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  • TB Treatment Initiation

    Content

    The Medical Officer (MO) of the referring health facility initiates TB treatment on receipt of the diagnostic test results. All efforts are made to initiate the treatment at the earliest.

    The treatment regimen is decided based on the type of patient and TB (based on drug sensitivity pattern, i.e., drug-sensitive TB or H-mono/ poly resistance, history of adverse drug reaction to anti-TB drugs).

    The patient needs constant support of a health volunteer or peer, who can monitor the treatment, help him in getting a follow-up, keep him motivated, counsel the family/ contacts, etc. These health volunteers/ peers are called treatment supporters in NTEP.

     

    The steps in treatment initiation include:

    • The MO performs a clinical evaluation of the patient and assesses for comorbidities.
    • Counselling of TB patients and their families should be done.
    • Peripheral health worker/ treatment supporters responsible for monitoring treatment adherence and treatment providers acceptable to the patient should be assigned.
    • A treatment card should be opened for each patient.
    • Each patient should be given a TB Identity Card.
    • Drugs should be made available at the treatment centre.
    • Public health action for all notified TB patients should be initiated.

    All the process related to patient treatment initiation should be documented in Nikshay. 

    Resources

     

    Assessment

    Question​

    Answer 1​

    Answer 2​

    Answer 3​

    Answer 4​

    Correct answer​

    Correct explanation​

    Page id​

    Part of Pre-test​

    Part of Post-test​

    What key activities are included during TB treatment initiation?

    Clinical evaluation

    Counselling

    Treatment card and TB ID card opened, Nikshay updated with treatment details

     All the above

    4

    During TB treatment initiation the key activities include clinical evaluation of the patient; counselling of patient and family members; opening of treatment card and TB ID card and updating of treatment details on Nikshay.

    ​

    Yes

    Yes

  • Follow-up of TB patient

    Content

    To know the TB treatment response and to determine that if patient is cured, TB patients are clinically evaluated at the end of every four weeks of treatment, and they are also followed up by performing sputum test at end of each treatment phase (i.e. Intensive phase and Continuation phase)

    TB patients during clinical evaluations are assessed to

    • Identify possible adverse reactions to medications;
    • Check for any comorbid conditions;
    • Weight change;
    • monitor adherence; and determine treatment efficacy by observing their symptoms

    Although each patient responds to treatment at a different pace, all TB symptoms should gradually improve and eventually go away.

    Patients whose symptoms do not improve during the first 2 months of treatment, or whose symptoms worsen after improving initially, should be re-evaluated for adherence issues and development of drug resistance.

  • TB Treatment Outcome

    Content

    When a TB patient consumes all the doses under the prescribed regimen, then Treatment Outcome is declared for a Patient.

     

    Treatment Outcome

    Description

    Cured

    A TB patient who was microbiologically confirmed for TB at the beginning of treatment but who is smear or culture negative at the end of complete treatment

    Treatment Complete

    A TB patient who completed treatment without evidence of failure or clinical deterioration BUT with no record to show that the smear or culture results of biological specimen in the last month of treatment was negative, either because the test was not done or because the result is unavailable

    Treatment Failure

    A TB patient whose biological specimen is positive by smear or culture at the end of treatment

     

    A case of paediatric TB who fails to have microbiological conversion to negative status or fails to respond clinically/or deteriorates after 4 weeks of compliant intensive phase shall be deemed to have failed response provided alternative diagnoses/reasons for non-response have been ruled out.

    Loss to Follow up

    A TB patient whose treatment was interrupted continuously for one month or more

    Not Evaluated

    A TB patient for whom no treatment outcome is assigned

    Treatment Regimen Changed

    A TB patient who is on first line regimen and has been diagnosed as having TB(DR-TB) and switched to DR-TB regimen prior to being declared as failed

    Died

    A patient who has died during anti-TB treatment(due to any reason)

    Treatment success is considered when a TB patient either Cured or Treatment completed is accounted in treatment success

  • Adverse Drug Reactions

    Content

    Adverse Drug Reactions(ADR) are unwanted or harmful reactions experienced following the use of a drug or combination of drugs and are suspected to be related to a drug. Severity of adverse effects varies from tolerable and mild ADRs to serious and life threatening ADRs.

