Genitourinary Tuberculosis Ganesh Gopalakrishnan, Sujata Patwardhan
Page numbers followed by f refer to figure, fc refer to flowchart, and t refer to table.
Abdomen 156
plain 52
Abdominal wall, posterior 64f, 118f
developing 113f, 117f
multiple 115f, 116f, 119f
perinephric 56, 64f
perirenal extension of 118f
thick-walled 117f
tuberculous 82f
wall of 113f, 114f
Absolute neutrophils count 23
Acid-fast bacilli 38f, 45, 49
Adherence monitoring system, mobile-based 3
Adnexa, oblique scan of 89f
Airborne infection control 12
Air-filled tract 74
Alanine aminotransferase 23
Amenorrhea 87
Amikacin 22, 47, 94
Aminosalicylic acid 94
Amoxicillin 9, 9f, 22
Anal canal 77f
Anorexia 98, 155
Antegrade nephrostogram 107f
Anti-Koch treatment 47
Antiretroviral therapy 10
Antitubercular therapy 6
Anti-tuberculosis drugs 22t
classes of 21
newer 14, 21
first-line drugs 94t
second-line drugs 94t
Appetite, decreased 114
Ascites 87
Aspartate aminotransferase 23
Asymmetric caliectasis 69f
Augmentation cystoplasty 108
Autonephrectomy 56, 74f
Autopsy 39
Bacillus Calmette-Guérin vaccine 13
Bacterial pyelonephritis, acute 54
Bacteriological monitoring 27
Balloon dilatation 95
Bedaquiline 14, 22, 23, 94
Bladder 99, 102
augmentation 102, 107
MCU-full 135f
MCU-small 156f
capacity 139f, 142f, 180f
contracted 157f
surgery 96
thickened 120f, 157f, 165f
wall of 123f, 132f, 146f
tuberculosis of 41
urine 46
Boari flap 106
Bowel segment 102
Brucellosis 43
Buccal mucosa 108f
Bulbar urethra 120f
Bulbomemberanous junction 169f, 180f
Calcified kidney 95, 183f
Calcium, milk of 67f
Calicorrhaphy 102
Calyceal infundibular stenosis, left superior 149f
lower 69f
mucosal thickening of 64f
thick-walled 122f
Calyectasis, evaluation of 57
focal caliectasis of minor 68f
lower pole 62f
middle 69f
selectively, left upper 162f
Capreomycin 22, 94
Caseating granulomas, multiple 39f
Caseous necrosis 37
large area of 37f
Catholic Bishops’ conference 11
Catholic Church healthcare facilities 11
Cavernotomy 100
Central caseous necrosis 36f, 37
Central tuberculosis division 4
Cerebrospinal fluid 7
Chemotherapy 98
Cilastatin 22
Clarithromycin 9, 94
Clavulanate 22
Clavulanic acid 9
Clofazimine 9, 9f, 22
Complete blood count 92
Computed tomography scan 54
Co-trimoxazole preventive therapy 10
Crohn's disease 102
CT urography 185, 185f, 187f
Cutaneous fistula 167f
Cycloserine 9, 22, 94
Cystectomy 96
Cystoplasty, complications of 108
Delamanid 22
Dense chunky calcification 186f
Dense perinephric adhesions 112
Deoxyribonucleic acid 47
Diabetes 93
mellitus 10, 48
Diethylenetriamine pentaacetate 104
scan 179, 181f, 182
Diffusion-weighted imaging 57
Directly observed treatment short-course 33
strategy 1
Disseminated infection 39
Distorted calyces 131f
Distorted pelvicalyceal system 131f
Distorting calyx 62f
District Tuberculosis Center 4, 19
District Tuberculosis Officer 4
DMSA renogram 134, 140
Dormant bacteria 92
Double J stent 99
diagnostic technology choice 18
tests 17
Drug-resistant tuberculosis 1, 20
center 16
classification of 14, 15
diagnostic algorithm guidelines 2019 20fc
management of 14, 24, 28, 29
programmatic 8, 9, 15, 20
Drug-susceptibility testing 17, 20, 29
methods for 14, 16
Drugs, new grouping of 22
Duodenal repair 112
Duodenum 55
Dystrophic calcifications 75f
Dysuria 186
Ectopia, cross-fused 144f
Eggshell calcification 122f
Ejaculatory ducts 78f, 79f
Endometrial osseous metaplasia 87
Endometrial polyp 87
Endometrial tuberculosis 87
Endometrium 90f, 91f
irregular contour of 87
role of 33
Epididymal cysts, multiple 79f
Epididymal tuberculosis 74
Epididymis 75, 78f, 79f, 84
head of 81f
tail of 81f83f
tuberculosis of 42
tuberculous lesion of tail of 82f
Epithelioid cells 36
Epithelioid granuloma 36, 36f
multiple 43
Epithelioid macrophages 37
Escherichia coli 43, 112
Ethambutol 9, 22, 47, 94
Ethionamide 9, 22, 94
Ethylene dicysteine 104
Extensive drug resistance 6, 15
Extensively drug-resistant tuberculosis, diagnosis of 9
Extrapulmonary tuberculosis, sequelae of 7
Fallopian tube 84, 90f
floating 87
Fibrotic bladder 109f
Fibrous tissue 37
First-line line probe assay 20
Fistulas 55
multiple 166f
persistent 95
rectal opening of 167f
Flank pain, bilateral 185
Fluid distended fallopian tube, thick-walled 90f
Fluid samples 46
Fluoroquinolone 20, 22
Focal calyectasis 147
Focal nodular heterogeneous lesion 83f
Food and Drug Administration 21
Fungal infections 36, 40
Gas-filled fistulous tract 77f
Gatifloxacin 22
GeneXpert 50
detection 140
Genital surgery 97
Genital tract
male 74
tuberculosis, female 84
Genitourinary physicians and surgeons 110
Genitourinary tract 36, 38
Genitourinary tuberculosis 14, 43, 45, 48, 52, 93
diagnosis of 45, 47, 48
disease 93
management of 45
sample collection for 45
Gerota's fascia 57, 114f
Giant hydrocalyx 103
Gömöri methenamine silver 42
Granuloma 36f, 37, 57
healing of 75f
multiple 126
noncaseating 40f
resection 41
Granulomatous disease, types of 36
Granulomatous infection 134
Granulomatous inflammation 40, 41
Granulomatous orchitis 43
Granulomatous prostatitis, nonspecific 42
Growth indicator tube 46
Heart failure 23
Hematological investigations 118
Hematuria 96, 140
Heminephrectomy 100, 104
Hemoglobin 23
B 92
C 92
Heterogeneous hypoechoic
nodules 75
texture 84f
High-resolution ultrasonography 60, 66f
Hilar lymph nodes 122f
Histoplasma capsulatum 43
Homogeneous hypoechoic
epididymis, diffusely enlarged 81f
nodules 75
Homogenous consolidation, large 141f
Horse shoe kidney 144f
Human immunodeficiency virus 1, 9, 43, 48, 92
testing 32
Hydrocalycosis, left superior 149f
Hydrocele 84f
chronic 83f
Hydronephrosis 66, 66f
evaluation of 57
left 157f
right 139f
moderate 134f, 135f
with left upper ureteric 146f
Hydronephrotic kidney 73f
calcified walls of 74f
right 152f
Hydrosalpinx 90f
bilateral 129f
proximal 146f, 148f
Hypodensities, multiple 127f
Hypoechoic epididymis 80f
Hypoechoic masses, multiple 160f
