UNIVERSAL CARE INITIATIVE FOR TUBERCULOSIS CONTROL 2B Saurabh, 24E Sarojini Road, Santacruz West, Mumbai 400 054 2001. PREFACE: Tuberculosis is a major public health problem in India. The HIV/AIDS epidemic is compounding the problem by increasing the number of tuberculosis cases by around 15 %. Drug resistant tuberculosis is also showing a rising trend. Adopting the DOTs strategy for tuberculosis control has revitalized the National tuberculosis control program. Under this program, emphasis is on diagnosing and treating sputum positive cases (thus, the stress on microscopy), ensuring that the patient swallows each dose of medicines in the presence of a health care worker (directly observed therapy). Earmarking individual course in treatment boxes ensures uninterrupted free supply of medicines. This ensures good patient compliance. Appropriate monitoring and evaluation of the program is facilitated by meticulous documentation of all events. Standard management guidelines have made the process simple and easy to follow even in remote areas. For any measurable epidemiological impact and for preventing drug resistance, this standard protocol of management needs to be universally applied. Around 60% of patients seeking health care have the private medical practitioner as the first contact. This is due to convenience, hours of operation and issues of confidentiality, some of which may not be provided by public health institutions. Universal Care Initiative for Tuberculosis Control is working towards establishing adequate uniformity in the management of tuberculosis both in public and private health care facilities. To meet this end we have come out with this volume of “TUBERCULOSIS AT A GLANCE”. This booklet deals with the questions which practicing family physicians come across in dealing with patients suspected or suffering from tuberculosis. This being the first edition, we request readers to give us opinion on further clinical problems which they my come across in their daily practice. We have also touched on the guidelines of the Revised National Tuberculosis Control Program (RNTCP). We request you to adopt these in the management of your patients. Your patients who are socioeconomically underprivileged can be referred to the nearest RNTCP center for treatment. Dr. Yatin Dholakia MD; TDD. INTRODUCTION: “The scientists have done their part to help rid the world of tuberculosis. The TB bacillus was discovered over a hundred years ago and the medicines that can cure nearly every TB patient have been available for the past fifty years. However these tools are not being widely or correctly used….. they produce stronger bacteria and weaker patients.” Dr. Kochi – WHO – TB Program. This booklet will help disseminate the „tools and their proper usage‟ to reverse the scene to „stronger individuals and weaker bacteria‟ fulfilling the mission of we the medical practitioners. GLOBAL TB DEATHS Deaths in millions 6 5 4 3 2 1 0 1850 1900 1950 2000 2050 Discovery of MTB. First TB drugs Global Emergency Sanatorium Rx The above scenario is best understood by the following table showing FATE OF SPUTUM POSITIVE CASE. In three different situations: NO Rx PROGRAM POOR Rx PROGRAM GOOD Rx PROGRAM DEAD 50% 10% 1.2% SPUTUM NEG 64% 98% (CURED) 32% SPUTUM POS.(CHRONIC 18% 26% 0.8% CASES) DEFINITION OF TB. Tuberculosis is the manifestation of the reaction in the tissues in the host caused by the presence and multiplication of Mycobacterium tuberculosis bacilli. MODE OF SPREAD: - Air borne spread from a sputum AFB positive pulmonary TB case – this is the commonest mode of spread. - Ingestion – rare cases of intestinal TB are due to M. bovis infection. - Inoculation – skin TB in crawling children and pathology workers. SUSCEPTIBILITY: Host factors. Increases in case of immune compromise as in case of Diabetics, HIV infected individuals Drug/substance abuse Malnourished individuals. Environment factors such as overcrowding e.g. in prisons, slums etc. increase susceptibility. CLINICAL: TB can affect any organ system in the body. The symptoms can be divided into: A. Constitutional such as: fever, anorexia, weight loss, malaise etc. B. Specific to the organ system involved. DIAGNOSIS: As per the definition of TB- diagnosis can be by: 1. Identifying MTB in the sputum, tissues and other body fluids by various methods – the commonest being smear examination for AFB. Other methods include culture, PCR etc. The identification of MTB is most specific though not very sensitive. 