Doctors TB

Orientation.
Date:22
December,2014
Vanue: TMC
&RCH ,Medicine
Class Room ,

1
1

***Tuberculosis :Global
and
**Contents**
Bangladesh
Scenario
***Technical aspect of
Tuberculosis Control
2

Global Tuberculosis Burden

Incidence: 8.6 million in 2012 (82% from
22 HBC)-2.9 million were women & 0.53
million were children.
Prevalance: 12 million in 2011 .
Death : 1.3 million in 2012 including
0.32 million HIV associated TB death.

Tuberculosis: Bangladesh Scenario

Estimates and notification rates for 2011,
Bangladesh
Incidence

of all forms of TB (per

1,00,000
population per year) *
Prevalance

of all forms of TB (per

225

434

1,00,000
population per year) *
TB

death rate (per 1,00,000

population per year
)*
Notification

rate of all forms of TB

45

1084

Tuberculosis: Bangladesh Scenario(cont.)

Notification

rate of new smearpositive cases

(per 1,00,000 population for the
year 2012) **

70

Treatment

92

success rate(%) of new

smearpositive cases for 2011 **

MDR

among new cases of TB

1.4%

MDR

among old cases of TB Source 29%5

Objective of NationalTB Control

Programme

The overall goal is

- to reduce morbidity, mortality and
transmission of
TB until it is no longer a public health
problem .
The objective are to sustain the
global targets of
-achieving at least 70% case detection and
85%
treatment success among new smearpositive TB
cases under DOTS;
7

for Control of
Tuberculosis

Strategies

The NTP adopted the DOTS

strategy and
started its field
implementation in 1993.
The programme progressively
expanded to
cover all upazilas by mid-1998.
By 2007 the DOTS services were
made
8

DOTS strategy have the following five

components

Political commitment with increased and

sustained
financing ;
Case detection through quality-assured
bacteriology ;
Standardized treatment with supervision
and
patient support (DOT) ;
An effective drug supply and
management system ;
Monitoring and evaluation system and
9

Stop TB strategy
The Stop TB strategy is the
approach recomended by
WHO to reduce the burden of
TB in the line with global
target set for 2015.
Bangladesh is implementing
Stop TB strategy since 2006 .
10

The six components of the stop TB strategy

Pursue high-quality DOTS expansion and
enhancement
Address TB-HIV, MDR-TB, and the needs of
poor
and
vulnerable populations
Contribute to health system strengthening
based
on
primary health care
Engage all care providers
Empower people with TB, and communities
through
partnership
11
Enable and promote research

Achievement of National TB Control Programme

DOTS coverage: The TB control

Services are available
throughout the country and geoadministrative
coverage is 100%
Case notification rate of new smear
positive cases is
70 in 2012 (per 100,000 population)
Treatment success rate of the
detected new smear
positive cases is 92% in 2011
12

Technical
Aspect of
Tuberculosi
s Control
13

Tuberculosis
Definition
An infectious disease caused by bacilli called
Mycobacterium tuberculosis

Mode of Spread of tuberculosis bacilli

Coughing, sneezing and spitting

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14

Definition of Tuberculosis: An infectious disease

caused by bacilli called Mycobacterium tuberculosis
Mode of Spread of tuberculosis bacilli:

Coughing, sneezing and spitting

15

Transmission of infection

Mode of entry of TB bacilli

Mostly - inhalation through lungs
Rarely - ingestion, accidental
inoculation etc.
Spread to other parts of the body:
Via the blood stream, lymphatic
system, or through direct
extension

17

Difference between TB infection and TB disease

TB bacilli in human body

TB Infection

Immunity
compromised

TB Disease

Immunity is not
compromised

Bacilli remain inactive (latent)

Sign/Symptom do not appear
Cannot spread TB bacilli
Not a case of TB
Do not need treatment
May be Tuberculin test + ve

Bacilli remain active

Sign/Symptom appear
Can spread TB bacilli
A case of TB
Need treatment

18

Case definitions
According to anatomical sites of the disease :

Pulmonary TB
Tuberculosis of the lungs
Most common form of TB and occurs in about 80% of cases

Extra-pulmonary TB
TB in any part of the body other than lungs such as bones, glands,
pleura, lymph nodes, spine, joints etc.