Hypoechoic nodules, multiple small 84f
Hypokalemia 23, 107
Hysteroscopic biopsy 87
Idiopathic granulomatous orchitis 43
Ileal conduits 109
Ileocalicostomy 101f
Imipenem 22
Immune reconstitution inflammatory syndrome 27
Indian Academy of Pediatrics 10
Infection control measures 14, 33
Infundibular stenosis 149f
multiple 136f
Infundibuloplasty 101f, 104
fibrosis of 68f
surgery for 96
Injectable agents, second-line 22
Institute of Leprosy and other Mycobacterial Diseases 4
Intensive case finding 2
Interstitial nephritis 39
drug-induced 40
Intestine, distal small 158
Intrarenal pelvis 164f
Intravenous pyelogram 53
nephrogram phase of 149f
Intravenous pyelography 105f, 140, 142f, 143, 148, 150f, 153, 156
normal 154f
Intravenous urography 52, 104
Irritative voiding symptoms 84
Isoniazid 6, 9, 47, 94
high-dose 9f, 22
preventive therapy 10, 13
Jan Dhan Yojana 3
Joint Secretary of Health 4
Kanamycin 22, 94
Kaplan-Meier survival estimator 111
Kerr's kink 66
Kidney 38, 120f
cement 40
coronal scan of 64f, 65f, 67f, 69f, 70f
cut surface of 184f
disease epidemiology collaboration, chronic 104
extensive calcification of 73f
high-resolution ultrasonography image of 60f63f
interstitium of 40f
material inside 138
nonfunctioning 95
nonvisualization of 56
transverse scan of 64f, 65f, 70f
tuberculosis of 38, 39f
underwent nephrectomy 106
Koch's contact 133, 151, 153
Langhans giant cells 36, 37
Langhans type 37f
Laparoscopic nephrectomy 95
Laparotomy, exploratory 158
Latent tuberculosis infection treatment 12
Left kidney 131f, 144f, 179
lower pole of 148f
nonfunctioning 139f, 180f
normal 183f
parenchymal calcification in 134f, 135f
region of 186f
upper pole of 67f
Left lower ureter 132f
stricture 121f, 132f, 142f
Left ureteric
calculus 145, 145f
dilatation 131f
wall calcification 123f
Leprosy 36, 43
Leukemia, acute 13
Levofloxacin 9, 22, 94
Line probe assay 9, 17
Linezolid 9, 9f, 22, 94
Lipoarabinomannan 51
Lithuria 140
Liver 55
disease, chronic 58
function test 92
Lobar caseation 56
Lung field, right 141f
Lymph nodes 39f
retroperitoneal 120f
Lymphadenopathy, abdominal 144f
Lymphocytes 37
Magnetic resonance urography 57
Malaria 11
Mass lesion 39
MCU/RGU prostatic-rectal fistula 167f
MCU-bilateral reflux 164f
MCU-bladder 160f
Medical Officer-Tuberculosis Control 4
Medically resistant hypertension 95
Medication event reminder monitor system 30
Medullary cavity
irregular 63f
large 62f
Meropenem 22
Micturating cystogram 130f
Micturating cystourethrogram 132f, 135, 139, 142, 155
high-resolution ultrasonography image of 67f
oblique scan of 71f
Midureteric strictures, bilateral 137f
Miliary tuberculosis 5
Millennium development goal 2
Minimally invasive management 95
Moxifloxacin 9, 22, 94
Multidetector computed tomography 54
pulmonary tuberculosis 25
tuberculosis 22
diagnosis of 9
Multinucleated giant cells 37f
Multiple drug therapy 92
Mycobacteria 38, 39
infections, atypical 56
Mycobacterium 47
avium-intracellulare 38
smegmatis 49
tuberculosis 5, 17, 45, 50, 92, 140
Mycolic acid 38
Nadir serum creatinine 108
Narrow pelvis, parenchymal calcification with 135f
National AIDS Control Programme 2
National Expert Technical Working Group 15
National Framework for Joint TB-HIV Collaborative Activities 2, 10
National Health Mission 2
National Institute for Research in Tuberculosis 4
National Japanese Leprosy Mission for Asia 4
National Reference Laboratory 8
National Strategic Plan for Tuberculosis Elimination 2
National Technical Working Group 11
National Tuberculosis Control Programme
free of cost 47
objectives of revised 33
revised 1, 10, 14, 15, 29, 34
National Tuberculosis Institute 4
National Tuberculosis Programme 1
surveillance system 32
Nausea 114
Nephrectomy 95, 98
after 139f
before 139f
partial 100, 101f, 104
specimen 184f
Nephrocutaneous fistula 62
Nephrostogram 101f
Nephrotic syndrome 13
Newer information and communication technology solutions 30
NIKSHAY 3, 14, 32
scheme 92
Nocturia 96
Nodular lesion 154f
Nucleic acid
amplification test 17, 50
cartridge based 7, 20, 47, 92
Omental flap 108f
Orchidectomy 97
Orthotopic bladder 102
Orthotopic substitution 109
P-aminosalicylic acid 22
Papillary necrosis 69
Para-aminosalicylic acid 9
Parenchyma 55, 152f
Parenchymal calcification 131f, 145f, 152f, 164f
left 124f
Parenchymal cavity 60, 64f
large irregular 61f
multiple 70f
Parenchymal cyst, small 67f
Parenchymal mass 60f, 61f
Parenchymal nodules 54
Parenchymal tuberculomas 53
Parietal wall 87
Paucibacillary disease 45
Pelvic brim 148f
level of 71f
Pelvic infundibular strictures 56
Pelvic stricture 54, 69f, 96
Pelvic tuberculosis, dry type of 90f
Pelvicalyceal anatomy of kidney 101f
Pelvicalyceal system 53, 96, 127
dilated 181f
left 156f
left 156
normal 137f, 168f
right 156f
right 164f
distorted 146f
Pelvis 96, 156
left small 136f
mucosal thickening of 64f
nonvisualized 181f
sagittal scan of 88f
tuberculosis of 41
Pelviureteric junction 64, 66, 105f
obstruction, lower moiety 144f
stenosis of 66f
Penis, ventral surface of 154f
Percutaneous nephrostomy 95, 99, 105f, 106, 109
obstruction 121, 121f, 132, 132f, 133, 133f, 136, 136f, 139, 142
Perinephric fat stranding 57, 112, 113f, 114f
Periodic acid-Schiff 42
Periodic ureteric dilatation 103
Peripheral Health Institution 5, 18
Perirenal fat stranding 117f
Peritoneum, thickening of 88f
Phantom calyx, left upper 162f
Phenotypic drug susceptibility testing, growth-based 17
Plasma cells 37
Pleura 55
Pleural fluid adenosine deaminase activity 7
Polymerase chain reaction 6, 47, 50
Post-ileocalicostomy nephrostogram 102f
Pott's spine, old healed 122f
Prostate 74, 86f, 99, 102
axial scan of 76f, 77f
gland 74
longitudinal scan of 76f
tuberculosis of 41
involvement of 41
Prostatectomy 166
Prostatic architecture, destroyed 168f
Prostatic substitution 102
Prothionamide 22
Pseudomonas aeruginosa 133, 140
Pseudotumor 39
abscess 114f
right 119f
and adjacent abdominal wall 116f
