Rntcp

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RNTCP orientation lecture (Updated) delivered on 03/08/2015.

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Rntcp

  1. 1. RNTCP Dr. Gyanshankar Mishra MD (Pulmonary Medicine) DNB(Respiratory Diseases) Assistant Professor Dept. of Pulmonary Medicine, GMC Nagpur
  2. 2. In our country…
  3. 3. Why is orientation to TB care important to us?
  4. 4. RNTCP Treatment o Objectives of TB treatment o Basis of TB treatment o Case definitions o Treatment regimens o Special situations o Directly Observed Treatment (DOT) o Monitoring of patients o Treatment outcome o Advanced categories under RNTCP – CAT IV & CAT V
  5. 5. o The objectives of RNTCP are to achieve and maintain a cure rate of at least 85% among new sputum smear-positive cases and to achieve and maintain detection of atleast 70% of such cases in the population.
  6. 6. Basis of TB treatment o Intermittent (thrice weekly) treatment regimens o Treatment given under direct observation o Standardized treatment regimens in two categories o Regimen decided by MO on basis of o Sputum smear results o History of previous anti-TB treatment
  7. 7. 1.Political and administra tive commitme nt 2.Good quality diagnosis, primarily by sputum smear microscop y 3.Uninterr upted supply of good quality drugs 4.Directly observed treatment (DOT) 5.Systemat ic monitoring and accountabi lity Components of DOTS
  8. 8. o A pulmonary TB suspect is defined as: An individual having cough of 2 weeks or more Contacts of smear-positive TB patients having cough of any duration Suspected/confirmed extra-pulmonary TB having cough of any duration HIV positive patient having cough of any duration
  9. 9. Sputum AFB smear Lab referral form
  10. 10. o Pulmonary Tuberculosis, Smear-Positive o TB in a patient with atleast one smear-positive for AFB out of the two initial sputum smear examination by direct microscopy o Pulmonary Tuberculosis, Smear Negative o A patient with symptoms suggestive of TB with two smear examination negative for AFB, with evidence of pulmonary TB by microbiological methods (culture positive or by other approved molecular methods) or Chest Xray is classified as having smear negative pulmonary tuberculosis
  11. 11. o Extra Pulmonary Tuberculosis o Tuberculosis in any organ other than lungs (eg. pleura, lymph nodes, intestine, genitor- urinary tract, joint and bones, meninges of the brain etc). o The diagnosis should be based on strong clinical evidence with the following investigations o Smear/Culture from extrapulmonary sites o Histopathological examination or o Radiological examination or o Biochemical and cytological examination including FNAC
  12. 12. Case definitions o NEW o A TB patient who has never had treatment for TB or has taken anti-tuberculosis drugs for less than one month o RELAPSE o A TB patient who was declared cured or treatment completed by a physician, but who reports back to the health service and is now found to be sputum smear positive.
  13. 13. Case definitions (contd) o TRANSFERRED IN o A TB patient who has been received for treatment into a Tuberculosis Unit, after starting treatment in another unit where s/he has been registered. o TREATMENT AFTER DEFAULT o A TB patient who received anti-tuberculosis treatment for one month or more from any source and returns to treatment after having defaulted, i.e., not taken anti-TB drugs consecutively for two months or more, and is found to be sputum smear positive.
  14. 14. Case definitions (contd) o FAILURE o Any TB patient who is smear positive at 5 months or more after starting treatment. o CHRONIC o A TB patient who remains smear-positive after completing a re-treatment regimen but has not been initiated on MDR TB treatment o OTHERS o TB patients who do not fit into the above mentioned types. Reasons for putting a patient in this type must be specified
  15. 15. Which bacilli are acted upon by the ATT drugs?
  16. 16. Treatment Regimens Category of Treatment Type of Patient Regimen* Category I All new pulmonary (smear-positive and negative), extra pulmonary and ‘others’ TB patients. 2H3R3Z3E3+ 4H3R3 Category II TB patients who have had more than one month anti-tuberculosis treatment previously Relapse , Failure, Treatment After Default ,Others 2H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3
  17. 17. Basis for Regimens CAT I: New sputum smear Positive patients, high bacillary population, chances for naturally occurring resistant mutants higher,therefore 4 drugs in intensive phase CAT II: Because of previous treatment, chances of harboring resistant bacilli are higher; hence 5 drugs in IP and total duration of treatment is 8 months.In continuation phase lower bacterial population;hence less chance of resistant organisms, therefore 3 drugs are enough.
  18. 18. Regimen for Non-DOTS treatment in RNTCP Areas o Self administered non rifampicin containing regimen o Needed in few cases of adverse reaction to rifampicin and pyrazinamide o Upto a maximum of 1% of patients may get Non-DOTS treatment in an RNTCP area. o Tuberculosis treatment card to be filled for these patients as well
  19. 19. Regimen for Non-DOTS treatment in RNTCP Areas Treatment Regimen Non-DOTS Regimen 2HSE+10 HE
  20. 20. DOTS in the context of HIV DOTS can: o Prolong and improve the quality of life. o Prevent emergence of MDRTB. o Stop the spread of TB. o Reverse the trend of MDRTB. o In the context of HIV, failure to use DOTS can result in - rapid spread of disease - tripling of cases - increased drug resistance.
  21. 21. Special situations o Hospitalization o general policy is treatment on ambulatory basis. o Indoor treatment adviced if general condition of patient is serious o Pneumothorax o Massive haemoptysis o Large pleural effusion o Treatment with prolongation pouches supplied by DTO of the district in which hospital is situated.