According to bacteriological status of PTB:

Bacteriologically confirmed TB cases-( Smear positive &
Xpert positive)
Smear negative cases- if bacilli cannot be identified on
microscopic examination of sputum specimens.
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Case Definition by previous treatment history

Presumptive TB : A person who presents with sign or symptoms

suggestive of TB disease. Presumptive PTB in particular, persistent
cough for 3 weeks or more , with or without production of sputum and
despite the administration of a non-specific antibiotc.

New case : A patient who has never received anti-TB drugs or received
anti-TB drugs for less than one month.

Relapse: Relasped patients have previously been treatment for TB

and were declared cured or treatment completed at the end of their
most recent course of treatment , and are now diagnosed with a
recurrent episode of TB ( either a true relaspe or a new episode of TB
caused by reinfection) .

Treatment after failure: Treatment after failure patients are those

who have previously been treatment for TB and whose treatment
failed at the end of their most recent course of treatment .

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Case Definitions ( Cont.)

Treatment after loss to follow up /default: Treatment after
loss to follow-up patients have previously been treated for
TB and declared loss to follow-up at the end of their most
recent course of treatment .(These were previously known
astreatment after default patients .
Transfer in : A patient already registered for treatment in a
DOTS centre and who is subsequently transferred to
another registration unit
Other(s): Other previously treated patients are those who
have previously been treated for TB but whose outcome
after their most recent course of treatment is unknown or
undocumented .

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Case defination by site and bacteriological status

in adult
Case
classification

Defination

A patient with at least one sputum

Pulmonary
smear-positive TB specimen positive for
(PTB+)
AFB including any scanty smear result .

-----------------Pulmonary
smear-negative
TB (PTB--)
but positive on
Xpert (MTB
+/RIF)

------------------------------------------------------------------------* A patient with symptoms suggestive of TB

with two sputum specimens negative for
AFB ;
and
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* Found positive on Xpert MTB +/RIF-(MTB

Case defination by site and bacteriological status

in adult(cont.)
Case
classification
Pulmonary
smearnegative TB
(PTB --)

Defination
A patient with symptoms suggestive of TB
with two
sputum specimens negative for AFB;

and

Xpert MTB /RIF (if available) is Negative

and

Chest X-ray abnormalities consistent with

active TB;

and

Diagnosis is made by a qualified physician.

23

Case defination by site and bacteriological status

in adult
(cont.)
Case
classification
ExtraPulmonary TB
(EPTB )

Defination

patient with TB of organs other than the

lungs as confirmed by a qualified physician
e.g
pleura, lymph nodes , abdomen, genitourinary
tract, skin, joints and bones, meninges .

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CASE FINDING AND DIAGNOSIS OF TUBERCULOSIS

Highest priority is to identify smear positive pulmonary TB cases.

Signs and symptoms of pulmonary TB

persistent cough for 3 weeks or more

Additional symptoms:
shortness of breath, chest pain, coughing up of blood
loss of weight, loss of appetite, fever, night sweats

** Sputum microscopy should always be requested for a patient,

who cough for 3 weeks or longer, even in the absence of any other
symptoms

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CASE FINDING AND DIAGNOSIS OF TUBERCULOSIS

Signs and symptoms of extra-pulmonary TB depend on the site involved

Examples are:
TB lymph adenitis: Swelling of lymph nodes
TB arthritis: Pain and swelling of joints
TB of the spine: Radiological findings with or without loss of function
Meningitis: Headache, fever, stiffness of neck and subsequent mental
confusion
*The diagnosis of extra-pulmonary TB should always be made by a
qualified physician and often requires special examinations such as Xray, FNAC, Biopsies, Culture examinations and others