involvement of 114f
muscle 127f
left 185
Public finance management system 3
Pulmonary Koch's 133, 151, 153
Pulmonary tuberculosis 5, 14, 48
active 141f
drug-sensitive 25
mono-drug resistant 26
poly-drug resistant 26
Punctuate calcification 56
Putty kidney 40, 53, 69, 73f, 186
left 125f
Putty-like calcification 68
Pyelo fistulae 55
Pyelography, retrograde 53
Pyelolysis 101f, 104
Pyelonephritis 39, 107
Pyeloureteric anastomosis 102
Pyogenic epididymo orchitis 43
Pyonephrosis 40, 70f
Pyosalpingitis 87
Pyrazinamide 22, 92, 94
QT syndrome, long 23
Radionucleotide scintigraphy 106
Rat tail anastomosis 97
Reconstructive surgery 99, 103
Reconstructive surgical procedures 99
indications for 100
Regional Medical Research Centre 4
Renal abscess 55, 64f, 117f
Renal area, coronal scan of 73f, 74f
Renal calcification, left 122f
Renal calculus, right multiple 146f
Renal disease, end-stage 52
Renal failure, chronic 106
Renal fistulae 55
Renal function 99
global 102
preservation of 99, 110
test 92
Renal infundibuloplasty 102
Renal lobes 98
Renal nuclear scintigraphy 104
Renal parenchyma 37f, 54, 57, 60
calcification, left 122f
left 186
Renal pelvis 69f
dilatation 66
extensive calcification of wall of 73f
kinking of 70f
Renal tuberculosis, localized 39
Renal unit
damage, obstruction related 98
assessment 111
opposite 111
Renocutaneous fistula 55
Respiratory infections, acute 12
Rifabutin 94
Rifampicin 6, 47, 50
Rifampin 94
Right kidney 124f, 144f
calcified lower pole of 120f
destroyed 183f
middle pole of 152f
nonfunctioning 120f
nonvisualized 142f
functioning 144f
hypertrophied 187f
Right renal
abscess 127f
calculus 145f
parenchyma 125f, 127f
calcification 183f
pelvis 164f
Sarcoidosis 36, 40
Scarred cavity 87
Scars 166f
Scrotal abscess formation 42
empty 166f
scan of 83f
Seminal vesicle 74, 84, 85f, 86f
tuberculosis of 80
Senior Tuberculosis Laboratory Supervisor 4
Senior Tuberculosis Treatment Supervisor 4
creatinine 109, 134, 166
continues 164
electrolytes 134, 152
Shrunken bladder, small 139f
Shrunken kidney, left 125f
Sinus 182f
tract 55, 128f
thick-walled 128f
Sonolucent tract 63f
Speleotomy 100, 103
procedure 100f
Spermatic cord 85f
State tuberculosis cells 4
State Tuberculosis Officer 4
State tuberculosis training and demonstration centre 4
Status simultaneous ureteropyelostomy 105f
Steroids, role of 93
Streptomycin 22, 47, 94
Stress incontinence 109
Synechia 87, 90f
Syphilis 36
Systemic infection 98
Terizidone 22
Testicular tuberculosis 74
Testis 75, 80, 84f
diffusely enlarged 84f
enlarged 84f
enlargement of 79
scan of 79f
tuberculosis of 42
Thiacetazone 9
Thioacetazone 22
Tifampicin-susceptible tuberculosis 20
Tissue 92
samples 46
Transplanted kidney, tuberculosis in 58
Transport box, technical specifications of 19f
Transureteroureterostomies 106
Transurethral resection 108
Treponema pallidum 42
Trigone area, Mucosal thickening of 71f
TRUS-prostate gland measures 160f
Tubercular urethral involvement 109
Tuberculoma, wall of 124f
Tuberculosis 911, 20, 36, 41, 43, 45, 74, 85f, 89f, 90f, 96, 98, 136
adhesive type 87
algorithm, integrated drug-resistant 14, 19, 21fc, 24
childhood 10
culture 50
diagnosis of 47
molecular approaches for 47
disease 1
dry type 87
epidemiology 1
etiology 119
extrapulmonary 5, 20, 27, 48
gastrointestinal 96
granulomas 52
infection 12
pathology of 36
pediatric 27
poly-drug resistant 15
recurrent 6
resistant 15, 20, 22
susceptible 20
sputum 140
strictures 95
treatment of 92
drug-resistant 14, 21
extensively drug-resistant 9
history of 5
multidrug-resistant 9
unit level 4
wet type 87
Tuberculous contracture 108
Tuberculous epididymitis 42, 74, 80f
Tuberculous epididymo-orchitis 43f
Tuberculous granulomatous interstitial nephritis 40f
Tuberculous interstitial nephritis 40
Tuberculous orchitis, isolated 42
Tuberculous perinephric abscess 64f
Tuberculous pyelonephritis 40
Tuberculous ulceration 95
Tubes, enlargement of 87
Tubo-ovarian abscess 89f
formation 87
Tunica vaginalis, calcification of 83f
Ulcerative colitis 102
Unhealthy bladder 158f
Upper calyx 69f
Upper ureteric stricture
buccal mucosa augmentation of 107
repair 108f
Ureter 95, 156f
color Doppler image of 71f
dilated 128f, 146f
left 119f
proximal 66f, 71f
thickened right 125f
replacement of 102
substitution of 107
narrow, right lower 156f
oblique scan of 71f
right 148f
lower 155
thick 116f
walled distal 146f
tuberculosis of 41
with thick walls, dilated right 124f
Ureteral urine samples 147
Ureteric calcification, bilateral 137f
Ureteric dilatation 103
efficacy of 103
mild 142f
Ureteric procedures, lower 104
Ureteric reimplant 105f, 106
surgical procedures of 106
Ureteric stricture 96
bilateral 138f
buccal mucosal grafting augmentation of 102
lower 139f
multiple left 133f
right distal 136f
Ureteric wall calcification and thickening 117f
Ureterocalicostomy 96, 102, 105, 106
Ureterogram, retrograde 108f
Ureteroneocystostomy 102, 106
Ureteropyelostomy 104
Ureteroureterostomy 106
Ureterovesical junction 95
obstruction, right 180f
Ureters with calcification, bilateral thickened 181f
Urethra 99
and anus, posterior 169f
gas outlining 77f
nonvisualization of posterior 180f
posterior 180f
procedures for 103
Urethral fistula excision 166
Urethral stricture 109
Urethroplasty 103, 109
Urinary bladder 68, 72f, 73f, 86f
and vagina 156f
fibrosis of walls of 73f
oblique scan of 71f
small capacity 142f
transverse scan of 72f
Urinary conduits, obstruction of 98
Urinary tuberculosis 49, 49t, 60, 69, 98, 110
context of 98
sonographic features of 60
acid-fast staining 49
analysis 179
collection, method of 45
samples 45
Urodynamic study 143
Uterus, longitudinal scan of 91f
Vagina, contrast in 157f
Vas deferens 86f
hypoechoic mass of 85f
Vasa deferentia 80
Vesicoureteric junction 130f
obstruction 129f
right 125f
stricture 133f, 139f
left 142f
Vesicoureteric reflux 71f
bilateral 132f
Vesicourethral anastomosis 166
