good morning dear students after a long time I'm doing another quick revision series and today it is about tuberculosis we will cover it in a very short and crisp manner so that you can rapidly revise it before your exams see the tuberculosis is broadly classified into three types basically pulmonary tuberculosis extra pulmonary tuberculosis of course Bine tuberculosis is another type of tuberculosis which is among animal population now the problem statement is very important whenever you start writing an answer for tuberculosis actually it is one of the biggest disease because it affects one/ third of the world population and among these people 5 to 10% will develop the disease so such is the magnitude of this problem and among act tuberculosis patients how many patients will get the disease from the active tuberculosis patient about 10 to 15 persons per year will be affected from one active tuberculosis patient and with respect to other parameters 8% of all tuberculosis patients are people living with HIV AIDS 78% of tuberculosis patients in India belong to multi diseases this is a worrisome Factor whereas the world average is 27% if you compare with the world is 27% multi decision but in India it is 78% multi resistance and it is otherwise called ref resistant tuberclosis India accounts for 26% of the global bord of tuberos so India is number one in terms of burden of tuberclosis in the world followed by second country which is Indonesia 8.5% followed by Third Country which is China it is 8.4% in terms of tuberculosis burden also there is another special type of tuberclosis pediatric tuberculosis which accounts for 10% of all tuberclosis patients in the world and 1 million cases are there in the world one lakh deaths per occur because of MDR tuberculosis and xdr tuberculosis respect to treatment success rate in India it is about 85% but for multi resistant tuberculosis patients the treatment success rate is only 57% for people living with ha heav AIDS and tuberculosis the success rate is 76% what are the social factors responsible for the transmission of the tuberculosis in the community malnutrition overcrowding economic recession indoor air pollution tobacco consumption alcohol abuse and diabet and course tuberculosis is such a big problem in our country in the world wh has given some International standards for tuberculosis care effective engagement of this is to provide effective engagement of care providers see initially it was stop tuberculosis strategy before stop tuberculosis strategy we have the dots strategy in 1994 so this is government committed case deduction through predominantly passive case finding in dots standardized the short course chemotherapy to all photom spere positive cases establishment of a system of regular drug Supply establishments and maintenance of monitoring system for program supervision evaluation this is the first thing uh which happened in 1994 the dot strategy thereafter in 2006 came stop tuberculosis strategy pursue high quality dots expansion and enhancement here the problem of drug resistance came so address the tuberclosis HIV multi tuberclosis then contribute to Health System strengthening engage all providers means not only government the private healthcare providers will also be engaged in this program because that time in 2006 and 12 the major problem for failure of tuberclosis the private practitioners were not following the government protocol so to engage them stops tu is strategy give more importance Empower people with tuberculosis and Community enable and promote research all these things were given in importance then came in 2015 anti tuberculosis strategy here the integrated patient centered care and prevention is given more importance bold policies and supportive systems are implemented are trying to be implemented intensified research and Innovation this is very very important to permanently erase tuberclosis from our world so the stop tuberculosis strategy the the following factors were given more importance for control of tuberculosis case deduction treatment success incidence prevalence and death rate of due to tuberculosis now the according to the end tuberculosis strategy the goal is very ambitious that is by 2035 95% reduction in cases and 90% deduction in tuberculosis incidents has to be achieved that is the ambitious goal of wh but what are the rates like covid pandemic poses a very big threat to tuberculosis control from our world whenever you write about global plan targets you have to write about 90 90 90 Target that is reach at least 90% of all people with tuberculosis and place them all on appropriate therapy that is first line second line or preventing therapy whatever is required 90% of the key population the most vulnerable third Aris population should be covered third 90% treatment success should be achieved for all people diagnosed with tuberculosis through affordable treatment services adherance to complete and correct treatment and social support so always write about the 9090 Target now coming to India in India constitutes already I told 26% of global burden and the incidence in India is 193 per 1 lakh treatment coverage in India is 82% and tuberculosis case fatality is 177% and incidence of HIV with tuberclosis is 71 per 1 lakh and insance of multi resistance is 124 per 1 lakh these values are very important now the classification of sh closes we have to write like uh based on four things one is based on an tropical site that is pulmonary or extrapulmonary tuberclosis second