This document provides guidelines for the Revised National Tuberculosis Control Programme (RNTCP) in India to address multidrug-resistant TB (MDR-TB). It outlines a framework for integrating MDR-TB diagnosis, treatment, and management into existing DOTS programs. Key points include establishing quality-assured laboratories for culture and drug susceptibility testing; treating MDR-TB patients according to international guidelines using standardized second-line drug regimens and directly observed therapy; ensuring an uninterrupted supply of quality-assured drugs; and implementing a standardized recording and reporting system. The guidelines aim to make MDR-TB diagnosis and treatment available nationwide by expanding services gradually over time.
This presentation intends to throw light on the Tuberculosis burden of our country with the prime focus on the rapid emergence of drug resistant TB.Along with it,the recent RNTCP guidelines for case detection,early diagnosis and complete pharmacotherapy and treatment duration of different cases of tuberculosis.
The revised guidelines for RNTCP include changes to case definitions, diagnostic algorithms, drug regimens, and treatment follow-up. Key changes include shifting to a daily drug regimen with fixed-dose combination therapy according to weight bands, shorter intensive phases, and clinical follow-up in addition to laboratory follow-up. Definitions of presumptive and drug-resistant TB cases were also updated.
Revised National Tuberculosis Control Program- Dr. Atul MD, PGIMERYogesh Arora
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). It discusses the burden of TB in India, the evolution of TB control programs from the National TB Programme (NTP) to the current RNTCP. It outlines the goals and strategies of the RNTCP and the National Strategic Plan (NSP) 2017-2025 to eliminate TB in India through improved detection, treatment, prevention, and building of infrastructure and resources. Key approaches include engaging private providers, active case finding, drug-resistant TB management, addressing social determinants, and strengthening surveillance and community engagement.
The document summarizes recent changes to India's Revised National Tuberculosis Control Programme (RNTCP), now called the National TB Elimination Programme (NTEP). Key points include:
- The program has evolved since 1962, with a shift to the DOTS strategy in 1997 and a goal of eliminating TB in India by 2025 under the National Strategic Plan 2017-2025.
- Diagnostic methods have advanced to include cartridge-based nucleic acid amplification tests and line probe assays to detect drug-resistant TB.
- Treatment services provide standardized drug regimens based on drug susceptibility testing results, with a focus on programmatic management of drug-resistant TB nationwide.
- Active case
1. Tuberculosis is caused by Mycobacterium tuberculosis and primarily affects the lungs. It can spread through airborne transmission. India has a high burden of TB with an estimated incidence of 211 cases per 100,000 population in 2016.
2. The Revised National Tuberculosis Control Programme was launched in India to decrease TB mortality and morbidity. It aims to achieve 90% cure rates for new smear-positive cases and detect 85% of expected new smear-positive cases.
3. Diagnosis involves smear microscopy, radiography, tuberculin skin test, culture, and rapid molecular tests. Treatment regimens include daily and intermittent options depending on if the patient has new or previously
Standards for TB care in India, RNTCP challenges: India, Maharashtra & Mumbai...Amol Patil
This document summarizes information from various reports on tuberculosis (TB) standards of care and organizational structure for TB treatment in India and Mumbai. It finds that while TB rates are declining globally and in some countries and regions, India still accounts for a large proportion of global TB cases. It outlines the Revised National Tuberculosis Control Programme (RNTCP) phases and 12th five year plan in India, and notes ongoing challenges around engaging private providers, ensuring consistent drug supplies, and reducing high mortality rates. The document also provides statistics on TB cases and deaths specifically in Mumbai.
This document provides an overview of tuberculosis (TB) and the Revised National TB Control Programme (RNTCP) in India. It discusses:
1. What TB is, how it spreads, and its global and national burden. In India, it accounts for 1.4 crore cases and 4.23 lakh deaths annually.
2. The objectives and components of the RNTCP, launched in 1992, which uses the WHO-recommended DOTS strategy of Directly Observed Treatment, Short Course to achieve cure rates above 90%.
3. The structure of the RNTCP at central, state, district, and sub-district levels to facilitate DOTS implementation across India by 2006.
This document summarizes the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses the evolution of TB control in India from the National TB Programme (NTP) in 1962 to the implementation of the RNTCP in 1997 based on the WHO DOTS strategy. The objectives, strategies, organization and core elements of the RNTCP are described, including its expansion across India from 1997-2006. Diagnosis, treatment categories, drug regimens and definitions are outlined. The emergence of drug-resistant TB and the Stop TB Strategy adopted in 2006 are also summarized.
This presentation intends to throw light on the Tuberculosis burden of our country with the prime focus on the rapid emergence of drug resistant TB.Along with it,the recent RNTCP guidelines for case detection,early diagnosis and complete pharmacotherapy and treatment duration of different cases of tuberculosis.
The revised guidelines for RNTCP include changes to case definitions, diagnostic algorithms, drug regimens, and treatment follow-up. Key changes include shifting to a daily drug regimen with fixed-dose combination therapy according to weight bands, shorter intensive phases, and clinical follow-up in addition to laboratory follow-up. Definitions of presumptive and drug-resistant TB cases were also updated.
Revised National Tuberculosis Control Program- Dr. Atul MD, PGIMERYogesh Arora
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). It discusses the burden of TB in India, the evolution of TB control programs from the National TB Programme (NTP) to the current RNTCP. It outlines the goals and strategies of the RNTCP and the National Strategic Plan (NSP) 2017-2025 to eliminate TB in India through improved detection, treatment, prevention, and building of infrastructure and resources. Key approaches include engaging private providers, active case finding, drug-resistant TB management, addressing social determinants, and strengthening surveillance and community engagement.
The document summarizes recent changes to India's Revised National Tuberculosis Control Programme (RNTCP), now called the National TB Elimination Programme (NTEP). Key points include:
- The program has evolved since 1962, with a shift to the DOTS strategy in 1997 and a goal of eliminating TB in India by 2025 under the National Strategic Plan 2017-2025.
- Diagnostic methods have advanced to include cartridge-based nucleic acid amplification tests and line probe assays to detect drug-resistant TB.
- Treatment services provide standardized drug regimens based on drug susceptibility testing results, with a focus on programmatic management of drug-resistant TB nationwide.
- Active case
1. Tuberculosis is caused by Mycobacterium tuberculosis and primarily affects the lungs. It can spread through airborne transmission. India has a high burden of TB with an estimated incidence of 211 cases per 100,000 population in 2016.
2. The Revised National Tuberculosis Control Programme was launched in India to decrease TB mortality and morbidity. It aims to achieve 90% cure rates for new smear-positive cases and detect 85% of expected new smear-positive cases.
3. Diagnosis involves smear microscopy, radiography, tuberculin skin test, culture, and rapid molecular tests. Treatment regimens include daily and intermittent options depending on if the patient has new or previously
Standards for TB care in India, RNTCP challenges: India, Maharashtra & Mumbai...Amol Patil
This document summarizes information from various reports on tuberculosis (TB) standards of care and organizational structure for TB treatment in India and Mumbai. It finds that while TB rates are declining globally and in some countries and regions, India still accounts for a large proportion of global TB cases. It outlines the Revised National Tuberculosis Control Programme (RNTCP) phases and 12th five year plan in India, and notes ongoing challenges around engaging private providers, ensuring consistent drug supplies, and reducing high mortality rates. The document also provides statistics on TB cases and deaths specifically in Mumbai.
This document provides an overview of tuberculosis (TB) and the Revised National TB Control Programme (RNTCP) in India. It discusses:
1. What TB is, how it spreads, and its global and national burden. In India, it accounts for 1.4 crore cases and 4.23 lakh deaths annually.
2. The objectives and components of the RNTCP, launched in 1992, which uses the WHO-recommended DOTS strategy of Directly Observed Treatment, Short Course to achieve cure rates above 90%.
3. The structure of the RNTCP at central, state, district, and sub-district levels to facilitate DOTS implementation across India by 2006.
This document summarizes the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses the evolution of TB control in India from the National TB Programme (NTP) in 1962 to the implementation of the RNTCP in 1997 based on the WHO DOTS strategy. The objectives, strategies, organization and core elements of the RNTCP are described, including its expansion across India from 1997-2006. Diagnosis, treatment categories, drug regimens and definitions are outlined. The emergence of drug-resistant TB and the Stop TB Strategy adopted in 2006 are also summarized.
This document discusses tuberculosis (TB) control in India under the Revised National Tuberculosis Control Programme (RNTCP). It provides background on the evolution of TB control in India from the 1950s to the present day RNTCP program. It describes the objectives, components, and scientific basis of the DOTS strategy used by RNTCP to diagnose and treat TB cases. It also addresses drug-resistant TB, the link between TB and HIV, and recent updates to RNTCP guidelines.
India has a high tuberculosis (TB) burden, accounting for 21% of global TB incidence. In 2014, India had 2.2 million TB cases out of the global total of 9 million. The Revised National TB Control Programme (RNTCP) was launched in 1993 based on the WHO recommended DOTS strategy to address the failures of the previous National TB Control Programme (NTP). RNTCP aims to achieve an 85% cure rate among new sputum-positive patients and detect 70% of estimated new sputum-positive cases. It relies on quality-assured sputum smear microscopy, adequate drug supply, directly observed treatment, and systematic monitoring. However, the 2014 Joint TB Monitoring Mission report identified ongoing weaknesses including additional
1. Tuberculosis remains a major global health problem, infecting over 2 billion people and causing millions of deaths annually.
2. In India, over 2 million new cases of TB develop each year, resulting in over 500,000 deaths. TB disproportionately impacts the poor and vulnerable.
3. The Revised National Tuberculosis Control Program (RNTCP) was launched in India in 1997 using the DOTS strategy to combat the TB epidemic. It has since expanded nationwide and achieved significant improvements in case detection and treatment success rates.
The RNTCP has updated its guidelines for the programmatic management of drug resistant TB in 2017. The key updates include:
1. Expanding the criteria for screening presumptive drug resistant TB cases to include contacts of microbiologically confirmed TB patients, people living with HIV/AIDS, diabetes, malnutrition, cancer and those on immunosuppressants.
2. Introducing a new diagnostic algorithm for pulmonary, extra-pulmonary and pediatric TB that places more emphasis on rapid molecular testing.
3. Establishing district drug resistant TB centers to decentralize drug resistant TB treatment and bring care closer to patients.
4. Revising treatment regimens for drug sensitive TB, mono/poly drug resistant
The document summarizes newer initiatives of the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses the introduction of newer rapid diagnostic tests like CBNAAT and GeneXpert, abolishing of category 2 patients, use of newer drugs for drug resistant TB, introduction of daily treatment regimens in different weight bands, and establishment of Nikshay for electronic notification of TB cases. It also discusses initiatives like 99DOTS for treatment adherence, intensified case finding, incentives for private providers, making non-declaration of TB a punishable offense, and nutritional support through Nikshay Poshan Yojana. The document concludes with references for further information.
- India has the highest burden of tuberculosis (TB) in the world, accounting for over 20% of global TB cases.
- The National Strategic Plan for TB Control aims to achieve universal access to quality TB diagnosis and treatment through intensified case finding, improved diagnosis rates, and expanded access to treatment, including for drug-resistant TB and HIV/TB co-infection.
