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Recent advances in
Revised National Tuberculosis
Control Programme (RNTCP)
Dr Amol Kinge
Epidemiologist cum Assistant Professor,
Department of Community Medicine,
SBHGMC, Dhule
Tuberculosis
Epidemiology
• Agent: MycobacteriumTuberculosis, M.bovis, other
atypical Mb.
• Host: Age (Early childhood, adolescent and old
age), Sex (Men), Nutrition, Social factors, illiteracy,
Immunity
• Environment: overcrowding, sanitation etc
Tuberculosis
Classification
1. Anatomical site: Pulmonary & Extra-pulmonary
2. History of Tt:
- New case:
- Previously treated case: a) Recurrent TB case (After Prev successful Tt.)
b) Tt after failure case
c) Tt after loss to follow up
d) Other previously treated
- Transferred in cases
3. Drug resistance: Mono-DR, MDR (HR), XDR (1st line+FQ+2nd line
injectables)
Tuberculosis
Signs and symptoms
1. Cough with /without expectoration >2 weeks
2. Low grade fever
3. Weight loss / general debility
4. Generalised Weakness
Diagnosis
• Sputum Examination
• X-ray chest
• Detection of Antigens / Genexpert
• Culture methods
• Tuberculin Test
Estimated number
of cases
Estimated number
of deaths
1.5 million*
• 140,000 in children
• 480,000 in women
• 890,000 in men
9.6 million
• 1 million children
• 3.2 million women
• 5.4 million men
480,000
All forms of TB
Multidrug-resistant
TB
HIV-associated TB 1.2 million
(12.5%)
390,000
Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB
The Global Burden of TB, 2014
190,000
Estimated incidence,
2014
Estimated number of
deaths, 2014
0.22 million*
(0.15–0.25 million)
2.2 million
(2.0–2.3 million)
(Rate 167)
All forms of TB
Multidrug-resistant
TB
HIV-associated TB 0.11 million
(0.09–0.12 million)
31,000
(25,000–38,000)
India TB situation
71,000
amongst notified cases
Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB
India is the highest TB burden country
Data source: Global TB Report 2015, WHO, Geneva
Evolution of TB Control Programme-Chronology
• 1946: Bhore Committee
– Wide gap between TB patients and number of beds
• 1947: TB Division under the Directorate General of Health Services
• 1951 : BCG Campaign
• 1956: TRC Established, Madras study : domiciliary treatment as
effective as sanatorium treatment
• 1959: NTI established
• 1962 : National TB Programme
• 1961 – 1986 : Era of Conventional Chemotherapy
• 1986 -1993 : Era of Short course chemotherapy
• 1993 : Directly Observed Treatment Short Course (DOTS) using
intermittent regimen tested
• 1997: RNTCP roll-out
RNTCP – journey so far and
way forward
8th Five Year Plan (1992-97)
TU 1
DMC
1
DMC
2
DMC
3
DMC
4
DMC
5
TU 2
DMC
1
DMC
2
DMC
3
DMC
4
DMC
5
Primary Healthcare infrastructure
3rd Five Year Plan (1961)
DTC
PHC
1
PHC
2
PHC
3
ASHA
ASHA
ASHA
ASHA
Health
Subcentre
12th Five Year Plan
(2012-17)
• PHCs ~4600
• Centralized TB Services
• Daily regimen
• Long treatment (12-18 months)
• PHCs scaled-up ~22000
• Health Sub-Centres manned by ANMs (~1,30,000)
• Decentralized TB Services (TU’s, DMCs)
• PHCs >25000
• >1,50,000 subcentres
• >900,000 ASHA workers
• PMDT following daily DOT
• TB Units aligned to CD blocks
• ICT tools (NIKSHAY)
Intermittent
regimen under
DOTS strategy
Daily (FDC)
regimen
feasible
Drugs
First Line Drugs
H- Isoniazid
R- Rifampicin
Z- Pyrazinamide
E- Ethambutol
S- Streptomycin
Second Line Drugs
Kanamycin
Ethionamide
Levofloxacin
Cycloserine
PAS
Daily Regimen: Adult Schedule
Daily Regimen: RNTCP
Paediatric Schedule
Directly Observed Treatment, Short-course
(DOTS) – a five point strategy
TB Register
 Political and Administrative
commitment
 Good Quality Diagnosis by Sputum
smear microscopy
 Uninterrupted supply of good quality drugs
 Directly observed treatment (DOT)
 Systematic monitoring and
accountability
Note: Directly Observed Treatment (DOT) is only one of the five components of DOTS strategy
RNTCP - Achievements
Infrastructure:
• State TB Programme Management Units established in
