Transcription of National Tuberculosis Management Guidelines
1 National Tuberculosis Management GuidelinesGovernment of Nepal Ministry of Health and Population Department of Health Services National Tuberculosis Centre Thimi, BhaktapurENDTB2019iiNATIONAL Tuberculosis Management Guidelines 2019 TABLE OF CONTENTS 1. INTRODUCTION AND INFORMATION ON THE National TB PROGRAM 12. BACKGROUND ON Tuberculosis BURDEN 93. GENERAL INFORMATION ABOUT Tuberculosis 114. Tuberculosis CLASSIFICATION AND DEFINITIONS 155. Tuberculosis CASE DETECTION AND diagnosis 186. TREATMENT OF Tuberculosis 337. diagnosis AND TREATMENT OF Tuberculosis IN CHILDREN 528. DRUG RESISTANT /MDR TB Management 759. TB INFECTION CONTROL 7810. Tuberculosis AND HIV 8311. Tuberculosis AND TOBACCO 8912. Tuberculosis AND DIABETES 9513. Management ASPECTS OF TB CONTROL PROGRAM 9914 MONITORING AND EVALUATION FOR TB CONTROL PROGRAM 101 ANNEXURESA nnex 1a: Procedure for obtaining clinical samples for bacteriological examination 108 Annex 1b: Job Aid for gastric aspiration 112 Annex 2: Recommended treatment regimens and dosages use of fixed dosed combined (FDC) drugs 113 Annex 3a: Guidance for dosing of INH preventive therapy 114 Annex 3b: Recommended Anti -TB drug dosages 114 Annex 4: Flow chart for Management of bacteriologically confirmed cases 115 Annex 5: Triple-layer packaging 116 Annex 6.
2 Recording and reporting forms 117ivNATIONAL Tuberculosis Management Guidelines 2019viNATIONAL Tuberculosis Management Guidelines 2019viiNATIONAL Tuberculosis Management Guidelines 2019 ACKNOWLEDGEMENTThe National TB Centre director (Dr. Sagar Rajbhandari) expresses my sincere gratitude to all the authors and reviewers of this guideline particularly to the World Health Organization and all the others who contributed in coming up with this comprehensive National Tuberculosis (TB) Management Guideline 20191. Dr. Bhim Singh Tinkari, Previous NTC Director2. Dr. Ashesh Dhungana, Chief Consultant Chest Physician, NTC3. Dr. Sharad Kumar Sharma, Chief SMEAR section, NTC4. Mr. Anil Thapa, Previous Chief SMEAR section, NTC 5. Dr. Naveen Prakash Shah, Consultant Chest Physician, NTC6.
3 Mr. Gokarna Raj Ghimire, Laboratory In-charge, NTC7. Mr. Pushpa Raj Joshi, Statistical officer, NTC8. Ms. Basundhara Sharma, Senior Public Health Officer, NTC9. Ms. Meera Hada, Medical Technologist, NTC10. Prof. Dr. Brajendra Srivastav, NAINS College of Medicine11. Dr. Suvesh Kumar Shrestha, Technical Specialist-TB, SCI12. Dr. Ashish Shrestha, National Consultant-TB, WHO13. Dr. Pramod Raj Bhattarai, Damien Foundation14. Dr. Bhawana Shrestha, Project Manager, NATA/GENETUP15. Dr. Praveen Sanker, Laboratory Consultant, SCI-FIND16. Mr. Rajendra Basnet, SCI/NTC17. Mr. Ratna Bahadur Bhattarai, Monitoring and Evaluation Specialist- SCI/NTC18. Mr. Gokul Mishra, Liaison Officer, NTC/LSTM19. Mr. Bhagawan Maharjan, Microbiologist, GENETUP20. Mr. Nilaramba Adhikari, SCI/NTC21. Mr. Lok Raj Joshi, SCI/NTC22. Mr. Naval Kishor Shrestha, SCI/NTC23.
4 Mr. Chitra Jung Shahi, DTLO, NTC24. Mr. Krishna Adhikari, Lab Technician Officer, NTC25. Ms. Kamala Devi Wagle, Public Health Nurse Officer, NTC26. Ms. Tara Sharma, NTC27. Ms. Anju Basnet, NTC28. Mr. Gopi Prasad Rupakheti, Kharidar/Supervisor, NTC29. Dr. Lungten Z. Wangchuk, Scientist, Team -Lead, CDS, WHO, NepalviiiNATIONAL Tuberculosis Management Guidelines 2019ixNATIONAL Tuberculosis Management Guidelines 2019 ABBREVIATIONSAFB Acid-Fast BacillusAM AmikacinAIDS Acquired Immuno-Deficiency SyndromeART Anti-Retroviral TherapyBCG Bacillus Calmette-Guerin (vaccine)BMU Basic Management UnitBMI Body Mass IndexCat Treatment CategoryCNS Central Nervous SystemCPT Cotrimoxazole Preventive Therapy CSS Community System StrengtheningCFR Case Fatality RateCNR Case Notification RateCM CentimetreCXR Chest X-rayCSF Cerebrospinal FluidCM Capreomycin DC Disease ControlDOT Directly Observed TreatmentDOTS Directly Observed Treatment, Short Course, (TB Strategy)
5 DRTB Drug Resistant TuberculosisDPT Diphtheria Preventative Therapy (DPT)DST Drug Susceptible TestDRS Drug Resistant SurveyE EthambutolEQA External Quality Assurance Eto Ethionamide EPTB (EP) Extra-pulmonary Tuberculosis EFV EfavirenzFDC Fixed Dose Combination FEFO First expiring, first outFoDST Fluoroquinolone Drug Susceptible TuberculosisFNA Fine Needle AspirationFNAB Fine Needle Aspiration BiopsyFNAC Fine Needle Aspiration CytologyGA Gastric Aspirate H IsoniazidHC Health CentreHEO Health Extension OfficerHIV Human Immunodeficiency VirusHPF High Power Field ( 100x10 magnification)HMIS Health Management Information SystemHSC Health Sub-CentreHRZE Isoniazid, Rifampicin, Pyrazinamide, EthambutolxNATIONAL Tuberculosis Management Guidelines 2019HR Isoniazid, RifampicinHRZELfx Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, LevofloxacinH&Fq Isoniazid.