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DIAGNOSIS OF TUBERCULOSIS

Tools For Diagnosis of TB

Sputum smear exam :Most cost-effective, easy & reliable tool
for Pulmonary TB.
X-ray exam: Radiological finding of smear- ve TB should always
be supported by Clinical features & qualified physicians should
decide on the diagnosis of TB
Mantoux test: The test does not differentiate between TB
infection & TB disease. Used for supporting TB diagnosis in
young children .
Culture of TB bacilli: More sensitive but not accessible to all
patients. Not use as routine procedure
Molecular Tests: X-pert MTB/RIF & Hain test (Line Probe Assay)
FNAC and Biopsy .
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Gene X-Pert Machine

(Up to June, 2013)

Examination of sputum specimen

Two Specimens within two consecutive
days:
Spot specimen : on first visit (1st day)
Early morning collection by patient: 2 nd
day

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Aims of TB Treatment

To cure
To prevent death
To prevent relapse
To decrease transmission
To prevent development of acquired drug resistant.

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Flow Chart for diagnosis and follow up of Pulmonary TB

** Exclude Clarithromycin ,
Quinolones,Amoxyclavulanate.

COUGH FOR 3 WEEKS OR MORE

2 SPUTUM SMEAR EXAMS ( 1 SPOT SPUTUM & 1- EARLY MORNING SPUTUM )

2 SMEARS NEGATIVE
DO ***Xpert MTB/RIF/CXR if *
highly suggestive of TB
1 or 2
SMEAR (S) +

CXR
POSITIVE

NEW

*RETREATMENT

START
CAT-1

Send sputum for

Xpert MTB/RIF &
START-II

MTB detected
RIF
Susceptible

If not highly suggestive of TB

Xpert
MTB/RIF
POSITIVE

MTB detected RIF

resistant

BOTH
NEGATIVE

** ANTIBIOTICS 1-2 WEEKS

IF SYMPTOMS PERSIST, REPEAT 2

SMEARS & REPEAT *** Xpert
MTB/RIF/CXR

START TREATMENT As per

result of the Xpert
MTB/RIF/CXR

Treat as MDR TB Refer

to PMDT Unit
CONTINUE CAT-II

POSITIVE

NEGATIVE
NON TB
CASE

FOLLOW UP

TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORY

TB
Diagnostic
Catgory
I

TB PATIENTS

INITENSIVE
PHASE
(DAILY )

II

iV

TB TREATMENT REGIMENS

New smear-positive bacteriologically

positive PTB patients;
New smear-negative PTB,
New Extra-pulmonary TB
New concomitant/associated HIV/AIDS

Sputum smear-positive PTB with history

of treatment of one month or more
relapse;
treatment after loss to follow up
treatment failure after Cat. 1 treatment
Others

DR/MDR-TB

CONTINUATION

PHASE
( DAILY)

2(HRZE)

4 (HR)

2(HRZE)S/
1(HRZE)

5 (HR)E

8(km,Z,Lfx,Eto,
Cs)

12(Z,Lfx,Eto,Cs)
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Dosages of FDC tablets

FDC tablets are composed as follows:
4-FDC: rifampicin 150 mg + isoniazid 75 mg + pyrazinamide 400 mg +ethambutol 275 mg
2-FDC: rifampicin 150 mg + isoniazid 75 mg
The dosages of FDC tablets for adults are as follows:

Category I:
Intensive Phase

Continuation Phase

Daily
(first 2 months)

Daily
(Next 4 months)

Number of 4FDC tablets

Number of 2 FDC tablets

2
3
4
5

2
3
4
5

Pre-treatment
weight (kg)

30 37
38 54
55 70
> 70

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Category II:

Pre-treatment
weight (kg)

30 37
38 54
55 70
> 70

Intensive Phase

Continuation Phase

Daily
(first 3 months)

Daily
(first 2 months)

Daily
(next 5 months)

Number of 4-FDC
tablets

Injection
Streptomycin

Number of 2FDC tablets

Ethambutol 400mg
(Number of tablets)

2
3
4
5

500mg
750mg
1gm*
1gm*

2
3
4
5

2
3
3
4

* The dose of streptomycin should not exceed 500 mg daily after the age of 50 years

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FOLLOW-UP OF TREATMENT
New smear/Xpert MTB/RIF positive patients
Sputum Exam at the end of 2nd month

