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TB newer updates.pptx

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Management of TB 2019
Management of TB 2019
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TB newer updates.pptx

  1. 1. Dr. Siddharth Medical Consultant – TB World Health organization Recent Updates in National TB Elimination Program
  2. 2. Learning Objectives • Basics of TB management • TB preventive treatment guidelines. • DR-TB management guidelines. • Index TB guidelines – EP sample collection 2
  3. 3. TB Burden- Global v/s India Estimates of TB Burden (2021) Global (Million) India % of Global Incidence TB cases 10.6 3 Million 28.3% Mortality of TB 1.4 494,000 35.3% Incidence HIV TB 0.7 54,000 7.7% Mortality of HIV-TB 0.18 11,000 5.9% MDR-TB 0.45 119,000 26.4% Children with TB 1.1 356,000 32.4% 3
  4. 4. ENDTB SUMMIT 13TH MARCH 2018 • Landmark event towards complete elimination of TB from the country • Hon’ble Prime Minister Shri Narendra Modi announced targets for Ending TB by 2025, much ahead of the global SDG targets of 2030 • Emphasized importance of working together for the cause as the disease is linked to the betterment of the lives of the poor 4
  5. 5. Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering Goal: End the Global TB epidemic Vision, goal, targets, milestones (2,8 million) (4.8 lakh) 5
  6. 6. Co-morbidities with increased risk of TB: • HIV infection: - 16-27 times higher life time risk of developing TB among PLHIV • Diabetes Mellitus: - 2-3 times of higher risk of developing TB among uncontrolled diabetic patients • Smoking/ use of tobacco: - 2.5 times of higher risk of TB among smokers • Malnutrition: - Leads to increased risk of TB especially among children with household contacts of TB patients 6
  7. 7. Definitions of presumptive TB •Cough > 2 weeks •Fever > 2 weeks •Significant weight loss •Haemoptysis •Abnormal chest radiograph Presumptive pulmonary TB •Swelling of lymph nodes •Pain and swelling in joints •Neck stiffness •Disorientation •Constitutional symptoms Presumptive extra pulmonary TB 7
  8. 8. Definitions of presumptive TB • Persistent fever or cough > 2 weeks • Loss of weight or no weight gain • H/o contact with infectious TB cases Presumptive paediatric TB •Failed treatment with first line drugs •Paediatric TB non responders •Contacts with DR –TB •Positive cases during follow up •Previous TB cases Presumptive DR TB 8
  9. 9. TB Care Smear Microscopy CBNAAT X-Ray USG/CT/MRI Clinical Judgement Medicine Pediatrics Surgery Obs/Gynae Ortho Pulm Skin ENT Ophthal DMC cum DOT Centre/Drug Resistant TB Ward Treatment for Drug Sensitive TB Treatment for Drug Resistant TB 9
  10. 10. Treatment of DS-TB • Frequency of dosage : DAILY (7 day/week) • Single daily dosage • New case & Previously treated DSTB regimen :-2 HRZE + 4HRE • No extension of Intensive Phase • Continuation phase may be extended for 3 to 6months in special situations like bone and joint TB, spinal TB with neurological involvement and Neuro – Tuberculosis • Weight Band wise drug dosage (5 weight bands in adults & 6 weight bands in children's) 10
  11. 11. 4FDC 3FDC 11
  12. 12. Revised Daily Dose Schedule for Adults - >18Yrs (as per weight bands)- 14th May 2019 Weight band Number of tablets Intensive phase Continuation phase HRZE (4FDC) HRE (3FDC) 75/150/400/275 mg 75/150/275 mg 25-34 kg 2 2 35-49 kg 3 3 50-64 kg 4 4 65-75 kg 5 5 ≥75kg* 6 6 * Patients >75kg may receive 5 tablets /day if they do not tolerate this dose. 12
  13. 13. Drug Dosage for Paediatric TB- upto 18Yrs *A=Adult FDC (HRZE = 75/150/400/275; HRE = 75/150/275) Weight category Number of tablets (dispersible FDCs) Intensive phase Continuation phase HRZ (3FDC) E HR (2FDC) E 50/75/150 100 50/75 100 4-7 kg 1 1 1 1 8-11 kg 2 2 2 2 12-15 kg 3 3 3 3 16-24 kg 4 4 4 4 25-29 kg 3 + 1A* 3 3 + 1A* 3 30-39 kg 2 + 2A* 2 2 + 2A* 2 13
