CURRENT RECOMMENDATIONS OF RNTC PROGRAM IN INDIA IN PULMONARY TUBERCULOSIS
A Post Graduate question in COMMUNITY MEDICINE – AND MICROBIOLOGY
Question - Describe the RNTC program in India its limitations and what are current recommendations?
It was a gold standard yesteryears, and the RNTC and DOTS were dependent on sputum smear examination by ZN methods and Florescent methods, Sputum microscopy for acid-fast bacilli (AFB) is the most appropriate method for case-finding in a tuberculosis (TB) control Programme. It is usually carried out by general technicians, often after minimal training. Quality control of their results therefore seems indispensable Several studies have shown that three serial sputum smear examination is ideal for diagnosis of pulmonary tuberculosis cases. AFB testing may be used to detect several different types of acid-fast bacilli, but it is most commonly used to identify an active tuberculosis (TB) infection caused by the most medically important AFB, Mycobacterium tuberculosis. Much of the RNTC program assumes the AFB are Mycobacterium proving it be sensitive but not specific in diagnosis of Tuberculosis
HOW THE SMEARS DONE - An AFB smear is used as a rapid test to detect mycobacteria that may be causing an infection such as tuberculosis. The sample is spread thinly onto a glass slide, treated with a special stain, and examined under a microscope for "acid-fast" bacteria. This is a relatively quick way to determine if an infection may be due to one of the mycobacteria, such as M. tuberculosis. AFB smears can provide presumptive results within a few hours and are valuable in helping to make decisions about treatment while culture results are pending. However, this rapid test is less sensitive than culture to diagnosis a mycobacterial infection.
The objectives of RNTPCP were to achieve at least 85% cure rate among the new smear-positive cases initiated on treatment and thereafter a case detection rate of at least 70% of such cases. The major addition of RNTCP was the establishment of a sub-district supervisory unit known as TB Unit, with RNTCP supervisor and decentralization of diagnostic and treatment services with treatment given under the support of DOT provider (DP).
Advantages:
Microscopy of sputum smears is simple and inexpensive, quickly detecting infectious cases of pulmonary TB; Sputum specimens from patients with pulmonary TB – especially those with cavitary disease – often contain sufficiently large numbers of acid-fast bacilli to be readily detected by microscopy.
Disadvantages: Direct smear microscopy is relatively insensitive as at least 5,000 bacilli per milliliter of sputum are required for direct microscopy to be positive.
Smear sensitivity is further reduced in patients with extra-pulmonary TB, those with HIV-co-infection, and those with disease due to non tuberculous mycobacteria (NTM).
The modalities of the National programs are changing as simple examination for AFB detection becoming obsolete for a variety of reasons as few
Limitations: Microscopy for acid-fast bacilli (AFB) cannot distinguish
Mycobacterium tuberculosis from NTM,
Viable from non-viable organisms,
Drug-susceptible from drug-resistant strains.
CHANGING ROLE OF RNTPCP 2016- 2017
Diagnostic algorithm of pulmonary TB has been completely changed from the previous guidelines
All presumptive TB will undergo sputum smear examination (spot–early morning or spot–spot). If the first sputum is positive and not at risk for DRTB, it is categorized as micro biologically confirmed TB
Smear-positive and presumptive multi-drug resistance TB (MDR TB): A Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) will be performed to rule out Rifampicin resistance and categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
If the first smear is negative and chest X-ray (CXR) is suggestive of TB, 2nd sample will be subjected to smear and CBNAAT simultaneously
Based on the CBNAAT result, patients will be categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
A RIF indeterminate result will get an additional CBNAAT to get a valid result and in case of indeterminate on second occasion, the specimen will be sent to the Intermediate Reference Laboratory (IRL) or Culture and Drug Sensitivity Test (C and DST) Center for Line Probe Assay (LPA) or Liquid Culture and Drug Sensitivity Test (LC and DST)
Whenever facilities are available, effort should be made to obtain DST results of all drugs
If both the sputum smear and CXR are negative, the patient should be referred to a pulmonologist
All key population (PLHIV, children, EPTB, etc.) will preferentially get a CBNAAT
All diagnostic health care facilities should have TB lab that are quality assured by competent authority.
Ref Advantage, Disadvantage and limitations of Microscopy to detect Acid Fast Bacilli (AFB)No ratings yet. DECEMBER 6, 2013 BY TANKESHWAR ACHARYAIN BACTERIOLOGY · Microbes online
Post graduates should refer the following article in detail
2 Recent changes in technical and operational guidelines for tuberculosis control Programme in India - 2016: A paradigm shift in tuberculosis control Arunabha D Chaudhuri JACP EDITORIAL Department of Pulmonary Medicine, R.G. Kar Medical College, Kolkata, West Bengal, India [cited 2017 May 6];5:1-9
3 Revised National Tuberculosis Control Programme National Strategic Plan for Tuberculosis Control 2012–2017
Program is created for the benefit of Postgraduates in Medicine and Diagnostic services
Dr.T.V.Rao MD created as on line resource for developing countries, and PANAFRICAN RESOURCES
A Post Graduate question in COMMUNITY MEDICINE – AND MICROBIOLOGY
Question - Describe the RNTC program in India its limitations and what are current recommendations?