NEGATIVE

POSITIVE

Start cont. phase

CURED

GENE Xpert for MTB/RIF

Sputum Exam 5th month

NEG

**POSITIVE

Sputum Exam 6th

month
Continue Cont.
phase

MTB-D &RIF not

MTB-D & RIF

resistant

Resistance

Start continuation phase

Registered in
DR TB

Sputum Exam 3rd month

NEG

Pos or Neg continue cont.phase& repeat

Sputum exam. at the end of 5th month

Declared as Failure &

Rergistered as Cat-II

MTB-D &RIF

not resistant

**POSITIVE

Xpert MTB/RIF &manage

according to result

Re-treatment smear/XpertMTB/RIF positive patients

NEG

POS

Gene Xpert for

MTB/ RIF

MTB-D, RIF not

resistant

MTB-D, RIFResistant

Start cont. phase

REG in DR-TB

Sputum Exam at the end of 3rd month

Start cont. phase

CURED

NEG

Repeat Sputum Smear Exam at the end of 4 th month

Pos or Neg continue cont. phase

Sputum exam
8th month

Continue
cont.phase

NEG

Sputum Exam 5thmonth

POS

If the smear is Positive at month 5 or 8 outcome

should be recorded as treatment failure & pt.
should be referred for exam. for DR TB

Follow-up Smear negative and extra-pulmonary patients

NEG

Sputum exam of smear negative

patient at the end of 2nd month

Continue treatment
& progress should be
assesed clinically .

POS , repeat
smear for
confirmation.
Declared as treatment
failure of cat-I
Start Cat-II or other
appropriate regimen
based on Xpert
MTB/RIF result .

Declared as
Treatment
Completed after
completion of
treatment.

Extra- pulmonary TB
If the patient is not
improved clinically, pt.
should be asssessed for
DR EPTB

No smear exam. is
necessary & pt. should be
assessed clinically.

Declared as Treatment
Completed after
completion of treatment

Treatment outcome
Cured: A pulmonary TB patient with bacteriologically confirmed TB at the
beginning of treatment who was smear or culture-negative in the last month
of treatment and on at least one previous follow up occasion .
Treatment completed: A TB patient who completed treatment without evidence
of failure but with no record to show that sputum smear or culture results in
the last month of treatment and on at least one previous follow up occasion
were negative, either because tests were not done or because resualts are
unavailable .
Extra-pulmonary TB are also recorded as treatment completed as no
sptum test is done after completion of full course treatment.
Treatment Failure: A TB patient whose sputum smear or culture is positive at
month 5 or later during treatment .
OR
A new or retreatment smear positive patient who was diagnosed DR-TB during
the course of treatment .
OR
A patient who was initially smear negative and was found smear positive at
the end of the second month of treatment .

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Treatment outcome (cont.)

Died: The patient who dies for any reason before starting
or during the course of treatment .
Lost to follow up / Defaulter: A patient who did not start
treatment or whose treatment was interrupted for 2
consecutive months or more .
Transfer out.A patient who has been transferred to another
recording and reporting unit and for whom the treatment
outcome is not known to the reporting unit .
Not evaluated: A patient whose treatment outcome is not
known ( other than transfer out)
Treatment success: The sum of cured or treatment completed
.

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DRUG REACTIONS
Minor Side Effects:

Side Effects

Responsible
Drugs

Management

Anorexia, nausea, RIFAMPCIN,

abdominal pain
PYRAZINAMIDE

Give drugs after

meal

Joint pain

Give NSAID

PYRAZINAMIDE

Burring sensation ISONIZID

in the feet

Pyridoxine 100 mg
daily .

Orange/red urine

RIFAMPCIN,

Reassurance.

