1. Innovations and changing
strategies in RNTCP and its
reasons
Presenter:
Dr Sadhana Meena
Resident (second yr)
Dep. of PSM

2. Background history of
RNTCP:
 1946- Bhore committee recommended to
setting up TB clinics in the districts and
mobile TB clinics in rural areas.
 1947- GOI established a TB division under
DGHS in the MoH.
 1951- Mass BCG vaccination campaign
launched.

3. ..continue
 1962- national TB control
programme(NTCP) launched.
 1992- programme reviewed (RNTCP
launched as phase manner)
 1993- WHO declared TB as a global
emergency.
 1997- RNTCP started as a national
programme.(first phase 1998-2005)

4. Some shortcomings were found in the NTCP-1962
such as-
1. Completion rate of treatment was 30% only.
2. Inadequate budgetary outlay.
3. Shortage and irregular supply of anti tubercular
drugs.
4. Undue emphasis on x-rays diagnosis.
5. Poor quality of sputum microscopy.
6. More emphasis on case detection rather than
cure,
7. Poor organisational set up and support for TB,

5. 8. Multiplicity of treatment regimens,
9. Poor acceptability of principles of integration of
NTCP in to general health services and
resistance from medical fraternity and
10. Poor awareness of TB patients about the disease
causation, prevention, duration of treatment, and
availability of TB treatment in general hospital.
11. Non- availability of trained staff.
 During this long period of operation of NTCP, all
districts still had not been covered.

6.  Around the same time in1993, the WHO
declared TB as a global emergency.
why-world bank has estimated global
burden of TB in terms of DALYs loss and
stated that TB stands 7th in the ten leading
causes of global DALYs loss, Because of its
severity and consequences, in 1993 WHO
has declared TB as a global emergency.
 In response to above and on basis of
reviewed report ,Government of India
revitalized NTCP as Revised National TB
Control Programme (RNTCP) in the same
year.

7. RNTCP objectives:
1. Emphasis on the cure of infectious
and seriously ill patients of
tuberculosis, through administration
of supervised short course
chemotherapy, to achieve a cure
rate of at least 85%.
2. Augmentation of the case finding
activities to detect 70% of estimated
cases, only after having achieved the
desired cure rate.

8. Revised strategy:
1. Augmentation of organizational support for
coordination.
2. Increased budgetary outlay.
3. Use of sputum testing as the primary
method of diagnosis among self-reporting
patients.
4. Augmentation of the peripheral level
supervision through the creation of a sub
district supervisory unit.
5. Ensuring a regular, uninterrupted supply of
drugs up to the most peripheral level.
6. Emphasis on training, IEC, operational
research and NGO involvement in the
program.

9.  To achieve RNTCP first objective,
DOTS was officially launched as the
RNTCP strategy in 1997,till that time
only two percentage population was
covered by RNTCP and by the end of
2005 the entire country was covered
under the programme.

10.  During 2006–11, in its second phase
RNTCP improved the quality and reach of
services, and worked to reach global case
detection and cure targets. These targets
were achieved by 2007-08.
 2009: Prevalence of all forms of TB ↓ from
338 per 100,000 population (1990) to 249
per 100,000 population and TB mortality in
the country ↓ from over 42 per 100,000
population in 1990 to 23 per 100,000
population (WHO global TB report 2010)

11.  Despite these achievements, undiagnosed
and mistreated cases continued to drive the
TB epidemic.
 TB was the leading cause of illness and
death among persons living with HIV/AIDS
and large number of multidrug resistant TB
(MDR-TB) cases were reported every year.
 Therefore in May 2012, Notification of TB is
made mandatory (The Central TB Division
developed a case based and web based
system called “Nikshay”)and In June 2012
prohibition on the import and sale of sero-
diagnostic tests for TB had been done by
GOI.

12.  The Standards for TB Care in India was also
developed and it was published in 2014.
 In 2015, out of estimated:
global annual(incidence)- 9.6 million TB cases,
2.2 million- india
 During this period for achievement of the long
term vision of a “TB free India”, National
Strategic Plan for Tuberculosis Control 2012-
2017 was documented with the goal of
‘universal access to quality TB diagnosis and
treatment for all TB patients in the community’.

13. National Strategic Plan for Tuberculosis
Control (2012-2017)
Significant interventions and initiatives were
taken during NSP 2012-2017 in terms of
 Mandatory notification of all TB cases,
 Integration of the programme with the
general health services (National Health
Mission),
 Expansion of diagnostics services,
 Programmatic management of drug
resistant TB (PMDT) service expansion,
 Single window service for TB-HIV cases,
 National drug resistance surveillance and
 Revision of partnership guidelines.

14. Achievements of NSP 2012-
2017
1. In the past five years, more than 7
million TB patients have been detected
and initiated on treatment with 1.2
million additional lives saved in the
country.
2. Among all cases registered under the
RNTCP, treatment success rates are
consistently about 85% in new cases
and 75% among retreatment cases.
3. NSP 2012-2017 took significant strides
in acceleration of MDR TB
management country wide.

15. 3. In the past 5 years, 120,299 DRTB
patients have been detected and put
110,808 on treatment.(I.e 92%)
4. All HIV infected patients showing the four
symptom complex are offered rapid
molecular tests along with daily treatment
regimen with FDCs for improved treatment
outcomes in the high risk group.
5. Newer weight bands for adult and
paediatric dosages are created
Achievements

16. 6.Bedaquiline CAP roll out in six sites
across the country. The conditional
access program (CAP) has been
rolled out in 2016 across six sites in
the country with a country wide scale
up planned in 2017-2020.
7. Standards of TB care for India (STCI)
to guide all health care providers on
expected standards / quality of care
across all sectors.

