Tuberculosis control

1. Tuberculosis control Dr. Pracheth R. MD, DNB, PGDPHSM. Assistant Professor, Dept. Community Medicine, YMC.

2. Outline • DOTS • MDR and XDR TB • Childhood TB • BCG vaccination • TB and HIV • RNTCP

3. Treatment : Anti-TB drugs Bactericidal: • Rifampicin • Isoniazid • Streptomycin • Pyrazinamide

4. Continued….. Bacteriostatic: • Ethambutol • Thioacetazone Second line drugs: • Fluroquinolones • Ethionamide • Capreomycin • Kanamicin, amikacin • Cycloserine

5. DOTS

6. DIRECTLY OBSERVED TREATMENT, SHORT COURSE (DOTS) CHEMOTHERAPY • Intensive phase- trained worker watches, patient swallows drug in his presence • Continuation phase- medicines for 1 week in a multiblistercombipack, first dose swallowed in presence of health worker

10. Daily regimen • In 2013: National Expert Committee • Will be implemented shortly • Category 1: • IP: 2HRZE, CP: 4HR • Category 2: • IP: 2HRZES+1HRZE, CP: 5HRE

11. MDR TB • Resistant: isoniazid, rifampicin • XDR TB: • almost all second line drugs • Rifampicin and Isoniazid • Fluroquinolone • One of: amikacin, capreomycin, kanamycin

12. Types and causes • Primary or pre-treatment: • Not received drug before-episomes • Secondary or acquired: • Initially sensitive • Incorrect prescription • Irregular supply drugs • Non-compliance • Lack of supervision, follow-up

13. DOTS-Plus- MDR TB (Cat IV)

14. XDR TB treatment

15. Childhood TB

16. Continued… • Around 6-8% all cases: < 15 years • Commonest age: 1-4 years • Source: adult • No. infectious cases • Closeness of contact • Age of child • Rarely: smear positive

20. Continued… • Severe disease, intolerance: hospitalize • Daily treatment • Discharge: thrice weekly • Doses: as per kg body weight • Patient wise boxes (6)-weight • INH Prophylaxis (10mg/kg): 6 months

21. INH Prophylaxis • Asymptomatic contacts (<5 years)- smear positive • HIV infected children: exposed-TB case/ Tuberculin positive • Mother: TB pregnancy

22. TB in pregnancy

23. Continued….. • HRE: 2 months • HR: 7 months • Stop E after 1 month if H,R sensitive • Z: only resistance • S: contraindicated

24. MDR-TB in pregnancy

25. BCG vaccination • Calmette and Guerin : 1906 began attenuating avirulent strain of M. bovis • Repeated subcultures, 13 years: BCG • Initial- oral: 1921-1925 • 1927: first injected intradermally • 1948: well accepted

26. Continued….. • Aim: • Benign, artificial primary infection • Reduce morbidity and mortality • Vaccine: • Live bacterial vaccine • Danish 1331 strain • Type of vaccine: • Freeze dried and liquid (fresh)

27. Continued….. • Stable-: refrigerated below 10 degree C • Normal Saline- reconstituent • Reconstituted vaccine- used within 3 hours, left over vaccine- discarded • Dosage: • Newborn <4 weeks: 0.05 ml; >4 weeks: 0.1 ml • Thin skin

29. Continued… • Administration: • Intradermal ; Tuberculin syringe • Subcutaneously- abscess • Just above insertion of deltoid • Satisfactory injection: wheal-5cm.

30. Continued… • Phenomena after vaccination: • 2-3 weeks: papule • Increases in size-4 to 8 mm-5 weeks • Breaks –ulcer-covered with a crust • Spontaneous healing: 6-12 weeks- scar:4-8mm • Mantoux +: 8 weeks

32. Continued… • Complications: • Severe ulceration • Suppurative lymphadenitis • Osteomyelitis • Disseminated BCG infection

34. Continued.. • Local abscess: • Aspiration • Incised, daily local applications-INH/ PAS powder • Assure patient • Avoid vaccination in same arm for 6 months

35. Continued… • Protective value: • For 15-20 years • Immunity response-delayed hypersensitivity • Range of protection: 0-80% • Partial protection

36. Continued… • Contraindications: • Generalized eczema • Infective dermatosis • History of deficient immunity (symptomatic HIV infection, congenital immunodeficiency leukaemia, lymphoma) • Immunosuppressive treatment • Pregnancy

37. Continued… • Direct BCG vaccination: • Without prior tuberculin test • Administer before contact : environmental mycobacteria

38. TB+ HIV

39. Continued… • HIV damages immunity • Reactivate latent infection • Primary infection-progresses faster • Recurring infection • Community

40. Diagnosis- TB in HIV • High negative smears • Tuberculin test may fail • Chest X-ray: less cavitation • More extra-pulmonary TB • Screen all HIV +: sputum smear • Negative: culture • Culture not done: X-ray +clinical symptoms

41. Diagnose HIV in TB patients • High prevalence: HIV test all TB patients • Pre-test , post-test counseling • Integrated Counseling and Testing Centre • High-risk behaviour

42. ART to patients with MDR-TB

43. TB and diabetes • Risk factor for TB • Around 15% of all TB cases • Weak immune system • All TB cases-screen: diabetes • High TB prevalence: all diabetes-TB screening • Death during treatment, relapse

44. RNTCP • NTP: 1962 • Inadequate funds • Over-reliance X-ray • Interrupted drug supply • Low rates: completion • In 1993: RNTCP • Pilot phase: 1998- 2% of country • By 2006: whole country

45. Objectives and components 1. Cure rate : 85% 2. Case detection: 70% • Political will • Diagnosis: quality assured sputum microscopy • Adequate supply of drugs • Directly observed treatment • Systematic monitoring, accountability

47. New initiatives • Nucleic Acid Amplification Test- GeneXpert • Nikshay: web based application • Mandatory TB notification • Ban on TB serology : • Remote infection • Poor specificity

48. Future • Case-finding, treatment: major disease • Bacilli capable: living body-years • Drug-resistant strains • TB+HIV • Social factors

49. Questions • Advantages of DOTS therapy (3 marks) • Defaulters in TB treatment (3 marks) • Define TB control. Explain it in detail (1+5=6 marks) • Explain early detection of tuberculosis (6 marks) • Define new case, relapse, failure with reference to TB (3 marks) • Explain briefly Mantoux Test (3 marks)

50. Questions 7. Enumerate the cardinal features of TB (2 marks) 8. What is supervised treatment in TB ( 2 marks) 9. Components of DOTS ( 3 marks) 10. Define MDR and XDR TB ( 3 marks) 11. DOTS-Plus strategy (3 marks).