ADMINISTERING TREATMENT

    Before a patient begins chemotherapy ,it is important to find out from the patient whether he has previously taken drugs for tuberculosis. Treatment regimens differ in type and number of drugs as well as duration.A patient who has never taken anti-TB drugs (or has taken these drugs for less than one month) will start on a different treatment regimen as compared to a patient who has taken anti-TB drugs in the past for one month or more. At this point, it is essential to understand the CASE DEFINITIONS and TYPES OF CASES as classified under the RNTCP.

CASE DEFINITIONS
Smear-positive pulmonary Tuberculosis
 TB in a patient with at least 2 initial sputum smear examinations positive for AFB  or TB in a patient with one sputum positive and X-Ray consistent with TB  or TB in a patient with one sputum positive and culture positive for M.tb.
Smear-negative pulmonary tuberculosis
TB in a patient with symptoms suggestive of TB with at least 3 sputum examinations negative for AFB, and X-ray consistent with active tuberculosis or Diagnosis based on positive culture but negative AFB sputum examinations.
Extra-pulmonary Tuberculosis
TB of organs other than the lungs, such as the pleura, lymphnodes, abdomen, genitourinary tract, skin, joints and bones, tubercular meningitis etc. Diagnosis should be based on one culture-positive specimen from the extra-pulmonary site, or histological evidence, or strong clinical evidence consistent with active extra-pulmonary TB.
Note: Pleurisy is classified as extra-pulmonary TB. A patient with both pulmonary and extra-pulmonary TB should be classified as pulmonary TB.

TYPES OF CASES
New: A patient who has never had treatment for tuberculosis or has taken anti-TB drugs for less than one month.
Relapse: A patient declared cured of TB by a physician, but who reports back and is found to be sputum positive.
Treatment after default: A patient who received ATT for one month or more from any source and who returns to treatment after having defaulted ie, not taken drugs consecutively for two months or more.
Failure: A smear positive patient who remains smearpositive at 5 months or more after starting treatment.It also includes a patient who was initially smear-negative but who becomes smear-positive during treatment.

Determine the category of treatment based on the following table.

* Regimen: The number before the letters refers to the number of months of treatment. The subscript after the letters refers to the number of doses per week.Doses are INH 600mg , Rifampacin 450mg (an extra 150mg is added if the weight of the patient is more than 60 kg), Pyrazinamide 1500mg , Ethambutol 1200mg and Inj.Steptomycin 0.75 gm unless patient is more than 50 years old or weighs less than 30kg in which case they receive 0.5gm.
 Examples of seriously ill extra-pulmonary cases are meningitis, disseminated TB, tuberculous pericarditis, peritonitis, bilateral or extensive pleurisy, spinal TB with neurological complications and intestinal and genitourinary TB.
In the rare instances that patients who are sputum smear negative or who have extra-pulmonary TB have Relapse or Failure the patient should be categorized as OTHER and given Category II treatment. However the diagnosis in all such cases must be supported by culture or histological evidence of current, active tuberculosis.
Category I: Intensive phase 2 months- 24 doses ; Continuation phase lasts
                 4 months-54 doses
Category II: Intensive phase lasts 3 months - 36 doses ; continuation 
                  phase lasts 5 months- 66 doses
Category III: Intensive phase 2 months -24 doses ; continuation phase
                   lasts 4 months- 54 doses.

OBTAINING AND DISBURSING DRUGS
The drugs are available in District TB Centres, microscopy centres and selected Peripheral Health Institutions. In the RNTCP, a box of medications for the entire treatment is earmarked for every patient registered , ensuring that the patient will never have to discontinue treatment from non-availability of drugs (one of the main drawbacks of the previous programme). RNTCP uses the best quality Anti tuberculous drugs available.
 Drugs are supplied in patient-wise boxes containing the full course of treatment, and packaged in blister packs. For the intensive phase, each blister pack contains one day's medication. For the continuation phase, each blister pack contains one week's supply of drugs. The combipack drugs for extension of the intensive phase are supplied separately.
The heart of the DOTS programme is "directly observed treatment" in which a health worker or any other trained person who is not a family member watches as the patient swollows the anti-TB medicines in their presence. It is important to realize that the DOTS provider need not belong to to the medical or paramedical community and can be any willing and conscientious member of the community .Doses are taken thrice a week. All the intensive phase doses and the first dose of every week in the continuation phase have to be taken under direct observation.

SPECIAL SITUATIONS:
Tuberculous meningitis
Treatment should be started as soon as possible. The continuation phase should be given for 6-7 months (total treatment 8-9 months). Steroids should be given initially to reduce meningeal inflammation and reduced gradually over 6-8 weeks.
Pregnancy
Streptomycin should not be given during pregnancy ; other drugs used in RNTCP are safe during pregnancy. Breast feeding should continue, regardless of the mother's TB status.