Tuberculosis

Learning objective
• Introduction
• NTEP history
• Objective
• Changes in NTEP
• Investigation
• Type of tuberculosis
• Diagnostic algorithm
• Integrated drug resistance TB algorithm
• Treatment of drug sensitive TB
• Treatment of drug resistance TB
• Prevention of TB
Introduction
• Tuberculosis is caused by M. Tuberculosis
• 56% world incidence in five countries- India, China, Pakistan,
Philippines, Indonesia.
• World TB day – 24 march
• TB bacilli was discovered by Robert Koch (1982)
NTEP History
Historical aspects of tuberculosis
NTP (1962)
DOTS

RNTCP 1997
Stop TB strategy

NTEP 1st Jan 2020

Objectives of NTEP
✓ To achieve >90% case detection
✓ To achieve > 90% success rate in new cases
✓ To achieve >85% success rate in retreated cases
✓ To achieve decreased morbidity and mortality for HIV associated TB
✓ To improve outcome of TB care in private sectors.
Investigation
A. Sputum smear Microscopy
B. Culture (LJ Medium, BACTEC 460, MGIT 960)
C. Line Prove Assay (LPA)
D. CBNAAT
E. True NAT
F. PCR
G. CXR
H. Skin Test for TB
Classification of tuberculosis
1. Based on anatomical site of disease
[Link] tuberculosis – Lung parenchyma, Tracheobronchial
tree, Miliary tuberculosis.
[Link] tuberculosis – Pleura, Lymph nodes, Intestine,
joints, bone, skin, meninges.
Diagnostic algorithm
1. Diagnostic algorithm for pulmonary tuberculosis in adult.
2. Diagnostic algorithm of extrapulmonary tuberculosis.
3. Diagnostic algorithm of tuberculosis in pediatrics.
Diagnostic algorithm for pulmonary tuberculosis in adult
PLHIV Presumptive TB patient
Sputum smear examination Chest X-Ray

Smear positive Smear positive Smear Negative Smear Negative

& but & &
CXR suggestive CXR not suggestive CXR suggestive CXR not suggestive
of tuberculosis or not available

CBNAAT If clinical suspicion

Microbiological high
confirm
Tuberculosis MTB detected MTB not detected or Consider Clinically
CBNAAT not available alternative diagnosed TB
diagnosis
and refer to
specialist
RIF sensitive RIF indeterminate RIF resistant Alternate
diagnosis

Repeat CBNAAT on Refer to management

2nd sample of RIF resistance

Indeterminate 2nd
sample collect fresh
sample for liquid
culture/LPA
Diagnostic algorithm for extrapulmonary tuberculosis (EPTB)
Presumptive extrapulmonary tuberculosis

Appropriate specimen from site

Available Not available

If CBNAAT not available Liquid culture High clinical

CBNAAT
suspicion

MTB detected MTB not detected Culture Positive Culture negative Use other Clinically
diagnostic diagnosed
tool TB
Microbiologically No TB
confirmed EPTB
Alternate
diagnosis

RIF sensitive RIF Indeterminate RIF resistance

Repeat CBNAT on Refer to management

Microbiologically
fresh 2nd specimen of RIF resistance
confirmed EPTB

Indeterminate on 2nd
specimen, collect
fresh specimen for
liquid culture
 Diagnostic algorithm for pulmonary tuberculosis in pediatric patient
Presumptive pediatric TB

CBNAAT (sputum)

Positive Negative or sputum

sample not available

Microbiologically
confirmed TB X-ray and tuberculin
skin test

CXR highly CXR nonspecific CXR normal CXR negative

suggestive & but TST negative
TST negative TST positive

Gastric lavage Antibiotics Evaluation by Look for other

expert for EPTB alternative cause

CBNAAT Not improve

Positive Negative

Tuberculosis Look for other cause

Integrated drug resistance
TB algorithm
Integrated drug resistance TB algorithm
•Presumptive TB Presumptive TB
•All notified TB Patient
•Non responders to Treatment
PLHIV
EPTB
Smear –Ve/Na
CBNAAT / TrueNat for X- ray suggestive of TB
rifampicin resistance Vulnerable populations
Contact of DR TB Patients

