BOLD STEP TAKEN BY COUNTRY HEAD

1. END TB -- (2017-2025)
Dr V NAgrawal
MDGoldMedalist
TuberculosisAndChestDiseases
ChestCareClinic
Gorakhpur

2. END TB CONCEPT
POST 2015 GLOBAL ‘‘TUBERCULOSIS
CONTROL STRATEGY’’ WAS CALLED AS
‘’END TB STRATEGY’’
GLOBAL TARGET --- 2030
INDIA TARGET--------2025

3. PM wows to end TB by 2025
The Prime Minister, Narendra Modi launching
the TB Free India Campaign
Creating a Swastha Bharat is part of Prime Minister's vision of New India and the
launch of the new strategic plan is another step in this direction.

4. END TB MEANING
TOTAL NIL TB FROM EARTH ?
TO END TB EPIDEMIC ?

5. MAIN TARGET OF END TB
REDUCE DEATH BY 95 %
CUT NEW CASE BY 90 %
NO FAMILY SHOULD BURDEN EXPENCE
DUE TO TB

6. TuberculosisandGlobal Challenges
• Tuberculosis persists asaglobal public
health problem of serious magnitude
requiring urgent attention. Current global
efforts to control TBhave three distinctbut
overlapping dimensions:
• Humanitarian,
• Public health, and Economics.

7. GlobalBurdenof TB
• ------2 billion infected, i.e. 1 in 3 ofglobal population
and
10.4 million (139/ lac) new casesin 2015,ofwhich
5.9 million(56%) were amongmen,
3.5 million (35%)among women and
01 million among children(10%)
80%in 22high- burden countries
-------SEARaccounts for 41%of global burden in term
of TBincidence( India and Indonesia havelargest
no.Of cases.
• 1.4m deaths in 2015, 98%in low-incomecountries
• MDR-TB-prevalence in new casesaround 3.6%

8. Problemof TBin India (WHO
SEAROREPORT2015-2016)
• Estimated incidence
• -2.8 MILLION CASES
– 167 (156-179) per 1 lac population annually
– 75 new smear positive PTBcases/1lakh population per
year
• Estimated prevalence of TBdisease
– 195 (131-271) per 1 lac population annually.
• Estimated mortality
– 480,000 deaths due to TBeachyear
– Over 1000 deaths a day
– 2 deaths every 3 minutes

9. Evolutionof TBControlinIndia
• 1950s-60s
• 1962
Important TBresearchat TRCandNTI
National TBProgramme(NTP)( Designedfor
DomiciliaryTreatment,usingselfadministereddrug regimens)
• 1992 ProgrammeReview
• only30%of patients diagnosed;
• of these, only 30%treatedsuccessfully
RNTCPpilotbegan
RNTCPscale-up( full fedgeedprog.)
450 million populationcovered
>80%of countrycovered
EntirecountrycoveredbyRNTCPon24th march
• 1993
• 1998
• 2001
• 2004
• 2006
• Sinceinceptionfrom97-98 to Dec2015 morethan 19million patients
were initiated ontreatment andMore than 3.5 million additional lives
havebeen saved.

10. Differencesin NTPand RNTCP
NTP,1962 RNTCP,1992
OBJECTIVE Early diagnosis and treatment Breaking chain of Transmission
OPERATIONALSTRATEGY Not defined 1. Curerate >85%
2. Casefinding>70%
STRATEGY 1. SCCsupervised
2. Conventional
1. DOTS
2. Uninterrupted drugsupply
DIAGNOSIS More emphasis onX-rays Mainly SputumMicroscopy

11. NSP for TBelimination2017-2025
• TheMOHFW in consultation with over 150
national and international experts working in the
field of public health, program managers, donor
agencies, technical partners, civil societies,
affected community representatives and other
stakeholders of TBcontrol both from public aswell
asprivate sector finalized the new National
Strategic Planfor TB2017-2025(NSP).

12. What isNSP?
• TheNSPfor TBelimination 2017–25 is a
framework to guide the activities of all
stakeholders including the national and state
governments, development partners, civil
society organizations, international agencies,
research institutions, private sector, andmany
others whose work is relevant to TB
elimination in India .
It is a3 year costed plan and a8 year strategy
document

14. VISION GOALS and
TARGETS OFNSP
VISION:-TB-FreeIndia with zero deaths,
disease and poverty due to tuberculosis.
GOALS:-Toachieve arapid decline in burden of
TB,morbidity and mortality while working
towards elimination of TBin India by2025.

