Services to Common People

1) Free diagnosis of tuberculosis through sputum microscopy.
2) Treatment is directly observed by Directly Observed Treatment (DOT) provider.
3) Treatment on tuberculosis is available free.

Programmatic Management of Drug Resistance TB ( DOTS PLUS PROGRAMME)  in Maharashtra

EPIDEMIOLOGY
            As per the estimates from the state, representative drug resistance surveillance (DRS) the prevalence of MDR – TB in New Smear Positive Pulmonary TB (PTB) cases <= 3% and 12% to 17% amongst smear positive previously treated PTB cases.

DEFINITION
            MDR TB is defined as resistance to Isoniazid and Rifampicin, with or without resistance to other anti TB drugs.

PREVENTION OF MDR-TB
The use of inadequate regimen and the absence of inappropriate application, of Directly Observed Treatment can lead to the development of drug resistance and potentially to an increase in drug resistance levels amongst the community. The implementation of a good quality DOTS programme will prevent the emergency of MDR- TB in the community, therefore the highest priority is to further improve the quality and reach of DOTS services in the state. For this all health care providers managing TB patients need to be linked to RNTCP and operational challenges in implementing DOTS needs to be addressed. The proportion of TB patients being treated outside the DOTS strategy needs to be minimized. The international standards of TB care need to be used by RNTCP and professional medical associations as a tool to improve TB care in the state. The fluoroquinolone group of drugs are not as yet recognized, or recommended, as first line anti TB drugs, and their use should be restricted only to the treatment and confirmed MDR-TB cases.

MANAGEMENT OF MDR-TB
MDR-TB management to be preferably undertaken only at selected health institution with expertise and availability of required diagnostic and treatment facilities.

Dignosis of MDR-TB

Drug resistance may be suspected in the following TB cases

Cat – I failure

Cat – II failure

Sputum positive contact of MDR – TB patient.

For patients in whom drug resistance is suspected, diagnosis of MDR-TB is through culture and drug susceptibility testing from a quality assured laboratory

Treatment regimen –

All relevant investigations to be performed prior to treatment initiation

Preferably the standardized regimen is recommended in the national DOTS PLUS guidelines should be used. [ 6(9) Km, Lfx, Eto, Cs, Z, E/18, Lfx, Eto, Cs, E](*)

Duartion of treatment

At least 6 months of Intensive Phase (IP) is given, extended up to 9 months in patients who have a positive culture result taken at 4 th month of treatment.

Minimum 18 months of Continuation Phase (CP) is given following  the Intensive Phase.

Follow up schedule

Smear examination is conducted monthly during IP  and quarterly during CP

Culture examination is done at least 4, 6, 12, 18 & 24 months of treatment

Relevant  additional investigations are performed  as indicated.

Treatment adherence & support

(*) Km=Kanamycin, Lfx = Levofloxacin, Eto= Ethionamide, Cs= Cycloserine ,Z= Pyrazinamide, E= Ethambutol

All patients initiated on treatment and their family members are intensively counseled prior to treatment initiation and during all follow up visits.

To reduce the risk of development of resistance to second line Anti TB drugs and promote optimal treatment outcomes, all efforts are made to administer treatment under direct observation ( DOT) over the entire course of treatment .

A systematic record of treatment regimen ,doses, duration, side- effects, investigation results and treatment outcome for all patients initiated on second line treatment is maintained at the DOTS  PLUS Sites.