Presenter:
Dr. Rohit A
Chairperson: Dr. Mayur S Sherkhane
TUBERCULOSIS - I
Seminar - I
Part 1
Part 2
 History
 Diagnosis
 Epidemiology
 Treatment
 Etiopathogeneis
 Drugs
 Clinical features
 RNTCP- in brief
Seminar - II
 MDR- TB
 HIV- MDR TB
 DOTS Plus
 Diagnosis
 Clinical features
 Prevention &
Treatment
History
 Tuberculosis in early civilization
 Other names: Kshaya roga[Indian
scriptures], Phthisis[Romans], Scrofula,
Consumption[Greece]
 Sanatorium movement
 The scientific advances
 White Plague
History of tuberculosis. Wikipedia.com[ last accessed on 21st august, 2012].
http://en.wikipedia.org/wiki/History_of_tuberculosis
History
History of tuberculosis. Wikipedia.com[ last accessed on 21st august, 2012].
http://en.wikipedia.org/wiki/History_of_tuberculosis
Problem statement- World
A Kumar. TB india 2011. Annual status report. New delhi: Central Tb publication division; 2012.
INDIA IS THE HIGHEST TB BURDEN COUNTRY
ACCOUNTING FOR MORE THAN ONE-FIFTH OF THE
GLOBAL INCIDENCE
Global annual incidence = 9.4 million
India
21%
India annual incidence = 1.96 million
Other countries
20%
Other 13 HBCs
16%
Phillipines
3%
Pakistan
3%
Ethiopia
3%
China
14%
Indonesia
6%
Bangladesh
4%
Nigeria
South Africa 5%
5%
WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing
India
Numbers in
millions(95% CI)
Rate per 1,00,000
persons
2.0
168
AFB positive
1.7
165
Bacillary
3.8
369
3.0
249
Incidence
All cases
Period Prevalence
Prevalence, all cases
(2009 WHO estimate)
A Kumar. TB india 2011. Annual status report. New delhi: Central Tb publication division; 2012.
TB-related Millennium
Development Goal
 GOAL 6 – to combat HIV/AIDS, malaria
and other diseases.
 Target 8 – to have halted by 2015 and begun to
reverse the incidence of malaria and other major
diseases, including tuberculosis.
 INDICATORS FOR TARGET
 Indicator 23: Between 1990 and 2015, to halve the
prevalence and death rates associated with
tuberculosis.
 Indicator 24: by 2005, to detect 70% of new smear
positive TB cases arising annually, and to successfully
treat 85% of these cases.
J Kishore. National health programmes of india. 9th edn. New Delhi: Century publications;
2011. Part 1 National health programmes, chapter 9 RNTCP; p 207-39.
Epidemiology
Agent
Host
Environment
• Agent
• Source
• Communicability
• Age
• Sex
• Heredity
• Social factors
K Park. Parks textbook of preventive and social medicine. 21 edn. m/s Banarsidas bhanot:
Jabalpur; 2011. Chapter 5 Respiratory infections on tuberculosis; p 164-82
Epidemiology
Agent
Host
Environment
• Agent
• Source
• Communicability
• Age
• Sex
• Heredity
• Social factors
K Park. Parks textbook of preventive and social medicine. 21 edn. m/s Banarsidas bhanot:
Jabalpur; 2011. Chapter 5 Respiratory infections on tuberculosis; p 164-82
Epidemiology
Agent
Host
Environment
• Agent
• Source
• Communicability
• Age
• Sex
• Heredity
• Social factors
K Park. Parks textbook of preventive and social medicine. 21 edn. m/s Banarsidas bhanot:
Jabalpur; 2011. Chapter 5 Respiratory infections on tuberculosis; p 164-82
Epidemiology
Agent
Host
Environment
• Agent
• Source
• Communicability
• Age
• Sex
• Heredity
• Social factors
K Park. Parks textbook of preventive and social medicine. 21 edn. m/s Banarsidas bhanot:
Jabalpur; 2011. Chapter 5 Respiratory infections on tuberculosis; p 164-82
Predisposing factors
 Direct
 Indirect
 Distant
J Kishore. National health programmes of india. 9th edn. New Delhi: Century publications;
