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  • TS: Tuberculosis

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    • Tuberculosis

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      Figure: Causative agent for Tuberculosis is Bacillus: Mycobacterium tuberculosis (M.tb)

       

      • Tuberculosis (TB) is a communicable disease that is a major cause of ill health.

      • TB is caused by the bacillus Mycobacterium tuberculosis (M.tb)

      • TB disease typically affects the lungs (pulmonary TB) (80%) but can also affect other parts of the body (extra pulmonary TB) (20%)

      • It spreads when people who are sick with TB expel bacteria into the air (for example by coughing, sneezing, shouting or singing)

      • It is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent

       

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      Resources

       

    • Burden of TB in India

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      TB is one of the top burdensome infectious diseases in India. It is estimated that, around 1/4th (26%) of the world's TB cases are in India, translating to about 30 Lakhs new TB cases emerging each year (TB incidence). Against this estimated incidence the National TB Elimination program reported around 19 lakh new and relapse cases in the year 2021.

      An estimated 5 Lakhs deaths occur due to TB each year in the country, translating to about 1 case of TB death every one-two minutes. Compared to this, there are only about 60 thousand deaths due to HIV and about 77 deaths due to Malaria each year.

      TB diagnosis and treatment services although provided free of cost in the public sector, the cost of accessing these services and related loss of wages drive the affected people with poverty (catastrophic costs). TB also has a huge impact on the world's and the country's economy because of loss of workdays (100 million workdays per year).

       

      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 is the estimated number of incident TB cases that emerge each year in India? 35 Lakh cases 26 Lakh Cases 26% of the Global Burden 19 Lakh Cases 2 The estimated number of new and relapse (incident) cases in India that emerge each year is about 26 Lakh ​ Yes Yes
      How many cases of deaths are estimated to be caused by TB in India Approximately One death every 2-3 minutes Approximately 5 Lakh deaths 60 Thousand deaths each year 1 and 2 4 In India it is estimated that there is around one death caused due to TB every one to two minutes, translating to about 5Lakh deaths each year in India   Yes Yes

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    • TB Causative organism

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      Figure Mycobacterium tuberculosis

       

      TB is caused due to the infection by a bacterium called Mycobacterium tuberculosis.

       

      Figure: Extra-Pulmonary Tuberculosis

       

      It often affects the lungs, and in such cases it is called Pulmonary Tuberculosis. But, it can affect almost any part of the body (except the hair and the nails), in which it is known as Extra-Pulmonary Tuberculosis.

       

       

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    • Determinants of TB Disease

      Content

      Determinants are any characteristics that affect the health of a patient.

      Biological Determinants Behavioral Determinants Socio Economic Determinants Occupational Determinants
      • People living with HIV(PL HIV)
      • History of contact with a case of TB
      • People with underlying medical conditions like Diabetes, Kidney disease, Cancer etc.
      • Existing lung disease
      • Old age
      • Use of tobacco and alcohol
      • Malnutrition
      • Person in contact with TB infected patient
      • Person living in areas with poor ventilation & over crowding
      • Poverty and Malnutrition
      • Homeless
      • Mining work
      • Quarry work(Silicosis)
      • Construction work
      • Migrant worker
      • Daily wagers

    • Vulnerable Population for Tuberculosis

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      TB can affect anyone but it is more prevalent in some communities which are vulnerable to TB disease due to various factors which are mentioned below:

      Increased exposure of TB due to where they live or work

      • prisoners
      • slum dwellers
      • miners
      • hospital visitors
      • healthcare workers

      Limited access to Quality TB services

      • Migrant workers
      • Women in settings with gender disparity,
      • Children
      • Physically challenged
      • Transgender population
      • Tribal and population living in hard to reach areas
      • Refugees or internally displaced people
      • Illegal miners and undocumented migrants

       

      Increased risk because of biological or behavioural factors that compromise immune functions in people who:

      • People who live with HIV
      • have diabetes or silicosis
      • undergo immunosuppressive therapy
      • are undernourished
      • use tobacco
      • suffer from alcohol use disorders.
      • inject drugs 

    • Mode of TB Transmission

      Content

      Tuberculosis is transmitted mainly through the air via droplet nuclei generated when a TB patient coughs or sneezes. 