17. Most recent-
 To eliminate TB in India by 2025, five years
ahead of the global target, a framework to
guide the activities of all stakeholders,
whose work is relevant to TB elimination in
India is formulated by RNTCP as National
Strategic Plan for Tuberculosis Elimination
2017-2025.

18. National strategic plan for
tuberculosis 2017-2025’ (NSP)
 Vision- TB free india with zero deaths, ds
and poverty due to TB.
 Expected outcomes are:
1) 80% reduction in TB incidence(i.e
reduction from 211 per lakh to 43 per lakh)
2) 90% reduction in TB mortality( i.e
reduction from 32 lakh to 3 per lakh)
3) 0% patient having catastrophic
expenditure due to TB.

19. Impact indicators of normal
strategy:
baseline Target
Impact
indicators
2015 2020 2023 2025
TB
incidence
rate
217
(112-355)
142
(76-255)
77
(49-185)
44
(36-158)
TB
prevalence
rate
320
(280-380)
170
(159-217)
90
(81-125)
65
(56-93)
Mortality due
to TB
32
(29-35)
15
(13-16)
6
(5-7)
3
(3-4)
Catastrophic
cost
35% 0% 0% 0%

20. Key strategies:(NSP 2017-
2025)
1. Private sector engagement
2. Active case finding
3. Drug resistance TB case
management
4. Addressing social determinant
including nutrition
5. Robust surveillance system
6. Community engagement & multi-
sectoral.

21.  According to the NSP TB(2017-2025)
elimination have been integrated into
the four strategic pillars of
“Detect Treat Prevent
Build” (DTPB).

22. Detect
1. Use high efficiency diagnostic tools for
early and accurate diagnosis linked
treatment across the country.
2. Strengthen surveillance systems.
3. Purchasing services and ensuring
notification through laboratories from
the private sector and link to laboratory
surveillance.
4. Promote and foster research in
conjunction with the TB Research
Consortium for new diagnostic tools.
5. Build capacity for diagnosis of LTBI

23. Treat:
 Initiate and sustain all TB patients on
appropriate anti-TB treatment wherever
they seek care, with patient friendly
system and social support.
1. Providing daily regimen using FDCs to
all TB patients.
2. DST guided treatment for DR TB.
3. Patient centric approach to treatment.
4. Prevent loss at cascade of TB care

24. Prevent:
Prevent emergence of TB in susceptible
population various measures are
indicated as:
1. Scale up air-borne infection control
measures at health care facilities
2. Treatment for latent TB infection in
contacts of bacteriologically-confirmed
cases
3. Address social determinants of TB
through inter-sectoral approach.

25. Build:
 building and strengthening enabling
policies, empowering institutions and
human resources with enhanced
capacities and financial resources to
match the plan.

26. Mobile based “Pill-in-Hand” adherence
monitoring tool(DOTS99)
 Each time a patient takes a dose of medication, a hidden
number appears which is printed on the strip behind the drug.

27.  The patient need to send a missed call
to a particular contact number with the
digits appeared on drug package.
 This will be documented at a
centralized ICT unit and thus, an
electronic treatment record of each
patient will be maintained to monitor
the treatment adherence.

28. Treatment category/group:
Treatment groups Type of patient
NEW 1. Microbiologically confirmed TB
case (definitive TB case)
2. Clinically diagnosed TB case
(probable case)
Previously treated 1. Recurrent TB
2. Treatment after failure
3. Treatment after loss to follow-
up
4. Other previously treated
patient.

29. some newer initiatives-
 In 2018, the TrueNat test, an
indigenously developed technology
under the “Make in India” initiative,
was deployed in about 350 PHCs.
 Regimens, with Bedaquiline and
Delamanid, have been made available
across the country, Delamanid use in
children from 6 to 17 years has also
been introduced.

30.  The Saksham Project of Tata Institute
of Social Sciences (TISS) has been
providing counseling support to all
DR-TB patients under PMDT in four
states- Rajasthan, Gujarat,
Maharashtra (Mumbai) and
Karnataka.
 Project Axshya Global Funded, The
Union’s Project Axshya supports in
enhancing the access to diagnosis
and treatment of TB cases among
vulnerable and marginalised groups in
128 chosen districts.

31. • SAATHI Catalyzing Pediatric TB
Innovations (CaPTB project)-
objective of CaP TB project in India is
to support rapid scale-up of pediatric
TB services across private health
sector through evidence generation.
 Project JEET(joint efforts for
elimination of TB)- improving the
quality services of patients seeking
care in private sectors.

32.  REACH(Resource Group for
Education and Advocacy for
Community Health)-
• REACH is working to amplify and
support India’s response to TB by
involving previously unengaged
stakeholders and broadening
conversation around the disease.
• Presently this working in six key states
– Assam, Bihar, Chhattisgarh,
Jharkhand, Odisha and Uttar Pradesh.

33.  Nakshatra initiative- Private sector
engagement initiative under TB Free
Chennai Initiative.
 Universal Drug-Susceptibility Testing
(U-DST): Testing all TB patients for
resistance to at least Rifampicin
constitutes U-DST. This is achieved by
offer of CBNAAT to all patients
diagnosed as TB.
 U-DST has been rolled out across the
country since January 2018.

34.  These interventions along with the
joint collaborative activities helped in
reducing TB related fatalities by 82%
(from baseline 2010).
 RNTCP has expanded its
collaboration with Diabetes and
Tobacco control programmes including
NPCDCS.

35. Thank you

36. Trends of TB burden in india
YEAR mortality
rate
Incidence
per lakh
Prevalence
per lakh
% of
smear+ in
new pul
cases
1990 43 168 338 -
1995 19 168 234 23
2000 24 168 248 35
2005 26 168 258 56
2009 23 168 249 60
2010 26 185 256 -
2016 32 211