- New diagnostic technologies like molecular diagnostics, urine lipoarabinomannan tests, and breathalyzer tests have improved TB detection rates. The shorter daily drug regimen has also improved treatment outcomes.
- Initiatives to address TB among high-risk groups like people with diabetes, tobacco users, and in private healthcare settings have expanded
Revised National Tuberculosis Control ProgramAmol Kinge
- The document summarizes recent advances in India's Revised National Tuberculosis Control Programme (RNTCP).
- It provides details on tuberculosis epidemiology, classification, diagnosis, treatment regimens, and achievements of the RNTCP over time such as establishing infrastructure across India and treating millions of patients.
- Going forward, it discusses expanding daily treatment regimens to more districts, increasing private sector engagement, strengthening surveillance, and controlling TB in urban and special populations to work towards ending TB in India by 2030.
The document discusses the history and current status of tuberculosis (TB) and the Revised National Tuberculosis Control Programme (RNTCP) in India. It describes how TB was discovered in 1882 by Robert Koch and remains a major public health problem worldwide and in India. The RNTCP was established in India in 1962 and reformed in 1993, aiming to diagnose TB cases early through sputum microscopy and successfully treat patients to reduce transmission. While progress has been made, India still accounts for a large number of global TB cases and deaths each year.
The new guidelines for Revised National Tuberculosis Control Programme (RNTCP) in India introduce several changes from previous guidelines. Some key changes include shifting to a daily drug regimen over intermittent dosing, new definitions for presumptive and drug-resistant TB cases, and classification of TB cases based on history of treatment and drug resistance. Treatment outcomes have also been redefined, and additional provisions for clinical and long-term follow-up of TB patients have been introduced.
This document summarizes updates to India's Revised National Tuberculosis Control Program (RNTCP) guidelines. Some key changes include:
- Expanding the criteria for presumptive TB cases to include high-risk groups like contacts of confirmed cases and those with comorbidities.
- Introducing a new diagnostic algorithm and case definitions. Daily fixed-dose combination therapy is now recommended over intermittent regimens.
- Updated treatment guidelines for drug-sensitive TB, drug-resistant TB, and special groups like pregnant women, those with liver or kidney disease.
- New classifications, treatment durations and regimens defined for various resistance patterns from mono- to extensive drug resistance.
- Revised follow-
This document outlines the Revised National Tuberculosis Control Programme (RNTCP) in India. It summarizes that tuberculosis poses a major public health burden in India, accounting for 1/3rd of global cases. The National Tuberculosis Control Programme started in 1962, but failed due to low treatment completion rates and organizational issues. RNTCP was launched in 1997 with DOTS strategy, which involves directly observed treatment, short-course. RNTCP aims to reduce morbidity, mortality, and transmission of TB in India through early case detection and standardized treatment. It utilizes a decentralized organizational structure and relies on community health workers to observe treatment. If fully implemented, RNTCP aims to achieve global targets for TB control by improving cure rates and case
The document provides an overview and critical review of India's Revised National Tuberculosis Control Programme (RNTCP). It summarizes the history and evolution of tuberculosis control efforts in India, from the initial National Tuberculosis Programme established in 1962 to the introduction of the RNTCP and DOTS strategy in 1993. It outlines the goals, objectives and organizational structure of the RNTCP, and reviews its achievements as well as ongoing challenges, including high rates of multi-drug resistant TB, lack of private sector engagement, and ensuring consistent treatment adherence among India's large population.
Training module for medical practitionersShybin Usman
This document provides information about the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses:
- The goals and components of RNTCP, which implements the WHO-recommended Directly Observed Treatment, Short-course (DOTS) strategy.
- Guidelines for diagnosing tuberculosis, including identifying suspects, conducting sputum examinations at Designated Microscopy Centers, and using tools like sputum microscopy, x-rays, and newer rapid diagnostic tests.
- Protocols for administering tuberculosis treatment under RNTCP, including categorizing patients, understanding treatment regimens and monitoring, and ensuring treatment adherence through mechanisms like DOTS.
- Efforts to expand universal access to tuberculosis
Revised national tuberculosis control programme (rntcp)VijayChoudhary53
The Revised National Tuberculosis Control Programme (RNTCP) was established in India in 1992 using the DOTS strategy recommended by the WHO to address the shortcomings of the previous National Tuberculosis Programme. RNTCP aims to reduce mortality and morbidity from TB and cut transmission by achieving 85% cure rates among new TB patients and 70% case detection using microscopy. It operates through a network of District Tuberculosis Centers and is fully funded by the central government with support from international organizations. The program follows the DOTS strategy of direct observation of TB treatment to help ensure adherence and cure.
Revised definitions of tb cases and management as per ntepDrSmritiMadhusikta
The document provides revised definitions and management guidelines for tuberculosis (TB) cases according to India's National Tuberculosis Elimination Program (NTEP). Key changes include:
- Updated case definitions for presumptive TB, DR-TB, pediatric TB, and EPTB.
- Classification based on history of treatment and drug resistance is revised.
- Diagnostic algorithms and tools are introduced, including new molecular tests.
- Treatment is shifted to daily fixed-dose combinations administered according to weight bands, with an 8-week intensive phase and 16-week continuation phase.
- Guidelines for managing DR-TB, hospitalized patients, EPTB and special groups are provided.
India has a large tuberculosis (TB) disease burden, with over 2 million new cases annually according to WHO. The Revised National Tuberculosis Control Programme (RNTCP) was established in 1993 to address India's TB epidemic using the WHO-recommended DOTS strategy of diagnosis, treatment and monitoring. RNTCP has since expanded nationwide and achieved high treatment success rates. Its Phase II aims to further improve TB detection and treatment, including of drug-resistant cases and among HIV patients. RNTCP is now the world's largest DOTS program and has successfully treated over 19 million TB patients.
Reasons for innovations and changing strategies in RNTCP 2019Drsadhana Meena
The RNTCP in India has undergone several innovations and strategy changes over time to address shortcomings in tuberculosis control. When launched in 1962 as the NTCP, it faced issues like low treatment completion rates, drug supply issues, and overemphasis on diagnosis over cure. In 1993, WHO declared TB a global emergency, prompting India to revamp the program as the RNTCP. Key strategies of the RNTCP included ensuring regular drug supplies, emphasis on training and DOTS treatment. It has now set a goal to eliminate TB in India by 2025, five years ahead of global targets, through strategies like engaging private providers, active case finding, addressing social determinants, and strengthening surveillance.
The Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997 based on the WHO DOTS strategy, with a goal of covering the entire country by 2006. RNTCP implements the five components of DOTS - sustained political commitment, quality-assured diagnosis, standardized short-course treatment, uninterrupted drug supply, and standardized recording and reporting. Objectives include achieving at least 85% cure rate of infectious cases through DOTS and detecting at least 70% of estimated cases through quality sputum microscopy and case finding activities.
Revised national tuberculosis control programmeHonorato444
- Tuberculosis is an infectious disease caused predominantly by Mycobacterium tuberculosis that commonly affects the lungs but can affect any part of the body. India accounts for one fourth of the global TB burden with over 6000 new cases and 600 deaths daily.
- The Revised National Tuberculosis Control Programme was launched in 1997 based on the WHO DOTS strategy and aims to achieve at least 85% cure rates through direct observation of treatment. It utilizes sputum microscopy, culture and drug susceptibility testing, chest x-rays, and more recently molecular diagnostics to detect TB.
- Drug resistant TB including multi-drug resistant TB has emerged as a major challenge for the programme. The Programmatic Management of Drug Resistant TB was
Diagnosis and management of tuberculosis with revised rntcpDrPrincePrakash
The document provides guidelines for the diagnosis and management of tuberculosis (TB) according to the Revised National Tuberculosis Control Programme (RNTCP). It discusses definitions of TB cases, classification based on treatment history, diagnostic methods, treatment regimens for pulmonary and extra-pulmonary TB, management of drug-resistant TB, and follow-up procedures. Key changes in the recent guidelines include introducing a daily treatment regimen for both new and previously treated TB cases, as well as additional guidance for diagnosing and treating multi-drug resistant TB.
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). Some key points:
- TB poses a major public health burden in India, with over 2 million estimated cases annually.
- RNTCP was launched in 1997 based on the DOTS strategy to decrease TB mortality and morbidity. Its objectives are to achieve 85% cure rates for new sputum-positive cases and detect 70% of estimated cases.
- RNTCP implements standardized treatment regimens, with drugs administered under direct observation at least during the intensive phase. This along with other measures like improved diagnostics and supervision have helped reduce TB prevalence.
- The program has expanded nationwide in phases since 1997 to achieve universal
This ppt contains all the information about Revised NationalTuberculosis Control programme (RNTCP) It is useful for students of the medical field learning Preventive and social medicine, Swasthavritta (Ayurved) and everyone who is interested in in knowing about it.
This document discusses tuberculosis (TB) control in India under the Revised National Tuberculosis Control Programme (RNTCP). It provides background on the evolution of TB control in India from the 1950s to the present day RNTCP program. It describes the objectives, components, and scientific basis of the DOTS strategy used by RNTCP to diagnose and treat TB cases. It also addresses drug-resistant TB, the link between TB and HIV, and recent updates to RNTCP guidelines.
India has a high tuberculosis (TB) burden, accounting for 21% of global TB incidence. In 2014, India had 2.2 million TB cases out of the global total of 9 million. The Revised National TB Control Programme (RNTCP) was launched in 1993 based on the WHO recommended DOTS strategy to address the failures of the previous National TB Control Programme (NTP). RNTCP aims to achieve an 85% cure rate among new sputum-positive patients and detect 70% of estimated new sputum-positive cases. It relies on quality-assured sputum smear microscopy, adequate drug supply, directly observed treatment, and systematic monitoring. However, the 2014 Joint TB Monitoring Mission report identified ongoing weaknesses including additional
1. Tuberculosis remains a major global health problem, infecting over 2 billion people and causing millions of deaths annually.
2. In India, over 2 million new cases of TB develop each year, resulting in over 500,000 deaths. TB disproportionately impacts the poor and vulnerable.
3. The Revised National Tuberculosis Control Program (RNTCP) was launched in India in 1997 using the DOTS strategy to combat the TB epidemic. It has since expanded nationwide and achieved significant improvements in case detection and treatment success rates.
The RNTCP has updated its guidelines for the programmatic management of drug resistant TB in 2017. The key updates include:
1. Expanding the criteria for screening presumptive drug resistant TB cases to include contacts of microbiologically confirmed TB patients, people living with HIV/AIDS, diabetes, malnutrition, cancer and those on immunosuppressants.
2. Introducing a new diagnostic algorithm for pulmonary, extra-pulmonary and pediatric TB that places more emphasis on rapid molecular testing.
3. Establishing district drug resistant TB centers to decentralize drug resistant TB treatment and bring care closer to patients.
4. Revising treatment regimens for drug sensitive TB, mono/poly drug resistant
The document summarizes newer initiatives of the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses the introduction of newer rapid diagnostic tests like CBNAAT and GeneXpert, abolishing of category 2 patients, use of newer drugs for drug resistant TB, introduction of daily treatment regimens in different weight bands, and establishment of Nikshay for electronic notification of TB cases. It also discusses initiatives like 99DOTS for treatment adherence, intensified case finding, incentives for private providers, making non-declaration of TB a punishable offense, and nutritional support through Nikshay Poshan Yojana. The document concludes with references for further information.