one is based on HIV status it is HIV positive tuberclosis or HIV negative thirdd one is based on drug resistance So based on drug resistance can be classified like monor resistance if the resistance to One firstline Drug then it is monor resistant poly drug resistance when there is resistance to more than one first anti CL L that is both Ison and refine then it is poly drug resistant multidrug resistant resistance to at least both a and refin extensive drug resistance here the resistance to any fluropon and at least one of the three second line injectable drug that is a caprine canine Amic acid in addition to multi resistance that is extensive Dr resist then refampin resistance this is resistance to refampin directed using phenotypic or genotypic method with or without resistance to other tuberculosis antituberculosis drugs so this is third class fourth one is based on his hisory of previous tuberculosis treatment new patient patients who have never been treated for tuberculosis or they have taken anti- tuberculose deck for less than 1 month and who is relapse relapse is previously treated for tuberculosis and were declared cured uh our treatment completed at the end of their most recent course of treatment and are now diagnosed with a recurrent episode of tuberculosis so here the patient is declared cured but again he got tuberculose that is relapse foras treatment after failure is uh previously treated for tuberculosis but declared lost to follow up the end of their most recent course of treatment so they were previously known as treatment after default treatment after failure that is those who have previously been treated for tuberculosis and whose treatment failed at the end of their most recent course of treatment treatment after loss to followup that is the patients have previously been treated for tuberculosis and were declared loss to follow up at the end of the most recent course of treatment so these are the four types of classification now coming to the agent factors you know microbacterium tuberculosis is the most important facultative intracellular parasite responsible for tuberculosis recent years there is a typical microbacteria which is causing tuberculosis like photochromes microbacterium consi scotochromogenic microbacterium scrum non photoch chromos microbacterium intercellular rapid Growers microbacterium fraum so atypical microbacteria also plays a role in recent time the source of infection it is the human source which is the most important source and as I told in the beginning uh each active patient will transmit at least 10 to 15 persons in the one year of within one year so there are two types of strain in source that is one is rapid multipliers another one is slow multipliers rapid multipliers they're more susceptible to bacteria sidal drug but low multipliers they are not susceptible to bacteria sidal drug so they become dormant and they are the bacteria that is responsible for relax next source of infections can also be Bain in case of Bain tuberculosis the Comm unability see the patient if untreated he is lifelong communicable but once treatment is started within 48 Hours 90% of the cases will become asymptomatic will reduce infectivity so the infectivity will reduce by 90% within 48 Hours of starting treatment cost factors see the 0 to 14 years age group only 2% of the people are affected with tuberculosis whereas in 15 to 24 year age group 20% are affected with tuberculos it is more prevalent in males heridity it is not a hereditary disease nutrition see Mal nutrition is a very important component Factor responsible for development of active disease immunity so man has no inherited immunity either he has to get natural infection uh so to get immunity or BCG vaccination to get immunity what are the social factors see the poor housing overcoding population explosion undernutrition smoking alcohol lack of awareness large families early marriages lack of Education all these are social factors responsible for disease what is the mode of transmission the mode of transmission is mainly by coughing so it's is not actually transmitted by formates it's not really important most important rout of transmission is by coffee incubation period see right from the receip of infection to the development of positive tuberculose tuberculin test it takes about 3 to 6 weeks so that is the incubation period it also depends upon the closeness of contact extense of disease see thereafter after infectivity the possibility of developing a disease depends upon closeness of contact extent of disease pum positivity Etc now the coming to the control of tuberculosis uh these are the two main components in the control of tuberculosis first Curative component and preventive component these two are very important in control of tuberculosis in Curative component we have case finding and treatment in preventive component we have vcg vaccination so this is the overall now coming to the each thing case finding see the case finding is the first step in tuberculosis control program for deduction of spotm positive cases it is an intensive ongoing program active case finding passive case finding is when there is persistent cough and fever patients come to the hospital where he is tested for phon positivity then intensified case finding so people whoever seek the health care not for tuberculosis but uh with or without symptoms or signs of tuberculosis but as a part of the program this intensified case finding is done uh those cases who are vulnerable population