RNTCP CORRECT FILE | Anatomy2Medicine
RNTCP CORRECT FILE

RNTCP CORRECT FILE

REVISED NATIONAL TB CONTROL PROGRAM

 

  • Clinical Vignette in exam:

 

    • A 25-year-old female has been diagnosed to be suffering from tuberculosis categorized as category I (sputum +ve) case of relapse. The new treatment regimen recommended under DOTS is – 2(HRSZE)3 + 1(HRZE)3 + 5(HRE)3 (mcq)

 

  • CATEGORIZATION AND TREATMENT REGIMENS IN RNTCP:
    CATEGORIZATION AND TREATMENT REGIMENS IN RNTCP:

    CATEGORIZATION AND TREATMENT REGIMENS IN RNTCP:

        • K-Kanamycin,O Ofloxacin, Et – Ethionamide, C — Cycloserine
        • The numbers before letters refer to months of treatment (2 imply two months of treatment)
        • The numbers letters refer to frequency of administration per week (3 imply thrice per week)
        • Seriously ill extra-pulmonary TB include :
          • Meningitis, disseminated TB
          • tuberculous pericarditis, peritonitis, bilateral or extensive pleurisy
          • spinal disease with neurological complaints
          • SS -ve TB with extensive perenchymal involvement
          • intestinal and genito-urinary TB
      • For sputum smear to come positive on ZN staining there should be minimum — 10,000 bacilli per ml sputum

     

  • Zeihl Neelsen (ZN) Staining IN RNTCP:
  • Sputum smear of a suspected TB patient is used for the diagnosis
        • Decolourizer: 25% sulphuric acid
        • Acid Fast Bacilli (AFB) of TB: ‘Rod shaped’ with ‘beaded appearance’ (Beads: Mycolic Acid)
        • 10,000 bacilli per ml sputum must be present for a positive result

     

        • Results of ZN staining: Minimum 100 fields examined
        • AFB SPUTUM SMEARS (SS) FOR DIAGNOSIS OF A CASE OF TB:
        • Interpretation of results of 3 sputum smear examination:
        • Follow-up smears examination timings:
        • Results of ZN staining: Minimum 100 fields examined

          Results of ZN staining: Minimum 100 fields examined

            • AFB SPUTUM SMEARS (SS) FOR DIAGNOSIS OF A CASE OF TB:

           

        • A person with productive cough > 3 weeks with or without hemoptysis, fever for > 3 weeks, chest pain, weight loss, night sweats, and loss of appetite is subjected to 3 SS examinations
              • ‘3 sputum smears’ over 2 days period (Mnemonic: SMS)
                • Spot Sample (Day I)
                • Morning Sample (Day 2)
                • Spot Sample (Day 2)
              • Chances of detecting smear positive cases:
                • With 1 sample: 80%
                • With 2 samples: 93%
                • With 3 samples: 100%
            • Interpretation of results of 3 sputum smear examination:
              • None +ve:
                • Declared SS -ve

           

        • Give antibiotics for 1 – 2 weeks
                • If symptoms persist later, go for Chest X-ray examination
                • if he/she is found X-ray +ve, consider such patients as SS -ve TB

           

        • One +ve:
                • Declared equivocal
                • Send for Chest X-ray examination
                • if he/she is found X-ray +ve, consider such patients as SS +ve TB

           

        • if found X-ray -ve, take it as Non-TB case
              • Two +ve: Declared SS +ve
              • Three +ve: Declared SS +ve

           

        • AFB SPUTUM SMEARS FOR FOLLOW-UP DURING TREATMENT:
              • ‘2 sputum smears’ over 2 days period
              • Interpretation of results of 2 sputum smear examination:
                • None +ve: Declared SS -ve
                • One +ve: Declared SS +ve
                • Two +ve: Declared SS +ve

           

        • If SS +ve at end of Intensive Phase (IP):
        • Cat I:
        • Extend IP by 1 month.
                  • Do SS examination at end of extended IP.
                  • Transfer the patient to Continuation phase (CP), irrespective of SS examination results
                • Cat II:
                  • Extend IP by 1 month.

