NTEP GUIDELINES FOR TB MANAGEMENT
PRESENTED BY-
AANCHAL JAIN
2017 BATCH
GMC BHOPAL
INDEX
• Goals and objectives of treatment.
• Diagnosis and Diagnostic algorithm for DSTB.
• Management of DSTB
• Infant born to mother with TB.
• Monitoring of therapy.
• Diagnostic algorithm for DRTB and management.
• Newer strategies under NTEP.
GOALS AND OBJECTIVES OF TREATMENT
• To render patient non infectious, break the chain of transmission and
decrease pool of infection.
• Decrease case fatality and morbidity by ensuring relapse free course.
• Minimize the development of drug resistance.
DIAGNOSIS OF TB AMONG CHILDREN
• High index of suspicion of TB in a child is the first step in the diagnosis.
• Tuberculosis should be suspected among children with presenting symptoms of
prolonged / unexplained fever and / or cough for more than 2 weeks, with no weight
gain or history of failure to thrive.
• It is to be remembered that cough may not be the predominant and constant
symptom unlike in an adult.
• Children presenting with neurological symptoms may be suspected to have TB
meningitis.
• The diagnosis is further based on-
• Sputum examination, if feasible, is a very helpful tool in the diagnosis.
• Tuberculin skin test- Induration of 10mm and above read after 48-72 hours of properly
administered tuberculin indicates that the child is infected.
• Chest X-ray, also aids in the diagnosis of TB among children.
CXR FINDINGS
Fig. Xray showing Ghon’s [Link] showing [Link] and
Focus and complex hilar lymph nodes
CXR FINDINGS
Fig. Xray showing lung cavitation and consolidation.
• For diagnosis tests available are-
CBNAAT- 94% Sensitive and 99% specific
LPA
Liquid cell culture
Culture media- LJ media(7 -10 weeks)
MGIT(2weeks)
Serological test IGRA – Banned in India
DIAGNOSTIC ALGORITHM FOR PEDIATRIC
DSTB
MANAGEMENT OF DSTB
• Pediatric cases are to be treated under NTEP in daily dosages as per 6
weight band categories. All adolescents up to 18 years of age and weighing
less than 39 kg, are to be treated using pediatric weight bands and children
weighing more than 39 kg with adult weight bands.
• Regimen for DSTB-
2HRZE+4HRE
• H=Isoniazid
R=Rifampicin
Z=Pyrazinamide
E=Ethambutol
• Treatement is given in two phases-
Intensive for 2 months and Continuation for 4 months.
DRUG DOSAGE FOR PEDIATRIC TB
• Dispersible FDC
H(50mg)+R(75mg)+Z(150mg)- Intensive phase
H(50mg)+R(75mg) – Continuation phase
• Dispersible loose drugs
E(100mg) – Both phases
• Pyridoxine 10mg per day may be given to all children.
• Dose in Instensive phase-56
• Dose in continuation phase- 112
ROLE OF CORTICOSTEROIDS
• Indications-
TB Meningitis
Endobronchial TB
Severe miliary TB
• Prednisolone 1-2 mg/kg/day for 4-6 weeks
INFANT BORN TO MOTHER WITH TB
Mother with
active TB
Infant screened Infant screened
and is negative and is positive
INH Prophylaxis
10mg/kg/day for 2HRZE+4HRE
6 months
CHEMOPROPHYLAXIS GUIDELINES
• DOC- Isoniazid
• Advisable for-
Age<6 years and known contacts of pulmonary TB case.
People living with HIV.
Children born to mother with TB during pregnancy.
Children on immunosuppressive therapy.
• Contraindications for chemoprophylaxis-
Hepatitis and known contacts of MDR TB.
MONITORING OF THERAPY
Monitoring of therapy
Clinical criteria Radiological criteria Microbiological criteria
1st xray – 8 weeks
Improvement in symptoms If smear +ve initially then
& weight gain&chest Radiological clearance – repeat sampling done at
findings complete,moderate,mild,no 2and 6 months
clearance
DIAGNOSTIC ALGORITHM FOR DRTB
OTHER REGIMENS UNDER NTEP FOR DRTB
• DRTB-
1. H-Mono/Poly DRTB- 6(ZERO)
Z-Pyrazinamide, E- Ethambutol ,R-Rifampicin, O-Levofloxacin
2. MDR/ RRTB-
- Shorter- 4-6 months CHOKZEE+5 months COZE
C-Clofazimine, H-Isoniazid, O-Moxifloxacin, K-Kanamycin, Z-Pyrazinamide, E-
Ethambutol, E-Ethionamide
-All oral longer- 18 to 20 months Bedaquiline+ linezolid+ levofloxacin+ cycloserine+
clofazimine.
SUMMARY
(CHANGES MADE IN NTEP)
• Under NTEP children are provided with 3 drug HRZ FDC with 100mg
Ethambutol.
• Pyridoxine 10mg/day is added because of risk of peripheral neuropathy.
• Use of standard regimens without sensitivity testing is now no more
recommended for both new as well as retreatment cases.
• Efforts is to manage the cases as per the sensitivity to key drugs so that
outcome is improved and further amplification of drug resistance is inhibited.
NEWER STRATIGIES UNDER NTEP
• NIKSHAY Software- for patient compliance and management.
• 99 DOTS- IT based compliance system where patient gets reminder to take
tablets.
• JEET- Joint efforts for elimination of TB.
• NIKSHAY Poshan Yojana-All TB notified patients get 500rupees/month.
• Incorporation of newer drugs like Delaminid and Bedaquiline.
TAKE HOME MESSAGES
• Outcome depends on adequacy of host immune response.
• Early detection of cases in order to break transmission chain.
• Adequate treatment to decrease morbidity and mortality.
• Sensitivity testing prior to treatment so that drug resistance is not
developed.
Thank you
