National Tuberculosis Control Program

National Tuberculosis Control Program DR. KANUPRIYA CHATURVEDI Lesson Objectives To know about the magnitude of TB problem To know about the evolution of TB control in India To learn about the goals, objectives and strategies To know about the achievements and progress 01/31/20

Dr. KANUPRIYA CHATURVEDI Magnitude of the Problem Global annual incidence = 9.1 million India annual incidence = 1.9 million India is 17th among 22 High Burden Countries (in terms of TB incidence rate) Source: WHO Geneva; WHO Report 2008: Global Tuberculosis Control; Surveillance, Planning and Financing 01/31/20 Dr. KANUPRIYA CHATURVEDI Global Burden of Tuberculosis

TB is one of the leading causes of death due to infectious disease in the world Almost 2 billion people are infected with M. tuberculosis Each year about: 9 million people develop TB disease 2 million people die of TB 01/31/20 Dr. KANUPRIYA CHATURVEDI Contribution of India to Global TB Control* 5.28 m 4.92 m ?

? 23% *WHO Global TB Report 2007 & 2008 01/31/20 23% Dr. KANUPRIYA CHATURVEDI The Beginning :National Tuberculosis Control Program Before the Revised National Tuberculosis Program (NTCP) came into force the existing Tuberculosis program had the following objectives: To identify and treat as large a number of TB patients as possible so that infectious cases are rendered non- infectious.

To reduce the magnitude of TB problem in the country to a level where it ceases to be a public health problem. 01/31/20 Dr. KANUPRIYA CHATURVEDI Organization and administration Central level District level Besides the Tuberculosis Division in the Directorate General Health services, National Tuberculosis Institute, Bangalore and Tuberculosis Research centre at Chennai

A district constitutes a functional unit of the NTCP and is called District Tuberculosis Control Program Peripheral level Comprises of chest clinics and Primary Health Centers (PHC) 01/31/20 Dr. KANUPRIYA CHATURVEDI Program Implementation( prior to RNTCP) Program activities were: Case detection Case treatment Health education BCG vaccination

01/31/20 Dr. KANUPRIYA CHATURVEDI Program performance and evolution of RNTCP Despite a nationwide network of facilities , NTCP failed to yield satisfactory results. The situation did not change much. The case finding efficiency was only 30 of the expected level although the mortality rate decreased to 53/100,00 population Government of India launched the Revised National Tuberculosis Control Program(RNTCP) in 1997 encouraged by the results of Pilot studies were tested in 1993-94 01/31/20

Dr. KANUPRIYA CHATURVEDI Evolution of TB Control in India 1950s-60s NTI 1962 1992 1993 1998

2001 2004 2006 01/31/20 Important TB research at TRC and National TB Programme (NTP) Programme Review only 30% of patients diagnosed; of these, only 30% treated successfully RNTCP pilot began RNTCP scale-up 450 million population covered >80% of country covered Entire country covered by RNTCP Dr. KANUPRIYA CHATURVEDI Revised National TB Control Program (RNTCP) Launched in 1997 based on WHO DOTS Strategy

Implemented as 100% centrally sponsored program Entire country covered in March06 through an unprecedented rapid expansion of DOTS Govt. of India is committed to continue the support till TB ceases to be a public health problem in the country All components of the STOP TB Strategy-2006 are being implemented 01/31/20 Dr. KANUPRIYA CHATURVEDI Objectives of RNTCP

To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases To achieve and maintain detection of at least 70% of such cases in the population 01/31/20 Dr. KANUPRIYA CHATURVEDI Strategy 1. 2. 3. 4.

Augmentation of organizational support at the central and state level for meaningful coordination Increase in budgetary outlay Use of Sputum microscopy as a primary method of diagnosis among self reporting patients Standardized treatment regimens. 01/31/20 Dr. KANUPRIYA CHATURVEDI contd. Augmentation of the peripheral level supervision through the creation of a sub district supervisory unit 8. Ensuring a regular uninterrupted supply of drugs up to the most peripheral level 9. Emphasis on training, IEC, operational research and NGO involvement in the program 7

01/31/20 Dr. KANUPRIYA CHATURVEDI Core elements of Phase I The core element of RNTCP in Phase I (19972006)was to ensure high quality DOTS expansion in the country, addressing the five primary components of the DOTS strategy Political and administrative commitment Good Quality Diagnosis through sputum Microscopy Directly observed treatment Systematic Monitoring and Accountability Addressing stop TB strategy under RNTCP 01/31/20 Dr. KANUPRIYA CHATURVEDI RNTCP Phase II( 2006-11)