           

        • Do SS examination at end of extended IP.
                • Transfer the patient to Continuation phase, irrespective of SS examination results
              • Cat III: Reregister the patient and begin Cat II treatment
          • Follow-up smears examination timings:
          • Follow-up smears examination timings

            Follow-up smears examination timings

           

          (* Irrespective of SS examination results, patients is started with CP treatment)

          • Tests for AFB:
          • Tests for AFB

            Tests for AFB

              • Staining procedures used in health programmes in India:
                • ZN staining: RNTCP (Mycobacterium tuberculosis):
                • Modified ZN staining: NLEP (Mycobacterium leprae):
                • JSB (Jaswant Singh Bhattacharya) staining: NVBDCP-Plasmodium
              • A 26 years old male has symptoms suggestive of tuberculosis. At DOTS clinic, he undergoes 3 sputum smears examinations. Only one of the sputum smears turns out to be positive for AFB. Next step of management will be – He is referred for Chest X-ray  (MCQ)
              • Which is the right number of doses of ATT for a category II patient under DOTS ? (MCQ)

          • IP-36, CP-66
          • Annual Risk of Infection

            Annual Risk of Infection

              • In RNTCP the schedule for sputum examination for category I patients is – 2, 4 and 6 months

          • Best indicator of trend of Tuberculosis unaffected by current control measures is – Annual Risk of Infection   
          • Annual Risk of Infection (ART):
              • proportion of population which will be primarily infected with tuberculosis in     course of 1 year
              • Is incidence of infection of TB
              • Is known as ‘Tuberculin Conversion Index’
              • Best indicator of trend of TB unaffected by current control measures
              • Most informative index of magnitude of problem of TB
              • ARI (India): 1 – 2 % (average ARI = 1.7%)
              • For every 1% rise of ARI, there are 50 SS +ve cases/ lac population

             

          • Key epidemiological indices for TB (India):
          • Key epidemiological indices for TB

            Key epidemiological indices for TB

          • DRUG RESISTANCE IN TB:
          • Multidrug resistance in TB is defined as resistance to –Isoniazid & Rifampicin (MCQ)
                • Primary (Initial) Resistance:
                  • When a person contract infection from a person with resistant bacilli of TB
                • Secondary (Acquired) Resistance: Resistance developing during the course of treatment for TB
                • Multidrug Resistant TB (MDR-TB):
                  • Resistance to Isoniazid and Rifampicin ‘with or without resistance to other drugs’
                • Treatment of MDR-TB must be done on the basis of sensitivity testing

          • Directly observed therapy certainly helps to improve outcomes and should be considered an integral part of the treatment of MDR-TB
                  • When sensitivities are known and the isolate is confirmed as resistant to both INH and RMP, five drugs should chosen in the following order (based on known sensitivities):
                    • an aminoglycoside (e.g., amikacin, kanamycin) or polypeptide antibiotic (e.g., capreomycin)
                    • pyrazimamide
                    • ethambutol
                    • fluoroquinolones: moxifloxacin preferred
                    • rifabutin
                • Extensive Drug Resistant TB (XDR—TB):
                  • Resistance to rifampicin and isoniazid as well as to any member of the quinolone family and at least one of the following second-line TB treatments: kanamycin, capreomycin, or amikacin

          • XDR-TB does not transmit easily in healthy populations, yet is capable of causing ‘epidemics in populations which    are already stricken by HIV’
          • HIV
            • Management of MDR – TB (DOTS – PLUS):
              • Refers to DOTS programmes that add components for MDR-TB diagnosis, management and treatment
              • Initiated as Category IV pilot projects (Gujarat)
              • Target: management of 5000 new MDR – TB cases per year
            • High yield facts on TB for MD Entrance exam
              • Every TB sputum positive patient can infect upto- 10-15 persons per year (MCQ)
              • TB is ‘Barometer of Social Welfare in India’
              • Objectives of Revised National Tuberculosis Control Programme (RNTCP): (MCQ)
                  • High yield facts on TB for MD Entrance exam
                    • Every TB sputum positive patient can infect upto- 10-15 persons per year (MCQ)
                    • TB is ‘Barometer of Social Welfare in India’
                    • TB (AFB) Bacillus discovered by: Robert Koch
                    • TB Bacilli are alcohol and acid fast