  22. 22. Special Situations (contd) o Pregnancy and post natal period o Streptomycin not to be given. Other drugs in RNTCP are safe o Breast feeding should continue o Chemoprophylaxis for baby if mother is smear positive o Renal failure o Rifampicin, isoniazid and pyrazinamide can be given o Streptomycin and ethambutol require close monitoring
  23. 23. Directly observed treatment (DOT) is one element of the DOTS strategy An observer watches and helps the patient swallow the tablets Direct observation ensures treatment for the entire course • with the right drugs • in the right doses • at the right intervals Directly Observed Treatment
  24. 24. DOTS Strategy A strategy to ensure treatment completion in which o Treatment observer (DOT provider) must be accessible and acceptable to the patient and accountable to the health system o DOT provider administers the drugs in intensive phase. o Ensures that the patient takes medicines correctly in continuation phase. o Provides the necessary information and encouragement for completion of treatment.
  25. 25. A suitable DOT provider and DOT center is selected in consultation with patient Tuberculosis Treatment Card is accurately and completely filled after initial home visit Initial counseling at the health facility and at patients home is important to achieve treatment compliance Ensure that treatment is being directly observed for all doses of the intensive phase and the first of the thrice weekly dose in the continuation phase Drug administration
  26. 26. Drug doses in RNTCP
  27. 27. Remember the correct doses of anti TB Drugs!
  28. 28. Why are correct doses important? Ref: Mishra G, Mulani J. Tuberculosis Prescription Practices In Private And Public Sector In India. NJIRM. 2013; 4(2): 71-78.
  29. 29. Why are correct doses important? Ref: Mishra G, Mulani J. Tuberculosis Prescription Practices In Private And Public Sector In India. NJIRM. 2013; 4(2): 71-78.
  30. 30. Pediatric weight bands
  31. 31. Streptomycin injections should be given • After oral drugs are administered • With disposable syringes and needles • First dose after sensitivity testing Chemoprophylaxis to be given to children (under 6 years of age) of smear-positive patients Patients missing doses should be traced and put back on treatment • Within one day in intensive phase • Within one week in continuation phase Drug administration(contd)
  32. 32. Monitoring of Treatment o Follow up sputum microscopy determines o Conversion rate o Cure rate o Sputum smear microscopy schedule o Initial sputum examination o End of Intensive phase of treatment o 2 months into Continuation phase of treatment o End of treatment
  33. 33. Cat. of Rx Pre–Rx Sputum Test at month If: result Then Cat–1 + 2 - C.P. – Sputum at 4 & 6 m + I.P. for 1month, Sp. At 3, 5 & 7 - 2 - C.P. Sputum at 6 months + I.P. for 1 month, SP. at 3, 5 & 7 Cat–II + 3 - C.P. Sputum at 5 & months + I.P. for 1 month, Sp. at 4, 6 & 9 Schedule of follow-up sputum smear examination
  34. 34. CURED • Initially sputum smear-positive patient who has completed treatment and had negative sputum smears, on two occasions, one of which was at the end of treatment TREATMENT COMPLETED • Sputum smear-positive patient who has completed treatment, with negative smears at the end of the intensive phase but none at the end of treatment. • Sputum smear-negative TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment. • Extra-pulmonary TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment Treatment Outcomes
  35. 35. Treatment Outcomes o DIED o Patient who died during the course of treatment regardless of cause o FAILURE o Any TB patient who is smear positive at 5 months or more after starting treatment.
  36. 36. DEFAULTED • A patient who has not taken anti-TB drugs for 2 months or more consecutively after starting treatment. TRANSFERRED OUT • A patient who has been transferred to another Tuberculosis Unit/ District and his/ her treatment result (outcome) is not known. Treatment outcomes
  37. 37. DRUG RESISTANT TB
  38. 38. Drug resistant TB
  39. 39. We need to screen drug resistant suspects Why? Previously when drug resistant suspects were not screened under the programme then drug resistant TB cases were left undiagnosed in the programme!
  40. 40. For all practical purposes, all retreatment cases, HIV-TB cases, TB cases who are contacts of known MDR TB case and new cases which are smear-positive at two months or later can be suspected to have MDR-TB. Who are MDR TB Suspects?
  41. 41. Advanced RNTCP Regimes Drug Resistant TB (PMDT) o MDR TB – Resistant to INH & Rifampicin
  42. 42. CAT IV – MDR TB INITIAL INTENSIVE PHASE : 6- 9 months o Inj. Kanamycin o Tab Ethionamide o Tab Ofloxacin o Tab. Pyrazinamide o Tab. Ethambutol o Cap Cycloserine CONTINUATION PHASE : 18 months o Tab Ethionamide o Tab Ofloxacin o Tab Ethambutol o Cap Cycloserine
  43. 43. CAT V- XDR TB o XDR TB- MDR TB+ Resistant to Second line injectable Anti TB drug & Fluroquinolone
  44. 44. CAT V- XDR TB The Intensive Phase (6-12 months) will consist of 7 drugs Capreomycin (Cm), PAS, Moxifloxacin (Mfx), High dose- INH, Clofazimine, Linezolid, and Amoxyclav The Continuation Phase (18 months) will consist of 6 drugs – PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav
  45. 45. Some practical points o 1. TB is a notifiable disease. o 2. If you not sure of individualized treatment regime, please do not start it. Instead you may register the patient under RNTCP. o 3. Do not start a fluroquinolone to a TB suspect. o 4.Please do simple sputum microscopy for afb smear for all TB suspects, rather than directly starting from higher investigations like CT scan. o 5. Serological TB tests are banned in India eg. TB IgG and TB IgM. o 6. Screen for drug resistant suspects. o 6. Do not even attempt to treat drug resistant TB, in absence of requisite training. Refer to specialist/ RNTCP /PMDT.

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