Rifampicin sensitive Rifampicin resistance

FL LPA
FL LPA to rule out INH,
pyrazinamide
resistance, SL LPA for
H Sensitive H resistance second line drug
resistance

Start first If H resistance

line detected then SL LPA
treatment for FQ and SL
injectable are done

If PQ resistance
detected then DST for
Mfx, Lzd done
Type of resistance
• H mono resistance: Resistance to Isoniazid
• Poly drug resistance: Resistance to more than one first line drug other
than H and R
• Rifampicin resistance: Resistance to rifampicin
• Multidrug resistance (MDR): Resistance to INH and rifampicin with or
without resistance to other FLD
• Extensive drug resistance TB: MDR TB + resistance to fluoroquinolone and
at least one of the injectable SLD (Kanamycin, Amikacin, Capreomycin)
Anti-tubercular drug
First line drugs 2nd line drugs
1. Fluoroquinolones
• H- Isoniazid A. Ofloxacin
B. Moxifloxacin
• R- Rifampicin
C. Gatifloxacin
• P- Pyrazinamide D. Levofloxacin
2. Injectable
• E- Ethambutol
A. Capreomycin
• S- Streptomycin B. Kanamycin
C. Amikacin
3. Linezolid
4. Clofazimine
5. Cycloserine
6. Ethionamide
7. PAS
8. Thioacetazone
9. Bedaquiline
10. Delamanid
Treatment of drug sensitive TB
Type of TB cases Intensive phase (IP) Continuous phase (CP)
New cases
Previously treated cases
(Relapse, failure, loss of 2HRZE 4HRE
follow up)

Note:
• Continuous phase can be extended for 12 – 24 weeks in case of CNS TB, Skeletal
TB, Disseminated TB etc.
• Extension beyond 12 weeks only by recommendation of specialist
Daily FDC regimen for adult

No. of tablets FDC

IP CP
Weight category
HRZE HRE
75/150/400/275 75/150/275
25 –34 kg 2 2
35 – 49 kg 3 3
50 – 64 kg 4 4
65 – 75 kg 5 5
> 75 kg 6 6
Daily FDC regimen for Pediatric (<18 years)

Number of tablets (FDC)

Weight category IP CP IP CP
HRZ E HR E
50/75/150 100 50/75 100
4 – 7 kg 1 1 1 1
8 – 11 kg 2 2 2 2
12 – 15 kg 3 3 3 3
16 – 24 kg 4 4 4 4
25 – 29 kg 3+1A 3 3+1A 3
30 – 39 kg 3+2A 2 3+2A 2
Follow up schedule
Follow up Smear examination at the end of IP and end of CP
Weight measurement: monthly
CXR- if required

Extension of treatment Extension of IP not require

Extension in CP based on clinical judgement
Action on follow up DST should be done if any follow up sputum comes
positive
Long term follow up Clinical and sputum examination at the end of 6, 12, 18,
24 months
Treatment of drug resistance TB
Type of TB Total
patient IP CP
duration
H mono/ Poly
resistance TB (6-9) LfxREZ 6-9 month
Shorter Oral
Bedaquiline (5) LfxCfzZE
MDR/RR-TB (4-6) Bdq(6)LfxEtoCfzH(h)ZE 9-11 month
regimen
All oral Longer
MDR TB (18-20) Bdq(6)LzdLfxCsCfz 18-20 month
Regimen

XDR TB Individualized regimen

Prevention of TB
• Drug sensitive TB
• 6 months Isoniazid (H)
• Drug resistance TB
• 6 months H
• 4 months R
• 6 months Levofloxacin