              • Diagnosis in RNTCP: Ziehl Neelsen Staining
                    • Generation time of TB bacilli: 20 hours
                    • World TB Day: 24th March
                    • TB was declared as ‘Global emergency in 1983’ by WHO
                    • TB is the MC Opportunistic Infection (OI) in HIV in India

              • TB bacteria remain alive: in sputum for 1 day and in droplet nuclei for 10 days
                    • Without treatment, 50% of TB patients will die, 25% will remain healthy and 25% will develop chronic infectious TB
                    • Elimination level for Tuberculosis (WHO and STOP TB Strategy): < 1 case per million population (to eliminate TB as a public health problem)
                    • TB Institutes of importance in India:
                    • National Tuberculosis Institute (NTI) – Bangalore
                    • Tuberculosis Research Centre – Chennai

              • LRS Institute of TB and Respiratory Diseases – New Delhi
                • Objectives of Revised National Tuberculosis Control Programme (RNTCP): (MCQ)
                  • To achieve a cure rate of atleast 85% through administration of short course chemotherapy (SCC)

                To achieve a case detection rate of 70% (only after having achieved the desired cure rate)

              • detection

                detection

                  • RNTCP (based on DOTS strategy),
                    • launched as a national program in 1997.
                    • The RNTCP designated ‘Microscopy Centre’ is established for approx. 100,000 population (50,000 in hilly and mountainous areas)
                    • Senior TB Laboratory Supervisor (STLS) is one for every 5 microscopy centres
                      • 1 STLS per 5 lac population

              • STLS rechecks all +ve slides and 10% of all -ve slides
                    • Under RNTCP, active case finding is not pursued: Case finding is passive
                    • ‘DOTS Agents’ (peripheral health staff) are paid Rs. 150/- per patient completing the treatment

              • To yield a positive sputum smear result on ZN Staining, there should be minimum of 10000 acid fast bacilli per ml of sputum (MCQ)
                    • In RNTCP, mainstay of diagnosis is Sputum microscopy
                    • the sputum smears are stained for acid fast Bacilli (AFB) with ‘Zeihl Neelson (ZN) Stain’
                      • Decolorizer. 25% sulphuric acid
                      • Counter-stain: 0.1% Loeffler’s methylene blue (or 1% picric acid or 0.2% malachite green)

              • Before giving result: Examine atleast 100 fields
                    • Grading of Smears:
                      • 1+ : 3 – 9 bacilli in entire smear
                      • 2+ : > 10 bacilli in entire smear
                      • 3+ :> 10 bacilli inmost oil immersion fields
                  • Tests for detection of TB

              • Auramine-rhodamine stain (AR):
                      • Histological technique to visualize AFB (fluorescence microscopy)

              • Acid-fast organisms display a reddish-yellow fluorescence
                      • More sensitive than ZN staining
                    • Culture
                      • IUAT-L JMedium/Kirchner Medium/Middlebrook 7H10 or 7H11 media
                      • Very sensitive; +ve even with ’10-100 bacilli per ml sputum’
                      • Incubation at 37° C for 4 days and at least twice weekly thereafter

              • Chest radiography:
                      • Findings suggestive of but not diagnostic of TB
                      • Mass Miniature Radiography – MMR is sufficiently accurate for diagnosis of TB

              • BACTEC Radiometric System:
              • C14 radio-labelled with palmitic acid
                      • Detect as early as 7 – 14 days

              • 95% sensitivity
              • Microscopic Observation Drug Susceptibility assay (MODS):
                      • Direct observation of TB and simultaneously yields drug-resistance

              • ELISA Test:
                      • A60 antigen
                      • Nor sufficiently sensitive nor specific
                      • Supportive value for diagnosis of extra-pulmonary TB
                    • PCR Test (Nucleic acid amplification tests – NAA T):
                      • Detect within 1 day
                      • Extremely sensitive; +ve even with ‘1-10 bacilli per ml sputum’

              • Restriction Fragment Length Polymorphism (RFLP):
                      • Combines Southern blotting and hybridization with DNA probes

              • Fast Plaque TB (FTB):
                      • Sputum, aspirates, pus, blood

              • Detect within 48 – 72 hours
              • 90% sensitivity and 100% specificity
              • Quantiferon TB Gold (QTG) [Interferon alpha—release assay]:
                      • Detect within 3-5 days
                      • Higher sensitivity

