hepatitis%20-%20viral
HEPATITIS - VIRAL
The majority of acute viral hepatitis infections are asymptomatic or they can cause an anicteric illness that may not be diagnosed as hepatitis.
Hepatitis A generally causes minor illness in childhood with >80% of infections being asymptomatic but more likely to produce clinical symptoms in adults. 
Hepatitis B, C, and D may also be asymptomatic.
Hepatitis A is predominantly transmitted through oral-fecal route.
Hepatitis B is transmitted through perinatal, percutaneous, or sexual routes or close person-to-person contact via open cuts and sores.
Hepatitis C infections are transmitted through perinatal, percutaneous, or sexual routes, blood transfusions, or organ transplants.
Hepatitis D's route of transmission is sexual or percutaneous, especially IV drug use.
Hepatitis E is transmitted primarily through contaminated drinking water and oral-fecal transmission.

Principles of Therapy

Chronic Infection of Hepatitis B

Patients For Whom Treatment is Not Recommended
  • Without clinical evidence of cirrhosis, with PNALT, HBV DNA <2,000 IU/mL, regardless of HBeAg status or age
Patients For Whom Treatment is Recommended
  • Evidence of compensated or decompensated cirrhosis regardless of HBeAg status or HBV DNA or ALT levels
  • Without clinical evidence of cirrhosis but with persistently abnormal ALT, HBV DNA >20,000 IU/mL, regardless of HBeAg status
  • Chronic HBV severe reactivation
Goals of Treatment
  • Continued viral suppression is necessary to reduce or prevent hepatic disease and disease progression
  • Primary goal of treatment is to permanently suppress HBV or to eliminate it
    • Short-term goal is the sustained suppression of HBV DNA, ALT normalization, to prevent decompensation and to decrease hepatic necroinflammation and fibrosis during and after therapy
    • Long-term goal of therapy is to avoid hepatic decompensation, reduce or prevent progression to cirrhosis and/or HCC and to prolong survival
  • Endpoints used to assess response:
    • Biochemical response: Normalization of serum ALT
    • Virological response: HBV DNA <104 copies/mL and sustained seroconversion from HBeAg to anti-HBe
    • Histological response: Decrease in histology activity compared to pretreatment liver biopsy or a reduction of at least 1 point in fibrosis by Metavir staging
    • Complete response: Fulfill criteria of biochemical and virological response and loss of HBsAg
  • Current treatments of chronic hepatitis B have limited long-term efficacy
Considerations Prior to Initiation of Treatment
  • Age of patient
  • Severity of liver disease
  • Likelihood of response
  • Potential adverse events and complications
  • HBeAg-positive patients with elevated ALT levels and compensated liver disease should be observed for 3-6 months for spontaneous seroconversion from HBeAg to anti-HBe prior to initiation of treatment
  • Choice of therapy will depend on availability, cost of medication, necessary number of clinic visits, expected duration of treatment and patient/clinician preference
Other Considerations in Pharmacological Therapy
  • There is no evidence that combination therapy of 2 direct antiviral agents results in better viral suppression compared to single agent
  • In treating concurrent infections such as hepatitis C virus, hepatitis D virus and HIV infection, it is important to identify the dominant virus as this will determine the therapeutic regimen
    • Concurrent hepatitis C infection may be treated with same antiviral therapy for HCV monoinfection
Hepatitis C

Antiviral therapy is currently widely accepted for the following Hepatitis C patient groups:
  • ≥18 years of age
  • Normal and abnormal ALT levels
  • Liver biopsy showing chronic hepatitis with significant fibrosis (stage F1 or above)
  • HCV genotype 2 or 3 regardless of stage
  • Compensated liver disease 
  • Acceptable hematological and biochemical indices
  • If there is a history of depression, the condition is well controlled
  • Willing to be treated and conform to patient requirements
  • Treated previously for HCV infection
Therapy should be individualized in patients with any of the following:
  • Failed prior treatment of either Interferon given alone or in combination with Ribavirin or Peginterferon given alone
  • Current illicit drug user or alcoholic but willing to participate in substance abuse program or alcohol support program
  • No or mild fibrosis on liver biopsy
  • Acute hepatitis C
  • Coinfected with HIV
  • <18 years
  • Chronic renal disease
  • Decompensated cirrhosis
  • Liver transplant recipient
Therapy is contraindicated in patients with any of the following1
  • Major, uncontrolled depressive illness
  • Renal, heart or lung transplant recipient
  • Autoimmune hepatitis or other condition known to be exacerbated by Interferon and Ribavirin
  • Untreated hyperthyroidism
  • <3 years of age
  • Pregnant or unwilling/unable to comply with adequate contraception
  • Severe concurrent disease (eg hypertension, HF, uncontrolled DM, etc)
  • Known hypersensitivity to drugs used to treat HCV
  • Hepatic decompensation