  14. 14. • Rs. 500/- per month given to every TB patient through DBT for duration of treatment • Scheme rolled out from April 2018 14 NIKSHAY Poshan Yojana Incentives Incentive for Treatment supporter Incentive for Private providers Incentive for Informant • Drug sensitive TB : Rs. 1000/- at completion of treatment • Drug Resistant Case: Rs.5000/- at completion of treatment • Notification incentive : Rs. 500/- for a diagnosed TB case • Outcome incentive : Rs. 500/- • An Informant is eligible for incentive of Rs. 500/- for a confirmed TB case
  15. 15. PMTPT Guidelines - 2021 15
  16. 16. Algorithm for TB screening and TPT 16 NO Defer preventive treatment YES Give preventive treatment5 NO NO <5 years TST or IGRA Symptomatic?2 Investigate for active TB Follow-up for active TB as necessary, even for patients who have completed preventive treatment YES Abnormal YES Positive or unavailable Negative Preventive treatment contraindicated?4 No active TB Normal or unavailable 5 years + CXR6 Any symptom1 of current cough or fever or weight loss or night sweats Household contact HIV positive Other risk group 3
  17. 17. TB Preventive Treatment – DSTB contacts Target population Treatment • People living with HIV (+ ART) o Adults and children >12 months o Infants <12 months with HIV in contact with active TB • HHC below 5 years of pulmonary* TB patients • 6-months daily isoniazid (6H) OR • 3-month weekly Isoniazid and Rifapentine (3HP) in persons older than 2 years • HHC 5 years and above of pulmonary* TB patients# • Children/adult on immunosuppressive therapy, silicosis, anti-TNF treatment, dialysis, transplantation 17
  18. 18. 18 Regimen Dose by age and weight band Six months of daily levofloxacin (6Lfx) for contacts of R resistant FQ sensitive patients# Age > 14 years, by body weight: < 45 kg, 750 mg/day; ≥ 45 kg, 1g/day Age < 15 years (range approx. 15–20 mg/kg/day), by body weight: 5–9 kg: 150 mg/day 10–15 kg: 200–300mg/day 16–23 kg: 300–400mg/day 24–34 kg: 500–750mg/day Four months of rifampicin daily (4R) for contacts of H resistant R sensitive patients* Age 10 years & older: 10 mg/kg/day@ Age <10 years: 15 mg/kg/day (range, 10–20 mg) # Lfx 100 mg dispersible tablets available for children. Children receiving 6Lfx should be watched for joint abnormalities. * In children from 0-14 years, 4R should only be used after ruling out active TB in limited geographies/populations for evidence generation to guide future scale up for country wide implementation. @ Maximum dose of R would be 600 mg/day. Note: 6H can be considered as the TPT regimen option for contacts of index patients with RR-TB with FQ and H sensitive, after ruling out active TB in them. TB Preventive Treatment – DR TB contacts
  19. 19. PMDT Guidelines - 2021 19
  20. 20. Classification and Definitions of DR-TB.…1 • Multidrug-resistant TB (MDR-TB). A TB patient, whose biological specimen is resistant to both H and R with or without resistance to other first-line anti-TB drugs. MDR-TB patients may have additional resistance to any/all FQ or any other anti-TB drug. • Pre-extensively drug resistant TB (Pre-XDR-TB). TB caused by Mycobacterium tuberculosis strains that fulfil the definition of MDR/RR-TB and are also resistant to any fluoroquinolone. • Extensively drug resistant TB (XDR-TB). TB caused by Mycobacterium tuberculosis strains that fulfil the definition of MDR/RR-TB and are also resistant to any fluoroquinolone (levofloxacin or moxifloxacin) and at least one additional Group A drug (presently to either bedaquiline or linezolid [or both]). 20
  21. 21. DR-TB Diagnostic Algorithm All notified TB patients Presumptive TB R resistance detected R resistance not detected H resistance not detected H resistance detected • PLHIV • EPTB • Smear -ve/NA with X-ray suggestive of TB including paediatric • Vulnerable populations • Contact of DR TB patient Non responder to treatment FL – LPA$, SL – LPA$ and DST for Mfx(1.0), Lzd*, Cfz*, Z*, Bdq*, Dlm* NAAT# FL LPA$ SL LPA$ DST for Z* DST for Mfx (1.0) & Lzd only if FQ or Z resistance detected # NAAT include CBNAAT & TruNAAT *whenever available $ Culture isolates to be subjected to LPA for smear negative specimens For discordance resolution – see text • DS TB • H mono/poly 21
