Part 2

7.Ensure that :- A.The Patient is put on treatment as

early as possible. B.The patient completes

the full course of treatment.

C.The Patient is subjected to follow up sputum Exams as per Schedule. D.The Patient must be subjected to the last follow up

sputum exam.

7.Always give a course of Non- tubercular broad spectrum

antibiotics for 10-15 days

8.Always take a good history of previous treatment

9. Good classification of cases

ensures better treatment & better outcome.

Diagnosis of Pulmonary Tuberculosis

1.Patients with T.B.feel ill and seek care promptly.

2.Active case finding is unneccesary&unproductive.

(No Use of Organising Camps,Their only use is political)

3.Microscopy is appropiate technology,indicating

infectiousness,risk of death,&priorityfor treatment.

X-ray is non-specific for T.B.diagnosis.

4.Serological & amplification technologies(PCRetc) currently of

no proven value in T.B.Control.

Role of Chest X-Ray

a)No chest X-Ray pattern is

typical of T.B.b)10-15 % of culture-

positive T.B.patients are not diagnosed by X-Ray.

(K.TOMAN-1997)

c) 40 % of patients diagnosed as having T.B. on the basis of x-ray

alone do not have active T,B.

Conclusion:-Xray is unreliable for diagnosing and monitoring

treatment of Tuberculosis (K.TOMAN-1997)

Objectivity & Reliability of Microscopy V/S X-Ray

(inter observer Agreement)

0%10%20%30%40%50%60%70%80%90%

100%

A.F.B.Micro. X-ray.Ex.

Inter-ObserverAgreement

Specificity of sputum Examination

v/s Chest X-Ray Examination

0%10%20%30%40%50%60%70%80%90%

100%

Sp.Smear X-Ray Ex.

Specificity

Role of THREE Sputum Exams.

(Three Sputum Smears are Optimal)

0%10%20%30%40%50%60%70%80%90%

100%

1st. Sput. 2nd Spu. 3rd.Spu.

Cumulative Positivity

No of Bacilli Seen Result Reported

NONE per oil immersion field. Negative

1-9 per 100 oil immersion fields

Scanty,Report Exact number

10-99 per 100 oil immersion fields

1 +

1-10 per oil immersion fields 2+

>10 per oil immersion field 3+

Priority to Sput. +ve cases WHY ?

1.Smear positive patients usually seek care. 2.Smear positive patients

are 4-20 times more infectious

3.Untreated, a smear +ve patient may infect 10- 15

persons / year.

4.Smear positive patients are much more likely to

die if left untreated.

Treatment Regimens of N.T.PStandard-Conventional Regimens:-(Inj

under supervision,Drugs issued monthly)R-1 All New Pulmonary Sputum

Positive Cases 2STH / 10 TH or 2SEH / 10 EHR-2 All Pulmonary Sputum Negative

Cases &Extra- Pulmonary cases 12 TH or 12 EH (contd)

Short Course Chaemotherapy(Inj Under supervision,Drugs issued

fortnightly)R-A All New Pulm.Sputum +ve

cases 2EHRZ /6 TH OR 6 EH

R-B All Retreatment cases(Relapse,Failure,T.A.D.)

2SHRZ / S2H2R2 (Intensive phase under Supervision)

Improvements in R.N.T.C.P. 1.Societies formed at State &

distt to facilitate flow of funds.

1.Burden of diagnosing &completing treatment of

the patient is on the service provider,not on the patient.

2.The patient is now aV.I.P.

3.The programme has been decentralized to a level of

virtual T.B.Clinic at a popln.of 5 Lakhs & upto the

level of DOT centres (popln. of 5000-7500).

4.Diagnosis is through a Diagnostic

Algorhythm

which gives the

maximum yield of T.B.patients.

5.Emphasis is now on a better tool of diagnosis

viz-SPUTUM

EXAMINATION,that too with a Binocular

microscope and with 3 sputum specimens.

6.Treatment is by standarized

regimens(Categories)

7.Almost all the doses are by means of DOTS.

8Default retrieval by means of a well developed system consisting of:-

a)Registration of only those patients

who reside within distt. b)checking of addresses before

doing registration. c)Default

retrieval of all the patients within a maximum of 2 days(before the next

dose)

9.Supply of drugs in seperate patientwise boxes.

No shortage of drugs at any point &

at any centre.

10.Strong system of Supervision-Provision of

contractual S.T.S &S.T.L.S & one two wheeler with

P.O.L.provided at T.U.level.

11. Strong system of accountability is in place.The

resposibility of reporting patient’s outcome is that of the

registering unit. 12.Goals are clearly defined ie-

85 % Cure rates & then 70 % case detection.

13.Monitoring & supervision from the level of C.T.D.to

the level of T.B.Unit.

14.Concept of I.E.C.

developed in the prog. Funds provided to

theDistt.T.B.Socities.

15.N.G.O. Participation is being encouraged in a big way.Honest and dedicated N.G.Os are being invited to own one of the 5 schemes

of the program.

R.N.T.C.P.

The 5 commitments of R.N.T.C.P.

• Political commitment.• Diagnosis by microscopy.• Adequate supply of S.C.C. Drugs.• Directly Observed Treatment.• Accontabilility.

Goals of R.N.T.C.P. 1. 85

% C U R E R A T E S

And then

2. 70 % CASE DETECTION

• Treatment Categories CAT-I 1.New Pulm.Smear Positive T.B.cases 2.Seriously ill Pulm.Smear Neg. & Extra –Pulm.Cases Regimen- 2(EHRZ)3 4(HR)3

CAT-2 Retreatment

Cases-Relapse,Failure & Treatment after Default Cases.

Regimen-2/3(SHERZ)3 5(HRE)

CAT-3New Pulm Smear Neg

T.B.Cases,New less Serious forms of

Exrta Pulm T.B.Cases

Reg.-2(HRZ)3 4(HR)

Directly Observed Treatment(DOTS)

Why ?• An observer watches and helps

the patient swallow the tablets.• Direct Observation ensures

treatment for the entire course

IS THE TREATMENT OF

The right Drugs In the right Doses

& At the right interval

Ensure that:-

1.Treatment Observer must be accesible & acceptable to the

Patient and accountable to the Health System 2 .Observation is a service to the patients & providers

DOTS gives the desired results even when:-

1.Many patients do not take medicines regularly, even if

excellent Health education is provided.

2.Impossible to predict which

patient will take medicines

.

Why is it necessary to Directly Observe the

Treatment ? 1.At least 1/3 of patients receiving self administered treatment do not adhere to treatment.

2.Impossible to predict which patients will take medicines.

3.DOT necessary at least in the initial phase of treament to ensure adherence and achieve

Sputum smear conversion. 4.A

T.B. patient missing one attendance can be traced immediately and counseled.

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