RNTCP in India

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RNTCP in India. An orientation programme lecture.

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RNTCP: 

RNTCP Dr. Gyanshankar Mishra MD (Pulmonary Medicine) DNB(Respiratory Diseases) Assistant Professor Dept. of Pulmonary Medicine, GMC Nagpur

In our country…: 

In our country…

RNTCP Treatment: 

RNTCP Treatment Objectives of TB treatment Basis of TB treatment Case definitions Treatment regimens Special situations Directly Observed Treatment (DOT) Monitoring of patients Treatment outcome Advanced categories under RNTCP – CAT IV & CAT V

PowerPoint Presentation: 

The objectives of RNTCP are to achieve and maintain a cure rate of at least 85% among new sputum smear-positive cases and to achieve and maintain detection of atleast 70% of such cases in the population.

Basis of TB treatment: 

Basis of TB treatment Intermittent (thrice weekly) treatment regimens Treatment given under direct observation Standardized treatment regimens in two categories Regimen decided by MO on basis of Sputum smear results History of previous anti-TB treatment Disease classification (pulmonary/extra pulmonary Severity of illness

Components of DOTS: 

Components of DOTS

PowerPoint Presentation: 

A pulmonary TB suspect is defined as: An individual having cough of 2 weeks or more Contacts of smear-positive TB patients having cough of any duration Suspected/confirmed extra-pulmonary TB having cough of any duration HIV positive patient having cough of any duration

Sputum AFB smear Lab referral form: 

Sputum AFB smear Lab referral form

PowerPoint Presentation: 

Pulmonary Tuberculosis, Smear-Positive TB in a patient with atleast one smear-positive for AFB out of the two initial sputum smear examination by direct microscopy Pulmonary Tuberculosis, Smear Negative A patient with symptoms suggestive of TB with two smear examination negative for AFB, with evidence of pulmonary TB by microbiological methods (culture positive or by other approved molecular methods) or Chest Xray is classified as having smear negative pulmonary tuberculosis

PowerPoint Presentation: 

Extra Pulmonary Tuberculosis Tuberculosis in any organ other than lungs (eg. pleura, lymph nodes, intestine, genitor-urinary tract, joint and bones, meninges of the brain etc). The diagnosis should be based on strong clinical evidence with the following investigations Smear/Culture from extrapulmonary sites Histopathological examination or Radiological examination or Biochemical and cytological examination including FNAC

Case definitions: 

Case definitions NEW A TB patient who has never had treatment for TB or has taken anti-tuberculosis drugs for less than one month RELAPSE A TB patient who was declared cured or treatment completed by a physician, but who reports back to the health service and is now found to be sputum smear positive.

Case definitions (contd): 

Case definitions (contd) TRANSFERRED IN A TB patient who has been received for treatment into a Tuberculosis Unit, after starting treatment in another unit where s/he has been registered. TREATMENT AFTER DEFAULT A TB patient who received anti-tuberculosis treatment for one month or more from any source and returns to treatment after having defaulted, i.e ., not taken anti-TB drugs consecutively for two months or more , and is found to be sputum smear positive.

Case definitions (contd): 

Case definitions (contd) FAILURE Any TB patient who is smear positive at 5 months or more after starting treatment. CHRONIC A TB patient who remains smear-positive after completing a re-treatment regimen but has not been initiated on MDR TB treatment OTHERS TB patients who do not fit into the above mentioned types. Reasons for putting a patient in this type must be specified

Which bacilli are acted upon by the ATT drugs?: 

Which bacilli are acted upon by the ATT drugs?

Treatment Regimens: 

Treatment Regimens Category of Treatment Type of Patient Regimen* Category I All new pulmonary (smear-positive and negative), extra pulmonary and ‘others’ TB patients . 2H 3 R 3 Z 3 E 3 + 4H 3 R 3 Category II TB patients who have had more than one month anti-tuberculosis treatment previously Relapse , Failure, Treatment After Default ,Others 2H 3 R 3 Z 3 E 3 S 3 + 1H 3 R 3 Z 3 E 3 + 5H 3 R 3 E 3

Basis for Regimens: 

Basis for Regimens CAT I: New sputum smear Positive patients, high bacillary population, chances for naturally occurring resistant mutants higher,therefore 4 drugs in intensive phase CAT II: Because of previous treatment, chances of harboring resistant bacilli are higher; hence 5 drugs in IP and total duration of treatment is 8 months.In continuation phase lower bacterial population;hence less chance of resistant organisms, therefore 3 drugs are enough.