              • Adenosine Deaminase (ADA):
              • Highest sensitivity in both pleural TB and TB meningitis
                    • Tuberculin Test and Mantoux Test (Pirquet test or PPD Test):
                      • Tool for detecting TB infection
                      • +ve reaction: past or present infection by Mycobacterium TB
                      • 1 Tuberculin Unit (TV) in 0.1 ml
                      • WHO advocated preparation: PPD-RT-23 with Tween-80
                      • Reading after 72 hours (horizontal transverse diameter of induration):
                        • Reactions > 10 mm: Positive
                        • Reactions 6-9 mm: Doubtful
                        • Reactions < 6 mm: Negative
                      • Tuberculin test conversion: An increase > 10 mm within a 2-year period, regardless of age

              • False Reactions of Tuberculin:
              • False Reactions of Tuberculin

                False Reactions of Tuberculin

                ANTITUBERCULAR DRUGS:

              • ANTITUBERCULAR DRUGS

                ANTITUBERCULAR DRUGS

                 

              • Isoniazid
              • May be bacteriostatic at lower concentrations
                    • Acts on extracellular as well as intracellular organisms

              • Rifampicin:
                    • Only bactericidal drug effective against ‘persisters’ or dormant bacilli in solid caseous lesions
                    • Acts on extracellular as well as intracellular organisms
                    • Acts best on slowly or intermittently dividing (spurters)

              • Pyrazinamide:
              • Acts on intracellular bacilli
              • Acts on bacilli at sites of inflammatory response
                  • Ethambutol

              • may cause ‘optic neuritis’ (ocular toxicity):
              • It may lead to ‘red-green color blindness’
              • Patients may thus develop ‘blue vision’
                    • Thus it is contraindicated in children < 6 years age, as they may not be able to report any deterioration of color vision

              • cause peripheral neuropathy and arthralgia
                  • Ethambutol is a bacteriostatic against actively growing TB bacilli

                 

                DOSAGES OF ANTITUBERCULAR DRUGS:

              • Top High yield Facts on Tuberculosis
                      • Most effective anti-tubercular drug: Rifampicin
                      • Most bactericidal antitubercular drug: Rifampicin
                      • Most toxic antitubercular drug: Rifampicin
                      • Antitubercular drug causing rapid sputum conversion: Rifampicin
                      • Antitubercular drug causing orange discoloration of urine: Rifampicin
                      • Antitubercular drug first to develop resistance: Rifampicin

              • Antitubercular drug contraindicatedAIDS patients on Protease Inhibitors: Rifampicin
              • Antitubercular drug contraindicated in HIV: Thiacetazone (Exfoliative dermatitis)
              • Antitubercular drugs contained in all phases of all categories of DOTS: Rifampicin and Isoniazid
                      • Antitubercular drug contraindicated in pregnancy: Streptomycin

              • Antitubercular drug contraindicated in children < 6years age: Ethambutol
              • Antitubercular drug causing Optic neuritis {Red-Green color blindness): Ethambutol
              • TB and Pregnancy
              • Pregnant women with active TB: Should start or continue their anti-TB treatment
                  • Breast feeding of infants should continue irrespective of the TB status of mother
                  • If mother SS +ve:
                    • Chemoprophylaxis to child for 3 months, then

              • If child is Tuberculin -ve: Vaccinate child with BCG
              • If child is Tuberculin +ve: Chemoprophylaxis continued for a total duration of 6 months
                • If mother SS -ve:
                  • Vaccinate child with BCG (No chemoprophylaxis)
                • Under RNTCP, a patient who was initially sputum smear +ve, who began treatment and who remained or became smear +ve again at 5 months or later during course of treatment is a – Failure case (MCQ)
                • Working definitions in RNTCP:
                  • NEW CASE:
                    • A person suffering from TB who has ‘never taken treatment or took treatment for <4weeks (1 month)’
                  • CURED:
                    • Sputum smear positive (SS +ve) who has completed treatment, and had ‘sputum smear negative (SS -ve) on atleast 2 separate occasions with one at the end’ (completion of treatment)
                  • RELAPSE:
                    • A person ‘declared cured returns back as SS +ve’
                  • FAILURE:
                    • A person on treatment who is SS +ve at or after 5 months of treatment
                  • DEFAULTER:
                    • A person who, at any time after registration, ‘has not taken anti-TB drugs for 2 months or more consecutively’
                • A failure case is given treatment in DOTS category II (RNTCP) for 8 months; start treatment from Day 1 of Cat II, whenever patient is labeled as a failure case
                  • Intensive Phase [2(HRZES)3 + 1(HRZE)3]
                  • Continuation Phase [5(HRE)3]