It was a gold standard yesteryears, and the RNTC and DOTS were dependent on sputum smear examination by ZN methods and Florescent methods, Sputum microscopy for acid-fast bacilli (AFB) is the most appropriate method for case-finding in a tuberculosis (TB) control Programme. It is usually carried out by general technicians, often after minimal training. Quality control of their results therefore seems indispensable Several studies have shown that three serial sputum smear examination is ideal for diagnosis of pulmonary tuberculosis cases. AFB testing may be used to detect several different types of acid-fast bacilli, but it is most commonly used to identify an active tuberculosis (TB) infection caused by the most medically important AFB, Mycobacterium tuberculosis. Much of the RNTC program assumes the AFB are Mycobacterium proving it be sensitive but not specific in diagnosis of Tuberculosis
HOW THE SMEARS DONE - An AFB smear is used as a rapid test to detect mycobacteria that may be causing an infection such as tuberculosis. The sample is spread thinly onto a glass slide, treated with a special stain, and examined under a microscope for "acid-fast" bacteria. This is a relatively quick way to determine if an infection may be due to one of the mycobacteria, such as M. tuberculosis. AFB smears can provide presumptive results within a few hours and are valuable in helping to make decisions about treatment while culture results are pending. However, this rapid test is less sensitive than culture to diagnosis a mycobacterial infection.
The objectives of RNTPCP were to achieve at least 85% cure rate among the new smear-positive cases initiated on treatment and thereafter a case detection rate of at least 70% of such cases. The major addition of RNTCP was the establishment of a sub-district supervisory unit known as TB Unit, with RNTCP supervisor and decentralization of diagnostic and treatment services with treatment given under the support of DOT provider (DP).
Advantages:
Microscopy of sputum smears is simple and inexpensive, quickly detecting infectious cases of pulmonary TB; Sputum specimens from patients with pulmonary TB – especially those with cavitary disease – often contain sufficiently large numbers of acid-fast bacilli to be readily detected by microscopy.
Disadvantages: Direct smear microscopy is relatively insensitive as at least 5,000 bacilli per milliliter of sputum are required for direct microscopy to be positive.
Smear sensitivity is further reduced in patients with extra-pulmonary TB, those with HIV-co-infection, and those with disease due to non tuberculous mycobacteria (NTM).
The modalities of the National programs are changing as simple examination for AFB detection becoming obsolete for a variety of reasons as few
Limitations: Microscopy for acid-fast bacilli (AFB) cannot distinguish
Mycobacterium tuberculosis from NTM,
Viable from non-viable organisms,
Drug-susceptible from drug-resistant strains.
CHANGING ROLE OF RNTPCP 2016- 2017
Diagnostic algorithm of pulmonary TB has been completely changed from the previous guidelines
All presumptive TB will undergo sputum smear examination (spot–early morning or spot–spot). If the first sputum is positive and not at risk for DRTB, it is categorized as micro biologically confirmed TB
Smear-positive and presumptive multi-drug resistance TB (MDR TB): A Cartridge-Based Nucleic Acid Amplification Test (CBNAAT) will be performed to rule out Rifampicin resistance and categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
If the first smear is negative and chest X-ray (CXR) is suggestive of TB, 2nd sample will be subjected to smear and CBNAAT simultaneously
Based on the CBNAAT result, patients will be categorized as micro biologically confirmed drug-sensitive TB or RIF-resistant TB
A RIF indeterminate result will get an additional CBNAAT to get a valid result and in case of indeterminate on second occasion, the specimen will be sent to the Intermediate Reference Laboratory (IRL) or Culture and Drug Sensitivity Test (C and DST) Center for Line Probe Assay (LPA) or Liquid Culture and Drug Sensitivity Test (LC and DST)
Whenever facilities are available, effort should be made to obtain DST results of all drugs
If both the sputum smear and CXR are negative, the patient should be referred to a pulmonologist
All key population (PLHIV, children, EPTB, etc.) will preferentially get a CBNAAT
All diagnostic health care facilities should have TB lab that are quality assured by competent authority.
Ref Advantage, Disadvantage and limitations of Microscopy to detect Acid Fast Bacilli (AFB)No ratings yet. DECEMBER 6, 2013 BY TANKESHWAR ACHARYAIN BACTERIOLOGY · Microbes online
Post graduates should refer the following article in detail
2 Recent changes in technical and operational guidelines for tuberculosis control Programme in India - 2016: A paradigm shift in tuberculosis control Arunabha D Chaudhuri JACP EDITORIAL Department of Pulmonary Medicine, R.G. Kar Medical College, Kolkata, West Bengal, India [cited 2017 May 6];5:1-9
3 Revised National Tuberculosis Control Programme National Strategic Plan for Tuberculosis Control 2012–2017
Program is created for the benefit of Postgraduates in Medicine and Diagnostic services
Dr.T.V.Rao MD created as on line resource for developing countries, and PANAFRICAN RESOURCES
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