RNTCP

Dr. Gyanshankar Mishra

MD (Pulmonary Medicine) DNB(Respiratory Diseases)
Assistant Professor
Dept. of Pulmonary Medicine, GMC Nagpur
In our country…
RNTCP
Treatment
o Objectives of TB treatment
o Basis of TB treatment
o Case definitions
o Treatment regimens
o Special situations
o Directly Observed Treatment (DOT)
o Monitoring of patients
o Treatment outcome
o Advanced categories under RNTCP – CAT IV & CAT V
o 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
o Intermittent (thrice weekly) treatment
regimens
o Treatment given under direct observation
o Standardized treatment regimens in two
categories
o Regimen decided by MO on basis of
o Sputum smear results
o History of previous anti-TB treatment
o Disease classification (pulmonary/extra pulmonary)
o Severity of illness
Components of DOTS

1. Political 2. Good 3. Uninterr 4. Directly 5. Systema

and quality upted observed tic
administra diagnosis, supply of treatment monitoring
tive primarily good (DOT) and
commitme by sputum quality accountabi
nt smear drugs lity
microscop
y
o 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
o Pulmonary Tuberculosis, Smear-Positive
o TB in a patient with atleast one smear-positive
for AFB out of the two initial sputum smear
examination by direct microscopy
o Pulmonary Tuberculosis, Smear Negative
o 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
o Extra Pulmonary Tuberculosis
o Tuberculosis in any organ other than lungs
(eg. pleura, lymph nodes, intestine, genitor-
urinary tract, joint and bones, meninges of
the brain etc).
o The diagnosis should be based on strong
clinical evidence with the following
investigations
o Smear/Culture from extrapulmonary sites
o Histopathological examination or
o Radiological examination or
o Biochemical and cytological examination
including FNAC
Case definitions
o NEW
o A TB patient who has never had treatment
for TB or has taken anti-tuberculosis drugs
for less than one month
o RELAPSE
o 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)
o TRANSFERRED IN
o 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.
o TREATMENT AFTER DEFAULT
o 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)
o FAILURE
o Any TB patient who is smear positive at 5
months or more after starting treatment.
o CHRONIC
o A TB patient who remains smear-positive
after completing a re-treatment regimen but
has not been initiated on MDR TB treatment
o OTHERS
o 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?
Treatment Regimens

Category of Type of Patient Regimen*

Treatment

Category I All new pulmonary (smear-positive and 2H3R3Z3E3+

negative), extra pulmonary and ‘others’ TB patients. 4H3R3

Category II TB patients who have had more than one month 2H3R3Z3E3S3 +
anti-tuberculosis treatment previously 1H3R3Z3E3 + 5H3R3E3

Relapse , Failure, Treatment After Default ,Others

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

o Self administered non

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

Treatment Regimen
Non-DOTS Regimen 2HSE+10 HE
DOTS in the context of HIV
DOTS can:
o Prolong and improve the quality of life.
o Prevent emergence of MDRTB.
o Stop the spread of TB.
o Reverse the trend of MDRTB.
o In the context of HIV, failure to use DOTS can
result in - rapid spread of disease - tripling
of cases - increased drug resistance.
Special situations
o Hospitalization
o general policy is treatment on ambulatory
basis.
o Indoor treatment adviced if general
condition of patient is serious
o Pneumothorax
o Massive haemoptysis
o Large pleural effusion
o Treatment with prolongation pouches
supplied by DTO of the district in which
hospital is situated.
Special Situations (contd)
o Pregnancy and post natal period
o Streptomycin not to be given. Other drugs in
RNTCP are safe
o Breast feeding should continue
o Chemoprophylaxis for baby if mother is smear
positive
o Renal failure
o Rifampicin, isoniazid and pyrazinamide can be
given
o Streptomycin and ethambutol require close
monitoring
Directly Observed Treatment

Directly observed An observer Direct observation

treatment (DOT) is watches and helps ensures treatment
one element of the the patient for the entire course
DOTS strategy swallow the tablets with the right
drugs
in the right
doses
at the right
intervals
DOTS Strategy
A strategy to ensure treatment completion in
which
o Treatment observer (DOT provider) must be
accessible and acceptable to the patient and
accountable to the health system
o DOT provider administers the drugs in
intensive phase.
o Ensures that the patient takes medicines
correctly in continuation phase.
o Provides the necessary information and
encouragement for completion of treatment.
Drug administration

A suitable DOT provider and DOT center is selected in

consultation with patient

Tuberculosis Treatment Card is accurately and completely

filled after initial home visit

Initial counseling at the health facility and at patients

home is important to achieve treatment compliance

Ensure that treatment is being directly observed for all

doses of the intensive phase and the first of the thrice
weekly dose in the continuation phase
Drug doses in RNTCP
Remember the correct doses of anti TB Drugs!
Why are correct doses important?