                Failure cases in DOTS categories in RNTCP:

                Failure cases in DOTS Cat I (RNTCP):

                Failure cases in DOTS Cat I (RNTCP)

                Failure cases in DOTS Cat II (RNTCP):

              • Failure cases in DOTS Cat II (RNTCP)

                Failure cases in DOTS Cat III (RNTCP):

              • Failure cases in DOTS Cat III (RNTCP)

                Failure cases in DOTS Cat III (RNTCP)

                  • A adult male patient presented in the OPD with complaints of cough and fever for 3 months and haemoptysis off and on. His sputum was positive for AFB. On probing it was found that he had already received treatment with RHZE for 3 weeks from a nearby hospital and discontinued. How will you categorize and manage the patient ?Category I, start 2 (RHZE)3  (MCQ)
                  • ‘DOTS’ indicates -Short-term treatment under supervision (MCQ)

              • Directly Observed Treatment Short Course (DOTS):
                    • a community based Tuberculosis treatement and care strategy
                    • combines the benefit of supervised treatment with community based care and support
                    • Ensures high cure rates through 3 components:

              • Appropriate medical treament
                    • Supervision and motivation by a health/ non-health personnel
                    • Monitoring of disease by health services
                    • DOTS is given by peripheral health staff- ‘DOTS Agents’ (MPWs, Voluntary workers like teachers, Anganwadi workers, Dais)
                    • Incentive/ honorarium paid: 150/- per patient completing treatment
                    • Drugs are supplied in patient-wise boxes containing full course of treatment
                    • Intensive phase: Each blister pack has one day’s medication ,
                    • Continuation phase: Each blister pack has one week’s medication
                  • The sputum examination under DTP is done when the patient present with:      
                  • Cough of 1-2 wks duration (MCQ)
                    • Sputum examination under TB program is done when patient presents with:

              • Cough more than 2 weeks
                      • Fever with an evening rise
                      • Hemoptysis
                      • Unexplained weight loss

              • Reduced appetite
                  • Treatment of choice for sputum positive pulmonary tuberculosis detected in the I trimester of pregnancy is – Start Category I immediately (MCQ)
                  • Disadvantage of INH prophylaxis are

              • Costly
              • Not effective
              • Risk of hepatitis
                • If after 2 months of conventional antituberculous therapy, sputum smear examination is positive, it indicates:   Return after default (MCQ)
                • A patient of tuberculosis was treated 5 years back. Now he represents with symptoms of cough, sputum culture was negative, x-ray changes show opacities, It did not respond to broad spectrum antibiotics. It belongs to which category: Category II (MCQ)
                • The drug which is used only in RNTCP CAT III is: Streptomycin
                • In revised National tuberculosis control programme main objective is:

                Achievements of high cure rates through DOTS

                  • Under directly observed treatment of short course chemotherapy, the recommended regimen of category-II treatment is 2(HRZES)3. 1(HRZE)3,5(HRE)3
                  • In the DOTS strategy under National Tuberculosis Control Programme, the letter ‘D’ & ‘O’ stand for which of the following?:  Daily observed

              • Treatment of recently sputum positive case of pulmonary TB is : RMP + INH + PZM + ETM
                  • The Pillars of Revised National Tuberculosis Control Programme (RNTCP) are
                  • Achievement of not less than 85% cure rate amongst infectious cases of tuberculosis through short couse chemotherapy involving peripheral health functionary
                    • Detecting 70% of estimated cases through Quality Sputum Microscopy
                    • Directly observed therapy (short term), is a community based TB treatment and care strategy
                  • According to RNTCP, tubercular pericarditis should be treated with which category of anti-tubercular regimen? : Category I MCQ)

              • According to RNTCP,the first action to be taken in a person with cough of more than three weeks with one sample of sputum positive?: Chest X-ray (MCQ)
              •