clinically and socially who those who are at greater risk of tuberculosis they will be undergoing the screening process especially the vulnerable population they will be assessed by phum test and intensified case finding is this vulnerable population will be is given more Focus for intensified case finding then screening strategies see Community screening and institutional screening uh Community screening is we go to the population by mobile facility where we do the screening institutional screening is in healthcare facilities now what are the case finding tools we have microscopy culture drug sensitivity test Rapid molecular test microscopy you know gal need and staining Flores training culture is L Stein Jensen media LJ media bch these are all used in culture but the problem with culture is it will take a long time for the result to come 2 to 8 weeks that is a problem photo microscopy is easy to diagnose but sensitivity is very low coming to the drug sensitivity testing modified proportionate sensitivity testing PST mg8 960 system and uh economic variant of proportion sensitivity testing using LJ medium these are drug sensitivity testing but uh these DST is now replaced by rapid molecular test because it's becoming very famous because of the speed and accuracy line probe as is used especially for deducting resistance it is very useful molecular test so line flow B is very useful in deducting the resistance and cbat is very useful in diagnosis and as well as in identifying the resistance so these days rapid molecular test are getting more importance so slide reporting in G lense training on the positivity come we classify as zero candy plus plus plus Plus+ plus so these are all uh the results based on the number of AFB for 100 100 oil immersion field uh first three and then last two number of AFV per oil immersion field so this is how we give SL reporting then tuberculin testing this is a two-step testing and this was the only available for estimating the prevalence in the prevalence of infection in a population so remember that still even though it was discovered in 1907 tuberc test is the only test still now available for estimating the prevalence of infection in your population so here what do we use in this tuberculate test in India we use PPD rd23 with TW 80 strain to identify the infectivity so remember this PPD rd23 tw80 this tuberc test is given in the left forarm .1 ml intradermally in the Flexar aspect of the left forearm we give midway between the elbow and the wrist the test is read after 48 to to 96 hours preferably 72 hours so the reactions exceeding more than 10 mm are considered positive 6 to 9 mm are doubtful less than 6 mm is negative next is tuberculin tuberculosis interferant GMA release a a igra we say this igra is mainly used to assess the person's immune system is not directly measuring in the tuberculosis here here what is measured is the cyto What is the cyto level in the population what is the capability of the person's immune system to deal with tuberculosis so the igra is mainly used to identify latent tuberculosis infection it is still under trial now let us move to the from case finding let us move to the treatment part the treatment part we use first Lane drugs and second lane drugs chemotherapy drugs that is anti-tuberculous drug so we will go to the next slide see here first line drugs and we have second line drugs in the first line drugs we have to classify them into bacteria sidal B static so in the first Lan drugs the only drug which is bacteriostatic is ethol this etham butol will prevent the replication multiplication of tuberculous Basil all other drugs here will kill the tuberculous basil rabine in pomine pyin made will kill so remember ramine has a side effect of hepatotoxicity Castries influenza like illness perpa thrombocytopenia nephro nephrotoxicity and it turns the urine red very common side effect of rampin and and next one is in Ison asid it is acts on rapidly multiplying bacteria it kills but it doesn't have bacterio static property the side effect are gastro irritation peripheral neuropathy blood disra hyperglycemia and liver damage so because of peripheral neuropathy along with py doxin along with in we give py doxin 10 to 20 mgam daily remember this next is streptomycin streptomycin the problem is it is a injectable drug and it can cause uh vestibular damage and nagas so it can cause ENT complications next is pyamid pyamid increases the sterilizing activity of re so the combination of rampin and pyamid is very very effective especially for tuberculous meningitis which affects the brain the complication of pyamid includes hypotoxicity and hyperthemia very interesting complication is hyperemia of pyramide now we will move on to the eam mutal which is a bacterio static drug the major side effect of EOL is retrobulbar netis let's now move to the second line drug flurinol that is coflin oxy lixin Moxy flosin gtif flosin are all folos used in second as a second L drug in MDT and Eide is structurally related to in especially it's effective against atypical microbacteria capry it is a bacteria cded drug Canam Amin are bacterial drug cyclosarin is bacteriostatic drugo crosses the placental barrier so it is also secrete milk so it should never be used in HIV patients can cause severe and fatal reactions thestone side effects include gastroin disturbance blur ring ofish hemolytic anemia Artica so it has lot of side effects very careful we should be very careful about this Stone Drug macro antibiotics ayine and