      It is estimated that every sputum smear-positive patient spreads the infection to 10 – 15 persons annually, if untreated..

      Figure: Transmission of TB bacteria through air via droplet

       

      Resources:

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    • Symptoms of TB Disease

      Content

      Active TB disease has 4 major symptoms (the 4 Symptom complex). Presence of any one of these symptoms without any other reason warrants evaluation for TB. These are:

      Figure: Signs and Symptoms of TB

      People affected with TB may experience other symptoms as well. These may be based on the site that is affected with TB or other more non-specific symptoms of an infection. The physician or doctor would evaluate these symptoms in view of diagnosis of TB.

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    • Progression to TB Disease

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      After exposure to infective droplets containing M.TB, only a small proportion gets infected and further progresses to active TB disease.

      • Majority of those that get infected persist in a stage of clinical latency known as TB infection (previously known as Latent TB infection). They do not have TB disease and do not show any symptoms of TB and no evidence of any TB related changes on chest X-ray.
      • A small proportion of those with prior infection may progress to active TB disease due to various environmental/ agent/ host factors.

      Figure: Flow chart for TB disease progression

       

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    • TB Infection

      Content

      • TB Infection (or previously known as Latent TB infection) is a stage in between uninfected and having active TB. In this stage the person has no symptoms and can only be identified using laboratory tests.

      • The vast majority of infected people may never develop TB disease. However, to achieve TB elimination, it is important to treat TB infection in people at risk of developing active TB disease.

      • It is a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifested active TB.

      • There is no single acceptable/reliable test for direct identification of Mycobacterium tuberculosis infection in humans. Tuberculin Skin Test (TST) and Interferon-gamma release assay (IGRA) are commonly used tests for identifying TB infection.

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    • TB Infection Vs Active TB Disease

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      TB Infection Active TB Disease
      May not have any signs & symptoms Has sign and symptoms such as cough for more than two weeks, fever, weight loss and blood in sputum
      Has dormant, contained bacteria is the body Has active, multiplying bacteria in the body
      Doesn't spread TB bacteria to others May spread TB bacteria to others
      Chest X-ray usually normal Lesion in Chest X- ray (usually)
      May advance to active TB. It is estimated that the lifetime risk of an individual with TB infection for progression to active TB is 5–10%. Needs treatment for TB disease

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  • TS: NTEP

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    • National TB Elimination Program [NTEP]

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      • The National Tuberculosis Elimination Program (NTEP) is the public health initiative of the Government of India that organizes the country’s Tuberculosis Elimination efforts. 
      • NTEP is a centrally sponsored scheme being implemented under the aegis of the National Health Mission with resources sharing between the State Governments and the Central Government.
      • The program provides various free of cost, quality tuberculosis diagnosis and treatment services across the country.

       

      NTEP Vision

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      Resources

       

       

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    • Tuberculosis Unit [TU]

      Content

      Tuberculosis (TB) unit (TU) is the sub-district level supervisory unit of National TB Elimination Program with the following organogram:

      Figure: Organogram of a TB Unit

       

      (PHI: Peripheral Health Institution)

      TUs are based mainly on National Health Mission (NHM) health blocks with the aim of aligning with the NHM Block Programme Management Unit (BPMU) for optimum resource utilization and appropriate monitoring.

      The TUs have been created based on a population of 1 per 2,00,000 (range 1.5 – 2.5 lakh) for rural and urban populations and 1 per 1,00,000 (0.75 – 1.25 lakh) population in hilly/tribal/difficult areas.

      The TU consists of a designated Medical Officer-Tuberculosis Control (MO-TC), as well as one full-time supervisory staff - Senior Treatment Supervisor (STS). However, one Senior TB Laboratory Supervisor (STLS) will be there in every 5 lakh population (one per 2.5 lakh population for tribal/hilly/difficult areas), mostly covering 2-3 TUs.