The RNTCP phase II is envisaged to: Consolidate the achievements of phase I Maintain its progressive trend and effect further improvement in its functioning Achieve TB related MDG goals while retaining DOTS as its core strategy 01/31/20 Dr. KANUPRIYA CHATURVEDI Diagnosis of TB in RNTCP: Smear examination Cough for 3 weeks or More 3 sputum smears 3 or 2 positives

3 Negative 1 positive smear Antibiotics 1-2 weeks X- ray positive smear Symptoms persist negative Smear-Positive TB X-ray Negative For TB

Anti-TB Treatment Non-TB 01/31/20 Dr. KANUPRIYA CHATURVEDI Positive Smear-Negative TB Anti-TB Treatment Classification of Patients in Categories for Standardized Treatment Regimen Category Type of Patient Regimen Duration in months Category I

New Sputum Positive Seriously ill sputum negative, Seriously ill extra pulmonary, 2 (HRZE)3, 6 Color of box: RED Category II Sputum Positive relapse Sputum Positive failure Sputum Positive Color of box: BLUE treatment after default 01/31/20 4 (HR)3 2 HRZES)3, 8 1 (HRZE)3

5 (HRE)3 Dr. KANUPRIYA CHATURVEDI Contd. Category Type of Patient Regime n Duratio n in months Category III Sputum Negative, extra pulmonary not Seriously ill 2

(HRZ)3, 6 4 (HR)3 Color of box: GREEN 01/31/20 Dr. KANUPRIYA CHATURVEDI Types of Drug-Resistant TB Mono-resistant Resistant to any one TB treatment drug Poly-resistant Resistant to at least any two TB drugs (but not both isoniazid and rifampicin) Multidrug- resistant (MDR TB) Resistant to at least isoniazid and rifampicin, the two best first-line TB treatment drugs

Extensively drug-resistant (XDR TB) Resistant to isoniazid and rifampicin, PLUS resistant to any fluoroquinolone AND at least 1 of the 3 injectable second-line drugs (e.g., amikacin, kanamycin, or capreomycin) 01/31/20 Dr. KANUPRIYA CHATURVEDI RNTCP Organization structure: State level Health Minister Health Secretary Director Health Services MD NRHM Additional / Deputy / Joint Director (State TB Officer)

State Training and Demonstration Center (TB) Director, IRL Microbiologist, MO, Epidemiologist/statistician, IRL LTs etc., 01/31/20 State TB Cell Deputy STO, MO, Accountant, IEC Officer, SA, DEO, TB HIV Coordinator etc., Dr. KANUPRIYA CHATURVEDI Program innovations

Creation of sub district level supervisory and monitoring unit TB Unit Patient-wise individual drug boxes for entire course of treatment Community involvement in DOTs shopkeepers, teachers, postmen, cured patients, etc Continuous Internal Evaluation of districts Monitoring strategy document with checklists NGO & PP (Private Provider) schemes Task Force mechanism for involvement of Medical colleges Web based IEC/ ACSM resource centre 01/31/20 Dr. KANUPRIYA CHATURVEDI Contd.

District TB Control Society Modular training Patient wise boxes Sub-district level supervisory staff (STS, STLS) for Treatment & microscopy Robust reporting and recording system 01/31/20 Dr. KANUPRIYA CHATURVEDI Quality Diagnostic and Treatment Services

~12,500 decentralized designated microscopy centers established External Quality Assurance (EQA) system for sputum microscopy as per international guidelines Quality assured anti-TB drugs Patient friendly DOT services 01/31/20 Dr. KANUPRIYA CHATURVEDI Data Management System: RNTCP 01/31/20 Dr. KANUPRIYA CHATURVEDI Public Private Mix (PPM) Activities for Involvement of All Health Care Providers

Involvement of NGOs and Private Practitioners Schemes revised in 2008 Presently > 2500 NGOs, 17,000 PPs involved Involvement of professional bodies like IMA, IAP Other Central government departments/PSUs CGHS, Railways, ESI, Mining, Shipping Corporate sector ~150 Corporate Houses participating Involvement of FBOs like CBCI Involvement of Medical Colleges Task Forces and Core Committees formed 260 Medical colleges involved