Vesicovaginal fistula 96
large 158f
Vomiting 114
Weight loss 98
World Health Organization 1
World Health Organization Global Tuberculosis Report 8
Xanthogranulomatous pyelonephritis 40
smear 49
stain 38, 38f, 42, 46
Chapter Notes

Save Clear

Tuberculosis Epidemiology in IndiaCHAPTER 1

Sunil D Khaparde
Each year, in India, an estimated 28 lacs people develop tuberculosis (TB) disease and approximately 4.8 lacs people die from TB— World Health Organization's (WHO's) Global Report 2017.
A study of mortality in India has estimated that TB is among the top four causes of death between the ages of 30 and 69 years, with an impact similar to cancer. The socioeconomic impact of TB in India is devastating and India continues to incur huge costs due to TB amounting to nearly US$ 350 billion between 2006 and 2015.
India continues to have the highest TB burden though the epidemic is on the decline. The incidence of TB, human immunodeficiency virus (HIV) and TB (5%), and drug-resistant tuberculosis (DR-TB) varies from region to region. The urban areas have lower prevalence of TB with a higher annual risk of tuberculous infection (ARTI) and vice versa.
This is the reason why different approaches are necessary to tackle the problem. The National TB Programme of India (NTP) was initiated in 1962 and was originally designed for domiciliary treatment, using self-administered standard drug regimens. NTP had created an extensive infrastructure for TB control with a network of > 446 district TB centers, 330 TB clinics and > 47,600 TB beds. The NTP had also raised awareness of TB and TB treatment facilities, and had succeeded in placing > 1.3 million patients on treatment annually.
The problems are HIV-AIDS epidemic and the spread of multidrug-resistant (MDR) TB were threatening to further worsen in the situation.
Inadequate funding, an over reliance on X-ray for diagnosis, had frequent interrupted supplies of drug, and low rates of treatment completion. The government decided to give new thrust to TB control activities by revitalizing the NTP with assistance from international agencies in 1993. Revised National TB Control Programme (RNTCP) was piloted in a population of 2.4 million of five states. This was later expanded to cover 13 million people by 1995 and 20 million by 1996.
In 1997, the RNTCP was launched as national program with the plan to scale up in phased manner. It adopted the internationally recommended directly observed treatment short-course (DOTS) strategy, as the systematic and cost-effective approach to revitalize the TB control program in India.
The program is credited with saving 3.5 million lives and initiation of 19 million patients.2
Emboldened by its achievements, the program in 12th Five Year Plan (2012–2017) has articulated a vision of universal access to TB care with the following objectives: (i) To achieve 90% notification rate for all cases; (ii) to achieve 90% success rate for all new and 85% for retreatment cases; (iii) to significantly improve the successful outcomes of treatment of DR-TB cases; (iv) to achieve decreased morbidity and mortality of HIV-associated TB; and (v) to improve outcomes of TB care in the private sector.
National AIDS Control Programme and RNTCP have started a “National Framework of Joint TB/HIV Collaborative Activities” by engaging the private sector of medical care and professional bodies like Indian Medical Association (IMA). A case-based web-based platform “Nikshay” in 2012 has now been scaled up nationally.
The private sector holds a factual predominance of healthcare service delivery in India. There is very little information about TB patients from the private sector which is available to the program and little is known about their quality of treatment, including treatment outcomes.
“The National Strategic Plan (NSP) for TB Elimination (2017–2025) is a statement of commitment to eliminate TB by 2025 by the Ministry of Health and Family Welfare, Government of India.” The NSP builds on the success and learnings of the last NSP and encapsulates the bold and innovative steps required to eliminate TB in India. It is in line with other health sector strategies and global efforts, such as the National Health Policy 2015, WHO's End TB strategy, and the sustainable development goals (SDGs) of the United Nations (UN). It proposes bold strategies with commensurate resources to rapidly decline TB incidence and mortality in India by 2025, 5 years ahead of the global End TB targets and SDGs. The NSP 2017–2025 aims to notify 260 lacs TB patients in 8 years including public and private sector.
In the 12th Plan period (2012–2017), RNTCP was implemented under the umbrella of the National Health Mission (NHM).1 The same is proposed to be continued in the current plan period. The program has successfully achieved the Millennium Development Goal for incidence and prevalence of TB.
  • The incidence of TB has come down from 289 per lac population in 2000 to 217 per lac (58%) population in 2015.
  • The mortality from TB has reduced from 56 in 2000 to 36 per lac (28%) population in 2015.
However, India still accounts for an estimated 27% of the global incident TB cases (28 lacs) and 27% of the global MDR-TB cases (1.3 lacs).
The activities under the program currently ongoing would be continued and specific activities/focus areas proposed are as under:
  • Increase participation of private sector TB care provider: TB notification has increased substantially in these pilot areas with providing free TB diagnostics and drugs provided either directly by state public health system or through nongovernmental organizations (NGOs) or agencies supporting the states. It is also proposed to provide incentives to the private sector TB care provider through direct beneficiary transfer to promote TB case notification, ensure treatment adherence, and treatment completion.