- India has the highest burden of tuberculosis (TB) in the world, accounting for over 20% of global TB cases.
- The National Strategic Plan for TB Control aims to achieve universal access to quality TB diagnosis and treatment through intensified case finding, improved diagnosis rates, and expanded access to treatment, including for drug-resistant TB and HIV/TB co-infection.
- New diagnostic technologies like molecular diagnostics, urine lipoarabinomannan tests, and breathalyzer tests have improved TB detection rates. The shorter daily drug regimen has also improved treatment outcomes.
- Initiatives to address TB among high-risk groups like people with diabetes, tobacco users, and in private healthcare settings have expanded
Revised National Tuberculosis Control ProgramAmol Kinge
- The document summarizes recent advances in India's Revised National Tuberculosis Control Programme (RNTCP).
- It provides details on tuberculosis epidemiology, classification, diagnosis, treatment regimens, and achievements of the RNTCP over time such as establishing infrastructure across India and treating millions of patients.
- Going forward, it discusses expanding daily treatment regimens to more districts, increasing private sector engagement, strengthening surveillance, and controlling TB in urban and special populations to work towards ending TB in India by 2030.
The document discusses the history and current status of tuberculosis (TB) and the Revised National Tuberculosis Control Programme (RNTCP) in India. It describes how TB was discovered in 1882 by Robert Koch and remains a major public health problem worldwide and in India. The RNTCP was established in India in 1962 and reformed in 1993, aiming to diagnose TB cases early through sputum microscopy and successfully treat patients to reduce transmission. While progress has been made, India still accounts for a large number of global TB cases and deaths each year.
The new guidelines for Revised National Tuberculosis Control Programme (RNTCP) in India introduce several changes from previous guidelines. Some key changes include shifting to a daily drug regimen over intermittent dosing, new definitions for presumptive and drug-resistant TB cases, and classification of TB cases based on history of treatment and drug resistance. Treatment outcomes have also been redefined, and additional provisions for clinical and long-term follow-up of TB patients have been introduced.
This document summarizes updates to India's Revised National Tuberculosis Control Program (RNTCP) guidelines. Some key changes include:
- Expanding the criteria for presumptive TB cases to include high-risk groups like contacts of confirmed cases and those with comorbidities.
- Introducing a new diagnostic algorithm and case definitions. Daily fixed-dose combination therapy is now recommended over intermittent regimens.
- Updated treatment guidelines for drug-sensitive TB, drug-resistant TB, and special groups like pregnant women, those with liver or kidney disease.
- New classifications, treatment durations and regimens defined for various resistance patterns from mono- to extensive drug resistance.
- Revised follow-
This document outlines the Revised National Tuberculosis Control Programme (RNTCP) in India. It summarizes that tuberculosis poses a major public health burden in India, accounting for 1/3rd of global cases. The National Tuberculosis Control Programme started in 1962, but failed due to low treatment completion rates and organizational issues. RNTCP was launched in 1997 with DOTS strategy, which involves directly observed treatment, short-course. RNTCP aims to reduce morbidity, mortality, and transmission of TB in India through early case detection and standardized treatment. It utilizes a decentralized organizational structure and relies on community health workers to observe treatment. If fully implemented, RNTCP aims to achieve global targets for TB control by improving cure rates and case
The document provides an overview and critical review of India's Revised National Tuberculosis Control Programme (RNTCP). It summarizes the history and evolution of tuberculosis control efforts in India, from the initial National Tuberculosis Programme established in 1962 to the introduction of the RNTCP and DOTS strategy in 1993. It outlines the goals, objectives and organizational structure of the RNTCP, and reviews its achievements as well as ongoing challenges, including high rates of multi-drug resistant TB, lack of private sector engagement, and ensuring consistent treatment adherence among India's large population.
Training module for medical practitionersShybin Usman
This document provides information about the Revised National Tuberculosis Control Programme (RNTCP) in India. It discusses:
- The goals and components of RNTCP, which implements the WHO-recommended Directly Observed Treatment, Short-course (DOTS) strategy.
- Guidelines for diagnosing tuberculosis, including identifying suspects, conducting sputum examinations at Designated Microscopy Centers, and using tools like sputum microscopy, x-rays, and newer rapid diagnostic tests.
- Protocols for administering tuberculosis treatment under RNTCP, including categorizing patients, understanding treatment regimens and monitoring, and ensuring treatment adherence through mechanisms like DOTS.
- Efforts to expand universal access to tuberculosis
Revised national tuberculosis control programme (rntcp)VijayChoudhary53
The Revised National Tuberculosis Control Programme (RNTCP) was established in India in 1992 using the DOTS strategy recommended by the WHO to address the shortcomings of the previous National Tuberculosis Programme. RNTCP aims to reduce mortality and morbidity from TB and cut transmission by achieving 85% cure rates among new TB patients and 70% case detection using microscopy. It operates through a network of District Tuberculosis Centers and is fully funded by the central government with support from international organizations. The program follows the DOTS strategy of direct observation of TB treatment to help ensure adherence and cure.
Revised definitions of tb cases and management as per ntepDrSmritiMadhusikta
The document provides revised definitions and management guidelines for tuberculosis (TB) cases according to India's National Tuberculosis Elimination Program (NTEP). Key changes include:
- Updated case definitions for presumptive TB, DR-TB, pediatric TB, and EPTB.
- Classification based on history of treatment and drug resistance is revised.
- Diagnostic algorithms and tools are introduced, including new molecular tests.
- Treatment is shifted to daily fixed-dose combinations administered according to weight bands, with an 8-week intensive phase and 16-week continuation phase.
- Guidelines for managing DR-TB, hospitalized patients, EPTB and special groups are provided.
India has a large tuberculosis (TB) disease burden, with over 2 million new cases annually according to WHO. The Revised National Tuberculosis Control Programme (RNTCP) was established in 1993 to address India's TB epidemic using the WHO-recommended DOTS strategy of diagnosis, treatment and monitoring. RNTCP has since expanded nationwide and achieved high treatment success rates. Its Phase II aims to further improve TB detection and treatment, including of drug-resistant cases and among HIV patients. RNTCP is now the world's largest DOTS program and has successfully treated over 19 million TB patients.
Reasons for innovations and changing strategies in RNTCP 2019Drsadhana Meena
The RNTCP in India has undergone several innovations and strategy changes over time to address shortcomings in tuberculosis control. When launched in 1962 as the NTCP, it faced issues like low treatment completion rates, drug supply issues, and overemphasis on diagnosis over cure. In 1993, WHO declared TB a global emergency, prompting India to revamp the program as the RNTCP. Key strategies of the RNTCP included ensuring regular drug supplies, emphasis on training and DOTS treatment. It has now set a goal to eliminate TB in India by 2025, five years ahead of global targets, through strategies like engaging private providers, active case finding, addressing social determinants, and strengthening surveillance.
The Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997 based on the WHO DOTS strategy, with a goal of covering the entire country by 2006. RNTCP implements the five components of DOTS - sustained political commitment, quality-assured diagnosis, standardized short-course treatment, uninterrupted drug supply, and standardized recording and reporting. Objectives include achieving at least 85% cure rate of infectious cases through DOTS and detecting at least 70% of estimated cases through quality sputum microscopy and case finding activities.
Revised national tuberculosis control programmeHonorato444
- Tuberculosis is an infectious disease caused predominantly by Mycobacterium tuberculosis that commonly affects the lungs but can affect any part of the body. India accounts for one fourth of the global TB burden with over 6000 new cases and 600 deaths daily.
- The Revised National Tuberculosis Control Programme was launched in 1997 based on the WHO DOTS strategy and aims to achieve at least 85% cure rates through direct observation of treatment. It utilizes sputum microscopy, culture and drug susceptibility testing, chest x-rays, and more recently molecular diagnostics to detect TB.
- Drug resistant TB including multi-drug resistant TB has emerged as a major challenge for the programme. The Programmatic Management of Drug Resistant TB was
Diagnosis and management of tuberculosis with revised rntcpDrPrincePrakash
The document provides guidelines for the diagnosis and management of tuberculosis (TB) according to the Revised National Tuberculosis Control Programme (RNTCP). It discusses definitions of TB cases, classification based on treatment history, diagnostic methods, treatment regimens for pulmonary and extra-pulmonary TB, management of drug-resistant TB, and follow-up procedures. Key changes in the recent guidelines include introducing a daily treatment regimen for both new and previously treated TB cases, as well as additional guidance for diagnosing and treating multi-drug resistant TB.
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). Some key points:
- TB poses a major public health burden in India, with over 2 million estimated cases annually.
- RNTCP was launched in 1997 based on the DOTS strategy to decrease TB mortality and morbidity. Its objectives are to achieve 85% cure rates for new sputum-positive cases and detect 70% of estimated cases.
- RNTCP implements standardized treatment regimens, with drugs administered under direct observation at least during the intensive phase. This along with other measures like improved diagnostics and supervision have helped reduce TB prevalence.
- The program has expanded nationwide in phases since 1997 to achieve universal
This ppt contains all the information about Revised NationalTuberculosis Control programme (RNTCP) It is useful for students of the medical field learning Preventive and social medicine, Swasthavritta (Ayurved) and everyone who is interested in in knowing about it.
DOTS is the WHO-recommended strategy for tuberculosis detection and treatment. It involves identifying infectious TB patients through microscopy, observing patients swallowing anti-TB drugs daily for 6-8 months, and regularly monitoring patients' progress. DOTS was launched in Pakistan in 1995 but faced challenges until being expanded nationwide by 2005. While cure rates and coverage increased under DOTS, Pakistan still faces ongoing issues with drug-resistant TB, capacity, and monitoring systems. The updated Stop TB Strategy aims to further improve TB control globally through universal access to diagnosis and treatment.
The National Tuberculosis Centre (NTC) is responsible for formulating TB policies and strategies in Nepal. It oversees TB control activities, provides technical support and training, and procures anti-TB drugs. The NTC aims to increase TB case detection, maintain high treatment success rates, expand DR-TB diagnosis and treatment, and strengthen community involvement in TB management. It works to achieve the targets of the End TB Strategy and SDG 3 of reducing TB incidence, mortality and eliminating TB as a public health problem by 2030. Currently, Nepal has a high burden of TB with over 200 cases and 30 deaths per 100,000 people annually.
National tuberculosis elimination programme [Autosaved].pptxSanaKhader1
The document provides an overview of tuberculosis (TB) in India, including key terminology, disease burden statistics, milestones in the country's TB program, and details of the current National Tuberculosis Elimination Program (NTEP). It notes that India accounts for over a quarter of global TB cases. The NTEP aims to eliminate TB in India by 2025 through strategies like improving diagnosis, ensuring appropriate treatment, preventing at-risk populations from developing TB, and strengthening related policies and resources. It outlines diagnostic protocols, treatment regimens, and initiatives to engage private providers and provide social support to patients.