Itching with
minor skin rash

All drugs

Exclude skin
diseases. Give
antihistamines 40
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DRUG REACTIONS
Major Side Effects
Side Effects

Responsible Drugs

Management

Itching with skin

Rash (Moderate
to severe)

All drugs

Stop all drugs. Identify the

offending drug . (Need expert
opinion)

Deafness

STREPTOMYCIN

Stop STREPTOMYCIN and never

use again. Use ETHAMBUTOL as
alternative

Dizziness

STREPTOMYCIN

Stop STREPTOMYCIN and never use

again. Use ETHAMBUTOL as
alternative

Jaundice

ISONIAZID
PYRAZINAMIDE
RIFAMPICIN

Stop anti-TB drugs until Jaundice

subsides. Reintroduce drugs one
by one under supervision

Vomiting and
confusion
(Suspect drug
induced acute
liver failure if
jaundice present)

Most anti-TB drugs

Stop anti-TB drugs until Jaundice

subsides. Urgent Liver Faction
Test and Pro-thrombin time Test

Visual impairment ETHAMBUTOL

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Stop ETHAMBUTOL and never

Diagnostic features of TB in children

The presence of 3 or more following features
strongly suggests a diagnosis of TB:
Symptom criteria suggestive of TB

A history of recent close contact (within the

past 12 month.)

Physical signs highly suggestive of TB

A positive Mantoux test

Chest X-ray suggestive of TB

NB: If a patient has 2 features , expert opinion from a
specialist should be sought .

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SYMPTOM CRITERIA FOR PULMONARY TB

Persistent

, non-remitting cough for >2 weeks not

responding to conventiontional antibiotcs (amoxicillin, cotrimoxazole or cephalosporin) and/or bronchodilators
and/or
Persistent documented fever (>38C/100F) > 2 weeks after
common cases such as typhoid, malaria or pneumonia
have been excluded
and/or
Documented weight loss or not gaining weight during the
past 3 months ( specially if not responding to de-worming
togather with food and/or micronutrient supplementation)
OR severe malnutrition
and/or
Fatigue and reduced playfulness
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Danger signs requesting urgent Hospital referral

Severe forms of PTB and EPTB for further investigation
and initial management .
Severe respiratory distress (TB pneumonia with/without
bacterial super infection, Pleural effusion).
Severe wheezing not responding to bronchodilators (signs
of severe airway compression ).
Headache (especially if accompanied by vomiting),
irritability, drowsiness, neck stiffness and convulsions
(signs of TB meningitis).
Acutely ill with big liver and spleen and ascites ( sign of
disseminated TB).
Breathlessness and peripheral oedema (signs of pericardial
effusion).
Acute angulation (bending) of the spine ( signs of TB spinegibbus ).
Other co-morbidities e.g. severe anaemia, severe malnutrition .
44

THE MOST COMMON RADIOLOGICAL SIGNS OF TB IN

CHILDREN

Increased density in the hilar region

due to enlarged hilar lymph nodes,
and/or a broad mediastinum due to
enlarged mediastinal lymph nodes.
Persistent opacity in the lung.

45

LESS COMMON RADIOLOGICAL SIGNS OF TB IN CHILDREN

Compression

of the airways due to due to enlarged

lymph nodes. Partial occlusion may lead to
segmental or lober hyperinflation . Complete airway
occlusion may cause collapse of a lung segment or
lobe .

Miliary pattern of opacification .

Pleural effusions ( usually in children > 5 years old)

46

ALGORITHM FOR THE DIAGNOSIS OF CHILDREN < 8 YEARS OF AGE WHO PRESENT WITH
SYMPTOMS SUGGESTIVE OF TB .
Present with symptoms suggestive of pulmonary TB
Do the symptoms meet symptom criteria ? * . Are there any danger sign? #

NO
Treat potential cause
Follow up after 1-2 weeks until
symptom resolution, or until
symptom s meet strict criteria .
Refer if any danger sign .

Chest X-ray not suggestive.

Treat potential alternative
cause . Follow up after 1-2
weeks .
Danger signs or persistent
symptoms

YES
Any documented TB contact in the preceding
year , Perform Mantoux test (MT)
AND
Refer for Chest X-ray

MT negative and no
documented TB contact PLUS
Chest X-ray suggestive

Refer to secondary/ tertiary level hospital

MT positive or documented
TB contact PLUS Chest x-ray
suggestive
Treat for TB .Enter into TB
register
If no/poor responce to
therapy after 2-3/12

Present with symptoms/signs suggestive of extra- pulmonary TB

Documented TB contact in the preceding year
Children >_ 8 years of age should be managed as an adult collect 2 sputum smear . Remember to
perform a CXR if sputum smear is negative.
47