  • Intensified TB control activities in high priority districts: Active case finding (ACF) or intensive case finding (ICF) activity is an activity with the primary objective of detecting TB cases early. Clinically, socially, and occupationally vulnerable populations 3are targeted by screening for TB symptoms, to conduct sputum examination of symptomatic using a high sensitive and specific tool in the field and to find and treat additional infectious TB patients.
  • Providing incentive to prevent catastrophic expenditure to the TB patients and their families due to TB and for nutritional support: This interaction is particularly important in the Indian context where poverty and undernutrition coexist with a large burden of tuberculosis. It is proposed to launch a scheme to provide a monthly cash incentive for every TB patient through direct beneficiary transfer.
  • Deploy a world-class national surveillance and tracking system for TB patients: Nikshay will be enhanced to establish comprehensive real time TB surveillance system. Information and communication technology (ICT) platform with handheld ICT devises for health staff, 250 seats call centers, adherence mechanisms through 99-DOTS, SMS reminders and other ICT-based platforms are proposed with corresponding HR and maintenance capacity.
Government of India envisages TB control as one of the key priority activities and is committed to an aspirational target of achieving this ahead of schedule—by the year 2025.
  • India has developed NSP for TB in India. The NSP for TB elimination in India has essentially 4 pillars to address the major challenges for TB control, namely “Detect, Treat, Build and Prevent”.
  • Priority for TB control in India are:
    • The first priority is “reaching the unreached”. We have to ensure access to care for some vulnerable populations such as tribals, people in urban slums, etc.
  • 25% of the budget is earmarked for patients managed in the private sector. This include free diagnosis with rapid molecular tests, free treatment with best quality drugs and regimens, financial and nutritional support to patients, online TB notification systems, mobile technology-based adherence monitoring system, interphase agencies for better private sector engagements, policy for transparent service purchase schemes, stronger community engagements, communication campaigns, regulatory systems to capture information on all those consuming anti-TB drugs, etc.
  • To provide access to patients in difficult-to-reach areas, both socially and geographically.
  • Policy have been in place now for using rapid molecular testing for TB diagnosis and universal drug resistance testing; now we have GenXpert tests available in every district.
  • Recently validation and field feasibility tests of a “Make in India” rapid molecular test—“Trunat” has been completed.
  • Daily fixed dose course (FDC) regimen for drug-sensitive TB has been now used in India with mobile-based adherence monitoring system (99-DOTS). For DR-TB patients, bedaquiline have been introduced and shorter MDR-TB regimen will be used for treatment.
  • Patient support such as nutritional support and financial enablers are ready to be rolled out through JAN scheme [Jan Dhan Yojana (bank account to citizen), Aadhar (unique identity card), Nikshay (electronic TB notification system) linked, direct beneficiary transfer of financial incentives or nutritional support to TB patients]. 20% of NSP budget has been earmarked for financial and nutritional support to TB patients and families.
  • Health system strengthening is one of the top priorities; in the NSP we have included a section called “Build”. For strengthening TB program management, we have now an efficient, transparent public finance management system (PFMS). An effective TB 4surveillance system is being developed in the country and, in 2 years, we expect to have a state of-the-art TB surveillance system in place to better understand and react to local TB epidemic.
  • In India, a series of scientific ventures, including development of newer vaccines, newer molecular diagnostics, and treatment regimens are underway.
The RNTCP works at five levels: national level, state level, district level, subdistrict level, and peripheral health institution level.
National Level
At the central level, the RNTCP is managed by the Central TB Division (CTD) under Ministry of Health and Family Welfare (MoHFW). Joint Secretary of Health from the administrative arm of the MoHFW and a national program manager—Deputy Director General-TB (DDG-TB), is in-charge of RNTCP.2,3 The CTD is assisted by six national level institutes, namely the National Tuberculosis Institute (NTI) in Bengaluru, the National Institute for Research in Tuberculosis (NIRT) in Chennai, the National Institute of TB and Respiratory Diseases (NITRD) in New Delhi, National Japanese Leprosy Mission for Asia (JALMA), Institute of Leprosy and other Mycobacterial Diseases in Agra, Bhopal Memorial Hospital and Research Centre (BMHRC) in Bhopal, and Regional Medical Research Centre (RMRC) in Bhubaneswar.
State Level
At the state level, the state TB officer (STO) does the planning, training, supervising, and monitoring of the program in their respective states. The STO, based at the state TB cell, is answerable to their respective state governments, whilst implementing the technical policies and guidelines issued by the CTD. The state TB cells (STC) have been provided with equipment, infrastructure, and RNTCP contractual staff to carry out its functions. The State TB Training and Demonstration Centre (STDC) has three units: A training unit, supervision, and monitoring unit and an intermediate reference laboratory (IRL). There is state drug store (SDS) for the effective management of anti-TB drug logistics. One SDS per 50 million populations is established in all larger states.
District Level
The District TB Centre (DTC) is the nodal point for all TB control activities in the district. In RNTCP, the primary role of the DTC has shifted from clinical to managerial functions. The district TB officer (DTO) at the DTC has the overall responsibility of management of RNTCP at the district level as per the program guidelines and the guidance of the District Health Society.
Subdistrict Level (Tuberculosis Unit Level)
The tuberculosis unit consists of a designated Medical Officer-Tuberculosis Control (MO-TC) who does RNTCP work in addition to other responsibilities. There are two full-time RNTCP contractual supervisory staff exclusively for TB work: A Senior TB Treatment Supervisor (STS) and a Senior TB Laboratory Supervisor (STLS). These tuberculosis units cover a population of approximately 200,000–250,000.5
There is one RNTCP designated microscopy center (DMC) for every 100,000 population under a TB unit (50,000 in tribal, desert, remote, and hilly regions). DMCs are also established in medical colleges, corporate hospitals, Employees State Insurance Corporation hospitals and railway health facilities, NGOs, private hospitals, etc., depending upon the requirement.
Peripheral Health Institutions
For the purpose of RNTCP, a peripheral health institution (PHI) is a health facility which is manned by at least a medical officer.
The RNTCP has developed clear definitions for pulmonary TB cases that allow clinicians to categorize patients in terms of their diagnostic status and outcomes of treatment.
Many TB patients do not have their diagnosis confirmed by a positive microbiological test either due to the limitations of the diagnostic tests currently available, or lack of access to a microbiological test. These patients are often treated based on the clinician's suspicion alone (empirical treatment).
Case Definitions
  • Microbiologically confirmed TB case refers to a presumptive TB patient with biological specimen positive for acid fast bacilli, or positive for Mycobacterium tuberculosis on culture, or positive for TB through quality assured rapid diagnosis molecular test.
  • Clinically diagnosed TB case refers to presumptive TB patient who is microbiologically confirmed, he has been diagnosed with active TB by a clinician on the basis of X-ray abnormalities. Histopathology or clinical signs with the design to treat the patient with full course of anti-TB treatment.
