IMA End TB Initiative: 10 points what every doctor should know about TB

IMA End TB Initiative: 10 points what every doctor should know about TB

Dr KK Aggarwal

1.    Tuberculosis is a public health emergency in view of the rising number of cases of MDR (Multi-Drug-Resistant) and XDR (Extensively-Drug-Resistant)TB, especially in Delhi and Mumbai.

2.    The prevalence of MDR TB is more than 2% in primary TB cases.

3.    Every sputum should be tested with GeneXpert test. It not only diagnoses the presence of TB, but also detects rifampicin resistance. No treatment should be started without first confirming rifampicin resistance. Rifampicin resistance indicates primary MDR TB.

4.    Treatment for MDR TB should be taken for the required 2 years to prevent conversion from MDR TB to XDR TB. Treatment of MDR TB in India is available free of cost. 

5.    All doctors/health establishments should register themselves with Nikshay, the online tool for monitoring of TB patients developed by the Central TB Division, Ministry of Health & Family Welfare (https://nikshay.gov.in/HFUSER/HFLogin.aspx). If you register with Nikshay, you can get free medicines for your TB patients.

6.    Every patient of TB has to be notified as required by the MCI Code of Medical Ethics under Regulations 5.2 and 7.14. Not doing so is professional misconduct.

“5.2 Public and Community Health: Physicians, especially those engaged in public health work, should enlighten the public concerning quarantine regulations and measures for the prevention of epidemic and communicable diseases. At all times the physician should notify the constituted public health authorities of every case of communicable disease under his care, in accordance with the laws, rules and regulations of the health authorities. When an epidemic occurs a physician should not abandon his duty for fear of contracting the disease himself.”

“7.14 The registered medical practitioner shall not disclose the secrets of a patient that have been learnt in the exercise of his / her profession except –

·         in a court of law under orders of the Presiding Judge;

·         in circumstances where there is a serious and identified risk to a specific person and / or community; and

·         notifiable diseases.

In case of communicable / notifiable diseases, concerned public health authorities should be informed immediately.”

7.    In sputum-positive cases, re-test sputum with GeneXpert test after 2 months of treatment to assess response and screen for drug-resistant TB.

8.    “Lekin TB Kis se hua?” Trace contacts of your patients with infectious TB and screen them for latent TB infection. Put them on full course of anti-tuberculosis treatment (ATT), if required. This will prevent further spread of TB, including MDR TB.

9.    Fixed-dose combination (FDC) drugs are now available for drug-sensitive TB. Treatment has to be as per body weight of the patient.

10. Preferably get a 6-month course of ATT at one time, so that the patient knows he/she has to take treatment for at least this duration of time.

GTN: IMA TB Initiative

GTN: IMA TB Initiative New WHO report highlights TB as a global priority for research and development A recently released new report from the World Health Organization (WHO) “Antibacterial Agents in Clinical Development An analysis of the antibacterial clinical development pipeline, including tuberculosis” portrays a grim scenario by highlighting the lack of new antibiotics under development to combat the growing threat of antimicrobial resistance, which has emerged as a serious global public health concern. Along with other priority antibiotic-resistant pathogens and Clostridium difficile, the report also focuses on Tuberculosis (TB) as a global priority for research and development. It draws attention to the fact that only seven new agents for TB are currently in clinical trials. Of these, four are in phase-1, and only one compound is in phase-3. This means that physicians have limited or no options for multidrug-resistant Mycobacterium tuberculosis (MDR-TB), particularly extensively drug-resistant M. tuberculosis (XDR-TB). Perhaps, in acknowledgement of this lack of therapeutic options, the Report also says, “This is especially problematic because treatment of TB infections requires a combination of at least three antibiotics. Novel treatment regimens of short duration that are assembling non-toxic drugs are desperately needed.” The seven agents being developed specifically for treatment of TB include pretomanid (nitroimidazole), delpazolid (oxazolidinone), SQ-109 (diamine), GSK-3036656 (Leu RS inhibitor[oxaborole]), Q-203 (imidazopyridine amide), PBTZ-169 (DprE1 inhibitor [benzothiazinone]) and OPC-167832 (DPrEq inhibitor). Only two new antibiotics for treatment of MDR-TB, bedaquiline and delamanid, have reached the market in more than seven decades. Bedaquiline has been introduced in India under Conditional Access Programme (CAP) to as treatment for MDR-TB as part of RNTCP at six identified tertiary centers. India has highest burden of both TB and MDR TB in the world. According to the Global Tuberculosis Report 2016, six countries, including India accounted for 60% of the new cases of TB in the world. The number of new tuberculosis cases in a year went up to 2.8 million in 2015. Along with China and the Russian Federation, India accounted for 45% of the combined total of 580,000 cases of MDR-TB globally, including rifampicin-resistant TB (RR-TB). About 1.3 lakh incident MDR-TB cases occur annually in India (TB India 2017 Report). TB is therefore a national public health emergency in India. Given the lack of innovative treatment options, as highlighted in the latest WHO report, there is a need for a concerted effort from all stakeholders including health care providers and policy makers, to check the emergence and spread of MDR-TB. Inaccurate diagnosis and/or delayed diagnosis, especially detection of latent TB (infected but asymptomatic patients) and incomplete treatment are factors propagating the epidemic of MDR TB in the country. Control of infection by timely diagnosis and treatment will prevent further transmission of TB. This is why, Indian Medical Association (IMA) has launched a campaign “IMA TB Initiative: GTN” to control this preventable and curable disease, where G stands for diagnosis of TB using GeneXpert test, T is for tracing the contacts and treating them and N stands for Notifying (mandatory) TB patients. All of us should actively support this initiative. Because, it is only through a united and collaborative effort that this public health threat can be controlled.