2. Identifying the tissue reaction to the presence of MTB: Radiology – X-ray chest, ultrasonography, CT scans etc. Pathological examination of the tissues by FNAC or biopsy. Tuberculin Test: indicates the level of cell mediated immunity in the host. The results are masked by BCG, nutritional status, presence of viral infection (like measles, HIV infection etc.) The value of this test is restricted to epidemiological investigation. ESR: This test has no role in diagnosis and prognosis. NEWER TESTS: 1. Detection of antibodies: by ELISA –IgG, IgM, IgA; these are not specific. 2. Detection of antigens: by PCR (polymerase chain reaction) test are very specific though expensive. These are not approved yet for commercial use. TUBERCULOSIS IN CHILDREN: In children, tuberculosis is difficult to diagnose since primary TB has insidious onset and therefore difficult to identify, and children are not able to bring out sputum. A scoring system is very helpful in identifying suspected cases of tuberculosis. FEATURE 0 1 3 SCORE Length of illness < 2 weeks 2 – 4 weeks > 4 weeks Nutrition (weight) > 80% for age 60 – 80% < 60% for age Family TB – None Reported Proved Sputum past/present. +ve. Score for other features if present: Positive tuberculin test (> 15 mm) 3 Lymph nodes 3 Unexplained fever, night sweats, no response to antibiotics 2 Malnutrition not improving after 4 weeks 3 Angle deformity of the spine 4 Joint swelling, bone swelling or sinuses 3 Unexplained abdominal mass or ascites 3 CNS involvement – send to hospital 3 SCORE 1-6 7 or > Chest X-ray Diagnostic Start TB Rx Not diagnostic Atypical pneumonia – Poor response Broad spectrum antibiotics Good response NO TB * Adapted from: Meeting the Child who might have Tuberculosis. In: Tuberculosis in Children by Sir John Crofton et. al. – CBS Publishers & Distributors, New Delhi, India. 1996. PP 48-49. CASE DEFINITIONS: PULMONARY TUBERCULOSIS – SPUTUM POSITIVE TB in a patient with at least 2 sputum smears positive for AFB OR with one smear positive for AFB and radiographic abnormalities consistent with active TB. OR with one smear positive for AFB and culture positive for M. Tb. PULMONARY TUBERCULOSIS SMEAR NEGATIVE: TB in a patient with symptoms suggestive of TB with at least 3 sputum smears negative for AFB and radiographic abnormalities consistent with active TB. OR Diagnosis based on one culture positive for M. Tb. But smear negative for AFB. EXTRAPULMONARY TB: TB of organs other than the lungs such as the pleura, lymph nodes, abdomen, genito-urinary tract, skin, bones CNS etc. Diagnosis should be based on one culture positive specimen from the related site, or histological evidence, or strong clinical evidence consistent with active TB. Pleurisy is classified as Extrapulmonary TB. When both pulmonary and extrapulmonary TB occur this should be classified as pulmonary TB. TYPES OF CASES: NEW: A patient who has never had treatment for tuberculosis OR has taken anti tuberculosis treatment for less than one month. RELAPSE: A patient declared cured of TB after complete treatment but who reports back and is found to be bacteriological positive. FAILURE: A smear positive patient who is smear positive at five months or more after starting treatment. OR a patient who is smear negative initially becomes smear positive during treatment. TREATMENT AFTER