Ref: Mishra G, Mulani J. Tuberculosis Prescription Practices In Private And

Public Sector In India. NJIRM. 2013; 4(2): 71-78.
Why are correct doses important?

Ref: Mishra G, Mulani J. Tuberculosis Prescription Practices In Private And

Public Sector In India. NJIRM. 2013; 4(2): 71-78.
Pediatric weight bands
Drug administration(contd)

Streptomycin injections should

be given Chemoprophylaxis to be
After oral drugs are given to children (under
administered 6 years of age) of smear-
With disposable syringes and
needles
positive patients

Patients missing doses should be

traced and put back on treatment
Within one day in intensive
phase
Within one week in
continuation phase
Monitoring of Treatment
o Follow up sputum
microscopy determines
o Conversion rate
o Cure rate
o Sputum smear microscopy
schedule
o Initial sputum examination
o End of Intensive phase of
treatment
o 2 months into Continuation
phase of treatment
o End of treatment
 Schedule of follow-up sputum smear
examination
Cat. Pre–Rx Test at If: Then
of Rx Sputum month result
- C.P. – Sputum at 4 & 6 m
+ 2
Cat–1 + I.P. for 1month, Sp. At 3, 5 & 7

- C.P. Sputum at 6 months

- 2
+ I.P. for 1 month, SP. at 3, 5 & 7

Cat–II - C.P. Sputum at 5 & months

+ 3
+ I.P. for 1 month, Sp. at 4, 6 & 9
Treatment Outcomes

CURED

●
Initially sputum smear-positive patient who has completed treatment and had negative
sputum smears, on two occasions, one of which was at the end of treatment

TREATMENT COMPLETED

●
Sputum smear-positive patient who has completed treatment, with negative smears at the end of the intensive phase but none at the end of treatment.
●
Sputum smear-negative TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment.
●
Extra-pulmonary TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment
Treatment Outcomes
o DIED
o Patient who died
during the course of
treatment regardless of
cause
o FAILURE
o Any TB patient who is
smear positive at 5
months or more after
starting treatment.
Treatment outcomes

TRANSFERR
DEFAULTED
ED OUT
A patient who has not
● A patient who has been
●

transferred to another
taken anti-TB drugs
Tuberculosis Unit/
for 2 months or more District and his/ her
consecutively after treatment result
starting treatment. (outcome) is not known.
Advanced RNTCP Regimes
Drug Resistant TB (PMDT)
o MDR TB – Resistant to
INH & Rifampicin
CAT IV – MDR TB
INITIAL INTENSIVE PHASE : 6- 9 months
o Inj. Kanamycin
o Tab Ethionamide
o Tab Ofloxacin
o Tab. Pyrazinamide
o Tab. Ethambutol
o Cap Cycloserine
CONTINUATION PHASE : 18 months
o Tab Ethionamide
o Tab Ofloxacin
o Tab Ethambutol
o Cap Cycloserine
CAT V- XDR TB

o XDR TB- MDR TB+ Resistant to Second line

injectable Anti TB drug & Fluroquinolone
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
Some practical points
o 1. TB is a notifiable disease.
o 2. If you not sure of individualized treatment regime, please do
not start it. Instead you may register the patient under RNTCP.
o 3. Do not start a fluroquinolone to a TB suspect.
o 4.Please do simple sputum microscopy for afb smear for all TB
suspects, rather than directly starting from higher investigations
like CT scan.
o 5. Serological TB tests are banned in India eg. TB IgG and TB IgM.
o 5. Do not even attempt to treat drug resistant TB, in absence of
requisite training. Refer to specialist/ RNTCP /PMDT.