DIAGNOSIS AND MANAGEMENT OF TUBERCULOSIS IN INDIA - CURRENT SCENARIO

Introduction

Tuberculosis (TB) is a common infectious disease in India. There are approximately world-wide 9 million new cases occurring and 3 million people die from TB annually. Of this, India accounts for one-third of the global TB burden. In India, there are about 14 million suspected and about 35 million bacteriologically proven cases of pulmonary tuberculosis (PTB) with a prevalence rate of 4.84/1000 population. TB kills more people in India than HIV, STD, malaria, leprosy and tropical diseases. 

Clinical presentation 

Main clinical features of TB are 

  1. Cough and expectoration lasting for more than two weeks. 

  2. Intermittent fever with evening rise in temperature/sweating for over two weeks. 

  3. Loss of weight and appetite 

  4. Haemoptysis

Supportive clinical features include Pleuritic - Chest pain, chronic fatigue, cognitive impairment, anorexia, or unexplained low-grade fever 

 Diagnosis

Approximately 80% of TB patients manifest primarily lung involvement, though TB can involve almost any organ in the body. Tuberculin skin test (Mantoux test) remains the diagnostic intervention of choice in children. However, due to prior BCG usage and waning of immunity, it is of limited utility in the diagnosis of active infection in the elderly and should not be used as proof of disease for treatment. Similarly, Interferon Gamma Release Assay (IGRA) tests like ‘Quantiferon Gold’ should not be used exclusively for diagnosis as it cannot differentiate between old and active TB.

Sputum smear examination and AFB culture for M. tuberculosis remains the cornerstone of diagnosis and should be done in all patients. All serological tests for tuberculosis are banned in India and should not be used to diagnose or treat tuberculosis. Rapid molecular tests such as CBNAAT (GeneXpert TB) and Line Probe Assay are especially important in the high-risk population such as HIV-infected and MDR-TB. 

A more aggressive diagnostic intervention like flexible fiberoptic bronchoscopy should be reserved only for patients who are unable to expectorate sputum; in some cases, endobronchial ultrasound may be required to sample mediastinal lymph nodes. Histologic examination of tissue from various other sites, such as the liver, lymph nodes, bone marrow, pleura, and synovium, reveal characteristic tissue reaction. 

 Notification: As GOI has declared TB to be a notifiable disease, every healthcare provider including clinical establishments run or managed by Government, private or NGO sectors and/or individual practitioners should report about all TB patients at least on a monthly basis (on diagnosis or initiation of anti-TB treatment). The prescribed format / online notification procedure is available through the website (http://tbcindia.nic.in/), by email (tbnotification@tbcindia.nic.in) or NIKSHAY mobile app

 Treatment

As per RNTCP guidelines, all new TB patients in India should receive the WHO-approved first-line treatment regimen. It includes an initial intensive phase of 2 months of Isoniazid (H), Rifampicin (R), Pyrazinamide (Z) and Ethambutol (E). The continuation phase should consist of 3 drugs [H, R and E], given for another 4 months. This is alternatively written as 2HREZ/4HRE. There is usually no need for an extension of the continuation phase. The amount of drug should be given according to the bodyweight of the patient. All patients should receive their daily TB medicine under direct observation (DOTS).

Under DOTS (Directly Observed Therapy Short Term) the patient has to take the TB medication in front of a DOTS agent who is usually a volunteer from the patient’s community and maybe a family member. Wherever possible, fixed-dose combinations (FDC) of 4 drugs (RHZE), 3 drugs (RHE) and 2 drugs (HR) should be available. FDC are helpful as they simplify getting TB drugs and the delivery of DOTS and this may increase adherence. The response to therapy in patients with pulmonary TB, both new and retreatment patients, should be monitored. This should be done by follow-up sputum microscopy/culture (one specimen) at the time of completion of the intensive phase of treatment and at the end of treatment.

Dr Puneet Khanna

Head- Department of Respiratory Medicine

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