1 Patients have detectable HCV RNA

Goals of Treatment
  • Antiviral treatment for acute hepatitis C aims to prevent progression to chronic hepatitis C
  • Antiviral treatment of chronic hepatitis C aims to prevent occurrence of liver-related complications
    • HCV therapy reduces decompensation rate and hepatocellular carcinoma risk in patients with cirrhosis
Principles of Treatment
  • Treatment is indicated for both treatment-experienced and treatment-naive patients with compensated and decompensated liver disease
  • Treatment responses are usually characterized by HCV RNA testing
  • Eradication of infection is considered when there is sustained virologic response (SVR)
    • SVR is defined as the absence of HCV RNA in serum by a sensitive test at the end of treatment and 6 months later
  • Rapid virologic response (RVR) is achieved when HCV RNA becomes undetectable (<50 IU/mL) in serum after 4 weeks of therapy
  • Early virologic response (EVR) is defined as 2-log drop or loss of HCV RNA 12 weeks into therapy
  • End of treatment response is defined as continued absence of detectable virus at end of treatment
  • Relapse is considered when HCV RNA becomes undetectable on treatment but is detected after discontinuation of therapy
  • Patients in whom HCV RNA levels remain stable while on treatment are considered non-responders while those whose HCV RNA levels decline but never become undetectable are referred to as partial responders
  • Choice, course and duration of therapy are influenced by the HCV genotype
Individualize treatment based on the following:
  • Severity of liver disease
  • Potential of serious side effects
  • Likelihood of treatment response
  • Presence of comorbid conditions
Spontaneous Resolution in Acute Infection
  • Chance of spontaneous resolution is greater in female patients and those with HCV genotype non-1 infection
  • Less likely to happen if infection lasts >12 weeks

