National Tuberculosis Control Program

Lesson Objectives

To know about the magnitude of TB problem To know about the evolution of TB control in India To learn about the goals, objectives and strategies To know about the achievements and progress

Magnitude of the Problem

Global annual incidence = 9.1 million India annual incidence = 1.9 million

India is 17th among 22 High Burden Countries (in terms of TB incidence rate)

Source: WHO Geneva; WHO Report 2008: Global Tuberculosis Control; Surveillance, Planning and Financing

Global Burden of Tuberculosis

TB is one of the leading causes of death due to infectious disease in the world Almost 2 billion people are infected with M.

tuberculosis

Each year about: 9 million people develop TB disease

2 million people die of TB

Contribution of India to Global TB Control*

4.92 m 5.28 m

23%

23%

*WHO Global TB Report 2007 & 2008

The Beginning :National Tuberculosis Control Program

Before the Revised National Tuberculosis Program (NTCP) came into force the existing Tuberculosis program had the following objectives:

To identify and treat as large a number of TB patients as possible so that infectious cases are rendered non- infectious. To reduce the magnitude of TB problem in the country to a level where it ceases to be a public health problem.

Organization and administration

Central level

Besides the Tuberculosis Division in the Directorate General Health services, National Tuberculosis Institute, Bangalore and Tuberculosis Research centre at Chennai A district constitutes a functional unit of the NTCP and is called District Tuberculosis Control Program

District level

Peripheral level

Comprises of chest clinics and Primary Health Centers (PHC)

Program Implementation( prior to RNTCP)

Program activities were:

Case detection Case treatment Health education BCG vaccination

Program performance and evolution of RNTCP

Despite a nationwide network of facilities , NTCP failed to yield satisfactory results. The situation did not change much. The case finding efficiency was only 30 of the expected level although the mortality rate decreased to 53/100,00 population

Government of India launched the Revised National Tuberculosis Control Program(RNTCP) in 1997 encouraged by the results of Pilot studies were tested in 1993-94

Evolution of TB Control in India

1950s-60s 1962 1992

1993 1998 2001 2004 2006

only 30% of patients diagnosed; of these, only 30% treated successfully

RNTCP pilot began RNTCP scale-up 450 million population covered >80% of country covered Entire country covered by RNTCP

Important TB research at TRC and NTI National TB Programme (NTP) Programme Review

Revised National TB Control Program

(RNTCP)

Launched in 1997 based on WHO DOTS Strategy

Entire country covered in March06 through an unprecedented rapid expansion of DOTS

Implemented as 100% centrally sponsored program

Govt. of India is committed to continue the support till TB ceases to be a public health problem in the country

All components of the STOP TB Strategy2006 are being implemented

Objectives of RNTCP

To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases To achieve and maintain detection of at least 70% of such cases in the population

Strategy
1.

2. 3.

4.

Augmentation of organizational support at the central and state level for meaningful coordination Increase in budgetary outlay Use of Sputum microscopy as a primary method of diagnosis among self reporting patients Standardized treatment regimens.

contd.
Augmentation of the peripheral level supervision through the creation of a sub district supervisory unit 8. Ensuring a regular uninterrupted supply of drugs up to the most peripheral level 9. Emphasis on training, IEC, operational research and NGO involvement in the program
7

Core elements of Phase I

The core element of RNTCP in Phase I (19972006)was to ensure high quality DOTS expansion in the country, addressing the five primary components of the DOTS strategy Political and administrative commitment Good Quality Diagnosis through sputum Microscopy Directly observed treatment Systematic Monitoring and Accountability Addressing stop TB strategy under RNTCP

RNTCP Phase II( 2006-11)

The RNTCP phase II is envisaged to:

Consolidate the achievements of phase I Maintain its progressive trend and effect further improvement in its functioning Achieve TB related MDG goals while retaining DOTS as its core strategy

Diagnosis of TB in RNTCP: Smear examination

Cough for 3 weeks or More

3 sputum smears
3 or 2 positives 1 positive smear

3 Negative Antibiotics 1-2 weeks Symptoms persist X-ray Negative For TB

X- ray
positive smear Smear-Positive TB negative

Positive Smear-Negative TB Anti-TB Treatment

Anti-TB Treatment Non-TB

Classification of Patients in Categories for Standardized Treatment Regimen

Category Category I Type of Patient Regimen Duration in months 6

New Sputum Positive 2 (HRZE)3, Seriously ill sputum negative, 4 (HR)3 Seriously ill extra pulmonary,

Color of box: RED Category II Color of box: BLUE Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default 2 HRZES)3, 1 (HRZE)3 5 (HRE)3 8

Contd.
Category Type of Patient Regimen Duration in months 2 (HRZ)3, 4 (HR)3 6

Category III

Sputum Negative, extra pulmonary not Seriously ill

Color of box: GREEN

Types of Drug-Resistant TB
Mono-resistant Resistant to any one TB treatment drug Poly-resistant Resistant to at least any two TB drugs (but not both isoniazid and rifampicin) Multidrug- resistant (MDR TB) Resistant to at least isoniazid and rifampicin, the two best first-line TB treatment drugs Extensively drug-resistant (XDR TB) Resistant to isoniazid and rifampicin, PLUS resistant to any fluoroquinolone AND at least 1 of the 3 injectable second-line drugs (e.g., amikacin, kanamycin, or capreomycin)

RNTCP Organization structure: State level

Health Minister

Health Secretary MD NRHM Director Health Services

Additional / Deputy / Joint Director (State TB Officer)

State Training and Demonstration Center (TB) Director, IRL Microbiologist, MO, Epidemiologist/statistician, IRL LTs etc.,

State TB Cell Deputy STO, MO, Accountant, IEC Officer, SA, DEO, TB HIV Coordinator etc.,

Program innovations

Creation of sub district level supervisory and monitoring unit TB Unit Patient-wise individual drug boxes for entire course of treatment Community involvement in DOTs shopkeepers, teachers, postmen, cured patients, etc Continuous Internal Evaluation of districts Monitoring strategy document with checklists NGO & PP (Private Provider) schemes Task Force mechanism for involvement of Medical colleges Web based IEC/ ACSM resource centre

Contd.

District TB Control Society Modular training Patient wise boxes Sub-district level supervisory staff (STS, STLS) for Treatment & microscopy Robust reporting and recording system

Quality Diagnostic and Treatment Services

~12,500 decentralized designated microscopy centers established External Quality Assurance (EQA) system for sputum microscopy as per international guidelines Quality assured anti-TB drugs Patient friendly DOT services

Well Defined IEC Strategy

Web based resource centre Communication facilitators provided to support IEC at district level Ongoing capacity building of program managers for planning and implementing need based IEC activities