      TB Unit manages the provision of TB services (Diagnosis, Treatment, Prevention, etc.) and programme management in the assigned geographical area. 

       

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    • Stages in TB Patient's Lifecycle

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      Those who are suspected of having TB disease are first screened for symptoms like cough and fever for more than 2 weeks, blood stained sputum and weight-loss. If found positive on screening, then TB patients are referred for testing to the nearest health facility. If diagnosed with TB, then they are subsequently initiated on treatment. The TB patients initiated on treatment are regularly monitored with the help of field staff or digital interventions like 99DOTS and MERM (Medication Event Reminder Monitor) technology. NTEP staff also ensures that the TB patients are regularly followed up on monthly basis till their treatment completion.

       

      Figure: Patient Flow

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    • Categorization of TB Treatment Regimen

      Content

      Daily Regimen is prescribed for TB patients, where patients need to consume the medicine daily.

       

      Daily Regimen comprises of the first line Anti TB drugs, based on

      • Age: Adult/Paediatric
      • Weight of the patient: Weight Bands

       

      Age: Based on the age, patients are categorized into

      • Adults: Patient's age should be 19 years or more.
      • Paediatrics: Patient's age up to 18 years and weight less than 39 Kgs

       

      Weight Bands: 

      • Treatment dosage is based on the TB patient’s weight.
      • A weight band category is defined for Adult and Paediatric patients separately and medicines are issued based on that weight category.

    • TB Case classification in NTEP

      Content

      TB cases are generally classified on the basis of previous history of TB treatment into New and previously treated cases.

      New case - A TB patient who has never had treatment for TB or has taken anti-TB drugs for less than one month is considered as a new case. 

      Previously treated patients have received 1 month or more of anti-TB drugs in the past. They could be further classified as:

      • Recurrent TB case - A TB patient previously declared as successfully treated (cured/treatment completed) and is subsequently found to be microbiologically confirmed TB case is a recurrent TB case. 
      • Treatment After failure patients are those who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment.  
      • Treatment after loss to follow-up - A TB patient previously treated for TB for 1 month or more and was declared lost to follow-up in their most recent course of treatment and subsequently found microbiologically confirmed TB case 
      • 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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    • Patient interaction with TB Care Ecosystem

      Content

      Health Volunteers/ Treatment Supporters are often the regular point of contact for a TB patient in the community. They support the TB patient during the entire episode of TB and ensure complete diagnosis and treatment. The next points of contact are with the MPHWs who periodically visit the patients to ensure specific delivery of services.  

      The Peripheral HeaIth Institution (PHI) is the nearest accessible health facility where the patient can access   a physician/ doctor for diagnosis and treatment services. These are often in the form of a Primary Health Centre, but can also be higher level institutions such as medical colleges and private health facilities that are most accessible to/ preferred by the patient. The PHI may also host a drug store/ pharmacy from where the patient's medicines would be dispensed.

      Other health facilities with diagnostic services such as DMCs, NAAT Sites and C&DST Labs may be accessed by the patient or by their biological specimen being collected and transported to the corresponding laboratory. Other higher order health institutions such as DRTB Centres may also be accessed by the patient on referral. 

      The District TB Centre, TB Unit and its staff provide programmatic support and supervision indirectly through the PHI. At times the National Call Centre may contact the patient for providing specific information, or for collecting feedback on quality of service delivery.

      Figure: Stakeholders interacting with HVs

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  • Ch 03: TB Diagnosis and Case Finding

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    • Presumptive TB

      Content

      Presumptive TB case refers to a patient who presents with symptoms or signs suggestive of TB disease (previously known as a TB suspect) and where further diagnostic workup including bacteriological investigation is required.