IMA TB Initiative: DTR-C

IMA TB Initiative: DTR-C Tuberculosis (TB) is a major public health concern in the country. Despite advances in TB care, the disease continues to be a major cause of morbidity and mortality. And, it takes a heavy toll on the economy too. Emergence and spread of drug-resistant TB has become a major public health concern now. India accounts for one fourth of the global TB burden, both TB and MDR TB, as reported in Global TB Report 2016. Every year, about 1.3 lakh incident multi-drug resistant (MDR) TB cases occur in India, including 79000 MDR-TB cases among the notified pulmonary cases (TB India 2017 Report). The incidence of primary MDR TB may be higher in selected states like Maharashtra. To prevent the epidemic of MDR TB, it should be declared a public health emergency. Multidrug resistant (MDR) TB is TB resistant to both isoniazid and rifampicin with or without resistance to other first-line anti-TB drugs. Extensive drug resistant (XDR) TB is TB resistant also to a fluoroquinolone (ofloxacin, levofloxacin or moxifloxacin) and a second-line injectable anti TB drug (kanamycin, amikacin or capreomycin). Early and complete treatment is important to prevent emergence of drug-resistant cases. This year, there has been a shift in policy under the government’s Revised National TB Control Programme (RNTCP) from the “intermittent thrice weekly” regimen to a “daily fixed-dose combination (FDC) drugs” regimen for drug-sensitive TB to improve patient compliance to treatment, prevent relapse and minimize chances of developing drug resistance. All cases of TB, whether in the public and private health care sector, should uniformly adopt and follow these standards. Bedaquiline, a new anti-TB drug to be used in the treatment of MDR-TB and XDR-TB was added to the RNTCP, at six identified tertiary care centres across India. Reporting is important to trace contacts of the person with infectious TB. All contacts of the patient should be screened for TB and put on treatment if required. This cascade of screening of contacts, at home and workplace, identifies individuals at risk and prevents further spread of TB, including MDR TB. All GPs should focus on tracing the contacts of their TB patients and screen them for latent TB infection. Accurate diagnosis is important in this endeavor. The rapid diagnostic molecular sputum GeneXpert test should be used to diagnosing TB including drug-resistant TB. Contact tracing increases community awareness about the disease. Contact tracing interrupts the chain of transmission of the disease by early diagnosis of cases as well as timely and complete treatment. Early diagnosis and complete treatment is important to prevent and control TB. To address the problem of rising drug resistance, TB is a notifiable disease. It was declared a notifiable disease in 2012. Every case of TB has to be notified to the local authorities. The approach to all notifiable diseases should therefore be based on DTR “Diagnose, Treat & Report”. • Diagnose early, using sputum GeneXpert test • Treat: Complete and effective treatment based on national guidelines, using FDC • Report: Mandatory reporting The Indian Medical Association (IMA) is launching a new campaign “IMA-TB Initiative: DTR-C” i.e. Diagnose, Treat, Report to track Contacts. IMA requests all its members to actively participate and support this initiative. It is only through a united and concerted effort that this public health menace can be controlled.