Pharmacotherapy

Hepatitis B

Adefovir dipivoxil
  • Adefovir dipivoxil has shown to be beneficial in patients with HBeAg-positive chronic hepatitis B infection
  • May be a preferred agent for patients with negative HBeAg, HBV DNA >105 copies/mL and elevated ALT
  • Inhibits reverse transcriptase and DNA polymerase activity and is incorporated into HBV DNA causing chain termination; however, it has a low barrier to resistance that can lead to drug resistance
  • Effective as an add-on agent in suppressing Lamivudine-resistant HBV; resulted in HBV DNA suppression of 82-87% and lower risk of Adefovir resistance of 4-8% in 3-4 years
    • 10-mg dose has a more favorable risk-benefit profile compared to 30-mg dose
  • HBeAg-positive chronic hepatitis patients may discontinue therapy after 1 year and confirmed HBeAg seroconversion but durability of response is unknown
    • Therapy may be continued in those who did not achieve HBeAg seroconversion but safety and efficacy has not been established
  • HBeAg-negative chronic hepatitis may need extended treatment (>1 year) to maintain response
    • Further studies are needed to determine optimal duration of therapy
Other Considerations
  • Renal function and bone profile must be monitored every 3 months for patients with predisposition to renal insufficiency and for patients on Adefovir dipivoxil for >1 year
Clevudine
  • Daily dose of 30 mg for 24 weeks has been shown to be associated with 59% undetectable HBV DNA (<300 copies/mL) and 7.6% HBeAg seroconversion in HBeAg-positive patients, with 92% undetectable HBV DNA in HBeAg-negative patients
  • Monitor for muscle symptoms and muscle weakness during therapy
Entecavir
  • Approved by United States Food and Drug Administration (USFDA) for treatment of chronic hepatitis B virus infection in adults with evidence of active viral replication and either evidence of persistent elevations in ALT or AST or histologically active disease
  • Considered 1st-line agent for treatment of HBV infection
  • Use is based on histologic, virologic, biochemical and serologic responses after 1 year of treatment in nucleoside-treatment-naive and Lamivudine-resistant adult patients with HBeAg-positive or HBeAg-negative chronic HBV infection with compensated liver disease
  • Appears to be superior to Lamivudine based on histologic improvement, reduction in viral load and ALT normalization
  • Effective in the treatment of Adefovir and Tenofovir resistance
  • Inhibits the following HBV polymerase activities: Base priming, reverse transcription of the negative strand from the pregenomic messenger RNA, and synthesis of the positive strand of HBV DNA
Other Considerations
  • Studies in rodents exposed to high doses (ie 3-40x that given to humans) of Entecavir showed increased incidence of lung adenomas, brain gliomas and hepatocellular carcinoma
Interferon alfa
  • Interferons have antiviral, antiproliferative and immunomodulatory effects
  • May be a preferred agent in the treatment of HBeAg-negative chronic hepatitis B and HBeAg-positive chronic hepatitis with elevated ALT
  • Suppresses HBV replication and induces remission of liver disease
  • Efficacy is limited to a small percentage of highly selected patients
    • Relapse is a major problem in HBeAg-negative chronic hepatitis B
  • For HBeAg-positive chronic hepatitis B, important predictors of response to therapy are high pretreatment ALT and lower levels of serum HBV DNA
  • Finite duration of therapy
Other Considerations
  • Prednisone priming prior to Interferon alfa therapy is not recommended
  • Contraindicated in patients with decompensated cirrhosis and coexisting autoimmune diseases
  • Not recommended for patients with compensated cirrhosis because of risk of hepatic decompensation associated with Interferon alfa-related flares of hepatitis
  • Side effects include mood swings and depression; patient’s mental health should be closely monitored by the clinician
  • Pregnancy is discouraged during Interferon therapy
    • If patient becomes pregnant during therapy, Interferon should be replaced with another drug
Lamivudine
  • Used for HBeAg-positive chronic hepatitis with elevated ALT but has a high rate of drug resistance during long-term treatment
  • Recommended in viremic patients (HBeAg-positive and HBeAg-negative patients) with ALT >5x ULN especially if there is concern regarding decompensation
  • Good safety profile and ease of administration are its advantages over Interferon alfa
  • Action: Premature termination of viral DNA chain termination thereby inhibiting HBV DNA synthesis
    • Induces histologic improvement and reduction in rate of development of hepatic fibrosis
  • Effects:
    • Pretreatment ALT is the most important predictor of response
    • Response is greatest in patients with an ALT 2-5x the normal value
  • Treatment may be discontinued in patients who have completed 1 year of treatment and have persistent HBeAg seroconversion to anti-HBe and undetectable HBV DNA by PCR assay
  • Treatment may be continued in patients who have not achieved HBeAg seroconversion and have no evidence of breakthrough infection because HBeAg seroconversion may occur with continued treatment
Other Considerations
  • While on therapy, monitor LFTs, HBeAg and anti-HBe every 3 months
  • Test for HBV DNA at 3 and 6 months of therapy and every 3-6 months thereafter
Lamivudine-resistant HBV
  • Emergence of Lamivudine-resistant HBV is increasingly common with prolonged treatment, together with a decreasing rate of remission
  • Associated with development of Lamivudine-resistant YMDD viral mutants, which appear to be less virulent than wild-type HBV, but have been associated with rapidly progressive liver disease in some patients
  • Lamivudine resistance is usually manifested as breakthrough infection with reappearance of HBV DNA in serum
  • There may be continued clinical benefit with continuation of treatment in spite of development of drug resistance
    • Benefits of continued treatment must be balanced against the risk of resistant mutants
Peginterferon alfa
  • Approved in a number of countries for chronic hepatitis B for both HBeAg-positive and HBeAg-negative chronic hepatitis in adult patients with compensated liver disease, evidence of viral replication and liver inflammation
    • In many countries in Asia, Peginterferon alfa 2b is approved for use in the treatment of chronic hepatitis B
  • Appears to have superior efficacy compared to Lamivudine based on HBeAg seroconversion, HBV DNA suppression and HBsAg seroconversion
    • Longer half-life compared to Interferon alfa and appears to impart a clinical benefit over conventional Interferon alfa
  • Action: Inert Polyethylene glycol is added to Interferon, decreases the drug’s renal clearance and increases its half life
    • Provides sustained viral suppression with efficacy similar to or better than standard Interferon alfa
  • Finite duration of therapy, no reported resistance
Other Considerations
  • Contraindicated in patients with decompensated cirrhosis
  • Side effects include mood swings and depression; patient’s mental health should be closely monitored by the clinician
Telbivudine
  • Orally bioavailable with potent and specific anti-HBV activity
  • Clinical trials show that Telbivudine gave more potent HBV suppression than Lamivudine or Adefovir in both HBeAg-positive and negative patients and showed equal potency to Entecavir in HBV suppression in HBeAb-positive patients but has a high rate of resistance
  • Action: Competitively inhibits viral reverse transcriptase blocking DNA polymerase activity
  • Monitor for muscle symptoms and muscle weakness during therapy
Tenofovir
  • A very effective antiviral agent for hepatitis B (chronic HBeAg positive or HBeAg negative) that has minimal resistance rate
  • Used as a 1st-line agent for treatment of HBV infection and as an alternative agent in patients with suspected or confirmed resistance to Adefovir, Entecavir, Lamivudine and Telbivudine
  • Monitor renal function and bone profile every 3 months