       Presumptive TB can be categorized into

      1. Presumptive Pulmonary TB (P TB) - Symptoms are directly related to lungs (Cough, hemoptysis)

      2. Presumptive Extra Pulmonary TB (EP TB) - Symptoms/ signs are specific to an extra pulmonary site (example: Lymph node swelling)

      3. Presumptive Pediatric TB - Symptoms of TB in young children are more difficult to identify and can be more general (fever, weight loss) 

       

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    • Presumptive Pulmonary TB

      Content

      Pulmonary TB(PTB) is primarily involves lungs. Screening should be done for the following symptoms:

      Figure: Signs and Symptoms of active TB

       

      Regular screening of Presumptive TB cases with unexplained cough of any duration should be done and checked for:

      • History of close contact with known active TB case 

      Covid 19 Coronavirus Social Distancing Prevention, People Avoid Contact, Outbreak Spread Vector Silhouette Style Icon Stock Vector - Illustration of pandemic, social: 186098434

      • Whether the patient has developed Presumptive/confirmed extrapulmonary TB(EPTB)

      Extrapulmonary Tuberculosis Objectives

      • High-risk groups: PL HIV, Diabetics, Malnourished, Cancer patients, patients on immunosuppressive therapy or steroids

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    • Testing for TB diagnosis

      Content

      National Tuberculosis Elimination Programme (NTEP) strives for all presumptive TB patients to be microbiologically confirmed. Under NTEP, the acceptable methods for microbiological diagnosis of TB are: 

      Sputum Smear Microscopy (for Acid Fast Bacilli - AFB): Sputum Smear microscopy is the primary tool which is reliable, inexpensive, easily accessible and rapid method of diagnosing PTB, where in the bacilli are demonstrated in the sputum. Two types:

      • Ziehl-Neelsen Staining

      • Fluorescence staining

      Rapid diagnostic molecular test: Rapid molecular tests that use techniques like NAAT are very specific. They amplify the genomic material in the patient sample and hence enhances detection

      • Nucleic Acid Amplification Test (NAAT) e.g., GeneXpert, TrueNat

        GeneXpert

        Figure: Genxpert Machine for CBNAAT

        Truenat

        Figure:  Truenat Machine

      • Line Probe Assay

       

      Culture and DST: A culture test involves studying bacteria by growing the bacteria on different substances. This is to find out if particular bacteria are present. In the case of the TB culture test, the test is to see if the TB bacteria Mycobacterium tuberculosis, are present. 

      Two types:

      • Solid (Lowenstein Jensen) media

      • Liquid media (Middlebrook) e.g., Bactec MGIT etc.

    • Biological Specimen for Diagnosis of TB

      Content

      For laboratory diagnosis of TB, different biological specimens are used.

      Pulmonary TB: Sputum sample is used. Sputum is a thick fluid produced in the lungs and in the adjacent airways. Normally, a spot sample and a fresh morning sample is preferred for the bacteriological examination of sputum.

      Extra Pulmonary TB:

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    • Sputum Collection Process

      Content

      Presumptive TB patients attending the TB Diagnostic centre (TDC) will be referred for sputum examination at the same facility. The patients are given the sputum container with laboratory serial number written on its side. The patient is:

      Figure: Sputum Collection Process

      • Provided with the labelled sputum cups and demonstrated how to open and close the container.
      • Given a labelled container with instructions to cough out sputum into the container early in the morning after rinsing the mouth with water. This is the early morning specimen. This is labelled as Specimen ‘b’.
      • Ensure collection of sputum samples in an open, well-ventilated area designated for this purpose.
      • Given a sputum container with instructions to collect an early morning specimen and go with the sputum specimen to the TDC(if the health facility is not a TDC) where the spot specimen can be collected. If the patient cannot travel to the TDC, then the spot specimen could be collected at the nearest health facility or sputum collection centre and transported to the TDC.

       

      Video: Process of sputum collection 

       

      Resources:

       

    • Role of Health Volunteers in TB Case Finding

      Content
      • Community Health Volunteers play a significant role in increasing awareness regarding the burden of TB and the importance of preventing it and regularly screening the population.
      • Community Health Volunteers should use the various platforms in the communities, such as the PRI meetings, school meetings etc., for spreading the information on TB. Using such media, the Community Health Volunteers should focus on building community awareness to improve the patients' health-seeking behaviour.