all states/UTs
• 728 District TB Programme Management Units
established
• 4117 TB Units established at Block level
• >13,000 Designated Microscopy Centers established
• > 6 lakh DOT centers established
• 62 C&DST laboratories established for diagnosis of
DR-TB
• 135 DRTB Centers established for treatment of DR-TB
RNTCP - Achievements
Since implementation:
• 86 million TB suspects examined,
• 19 million patients placed on treatment,
• > 3.4 million additional lives saved
• 70,000 MDR-TB patients put on treatment
• 2000 XDR-TB patients put on treatment
Trends in suspects examined per smear
positive TB case diagnosed (2000-2015)
6.4
7.1 7.0 7.1 7.2
7.5 7.4 7.4 7.5
7.8
8.0
8.3
8.4
8.7
8.9
9.6
y = 0.1643x + 6.3772
R² = 0.9068
6.0
6.5
7.0
7.5
8.0
8.5
9.0
9.5
10.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Progress towards MDG
Year
Incidence
(per lakh population)
Prevalence
(per lakh population)
Mortality
(per lakh population)
1990 216 465 38
1995 216 465 38
2000 216 438 39
2005 209 365 36
2009 190 289 29
2010 185 269 27
2011 181 249 24
2012 176 230 22
2013 171 211 19
2014 167 195 17
Achieved…. based on WHO estimates….
Maharashtra: State profile
Population 1194 Lakhs
STDCs 2
State Drug Stores 3
Districts 79
Tuberculosis Units 444
DMCs 1448
DOT Centres 35,339
C&DST Labs 10
CBNAAT Labs 72
DR TB Centres 16
Dist DR TB Centres 9
ART Centres 86
Stand Alone ICTCs 657
F-ICTCs 1,645
The DOTS Strategy
1. Government commitment
2. Case detection through
predominantly passive case
finding
3. Standardized short-course
chemotherapy to at least all
confirmed sputum smear
positive cases of TB under proper
case management conditions
4. Establishment of a system of
regular drug supply of all
essential anti-TB drugs
5. Establishment and
maintenance of a monitoring
system, for both programme
supervision and evaluation
The Stop TB Strategy
1. Pursue high-quality DOTS
expansion and enhancement
2. Address TB/HIV, MDR-TB
and other challenges
3. Contribute to health
system strengthening
4. Engage all care providers
5. Empower people with TB
and communities
6. Enable and promote
research
The Post-2015
End TB Strategy
1. Integrated, patient-
centred TB care and
prevention
2. Bold policies and
supportive systems
3. Intensified research
and innovation
Evolution of global strategies to control TB
1994 2006 2014
Moving from halting TB to ending TB by 2030
Global commitment to End TB
The End TB Strategy:
Vision, Targets and Pillars
Vision:
A world free of TB
Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal:
End the Global TB Epidemic
Global projections to 2035 compared
with current trends
India’s Address to TB Situation
12th Five Year Plan (2012-17)
• To achieve 90% notification for all cases
• To achieve 90% success rate for all new & 85% for
re-treatment cases
• To significantly improve the successful outcome of
treatment of DR-TB cases
• To achieve decreased morbidity and mortality of
HIV-TB
• To improve outcomes of TB care in the private
sector
Action for 12th Plan Objectives
• Strengthened & improved basic DOTS services
• TU alignment with BPMU’s of NHM
• Availability of rapid diagnostics to field level
• Increase efforts for engaging all care providers
• Strengthen Urban TB Control
• Expansion of PMDT services
• Gazette notification prohibiting import, manufacture,
sale, distribution of sero-diagnostic tools for
diagnosing TB
• Government Order mandating notification about TB
to local health authorities
• Strengthen TB Surveillance using a case based
web based system NIKSHAY
Action for 12th Plan Objectives
Standard 7: Treatment with first-line regimen
7.1 Treatment of New TB patients:
• The initial phase - H, R, Z, E for two months
• The continuation phase - H, R, E for at least four months
7.2 Extension of Continuation Phase: Extend CP by 3 to 6 months in special situations like Bone & Joint
TB, Spinal TB with neurological involvement and neuro-tuberculosis.
7.3 Drug Dosages: As per body weight in weight bands
7.4 Bioavailability of Drugs: ensured for every batch
7.5 Dosage frequency:
• Daily/ Intermittent regimen
• OR to assess the feasibility of daily observed therapy under programmatic settings.
7.6 Drug formulations: FDCs may be considered if the recommendations are accepted.
7.7 Previously treated TB patients: No MDR :- 2HREZS/1HREZ/5HRE or
2H3R3E3Z3S3/1H3R3E3Z3/5H3R3E3
Standards of TB Care in India..
Private sector
• The private sector holds a factual predominance of
health care service delivery in India
• Very little information about the TB patient from the
private sector available to the programme
• Little is known about quality of treatment, including
treatment outcomes in the private sector
• Engaging the private sector effectively is the single
most important intervention required for India to
achieve the overall goal of universal access to quality
TB care
• Himachal Pradesh
• Sikkim
• Bihar
• Maharashtra
• Kerala
Rollout of Daily Regimen
in 104 districts/5 States Total population
coverage - 2,690 Lakh
Rajas than
Gujarat
Maharas htra
Oriss a
Karnataka
Madhya Prades h
Bihar
Uttar
Pradesh
Jam m u &
Kas hm ir
Tam il Nadu
Assam
Telangana
Chhattis garh
Andhra Pradesh
Jhark hand
Punjab
W est B engal
Kerala
Haryana
Himac hal
Pradesh
Manipur
Mizoram
Andam an & N icobar
Dam an & Diu
Uttarakhand
Sikkim
Arunachal
Pradesh
N aga lan d
Tripura
Way-forward for 2015-16
• Rolling out of daily regimen in 5 states
• Involvement of Private sector
• TB Surveillance
• Social support
• Urban TB control
• Special population
Thanks

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Revised National Tuberculosis Control Program

  • 1. Recent advances in Revised National Tuberculosis Control Programme (RNTCP) Dr Amol Kinge Epidemiologist cum Assistant Professor, Department of Community Medicine, SBHGMC, Dhule
  • 2. Tuberculosis Epidemiology • Agent: MycobacteriumTuberculosis, M.bovis, other atypical Mb. • Host: Age (Early childhood, adolescent and old age), Sex (Men), Nutrition, Social factors, illiteracy, Immunity • Environment: overcrowding, sanitation etc
  • 3. Tuberculosis Classification 1. Anatomical site: Pulmonary & Extra-pulmonary 2. History of Tt: - New case: - Previously treated case: a) Recurrent TB case (After Prev successful Tt.) b) Tt after failure case c) Tt after loss to follow up d) Other previously treated - Transferred in cases 3. Drug resistance: Mono-DR, MDR (HR), XDR (1st line+FQ+2nd line injectables)
  • 4. Tuberculosis Signs and symptoms 1. Cough with /without expectoration >2 weeks 2. Low grade fever 3. Weight loss / general debility 4. Generalised Weakness
  • 5. Diagnosis • Sputum Examination • X-ray chest • Detection of Antigens / Genexpert • Culture methods • Tuberculin Test
  • 6. Estimated number of cases Estimated number of deaths 1.5 million* • 140,000 in children • 480,000 in women • 890,000 in men 9.6 million • 1 million children • 3.2 million women • 5.4 million men 480,000 All forms of TB Multidrug-resistant TB HIV-associated TB 1.2 million (12.5%) 390,000 Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB The Global Burden of TB, 2014 190,000
  • 7. Estimated incidence, 2014 Estimated number of deaths, 2014 0.22 million* (0.15–0.25 million) 2.2 million (2.0–2.3 million) (Rate 167) All forms of TB Multidrug-resistant TB HIV-associated TB 0.11 million (0.09–0.12 million) 31,000 (25,000–38,000) India TB situation 71,000 amongst notified cases Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB
  • 8. India is the highest TB burden country Data source: Global TB Report 2015, WHO, Geneva
  • 9. Evolution of TB Control Programme-Chronology • 1946: Bhore Committee – Wide gap between TB patients and number of beds • 1947: TB Division under the Directorate General of Health Services • 1951 : BCG Campaign • 1956: TRC Established, Madras study : domiciliary treatment as effective as sanatorium treatment • 1959: NTI established • 1962 : National TB Programme • 1961 – 1986 : Era of Conventional Chemotherapy • 1986 -1993 : Era of Short course chemotherapy • 1993 : Directly Observed Treatment Short Course (DOTS) using intermittent regimen tested • 1997: RNTCP roll-out
  • 10. RNTCP – journey so far and way forward
  • 11. 8th Five Year Plan (1992-97) TU 1 DMC 1 DMC 2 DMC 3 DMC 4 DMC 5 TU 2 DMC 1 DMC 2 DMC 3 DMC 4 DMC 5 Primary Healthcare infrastructure 3rd Five Year Plan (1961) DTC PHC 1 PHC 2 PHC 3 ASHA ASHA ASHA ASHA Health Subcentre 12th Five Year Plan (2012-17) • PHCs ~4600 • Centralized TB Services • Daily regimen • Long treatment (12-18 months) • PHCs scaled-up ~22000 • Health Sub-Centres manned by ANMs (~1,30,000) • Decentralized TB Services (TU’s, DMCs) • PHCs >25000 • >1,50,000 subcentres • >900,000 ASHA workers • PMDT following daily DOT • TB Units aligned to CD blocks • ICT tools (NIKSHAY) Intermittent regimen under DOTS strategy Daily (FDC) regimen feasible
  • 12. Drugs First Line Drugs H- Isoniazid R- Rifampicin Z- Pyrazinamide E- Ethambutol S- Streptomycin Second Line Drugs Kanamycin Ethionamide Levofloxacin Cycloserine PAS
  • 15. Directly Observed Treatment, Short-course (DOTS) – a five point strategy TB Register  Political and Administrative commitment  Good Quality Diagnosis by Sputum smear microscopy  Uninterrupted supply of good quality drugs  Directly observed treatment (DOT)  Systematic monitoring and accountability Note: Directly Observed Treatment (DOT) is only one of the five components of DOTS strategy
  • 16. RNTCP - Achievements Infrastructure: • State TB Programme Management Units established in all states/UTs • 728 District TB Programme Management Units established • 4117 TB Units established at Block level • >13,000 Designated Microscopy Centers established • > 6 lakh DOT centers established • 62 C&DST laboratories established for diagnosis of DR-TB • 135 DRTB Centers established for treatment of DR-TB
  • 17. RNTCP - Achievements Since implementation: • 86 million TB suspects examined, • 19 million patients placed on treatment, • > 3.4 million additional lives saved • 70,000 MDR-TB patients put on treatment • 2000 XDR-TB patients put on treatment
  • 18. Trends in suspects examined per smear positive TB case diagnosed (2000-2015) 6.4 7.1 7.0 7.1 7.2 7.5 7.4 7.4 7.5 7.8 8.0 8.3 8.4 8.7 8.9 9.6 y = 0.1643x + 6.3772 R² = 0.9068 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
  • 19. Progress towards MDG Year Incidence (per lakh population) Prevalence (per lakh population) Mortality (per lakh population) 1990 216 465 38 1995 216 465 38 2000 216 438 39 2005 209 365 36 2009 190 289 29 2010 185 269 27 2011 181 249 24 2012 176 230 22 2013 171 211 19 2014 167 195 17 Achieved…. based on WHO estimates….