DEFAULT: A patient who received anti TB treatment for one month or more and who returns to treatment after having defaulted for two consecutive months or more. TRANSFERRED IN: A patient who has moved into a district after having started treatment at another unit where treatment has been recorded. CHRONIC: A patient who remains sputum positive after completing a retreatment regimen. OTHER: Patients who do not fit into the above categories. TREATMENT: PRINCIPLES OF CHEMOTHERAPY: Special bacterial population in a lesion a. Extracellular – drugs which act are INH, RMP, SM b. Intracellular – drugs which act here PZA, INH, RMP. c. Spurts of metabolism – RMP d. Dormant – no drugs effective. DRUGS AND REGIMEN: DRUG SHORT FORM DAILY DOSE THRICE A WEEK Rifampicin RMP / R 10 mg/kg. 10mg/kg. Isoniazid INH / H 5 mg/kg. 10mg/kg. Pyrazinamide PZA / Z 25mg/kg. 35mg/kg. Ethambutol EMB / E 15mg/kg. 30mg/kg Streptomycin SM / S 15mg/kg. 15mg/kg. COMBINATIONS: The above drugs are used in combination so as to: Achieve early kill of mycobacteria-thus ensuring sterilization of the lesions. Prevent drug resistance. Prevent relapse. ADMINISTRATION OF DRUGS: Intermittent administration The doubling time of Mycobacterium tuberculosis is about eighteen hours. The above drugs can hence fe taken thrice or twice a week due to the fact that they have a long lag period i.e. the time duration during which the drug remains in the blood and maintains its efficacy against the organisms.(Bull. WHO 1964;31:247:271; Tuberculosis Research Centre, Chennai. Brit. Med. J 1973;2;7:11; Am. Rev. Resp. Dis. 1991;143;700-706.) The studies were conducted in India. However alternate day / intermittent regimen should always be used under supervision. Relation to food. All the drugs can be given together; if tolerated well – ideally on empty stomach or else can be given one hour after food. The minimum inhibitory concentration (MIC) of the drugs thus taken is not affected and their efficacy is maintained. REGIMEN: consist of two phases i.e. Initial intensive phase and a Continuation phase. TREATMENT, FOLLOW UP AND MANAGEMENT OF TUBERCULOSIS CASES: Treatment Regimen Sputum examination Category Type of pt. Regimen Pre- Rx Test If result Then of sputum at mth is: Treatment New sp +ve + 2 - ve Start CP 2 (HRZE)3 4(HR) 3 +ve Extend IP x 1 mth. Category I Seriously ill sp -ve -ve 2 -ve Start CP Seriously ill EPTB Category II Sp +ve Relapse 2(HRZES)3 - ve Start CP Sp +ve Failure 1(HRZE)3 + 3 Sp +ve Rx 5 (HRE)3 + ve Extend IP x 1 mth. after default Category III Sp -ve, -ve Start CP not seriously ill 2(HRZ)3 -ve 2 EPTB 4(HR) 3 +ve Failure start not seriously ill Cat II Prefix indicates number in months Suffix indicates the frequency of dose (here thrice a week). IP – Intensive Phase; CP – Continuation Phase. USE OF STEROIDS IN TUBERCULOSIS: The use of steroids is restricted to TB meningitis to reduce the raised intracranial tension, pericardial effusion to prevent complicating constrictive pericarditis, certain varieties of tuberculosis of the eye, life threatening situations, where the use of steroids is recommended to treat associated illness. SURGERY IN TUBERCULOSIS: Diagnostic: Aspiration of fluids in serous cavities for bacteriological and cytochemistry examination. Fine Needle Aspiration Cytology (FNAC) Biopsy for tissue diagnosis – both these can be done for tissues like lymph nodes, pleura, peritoneum, lung, liver, kidney etc. Bronchoscopy – for diagnoses of endobronchial lesions. Therapeutic: Excision biopsy/block dissection of lymph node groups. Drainage of cold abscesses. Drainage of pleural fluid / air by needle or intercostal drainage in cases of moderate to massive pleural effusion / empyema, open pneumothorax/hydro/pyo-pneumothorax. Bones & joints – Spinal TB with paraspinal abscess or neurological involvement; joint surgery is rarely required. Intestinal obstruction. Bronchoscopy – to treat massive