not effective, causes drug inducedhepatitis.Chemoprophylaxis with INH can prevent thedevelopment of tb in infected individuals, but impact onthe community will be minimal because it cannotapplied on mass scale.
  • 33. surveillanceIt is an integral part of any effective tuberculosisprogrammeBy annual infection ratesSurveillance of control measures applied such as BCGvaccination and chemotherapy.
  • 34. Revised National TuberculosisControl Programme (RNTCP) The Goal and Objectives of the RNTCPGoal: The goal of RNTCP is to decrease mortality andmorbidity due to TB and cut transmission until TB ceasesto be a major public health problem in India.Objectives:1) To achieve at least 85% cure rate of the newlydiagnosed sputum smear-positive TB patients; and2) To detect at least 70% of new sputum smear-positivepatients after the 1st goal is met. Strategy: DOTS is a systematic strategy which has fivecomponents.
  • 35. Cont…The revised strategy was introduced in the country as apilot project since 1993 in a phased manner as PilotPhase I, II, III.RNTCP has expanded rapidly over the years and now itcovers the whole country.It has now entered into its second phase.
  • 36. Technical Organization of the Tuberculosis Programme in India National level Deputy Director General, TB National Institutes State level (State TB Officer) State TB Training and Demonstration Centre District level Metropolitan City (District TB Officer) (City TB Officer) District TB Centre Sub-district level Municipal Ward (Medical Officer-TB Control) (Chest Clinic) Tuberculosis Unit Peripheral health level Primary Health Centre Health Post / Medical Officer Microscopy Centres Microscopy Centres
  • 37. RNTCP Structure and Service Delivery Mechanisms At the Center: The Central TB Division (CTD) is responsible for developing technical policies, procuring drugs, preparing training modules, quality assurance, advocacy, operational research priorities and mobilizing funds. At the State: State Tuberculosis Officer ( STO) is responsible for planning, training, supervising and monitoring the programme in their states as per guidelines.
  • 38. Cont..At the District: District TB Centre(DTC) is the keyorganizational unit for implementation of the programme. It’sthe nodal point for TB control activities in the district.In RNTCP, the primary role of DTC has shifted from aclinical one to a managerial one.District TB Officer (DTO) has overall responsibility ofmanagement of RNTCP at district level.
  • 39. Cont..Tuberculosis Unit(TU): A major organizational change inRNTCP is the creation of a sub-district level TuberculosisUnit.TU consists of a designated Medical Officer-TuberculosisControl(MO-TC), as well as a Senior Treatment Officer(STS)and a Senior Tuberculosis Laboratory Supervisor(STLS).TU covers a population of approximately 5lakh or it covers 5Designated Microscopic Centres(DMC)
  • 40. Key Functions of the TUMaintain the TB Register which containsinformation on the diagnosis and treatment ofevery patientEnsure effective diagnosis by microscopy anddirectly observed treatmentComplete quarterly reports on diagnosis, sputumconversion, treatment outcome, and programmemanagement
  • 41. Programme Surveillance System Peripheral Health Institute (DMC and other PHIs) Monthly PHI Report Tuberculosis Unit Cohort analysisSystem electronicfrom district level Quarterly CF, SC, RT, PM Reports upwards Additional District TB Centre Quarterly Feedback Electronic reports) Feedback Quarterly Reports CF, SC, RT, PM Central TB Division State TB Cell
  • 42. WHO-recommended Stop TB Strategy (2006) to Reach the 2015 MDGs
  • 43. Millennium Development Goals related to TuberculosisGoal 6--to combat HIV/AIDS, malaria and other diseases.Target 8– to have halted by 2015 and begun to reverse theincidence of malaria and other major diseases, includingtuberculosis.Indicators for Target 8 to be used to evaluate theimplementation and impact of TB control (derived from STOP TBstrategy)Indicator 23: Between 1990 and 2015, to halve the prevalenceand death rates associated with tuberculosis; andIndicator 24: By 2005, to detect 70% of new smear positive TBcases arising annually, and to successfully treat 85% of thesecases.
  • 44. Programmatic management of drug resistant TB(PMDT)The RNTCP PMDT Vision is as follows: By end 2011, basic RNTCP PMDT services will be initially introduced in all states, with complete geographical coverage by end 2012 By 2013, access to laboratory based quality assured DST and appropriate treatment for at least all smear-positive re-treatment TB cases at diagnosis, and all cases who remain smear-positive after first-line drug treatment By 2015, access to MDR-TB diagnosis and treatment for all smear-positive TB (new and retreatment) cases registered under RNTCP early during their treatment RNTCP plans to initiate at least 30,000 MDR cases on treatment annually by 2013
  • 45. GoI commitment at Beijing Ministerial Meeting – 2009 Plan for patients to be tested and treated for MDR- TB*Based on RNTCP 2012 goal of MDR diagnosis for all S+ retreatment patients,
  • 46. 12th Five year plan12th Five Year Plan: RNTCP has developed NationalStrategic Plan to be implemented during 2012-2017, thenational 12th Five Year plan period, with following Visionand objectives for RNTCP:Vision: "TB-free India“Goal: Universal Access to quality TB diagnosis & treatmentfor all pulmonary & extra pulmonary TB patients includingdrug resistant and HIV associated TB.
  • 47. Cont…Objectives:To achieve 90% notification rate for all types of TB casesTo achieve 90% success rate for all new and 85% for re-treatment casesTo significantly improve the successful outcomes oftreatment of Drug Resistant TBTo achieve decreased morbidity and mortality of HIVassociated TBTo improve outcomes of TB care in the private sector
  • 48. TB/HIV Collaborative Efforts Central TB Division(CTD) & National AIDS Control Organization(NACO) have revised the “National framework for joint TB-HIV collaborative activities” in Oct 2009. All the WHO recommended TB/HIV collaborative activities have been incorporated and include the following:1) Strengthen NACP-RNTCP coordination mechanisms at national, state and district levels.2) Joint Monitoring and Evaluation between 2 programmes.
  • 49. Cont..3) Training of Programme and field staff4) Scaling up of Intensified TB/HIV Package of services across the country5) Activities to reduce the burden of TB among HIV- infected individuals6) Involvement of NGO’s7) Operational research
  • 50. World TB dayFalling on March 24th each year, is designed to buildpublic awareness that TB today remains an epidemic inmuch of the day, causing deaths of several millionpeople each year.It commemorates the day in 1882 when Dr.RobertKoch astounded the scientific community byannouncing that he had discovered the cause oftuberculosis, the TB bacillus.
  • 51. Theme for 2012Theme for 2012’s world TB day is “Stop TB--- in my life time”Some hopes people of different ages and living indifferent countries may have for stopping TB in theirlifetimes…Zero deaths from TBFaster treatmentA quick, cheap, low-tech testAn effective vaccineA world free of TB
  • 52. ReferencesWHOs Global TB Report of 2011.Multidrug and extensively drug-resistant TB (M/XDR-TB) - 2010Global Report on Surveillance and Response.TB India annual report 2012.Park’s text book of Preventive and Social Medicine 21st edition.AFMC Text book of Public Health and Community Medicine.J . Kishore’s National Health Programs of India 10th edition.www.WHO.intNational Scale-up Plan for the Programmatic Management of DrugResistant Tuberculosis (PMDT)2011 – 2012.http://www.stoptb.org/Tuberculosis Control Laws and Policies: A Handbook for PublicHealth and Legal Practitioners by CDC.