6 Fluoroquinolone HCW Health Care WorkerINH IsoniazidIPT Isoniazid Preventive TherapyIDP Internally Displaced PeopleKM Kanamycin LPV/r Lopinavir RitonavirLIP Lymphocytic Interstitial PneumoniaLJ Lowenstein-Jensen MDR Multi-Drug ResistantM & E Monitoring and EvaluationMTB Multi Drug Resistant TuberculosisMTB/RIF Multi Drug Resistant TB/Rifampicin ResistantMAM Moderate Acute MalnutritionMUAC Mid Upper Arm Circumference mg MilligramNTC National Tuberculosis ProgrammeNTP National Tuberculosis ProgrammeNVP Nevirapine NRL National Reference Laboratory NG Nasogastric TubeOfx OfloxacinPMDT Programmatic Management of Drug Resistant TuberculosisPICT Provider Initiated Counselling and TestingPTB Pulmonary TuberculosisPBC TB Pulmonary Bacteriological Confirmed TuberculosisPYZ PyrazinamidePLHIV People Living with HIVPAS Para Amino Salicylic AcidQMRL Quality Management in Reference LaboratoryR/RIF RifampicinRR/MDR Rifampicin Resistant/ Multi Drug ResistantSDG Sustainable Development GoalSAM Severe Acute MalnutritionSL-LPA Second Line- Line Probe Assay SLD Second Line DrugSS-ve Sputum Smear NegativeSS+ve Sputum Smear PositiveSOP Standard Operation ProcedureTB TuberculosisTB/HIV Tuberculosis /Human Immune Virus TBM Tuberculosis MeningitisTWG Technical Working GroupUVGI Ultraviolet Germicidal
7 IrradiationVCT Voluntary Counselling and Testing (for HIV/AIDS) WHO World Health OrganizationW/A Weight for AgeXDRTB Extremely Drug Resistant Tuberculosis Z PyrazinamideINTRODUCTION AND INFORMATION ON THE National TB INTRODUCTIONThis guideline is to provide basic information about TB and its Management to all health workers in Nepal. Early detection, appropriate diagnosis and timely treatment of TB result in good treatment outcomes. Health workers need to be equipped with the right information on the diagnosis and treatment of TB. Poor Management of TB results in death and creates drug resistant (DR) TB which is very hard and costly to treat resulting in often poorer health workers in Nepal regardless of their involvement in TB services should be aware of TB, its transmission and prevention and its diagnosis and Management .
8 Health workers managing TB patients need proper guidance in diagnosis and treatment of TB and it is for this purpose that this guideline is produced. In developing this guideline, the National TB Program takes into consideration the emerging problems of TB/HIV and DR TB as well as other revisions including Latent TB infection made to TB Management by World Health Organization. This guideline is therefore, an update from the 2012 General Manual (Third Edition) and the following are the major changes to TB Management for Nepal: Only 2 sputum samples required for initial diagnosis of TB. Same-day diagnosis of TB by Microscopy (2 samples same day-1 hour apart) Only 1 sputum sample required for follow up examination. Even new presumptive TB cases should have access to GeneXpert diagnosis whereever it is possible Treatment is not extended at the end of the intensive phase, even though the sputum follow up examination result remains positive at the end of two months, continuation phase is commenced regardless of whether the sputum is positive or not.
9 Streptomycin containing Category II regimen for retreatment cases will No Longer be used in Nepal New definitionso TB suspect is changed to Presumptive TBo Previously treated patients definitions have been changed and are based on the outcome of their most recent course of treatment and are independent of bacteriological confirmation or site of The treatment regimen for re-treatment TB cases has been removed. All previously treated TB patients will receive new treatment regimen and will be screened for drug resistant Recording and reporting forms have been edited to suit new definitions and change in the treatment regimenCHAPTER12 National Tuberculosis Management Guidelines National TB STRATEGY ALIGNMENT TO END TB STRATEGY AND THE RESPONSIBILITIES OF TB TEAMS AT DIFFERENT LEVELSWHO s End TB Strategy, developed within the context of the United Nations Sustainable Development Goals (SDGs), is a logical evolution, reflecting a paradigm shift from past global TB strategies.
10 The original WHO DOTS strategy of 1994 created the basis for effective TB control activities by standardizing the requirements for addressing the epidemic. WHO s Stop TB Strategy of 2006 broadened this response by addressing the emerging challenges of HIV- associated TB and MDR-TB. It contributed to improving access to quality TB care by engaging all public and private care providers, and civil society organizations and communities, and it encouraged investment in research to develop better tools and approaches. Ending the TB epidemic is one of the SDG targets that requires the implementation of a mix of biomedical, public health and socioeconomic interventions, often extending beyond the health sector, along with major breakthroughs in research and innovation to accelerate the decline in global TB incidence rates to reach the 2030 and 2035 targets for the End TB Strategy.