  22. 22. Regimen class Intensive phase Continuation phase H mono/poly DR TB (R resistance not detected and H resistance) All oral H mono-poly DR TB regimen@ (6/9) Lfx R E Z MDR/RR TB Shorter Bdq MDR TB regimen@ Bdq(6) (4-6)Lfx Eto Cfz Z Hh E (5) Lfx Cfz Z E All oral longer MDR TB regimen@ (18-20) Bdq(6) Lfx Lzd# Cfz Cs DRTB Regimen and duration 22
  23. 23. INDEX- TB GUIDELINES (INDian EXtra-pulmonary Tuberculosis Guidelines) 23
  24. 24. • 5.8 million people developed tuberculosis globally in 2021 • 1.5 million perished in 2020 • EPTB accounts for: • 15-20% of all TB cases in HIV negative patients • 40-50% of all TB cases in HIV positive patients EPTB: Extra-pulmonary Tuberculosis * Global Tuberculosis Report, 2021 Burden of the Disease 24
  25. 25. Why to collect- Rationale Evidence required to establish etiological relationship between microorganism and disease Diagnosis of TB Detection of Drug Resistance Monitoring treatment 25
  26. 26. What to collect- Types of Samples Fluids • Spinal • Pleural • Pericardial • CSF • Synovial • Ascitic • Bone Marrow • Bronchial washings • Nasal Secretions • Gastric washings • Urine • Vitreous fluid • Blood • Swabs Tissues • Tissues • Lymph Node • Tissue Biopsy • Stool • Bone • Endometrial scrapping Aspirate • Fine Needle Aspirate • Pus Pulmonary • Sputum • Induced sputum 26
  27. 27. In which to collect- Containers used for Sample collection Sterile screw capped conical tube Sputum container 27 Specimen collection container: Sterile 50 ml screw capped and graduated conical bottom polypropylene tube
  28. 28. Quality of Sputum specimen 1. Thick (semi solid), coughed out deeply from the lungs 2. Mucopurulent (yellowish mucus) 3. Adequate in quantity 4. Properly labelled container 1. Contains only saliva, (watery),nasal secretions, food / tobaco particles 2. Inadequate quantity (less than 2 ml) 3. Not properly labelled container 28 Good Quality Sample Poor Quality Sample
  29. 29. Collection of Extra Pulmonary sample- 1 Blood: • Blood for isolating M. tuberculosis should be generally discouraged for the low diagnostic yield and high possibility of contamination with respect to the technique required for its culture. • Specific indications- liquid/Solid culture • Body fluids should be aseptically collected in a sterile container by the physician using aspiration techniques or surgical procedures. • Specimens should be transported to the laboratory as quickly as possible. Pleural fluid : • Considered a suboptimal specimen as tubercle bacilli • The minimum volume for pleural fluid required for processing for culture is 20–50ml. • The fluid is collected using pleural tap or thoracocentesis. 29
  30. 30. Tissues: • Aseptically collected tissues are collected in sterile containers preferably without fixatives or preservatives. • If the specimen is to be shipped, it should be protected from drying by adding sterile saline and maintaining a temperature of 4-15 degree C. • Specimens should be transported to the laboratory as quickly as possible. Collection of Extra Pulmonary sample-2 Bronchial secretions: Other respiratory specimens that can be submitted to the laboratory for mycobacteria culture are • bronchial secretions (minimum volume: 2- 5ml) and • bronchial alveolar lavage (BAL) (minimum volume of 20 – 50 ml). Pericardial fluid :Should be collected using ultra sonogram CSF: Lumbar Puncture 30
  31. 31. Swabs: • A sterile absorbent cotton swab should be used for collection. • The best time for the collection is early morning before food and drinks are taken. • The swab should be placed in a screw capped container containing normal (0.9%) saline to prevent drying.. • Swabs except for laryngeal swabs or from discharging sinus should be avoided. Collection of Extra Pulmonary sample-3 Urine: Among specimens expected to be contaminated, urine is the most common. • Early morning sample should be collected in screw capped sterile containers. • Once received in the laboratory, urine must be immediately processed or centrifuged and the pellet refrigerated for further processing. • As excretion of tubercle bacilli in urine is intermittent, three early morning specimens must be collected on different days. 31