In children, clinically diagnosed TB case is diagnosed based on the presence of abnormalities consistent with TB radiography a history of exposure to an infectious case, evidence of TB infection [Positive tuberculin skin test (TST)] and clinical findings suggestive of TB in children in event of negative or unavailable microbiological result.
Microbiologically confirmed or clinically diagnosed case of TB are also classified according to:
  • Anatomical site of disease
  • History of previous treatment.
Classification based on anatomical site of disease:
  • Pulmonary tuberculosis (PTB) refers to any microbiologically confirmed or clinically diagnosed case of TB involving the lungs parenchyma or tracheobronchial tree.
  • Extrapulmonary tuberculosis (EPTB) refers to microbiologically confirmed or clinically diagnosed case of TB involving organ other than the lungs such as pleura, lymph nodes, intestine, genitor urinary tract, joint and bones, meninges of brain, etc.
  • Miliary TB is classified such as PTB because there are lesions in the lungs. A patient with both PTB and EPTB should be classified as case of PTB.
Classification based on history of TB treatment:
  • New case: A TB patient who has never had treatment for TB or has taken anti-TB drug for < 1 month is considered as new case.
  • Previously treated patient has received 1 month or more of anti-TB drug in the past.6
  • Recurrent TB case: A TB patient previously declared as successfully treated, cured or treatment completed and subsequently found to be microbiologically confirmed TB case is recurrent TB case.
  • Treatment after loss to follow up: A TB patient previously treated for TB for 1 month or more and was declared lost to follow-up in their most recent course of treatment and subsequently found microbiologically confirmed TB case.
  • Other previously treated patients are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented.
  • Transferred in: A TB patient who has received treatment in tuberculosis unit, after being registered for treatment in another TB unit is considered as case of transferred in.
Classification based on drug resistance:
  • Mono resistance (MR): A TB patient whose biological specimen is resistant to one first line anti-TB drug only.
  • Poly drug resistance (PDR): A TB patient whose specimen is resistant to more than one first line anti-TB drug, other than both isoniazid (INH) and rifampicin.
  • Multidrug resistance: A TB whose biological specimen is resistant to both isoniazid and rifampicin with or without resistance to other first-line drug based on the result from a quality assured laboratory.
  • Extensive drug resistance (XDR): An MDR-TB case whose biological specimen is additionally resistance to a fluoroquinolone (ofloxacin, levofloxacin, or moxifloxacine) and a second line injectable anti-TB drug (kanamycin, amikacin, or capreomycin).
Definition under RNTCP
Working Case Definitions
Presumptive case: A patient with symptoms and signs of EPTB who needs investigation
Bacteriologically confirmed case: A patient with microbiological diagnosis of EPTB, based on positive microscopy, culture or a validated PCR (polymerase chain reaction)-based test.
Clinically diagnosed case: A patient with negative microbiological tests for TB (microscopy, culture and validated PCR-based tests), but with strong clinical suspicion and other evidence of EPTB, such as compatible imaging findings, histological findings, ancillary diagnostic tests or response to anti-TB treatment. A presumptive case started on antitubercular therapy (ATT) empirically, without microbiological testing, should also be considered a clinically diagnosed case (empirically treated). A clinically diagnosed case subsequently found to be bacteriologically positive (before or after starting treatment) should be reclassified as bacteriologically confirmed.
Non-EPTB case: A patient who has been investigated for EPTB and has been diagnosed with a different condition, with no microbiological evidence of EPTB found.
Presumptive relapse: A patient who was declared successfully treated and now presents again with symptoms and signs of any form of TB.
Bacteriologically confirmed relapse: A patient with presumptive relapse who has microbiological evidence of persisting M. tuberculosis infection on subsequent diagnostic sampling.7
Clinically diagnosed relapse: A patient with presumptive relapse who does not have microbiological evidence of persisting M. tuberculosis infection on repeat diagnostic sampling.
A patient with presumptive relapse who is started on ATT empirically without repeat microbiological tests should also be considered a clinically diagnosed relapse (empirically treated). A clinically diagnosed relapse subsequently found to be bacteriologically positive (before or after starting treatment) should be reclassified as bacteriologically confirmed relapse.
Ancillary diagnostic tests refer to organ system-specific tests such as pleural fluid adenosine deaminase activity (ADA) in pleural TB, or cerebrospinal fluid (CSF) biochemistry and differential cell count in TB meningitis.
Working Outcome Definitions1
Successfully treated: A TB patient who has clinical and radiological evidence of resolution of active TB at the end of ATT. Some people have residual tissue damage that causes ongoing symptoms or radiological change (sequelae) despite resolution of TB infection.
Completed treatment: A TB patient who completed treatment without clinical evidence of failure but with no record to show complete resolution by radiological or bacteriological evidence of persisting infection by the last month of treatment because tests were not done.
Presumptive treatment failure: A patient who has no satisfactory clinical or imaging response to treatment after completing 3–6 months ATT.
Bacteriologically confirmed treatment failure: A patient with presumptive treatment failure who has microbiological evidence of persisting M. tuberculosis infection on repeat diagnostic sampling.
Clinically diagnosed treatment failure: A presumptive treatment failure case who does not have microbiological evidence of persisting M. tuberculosis infection on repeat diagnostic sampling and has no evidence of another disease process, but has strong clinical suspicion of treatment failure and other evidence of active TB, such as imaging findings.
The difficulty in defining treatment end-points in EPTB is due to the development of sequelae as a result of the inflammation and subsequent fibrosis.4 Patients with sequelae though may have complete microbiological cure, but continue to have symptoms. In EPTB at times, sequelae can mimic the signs and symptoms of active TB infection, and to declare the patient successfully treated difficult.
Early accurate diagnosis of TB and enhancing case finding efficiency, identification of presumptive TB cases and avail the best available diagnostic tests are of paramount importance to interrupt the transmission of TB disease. RNTCP screens around 20 million TB symptomatic by microscopy and initiates around 1.5 million cases of TB on treatment annually since 2007–2008. Rapid molecular diagnostics and line probe assay and cartridge based-nucleic acid amplification test (CBNAAT) testing is available throughout 8the country. In 2016, 520,000 patients have been tested and 35,000 rifampicin resistant (RR)/MDR-TB patients are diagnosed using these tests. Second-line drug susceptibility testing (DST) using liquid culture systems are available in the entire country. RNTCP has a three-tier laboratory network system. The National Reference Laboratory (NRL), IRL, DMCs, and all the laboratories under RNTCP follow the quality assurance (QA) protocol for all technologies as per the WHO guidelines.
The program has a very well established QA mechanism which follows the WHO system of hierarchal control from the highest level of NRLs to state.
Strengthening of these patient-centered treatment services in RNTCP with enhanced capacity to rapidly accommodate new drugs and treatment modalities will be the cornerstone of the current NSP.