haemoptysis. Pleural surgeries like decortication in cases of non-expansion of lung in pneumothorax. Lung surgery – lobectomy, pneumonectomy in certain non-responders or with recurrent haemoptysis or secondary infections. Complications of tuberculosis as in hydrocephalus, for arthrodesis of joints, renal or genitourinary tract TB. HOSPITALIZATION IN TUBERCULOSIS: Almost all tuberculosis patients can be treated on domicillary / ambulatory basis. The need for institution treatment arises in case of: Severe massive haemoptysis. For control of associated Diabetes Mellitus. In case of respiratory distress arising out of complications / sequlae of tuberculosis. For surgical intervention. TREATMENT UNDER SPECIAL CONDITIONS: 1. WOMEN & TB: Women in childbearing age should be counseled to avoid pregnancy while on anti TB treatment and at least 6 months after. The effect of oral contraceptives is reduced by medicines and hence other methods of contraception should be advocated. Streptomycin should not be given in the first trimester of pregnancy. 2. DIABETES & TB: The effect of oral hypoglycaemic agents may be affected with anti TB treatment. A need to supplement with Insulin may arise. Inadequate control of DM will affect the response to anti TB treatment. 3. HIV & TB: The response to treatment does not differ from HIV negative TB patients. Relapses may be higher. Recommended duration of treatment is 9 months in fresh cases (NACO). SM should be administered using disposable needles and syringes. 4. GASTROINTESTINAL INTOLERANCE: This is very common on starting treatment and is usually self limiting within the first 8 to 10 doses. The patient needs to be reassured. If required, Domperidone can be given. 5. HEPATIC IMPAIRMENT: SM and EMB are safe in hepatic impairment. RMP, INH and PZA should be used cautiously. Management of drug induced hepatic impairment: If the patient is icteric and has a raised S. Bilirubin - stop all medication (if seriously ill, start SM and EMB). - When LFT comes to normal, reintroduce medicines one by one every 3 to 5 days in the following order: PZA, RMP and lastly INH. - If after starting any drug, icterus develops- that drug is suspect and withdrawn from the regimen. 6. HYPERSENSITIVITY REACTIONS: - RASH: Any drug can cause this condition. All medications are to be discontinued, the offending drug is to be identified by reintroduction after the reaction clears and avoided. If vital then hyposensitization should be carried out. 7. ARTHRALGIA & ARTHRITIS: PZA is the commonest cause. Treatment with anti-inflammatory agents esp. aspirin alleviates the condition. If severe and if uric acid levels are elevated, PZA should be discontinued. 8. RENAL IMPAIRMENT: Use of RMP and PZA is safe Use of INH is relatively safe – if GFR <10ml/min reduce the dose to 200mg and add vit B6 10mg. AVOID aminoglycosides like SM and EMB – they are NOT SAFE. 9. MISCELLANEOUS: In case of: Auditory & vestibular disturbance – SM should be stopped Purpura/bleeding disorder – RMP should be stopped. Sudden reduction in acuity, field of vision and colour blindness – EMB should be stopped. < 5 years age, EMB is avoided. RESPONSE TO TREATMENT: Provided the diagnosis, typing and categorization of the patient are accurate the response to treatment as suggested is excellent. Relapse rates are very low as reported by analysis from the RNTCP in K East ward in Mumbai. Monitoring the response is done: 1. by bacteriological (sputum smear) examination as follows- nd CATEGORY 1 - 0, 2, 4, & 6 months (when 2 . Month sputum is negative) nd CATEGORY 1 - 0, 2, 3, 5 & 7 months ( when 2 . Month sputum is positive) rd CATEGORY 2 – 0, 3, 5, & 8 months ( when 3 . month sputum is negative) rd CATEGORY 2 – 0, 3, 4, 6, & 9 months (when 3 . month sputum is positive) CATEGORY 3 – 0, 2 & 6 months. 