  32. 32. Gastric Lavage : • In children, who rarely produce sputum, the aspiration of the early morning (gastric content) may be used for TB diagnosis. • This is done as an inpatient procedure. • This should be transported immediately to the lab and processed (not more than 4 hours) to prevent the killing action of the acid content in the gastric lavage on the tubercle bacilli. • In the event of delay, the sample can be neutralised using 1-2 ml of sterile 10 % sodium bicarbonate solution depending on the volume of gastric aspirate. Collection of Extra Pulmonary sample - 4 32
  33. 33. Precautions  Samples for culture should never be collected in formalin.  If histo pathological examination is required, two samples should be collected  No preservative (unless indicated) should be used for any extra-pulmonary specimen for culture.  Necessary instructions are to be given to the concerned staff for sending the biopsy specimen in normal saline for culture and NOT IN FORMALIN as it will kill the bacilli. 33
  35. 35. 1. Should Xpert MTB/Rif be recommended for use in diagnosis of: • Lymph node TB • TB meningitis • Pleural TB? Key question - 1 35
  36. 36. First line test for diagnosis of pulmonary TB and endorsed by NTEP for the same Widely available and an attractive option as it provides faster results Not reliable in certain EPTB cases, hence, indiscriminate and unregulated use may lead to higher false negative results Need for Guidelines on Xpert? 36
  37. 37. 1. Should Xpert MTB/Rif be recommended for use in diagnosis of: Key question - 1 Site of disease Recommendations Lymph node TB • Should be used as an additional test to culture and cytology TB meningitis • Additional test. • Negative test will not rule out TB. • Clinical features and CSF profile to be considered to start ATT. Pleural TB • High false negatives. 37
  38. 38. 2. How long should ATT be given in the treatment of • Lymph node TB • TB meningitis • Abdominal TB ? Key questions - 2 38
  39. 39. 2. How long should ATT be given in the treatment of Key question - 2 Site of disease Recommendations Lymph node TB Standard 6months regimen (2HRZE+4HRE) TB meningitis First line ATT for 9months Abdominal TB Standard 6months regimen (2HRZE+4HRE) 39
  40. 40. Thank you 40

Editor's Notes

  • Good evening everyone, I hope everyone is doing great.. Todays topic is
  • We have to now move towards new era of SDG and from STOP TB Strategy to END TB Strategy.
    Everyone with TB should have access to the innovative tools and services they need for rapid diagnosis, treatment and care. This is a matter of social justice, fundamental to our goal of universal health coverage. Given the prevalence of drug-resistant tuberculosis, ensuring high quality and complete care will also benefit global health security.

  • Undernutrition is an established risk factor for progression of latent TB infection to active TB and contributes to 7 lakh TB patients annually
    To address this critical determinant, Nikshay Poshan Yojana has been rolled out from April’2018, one of the largest social support schemes for TB patients globally.
    Under this scheme, each TB patient is eligible for Rs. 500 per month for the duration of TB treatment and benefits are transferred directly in their bank account.
    Since the inception of the scheme, 39 lakh TB patients have been benefited from the scheme from April 2018 till date.
    Challenges in NPY includes the following:
    Non availability of bank accounts of patients
    Patient’s non-acceptance of benefits in the private sector where the coverage is a mere 23%.