Patients are classified based on drug sensitive and drug-resistant patterns like mono, poly, multi, and extensive drug resistance. For drug-sensitive TB patients, thrice-weekly regimen being followed since program inception has been switched to daily regimen for treatment of all TB patients.
The principles of treatment for TB are:
  • Compulsory screening of all patients for rifampicin-resistance and additional drugs as clinically decided.
  • For drug-sensitive TB, administer daily fixed dose combinations of first-line anti-tuberculosis drugs including four-drug fixed-dose combinations (FDCs) in the intensive phase and three-drug FDCs in the continuation phase.
  • All RR or MDR-TB patients are subjected to baseline kanamycin and levofloxacin.
  • Rifampicin-resistant or MDR-TB patients without additional drug resistance are treated with standard short course treatment regimen for MDR-TB. and, mixed patterns of resistance, standard MDR-TB regimens were modified.
  • Essential optimized regimen for patients diagnosed with drug resistance other than MDR-and XDR-TB.
  • Maximize adherence through innovative patient support strategies and real time monitoring.
As part of new drug and treatment services introduction, the program plans to introduce shorter MDR-TB regimen as per WHO treatment guidelines. With extended DST for second-line drugs being available upfront, the NSP 2017–2025 also envisages countrywide scale up of new drugs like bedaquiline (being currently provided in six sites across the country) and delamanid.
The World Health Organization's Global TB Report 2015 estimates approximately 71,000 cases of MDR-TB that emerge annually from the notified cases of pulmonary TB in India. Based on subnational drug resistance surveys carried out in three states of India, ~3% among new TB cases and 12–17% among previously-treated TB cases have MDR-TB.
Strategies for controlling DR-TB include: (i) Sustained high-quality DOTS implementation, daily regimen in high-risk groups and patient-friendly treatment 9to improve treatment adherence; (ii) implementing airborne infection control (AIC) measures; cut down diagnostic delays with rapid diagnostics, offer universal DST and prompt appropriate decentralized treatment; (iii) strengthening procurement, supply chain: Strengthen the procurement, supply and availability of second-line anti-TB drugs in India; (iv) nutritional assessment and supplementation: Linkages with public distribution systems, Panchayati Raj institutions, corporate social responsibility, etc.; and (v) improving adherence through counseling support: One DR-TB counselor per DR-TB center and district each for both institutional and home-based counseling.
The key features from programmatic management of DR-TB (PMDT) guidelines are described here.
Diagnosis of Multidrug or Extensively Drug-resistant TB
Decentralized diagnosis with with specimen transported to laboratory in cold chain. Rapid molecular DST [CBNAAT or line probe assay (LPA)] is the first choice of DST. All failures of first-line regimen, contacts of known MDR-TB case, all retreatment cases at diagnosis, any patient with smear positive follow up results, and all TB-HIV cases are offered DST.
Apart from these, presumptive TB cases among people living with HIV/AIDS (PLHA) are prioritized for early diagnosis of TB using CBNAAT and the resulting DR-TB cases detected are also considered for treatment under PMDT. Baseline second-line drug in confirmed MDR-TB cases with a fluoroquinolone and second-line injectables. The patients diagnosed with ofloxacin/kanamycin (Ofx/Km) resistance are treated with modified MDR-TB regimen whereas the Ofx/Km resistance among nonresponders and failures of MDR-TB regimen are treated with XDR-TB regimen.
Treatment of Multidrug or Extensively Drug-resistant Tuberculosis
Treatment is based on DR or DST results. Initial hospitalization is done at DR-TB center followed by ambulatory care. A standardized treatment regimen is used for MDR-TB—daily DOT that consists of 6–9 months of kanamycin; levofloxacin; cycloserine; ethionamide; pyrazinamide; ethambutol or 18 months of levofloxacin; cycloserine; ethionamide; ethambutol. Para-aminosalicylic acid (PAS) is used as a substitute drug in case of intolerance.
Standardized treatment regimen for XDR-TB—daily DOT, consisting of 6–12 months of capreomycin; PAS; moxifloxacin; high-dose isoniazid; clofazimine; linezolid; amoxycillin-clavulanic acid or 18 months of PAS, moxifloxacin, high-dose isoniazid, clofazimine; linezolid; amoxycillin-clavulanic acid. Clarithromycin and thiacetazone are used as a substitute drug in case of intolerance.
Tuberculosis is commonest opportunistic infection in HIV-infected individuals and HIV-infection is an important risk factor for acquiring TB infection and its progression to active TB. About 120,000 HIV-associated TB patients are emerging annually in India and accounts for about 10% of the global burden of HIV-associated TB. The mortality in among TB/HIV coinfected patients is 38,000 people every year.10
The interventions to reduce the burden of TB among PLHA include the early provision of antiretroviral therapy (ART) for people living with HIV in line with WHO guidelines and the three I's for HIV/TB—intensified TB case finding followed by high quality ATT, isoniazid preventive therapy (IPT), and infection control for TB.
The National Framework for Joint TB-HIV Collaborative Activities was developed in 2007 and has been updated based on experiential learning and scientific evidence. Currently, the TB/HIV package is being implemented nationwide by both the programs.
In 2014, 74% TB patients knew their HIV status and 44,067 were diagnosed as HIV positive. The 93% HIV-TB patients were provided co-trimoxazole preventive therapy (CPT) and 91% coinfected patients are put on ART.
The 4% additional TB cases were diagnosed with intensified TB case finding activities at HIV care settings.
The success rate among the HIV-TB coinfected patients for patients registered in 2013 was 76% with high death rate 13% and default rate was 6%.
The increasing co-occurrence of TB with tobacco consumption and diabetes mellitus (DM) is well evident. Smoking is three times more prevalent in TB patients and is strongly associated with increased rates of TB infection. Similarly, the prevalence of DM is as high as 13% and the prevalence even goes higher in MDR-TB cases. Patients with TB may have lung damage that is aggravated by continued tobacco use.
Feasibility of including tobacco cessation activities with RNTCP, a TB tobacco pilot project was conducted in Gujarat by Government of India in 2010. The pilot projects done by the TB-DM collaborative group has demonstrated at eight tertiary care centers that missed opportunities can be addressed through developing routine screening system in RNTCP with no additional cost to program.
As per the Global Report on TB 2014, there were an estimated 550,000 TB cases among children (under 15 years of age) and 80,000 TB deaths (among HIV-negative children) in 2013 (6% and 8% of the global totals, respectively). It is one of the top 10 causes of childhood mortality.
Revised National TB Control Programme in association with Indian Academy of Pediatrics (IAP) has revised the pediatric TB guideline in 2012. It laid down specific algorithm diagnosis of TB among children. The treatment strategy comprises two key components. First, as in adults, children with TB are treated with standard SCC, given under direct observation and the disease status is monitored during the course of treatment. Second, patient wise boxes designed according to weight bands for complete course of anti-TB drugs.