15. TARGET
PRIVATE SECTOR ENGAGEMENT
PLUGGING THE LEAK OF TB Ptients
ACF AMONG KEY POPULATION & HIGH
RISK GROUP
PREVENTING CONVERSION OF LATENT
TB TO ACTIVE TB

16. 4 STRTEGIC PILLER OF NSP
DETECT
TREAT
PREVENT
BUILD

17. DETECT
1-SCALING UP FREE ,HIGH SENSITIVE
TB DIAGNOSTIC TEST-CB NAAT
2-SCALING UP PVT PROVIDER
ENGAGEMENT
UNIVERSAL TESTING OF DR TB
SCREENING OF HIGH RISK POPULATION

18. DETECT---HOW ?
1.Tousehigh efficiency diagnostic tools for early and
accurate diagnosis linked treatment acrossthe
country
2.To strengthen surveillance systems including
introduction and scale up of next generation
sequencing platforms
3.Purchasing services and ensuring notification
through laboratories from the private sectorand
link to laboratorysurveillance
4.Topromote and foster research for newdiagnostic
tools
5.Tobuild capacity for diagnosis of LTBI

19. How it can be achieved?
1. GOODANDRELIABLE AND WIDELYAVAILABLE
LABORATORYSYSTEMS
2. ACTIVECASE FINDINGS
3. PATIENTSIN PRIVATESECTORS

20. Laboratory System
• Scaleup of rapid molecular tests for TBdiagnosis.
• Provision of Digital X-Ray
reimbursement of costs.
UNIVERSAL DST FOR ATLEAST RIFAMPICIN

21. • Health Insurance for healthcare workersincluding
laboratory personnel will be extended by the
programme.
• The programme will empanel accredited private
labsfor diagnosis
• Implementation of laboratory information
management system and linking it to e-Nikshaywill
also be hastened during this planperiod.

22. • Thekeystrategies of active casefinding will include:
1. Screeningat every visit with the most sensitive
screening tool. Thescreening test is not intended to
be diagnostic and people with positive results onthe
screening test will undergo diagnosticevaluation.
a. Screening strategies
i. Community screening canbe done by:
2.Inviting people to attend screening atamobile facility
or afixed facility. Invitations may target specifically
people within agiven vulnerable group, those who
havehad recent close contact with someone who has
TBand people with symptoms of TB.
3.Going door to door toscreen households .

23. ii. Institutional screening:
(1)In Health care facilities : Systematically perform
active screening of vulnerable individualsattending
hospitals and other health careinstitution
(2)In congregate settings: Systematically perform
active screening of vulnerable individuals in
shelters, old agehomes, refugee camps,
correctional facilities and other specificlocations
suchasworkplaces.
2. Linking to nearest TBdiagnostic facilities will ensure
confirmation of diagnosis thereby ensuring early
detection.

24. • The NITIAyoghasrecognized the role of pvt
doctors
• As per niti ayoge
• 80% TB patient attend PVT Doctors
Effective engagement of the private sector
with their dominant presence in Indian
healthcare is crucial to achieve Universal
Accessto TBCare.

26. TREAT
• EARLY DRUGS PROVISIN TO DSAND DR TB
• CONTINU OUS DRUG PROVISION FORALL
• DRUG POVISION AT CONVIENIENT PLACE OF
PT
• FREE DRUGATPVT PHARMACY
• REGULER WATCH ON SIDE EFFECTS OF
DRUGS
• APPROPIATE WEIGHT BANDING OF DRUGS
• DRUGS FOR SPECIAL SITUATION LIKE
JAUNDICE , RENALFAILURE,PREGNANCY ECT.

27. 5. NTM treatment:-
Non-tuberculous Mycobacterium are
environmental opportunistic microorganisms that
cancausehuman diseasewith signsand symptoms
similar to MTB.RNTCPwill initiate addressing NTM
and will be scaled up acrossIndia by end of2018.
6. Palliative careandrehabilitation :-
Patients with extensive drug resistance in whom an
appropriate regimen could not be formed asperthe
WHOrecommended regimen, even with addition of
newer drugs and who need care beyond cure willbe
offered palliative care through the nodal DR-TB
centers or at the community level under guidance
of nodal DR-TBcenter.

28. 3. PATIENTSUPPORTSYSTEM:-
• Agood patient support plan is imperative fortreatment
successand will be developed at the time of initiation
of treatment. This support will include the following:
1.initial and frequent follow-up counselling of the patient
and family members,
2.supervision of treatment by atrained treatment
supporter (a health worker or communityvolunteer),
3. locally managed additional nutritional support,
4.retrieval of treatmentinterrupters,
5. screening for adversereactions,
6.appropriate social support scheme,
7.psycho-social support,
8.co-morbidity management,and
9.follow-up laboratory investigations.