ALGORITHM FOR THE SCREENING OF CHILDREN IN CLOSE CONTACT WITH A

NEWLY DIAGNOSED ADOLESCENT OR ADULT WITH PULMONARY TB .
Documented TB exposure
Close contact with an adult or adolescent or child > 8 yrs with Pulmonary TB
Any current symptoms suspicious of TB ?
Cough, wheeze , fever lethergy, fatigue, weight loss, or visible mass in the neck, abdominal mass
&ascites
No current symptoms
<5yrs
or
Immune compromised
INH for 6 months

Current symptoms present

>_ 5yrs and NOT immune
compromised
No INH

Observe for symptoms

Refer if symptoms
suggestive of TB or
danger signs .
NO
<5yrs- INH for 6 months
>_ 5yrs No INH
Observe for symptoms
Refer if symptoms suggestive of TB or
danger signs .

Does it meet strict symptom

criteria ?
( Are there any danger signs ?)

NO
Follow up after 1-2
weeks .
Persistent non remitting
symptoms .
YES
Refer for Chest X-ray and formal
evaluation at Upazilla
48

Treatment regimens for children in each diagnostic category

TB
diagnos
tic
categor
y

TB cases
Regimen
Intensive
phase

Continuati
on phase

Intrathoracic TB without lung cavities or

extensive
alveolar consolidation

2(HRZ)

4(HR)

Intrathoracic TB with lung cavities or

extensive
alveolar consolidation .

2(HRZ)E

4(HR)

TB Lymph Node

2(HRZ)

4(HR)

TB pleural effusion

2(HRZ)

4(HR)

Pericardial TB *

2(HRZ)

4(HR)

Abdominal TB

2(HRZ)

4(HR)

TB meningitis *

2(HRZ)S*
*

10(HR)

Osteoarticular TB

2(HRZ)E

10(HR)49

Prevention of TB in children

Early diagnosis and effective treatment of source cases .

Screening contacts
- identify symtomatic children(i.e. children of any age with
undiagnose TB disease)

INH preventive therapy

- provide preventive therapy for susceptible individuals(i.e.
asymtomatic children under 5 years of age in close contact
with a smear-positive pulmonary TB case
50

Drug Resistant TB (DR TB)

Definition: Drug-Resistant TB (DR-TB) is defined as TB
resistant to one or more anti-tuberculosis drugs.
Four categories of Drug-Resistant TB (DR-TB):
Mono-resistant TB :TB resistant to one anti-tuberculosis
drug.
Poly- resistant TB: TB resistant to more than one antituberculosis drug other than isoniazid and rifampicin.
Multidrug-Resistant TB (MDR-TB):TB resistant to at least
isoniazid and rifampicin, the two most potent anti-TB
agents.
Extensively drug-resistant TB (XDR-TB) : MDR-TB, plus
resistant to at least one of the fluoroquinolones, and at
least one of the three injectable second-line drugs
( kanamycin, capreomycin and amikacin).
51

Multi-drug resistant tuberculosis (MDR-TB)

Definition:
Multidrugs-Resistant TB (MDR-TB) is
defined as TB resistant to both
isoniazid and rifampicin, the two
main anti-tuberculosis drugs, with or
without resistance to other drugs.
MDR-TB is a man made phenomenon
due to ineffective administration of
effective drugs.
52

Causes of DR TB
1. Microbial : From a microbiological
perspective, resistant is caused by a genetic
mutation that make a drug ineffective against
the mutant bacilli .
2. Clinical and/or programmatic: From a
clinical and programmatic perspective it is an
inadequate or poorly administered treatment
regimen that allow a Drug Resistant strain to
become the dominant strain in a patient infected
with TB .
53

Causes of Inadequate Anti-TB Treatment

Health-care
providers:
Inadequate regimens

Drugs: Inadequate
supply or quality

Patients: Inadequate
drug intake

Inadequate

Poor quality;

Poor adherence;
Lack of information;
Adverse effects of
treatment;

Absence of
guidelines:

Unavailability of
certain
drugs ( stock-outs or
delivery
disruption);

Social barriers

Poor training;

poor storage
conditions;

Substance
dependency
disorders;

No monitoring of

Wrong dose or

treatment and poor

DOT ;

combination of
drugs.

