1. Universal access to TB care
RNTCP
DR.P.S.SARMA
TECHNICAL CONSULTANT
9440118712;
drpappuss@yahoo.co.in

2. Aim
• TO EDUCATE / SENSITISE PRIVATE
HEALTH CARE PROVIDERS REG
• TB CONTROL AND RNTCP – A
NATIONAL HEALTH PROGRMME
• OF G.O.I
• SPECIAL EMPAHSIS ON TB
NOTIFICATION & BANNING OF BLOOD
TESTS FOR TB DIAGNOSIS

3. • The Union Health Ministry's notification
was issued with on May 7. The notification
clearly states that 'all healthcare providers
(clinical establishments run or managed
by government including local authorities,
private or NGOs and/ or individual
practitioners) in all the districts and towns
in your concerned state/UT be
immediately kept informed (through
appropriate mechanism) on the contents
of the Government Order on TB
notification in India for their compliance
with immediate effect.’

4. • The notification further said: "In order to
ensure proper TB diagnosis and case
management, reduce TB transmission and
fight emergence of drug resistant TB, it is
essential to have complete information of
all TB cases. Therefore the healthcare
providers shall notify every TB case to
local authorities - district health
officer/chief medical officer of a district and
municipal health officer of a municipal
corporation, every month

5. TB NOTIFICATION
• Many options
• The notification can be done through hard
copy, email, mobile phones (IVRS or
SMS), or by uploading the information
directly on to the Nikshay portal (
http://nikshay.gov.in). They can also get in
touch with the respective nearest nodal
officers (http://tbcindia.nic.in) to notify the
cases.
• Contact your DTCO giving your details

6. New G.O
• New Delhi, 18 June 2012: In a welcome
step, a gazette notification by the Ministry
of Health & Family Welfare banning
serological test (commonly referred to as
blood or antibody test) for TB, under the
Drugs & Cosmetic Act, has finally been
made public today. This gazette
notification also, in particular bans the
importation of the serological test kits.
• The notification is online at
https://picasaweb.google.com/101502226047950368947/GovernmentOfIndiaNotifi

7. G.O
• The serological test for TB is widely used
in the private sector, even though they are
known to be inaccurate, inconsistent and
with no clinical value for TB diagnosis. The
World Health Organization (WHO) in its
first-ever negative policy recommendation
recently called on governments to
immediately ban blood tests prescribed
and used to detect TB.

9. RNTCP – Goal and Objectives
• Goal
– The goal of TB control Programme is to decrease
mortality and morbidity due to TB and cut
transmission of infection until TB ceases to be a
major public health problem in India.
• Objectives:
– To achieve and maintain a cure rate of at least 85%
of new sputum positive TB patients
– To achieve and maintain a case detection of at least
70% of new sputum positive TB patients

10. RNTCP (revised) Goals and
Objectives
• Goal:
– To reduce the burden of Tuberculosis by providing
universal access to TB care
• Objectives:
– 90/90
– Detection of at least 90% of all incident TB Cases
– Successfully treat at least 90% of new smear
positive cases

12. Population attributable fraction – PAF =
P × ( RR − 1)
P × ( RR − 1) + 1
selected risk factors & determinants
Relative risk for Weighted Population
active TB disease prevalence Attributable
(22 HBCs) Fraction
HIV infection 20.6/26.7* 1.1% 19%
Malnutrition 3.2** 16.5% 27%
Diabetes 3.1 3.4% 6%
Alcohol use 2.9 7.9% 13%
(>40g / d)
Active 2.6 18.2% 23%
smoking
Indoor Air 1.5 71.1% 26%
Pollution
Sources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med
2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lönnroth et
al. A consistent log-linear relationship between tuberculosis incidence and body-mass index. Submitted, 2009

13. “Diabetes makes
a substantial
contribution to
the burden of
incident
tuberculosis in
India…”

17. Universal Access to TB Care-
Concept/Definition
• All TB patients in the community to have access to
– early, good quality diagnosis and treatment services
• in a manner that is affordable and convenient to the patient in
time, place and person.
• All affected communities must have full access to TB
prevention, care and treatment,
– including women, children, elderly, migrants, homeless
people, alcohol and other drug users, prison inmates,
people living with HIV and other clinical risk factors, and
those with other life-threatening diseases.