Acute Hepatitis C

  • Treatment may be delayed for 8-12 weeks to allow spontaneous resolution
  • Interferon (high-dose) or Peginterferon may be used
    • Treat HCV genotype 1 for 24 weeks, genotype 2 , 3, or 4 for 12 weeks
    • Patients unresponsive to monotherapy should be given Peginterferon/Ribavirin or a protease inhibitor-based triple therapy

Chronic Hepatitis C 

  • In limited-resource settings, Peginterferon/Ribavirin combination therapy may be considered in HCV genotypes 1, 4, or 6 treatment-naive patients with favorable IL28B genotypes and low viral load and in HCV genotypes 2 or 3 treatment-naive patients
    • For treatment-experienced patients, Peginterferon/Ribavirin can only be given in those who relapse with favorable IL28B genotype and without cirrhosis
  • Sofosbuvir with Peginterferon/Ribavirin for 12 weeks can be utilized as an alternative regimen in patients with genotypes 1, 3, 5 and 6

HCV Genotype 1a treatment-naive patients without cirrhosis

  • Recommended treatments:
    • Elbasvir/Grazoprevir x 12 weeks and in patients with no baseline NS5A RAVs for Elbasvir1
    • Ledipasvir/Sofosbuvir x 12 weeks
    • Paritaprevir/Ritonavir/Ombitasvir plus twice-daily dosed Dasabuvir with weight-based Ribavirin x 12 weeks
    • Simeprevir plus Sofosbuvir x 12 weeks
    • Sofosbuvir/Velpatasvir 12 weeks
    • Daclatasvir plus Sofosbuvir x 12 weeks
  • Alternative treatment:
    • Elbasvir/Grazoprevir with weight-based Ribavirin x 16 weeks and in patients with baseline NS5A RAVs for Elbasvir1

HCV Genotype 1a treatment-naive patients with compensated cirrhosis

  • Recommended treatments:
    • Elbasvir/Grazoprevir x 12 weeks and in patients with no baseline NS5A RAVs for Elbasvir1
    • Ledipasvir/Sofosbuvir x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks
  • Alternative treatments:
    • Paritaprevir/Ritonavir/Ombitasvir plus twice-daily dosed Dasabuvir with weight-based Ribavirin x 24 weeks
    • Simeprevir plus Sofosbuvir with or without weight-based Ribavirin x 24 weeks and in patients with no Q80K polymorphism
    • Daclatasvir plus Sofosbuvir with or without weight-based Ribavirin x 24 weeks
    • Elbasvir/Grazoprevir with weight-based Ribavirin x 16 weeks and in patients with baseline NS5A RAVs for Elbasvir

1Includes G1a polymorphisms at amino acid positions 28, 30, 31, or 93

HCV Genotype 1b treatment-naive patients without cirrhosis

  • Recommended treatments: 
    • Elbasvir/Grazoprevir x 12 weeks
    • Ledipasvir/Sofosbuvir x 12 weeks
    • Paritaprevir/Ritonavir/Ombitasvir plus twice-daily dosed Dasabuvir x 12 weeks
    • Simeprevir plus Sofosbuvir x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks
    • Daclatasvir plus Sofosbuvir x 12 weeks