2011. Part 1 National health programmes, chapter 9 RNTCP; p 207-39.
Predisposing factors
 Direct
J Kishore. National health programmes of india. 9th edn. New Delhi: Century publications;
2011. Part 1 National health programmes, chapter 9 RNTCP; p 207-39.
Predisposing factors
 Indirect
J Kishore. National health programmes of india. 9th edn. New Delhi: Century publications;
2011. Part 1 National health programmes, chapter 9 RNTCP; p 207-39.
Predisposing factors
 Distant
J Kishore. National health programmes of india. 9th edn. New Delhi: Century publications;
2011. Part 1 National health programmes, chapter 9 RNTCP; p 207-39.
Epidemiological indices
 Prevalence of infection
 Incidence of infection
 Prevalence of disease
 Incidence of disease
 Prevalence of ‘suspect’ cases
 Mortality rate
K Park. Parks textbook of preventive and social medicine. 21 edn. m/s Banarsidas bhanot:
Jabalpur; 2011. Chapter 5 Respiratory infections on tuberculosis; p 164-82
Etiology: M tuberculosis
 Fungus like bacteria
 Aerobic
 Non motile
 Non capsulated
 Non sporing
J Paniker ,Ananthnarayan. Ananthnarayan’s textbook of microbiology. 8th edn. Cochin:
National Publishers; 2011.
 Gram positive
 Acid fast
 Alcohol fast
 Biochemical reactions
J Paniker ,Ananthnarayan. Ananthnarayan’s textbook of microbiology. 8th edn. Cochin:
National Publishers; 2011.
Cultural characteristics
M tuberculosis
M bovis
 Obligate aerobe
 Micro aerophilic[isolation]
 Eugonic
 Dysgonic
 Dry, rough, raised, irregular
 Flat, smooth, moist, break
colonies
up easily
J Paniker ,Ananthnarayan. Ananthnarayan’s textbook of microbiology. 8th edn. Cochin:
National Publishers; 2011.
Pathogenesis
Kumar, Abbas, Fausto, Mitchell. Robbins basic pathology. 8th edn. Philadelphia: Saunders;
2011. Chapter 13, the lungs.p 516-22
Kumar, Abbas, Fausto, Mitchell. Robbins basic pathology. 8th edn. Philadelphia: Saunders;
2011. Chapter 13, the lungs.p 516-22
Natural history
Kumar, Abbas, Fausto, Mitchell. Robbins basic pathology. 8th edn. Philadelphia: Saunders;
2011. Chapter 13, the lungs.p 516-22
Clinical features- Primary
pulmonary tuberculosis
 Asymptomatic
 Febrile illness at the time of tuberculin
conversion
 In children:
 Loss of appetite, fretfulness and failure to
thrive
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
 Cough
 Expectoration
 Haemoptysis
 Wasting
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
 Fever : intermittent and has an insidious
onset
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
Clinical features- Signs
 Bilateral crackles on auscultation
 Hepatomegaly, splenomegaly and
lymphadenopathy
 Choroid tubercles are seen in children
 Miliary lesions of the skin
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
Clinical features- Post
primary TB
 commonest form
 insidious onset of fever, cough, chest pain
and haemoptysis
 not specific
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
Clinical features- Miliary
TB
 Insidious onset
 Gradual development of ill-health, anorexia,
loss of weight and fever
 Clinical evidence of associated tuberculous
meningitis particularly in children
GS Sainani et al. API textbook of medicine. 6th edn. The national book depot: Mumbai;
2005 . section 6 respiratory disease
Miliary TB
Kumar, Abbas, Fausto, Mitchell. Robbins basic pathology. 8th edn. Philadelphia: Saunders;
2011. Chapter 13, the lungs.p 516-22
Evolution of TB Control in
India
 1950s-60s
Important TB research at TRC and NTI
 1962
National TB Programme (NTP)
 1992
Programme Review
• only 30% of patients diagnosed;
• of these, only 30% treated successfully
 1993
RNTCP pilot began
 1998
RNTCP scale-up
 2001
450 million population covered
 2004
>80% of country covered
 2006
Entire country covered by RNTCP
Objectives: RNTCP
 Emphasis on cure through supervised short
course chemotherapy, to achieve cure rate of
85%
 Augumentation of case finding activities to
detect 70% of estimated cases.