Tuberculosis is caused by bacteria that usually affect the lungs and can spread through air droplets from coughing or sneezing. Left untreated, a TB patient may infect 10-20 people over two years. The DOTS strategy endorsed by WHO aims to control TB through early detection, standardized treatment, and ensuring patients complete their multi-drug regimen over 6-12 months to cure the disease. In the Philippines, community health workers are trained to provide TB education, testing, treatment and monitoring to improve access and cure rates in remote areas as part of programs like the National TB Program and AKAP.
After the successful NSP 2017-2025,Goi is lauching NSP 2017-2025 for elimination of TB on 24th march( World TB day ) 2017. Module is on MOHFW site but i have try to keep it brief,hope its ll be useful specially for academic and administrative purposes.
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). Some key points:
1) RNTCP was established in 1993 to address the failures of the previous National Tuberculosis Programme, such as low treatment completion rates. RNTCP's goals are to reduce TB mortality and interrupt transmission.
2) RNTCP follows the DOTS strategy - ensuring political commitment, quality diagnosis, quality drugs, direct observation of treatment, and systematic monitoring. It has treatment categories based on patient type with standardized regimens.
3) Major achievements include treating over 19 million patients since inception and achieving case detection and treatment success rates in line with global targets. However, challenges remain such as ineffective private
India has moved from a tuberculosis (TB) control program to eliminating TB through its National Strategic Plan for TB Elimination (2017-2025). Key challenges include engaging private providers, addressing drug-resistant TB, and preventing new TB cases. The plan aims to reduce TB incidence and mortality by 80% and 90% respectively by 2025. Strategies include engaging private providers, active case finding, addressing social determinants, and a multisectoral approach. The government's digital Nikshay program tracks TB cases and outcomes nationwide to support elimination goals.
Facilitor's guide for cv training draft1Abhijit Dey
This document provides training materials for community volunteers on tuberculosis (TB) including:
1. Basic information about TB such as what it is, how it spreads, and its magnitude in India with over 28 lakh new cases annually and 1.2 lakh deaths daily.
2. Classification of TB into pulmonary TB affecting the lungs and extra-pulmonary TB affecting other parts of the body.
3. Signs and symptoms of TB and how it is diagnosed using sputum smear microscopy, chest X-ray, and Cartridge Based Nucleic Acid Amplification Test (CBNAAT).
4. Details on India's Revised National Tuberculosis Control Programme (RNTCP)
Drug Resistant Tuberculosis Management GuidelineNabin Bist
This document provides national guidelines for drug resistant tuberculosis (DR-TB) management in Nepal. It outlines the background and burden of multi-drug resistant TB (MDR-TB) worldwide and in Nepal. Key points include an estimated 558,000 incident cases of MDR-TB globally in 2017, with treatment success at only 55%. In Nepal, around 1500 cases of DR-TB occur annually, though only 350-450 are notified. The guidelines cover diagnosis, treatment regimens, management, and monitoring of DR-TB.
1) India has a high burden of tuberculosis, accounting for nearly 1/4 of global TB cases. The social and economic costs of TB in India are also high, with estimated indirect costs of $3 billion and direct costs of $300 million annually.
2) The National Tuberculosis Program (NTP) was implemented in 1962 but had low treatment success rates of only 30%. The Revised National Tuberculosis Control Program (RNTCP) was launched in 1993 using the WHO-recommended DOTS strategy.
3) RNTCP has expanded coverage to the entire country and achieved targets of 70% case detection and 85% treatment success rates. It has contributed to reducing prevalence and mortality rates of TB in India
COUNTDOWN on WHO 2020 Targets: Strengthening Health Systems Interventions for...COUNTDOWN on NTDs
This presentation was given by Professor Russell Stothard on 27th June 2019 during Nigeria's 1st International Scientific Conference on NTDs Control and Elimination in Nigeria
This case study describes the SIMpill project in South Africa, which aims to improve TB treatment compliance monitoring using a wireless pill bottle that sends SMS notifications when opened. Initial pilots involving 100 and 130 patients found that treatment adherence increased significantly with the use of the technology. Larger trials are now planned, though high per-patient costs remain a challenge. The project demonstrates the potential for mHealth technologies to enhance DOTS programs through remote electronic monitoring of medication use.
DOTS (Directly Observed Treatment, Short-course) is the WHO-recommended strategy for treating tuberculosis. It has five main components: political commitment to provide resources for TB control, diagnosis of TB using quality-assured microscopy, standardized short-course anti-TB treatment administered under direct observation, assured drug supply, and standardized recording and reporting of treatment outcomes. DOTS has been successful worldwide in curing TB patients, preventing drug-resistant strains, and reducing the global TB burden. Between 2000-2015, DOTS saved an estimated 49 million lives through effective diagnosis and treatment.
The document outlines The End TB Strategy, which provides a global strategy and targets for tuberculosis prevention, care, and control after 2015. It establishes a vision of a world free of tuberculosis with zero deaths, disease, and suffering from tuberculosis. The goal is to end the global tuberculosis epidemic. Milestones for 2025 include reducing tuberculosis deaths by 75% and reducing the tuberculosis incidence rate by 50% compared to 2015 levels. Targets for 2035 are a 95% reduction in tuberculosis deaths and a 90% reduction in the tuberculosis incidence rate compared to 2015 levels. The strategy aims to achieve these targets through three pillars - integrated patient-centered care and prevention, bold policies and supportive systems, and intensified research and innovation.
The National Tuberculosis Control Programme and Revised National Tuberculosis Control Programme were implemented in India to deal with the tuberculosis problem. The objectives are to reduce infection rates through case detection, treatment, and BCG vaccination. In the 1990s, the programmes suffered from management issues and inadequate funding. The RNTCP adopted the DOTS strategy recommended by the WHO to improve cure rates and case detection through direct observation of treatment. Treatment involves a two-phase regimen administered under direct observation at least initially. Nurses play an important role in treating TB patients through home visits, education, and contact screening.
The document discusses the need for collaborative programs between HIV and tuberculosis (TB) programs. It notes that HIV is the strongest risk factor for TB and TB is a leading cause of death for people living with HIV. It recommends establishing coordinating bodies between HIV and TB programs to conduct joint planning, monitoring and evaluation. Key collaborative activities include intensified TB case finding, TB preventive therapy, and TB infection control for HIV programs and HIV testing, prevention, care/support and antiretroviral therapy for TB programs. Close collaboration is needed to integrate diagnostic, care and prevention services for people affected by both diseases.
The document summarizes India's Revised National Tuberculosis Control Programme (RNTCP). It provides background on tuberculosis (TB), including symptoms, diagnosis methods, and treatment drugs. It then describes the objectives and activities of the RNTCP, including expanding DOTS treatment coverage nationwide, increasing detection and treatment rates, and addressing multi-drug resistant TB. The RNTCP aims to achieve 90% detection and treatment success rates for new and previously treated TB cases by 2017 through improved diagnostics, drug-resistant TB management, and public-private partnerships. Ongoing challenges include maintaining service quality, addressing multi-drug resistant TB, and engaging all healthcare providers.
This clinical case study describes a 16-year-old boy presenting with fever, vomiting, headache, and convulsions. His past medical history is significant for bilateral cataracts, recurrent convulsions since age 10, headaches, weakness, and reduced growth. Physical exam reveals wasting, hypotonia, areflexia, and pseudophakia. Investigations show features of Fanconi syndrome including metabolic acidosis, hypokalemia, hyperchloremia, proteinuria, and glucosuria. Radiographs show reduced bone density. The constellation of findings are consistent with Lowe syndrome, a rare X-linked condition causing Fanconi syndrome, cataracts, and neurological impairment.
Approach to a patient with peripheral neuropathyTikal Kansara
This document provides an overview of approaching a patient with peripheral neuropathy. It discusses:
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- The basic anatomy of peripheral nerves and pathogenic mechanisms of nerve damage, including segmental degeneration, Wallerian degeneration, and axonal degeneration.
- Key questions to ask patients regarding the systems involved, duration and nature of symptoms, evidence of upper motor involvement, temporal evolution, potential hereditary causes, and other medical conditions.
- Types of neuropathy classified by pattern of involvement, clinical course, and other factors to help differentiate diagnoses.
A case of rapidly progressive generalised weaknessTikal Kansara
This document summarizes a case study of a 42-year-old female patient presenting with rapidly progressive weakness. Upon examination, the patient showed reduced motor strength and diminished reflexes across all four limbs. Initial testing revealed hypokalemia and metabolic acidosis. Through intravenous and oral potassium supplementation and acetazolamide treatment, the patient's symptoms improved. The clinical picture is consistent with an episode of periodic paralysis.
This document provides an overview of syncope, including its definition, causes, evaluation, and treatment. Syncope is defined as a brief loss of consciousness due to decreased blood flow to the brain. Evaluation involves taking a thorough history and physical exam, with ECG, carotid sinus massage, tilt table testing, and monitoring tests used as indicated. Causes include reflex or neurally-mediated syncope, orthostatic hypotension, cardiac arrhythmias, and structural heart issues. Treatment focuses on managing the underlying cause, lifestyle modifications, and medications depending on the type of syncope. Syncope can be serious if cardiac in origin, so risk stratification helps determine need for further testing and guide management.
This document presents the case of a 50-year-old female patient who presented with long-standing abdominal distention and discomfort. Examination revealed ascites and dilated abdominal veins. Investigation showed features of cirrhosis and Budd-Chiari syndrome, which is hepatic vein obstruction. Testing found the patient had a protein C deficiency, which can cause hereditary thrombophilia and contribute to Budd-Chiari syndrome. The patient was assessed as having portal hypertension secondary to Budd-Chiari syndrome likely caused by her hereditary thrombophilia.
The document discusses substance abuse and toxicology. It begins by explaining the physiological pathways in the brain that are activated by addictive substances like drugs and gambling, focusing on the dopaminergic pathway. It then covers specific substances like alcohol, tobacco, and various drugs. For each substance, it discusses medical complications of abuse, treatment options, and pharmacotherapies used. It also covers topics like fetal alcohol syndrome, organophosphate poisoning, and heavy metal poisoning. The document provides an overview of substance abuse and toxicology from a physiological and clinical perspective.
This document provides an overview of diabetes mellitus (DM), including its classification, pathogenesis, complications, diagnosis and treatment. DM is a group of metabolic disorders characterized by hyperglycemia and is classified as type 1 DM, type 2 DM, and other specific types. Chronic complications of DM can affect the eyes, kidneys, nerves, heart and blood vessels. Treatment involves patient education, medical nutrition therapy, exercise and medications like insulin and oral hypoglycemics to control blood glucose levels.
1) Acute coronary syndrome (ACS) includes unstable angina, non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI).
2) ACS results from a reduction in blood supply to the heart muscle such as from a blockage in one of the coronary arteries.
3) Diagnosis involves electrocardiograms, cardiac biomarker tests, and cardiac imaging to determine if the heart muscle has been damaged.
Myasthenia Gravis is an autoimmune neuromuscular disorder characterized by muscle weakness and fatigability. It is caused by antibodies that block acetylcholine receptors at the neuromuscular junction, preventing muscle contraction. Symptoms vary widely and can include weakness of the eye muscles, facial muscles, limbs, and respiratory muscles. Diagnosis involves physical exams, blood tests to detect antibodies, and electrodiagnostic tests. Treatment options include acetylcholinesterase inhibitors, immunosuppressants, plasmapheresis, intravenous immunoglobulin, and thymectomy.
