Authors: Kavita Ayyagari, MA and Jamhoih Tonsing, MBBS, DPM, MSc—Authors
Number of pages: 2
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Overview: The Call to Action for a TB-Free India echoes WHO’s ‘End TB Strategy’ and calls for the country to intensify TB care and prevention efforts to end TB in India. The vision of the End TB Strategy is A World free of TB: Zero TB deaths, Zero TB disease, and Zero TB suffering.
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Authors: Indira Behara, MBBS, MPH; Karishma Saran, MSc; Aasit G. Nanavati, MPH; Deepti Chavan Musale, Patient Advocate—Authors
Number of pages: 4
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Overview: Persons affected by tuberculosis and their family members should be counselled at every opportunity, to address information gaps and to enable informed decision-making. Counselling should also address issues such as healthcare, physical, financial, psycho-social and nutritional needs. The objective of counselling is to meet the needs and ensure the rights of the patient. The objective is also to support the patient where possible to overcome barriers to successful treatment. During counselling, patients need to be informed about TB, how the disease spreads, signs and symptoms, consequences of not following treatment guidelines, why treatment is long and why completion of treatment is critical, likely adverse events during therapy, and cost involved in treatment and what free/public services are available to patients. Patients need to be told that TB is a fully curable and treatable disease. We must use patient centred approaches, and recognize that all TB patients deserve a minimum package of holistic TB care services that are not restricted to diagnosis and pharmacological treatment, but include counselling and support services as well.
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Authors: Srinath Satyanarayana, MD—co-author; Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 3
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Overview: Indian TB patients get diagnosed after a delay of nearly two months, and are seen by 3 different providers before a diagnosis is made. At the primary care level, patients rarely get investigated for TB, even when they present with classic TB symptoms. Instead, providers give broad-spectrum antibiotics (e.g., fluoroquinolones) and remedies such as cough syrups and steroids. Even when TB is considered likely, private physicians tend to order tests that are non-specific, such as complete blood count, ESR, Mantoux test, and chest X-rays. They rarely seek microbiological confirmation via sputum smear microscopy, culture or polymerase chain reaction tests. Even if the diagnostic hurdle is overcome, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug regimens that are not recommended by WHO or the International Standards of TB Care. Furthermore, private practitioners often fail to ensure treatment completion, and provide adherence support to their patients. This article discusses the 10 most common pitfalls that doctors should avoid. Addressing these pitfalls should great improve the quality of TB care in India.
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Authors: Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 3
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Overview: GPs frequently see children in their clinical practice, and should be alert to the possibility of pediatric TB, especially in malnourished children. Children with TB often present with vague, non-specific symptoms, and this makes it hard to suspect and diagnose TB. Symptoms could include chronic fever, cough, weight loss, fatigue, loss of appetite, failure to gain weight, and lymph node enlargement. History of contact with an adult with TB is therefore a very important component of history that should be elicited. There is no adequate gold standard test for childhood TB, and diagnosis requires multiple tests. Smears for acid-fast bacilli (AFB) are often negative because of the low numbers of AFB in childhood TB. Therefore, liquid culture and molecular tests (Xpert MTB/RIF) will be most helpful, along with signs, symptoms, chest radiology, evidence of TB infection (e.g. positive Mantoux skin test), and history of contact with active TB. All children who have not been treated previously and do not have other risk factors for drug resistance should receive a WHO-approved first-line treatment regimen for a total of 6 months. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide and ethambutol. The continuation phase should consist of isoniazid and rifampicin given for 4 months. Daily treatment is preferable to intermittent therapy. Drug dosages are calculated according to weight (not age). Adherence to the full course of anti-TB therapy is very important to ensure high cure rates. In general, children tolerate first-line anti-TB therapy very well with low risk of toxicity.
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Authors: Sujeet Rajan, MD—co-author
Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 5
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Overview: Drug-resistant TB (DR-TB) is a serious and growing threat in India, especially in urban areas such as Mumbai. Multidrug-resistant TB (MDR-TB) is resistance to two of the most important first-line anti-TB drugs – isoniazid and rifampicin. Some patients develop more severe forms of DR-TB. Extensively drug-resistant TB (XDR-TB) is resistance to isoniazid and rifampicin, plus any fluoroquinolone, and at least one of 3 injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). DR-TB occurs when patients fail to complete first-line drug therapy, have relapse, or newly acquire it from another person with DR-TB. If patients have any risk factors for drug-resistance, or live in a high MDR-TB prevalence area (e.g., Mumbai city), or do not respond to standard drug therapy, they must be investigated for MDR-TB using drug-susceptibility tests (DST) like GeneXpert, line probe assays, and liquid cultures. MDR-TB requires long-term and specialized treatment. So, patients should be referred to specialists, either in the private sector, or in the public sector where free MDR treatment is available. This Q&A covers commonly asked questions by the primary care doctor about identification and referral of patients with suspected or confirmed DR-TB.
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Authors: Faiz Ahmad Khan, MD, MPH—co-author
Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 6
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Overview: Tuberculosis (TB) is the leading cause of morbidity and mortality in people living with HIV (PLWH). The epidemiologic link between HIV and TB is strong even in a low HIV prevalence country such as India
– hence all Indian physicians that see patients with suspected or confirmed TB should understand how to approach TB diagnosis and treatment among PLWH, even if they are not working in a community where HIV infection is common. This article provides general practitioners with a concise and practical overview of TB screening, prevention, diagnosis and treatment, in PLWH.
