National TB Elimination Programme Overview Key Priorities Vikas

National TB Elimination Programme Overview - Key Priorities Vikas Sheel Joint Secretary - Health Ministry of Health and Family Welfare

What is Tuberculosis? Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB) which generally affects the lungs, but can also affect other parts of the body Risk factors: Malnutrition Diabetes HIV infection Poor immunity Severe kidney disease Other lung diseases e. g. silicosis o Substance abuse etc. o o o o Overcrowding o Inadequate ventilation o Enclosed living/ working conditions o Occupational risks One patient with infectious pulmonary TB if untreated can infect 10 -15 persons in a year

TB Notification under NTEP 35 28. 8 30 27. 4 23. 2 15 26. 4 24. 04 lakhs 26. 9 25 20 28. 7 21. 5 lakhs 18. 3 lakhs 5. 3 lakhs (25%) 3. 8 lakhs (21%) 12% increase in case finding 18% increase in case finding 10 6. 8 lakhs (28%) 14. 4 lakhs (79%) 16. 1 lakhs (75%) 17. 2 lakhs (72%) 2018 2019 5 0 2017 Public Private NTEP Target Incidence Estimate (WHO Global Report) 3

Sustainable Development Goals (SDG) Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering Goal: End the Global TB Epidemic (<10 cases per 100, 000 population) INDICATORS Reduction in number of TB deaths compared with 2015 (%) Reduction in TB incidence (new case) rate compared with 2015 (%) TB-affected families facing catastrophic expenditures due to TB (%) TARGETS SDG 2030 90% 80% Zero

TB Free India • India has committed to End TB by 2025, 5 years ahead of the global SDG target • Prime Minister of India launched TB Free India campaign at ‘Delhi End TB Summit’ on 13 th March, 2018 • The campaign calls for a social movement focused on patient-centric and holistic care driven by integrated actions for TB Free India

More & more States committing to Ending TB Chhattisgarh Tamil Nadu Himachal Pradesh Lakshadweep Kerala Jharkhand State level commitment 14 State/UT 2020 - Kerala 2021 - Himachal Pradesh 2022 - Gujarat, Lakshadweep & Sikkim 2025 - Bihar, Chhatisgarh, Daman & Diu and Dadra & Nagar Haveli, Jammu & Kashmir, Jharkhand, Madhya Pradesh, Puducherry, Tamil Nadu and Andaman & Nicobar Islands

National Strategic Plan (2017 -25) Community Engagement Preventive Measures Multisectoral response Active Case Finding Strategies ICT Tools for adherence and monitoring Drug Resistant TB TB Comorbidities Private sector engagement 7

Organizational structure Supporting Facilities § National Reference Laboratories (6) § Intermediate Reference Laboratories (31) § Culture and DST Laboratories (81 including IRL/NRL) § CBNAAT Laboratories (1268) § DRTB Centres- 703

Key Services 1. Free diagnosis and treatment for TB patient 2. Public health action- contact tracing, testing for co-morbidities etc. 3. Treatment adherence support 4. Nutrition assistance to TB patients (DBTNikshay Poshan Yojana) 5. Preventive measures

Strengthening Case Finding in the Public Sector PASSIVE APPROACH TO CASE FINDING Chest X Ray: Clinically diagnosed TB increased from 8. 8 lakhs in 2017 to 12. 7 lakhs in 2019 Revised Diagnostic Algorithm for TB: Increase in DR-TB cases from 38, 000 in 2017 to 66, 000 in 2019 Upfront Rapid Molecular Testing: Increased from 5. 23 lakhs upfront tests in 2017 (16% yield) to 11. 34 lakhs in 2019 (17% yield) ACTIVE APPROACH TO CASE FINDING Intensive Case Finding in Health facilities- Screening for TB among: -DM patients increased from 11. 5 L in 2018 to ~20 L in 2019 - ICTC/ART referrals increased from 3. 35 L in 2017 to 3. 94 L in 2019 Active Case Finding in vulnerable population: from 5. 5 crore population screened in 2017 to 28 crores screened in 2019. Yield increasing from ~27, 000 to ~63, 000 TB patients. Leveraging Outreach of other Healthcare Programmes: 8. 3 lakhs referrals from Health & Wellness Centres.

Strengthening Case Finding in the Private Sector Schedule H 1 Implementation: The number of chemists registered in Nikshay increased from 15221 in 2017 to over 43000 chemists notifying 20, 609 TB cases in 2019. Mandatory Notification of TB: Gazette notification issued in March 2018; Provisions of Sections 269 and 270 of the Indian Penal Code (IPC) in 2019 Patient Provider Support Agency through JEET and Domestic Resources: From 48 PPSAs in 2017 to 220 PPSAs in 2019 and 266 PPSAs in 2020. 77% Increase in private sector notification from 3. 8 lakhs in 2017 to 6. 8 lakhs in 2019.