This presentation was provided by Rebecca Benner, Ph.D., of the American Society of Anesthesiologists, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
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These slides walk through the story of 1 Samuel. Samuel is the last judge of Israel. The people reject God and want a king. Saul is anointed as the first king, but he is not a good king. David, the shepherd boy is anointed and Saul is envious of him. David shows honor while Saul continues to self destruct.
Level 3 NCEA - NZ: A Nation In the Making 1872 - 1900 SML.pptHenry Hollis
The History of NZ 1870-1900.
Making of a Nation.
From the NZ Wars to Liberals,
Richard Seddon, George Grey,
Social Laboratory, New Zealand,
Confiscations, Kotahitanga, Kingitanga, Parliament, Suffrage, Repudiation, Economic Change, Agriculture, Gold Mining, Timber, Flax, Sheep, Dairying,
Elevate Your Nonprofit's Online Presence_ A Guide to Effective SEO Strategies...TechSoup
Whether you're new to SEO or looking to refine your existing strategies, this webinar will provide you with actionable insights and practical tips to elevate your nonprofit's online presence.
🔥🔥🔥🔥🔥🔥🔥🔥🔥
إضغ بين إيديكم من أقوى الملازم التي صممتها
ملزمة تشريح الجهاز الهيكلي (نظري 3)
💀💀💀💀💀💀💀💀💀💀
تتميز هذهِ الملزمة بعِدة مُميزات :
1- مُترجمة ترجمة تُناسب جميع المستويات
2- تحتوي على 78 رسم توضيحي لكل كلمة موجودة بالملزمة (لكل كلمة !!!!)
#فهم_ماكو_درخ
3- دقة الكتابة والصور عالية جداً جداً جداً
4- هُنالك بعض المعلومات تم توضيحها بشكل تفصيلي جداً (تُعتبر لدى الطالب أو الطالبة بإنها معلومات مُبهمة ومع ذلك تم توضيح هذهِ المعلومات المُبهمة بشكل تفصيلي جداً
5- الملزمة تشرح نفسها ب نفسها بس تكلك تعال اقراني
6- تحتوي الملزمة في اول سلايد على خارطة تتضمن جميع تفرُعات معلومات الجهاز الهيكلي المذكورة في هذهِ الملزمة
واخيراً هذهِ الملزمة حلالٌ عليكم وإتمنى منكم إن تدعولي بالخير والصحة والعافية فقط
كل التوفيق زملائي وزميلاتي ، زميلكم محمد الذهبي 💊💊
🔥🔥🔥🔥🔥🔥🔥🔥🔥
This presentation was provided by Racquel Jemison, Ph.D., Christina MacLaughlin, Ph.D., and Paulomi Majumder. Ph.D., all of the American Chemical Society, for the second session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session Two: 'Expanding Pathways to Publishing Careers,' was held June 13, 2024.
Andreas Schleicher presents PISA 2022 Volume III - Creative Thinking - 18 Jun...EduSkills OECD
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Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) CurriculumMJDuyan
(𝐓𝐋𝐄 𝟏𝟎𝟎) (𝐋𝐞𝐬𝐬𝐨𝐧 𝟏)-𝐏𝐫𝐞𝐥𝐢𝐦𝐬
𝐃𝐢𝐬𝐜𝐮𝐬𝐬 𝐭𝐡𝐞 𝐄𝐏𝐏 𝐂𝐮𝐫𝐫𝐢𝐜𝐮𝐥𝐮𝐦 𝐢𝐧 𝐭𝐡𝐞 𝐏𝐡𝐢𝐥𝐢𝐩𝐩𝐢𝐧𝐞𝐬:
- Understand the goals and objectives of the Edukasyong Pantahanan at Pangkabuhayan (EPP) curriculum, recognizing its importance in fostering practical life skills and values among students. Students will also be able to identify the key components and subjects covered, such as agriculture, home economics, industrial arts, and information and communication technology.
𝐄𝐱𝐩𝐥𝐚𝐢𝐧 𝐭𝐡𝐞 𝐍𝐚𝐭𝐮𝐫𝐞 𝐚𝐧𝐝 𝐒𝐜𝐨𝐩𝐞 𝐨𝐟 𝐚𝐧 𝐄𝐧𝐭𝐫𝐞𝐩𝐫𝐞𝐧𝐞𝐮𝐫:
-Define entrepreneurship, distinguishing it from general business activities by emphasizing its focus on innovation, risk-taking, and value creation. Students will describe the characteristics and traits of successful entrepreneurs, including their roles and responsibilities, and discuss the broader economic and social impacts of entrepreneurial activities on both local and global scales.
Philippine Edukasyong Pantahanan at Pangkabuhayan (EPP) Curriculum
RNTCP by Tikal
1. Revised National Tuberculosis
Control Programme
By:
Tikal Kansara
Jalnidhi Patel
Pooja Kelawala
Reference
Central TB Division, Directorate General of Health Services,
Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi – 110011
2. INDEX
1. Introduction
2. Framework for effective control of multidrug-resistant TB
3. Government commitment and coordination
4. Case finding and definitions
5. Diagnosis and evaluations
6. Laboratory aspects
7. Treatment of multidrug-resistant TB
8. Monitoring and management of adverse drug reactions
9. MDR-TB in special situations
10. Treatment delivery and adherence
11. Human resource development for DOTS-Plus under RNTCP
12. Logistics of second-line anti-TB drugs
13. Recording and reporting system
3. INTRODUCTION:
The emergence of resistance to drugs used to treat tuberculosis (TB), and particularly multidrug-resistant
TB (MDR-TB), has become a significant public health problem in a number of countries and an obstacle to
effective TB control. In India, the available information from the several drug resistance surveillance
studies conducted in the past suggest that the rate of MDR-TB is relatively low in India. However this
translates into a large absolute number of cases and as yet the management of patients with MDR-TB is
inadequate. Specific measures are being taken within the Revised National Tuberculosis Control
Programme (RNTCP) to address the MDR-TB problem through appropriate management of patients and
strategies to prevent the propagation and dissemination of MDR-TB.
Traditionally, DOTS-Plus refers to DOTS programmes that add components for MDR-TB diagnosis,
management and treatment. These guidelines promote full integration of DOTS and DOTS-Plus activities
under the RNTCP, so that patients with MDR-TB are both correctly identified and properly managed under
the recommendations set out in this document.
Finally, the guideline introduces new standards for registering, monitoring and reporting outcomes of
multidrug-resistant TB cases. This uniform information management system will allow systematic,
consistent data collection and analysis which will facilitate appropriate supervision and monitoring of the
DOTS Plus activities and will play an important role in shaping future policies and recommendations.
REASONS FOR MDR-TB
MDR-TB & DOTS-PLUS:
Although the standardized drug regimens used by RNTCP are highly effective, with low failure rates of
around 2% and 6% amongst Category I and II cases respectively, the issue of the treatment of those
pulmonary tuberculosis patients who remain smear-positive following a fully supervised Cat I, II or III
treatment regimen, has previously not been well addressed by the RNTCP. Although these cases represent
a small minority of the overall caseload of TB patients in India, they are an important group from
4. epidemiological and human rights viewpoint. Also, although small in relation to percentages and
proportions, these rates translate into large absolute numbers. Moreover, MDR-TB patients often live a
number of years before succumbing to the disease. Therefore MDR-TB prevalence may be three times
greater than its incidence.7 After successfully establishing the DOTS services across the country RNTCP is
now introducing the DOTS Plus services to address the needs of this group of patients.
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, the treatment will follow the internationally recommended
6 DOTS-Plus guidelines and will be done in designated RNTCP DOTS-Plus sites. These sites will be in
highly specialized centres (e.g. Medical College hospitals, Chest and respiratory disease institutes etc.)
which will have ready access to an RNTCP accredited culture and DST laboratory, with qualified staff
available to manage patients using standardized second-line drug regimens given under daily DOT and
standardizedfollow-up protocols, have systems in place for an initial short period of in-patient care to
stabilise the patient on the second-line drug regimen followed by ambulatory DOT and with a logistics
system and standardized information system in place. Each DOTS Plus site will cater to approximately 10
million population. However this norm is neither limiting nor restrictive and will be reviewed and revised
periodically. The DOTS-Plus sites will be initiated in a phased manner similar to that for the establishment
of the culture and DST laboratory network.
RNTCP DOTS Plus vision
It is envisioned that by the year 2010 the DOTS Plus services will be introduced in all the states across the
country. By 2012, it is aimed to extend these services to all smear positive retreatment cases and new cases
who have failed an initial first line drug treatment. And by 2015, these services will be made available to
all smear positive pulmonary TB cases registered under the programme. It is intended to treat at least
30,000 MDR cases annually by 2012-13.
Special considerations for DOTS-Plus
DOTS-Plus is more complex than the basic DOTS strategy. For DOTS-Plus to be successful, special
attention is needed for the following:
Quality-assured laboratory capacity (smear, culture and DST);
Treatment design;
Adherence to difficult-to-take regimens for long periods;
Side-effect management;
Drug procurement;
Recording and reporting; and
Human and financial resource constraints.
5. Framework for effective control of multidrug-resistant TB:
The framework is organized around the same five components of the DOTS strategy, as the underlying
principles are the same. The core components are comprehensive, ensuring that all essential elements of the
DOTS-Plus strategy are included, and are:
Sustained government commitment;
Accurate, timely diagnosis through quality assured culture and drug susceptibility testing;
Appropriate treatment utilizing second-line drugs under strict supervision;
Uninterrupted supply of quality assured anti-TB drugs; and
Standardized recording and reporting system.
Each of these components involves more complex and costly operations than those for controlling drug
sensitive TB. However addressing multidrug-resistant TB will strengthen the existing TB control
programme.
FIVE COMPONENTS OF DOTS-PLUS
1. Sustained political and administrative commitment
a. A well functioning DOTS programme
b. Long term investment of staff and resources
c. Coordination efforts between community, local governments, and international agencies
d. Addressing the factors leading to the emergence of MDR-TB
2. Diagnosis of MDR-TB through quality-assured culture and drug
susceptibility testing
a. Proper triage of patients for Culture & DST testing and management under DOTS-Plus
b. Co-ordination with National and Supra-National Reference Laboratories
c.
3. Appropriate treatment strategies that utilize second-line drugs under
proper management conditions
a. Rational standardized treatment design (evidence-based)
b. Directly observed therapy (DOT) ensuring long-term adherence
c. Monitoring and management of adverse drug reactions
d. Adequate human resources.
e.
4. Uninterrupted supply of quality assured anti-TB drugs.
5. Recording and reporting system designed for DOTS-Plus programmes that
enable performance monitoring and evaluation of treatment outcome
6. GOVERNMENT COMMITMENT &
COORDINATION:
Political Commitment
Administrative commitment must be expressed at all stages of the health intervention process, from
planning and implementation to monitoring and evaluation. Political support needs to be garnered from
many sources including government ministries (central and state), non-governmental organizations (NGOs)
and the private sector, the pharmaceutical industry, academic and research institutions, professional
medical societies and the donor community. This commitment comes in the form of financial and human
resources, training, legal and regulatory documents, infrastructure, and coordination of all stakeholders.