2. Clinical examination: Defervesence of symptoms especially constitutional symptoms is a positive sign. Local symptoms will improve but there might be persistence of local symptoms due to the residual damage to the organ involved. Persistence of local symptoms does not necessarily mean activity. 3. Radiological examination where indicated: There are no markers for predicting complete resolution of the radiological shadows. Nearly 80% patients have residual lesions. These are inactive and do not require anti TB treatment beyond the stipulated course of the regimen. CAUSES OF TREATMENT FAILURE: FAILURE OF COMPLIANCE: 1. Patient - inadequate explanation to patients - feeling of well being - occurrence of side effects 2. Failure of treatment services - wrong location. - Unsuitable clinic hours - Lack of motivated/ hostile staff. 3. Social factors - personal problems such as job, hunger, stigma etc. - psychiatric illness, substance abuse like alcohol, drugs etc. FAILURE OF CORRECT PRESCRIPTION: Inadequate drug combination Inadequate doses Inadequate duration of regimen. All leading to drug resistance. DRUG RESISTANCE: The ability of the organisms to remain viable and grow in the presence of drug in concentrations that would have normally inhibited them is drug resistance (DR). Drug resistance is a laboratory diagnosis. Failure of treatment (as discussed above) may be a cause or effect of drug resistance. Clinically DR can only be presumed. Identification is easy when standard treatment protocols are universally followed. (see treatment outcomes – failures & chronic cases.) Symptoms in tuberculosis take a long time to be relieved, hence DR should not diagnosed clinically. Changing treatment indiscriminately will contribute to drug resistance. Second line drugs are expensive, less effective and have many side effects. Hence ideal management of DR is its prevention by taking care of the causes of treatment failure. Drug resistant tuberculosis should always be diagnosed and managed in consultation with a TB specialist experienced in managing such cases. COMPLICATIONS AND SEQUELAE OF TUBERCULOSIS: Complications: 1. Haemoptysis: this can occur any time during the illness. It may also occur after complete cure of tuberculosis. Thus it is both a complication and a sequelae of tuberculosis. Anti TB medicines should be continued if during therapy and other medicines like broad- spectrum antibiotics, cough suppressants, hemostat agents are useful in the management. Reassurance of the patient and avoiding pungent food is advisable during episodes. 2. Spontaneous pneumothorax: This may present with acute chest pain and breathlessness. Urgent surgical intervention is essential. This condition also can occur as a complication or sequelae. Sequelae: 1. Open negative syndrome – leading to haemoptysis, relapse, pyogenic abcess, aspergilloma, spontaneous pneumothorax, respiratory insufficiency, malignancy etc. 2. Bronchiectasis. 3. Chronic Obstructive Pulmonary Disease (COPD). 4. Cor pulmonale. etc. may present with chronic cough. These are due to lung lesions which are seen on chest X-rays and commonly misinterpreted as tuberculous lesions. Symptomatic treatment keeps the conditions under check. TREATMENT OUTCOMES: CURED: Initially sputum positive patients who have completed treatment and have negative sputum smears on atleast two occasions one of which is at completion of treatment. TREATMENT COMPLETED: Sputum positive cases who had completed treatment with negative smears at end of initial phase and none at the end of treatment. OR Sputum negative TB patients who has received full course of treatment and who has not become sputum positive during or at the end of treatment. OR Extrapulmonary TB who has received full course of treatment. DIED: Patient who died during treatment regardless of any cause. FAILURE: A smear positive patient who is smear positive at five months or more after starting treatment. OR a patient who is smear negative initially becomes smear positive during treatment. DEFAULTED: