lecture for mbbs

1. DR RAGHURAM V, MD
PROFESSOR AND HEAD
DEPT OF COMMUNITY MEDICINE
DOTS-PLUS

2. INTRODUCTION
 It is a regimen included under RNTCP
programme for treating cases of drug resistant TB
 Involves use of second line anti-tubercular drugs
 Duration of treatment longer.

4. WHAT IS DOTS -PLUS

6. DOTS –PLUS REGIMEN
 The regimen should usually comprise 6 drugs
Pyrazinamide, Ethambutol, a later generation
Fluoroquinolone (such as high dose Levofloxacin)
and a parenteral agent (such as Kanamycin or
Amikacin), Ethionamide (or Prothionamide), and
either Cycloserine or PAS (P-aminosalicyclic
acid), if Cycloserine cannot be used.

7. CONTD..
 This regimen should be used during six to nine
months of the intensive phase.
 Four drugs usually Levoflaxacin, Ethionamide,
Ethambutol and Cycloserine, should be used
during the 18 months of the continuation phase.

9. CHILDHOOD TB
 Prevalence of the disease in India
 15-25 per 1000 population
 15 million infected, 25% sputum positive
 3 to 4 million infected are children

10. Portal of entry for tuberculosis
 Inhalation of Tubercle bacilli in >95% (M.TB)
 Ingestion of milk containing Bovine Tubercle
bacilli (M. bovis)
 Contamination of superficial skin or mucous
membrane lesion with tubercle bacilli
 Congenital infection when mother has
lymphohematogenous spread during
pregnancy

11. Primary infection- Children vs. Adults
 Adult primary infection tends to be more local and
pulmonary.
 In children the disease tends to be more
disseminated .

12. Symptoms of childhood
tuberculosis
 Failure to thrive } &
 Intermittent fever } are the commonest symptoms
 Pleural effusion
 Ascites
 Abdominal mass (Painless)
 Limp / Arthritis
 Painless lymphadenopathy
 Persistent skin ulcer
 Sterile pyuria
 Meningitis

13. Diagnosis of TB
 Z-N staining
 AFB culture on L-J Medium
 PCR amplification of targeted mycobacterial DNA
sequences
 BACTEC radiometric assay
 Septichek AFB system
 MGIT – mycobacterial growth indicator tube
system

14. Mantoux test
 For establishing diagnosis of TB in children
 Delayed type hypersensitivity reaction
 0.1 ml of 5 TU PPD is injected intradermally into
the volar aspect of the forearm (or 2 TU of PPD
RT 23)
 A wheal of 5 mm should be raised
 Reaction is read after 48 – 72 hrs
 Look for induration and erythema

15. Interpretation
 48-72 hours later diameter of induration is measured
transversely to the long axis of the forearm.
 Induration > 10mm is suggestive of natural infection.
 5-10 mm - borderline; considered positive in
immunocompromised host
 <5mm - Negative mantoux test does not rule
out TB

16. Positive Mantoux

18. Treatment for TB
 Isoniazid (INAH) 5 mg/kg/day H
 Rifampicin 10 mg/kg/day R
 Pyrazinamide 25 mg/kg/day Z
 Ethambutol 20 mg/kg/day E
 Streptomycin 20mg/kg/day S

19. 2nd Line drugs
 Drug resistant cases or when first line drugs cant
be used
 Eg. Cycloserine, ethionamaide, PAS, kanamycin
 Other drugs
 Strictly for drug resistant cases
 Eg. Quinolones, rifamycin, amikacin, imipenem,
ampicillin

20. Phases of Treatment
 Intensive Phase
 Eliminate bacterial load
 Prevent emergence of drug resistant strains
 Atleast 3 Bactericidal Drugs used
 Continuation Phase
 Continue and complete therapy
 Atleast 2 Bactericidal drugs used

22. BCG VACCINE

23. Introduction
 BCG (Bacille Calmette Guerin) prepared from
Mycobacterium bovis DANISH 1331 strain which
is closely related to Mycobacterium tuberculosis,
the agent responsible for tuberculosis.
 It prevents development of more severe forms
of TB, particularly TB meningitis in children .

24. Contd..
 It is freeze-dried and need to be mixed with the
correct diluent from the same manufacturer
before administration
 Dose:
 a vial with 20doses, dose for new born is 0.05ml.
 Route:
 ID into the Rt. upper arm.
 BCG vaccine vials must be discarded 6hrs after
mixing.
 BCG can be given up to 1 year .

27. Adverse reactions

28. Contd..

29. Contraindications

30. TB- HIV CO INFECTION

31. Problem statement
 As per NACO sentinel surveillance report of
2007, the prevalence of HIV infection is estimated
to be 0.34 % of the population, which translates
to 2.31 million people living with HIV/AIDS in
India.
 Tuberculosis (TB) continues to be a public health
challenge in India and is estimated that 1.9 million
new cases of TB occur in India annually.
 Active TB disease is the commonest opportunistic
infection amongst HIV-infected individuals.

35. TB –HIV COLLABORATION
 TB-HIV collaborative activities between RNTCP
and NACP started initially in the year 2001, in the
six states with high prevalence of HIV/AIDS i.e.
Andhra Pradesh ,Karnataka, Maharashtra,
Manipur, Nagaland and Tamil Nadu.
 The collaborative activities were extended to 8
additional states in 2004.

36. OBJECTIVES
 To strengthen the mechanisms for coordination
between RNTCP and NACP at National, State
and District levels.
 To decrease morbidity and mortality due to
tuberculosis among persons living with HIV/AIDS.
 To decrease the impact of HIV in tuberculosis
patients and provide access to HIV related care
and support to HIV- infected TB patients

37. SPECIFIC TB/HIV
COLLABORATIVE ACTIVITIES
 Establish / Strengthen NACP-RNTCP
coordination mechanisms at national, state and
district level.
 Scaling up of Intensified TB/HIV Package of
Services across the country.
 Joint Monitoring and Evaluation including
standardized reporting shared between the two
programmes.
 Training of the programme and field staff on
TB/HIV
 TB and HIV service delivery coordination

39. THANK YOU