Coordination
As RNTCP embarks on DOTS-Plus activities for the management of MDR-TB, coordination of activities
at all levels is critical. Co-ordination needs to include the contribution of all the key stakeholders,
organizations and external partners, as considered below:
Central TB Division (CTD), Ministry of Health and Family Welfare, Government of India.
The CTD is the central coordinating body for the activities described in the framework.
Commitment of thenecessary resources, particularly towards a strong central management team,
ensures that all aspects are in place from the procurement of second line anti-TB drugs to the
appropriate implementation and monitoring of the DOTS-Plus programme. As needed, partnerships
with all relevant health care 13 providers can be built. The CTD is supported by a National DOTS-
Plus Committee, comprised of members from CTD, the three central TB institutes (NTI, TRC and
LRS), medical colleges and WHO.
Local Health System. RNTCP DOTS-Plus activities will be tailored to fit into the respective state
and district levels infrastructure. The exact organizational structure of the RNTCP DOTS-Plus
programme may vary between the different settings depending on how the local health care is
provided. Transfer between hospitals to outpatient settings or between DOT centres requires great
care, advance planning, good communication. Given the type of care required in the treatment of
MDR-TB, a team of health workers including physicians, nurses, and social workers (wherever
available) should be used.
Community Level. Community involvement and communication with the community leaders can
greatly facilitate implementation of DOTS-Plus, and may respond to needs that cannot be met by
them medical services alone. Community education, involvement, and organization around TB
issues can encourage a feeling of community ownership of TB programmes and reduce stigma. In
some circumstances, communities can also help address the patient’s interim needs including the
provision of DOT, food and/or housing.
International Level. CTD is supported in its DOTS Plus activities by international technical
support through WHO, GLC, and other technical agencies. The collaboration between such entities
requires effective coordination and communication on an ongoing basis.
7. Check list for Programme Manager
Political Commitment:
Clear definition of the roles and responsibilities of each stakeholder/ organization
DOTS-Plus manual approved by CTD
Overall budget secured (including budget for all the components below)
Human Resources:
Estimation of human resources calculated
Organizational structure and management system of human resources
Workforce in post
Training:
Training Curriculum
Training schedule in place
Refresher courses in place
Separate training activities for general medical community
Data Gathering, Analysis, and Application:
Surveillance Systems
Accurate reporting systems to identify and track MDR-TB patients (treatment cards, registers, forms for ordering and reporting
lab results
Laboratory:
Specimen collection system for smears and cultures
Dedicated culture and DST laboratory space
Adequate staffing and training
Testing and maintenance of equipment
Biosafety measures in place
Reagents supply
Supervision and quality assurance system (relationship with a WHO Supra-National Reference Laboratory established)
Results reporting system to treatment care centre
Laboratory for the free monitoring of electrolytes, creatinine, thyroid function , and liver enzymes in place.
HIV testing, counselling and referral available
Pregnancy testing
Patient Care
DOTS-Plus site committee set up
Adequate capacity and trained staff at the health centre for DOT and patient support
Adequate DOT in place and plan to assure case holding
System to detect and treat adverse effects including appropriate medications
Patient and family support to increase adherence to treatment, including support group, psychotherapy, transportation subsidy,
Patient, family, and community education, including stigma reduction
Programme strategy:
DOTS-Plus activities fully integrated within DOTS programme
DOTS-Plus manual published and disseminated (and understood)
Location of care defined and functional (ambulatory and in-door)
Prevention:
Training of all health care workers to identify, refer, and diagnose possible TB cases and individuals at high risk
Maintain high case detection and cure rates under DOTS programme to prevent emergence of MDR-TB
MDR-TB case finding and treatment amongst Category II cases as per RNTCP guidelines
Screening of household contacts of MDR-TB cases as per RNTCP guidelines
Drug and supply procurement:
Projected needs
Ordering with long lead times to receive second line drugs
Adequate budget for drug procurement
Adequate budget for consumable items (sputum cups, laboratory reagents…etc)
Drugs to treat side effects available
Logistics:
Inventory and expiration date management
Transportation and distribution
Adequate national, state, and local drug storage facilities
8. CASE-FINDING AND DEFINITIONS:
Case finding strategy
At present, RNTCP does not have sufficient quality assured laboratory capacity to do culture and DST in
all TB patients. Hence the programme will use a strategy that enrols patients with a very high risk of MDR-
TB into RNTCP DOTS-Plus activities and treatment with the RNTCP Category IV regimen. Patients who
are defined as an “MDR-TB suspect” should be identified and investigated further for MDR-TB.
MDR-TB Suspect can be any of the following:
Any TB patient who fails an RNTCP Category I or III treatment regimen;
Any RNTCP Category II patient who is sputum smear positive at the end of the fourth month of
treatment or later; or
Close contacts of MDR-TB patients who are found to have smear positive pulmonary TB (PTB)
disease
After a TB patient has been declared as a failure of an RNTCP Category I or III treatment, the initial
priority is to ensure that the patient is initiated on an RNTCP Category II regimen and is re-registered in
the appropriate TB Register as a Category II type “failure” patient. Similarly close contacts of MDR-TB
patients should be screened as per RNTCP guidelines and if found to be smear positive PTB, such patients
should be started on Category I or II based on whether they are new or re-treatment cases. 16 A patient who
is an “MDR TB Suspect” should be referred by the respective medical officer – peripheral health institute
(MO-PHI) to the District TB Officer (DTO) for confirmation. It should be ensured that the MDR
suspects are identified and referred to the DTO for confirmation at the earliest i.e. within 2 weeks
of failing a Category I or III regimen, and in case of Category II patients (who have taken at least 4
months of treatment) and close contacts of MDR-TB cases as soon as the sputum results are
available. All women of child bearing age identified as MDR TB suspects should be advised to use a
reliable and appropriate contraceptive method till the results of culture and DST are available.
9. Patient Flow … … … … Diagnosis:
Drug Resistant Cases
A patient is confirmed to have multi-drug resistant TB only by an RNTCP quality assured culture and DST
laboratory. Such patients are classified according to the following definition:
• Confirmed MDR-TB case: An MDR-TB suspect who is sputum culture positive and whose TB is
due to Mycobacterium tuberculosis that are resistant in-vitro to at least isoniazid and rifampicin
(the culture and DST result being from an RNTCP accredited laboratory).
10. DIAGNOSIS AND EVALUATIONS:
Diagnostic examination
Presently conventional solid egg-based Lowenstein-Jensen (LJ) media will be used for primary culture at
the RNTCP accredited laboratory. DST will be performed for streptomycin (S), isoniazid (H), rifampicin
(R) and ethambutol (E) only. Pyrazinamide (Z) sensitivity testing may be included at a later period of
DOTS-Plus implementation.
Follow up smear and culture schedule during treatment
For follow up examination four sputum specimens will be collected and examined by smear and culture at
least 30 days apart from the 3rd to 7th month of treatment (i.e. at the end of the months 3, 4, 5, 6 and 7) and
at 3- monthly intervals from the 9th month onwards till the completion of treatment (i.e. at the end of the
months 9, 12, 15, 18, 21 and 24). Of the four specimens, two specimens for AFB (one early morning and
one supervised spot) will be collected and examined at the respective DMC/DTC (at the end of the months
3, 4, 5, 6, 7, 9, 12, 15, 18, 21 and 24). The other two specimens for culture (one early morning and one
supervised spot) will be ollected and transported in CPC bottles from the respective DTC to the RNTCP
accredited laboratory (at the end of the months 3, 4, 5, 6, 7, 9, 12, 15, 18, 21 and 24). If any of the cultures
in the last three quarters becomes positive, it will be followed up by monthly cultures in the following 3
months
The importance of the sputum examination during treatment needs to be emphasized, since the most
important objective evidence of improvement is the conversion of sputum smear and culture to negative.
Patients will be considered culture converted after having two consecutive negative cultures taken at least
one month apart. Time to culture conversion is calculated as the interval between the date of MDR-TB
treatment initiation and the date of the first of these two negative consecutive cultures (the date that the
sputum specimens are collected for culture should be used). Similarly patients will be considered smear
converted after having two consecutive negative smears taken at least one month apart. Two separate
indicators, one based on sputum smears and the other on cultures will be calculated and interim reports will
be given by the state level DOTS Plus site for smear and culture after completing 6 months and 12 months
of treatment. Though smear conversion can be taken as an indicator, culture conversion which reflects
viability of tubercle bacilli, is more sensitive and is necessary to monitor progress in MDR-TB patients.
Good quality sputum is essential to get proper results.
Pre-treatment Evaluation
Pre-treatment evaluation should include a thorough clinical evaluation by a physician, chest radiograph,
and relevant haematological and bio-chemical tests detailed below.
Since the drugs used for the treatment of MDR-TB are known to produce adverse effects, a proper
pretreatment evaluation is essential to identify patients who are at increased risk of developing such
adverse effects.
The pre-treatment evaluation will include the following:
1. Detailed history (including screening for mental illness, drug/alcohol abuse etc.)
2. Weight
3. Height
4. Complete Blood Count
11. 5. Blood sugar to screen for Diabetes Mellitus
6. Liver Function Tests
7. Blood Urea and S. Creatinine to assess the Kidney function
8. TSH levels to assess the thyroid function
9. Urine examination – Routine and Microscopic
10. Pregnancy test (for all women in the child bearing age group)
11. Chest X-Ray
All MDR-TB cases will be offered referral for HIV counselling and testing at the nearest centre
Monitoring progress during treatment
Clinical monitoring
Patients should be seen by the respective DTO for clinical evaluation at monthly intervals during the IP,
after discharge from the state DOTS-Plus site, and at 3-monthly intervals during the CP until the end of
treatment.
The DTO should screen patients for clinical improvement and possible adverse reactions. Body weight
should be monitored by the DTO at every visit. The patient may need to be hospitalized during treatment
for medical or sociological reasons.
Investigations during treatment
Chest radiograph will be done during the pre-treatment evaluation, at the end of the IP, end of treatment
and when clinically indicated. Serum creatinine is to be done every month for the first 3 months and every
three months thereafter whilst the patient is receiving kanamycin. Other relevant investigations may be
done as and when clinically indicated.
These investigations can be done at the DOTS-Plus site or district hospitals/medical colleges as per
the arrangement, however patients should not be charged for these investigations.
13. LABORATORY ASPECTS:
Drug-resistant case: A patient whose TB is due to tubercle bacilli that are resistant in vitro to at least
one anti-TB drug according to accepted laboratory methods in an RNTCP accredited laboratory.
Mono-resistance: A patient whose TB is due to tubercle bacilli that are resistant in vitro to exactly
on anti-TB drug in an RNTCP accredited laboratory.
Poly-resistance: A patient whose TB is due to tubercle bacilli that are resistant in-vitro to more
than one anti-TB drug, except not both isoniazid and rifampicin in an RNTCP accredited
laboratory.
MDR-TB case: An MDR-TB suspect who is sputum culture positive and whose TB is due to
Mycobacterium tuberculosis that are resistant in-vitro to isoniazid and rifampicin with or without
other anti-tubercular drugs based on DST results from an RNTCP accredited Culture & DST
Laboratory.