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Management of HIV and Tuberculosis: What Every GP Should Know
Authors: Madhukar Pai, MD, PhD—Author and Series Editor; Camila Rodrigues, MD—co-author
Number of pages: 4
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Overview: Most individuals who get exposed to Mycobacterium tuberculosis (MTB) manage to eliminate or contain the infection using host T-cell immune defenses. However, some MTB bacilli may remain viable (latent) and “reactivate” later to cause active TB disease. This state is called Latent TB Infection (LTBI). Identification and treatment (i.e. preventive therapy or prophylaxis) of LTBI can substantially reduce the risk of development of active disease (by as much as 60%). However, because 40% of Indians are latently infected, LTBI screening must be restricted to specific high risk populations in India, where the benefits of LTBI treatment outweigh any risks. These include people living with HIV, adult and child contacts of pulmonary TB cases, patients initiating anti-tumour necrosis factor (TNF-alpha) treatment, patients with end stage renal failure on dialysis, patients preparing for organ or haematologic transplantation, and patients with silicosis. While either tuberculin skin test (Mantoux) or interferon-gamma release assays (e.g., TB Gold) can be used for LTBI screening, it is important to make sure that these tests are not used for active TB diagnosis. For persons with symptoms or abnormal chest x-rays, physicians should order smears, cultures, and molecular tests (e.g., Xpert MTB/RIF). If LTBI is diagnosed, then physicians must rule-out TB disease with chest x-rays before starting one of the recommended drug regimens. It is important to ensure adherence, and provide adequate counseling to ensure that patients do not stop therapy prematurely.
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Management of Latent Tuberculosis Infection
Authors: Ruvandhi Nathavitharana, MD, MPH—Author; Madhukar Pai, MD, PhD—co-author and Series Editor
Number of pages: 6
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Overview: Clinical presentations of extrapulmonary TB (EPTB) is diverse, leading to missed cases and delayed diagnoses. Since the diagnosis of EPTB is often compromised by the paucibacillary nature of the disease, new diagnostic tools and policies have been eagerly awaited. At long last, new tools, and new policies are here. The International Standards for TB Care (ISTC) recommends that all patients, including children, who are suspected of having EPTB, should have appropriate specimens obtained from the suspected sites of involvement for microbiological and histological exam. The World Health Organization (WHO) has endorsed the use of Xpert MTB/RIF assay (Cepheid Inc., Sunnyvale, California), a cartridge based nucleic acid amplification test (NAAT), for EPTB. Xpert MTB/RIF is now considered a central test in the work-up of EPTB, and should be used along with existing tools such as microscopy, liquid cultures (which are the most sensitive technologies for MTB detection), and histopathology (biopsy) to arrive at the final diagnosis. Xpert is particularly useful in cerebrospinal fluid samples and in lymph node and other tissues. Once diagnosed, EPTB must be treated with standardized treatment regimens, as recommended by ISTC.
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Extrapulmonary Tuberculosis: New Diagnostics and New Policies
Authors: Lancelot M. Pinto, MD, MSc—Author; Madhukar Pai, MD, PhD—co-author and Series Editor
Number of pages: 4
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Overview: Nearly 50% of patients with TB in India are treated in the private sector. GPs therefore share the responsibility of TB control in India, and play a major role in preventing the spread of the disease by curing patients and arresting transmission. Every GP will need to consider TB as a differential diagnosis in persons with cough lasting two weeks or more, or with abnormal findings on chest radiography. In such patients, TB must first be microbiologically confirmed, either using sputum smear microscopy, Xpert MTB/RIF (i.e., GeneXpert), or liquid cultures. Once TB is confirmed, the next step is to begin the correct anti-tuberculosis therapy (ATT) regimen, as recommended by Standards for TB Care in India (STCI) and the International Standards for TB Care (ISTC). All patients who have not been treated previously and do not have other risk factors for drug resistance should receive a WHO-approved first-line treatment regimen for a total of 6 months. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide and ethambutol. The continuation phase should consist of isoniazid and rifampicin given for 4 months (ethambutol can also be added to the continuation phase in areas with high levels of isoniazid resistance). Treatment can be given daily or as thrice-weekly intermittent dosing. Adherence to the full course of ATT is very important to ensure high cure rates and to prevent the emergence of drug-resistance. If patients have any risk factors for drug-resistance, or do not respond to standard ATT, they must be investigated for MDR-TB using drug-susceptibility tests (DST) like GeneXpert, line probe assays, and liquid cultures. MDR-TB requires long-term and specialized treatment. So, patients should be referred to chest specialists, either in the private sector, or in the public sector where free MDR treatment is available.
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Treatment of Pulmonary Tuberculosis: What Every GP Should Know
Authors: Madhukar Pai, MD, PhD—Author and Series Editor
Number of pages: 5
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Overview: This article describes the Initiative for Promoting Affordable, Quality TB tests (IPAQT; www.ipaqt.org), a coalition of private laboratories in India, supported by industry and non-profit groups, that has made several WHO-endorsed TB tests available at more affordable prices to patients in the private sector. General practitioner who manage TB should avoid inaccurate blood-based tests and use WHO-endorsed sputum tests for TB, including LED fluorescence smear microscopy, liquid cultures, line probe assays, and automated, cartridge-based molecular tests (i.e., Xpert MTB/RIF). These tests are validated and backed by strong evidence and WHO policy recommendations. Thanks to IPAQT, their prices have been reduced considerably in the Indian private sector.
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