18. Universal Access to TB Care-
All TB patients
• including women, elderly, children, migrants,
homeless people, alcohol and other drug users,
prison inmates, people living with HIV and
other clinical risk factors, and those with other
life-threatening diseases.
• All types- Smear positive, negative, EP, Drug
Resistant TB

19. Early Diagnosis
Approaching a
Onset of Symptom Diagnosis
health care facility
Patient delay Diagnosis delay
Treatment delay
Initiation of treatment

21. Algorithm 1: Diagnostic Algorithm For Pediatric Pulmonary TB
Pulmonary TB Suspect
• Fever and / or cough 3 weeks
• Loss of wt/No wt gain
• History of contact with suspected
Or diagnosed case of active TB
Is expectoration present?
If no, refer to
Pediatrician
If yes, examine 3 sputum smears
2 or 3 Positives 3 Negatives
Antibiotics
10-14 days
Cough Persists
Repeat 3 Sputum
Examinations
1 Positive
Negative 2 or 3 Positives
X-Ray
X-ray + Sputum Positive
Mantoux TB (Anti TB
Suggestive of TB Negative for TB Treatment)
Sputum-Positive TB Negative for TB Suggestive of TB
(Anti-TB Treatment)
Refer to Pediatrician Sputum-Negative TB
(Anti-TB Treatment)

22. PAEDIATRIC TB
• 1.DIFFICULT TO BRING OUT SPUTUM IN CHILDREN
• 2.RELY ON OTHER TESTS - MONTOUX ; & X RAY
• 3.LOOK FOR HISTORY OF CONTACT WITH
KNOWN TB CASE
• 4.PAEDIATRICIAN’S DIAGNOSIS IS HONORED.

23. Two Types of Generic Boxes –
4 WEIGHT BANDS
• 6 – 10 kg would require PC 13
• 11 – 17 kg would require 14
PC
PC 13 PC 14
• 18 – 25 kg would require and
PC 14 PC 14
• 26 – 30 kg would require and

24. PAEDIATRIC UPDATE
• 6 WEIGHT BANDS & 3 generic
• Patient wise boxes
• 6-8 Kgs – Product -1
• 9-12 Kgs – Product -2
• 13-16 Kgs – Product -3
• 17-20 Kgs – Product -1 +2
• 21-24 Kgs – Product – 2+ 2
• 25-30 Kgs – Product - 3+3

25. Treatment Regimens -new
NT New smear positive; seriously ill 2H3R3Z3E3 /
smear negative; all extra- 4H3R3
pulmonary
PT Previously treated smear 2H3R3Z3E3S3 /
positive (relapse, failure, 1H3R3Z3E3 /
treatment after default) 5H3R3E3

26. Delay in diagnosis
• Cough as the presenting symptom
• Awareness among patients
• Awareness among providers
• Accessibility to diagnostic facilities
• ? Lack of “interest” in smear negative TB

27. Intensified Case Finding?
• Settings
– Contact investigation
– HIV
– DM
– ?Smokers
– ?Migrants
– ?Slums
– ?Mines
– Other occupations
– Prisoners…………………………

28. Intensive case finding among high risk groups:
• HIV care centres
• Active TB case finding should be implemented in all
facilities providing HIV care, like ICTCs, ART Centres,
Care and support centres etc.
• Train Medical Officers in the algorithum for
diagnosis of TB in HIV positive patients.
• Involve NGOs working with HIV programme in TB
case finding activities.

29. Intensive case finding among high risk groups:
– Diabetic patients.
• Sensitize medical officers to actively search for
TB in diabetic patients.
• Active TB case finding in diabetic clinics
– Smokers
• TB control programme to actively associate
with anti smoking programme.
• Chronic smokers attending OPDs with
respiratory symptoms to be screened for TB.

30. OTHER POINTS
• PREGNANT LADIES CAN TAKE ANTI TB DRUGS
EXCEPT FOR INJ.STREPTOMYCIN.
• ANTI TB DRUGS ARE TOXIC. PATIENTS WILL
HAVE SIDE EFFECTS LIKE NAUSEA;
VOMITINGSHEADACHE; JOINT PAINS ETC.
• THEY NEED SYPTOMATIC TREATMENT.
• IF THE PT DEVELOPES JAUNDICE – STOP ALL
ANTI TB DRUGS ; TREAT JAUNDICE AND THEN
RESTART ANTI TB DRUGS.
• CO-INF OF TB & HIV NEEDS CPT ALSO.

31. PPM….
• Involvement of NGOs and Private
Practitioners
– Schemes revised in 2008
– Presently ~19,000 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

32. Promote Universal access of care for TB in
all Medical Colleges
– State and Zonal Task force mechanism to
further strengthen medical college involvement
in RNTCP.
– Medical colleges need
• System of active screening and fast tracking of TB
suspects
• System of tracking patients both within the
institution and outside for diagnosis as well as
treatment.
• Strengthening of interdepartmental collaboration
and monitoring

33. Thanking you all!!!
www.tbcindia.nic.in
www.stoptb.org