      • Community Health Volunteers should screen the vulnerable population for Tuberculosis during the Active Case Finding Campaign. Positive TB suspects identified should then be referred for testing, post which, if diagnosed with TB, should be initiated on treatment.
      • Community Health Volunteers should also ensure that those TB patients initiated on treatment adhere to the treatment.
      • Community Health Volunteers should also record the population screened; sputum examined cases, diagnosed cases and patients initiated on treatment.
      • Community Health Volunteers should also confirm the patient's address in their respective locality for correct patient identification.

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    • Prevention of TB

      Content

      As TB is an airborne infection, TB bacteria are released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by taking simple precautions:

      Figure: Measures for control and prevention of tuberculosis

      TB Preventive Treatment(TPT) also has a very important role in prevention of TB. Presently, household contacts of sputum-positive TB patients are given TPT upon confirmation of TB infection and ruling our active Tuberculosis.

      Resources:


       

  • Ch 04: Nikshay & Treatment Supporter

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    • Nikshay

      Content

      Nikshay is an Integrated ICT system for TB patient management and care in India. Nikshay was launched in 2012 and since then, various improvements have been made in the system.

      Nikshay provides-

      • A Unified interface for public and private sector health care providers
      • Different types of Logins such as State, District, TU, PHI, Staff logins, Private providers, Chemist, Labs and PPSA/JEET Logins
      • Integration of all adherence technologies such as 99DOTS and MERM
      • Unified DSTB and DRTB data entry forms
      • Mobile friendly website with mobile app

      Nikshay is accessible either via web browser(https://Nikshay.in ) or mobile App called ‘Nikshay’ that can be downloaded from Google Play Store(Android).

      Figure: Nikshay Login Pages

    • Nikshay interfaces- Web and Mobile application

      Content

      Figure: Nikshay Home Page

      After login in Nikshay, using the login credential shared by NTEP Health Staff, Treatment Supporter will be able to access the following button:

      • New Enrolment: Allows to enrol new cases in Nikshay
      • Search Patient: Allows to search for patients that are mapped to him /her, using Patient Name, Nikshay ID and Old Nikshay ID
      • Add Patient Test: Allows to add tests for all the patients.
      • Diagnosis Pending: View the list of the patients that are pending for diagnosis
      • Not on Treatment: View the list of the patients that are diagnosed but pending to be initiated on treatment
      • On Treatment Patients: Gives the list of on treatment patients
      • Outcome assigned: Gives the list of the patients that have completed their treatment
      • Training Material; Access the training content available on Nikshay
      • Patient Summary: Gives a brief overview on the Presumptive cases registered, Diagnosed and patients that are initiated on treatment
      • Task List: Allows to view the list of pending activities pertaining to adherence, Treatment Outcome and Bank details missing for mapped patient
      • Latest Updates: New updates of features that are released on Nikshay

    • TB Aarogya Sathi

      Content

      TB Aarogya Sathi empowers Citizens(including TB Patients under NTEP) and to serve as a Direct interface with the healthcare system. The App is aimed at augmenting the initiatives of the Central TB Division, Government of India in proactively increasing awareness among the citizens and ensuring availability of free and quality assured drugs and diagnostics to all citizens in the country.

      Citizens using the TB Aarogya Sathi App will have access to common FAQs regarding TB, Information on the symptoms of TB and Side effects of Anti TB drugs. Using the app, any user will be able to find the closest health facilities that can assist in diagnosis of TB.

      Patients registered with Nikshay will have access to the Adherence, Treatment Progress and DBT Details.

      Citizen:

      • Informative Content available for all Citizens using the App(no login required to access this content)
        • Information on TB 
        • Symptoms of TB
        • Side Effects of TB
        • Health Facility Search
        • BMI Assessment
        • Nikshay Sampark Helpline
        • Motivational Videos
        • Nutritional Advice

      Patient:

      • Patients registered in Nikshay get access to additional information(after login)
        • Adherence Details
        • Treatment Progress Details
        • DBT Details

       

      TB Aarogya Sathi App is available in Google play store and can be download using this QR Code

      Figure: TB Aarogya Sathi Application snapshot