In 2014, 72,307 new TB cases were notified accounting for 6% of all cases. This is in the range of the expected incidence by WHO report. The contact screening is one of the ways for intensified case finding activity which RNTCP has implemented since its inception.11
The National Technical Working Group on pediatric TB has been constituted to examine the policy and practices and provides suggestions to CTD for improving situation of childhood TB.
To accelerate access to quality TB diagnosis for pediatric, RNTCP has initiated a project in four major cities in India’: RNTCP United States Agency for International Development (USAID) Foundation for Innovative New Diagnostics (FIND) Pediatric TB Xpert Project.
In India, the private sector is the first point of care in many episodes of ill health. While most TB cases are ultimately treated by the RNTCP, most patients by then have already approached the private sector for TB diagnosis and treatment.
After experiences of implementing models of private sector collaboration, CTD published guidelines for the participation of the NGOs (in 2001) and private practitioners (in 2002). Currently, 24 partnership options for involvement of NGOs, corporates, private practitioners and research institutions are incorporated under the National Guidelines for Partnership.
Indian Medical Association has been engaged with the program through Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) supported project in 16 states and union territories. Similarly, civil society organization, CBCI-CARD (The Catholic Bishops’ Conference of India-Coalition for AIDS and Related Diseases) is working under GFATM project of RNTCP, to improve access to the diagnostic and treatment services provided by the RNTCP within the Catholic Church Healthcare Facilities (CHFs)
In addition, partners like UNION, World Vision, and FIND also support the program. RNTCP has partnered with more than 350 medical colleges in India and, in 2014, they have contributed in a major way in finding more TB cases, especially smear negative and EPTB cases.
Advocacy communication and social mobilization (ACSM) is an inbuilt component of RNTCP and is recognized as an important element.
Information, education and communication (IEC) materials are developed at the national level and shared with states for use—“as it is” or post modification to suit local requirements. Several of these materials including television spots, radio jingles and posters are available in nearly 13 regional languages. Advocacy communication and social mobilization module is incorporated in all health workers training on basic DOTS.
In addition to better diagnostic tool and treatment regimens, other patient supportive initiatives including better nutrition, counseling and financial support are equally essential. WHO's “End TB strategy” has this important target of “no affected family face catastrophic costs due to TB”.
However, the free diagnosis and treatment is only accessible to those patients seeking care under RNTCP. Large number of patients seeking care in private sector has to bear 12substantial cost for TB care. Though large part of cost of treatment is borne by the program, patients still have to bear expenditures such as cost for travel to the facilities, loss of wages due to sickness, etc. The support activities are implemented through departments such as social welfare department, public distribution system, NGOs, CSR funding, etc.
Airborne Infection Control
Acute respiratory infections (ARIs) are the leading cause of morbidity and mortality affecting the youngest and oldest people in low- and middle-income nations. These infections, typically caused by viruses or mixed viral–bacterial infections, can be contagious and spread rapidly. Although knowledge of transmission modes is ever-evolving, current evidence indicates that the primary mode of transmission of most acute respiratory diseases is through droplets, but transmission through contact (including hand contamination followed by self-inoculation) or infectious respiratory aerosols at short range can also happen for some pathogens in particular circumstances.
Contact Tracing
In RNTCP, contact screening has been a clinical function and the end result expected is that most TB patients will have their contacts screened, with secondary cases detected and treated.
Contact investigation:
  • All close contacts, especially household contacts by X-rays
  • In case of pediatric TB patients, reverse contact tracing for active TB case in the household of the child.
Use of chest X-rays upfront for screening of contacts will be prioritized during the NSP period. Setting specific screening approaches (for example in prisons, urban slums, etc.) according to the RNTCP technical and operational guidelines (TOG) will be undertaken.
All close contacts of DR-TB cases will be identified through contact tracing and evaluated for active TB disease as per RNTCP guidelines. If the contact is found to be suffering from pulmonary TB disease irrespective of the smear results, he will be identified as “presumptive MDR-TB”.
Preventive Therapy or Latent Tuberculosis Infection Treatment
Tuberculosis infection is the seedbed for developing TB disease and continued transmission. The lifetime risk of reactivation of latent tuberculosis infection (LTBI) in healthy HIV-uninfected individuals is 10%, with 5% developing TB disease during the first 2–5 years after infection. The risk of reactivation is greatly increased in the context of immunosuppression, primarily due to HIV infection. Child contacts living in TB-affected households are particularly vulnerable populations for progression to TB and severe disease forms such as disseminated and meningeal TB. WHO has included scaling up TB preventive therapy for persons at high risk of developing TB in its End TB strategy and increasing coverage of contact investigations and TB preventive therapy for people living with HIV (PLHIV) and child contacts are important strategies. Scaling up TB preventive therapy is therefore important to meet the goals of ending TB in India.13
India, with one-fourth of the global burden of TB, has 40% of the population infected with M. tuberculosis . Treating 40% of the population for LTBI based on TST positivity or interferon-gamma release assay is neither rational nor practicable, thus emphasizing the need for a focused approach. The selection of the risk group that will be prioritized for screening, investigation to rule out TB and treatment is as follows:
  • People living with HIV
  • Child PTB contacts
  • Patients with silicosis
  • All patients where clinically indicated (high risk),e.g., points in immunosuppressants
  • High-risk adult contacts.
Isoniazid Preventive Therapy
Children <6 years of age, who are close contacts of a TB patient, will be evaluated for active TB by a medical officer/pediatrician. After excluding active TB, he/she will be given INH preventive therapy irrespective of their Bacillus Calmette–Guérin (BCG) vaccine or nutritional status. The dose of INH for preventive therapy is 10 mg/kg body weight daily for 6 months be collected on monthly basis. INH preventive therapy:
  • For all HIV infected children with known exposure to an infectious TB case or are TST positive (≥5 mm induration) but have no active TB disease.
  • All TST-positive children receiving immunosuppressive therapy (e.g., children with nephrotic syndrome, acute leukemia, etc.).
  1. Ministry of Health and Family Welfare. (2017). National Strategic Plan for Tuberculosis Elimination 2017-2025. Revised National Tuberculosis Control Programme.  [online] Available from [Last accessed January, 2020].
  1. MGMIS Sevagram. (2018). National Strategic Plan (NSP) for Tuberculosis Step Towards ending TB by 2025. [online] Available from;year=2019;volume=24;issue=1;spage=17;epage=18;aulast=Khaparde. [Last accessed January, 2020].
  1. Revised National Tuberculosis Control Programme Technical and Operational Guideline 2016, Directorate General of Health Services,  MOHFW, New Delhi.
  1. Sharma SK, Ryan H, Khaparde S, Sachdeva KS, Singh AD, Mohan A, et al. Index TB: Guidelines for extra pulmonary tuberculosis in India. 2017;145(4):448–63.