Organization and development of the laboratory network
RNTCP has a three tier laboratory network based on the designated microscopy centres (DMCs) covering 1
lakh populations and providing sputum smear microscopy services, and IRLs (undertaking training,
external quality assessment [EQA] of sputum smear microscopy network in the districts and DMCs, and
culture and DST for first line drugs for M. tuberculosis), and NRLs (undertaking training, EQA of sputum
smear microscopy network in the states allotted to them, and culture and DST for first and second line
drugs for M. tuberculosis).
16. SPECIMEN COLLECTION
In tuberculosis bacteriology an often-overlooked problem is that of obtaining adequate good quality
specimens. The advantages of decontamination techniques, obtaining maximum yield by cultures, sensitive
culture media and simple identification schemes will not be complete unless specimens are collected with
care and promptly transported to the laboratory.
A good sputum specimen consists of recently discharged material from the bronchial tree, with minimum
amounts of oral or nasopharyngeal material. Satisfactory quality implies the presence of mucoid or
mucopurulent material. Ideally, a sputum specimen should have a volume of 3-5ml. Specimens should be
transported to the laboratory as soon as possible after collection. If delay is unavoidable, the specimens
should be refrigerated to inhibit the growth of unwanted micro-organisms. If refrigeration is not
possible and a delay of more than 3 days is anticipated, a suitable preservative viz., an equal volume of a
mixture of 1% CPC and 2 % sodium chloride (NaCl) solution is recommended to be used.
17. HOMOGENISATION AND DECONTAMINATION
M. tuberculosis requires special media not used for other organisms and grows slowly, taking three to six
weeks or longer to give visible colonies. Cultures are usually made in bottles rather than in petri dishes
because of the long incubation time required. The bottles are tightly stoppered to prevent drying of the
cultures. The majority of clinical specimens received at the tuberculosis culture laboratory are
contaminated to varying degrees with more rapidly growing normal flora. These would rapidly overgrow
the entire surface of the medium and digest it before the tubercle bacilli start to grow. Most specimens
must, therefore, be subjected to a harsh digestion and decontamination procedure that liquefies the organic
debris and eliminates the unwanted normal flora. All currently available digesting/decontaminating agents
are to some extent toxic to tubercle bacilli and therefore, to ensure the survival of the maximum number of
bacilli in the specimen, the digestion/decontamination procedure must be precisely followed. For tubercle
bacilli to survive to give a confirmatory diagnosis, it is inevitable that a small proportion of cultures may be
contaminated by other organisms of the respiratory tract. As a general rule, a contamination rate of 2%-3%
is acceptable in laboratories that receive fresh specimens. If specimen transportation (especially sputum)
takes several days to reach the laboratory then losses due to contamination may be as high as 5%. It is also
important to note that a laboratory which experiences no contamination is probably using a harsher method
that kills too many of the tubercle bacilli.
When culturing tubercle bacilli, the following aspects should be borne in mind:
• Specimens must be homogenized to free the bacilli from the mucus, cells or tissue in which they may be
embedded. The milder this homogenisation the better would be the results
• Neither homogenisation nor decontamination should unnecessarily reduce the viability of tubercle bacilli
• The success of homogenisation and decontamination depends on:
The greater resistance of tubercle bacilli to strongly alkaline or acidic digesting solutions
The length of exposure time to these agents
The temperature build-up in the specimen during centrifugation
The efficiency of the centrifuge used to sediment the tubercle bacilli
Many different methods of homogenisation and decontamination of sputum specimens for culturing have
been described but there is no universally recognised best technique. The choice of a suitable method is to a
large extent determined by the technical capability and availability of staff in a laboratory, as well as the
quality and type of equipment available, and cost. Each method has its limitations and advantages and it is
recommended that laboratories standardise on one method only. Methods which consistently yield the
highest percentage of positive cultures are those which require:
• Well trained staff
• Relatively expensive equipment (e.g. centrifuges) and related supplies
• Continued maintenance of equipment and of good staff performance.
18. DIGESTION AND DECONTAMINATION PROCEDURES
Since the exposure time to digestants/decontaminants has to be strictly controlled it is best to work in sets
equivalent to one centrifuge load (e.g. eight or twelve specimens at a time). Always digest/decontaminate
the whole specimen, i.e., do not attempt to select portions of the specimen as is done for direct microscopy.
Since sputum specimens are the most common clinical specimens submitted for
tuberculosis culture, homogenisation and decontamination procedures have been largely targeted towards
their processing. Specimens other than sputum require even more care during processing because of the
low numbers of tubercle bacilli present in positive specimens.
PROCESSING OF SPUTUM SPECIMENS CONTAINING CPC and NaCl
If delay of more than 48-72 hours between collection of sputum samples and processing of the same by
culture is anticipated, the sputum sample should be collected in a container with 1% CPC and 2% NaCl.
CPC, a quaternary ammonium compound, is used to decontaminate the specimen while NaCl effects
liquefaction. The use of this method not only decreases the number of cultures lost by contamination as a
result of prolonged transit time but also decreases significantly the laboratory time required for processing
the specimens.
INOCULATION AND INCUBATION
Two slopes per specimen are inoculated each with one 5 mm loopful of the centrifuged sediment,
distributed over the surface. An additional slope containing sodium pyruvate is commonly used to identify
M. bovis but is not required to be included as a routine in India since available evidence does not indicate
prevalence of widespread disease due to M.bovis. Bottle caps should be tightened to minimize evaporation
and drying of media. Care should be taken to avoid using red hot loop and loop should be cooled
sufficiently before inoculation.
All cultures should be incubated at 35-37oC until growth is observed or discarded as negative after eight
weeks. Slopes that are grossly contaminated are also discarded.
20. RECORDING AND REPORTING OF
LABORATORY RESULTS
Tuberculosis laboratories must establish a uniform procedure for reporting culture results. If laboratory
findings are to be useful, they must be communicated in ways that make sense to the different authorities.
Culture procedures for tuberculosis bacteriology are notoriously time-consuming, often taking 8-9 weeks to
complete. For this reason, interim reports should be issued.
The following schedule is recommended:
If the cultures are contaminated, a report should be sent out immediately.
At eight weeks a final report should be issued for culture negative specimens.
If cultures are positive and growth has been identified as M. tuberculosis, a report should have drug
susceptibility test results for patients of DOTS-Plus.
If the colony count is less than 20 or faint growth in the first or second week, incubation is
continued up to 4th week to obtain a colony count of at least more than 50 colonies or more than one
loopful of growth (3mm).
If the growth is still insufficient at the end of 4th week, a subculture should be done on a fresh LJ by
touching all the colonies. The exact number of colony count in primary growth should be recorded
before doing subculture and incubated at 370C not exceeding three weeks. During this period when
sufficient growth is obtained DST is done.
Note :
If increased negative results observed in specimens received, the following could be the reasons and
should be rectified :
o Increased concentration of malachite green used for LJ media preparation:
o Increased temperature of incubation of cultures or
o Increased time and temperature of inspissation.
If increased negative results along with contamination is seen, the decontamination or the
liquefaction is not complete, ambient temperature less than 250C.
A detailed list of equipment and consumables has been prepared by CTD, and they will be provided
by CTD to the concerned IRL involved in DOTS-Plus.
IDENTIFICATION TESTS
Although a presumptive diagnosis of tuberculosis may be made by an experienced laboratory technologist
on the basis of the morphological characteristics of tubercle bacilli described before, it is best to do
confirmatory tests. Unfortunately there is no completely reliable single test that will differentiate M.
tuberculosis from other mycobacteria. Nevertheless, the following tests, when used in combination with the
characteristics described below will enable the precise identification of >95% of M.tuberculosis strains:
1) susceptibility to p-nitrobenzoic acid (PNB); and
2) niacin test.
21. Of these, the PNB test can be included along with the drug susceptibility test.
M. tuberculosis does not grow on medium containing 500µg/ml of PNB. All other mycobacteria are mostly
resistant to PNB and hence grow on medium containing 500µg/ml of PNB.
DST METHODS
Absolute Concentration Method:
This method uses a standardized inoculum grown on drug-free media and media containing graded
concentrations of the drug(s) to be tested. Several concentrations of each drug are tested, and resistance is
expressed in terms of the lowest concentration of the drug that inhibits growth; i.e., minimal inhibitory
concentration (MIC). This method is greatly affected by inoculum size and the viability of the organisms.
The Resistance Ratio Method
It compares the resistance of unknown strains of tubercle bacilli with that of a standard laboratory strain.
Parallel sets of media, containing twofold dilutions of the drug, are inoculated with a standard inoculum
prepared from both the unknown and standard strains of tubercle bacilli. Resistance is expressed as the
ratio of the MIC of the test strain divided by the MIC for the standard strain in the same set.
Proportion Method
This is the method recommended for DOTS-Plus sites in India. It enables precise estimation of the
proportion of mutants resistant to a given drug. Several 10-fold dilutions of inoculum are planted on to both
control and drug –containing media; at least one dilution should yield isolated countable (50 -100)
colonies. When these numbers are corrected by multiplying by the dilution of inoculum
used, the total number of viable colonies observed on the control medium, and the number of mutant
colonies resistant to the drug concentrations tested may be determined. The proportion of bacilli resistant to
a given drug is then determined by expressing the resistant portion as a percentage of the total population
tested. The proportion method is currently the method of choice. The economic variant of proportion
method is used for DOTS-plus.
CRITERIA OF RESISTANCE
Any strain with 1% (the critical proportion) of bacilli resistant to any of the four drugs – rifampicin,
isoniazid, ethambultol, and streptomycin – is classified as resistant to that drug. For calculating the
proportion of resistant bacilli, the highest count obtained on the drug free and on the drug-containing
medium should be taken (regardless of whether both counts are obtained on the 28th day, both on the 42nd
day, or one on the 28th day and the other on the 42nd day.)
22. TREATMENT OF MULTI-DRUG
RESISTANT TB:
Initiation of treatment
Deciding drug dosages and administration
Deciding treatment duration
Providing health education
Method of grouping anti-TB agents
Category IV regimen
RNTCP will be using a Standardised Treatment Regimen (Cat IV) for the treatment of MDR-TB cases
(and those with rifampicin resistance) under the programme. Cat IV regimen comprises of 6 drugs-
kanamycin, ofloxacin (levofloxacin)†, ethionamide, pyrazinamide, ethambutol and cycloserine during 6-9
months of the Intensive Phase and 4 drugs- ofloxacin (levofloxacin), ethionamide, ethambutol and
cycloserine during the 18 months of the Continuation Phase. p-aminosalicylic acid (PAS) is included in the
regimen as a substitute drug if any bactericidal drug (K, Ofl, Z and Eto) or 2 bacteriostatic (E and Cs) drugs
are not tolerated.
RNTCP CATEGORY IV REGIMEN: 6 (9) Km Ofx (Lvx) Eto Cs Z E / 18 Ofx (Lvx)Eto Cs E
23. Dosage and weight band recommendations
Treatment Duration
The treatment is given in two phases, the Intensive phase (IP) and the Continuation phase (CP). IP should
be given for at least six months. After 6 months of treatment, the patient will be reviewed and the treatment
changed to CP if the 4th month culture result is negative. If the 4th month culture result remains positive, the
treatment is extended by 1 month. Extension of IP beyond 1 month will be decided on the results of sputum
culture of 5th and 6th months. If the result of the 4th month culture is still awaited after 6 months of
treatment, the IP is extended until the result is available, with further treatment being decided according to
the culture result. The IP can be extended up to a maximum of 3 months after which the patient will be
initiated on the CP irrespective of the culture result. The recommended duration for CP is 18 months.