A patient who at any time after registration, has not taken anti TB treatment for two months or more consecutively. TRANSFERRED OUT: A patient who has been transferred to another treatment unit and his results are not known. REVISED NATIONAL TUBERCULOSIS CONTROL PROGEAM – RNTCP India has a long history of research and demonstration projects in tuberculosis. Unfortunately, despite the existence of a National TB Control Program since 1962, the desired results have not been achieved. A review carried out by a joint expert committee comprising various national and international experts from WHO, SIDA, NTP, NTI etc. showed that there is an over-dependence on X-rays for diagnosis; treatment regimens used are often non-standard and ineffective. In both public and private sectors, incomplete treatment is a norm rather than exception. On recommendation from the expert committee, a revised strategy to control tuberculosis was pilot tested in 1993 in a representative population. In these areas, diagnostic practices improved with the effective use of quality sputum microscopy, and cure rates doubled as compared to those achieved with traditional treatment delivery process. These encouraging results led to the formulation of the Revised National Tuberculosis Control Program (RNTCP). GOAL OF RNTCP: The goal is to ensure that at least 85% of all newly detected sputum positive cases are cured and thus interrupt the chain of transmission DOTS: Dots is a strategy. It is a well designed cost effective tool whose essential principles were first demonstrated in India at Chennai in the early 1950‟s. Thus it is re-imported into our country after having been tested and proved successful n various parts of the world. The key to the success of this DOTS strategy is that it places the responsibility for curing tuberculosis patients on the the health care providers and not the patients. COMPONNENTS OF DOTS The components of the strategy are: Diagnosis of patients who present to the health facility with cough of three weeks or more shall be done primarily by high quality sputum microscopy. The system includes multi-tier cross-checking and quality assurance of sputum smears. Regular and uninterrupted supply of drugs in patient-wise boxes with sufficient buffer stocks ensured. The drugs will be of approved quality. Short course chemotherapy given, as per designated schedule in a program of direct observation – health workers and community volunteers will provide direct observation of drug consumption. Systematic recording, monitoring and evaluation of the whole process. Commitment by all health care providers to implement the program as per recommendations. SERVICES PROVIDED BY RNTCP: High quality sputum microscopy with prompt reporting of results. High quality evaluation and appropriate treatment. High quality and free, uninterrupted supply of drugs. Ensuring that drugs are consumed by the patients till cure. Technical assistance in the care of patients and control of tuberculosis. ROLE OF PRIVATE MEDICAL PRACTITIONERS IN RNTCP Private medical practitioners have become the de facto primary health care providers. Around 60% of patients seeking health care have the PMP as the first contact. This may be due to convenience, hours of operation and issues of confidentiality some of which may not be provided by the public health institutions. For any measurable epidemiological impact and also for preventing drug resistance standard protocol for diagnosis and management of tuberculosis needs to be universally applied. Such a standard is not universally followed in private health care systems. Thus the role of PMP is vital for Tuberculosis Control. The private medical practitioners can help by: Ensuring that each and every person with a productive cough for 3 weeks or more ahs three sputum samples examined in a designated laboratory. Using sputum microscopy as the basic tool for diagnosis and