clarine can be used Boline is a newer group of antitubercular drug espcially targets a microbacterial ATP synthes it's a bacteria cidal drug pregnancy is a candicate ation for Boline cardiac ariia is a contraindication for Boline age of the patient should be more than 18 years so remember these three points with respect to baculate now next one is damade damade is a recently approved drug for treatment of tuberculosis 50 mgram is given especially for MDR tuberculosis now coming to the approaches of tuberculosis control initially we used shortcat chemotherapy in 1972 this short Coast chemotherapy was introduced intensive and then continuation phase intensive phase we are trying to kill the bacteria so using the All In Define pomine and EOL then for the next two months we use continuation pH I andine but this is a older thing shortcat chemotherapy now Dots Dots was introduced later this supposed to be the most effective program on a program basis dots strategy is very effective directly absorb treatment short course the patient should follow the drug in the presence of the health worker in intensive phase in continuation phase the patient has issued the medicine for one week in a multipl comi pack the patient has to bring back the empty pack to get the next dose so dot is a very interesting and very effective chemotherapy strategy in the program but thereafter in recent years now this program is changed in 2016 to daily dose regimen this daily dose regimen replaces the dots in dots we use intermittent regimen like weekly three times we give but that is replaced by every day it should be given daily dose regiment it is introduced in the program in the daily dose regiment fixed dose combination that is four FDC that is HR every day four HR is given during the Intensive phase and then 3 3 FDC is given in the continuation phase means a three fixed dose combination is given in the continuation phase that is HR e for Pediatric patients we use fix do combination three HR res during continuation phase and two HR doing three HR is during intensive phase and two HR during continuation phase for Pediatric patients now whenever you write an exam this diagnostic algorithm is very important so the for presentive tuberculosis Patient First is smear examination when the smear examination is positive or negative based on that we go for the diagnostic algorithm near Chest xray can be taken and if chest xay is also negative then we go for CB net and then from cbnet we have to go for micum tuberclosis sensitivity testing like whether is sensitive for and all we have to check then repeat CB net and then go on for treatment if the spum is negative chest xray then again you have follow the same process for drug resistant tuberculosis patients presumptive tuberculosis all notify tuberculosis patient nonresponder to treatment here pres to Patient we have categorized them into special categories PL HIV PTV SP negative vulnerable and based on that separately give treatment otherwise all NE tuberclosis patient will be undergoing CB not will'll be testing for resistance and then they will be going along same algorithm for treatment of course the treatment here will vary because it is drug resistant to tuberculosis here we use second line drugs childhood tuberculosis affects 6 to 8% of all tuberculosis patient is childhood tuberculosis like Active cases of children trasp tuberculosis mainly children's tuberculosis occur because there is failure of tuberculosis in adult tuberculosis control in adults because of that it will spread to the child that is the most important thing so when do you go for a childhood tuberculosis is screening when when there is persistent Fe for more than or equal to 2 weeks when there is unremitting cough for more than 2 weeks weight loss of 5% in 3 months or no weight gain in past 3 months so then you Aras a suspicion of tuberculosis and go for testing of tuberclosis in children so remember this is a very important algorithm like same like before for childhood Tu closes here these are the things persistent fever more than 2 weeks uniting cough more than 2 weeks weight loss of 5% then you go for CB n directly here for Children First immediately you go for CB n and then from C not you proceed whether it is sensitive or not sensitive uh chest x-ray and then go for treatment chest x-ray is needed only if there is if you suspect extra pulmonary tuberculosis and it is very common in children extrapulmonary tuberculosis now the special group is tuberculosis in pregnancy and lactating woman so the duration of pregnancy if it is less than 20 weeks more than 20 weeks based on that we give the treatment and similarly sometimes there could be special emphasis on tuberculosis and diabetes tuberculosis and HIV osis and too tuberculosis and covid these can also occur so these are Co infections or a non-communicable disease with a communicable disease I hope for undergraduate level for tuberclosis question this level of understanding and knowledge is enough to write in the paper even though the in the book it is a 36 page document the whole program document is given there you cannot write the whole 36 pages in your exam paper so I have given it in a concise manner about your closes try to write all these points in your exam paper you will get 10 out of 10 for this essay of course I didn't cover National program for tuberculosis finally go into my another video on National program rntcp for tuberculosis I have given it separately go and watch the program for Rapid revision