Mental disorders;
Non-cooperative;

guidelines or
noncompliance with
guidelines:

(stigma,restrictions);
Mal-absorption due
to
other causes;

54

Patient with previous treatment history often

Resistance to Isoniazid ( 20% to 35% )
Retreatment cases put on CAT-1 :
2 E{RH}Z / 4 {RH}-------MDR (failure!)
RH

Placed on retreatment regimen:

2 SE{RH}Z / 1 E{RH}Z / 5 E{RH}-- Failure

Issues to be
strengthened
to prevent acquisition of
resistance

History of
previous anti
TB treatment:
Poor history taking leads to wrong categorization
of patients and resulted acquired resistance

Follow-up Sputum microscopy!

Poor microscopy failed to recognize
patients remain positive at the end of
intensive phase and at the end of
treatment-Those who are susceptible for
MDR!

Consequences- poor lab

performance

Failed to identify patients remain positive at

5th month or at the end of treatment meaning

false sense of cure for an

Probable MDR!!!
It has been observed that over 60% of
the Cat-1 failure and over
90% of the cat2 failures are
MDR.

Undetected MDR TB cases continue to spread

the resistance bacilli and contributing in the
development of primary MDR TB cases.

Presumptive DR-TB :
Failure of CAT I (remain positive at Month 5 or Category 1 smear negative
becomes smear positive at Month 2 )
Failure of CAT II (remain positive at Month 5 or 8 )
Non- converters of CAT I (remain positive at Month 2 )
Non- converters of CAT II (remain positive at Month 3 )
All relapses ( CAT I and CAT II)
All return after default (CAT I and CAT II)
Close Contacts of MDR-TB patients with symptoms of TB
(first do sputum microscopy for AFB)
All TB-HIV co-infection at the beginning of treatment
Others .
59

Diagnosis:
Tools for diagnosis of MDR-TB
1. Sputum Culture
2. Drugs susceptibility testing (DST)
3. New Diagnostic Tools : X-pert
Sputum Culture & DST available in:
National TB Reference Laboratory (NTRL)-NIDCH,
Mohakhali, Dhaka
Regional Reference Laboratory (RRL)-CDH,
Rajshahi
Regional Reference Laboratory (RRL)-General
Hospital, Chittagong.
60

Comperative study of MTB case detection

from NSN patients by GeneXpert at CDC,
Bogra Unit between 2nd & 3rd Quarter-2014

61

Comperative study of MTB case detection

from SN patients by GeneXpert at CDC,
Bogra Unit between 2nd & 3rd Quarter-2014

62

Duration of treatment of MDR TB:

Total duration- 20 to 24 months
Two Phase- 1. Intensive Phase- Minimum 8 months
(Guided by smear and culture conversion)
2. Continuation Phase - Minimum 12 months
(Guided by smear and culture conversion)

Drug Regimen:
Intensive phase- minimum 8 months ( Km, Z, Lfx, Eto, Cs )
Continuation phase- minimum 12 months ( Z, Lfx, Eto, Cs )
Z: Pyrazinamide; Km: Kanamycin; Lfx: Levofloxacin;
Eto: Ethionamide; Cs: Cycloserine
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Length of Treatment for the Standard MDR TB Regimen

Date of first Length of

sustained
injectable
conversion agent
***

Length of
Total
treatment
for
Standard
MDR TB
regimen

Between
8 months
20-22
month 0
months
and 4
***Date of first negative smear
& culture
Between
Add
4 by two consecutive
Addmonths
18
month 5
months
months

65

Links between TB and

Diabetes

NTP Expectations
Referral of presumptive TB to NTP designated

centers for diagnosis

Diagnosis of pulmonary TB based on sputum

smear microscopy
Referral of diagnosed patients to the nearest

NTP designated centre for management

Ensure daily DOT

Maintaining recordings and reporting

Strictly follow NTP operational guidelines

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