monitoring of treatment and recognizing the limitations of X-rays in the diagnosis of TB. Referring patients to RNTCP sites for diagnosis &/or treatment. Emphasizing to the patients the critical importance of complete treatment to achieve cure from TB. Emphasizing the necessity of fully supervised treatment. Educating the community about tuberculosis and the availability of services. Offering their offices as DOT centers. Cough for > 3 weeks Other organ involvement FNAC/BIOPSY/CYTOCHEM/ 3 Sputum Smears USG/CTSCAN/MRI etc. 3 or 2 smears Positive 1 Smear Positive 3 Smears Negative X-ray Antibiotics (1-2 weeks) Positive Symptoms persist Positive Negative X-ray Positive Sputum Positive Pulmonary TB Not TB Sputum Negative Pulmonary TB Has the patient been treated for TB for one month or more previously? Is the patient seriously ill? Yes No Yes No Category II Category I Smear Positive Relapse New Smear Positive Category III Smear Positive treatment after Seriously ill Smear Negative and New Smear Negative Pulmonary TB Default Extrapulmonary TB Extrapulmonary TB (Not seriously ill) 8 Month Treatment Regimen 6 Month Treatment Regimen IP 2 mths: SM, INH, RMP, PZA, EMB IP – 2 mths: INH, RMP, PZA, EMB. 6 Month Treatment Regimen 1 mth: INH, RMP, PZA, EMB CP- 4 mths: INH,RMP IP – 2 mths: INH, RMP, PZA CP 5 mths: INH, RMP, EMB. CP – 4 mths: INH, RMP Sputum smear follow-up Sputum smear follow-up Sputum smear follow-up 2,4,6 mths (2 samples) 2, 6 mths (2 samples) 2,3,5,8 mths (2 samples) Outcome Cured if 8 mth sputum neg. Outcome cured if 6 mth sputum neg Outcome Treatment Completed if 6 mth sputum neg ORGANIZATION OF THE MUMBAI CITY TB CONTROL PROGRAM MUMBAI DISTRICT TB CONTROL SOCIETY MDTCS Executive Committee Chairman – AMC – (Health) – MCGM Secretary – DHO - TB ZONES – 6 FOR MUMBAI DISTRICT DTO - (AHO) WARD LEVEL TREATMENT UNIT MOTU STS – SENIOR TREATMENT SUPERVISOR STLS- SENIOR TREATMENT LABORATORY SUPERVISOR MICROSCOPY CENTER – 1 LAB. TECHNICIAN 1MC FOR 100,000 POP. HEALTH POST 1 FOR ~ 75000 POP. 1 FTMO 1 PHN- PUBLIC HEALTH NURSE ANM- AUXILLARY NURSE MIDWIFE - 3 MPW- MULTIPURPOSE WORKER – 3 COMMUNITY HEALTH WORKER (HON) 1 FOR ~ 3000 POP. TREATMENT UNITS IN MUMBAI WARD TREATMENT UNIT A, B, & C. Princess Street TB Clinic, S. G. Marg, Mumbai 400 002 D Balaram Street TB Clinic, R. S. Marg, Grant Road, Mumbai 400 007. E Nawab Tank TB Clinic, Dockyard Road, Mazgaon, Mumbai 400 010. F South Ramkunwar Daftary TB Clinic, Dadasaheb Phalke Road, Near Gautam Nagar, Dadar East, Mumbai 400 014. F North LTM Sion Hospital, Dr. Babasaheb Ambedker Road, Sion West,Mumbai 400022. G South Prabhadevi Dispensary, Near Prabhadevi Mun. School, Veer Savarkar Marg, Prabhadevi, Mumbai 400 018. G North Urban Health Centre, Dharavi, 60 feet road, Mumbai 400 017. H West M M Munshi Khar TB Clinic, Opp. Old Masjid, S. V. Road, Khar, Mumbai 400052. th H East V. N. Desai Hospital, TPS III 11 . Road, Santacruz East, Mumbai 400 055. K East Koldongri Dispensary, Opp. Garware Plastics, Sahar Road, Andheri East, Mumbai 400 069. K West Dr. R. N. Cooper Hospital, Gulmohar Road, JVPD Scheme, Mumbai 400 056. P South Siddharthnagar Hospital, Goregaon West , Mumbai 400 062. P North M. W. Desai hospital, Govindnagar, Malad East, Mumbai 400 097. R South Centenary Hospital, Parekh Nagar, S V Road, Kandivili West, Mumbai 400 067. R North Bhagwati Hospital, S.V. P. Road, Borivili West, Mumbai 400 092. M East Centenary Hospital Govandi, Waman Tukaram Patil Marg, Mumbai 400 088. M West MAA Hospital, Postal Colony, Chembur, Mumbai 400 071. L Kurla Bhabha Hospital, Belgram Road, Kurla West, Mumbai 400 070. L Rajawadi Mun. Gen. Hospital, Ghatkopar East, Mumbai 400 077. S Mahatma Jotiba Phule Hospital, Kanamvar Nagar 2, Vikhroli West,Mumbai 400075. T Mulund Gen. Hospital, M. P. Road, Mulund East, Mumbai 400 081. T Mulund Gen. Hospital, R. P. Road, Mulund West, Mumbai 400 080.
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