     

    Figure: Various Adverse Drug Reactions

     

    Common ADR Symptoms:

    • Pain in upper abdominal area, with loss of appetite
    • Nausea – Uneasy feeling with inclination to vomit, after having the drugs
    • Gastritis – Burning sensation in lower chest region, bloating sensation, sourness in mouth
    • Diarrhoea - Loose stool(2-3 in a day)

  • Long Term Post-treatment follow up of TB patients

    Content

    After completion of TB treatment, all patients should be followed up at the end of

    • 6 months,
    • 12 months,
    • 18 months &
    • 24 months

    TB patients at the follow up should be screened for any clinical symptoms and/or cough. If found positive on screening, then sputum microscopy and/or culture should be considered. This is important in detecting the recurrence of TB at the earliest.

    After completion of TB treatment, if the patient has not developed any clinical symptoms and/or cough and also if the microscopy remains negative during their follow up, then the patient is considered as “Relapse Free Cure from TB.”

     

  • Universal DST [UDST]

    Content

    Drug Susceptibility Testing (DST) refers to in-vitro testing using either of the phenotypic methods to determine susceptibility. Drug Resistance Testing (DRT) refers to in-vitro testing using genotypic methods (molecular techniques) to determine resistance.    

     

    Universal Drug Susceptibility Testing (UDST) refers to universal access to rapid DST for at least Rifampicin (R), and further DST for at least Fluoroquinolones (FQs) among all TB patients with rifampicin-resistance.

    • UDST is essential to identify patients who can be initiated on Drug-resistant TB (DR-TB) treatment instead of Drug-sensitive TB (DS-TB) treatment, especially in a situation where the drug-resistance level is high.
    • It should be done preferably before initiation of treatment to a maximum within 15 days of diagnosis.
    • UDST is a part of national policy under the National TB Elimination Programme (NTEP).
    • NTEP has undertaken decentralization of quality assured diagnostics for scale up of UDST across the country which has helped in early detection of DR-TB treatment and reducing associated morbidity and mortality.

  • Screening and diagnosis for DRTB

    Content

    Drug-resistant TB (DR-TB) diagnosis is predominantly based on laboratory diagnosis. Presumptive-TB/ DR-TB is identified by the health facility doctor during passive screening or by health staff/ community volunteers during Active Case Finding (ACF). 

    The vision of National TB Elimination Programme (NTEP) is to provide early diagnosis to all persons with any form of DR-TB through Universal Drug Susceptibility Testing (UDST).

    All diagnosed TB patients are eligible for a NAAT test to know their Rifampicin sensitivity status. The integrated diagnostic algorithm for diagnosis of TB offers upfront Nucliec Acid Amplification Test (NAAT) for diagnosis of TB to vulnerable population. Among other eligible groups for NAAT are: non-responders to treatment and contacts of DR-TB patients are also offered upfront NAAT.

    Rapid identification of DR-TB is achieved by using a combination of NAAT (CBNAAT/ Truenat) followed by sequential testing by first- and second-line Line Probe Assay (LPA) and Liquid Culture (LC) and Drug Susceptibility Testing (DST) for specific drugs as described below:

    • When Rifampicin resistance is not detected by NAAT, the patient is offered First-line (FL) LPA.FL-LPA provides information on Isoniazid resistance.
    • For Rif resistance/Inh resistance cases, SL-LPA  is done and it provides information on resistance to Levofloxacin, Moxifloxacin and Amikacin.
    • For all Rif resistance cases, LC and DST is done for Pyrazinamid, Moxifloxacin (if resistance detected by LPA), Linezolid, Clofazimine*, Bedaquiline* and Delamanid*.

     

    (* when available)

     

    Resources

     

    Assessment

    Question​ Answer 1​ Answer 2​ Answer 3​ Answer 4​ Correct answer​ Correct explanation​ Page id​ Part of Pre-test​ Part of Post-test​
    Liquid Culture and DST is done before NAAT. True False     2 Rapid identification of DR-TB is achieved by using a combination of NAAT (CBNAAT/ Truenat) followed by sequential testing by first- and second-line LPA and then liquid culture and DST. ​ Yes Yes