Regimen for Non-DOTS treatment in RNTCP Areas: 

Regimen for Non-DOTS treatment in RNTCP Areas Self administered non rifampicin containing regimen Needed in few cases of adverse reaction to rifampicin and pyrazinamide Upto a maximum of 1% of patients may get Non-DOTS treatment in an RNTCP area. Tuberculosis treatment card to be filled for these patients as well

Regimen for Non-DOTS treatment in RNTCP Areas: 

Regimen for Non-DOTS treatment in RNTCP Areas Treatment Regimen Non-DOTS Regimen 2HSE+10 HE

DOTS in the context of HIV: 

DOTS in the context of HIV DOTS can: Prolong and improve the quality of life. Prevent emergence of MDRTB. Stop the spread of TB. Reverse the trend of MDRTB. In the context of HIV, failure to use DOTS can result in - rapid spread of disease - tripling of cases - increased drug resistance.

Special situations: 

Special situations Hospitalization general policy is treatment on ambulatory basis Indoor treatment adviced if general condition of patient is serious Pneumothorax Massive haemoptysis Large pleural effusion Treatment with prolongation pouches supplied by DTO of the district in which hospital is situated.

Special Situations (contd): 

Special Situations (contd) Pregnancy and post natal period Streptomycin not to be given. Other drugs in RNTCP are safe Breast feeding should continue Chemoprophylaxis for baby if mother is smear positive Renal failure Rifampicin, isoniazid and pyrazinamide can be given Streptomycin and ethambutol require close monitoring

Directly Observed Treatment: 

Directly Observed Treatment

DOTS Strategy: 

DOTS Strategy A strategy to ensure treatment completion in which Treatment observer (DOT provider) must be accessible and acceptable to the patient and accountable to the health system DOT provider administers the drugs in intensive phase. Ensures that the patient takes medicines correctly in continuation phase. Provides the necessary information and encouragement for completion of treatment.

Drug administration: 

Drug administration

Drug doses: 

Drug doses

Pediatric weight bands: 

Pediatric weight bands Pediatric patient wise boxes are available with different dosages as two product codes to be used under four weight bands for children weighing 6 to 10 kgs, 11 to 17 kgs, 18 to 25 kgs and 26 to 30 kgs.

Drug administration(contd): 

Drug administration(contd)

Monitoring of Treatment: 

Monitoring of Treatment Follow up sputum microscopy determines Conversion rate Cure rate Sputum smear microscopy schedule Initial sputum examination End of Intensive phase of treatment 2 months into Continuation phase of treatment End of treatment

Schedule of follow-up sputum smear examination: 

Cat. of Rx Pre–Rx Sputum Test at month If: result Then Cat–1 + 2 - C.P. – Sputum at 4 & 6 m + I.P. for 1month, Sp. At 3, 5 & 7 - 2 - C.P. Sputum at 6 months + I.P. for 1 month, SP. at 3, 5 & 7 Cat–II + 3 - C.P. Sputum at 5 & months + I.P. for 1 month, Sp. at 4, 6 & 9 Schedule of follow-up sputum smear examination

Treatment Outcomes: 

Treatment Outcomes

Treatment Outcomes: 

Treatment Outcomes DIED Patient who died during the course of treatment regardless of cause FAILURE Any TB patient who is smear positive at 5 months or more after starting treatment.

Treatment outcomes: 

Treatment outcomes

Advanced RNTCP Regimes Drug Resistant TB: 

Advanced RNTCP Regimes Drug Resistant TB MDR TB – Resistant to INH & Rifampicin

CAT IV – MDR TB: 

CAT IV – MDR TB INITIAL INTENSIVE PHASE : 6- 9 months Inj. Kanamycin Tab Ethionamide Tab Ofloxacin Tab. Pyrazinamide Tab. Ethambutol Cap Cycloserine CONTINUATION PHASE : 18 months Tab Ethionamide Tab Ofloxacin Tab Ethambutol Cap Cycloserine

CAT V- XDR TB: 

CAT V- XDR TB XDR TB- MDR TB+ Resistant to Second line injectable Anti TB drug & Fluroquinolone

CAT V- XDR TB: 

CAT V- XDR TB The Intensive Phase (6-12 months) will consist of 7 drugs Capreomycin (Cm), PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav The Continuation Phase (18 months) will consist of 6 drugs – PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav