Tuberculosis National Health Program

1. Tuberculosis National Health
Programs
(Source : DOHS annual report FY 2075/76)
BPH ,MPH
Binam Raj Shrestha

2. Outline
• Introduction to TB
• Vision, goal, objectives of the National TB Programme
• The End TB Strategy
• Major activities in fiscal year 2075/76
• Progress and epidemiology of TB
• Challenges
• References

3. Definition
• Latent case : Persons with latent TB infection are not infectious and cannot spread TB infection to
others.
• Active case: Active tuberculosis refers to disease that occurs in someone infected
with Mycobacterium tuberculosis. It is characterized by signs or symptoms of active disease, or
both, and is distinct from latent tuberculosis infection, which occurs without signs or symptoms of
active disease.
• mono-resistance cases refer to resistance to a single first-line drug, and .

4. • Poly-resistance cases refer to resistance to two or more first-line drugs but not to both isoniazid
and rifampicin i.e. not MDR–TB
• Multidrug-resistant tuberculosis (MDR-TB) is a form of tuberculosis (TB) infection caused by
bacteria that are resistant to treatment with at least two of the most powerful first-line anti-TB
medications(drugs), isoniazid and rifampin.
• Extensively drug resistant TB (XDR TB) is a severe form of MDR-TB that is multidrug-resistant
(MDRTB) to all the fluoroquinolones and second line injectable drugs.

5. Source : WHO

6. Source : WHO

7. Introduction
• Tuberculosis (TB) is a public health problem in Nepal that affects thousands of people each year
and is one of the leading cause of death in the country.
• WHO estimates that around 45,000 people develop active TB every year in Nepal. Nearly fifty
percentage of them are estimated to have infectious pulmonary disease and can spread the disease
to others.
• TB mortality is high given that most deaths are preventable if people can access tuberculosis care
for diagnosis and the correct treatment is provided.

8. • Nepal NTP has adopted the global WHO’s END TB Strategy as the TB control strategy of the
country.
• The Directly Observed Treatment, Short Course (DOTS) has been implemented throughout the
country since April 2001.
• There are 4,323 DOTS treatment centres in Nepal

9. Vision, goal, objectives of the National TB
Programme
• Vision: TB Free Nepal
• Goal : To reduce the TB incidence by 20% by the year 2021 compared to 2015 and
increase case notifications by a cumulative total of 20,000 from July 2016 to July 2021,
compared to the year 2015.
• Objective 1: Increase case notification through improved health facility-based diagnosis;
increase diagnosis among children (from 6% at baseline, to 10% of total cases by 2021);
examination of household contacts and expanded diagnosis among vulnerable groups
within the health service, such as PLHIV (from 179 cases at baseline to over 1,100 cases
in 2020/21), and those with diabetes mellitus (DM).

10. Objective 2: Maintain the treatment success rate at 90% of patients (all forms of TB) through to 2021
Objective 3: Provide DR diagnostic services for 50% of persons with presumptive DR TB by 2018 and
100% by 2021; successfully treat at least 75 % of the diagnosed DR patients
Objective 4: Further expand case finding by engaging providers for TB care from the public sector
(beyond MoHP), medical colleges, NGO sector, and private sector through results-based financing (PPM)
schemes, with formal engagements (signed MoUs) to notify TB cases.
Objective 5: Strengthen community systems for management, advocacy, support and rights for TB patients
in order to create an enabling environment to detect & manage TB cases in 60% of all districts by 2018
and 100% by 2021

11. Objective 6: Contribute to health system strengthening through HR management and capacity
development, financial management, infrastructures, procurements and supply management in TB
Objective 7: Develop a comprehensive TB Surveillance, Monitoring, and Evaluation system
Objectives 8: To develop a plan for continuation of NTP services in the event of natural disaster or
public health emergency

12. The End TB Strategy
VISION: A world free of TB
Zero deaths, disease and suffering due to TB
GOAL: End the Global TB Epidemic
MILESTONES FOR 2025:
1) 75% reduction in TB deaths (compared with 2015)
2) 50% reduction in TB incidence rate (less than 55 TB cases per 100,000 population)
3) No affected families facing catastrophic costs due to TB

13. TARGETS FOR 2035:
1) 95% reduction in TB deaths (compared with 2015)
2) 90% reduction in TB incidence rate (less than 10 TB cases per 100,000 population)
• No affected families facing catastrophic costs due to TB
• The End TB Strategy was unanimously endorsed by the World Health Assembly in 2014. Its three
overarching indicators are i) the number of TB deaths per year, ii) TB incidence rate per year, and
iii) the percentage of TB-affected households that experience catastrophic costs as a result of TB.
These indicators have related targets for 2030 and 2035.

14. The main principles for implementing the strategy are:
• Government stewardship and accountability, with monitoring and evaluation;
• Strong coalitions with civil society organizations and communities;
• The protection and promotion of human rights, ethics and equity; and
• The adaptation of the strategy and targets at country levels, with global collaboration

15. The strategy’s components (three pillars) and related strategies are as follows:
1) Integrated, patient- entered care and prevention:
• Early diagnosis of TB including universal drug-susceptibility testing, and systematic screening of
contacts and high-risk groups.
• Treatment of all people with TB including drug-resistant TB.
• Collaborative TB/HIV activities and the management of co-morbidities.
• The preventive treatment of persons at high risk, and vaccination against TB.

16. 2. Bold policies and supportive systems:
• Political commitment with adequate resources for TB care and prevention.
• The engagement of communities, civil society organizations, and public and private care providers.
• Universal health coverage policy and regulatory frameworks for case notification, vital registration,
quality and rational use of medicines, and infection control.
• Social protection, poverty alleviation and actions on other determinants of TB.
3. Intensified research and innovation:
• The discovery, development and rapid uptake of new tools, interventions and strategies.
• Research to optimize implementation and impact and promote innovations.

17. Major activities in fiscal year 2075/76
• Provided effective chemotherapy to all patients in accordance with national treatment policies.
• Promote early diagnosis of people with infectious pulmonary TB by sputum smear examination
and GeneXpert.
• Implemented active case finding interventions across high burden districts to identify missing
tuberculosis cases among high risk groups through sub recipients of Global Fund grant.
• Provided continuous drugs supply to all treatment centres.

18. • Maintained a standard system for recording and reporting
• Monitored the result of treatment and evaluate progress of the programme
• Strengthened cooperation between NGOs, bilateral aid agencies and donors involved in the NTP.
• Coordinate and collaborate NTP activities with and HIV /AIDS programmes.
• E-TB Orientation to private practitioner to notify the TB patients diagnosed at private health
facilities.

19. • Roll out of DR TB Tracking and Laboratory System at all the DR and GX sites.
• Linkage of DOTS centres to Microscopic centre through courier.
• Provided training to health personnel.
• Training to medical doctors for childhood TB diagnosis.

20. Progress and epidemiology of TB

21. Institutional coverage and estimation of TB burden
• Nepal adopted the DOTS strategy in 1996 and achieved nationwide coverage in 2001
• In 2075/76, 4,323 institutions were offering TB diagnosis and treatment DOTS-based TB control
services. Among them, 4,204 are government health institutions.
• The burden of TB can be measured in terms of incidence , prevalence and mortality.
• WHO estimates the current prevalence of all types of TB cases for Nepal at 60,000 (241/100,000)
• while the number of all forms of incidence cases (newly notified cases) is estimated at 45,000
(152/100,000).

22. Case notification
• Based on the CNR , there are 20 districts With CNR more than 120, while 24 districts had CNR
between 75-120 and remaining 33 districts had below 75 CNR .
• Among 20 high burden districts,14 districts are from the terai belts while remaining 6 are from the
hilly region
• Province 5 had the highest CNR (127 per 100,000 population )
• CNR was very low at karnali province (78 per 100,000 population).

24. • In fiscal year 2075/76, total of 32,043 cases of TB was notified and registered at NTP.
• There were 97.98% incident TB cases registered (New and Relapse) among all TB cases.
• Among the notified TB cases ,71% of all TB cases were pulmonary cases and out of notified
pulmonary TB cases , 82 % were bacteriologically confirmed.
• Among those bacteriologically confirmed and notified, 39% (12520) were confirmed using Xpert
MT/RIF testing .

25. Distribution by age and sex
• In FY 2075/76 , around 5.5% of cases were registerd as child TB cases the remaining 94.5% were
registered as adult TB.
• Among them Male TB were reported nearly 2 times more than female.
• Among the TB cases , most of them(63%) were between (5-14) years of age group
• In Nepal ,men were nearly twice as more reported to have TB than women which were nearly the
same in the region and global context.

26. Treatment outcome
• The NTP has achieved excellent treatment success rate, with or above 90 percent
success rate sustained since the introduction of DOTS in 1996. Since then, NTP has
always exceeded the global target of 85 percent treatment success.
• The trend of TB treatment success rates for TB has been consistently above 90%
since the last few years.
• Annual trend of TB treatment success rates at national level for newer cases (New and
Relapse) is constantly high at around 90%, for this FY 2075/76 it is 91%.

27. • However, the trend of success rates among the retreatment cases (Failure, Loss to Follow-up and
Other previously treated) had been constantly lesser (in comparison to treatment success among
newer cases).

28. Drug resistant tuberculosis (DR TB)
• Drug-resistant TB (DRTB) has become a great challenge for the NTP and a major public health
concern in Nepal.
• Innovative approaches and more funding are urgently needed for the programmatic management of
drug resistance TB nationally to detect and enrol more patients on multi-drug resistant (MDR) TB
treatment, and to improve outcomes.

29. Case finding
• The National MDR TB Treatment Guideline defines three types of MDR-TB (RR TB, Pre-XDR
TB and XDR TB) cases which are further classified in six different categories.
• Drug resistant forms of TB are detected through GeneXpert, Culture/DST and LPA methods in
Nepal.
• Burden of Pre-XDR and XDR TB patients was found more at province 5

30. TB/HIV co-infection
• TB /HIV co-infection status .
• Out of total screened for TB ,0.7% were diagnosed to have HIV .
• In those diagnosed with TB- HIV co-infection ,97% were enrolled in ART .

31. NTP’s laboratory network
• The diagnosis and treatment monitoring of TB patients relies on sputum smear microscopy because
of its low cost and ease of administration. It is also the worldwide diagnostic tool of choice
worldwide.
• Nepal has 603 microscopy centers (MCs) that carry out sputum microscopy examinations.
• Most of the MCs are run by the government health facilities while few are operated by NGOs and
private instructions.
• There are well established networks between the microscopy centres (MCs) at PHCCs, DHOs and
DPHO, the five regional TB quality control centres (RTQCCs) and with the National TB Centre
(NTC).

32. • The microscopy centres send examined slides to their RTQCCs via DHOs according to the Lot
Quality Assurance Sampling/System (LQAS) method.
• At the federal structure, NTP has already initiated coordination and communication with
respective provinces to provide technical and financial support to establish provincial structure for
the external quality assurance of smear microscopy slides.
• The external quality assurance (EQA) for sputum microscopy is carried out provincial health
directorates (previously regional health directorates) at seven provinces and at the National TB
centre in Kathmandu.

33. • A lot quality assurance sampling/system (LQAS) has been implemented throughout Nepal.
• At each microscopy centre, examined slides for EQA are collected and selected according to the
LQAS.
• In LQAS, slides are collected and selected using standard procedures to give a statistically
significant sample size.
• LQAS is a systematic sampling technique that helps maintain good quality sputum results between
microscopy centres and quality control centres. The two means of testing for MDR-TB.

34. 4,323
603
58
18
86
Source : WHO and DOHS annual report FY 2075/76

35. M & E framework of NTP
• Policy environment
• Human resources
• Financial resources
• Infrastructure
• Monitoring ,supervision,
review
• Training
• Drug management
• Laboratories
• Advocacy,communication
, social
mobilization(ACSM)
• Public –private sector mix
• TB/HIV collaboration
• Strengthening health
system
• Evidence/Reasearch base
for management
Diagnostic services in place:
• Staff trained
• Centers & labs equipped
Treatment services in place:
• staff trained
• Centers equipped
Improved recording &
reporting
Improved knowledge,
attitudes, practices;
• Community
• Providers
Case(TB and MDR-Tb);
• Detected
• Treated
• cured
Input Process/activities Output Outcome
• Reduced incidence of
TB infection
• Reduced prevalence of
TB
• Reduced TB mortality
Impact

36. Logistics supply management
• The NTP’s logistics management system supplies anti-TB drugs and other essentials every four
months to service delivery sites based on the number of new cases notified in the previous quarter
and the number of cases under treatment.
• Prior to procurement of Anti TB Drugs, forecasting and quantification is done considering all
available data.
• NTC follows rules and regulations of PPMO to procure drugs from GoN Budget while Pooled
Procurement Mechanism (PPM) is adopted to import medicines from the Global Drug Facility
(GDF), Switzerland.

37. • All the drugs from procurements are received in the central NTC Store and stored by adopting
proper storage methods.
• Drugs are supplied every 4 months to District Medical Store via Regional Medical Store (RMS)
after receiving order as a result of workshops in each Region.
• In case of First Line Drugs buffer of 4 months is added in the order while supplying but no such
buffer quantity is given in case of DR Drugs.
• Supply of DR drugs is done directly to DR Centers and to some DR Sub Centers.

38. Logistic supply management
Central
store(NTC)
Clients
RMS
District
level stores
DOTS
centers
DR centers &
sub-centres
Flow of commodity
Flow of Information
For second line drugs
Drug order forms,
trimester
Drug order
forms,
trimester
Stock & issue report
(non-standard ),
trimester
Source : DOHS annual report FY 2075/76

39. Supervision system
Center(Quarterly)
Province(Quarterly)
Palika(Bimonthly)
Diagnostic and treatment
centers at central ,province
and palika level
Diagnostic and treatment
center at province and
palika level
Diagnostic and treatment
centers
Source : DOHS annual report FY 2075/76

40. Monitoring system
International International Review Annual
National National reporting &
planning workshop
4 monthly
Provincial Provincial reporting &
planning workshop
4 monthly
Treatment center Treatment center
reporting & planning
workshop
4 monthly
Palika level(local
body)
Local level reporting &
planning workshop
4 monthly
Source : DOHS annual report FY 2075/76

41. Challenges
• Lack of focal person for TB program at Palika and Province in the federal context
• Staff restructuring and its impact on staff motivation
• Insufficient income generation program for the patient and their family members.
• Inadequate TB management training to medical doctors
• Minimum interventions for strengthening PPM component

42. • Lack of operational research regarding increasing retreatment cases
• Lack of patient-friendly TB treatment service
• Lack of sputum transportation services at all districts
• Availability of TB IEC materials at health facilities
• Difficult to coordinate with regional and provincial hospitals

43. Action to be taken:
• Expansion of CB-DOTS programme throughout the country
• Endorsement of PPM guideline to strengthen Public-Private Mix approach
• Strengthen the community support system programme
• Explore operational research areas on TB prevention, treatment, and care
• Develop and distribute patients centered on TB IEC materials
• Expansion of Genexpert machine atleast one in each district by 2021
• Expansion and operationalize at least three culture/DST labs at provincial level by 2020
• Operationlize National Chest Hospital by 2021

44. Reference
• https://dohs.gov.np/wp-content/uploads/2020/11/DoHS-Annual-
Report-FY-075-76-.pdf