Components of DOTS
 Political commitment
 Good quality sputum microscopy
 Directly observed treatment
 Uninterrupted supply of good quality drugs
 Accountability
Annualized New Smear-Positive Case Detection Rate
and Treatment Success Rate in DOTS Areas, India, 2000-2009*
120%
110%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2000
2001
2002
2003
2004
2005
Annualised New S+ve CDR
2006
2007
Success rate
•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)
2008
2009
Structure of RNTCP at district levels
Nodal point for TB
control
One/ 500,000
(250,000 in hilly/
difficult/ tribal area)
One/ 100,000
(50,000 in hilly/ difficult/
District Administration
District Magistrate/
District Collector
District Health Services
Chief Medical Officer and
other supporting staff
District TB Centre
Tuberculosis Unit
Microscopy Centre
DTO, MO-DTC
Driver, Urban TB Coordinators,
TBHVs, Communication Facilitators
Medical officer-TB Control,
Senior Treatment supervisor(STS),
Senior TB Laboratory Supervisor(STLS)
Medical Officer, paramedical staff
And Laboratory Technician
tribal area)
DOT Centre
TB Health Visitors (TBHV),
DOT Provider
(MPW, NGO, ASHA,
Community Volunteers)
Components of Stop TB
Strategy, 2006
Pursuing high-quality DOTS expansion and
enhancement
2. Addressing TB/HIV, MDR-TB and other
challenges
3. Contributing to health system strengthening
4. Engaging all health providers
5. Empowering people with TB, and communities
6. Enabling and promoting research
1.
India
A Kumar. TB india 2011. Annual status report. New delhi: Central Tb publication division; 2012.
Stop TB Partnership Targets
 By 2005:
 At least 70% people with sputum smear positive TB will be diagnosed.
 At least 85% cured.
 By 2015:
 Global burden of TB (prevalence and death rates) will be reduced by 50%
relative to 1990 levels.
 Reduce prevalence to <150 per lakh population
 Reduce deaths to <15 per lakh population
 Number of people dying from TB in 2015 should be less than 1 million,
including those co-infected with HIV
 By 2050:
 Global incidence of TB disease will be less than or equal to 1 case per million
population per year
Directly Observed Treatment,
Short-course strategy(DOTS),1994
1. Government commitment to TB control
2. Diagnosis by smear microscopy mostly on selfreporting symptomatic patients
3. Standardised short course chemotherapy (SCC) with
direct observation of treatment (DOT)
4. Efficient system of drug supply
5. Efficient recording and reporting system with
assessment of treatment results
Five components were expanded in 2002
RNTCP Organization structure: State
level
Health minister
Health secretary
MDNRHM
Director Health Services
Additional / Deputy / Joint
Director
(State TB Officer)
State Training and Demonstration
Center (TB)
Director, IRL Microbiologist, MO,
Epidemiologist/statistician, IRL LTs etc.,
State TB Cell
Deputy STO, MO, Accountant,
IEC Officer, SA,
DEO, TB HIV Coordinator etc.,
Objectives of RNTCP
 To achieve and maintain a cure rate of at least
85% among newly detected infectious (new
sputum smear positive) cases
 To achieve and maintain detection of at least
70% of such cases in the population
Unique features of RNTCP
• District TB Control Society
• Modular training
• Patient wise boxes
• Sub-district level supervisory staff (STS, STLS) for
treatment & microscopy
• Robust reporting and recording system