29. 3. PREVENT
• What doesit entail?
air-born infection control measuresat health
carefacilities.
1.Treatment for latent TBinfection in contactsof
bacteriologically-confirmed cases.
2.Contact tracing

30. 1. AIRBORNEINFECTIONCONTROL:
•CHALLENGESATCOMMUNITYLEVEL:-
Socialhabits
• Coughetiquettes not beingfollowed
• Indiscriminate spitting
• Sneezingwithout covering face
• Alcoholics and mentally challenged patients
• Delay in reaching health facility for specificdiagnosis
Specialgroups
•Migrant population, back ward areas and tribalpockets
Old agehomes, poor homes, children homes, jails, hard to reachareas
• Delay in diagnosis in co-morbid conditions like Diabetes, HIV,Cancers,
etc.

31. •CHALLENGESATINSTITUTIONALLEVEL
Outpatient facility
•Patients with chest infection at outpatient settings
• Overcrowding - mixing of patients inqueues and waiting
areas
• Poor ventilation in thefacilities
in patient facility
• Coughscreening & separation, use of mask
counseling provision Infectious
patients getting admitted atGeneral wards
improveCoughetiquettes not followed inwards
Overcrowding in the wards – no restrictedentries

32. CONTACTTRACING;-
In RNTCPcontact screening hasbeen aclinical
function with programmatic monitoring. In this
NSPcontact tracing will be made more-----
rigorous, expansive and accountable.
The end result expected is that most TBpts will
have theircontacts screened

33. Contactinvestigation
• All close contacts, especially householdcontacts
will be screened for TBusing ChestXRays.
• In caseof paediatric TBpatients, reversecontact
tracingfor searchof anyactiveTBcasein the
householdof the childmustbe undertaken.
• Particular attention will be paid tocontacts with
the highest susceptibility to TBinfection like
with immunosuppression and diabetes

34. PREVENTIVETHERAPY/LATENTTBINFECTION
TREATMENT:-
TBinfection is the seedbed for developing TB
diseaseand continued transmission. Thelifetime
risk of reactivation of LTBIin healthyHIV-uninfected
individuals is 10%,with 5%developing TBdisease
during the first 2 to 5 yearsafterinfection.
ARTreduces the risk of TBby approximately two
thirds.

35. • Isoniazid Preventive Therapy
• Children are more susceptible to TBinfection, more
likely to develop active TBdiseasesoon after infection,
and more likely to develop severe forms of
disseminated TB.Children <6 years of age,who are
close contacts of aTBpatient.

36. • Thedose of INHfor preventive therapy is 10mg/kg
body weight administered daily for aminimum
period of six months. TheINHtablets will be
collected on monthly basis.Thecontacts will be
closely monitored for TBsymptoms.

37. In addition to above, INHpreventive therapy willbe
considered in following situation:-
• For all HIVinfected children who either had aknown
exposure to an infectious TBcaseor are Tuberculin
skin test (TST)positive (>=5mm induration) but
haveno active TBdisease.
• All TSTpositive children who are receiving
immunosuppressive therapy (e.g. Childrenwith
nephrotic syndrome, acute leukemia,etc.).
• Achild born to mother who wasdiagnosed to have
TBin pregnancy will receive prophylaxis for 6
months, provided congenital TBhasbeen ruled out.
BCGvaccination canbe given at birth even if INH
preventive therapy isplanned.

38. 4. BUILD
What doesit meansin term of NSP?
HIGH LEVEL POLITICAL COMMITMENT
RESTRUCTURING RNTCP
BUILDING SUPPORTIVE SRTUCTURE
FORSURVEILLANCE
SCALING UP TECHNICALASSISTANCE

39. Strategic interventions:
1. Boldpolicy initiatives:
a. National TBPolicyandTBBill:-
TB CARE IS RIGHT OF PATIENT
-will hasten the control of TBin the
country. Thevarious clausesof the bill will cover
all aspects of TBprevention and care to protect,
promote and fulfil the rights of persons with
Tuberculosis during delivery of TBcare .

40. National TBEliminationBoard
Apex body to facilitate policy development
Proposed constituents include Prime Minister as
patron,
Central TBDivision will directly report to
National TBElimination Board(NTEB).

41. THANKS……
DR V N AGRAWAL