Treatment Interruption and default
o Cat IV patients in IP/CP who miss doses:
All the missed doses during IP must be completed prior to switching the patient to CP. Similarly
all missed doses during CP must be administered prior to ending treatment.
o Cat IV patients who interrupt treatment for less than 2 months during IP:
When the patient returns to resume treatment the IP will be continued, however the duration of
treatment will be extended to complete IP. The follow up cultures will be done as per the
revised schedule.
o Cat IV patients who interrupt treatment for less than 2 months during CP:
24. When the patient returns to resume treatment, the CP will be continued, however the duration of
treatment will be extended to complete the CP. The follow up cultures will be done as per the
revised schedule.
o Cat IV patients who default (interrupt treatment for 2 or more months) and return back
for treatment:
Such patients will be given an outcome of “default” and then will be re-registered for further
treatment which is based on the duration of default as per the flow charts given in Figures 3 and
4 on the next page. Re-registration of patients will be done by the DOTS Plus site.
Management of Cat IV patients who default and return for treatment within 6
months of discontinuing Cat IV treatment
25. Management of Cat IV patients who default and return for treatment 6 months or later of
discontinuing Cat IV treatment
Treatment Outcomes
Cure: An MDR-TB patient who has completed treatment and has been consistently culture
negative (with at least 5 consecutive negative results in the last 12 to 15 months). If one follow-up
positive culture is reported during the last three quarters, patient will still be considered cured
provided this positive culture is followed by at least 3 consecutive negative cultures, taken at least
30 days apart, provided that there is clinical evidence of improvement.
Treatment completed: An MDR-TB patient who has completed treatment according to guidelines
but does not meet the definition for cure or treatment failure due to lack of bacteriological results.
Death: An MDR-TB patient who dies for any reason during the course of MDR-TB treatment
Treatment failure: Treatment will be considered to have failed if two or more of the five cultures
recorded in the final 12-15 months are positive, or if any of the final three cultures are positive.
Treatment default: An MDR-TB patient whose MDR-TB treatment was interrupted for two or
more consecutive months for any reasons.
26. Transfer out: An MDR-TB patient who has been transferred to another reporting unit (DOTS Plus
site in this case) and for whom the treatment outcome is not known. Till the time the DOTS Plus
services are available across the country, the Cat IV patients can be transferred out only to those
districts, within or outside the state, where these services are available. If a Cat IV patient moves
from one district to another, both of which are covered by the same DOTS Plus site, transfer out
will not be required.
Treatment stopped due to adverse drug reactions: A patient on MDR-TB treatment who
develops severe adverse reactions and could not continue the MDR-TB treatment in spite of the
management of the adverse reactions as per the defined protocols and decision has been taken by
the DOTS-Plus site committee to stop treatment
Treatment stopped due to other reasons: A patient on MDR-TB treatment who could not
continue the MDR-TB treatment for any other medical reason (than adverse drug reactions), and a
decision has been taken by the DOTS-Plus site committee to stop treatment.
Switched to Category V treatment: A Category IV patient who during treatment is identified as
an “XDR-TB suspect” and who is found to have XDR-TB on testing by an NRL, who subsequently
has had their Category IV treatment stopped and RNTCP Category V treatment initiated.
Still on treatment: An MDR-TB patient who, for any reason, is still receiving their RNTCP CAT
IV treatment at the time of the submission of the RNTCP DOTS- Plus Treatment Outcome Report.
27. Monitoring and management of adverse drug
reactions
Aminoglycosides – Kanamycin
• Ototoxicity 6,7
• Nephrotoxicity
• Vertigo
• Electrolyte imbalance
Quinolones - Ofloxacin
• Gastro Intestinal symptoms: diarrhoea, vomiting, and abdominal pain
• Central nervous system (CNS): dizziness and convulsions
• Phototoxicity and photosensitivity
• Tendinopathy and tendinitis
• Nephrotoxicity
• Skin rash
• Cardiotoxicity
• Arthralgia
Ethambutol
• Visual disturbance
Pyrazinamide
• Arthralgia
• Hyperuricaemia
• Hepatitis
• Pruritis with or without rash
Ethionamide
• Gastro-intestinal: epigastric discomfort, anorexia, nausea, metallic taste, vomiting, excessive salivation,
and sulfurous belching
• Psychiatric: hallucination and depression
• Hepatitis
• Hypothyroidism and goitre with prolonged administration
• Gynaecomastia, menstrual disturbances, impotence, acne, headache, and peripheral neuropathy
Cycloserine
• CNS: dizziness, slurred speech, convulsions, headache, tremor, and insomnia
• Psychiatric: confusion, depression, altered behaviour, and suicidal tendency
• Hypersensitivity reaction
PAS
• Gastro-intestinal: anorexia, nausea, vomiting, and abdominal discomfort
• Skin rash
• Hepatic dysfunction
• Hypokalemia
28. • Hypothyroidism and goitre with prolonged administration
MDR-TB in special situations
Pregnancy with MDR-TB
MDR-TB with HIV co-infection
The presentation of MDR-TB in the HIV-infected patient does not differ from that of drug-sensitive
tuberculosis in the HIV-infected patient. However the diagnosis of TB in HIV-positive persons can be
more difficult and may be confused with other pulmonary or systemic infections. As the HIV disease
progresses and the individual become more immunocompromised, the clinical presentation is
proportionately more likely to be extrapulmonary or smear-negative than in HIV-uninfected TB patients.
This can result in misdiagnosis or delays in diagnosis, and in turn, higher morbidity and mortality.
29. Initiating ART (Anti-Retroviral Therapy) in patients with MDR-
TB
Dose adjustment of anti-TB drugs in presence of renal impairment
30. TREATMENT DELIVERY AND
ADHERENCE
The patient will be admitted in the designated State level DOTS-Plus site in-door facility for at least seven
days post- treatment initiation.
This period of admission will allow for
• All necessary investigations to be undertaken;
• Initiation of the Category IV regimen;
• Monitoring of patient tolerance of the Category IV regimen;
• Motivation, counseling and providing health education to the patient and their families;
• Developing linkages with the services in the respective district where the patient resides
(including identification and training of a local DOT provider and family treatment supporter);
• Contact assessment.
MDR-TB treatment can be successful with high overall rates of adherence when adequate support
measures are provided.1 These measures include enablers and incentives for delivery of DOT to ensure
adherence to treatment and may include the following:
• Reimbursement of travel expenses to patient and attendants for visits to DTC and designate DOTS-
Plus site
• Emotional support and counselling to the patient and family members and education on MDR-TB
treatment;
• Early and effective management of adverse drug reactions;
• Honorarium to the non salaried DOT providers.
Directly observed therapy (DOTS)
Because MDR-TB treatment is the last therapeutic chance for patients and there is a high public health
consequence if a patient with MDR-TB fails therapy, it is recommended that all patients receiving RNTCP
Category IV treatment for MDR-TB receive daily DOT wherever they are receiving the treatment, be it
either in the community, at health centres, or within the hospital setting i.e every dose of RNTCP Category
IV treatment is to be given under DOT by an appropriate, acceptable and accountable DOT provider. DOT
should be provided in a way that does not introduce undue burdens to patients and their families. Long
transportation times and distances, short clinic operation hours, and difficulty accessing services may all
contribute to a decreased efficacy of DOT.
Who can deliver DOT for MDR-TB patients?
Since the treatment of MDR TB requires administration of injection kanamycin during the intensive phase,
the identified DOT provider should be someone, maybe a health worker or someone from the community,
who is able to give injections. If required, a second DOT provider may be utilised for delivering the CP.
Therefore the patient can have two different DOT providers during the course of treatment, one for IP and
the other for CP.
31. Needless to say, the DOT provider should be acceptable and accessible to the patient and accountable to
the system. DOT providers should be adequately trained, supervised and supported to deliver DOT to
MDR patients. A family member should not deliver DOT. Family dynamics are often complicated for the
MDR-TB patient, and a family observer could be subject to subtle manipulation by the patient, relatives,
etc.
Adherence promotion strategies for DOTS-Plus
• Directly observed therapy
• Social support
• Support to adherence team approach
• Effective management of adverse drug reactions
32. LOGISTICS OF SECOND-LINE ANTI-TB
DRUGS:
RNTCP CATEGORY IV REGIMEN: 6 (9) Km Ofx (Lvx) Eto Cs Z E / 18 Ofx (Lvx) Eto Cs E
Main elements to consider when planning procurement of second-line ant-TB drugs
• Drug forecast based on treatment regimen, cohort size and expected cases to be
treated in 1 year.
• Drug labeling
• Shelf-life of the products
• Lead-time for delivery of full drug request
• Delivery period
33. • No of Tranches
• Estimated size of buffer stock .
39. A: To facilitate communication with the patient, record contact telephone number, if available,
from the treatment card.
B: Summary (DOTS cases only):
• This section summarizes the cases registered on DOTS on the current page of the TB
register to facilitate quarterly report preparation.
• Please note that all types of cases have been disaggregated into two age groups (0-14
years and > 15 years) and also sex-wise (Male and Female). This will facilitate reporting
in the block 1 of quarterly case finding report.
C: HIV status: (for intensified TB/HIV package)
• HIV Status as provided in the original TB treatment card should be recorded in the space
provided at the time of registration. Record ‘P’ for HIV-positive; ‘N’ for HIV-negative; ‘U’
for unknown.
• At the time of the case finding report preparation, all ‘blank’ entries in the HIV Status
column in the TB register should be counted as 'Unknown' for the purposes of reporting.
• If the HIV status in the TB patient is initially recorded as ‘unknown’ on the TB treatment
cards and is later ascertained and updated during the course of TB treatment, the same
should be updated in the TB register.
• By the time of Results of Treatment quarterly report preparation, ALL TB treatment cards
should have an entry for HIV status (P, N, or U). Similarly, the TB register should reflect
the entry on the TB treatment cards. If the HIV status information on the TB treatment
card for whatever reason remains blank, that is to be recorded as 'Unknown' in the TB
register.
40. D. Summary (DOTS cases only):
• This section summarizes the TB treatment outcomes of cases registered on DOTS
to facilitate quarterly report preparation.
• Segregate treatment outcomes of TB patients as shown. This will facilitate
reporting in the quarterly results of treatment report. Note: New others TB cases
have been included in the summary table.
E. CPT and ART delivery: (for intensified TB/HIV package)
• The section is to be filled up for all TB patients known to be HIV-infected and
should be left blank for others.
• CPT and ART information should be recorded on the register at the same time of
treatment outcome recording i.e. within a month of TB treatment completion.
• Record CPT started as ‘yes’, with the date, if at least one month of CPT delivery is
recorded in the original treatment card.
• Record ART started as ‘yes’ if recorded as ‘yes’ in the original TB treatment card.
Record the documented approximate date of ART initiation from the original TB
treatment card.
• For patients who were already taking CPT or ART at the time of TB diagnosis, the
dates for CPT and/or ART initiation would be expected to be earlier than the date
of initiation of TB treatment.