HCV Genotype 1b treatment-naive patients with compensated cirrhosis

  • Recommended treatments: 
    • Elbasvir/Grazoprevir x 12 weeks
    • Ledipasvir/Sofosbuvir x 12 weeks
    • Paritaprevir/Ritonavir/Ombitasvir plus twice-daily dosed Dasabuvir x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks
  • Alternative treatments:  
    • Daclatasvir plus Sofosbuvir with or without weight-based Ribavirin x 24 weeks
    • Simeprevir plus Sofosbuvir with or without weight-based Ribavirin x 24 weeks
    • Asunaprevir plus Daclatasvir2 x 24 weeks

2Screening for NS5A resistance-associated variants (RAVs) is recommended prior to starting therapy

HCV Genotype 2 treatment-naive patients without cirrhosis

  • Recommended treatment:
    • Sofosbuvir/Velpatasvir x 12 weeks
  • Alternative treatment: 
    • Daclatasvir plus Sofosbuvir x 12 weeks

HCV Genotype 2 treatment-naive with compensated cirrhosis

  • Recommended treatment: 
    • Sofosbuvir/Velpatasvir x 12 weeks
  • Alternative treatment: 
    • Daclatasvir plus Sofosbuvir x 16-24 weeks

HCV Genotype 3 treatment-naive patients without cirrhosis

  • Recommended treatments:
    • Daclatasvir plus Sofosbuvir x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks

HCV Genotype 3 treatment-naive  patients with compensated cirrhosis

  • Recommended treatments: 
    • Sofosbuvir/Velpatasvir x 12 weeks3
    • Daclatasvir plus Sofosbuvir x 24 weeks with or without weight-based Ribavirin

3RAV testing for Y93H is recommended for cirrhotic patients and Ribavirin should be included in the regimen, if present

HCV Genotype 4 treatment-naive patients without cirrhosis

  • Recommended treatments: 
    • Paritaprevir/Ritonavir/Ombitasvir and weight-based Ribavirin x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks
    • Elbasvir/Grazoprevir x 12 weeks
    • Ledipasvir/Sofosbuvir x 12 weeks

HCV Genotype 4 treatment-naive patients with compensated cirrhosis

  • Recommended treatments:
    • Paritaprevir/Ritonavir/Ombitasvir and weight-based Ribavirin x 12 weeks
    • Sofosbuvir/Velpatasvir x 12 weeks
    • Elbasvir/Grazoprevir x 12 weeks
    • Ledipasvir/Sofosbuvir x 12 weeks 

HCV Genotype 5 or 6 treatment-naive patients with and without cirrhosis

  • Recommended treatments: 
    • Sofosbuvir/Velpatasvir x 12 weeks
    • Ledipasvir/Sofosbuvir x 12 weeks

New HCV Fixed-dose Combination Agents

  • Sofosbuvir/Velpatasvir/Voxilaprevir  
    • For patients with chronic HCV infection without cirrhosis or with compensated cirrhosis who have:
      • Genotype 1, 2, 3, 4, 5, or 6 infection and have been treated previously with an HCV regimen containing an NS5A inhibitor
      • Genotype 1a or 3 infection and have been treated previously with an HCV regimen containing Sofosbuvir without an NS5A inhibitor
    • Treatment duration is 12 weeks
  • Glecaprevir/Pibrentasvir  
    • For patients with chronic HCV infection genotypes 1-6 without cirrhosis or with mild cirrhosis, including patients with moderate to severe kidney disease and those on dialysis
    • Also for genotype 1 infection that has been treated previously with an HCV regimen either containing an NS5A inhibitor or an NS3/4A protease inhibitor but not both
    • Treatment duration is 8 weeks for genotypes 1-6 treatment-naive patients without cirrhosis

Decompensated Cirrhosis

HCV Genotype 1 or 4 

With decompensated cirrhosis who are Ribavirin ineligible  

  • Recommended treatment:
    • Daclatasvir plus Sofosbuvir x 24 weeks

HCV Genotype 1, 4, 5 or 6

With decompensated cirrhosis who are Ribavirin eligible  

  • Recommended treatments:
    • Sofosbuvir/Velpatasvir with weight-based Ribavirin x 12 weeks
    • Ledipasvir/Sofosbuvir with low initial dose of Ribavirin (may be increased as tolerated) x 12 weeks