  • 20. Maharashtra: State profile Population 1194 Lakhs STDCs 2 State Drug Stores 3 Districts 79 Tuberculosis Units 444 DMCs 1448 DOT Centres 35,339 C&DST Labs 10 CBNAAT Labs 72 DR TB Centres 16 Dist DR TB Centres 9 ART Centres 86 Stand Alone ICTCs 657 F-ICTCs 1,645
  • 21. The DOTS Strategy 1. Government commitment 2. Case detection through predominantly passive case finding 3. Standardized short-course chemotherapy to at least all confirmed sputum smear positive cases of TB under proper case management conditions 4. Establishment of a system of regular drug supply of all essential anti-TB drugs 5. Establishment and maintenance of a monitoring system, for both programme supervision and evaluation The Stop TB Strategy 1. Pursue high-quality DOTS expansion and enhancement 2. Address TB/HIV, MDR-TB and other challenges 3. Contribute to health system strengthening 4. Engage all care providers 5. Empower people with TB and communities 6. Enable and promote research The Post-2015 End TB Strategy 1. Integrated, patient- centred TB care and prevention 2. Bold policies and supportive systems 3. Intensified research and innovation Evolution of global strategies to control TB 1994 2006 2014
  • 22. Moving from halting TB to ending TB by 2030 Global commitment to End TB
  • 23. The End TB Strategy: Vision, Targets and Pillars Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering Goal: End the Global TB Epidemic
  • 24. Global projections to 2035 compared with current trends
  • 25. India’s Address to TB Situation
  • 26. 12th Five Year Plan (2012-17) • To achieve 90% notification for all cases • To achieve 90% success rate for all new & 85% for re-treatment cases • To significantly improve the successful outcome of treatment of DR-TB cases • To achieve decreased morbidity and mortality of HIV-TB • To improve outcomes of TB care in the private sector
  • 27. Action for 12th Plan Objectives • Strengthened & improved basic DOTS services • TU alignment with BPMU’s of NHM • Availability of rapid diagnostics to field level • Increase efforts for engaging all care providers • Strengthen Urban TB Control • Expansion of PMDT services
  • 28. • Gazette notification prohibiting import, manufacture, sale, distribution of sero-diagnostic tools for diagnosing TB • Government Order mandating notification about TB to local health authorities • Strengthen TB Surveillance using a case based web based system NIKSHAY Action for 12th Plan Objectives
  • 29. Standard 7: Treatment with first-line regimen 7.1 Treatment of New TB patients: • The initial phase - H, R, Z, E for two months • The continuation phase - H, R, E for at least four months 7.2 Extension of Continuation Phase: Extend CP by 3 to 6 months in special situations like Bone & Joint TB, Spinal TB with neurological involvement and neuro-tuberculosis. 7.3 Drug Dosages: As per body weight in weight bands 7.4 Bioavailability of Drugs: ensured for every batch 7.5 Dosage frequency: • Daily/ Intermittent regimen • OR to assess the feasibility of daily observed therapy under programmatic settings. 7.6 Drug formulations: FDCs may be considered if the recommendations are accepted. 7.7 Previously treated TB patients: No MDR :- 2HREZS/1HREZ/5HRE or 2H3R3E3Z3S3/1H3R3E3Z3/5H3R3E3 Standards of TB Care in India..
  • 30. Private sector • The private sector holds a factual predominance of health care service delivery in India • Very little information about the TB patient from the private sector available to the programme • Little is known about quality of treatment, including treatment outcomes in the private sector • Engaging the private sector effectively is the single most important intervention required for India to achieve the overall goal of universal access to quality TB care
  • 31. • Himachal Pradesh • Sikkim • Bihar • Maharashtra • Kerala Rollout of Daily Regimen in 104 districts/5 States Total population coverage - 2,690 Lakh Rajas than Gujarat Maharas htra Oriss a Karnataka Madhya Prades h Bihar Uttar Pradesh Jam m u & Kas hm ir Tam il Nadu Assam Telangana Chhattis garh Andhra Pradesh Jhark hand Punjab W est B engal Kerala Haryana Himac hal Pradesh Manipur Mizoram Andam an & N icobar Dam an & Diu Uttarakhand Sikkim Arunachal Pradesh N aga lan d Tripura
  • 32. Way-forward for 2015-16 • Rolling out of daily regimen in 5 states • Involvement of Private sector • TB Surveillance • Social support • Urban TB control • Special population