01/31/20 Dr. KANUPRIYA CHATURVEDI Well Defined IEC Strategy Web based resource centre Communication facilitators provided to support IEC at district level Ongoing capacity building of program managers for planning and implementing need based IEC activities 01/31/20 Dr. KANUPRIYA CHATURVEDI RNTCP: Assessment of Impact

Nation wide ARTI Survey 2008-10 Coordinated by NTI, Bangalore in association with New Delhi TB Centre (North Zone) MGIMS, Wardha (West Zone) LRS Institute, New Delhi (East Zone) CMC, Vellore (South Zone) Symptomatic screening + CXR + Sputum Smear + Culture 01/31/20 Dr. KANUPRIYA CHATURVEDI External Evaluations Undertaken

Joint Monitoring Mission (JMM) by WHO and other development partners in 2000, 2003 and 2006 Conclusions JMM 2000 RNTCP is succeeding and its results have been excellent JMM 2003 Extra-ordinarily rapid expansion of the programme & highly economical JMM 2006 Excellent system of recording & reporting with indicators for monitoring & evaluation; well integrated into general health system Future plan

JMMs planned in 2009 and 2012 01/31/20 Dr. KANUPRIYA CHATURVEDI Contd. Disease prevalence Surveys 2007-09 TRC Chennai MDP project NTI, Bangalore MGIMS, Wardha

PGI, Chandigarh AIIMS, New Delhi JALMA, Agra RMRCT, Jabalpur Symptomatic screening + Sputum Smear + Culture Repeat ARTI and Disease prevalence surveys planned in 2015 01/31/20 Dr. KANUPRIYA CHATURVEDI Impact of RNTCP Trends in prevalence of culture-positive and smearpositive tuberculosis in south India(5 Blocks), 19682006 RNTCP era Pre-SCC treatment era 01/31/20 SCC treatment era

Dr. KANUPRIYA CHATURVEDI Achievements Under RNTCP 412766 Since implementation > 40 million TB suspects examined > 9 million patients placed on treatment > 1.6 million lives saved (deaths averted) Achievements in line with the global 01/31/20 targets Dr. KANUPRIYA CHATURVEDI Progress Towards Millennium Development Goals Indicator 23: between 1990 and 2015 to halve

prevalence of TB disease and deaths due to TB Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients The global NSP case detection rate is 61% (2006) and treatment success rate is 85% RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and case detection rate 70% (2007) 01/31/20 Dr. KANUPRIYA CHATURVEDI Cost Effectiveness of Program in India*

Total costs of TB control per capita is US $ 0.1 (2007) Cost of first line drugs per patient treated in India is US $ 14 compared to US $ 30 (median) for HBCs India remains the country with the lowest cost per patient treated (US $ 84) compared to US $ 274 (median) for HBCs *Source: WHO Report 2008, Global Tuberculosis Control; pg 71 &112; HBCs= High Burden Countries 01/31/20 Dr. KANUPRIYA CHATURVEDI TB-HIV: Accomplishments Developed and implemented mechanism for TB & HIV

program collaboration at all levels (National, State, District) Conducted surveillance and determined national burden of HIV in TB patients Mainstreamed TB-HIV activities as core responsibility of both programs (training & monitoring) 01/31/20 Dr. KANUPRIYA CHATURVEDI TB-HIV: Current Policies (2008) TB/HIV activities in all States

Coordination & Training on TB/HIV Intensified Case Finding (ICF) Referral of all HIV- TB patients for HIV care and support (CPT & ART) Involve NGOs Activities in high-HIV states 01/31/20 Provider-initiated HIV counseling and testing for all TB patients Decentralized provision of Co-trimoxazole Expanded TB-HIV monitoring Dr. KANUPRIYA CHATURVEDI RNTCP- DOTS-Plus Vision

By 2010 DOTS-Plus services available in all states By 2012, universal access under RNTCP to laboratory based quality assured MDR-TB diagnosis for all retreatment TB cases and new cases who have failed treatment By 2012, free and quality assured treatment to all MDR-TB cases diagnosed under RNTCP (~30,000 annually) By 2015, universal access to MDR diagnosis and treatment for all smear positive TB cases under RNTCP 01/31/20 Dr. KANUPRIYA CHATURVEDI

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