Treatment Patient Centric Care • Daily Regimen • Shorter Regimen • Newer Drugs • IT Enabled Adherence Support • Comorbidity management • Financial incentives Reduce Out-of-pocket • Direct Benefit Transfer Expenditure

Direct Benefit Transfer (DBT) schemes 1. Honorarium to Treatment Supporters – For provision of treatment support to TB patients (Adherence, ADR monitoring, counselling @Rs. 1000/- to Rs. 5000/-) 2. Patient Support to Tribal TB Patients (Financial Patient Support @Rs 750/-) 3. Nutritional Support to All TB patients (Financial Support to Patients @Rs. 500/-month) 4. Incentives to Private Providers (Rs. 500/- for Notification & Rs. 500/- for reporting of Treatment Outcome 5. Incentives to Informant (Rs. 500/- is given on diagnosis of TB among referrals from community to public sector health facility)

Prevent • Air borne infection control measures • Strengthen Contact Investigation • Preventive treatment in high risk groups • Manage Latent TB Infection • Address determinants of disease

Paradigm shift in management of Drug Resistant TB MDR-TB Success Rate 70% Shorter MDR TB Regimen 60% 50% 46% 47% 48% 2016 2017 2018 2019 30% Conventional MDR Regimen Shorter MDR Regimen DR-TB Success Rate (MDR with additional resistance & XDR) Bedaquilline (CAP) 60% 66% 40% 27% 2016 28% 2017 Conventional XDR Regimen 31% 2018 36% 2019 Shorter MDR TB regimen 66, 308 BDQ Containing regimen 12589 Dlm Containing regimen 445 All oral longer regimen 4072 All Oral Longer Regimen Launch by AS&DG, Jharkhand (Jan 2020)

Multi-sectoral Engagement TB care services in health infrastructure Infection Prevention Address Determinants Prevention and Care at Work Place Socio-economic support & Empowerment Information Education Communication Corporate Social Responsibility TB - A social problem & needs multi-sectoral approach

Inter-Ministerial Coordination AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy) • 1 st meeting of National Technical Expert Group on NTEP-AYUSH Collaboration & e-consultation of experts held • 2 nd draft of Policy Document and Joint Letter drafted Railways • Joint Working Group to be formed to monitor implementation Defence • Action Plan developed. • 95 Ex- Servicemen Contributory Health Scheme (ECHS) Polyclinics registered in Nikshay, remaining underway Labour and Employment • Mo. U signed in September 2020

Community Engagement ØTransformation of TB survivors to TB champions ØCapacity building and mentoring programme ØEngagement of existing community groups like PRI, SHG, VHSNC, MAS, Youth Club ØGrievance redressal mechanism ØInvolvement of community representatives in different forums TB Forums at the National, State and District level to provide a platform for all stakeholders, including the community, to voice their views

Call Centre- Nikshay Sampark § 1800 -11 -6666 § § § Counselling Nikshay Outbound & Inbound Poshan Yojana Time – 7 to 11 Languages – 14 100 call centre agents Information Pan-India coverage TB Citizen – Patient - Providers Notification Policy Update in RNTCP, 2018 Treatment Adherence Grievance Redressal Follow Up

Sub-National Disease Certification District Award Criteria Decline in incidence rate compared to 2015 Monetary Award for District (in Rs. ) Bronze 20% 2 lakhs Silver 40% 3 lakhs Gold 60% 5 lakhs TB Free Status 80% 10 lakhs Accelerate efforts Contextual strategies State Award State/Uts with State/Uts population (population <50 lakh – 5 Cr >5 Cr Bronze 10 lakhs 15 lakhs 25 lakhs Silver 20 lakhs 35 lakhs 50 lakhs Gold 40 lakhs 60 lakhs 75 lakhs TB Free Status 60 lakhs 75 lakhs 1 Crore Generate healthy competition Monetary and non-monetary awards

State TB Index Policy Update in RNTCP, 2018

Key Challenges 1. Under reporting and uncertain care of TB patients in private sector 2. Reaching the unreached – Slums, Tribal, vulnerable 3. Drug Resistant TB 4. Co-morbidities – HIV, Diabetes 5. Undernutrition, overcrowding 6. Lack of awareness and poor health seeking behaviour lead to delay in diagnosis

Key Take Away • Improve TB notification rate Ensure mandatory TB notification from private sector • Active TB Case Finding to reach the unreached • Optimum utilization of CBNAAT machines • Expand Universal Drug Susceptibility Testing coverage • NIKSHAY Poshan Yojana to every TB patients • 100% reporting through NIKSHAY • Collaboration with Line Ministries to tackle social determinants of TB • Community participation for TB Elimination

Bending the Curve Accelerating towards a TB free India Thank You