With decompensated cirrhosis who are Ribavirin ineligible  

  • Recommended treatments:
    • Sofosbuvir/Velpatasvir x 24 weeks
    • Ledipasvir/Sofosbuvir x 24 weeks

With decompensated cirrhosis and in whom previous Sofosbuvir- or NS5A-based treatment has failed

  • Recommended treatments:
    • Ledipasvir/Sofosbuvir with low initial dose of Ribavirin (may be increased as tolerated) x 24 weeks
    • Sofosbuvir/Velpatasvir with weight-based Ribavirin x 24 weeks 

HCV Genotype 2 or 3

With decompensated cirrhosis who are Ribavirin ineligible  

  • Recommended treatments:
    • Sofosbuvir/Velpatasvir x 24 weeks
    • Daclatasvir plus Sofosbuvir x 24 weeks

With decompensated cirrhosis and in whom previous Sofosbuvir- or NS5A-based treatment has failed  

  • Recommended treatment:
    • Sofosbuvir/Velpatasvir with weight-based Ribavirin x 24 weeks

Hepatitis D

  • Interferon alfa may have a role, Peginterferon alfa-2a given for 48 weeks
    • Treatment is stopped after HBsAg seroconversion or if HDV RNA did not decrease with treatment of 6-12 months

Non-Pharmacological Therapy

Hepatitis D

  • Aim of treatment is to eradicate or to achieve long-term suppression of both hepatitis D virus and hepatitis B virus
  • Supportive care
  • Consider hospitalization if there is vomiting, dehydration, signs of hepatic decompensation
  • Screen for other STDs in cases of sexually-acquired hepatitis or if otherwise appropriate
  • Consider expert referral

Surgical Intervention

Liver Transplantation

  • Indicated in patients with end-stage liver disease (cirrhosis), hepatocellular carcinoma, and acute liver failure (ie caused by viruses, drugs and toxic agents)
    • Considered in patients with expected survival of ≤1 year without transplantation or if quality of life is unsatisfactory due to the liver disease 
  • Patients with HBV infection should be evaluated for liver transplantation despite antiviral therapy as development of liver failure cannot be predicted 
    • Combination therapy with hepatitis B immunoglobulin and nucleos(t)ide analogues helps prevent HBV recurrence in these patients undergoing liver transplantation
  • Recipient patients without anti-HBs should receive prophylaxis for HBV recurrence if transplanted liver is anti-HBc positive 
  • Patients with HCV infection should be treated prior to transplant to decrease the risk of HCV recurrence 
    • If with hepatitis C recurrence, treatment with antivirals is done and is started early in patients with significant graft damage 
  • HCV replication is not a contraindication for liver transplantation, though antiviral therapy should be given after transplant 
  • HDV replication is not a contraindication for liver transplantation
Digital Edition
Asia's trusted medical magazine for healthcare professionals. Get your MIMS Gastroenterology - Malaysia digital copy today!
DOWNLOAD
Editor's Recommendations
Most Read Articles
Elvira Manzano, 3 days ago
Bisphosphonates have proven antifracture efficacy and remain to be the cornerstone of osteoporosis treatment. However, a drug holiday is of particular importance with bisphosphonates due to some signals with long-term use of the drug, including rare incidence of atypical femoral fracture (AFF) and osteonecrosis of the jaw (ONJ), says a leading endocrinologist at AFOS 2017.
Pearl Toh, 13 Oct 2017
Women with higher plasma tryptophan concentrations were less likely to have poor sleep quality during pregnancy, especially among those with anxiety symptoms, according to the GUSTO* study.
5 days ago
Second eye cataract surgery provides greater improvement in visual function and quality of life compared with first eye cataract surgery alone, a recent study claims.
Dr Joslyn Ngu, 4 days ago

The main goal of the National Strategic Plan (NSP) for TB Control (2016 to 2020) is to reduce tuberculosis (TB) burden by ensuring universal access to timely and quality diagnosis and treatment of all types of TB, and preventing the development of drug resistant TB, says an expert.