Part 2

7.Ensure that :- A.The Patient is put on treatment as early as possible. B.The patient completes the full course of treatment. C.The Patient is subjected to follow up sputum Exams as per Schedule. D.The Patient must be subjected to the last follow up sputum exam.

7.Always give a course of Non- tubercular broad spectrum antibiotics for days 8.Always take a good history of previous treatment 9. Good classification of cases ensures better treatment & better outcome.

Diagnosis of Pulmonary Tuberculosis 1.Patients with T.B.feel ill and seek care promptly. 2.Active case finding is unneccesary&unproductive. (No Use of Organising Camps,Their only use is political)

3.Microscopy is appropiate technology,indicating infectiousness,risk of death,&priorityfor treatment. X-ray is non-specific for T.B.diagnosis. 4.Serological & amplification technologies(PCRetc) currently of no proven value in T.B.Control.

Role of Chest X-Ray a)No chest X-Ray pattern is typical of T.B. b)10-15 % of culture- positive T.B.patients are not diagnosed by X-Ray. (K.TOMAN-1997)

c) 40 % of patients diagnosed as having T.B. on the basis of x-ray alone do not have active T,B. Conclusion:-Xray is unreliable for diagnosing and monitoring treatment of Tuberculosis (K.TOMAN-1997)

Objectivity & Reliability of Microscopy V/S X-Ray (inter observer Agreement)

Specificity of sputum Examination v/s Chest X-Ray Examination

Role of THREE Sputum Exams. (Three Sputum Smears are Optimal)

No of Bacilli SeenResult Reported NONE per oil immersion field.Negative 1-9 per 100 oil immersion fields Scanty,Report Exact number per 100 oil immersion fields per oil immersion fields2+ >10 per oil immersion field3+

Priority to Sput. +ve cases WHY ? 1.Smear positive patients usually seek care. 2.Smear positive patients are 4-20 times more infectious

3.Untreated, a smear +ve patient may infect persons / year. 4.Smear positive patients are much more likely to die if left untreated.

Treatment Regimens of N.T.P Standard-Conventional Regimens:-(Inj under supervision,Drugs issued monthly) R-1 All New Pulmonary Sputum Positive Cases 2STH / 10 TH or 2SEH / 10 EH R-2 All Pulmonary Sputum Negative Cases &Extra- Pulmonary cases 12 TH or 12 EH (contd)

Short Course Chaemotherapy(Inj Under supervision,Drugs issued fortnightly) R-A All New Pulm.Sputum +ve cases 2EHRZ /6 TH OR 6 EH R-B All Retreatment cases(Relapse,Failure,T.A.D.) 2SHRZ / S2H2R2 (Intensive phase under Supervision)

Improvements in R.N.T.C.P. 1.Societies formed at State & distt to facilitate flow of funds. 1.Burden of diagnosing &completing treatment of the patient is on the service provider,not on the patient.

2.The patient is now a V.I.P. 3.The programme has been decentralized to a level of virtual T.B.Clinic at a popln.of 5 Lakhs & upto the level of DOT centres (popln. of ).

4.Diagnosis is through a Diagnostic Algorhythm which gives the maximum yield of T.B.patients.

5.Emphasis is now on a better tool of diagnosis viz-SPUTUM EXAMINATION,that too with a Binocular microscope and with 3 sputum specimens.

6.Treatment is by standarized regimens(Categories) 7.Almost all the doses are by means of DOTS.

8Default retrieval by means of a well developed system consisting of:- a)Registration of only those patients who reside within distt. b)checking of addresses before doing registration. c)Default retrieval of all the patients within a maximum of 2 days(before the next dose)

9.Supply of drugs in seperate patientwise boxes. No shortage of drugs at any point & at any centre. 10.Strong system of Supervision- Provision of contractual S.T.S &S.T.L.S & one two wheeler with P.O.L.provided at T.U.level.

11. Strong system of accountability is in place.The resposibility of reporting patient’s outcome is that of the registering unit. 12.Goals are clearly defined ie- 85 % Cure rates & then 70 % case detection.

13.Monitoring & supervision from the level of C.T.D.to the level of T.B.Unit. 14.Concept of I.E.C. developed in the prog. Funds provided to theDistt.T.B.Socities.

15.N.G.O. Participation is being encouraged in a big way.Honest and dedicated N.G.Os are being invited to own one of the 5 schemes of the program.

R.N.T.C.P. The 5 commitments of R.N.T.C.P. Political commitment. Diagnosis by microscopy. Adequate supply of S.C.C. Drugs. Directly Observed Treatment. Accontabilility.

Goals of R.N.T.C.P % C U R E R A T E S And then % CASE DETECTION

Treatment Categories CAT-I 1.New Pulm.Smear Positive T.B.cases 2.Seriously ill Pulm.Smear Neg. & Extra –Pulm.Cases Regimen- 2(EHRZ)3 4(HR)3

CAT-2 Retreatment Cases- Relapse,Failure & Treatment after Default Cases. Regimen-2/3(SHERZ)3 5(HRE)

CAT-3 New Pulm Smear Neg T.B.Cases, New less Serious forms of Exrta Pulm T.B.Cases Reg.-2(HRZ)3 4(HR)

Directly Observed Treatment(DOTS) Why ? An observer watches and helps the patient swallow the tablets. Direct Observation ensures treatment for the entire course

IS THE TREATMENT OF The right Drugs In the right Doses & At the right interval

Ensure that:- 1.Treatment Observer must be accesible & acceptable to the Patient and accountable to the Health System 2.Observation is a service to the patients & providers

DOTS gives the desired results even when:- 1.Many patients do not take medicines regularly, even if excellent Health education is provided. 2.Impossible to predict which patient will take medicines

. Why is it necessary to Directly Observe the Treatment ? 1.At least 1/3 of patients receiving self administered treatment do not adhere to treatment. 2.Impossible to predict which patients will take medicines. 3.DOT necessary at least in the initial phase of treament to ensure adherence and achieve Sputum smear conversion. 4.A T.B. patient missing one attendance can be traced immediately and counseled.

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