National Tuberculosis Control Program DR KANUPRIYA CHATURVEDI Lesson

National Tuberculosis Control Program DR. KANUPRIYA CHATURVEDI

Lesson Objectives n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Magnitude of the Problem Global annual incidence = 9. 1 million India annual incidence = 1. 9 million India is 17 th among 22 High Burden Countries (in terms of TB incidence rate) Source: WHO Geneva; WHO Report 2008: Global Tuberculosis Control; Surveillance, Planning and Financing 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Global Burden of Tuberculosis n n 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 n Each year about: n 9 million people develop TB disease n 2 million people die of TB 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Contribution of India to Global TB Control* 5. 28 m 4. 92 m ? ? 23% *WHO Global TB Report 2007 & 2008 12/1/2020 23% Dr. KANUPRIYA CHATURVEDI

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. 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Organization and administration n Central level n n District level n n 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 Peripheral level n Comprises of chest clinics and Primary Health Centers (PHC) 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Program Implementation( prior to RNTCP) Program activities were: n Case detection Case treatment Health education n BCG vaccination n n 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Program performance and evolution of RNTCP n n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Evolution of TB Control in India n n n 1950 s-60 s 1962 1992 Important TB research at TRC and NTI National TB Programme (NTP) Programme Review n n n n 1993 1998 2001 2004 2006 12/1/2020 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 Dr. KANUPRIYA CHATURVEDI

Revised National TB Control Program (RNTCP) n Launched in 1997 based on WHO DOTS Strategy n n Implemented as 100% centrally sponsored program n n Entire country covered in March’ 06 through an unprecedented rapid expansion of DOTS 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 Strategy 2006 are being implemented 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Objectives of RNTCP n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

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. 12/1/2020 Dr. KANUPRIYA CHATURVEDI

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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Core elements of Phase I n 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 n Political and administrative commitment n Good Quality Diagnosis through sputum Microscopy n Directly observed treatment n Systematic Monitoring and Accountability n Addressing stop TB strategy under RNTCP 12/1/2020 Dr. KANUPRIYA CHATURVEDI

RNTCP Phase II( 2006 -11) n The RNTCP phase II is envisaged to: n n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Diagnosis of TB in RNTCP: Smear examination Cough for 3 weeks or More 3 or 2 positives 3 sputum smears 3 Negative 1 positive smear Antibiotics 1 -2 weeks X- ray positive smear Symptoms persist negative Smear-Positive TB X-ray Negative For TB Anti-TB Treatment 12/1/2020 Positive Non-TB Smear-Negative TB Dr. KANUPRIYA CHATURVEDI Anti-TB Treatment

Classification of Patients in Categories for Standardized Treatment Regimen Category Type of Patient Regimen Duration in months Category I New Sputum Positive 2 (HRZE)3, Seriously ill sputum negative, 4 (HR)3 Seriously ill extra pulmonary, 6 Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default 8 Color of box: RED Category II Color of box: BLUE 12/1/2020 2 HRZES)3, 1 (HRZE)3 5 (HRE)3 Dr. KANUPRIYA CHATURVEDI

Contd. Category Type of Patient Regimen Duration in months Category III Sputum Negative, extra pulmonary not Seriously ill 2 (HRZ)3, 6 4 (HR)3 Color of box: GREEN 12/1/2020 Dr. KANUPRIYA CHATURVEDI

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) 12/1/2020 Dr. KANUPRIYA CHATURVEDI

RNTCP Organization structure: State level Health Minister Health Secretary Director Health Services MD NRHM Additional / Deputy / Joint Director (State TB Officer) State Training and Demonstration Center (TB) Director, IRL Microbiologist, MO, Epidemiologist/statistician, IRL LTs etc. , 12/1/2020 State TB Cell Deputy STO, MO, Accountant, IEC Officer, SA, DEO, TB HIV Coordinator etc. , Dr. KANUPRIYA CHATURVEDI

Program innovations n n n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Contd. n n n District TB Control Society Modular training Patient wise boxes Sub-district level supervisory staff (STS, STLS) for Treatment & microscopy Robust reporting and recording system 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Quality Diagnostic and Treatment Services n n ~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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Data Management System: RNTCP 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Public Private Mix (PPM) Activities for Involvement of All Health Care Providers n n n Involvement of NGOs and Private Practitioners n Schemes revised in 2008 n Presently > 2500 NGOs, 17, 000 PPs involved Involvement of professional bodies like IMA, IAP Other Central government departments/PSUs q CGHS, Railways, ESI, Mining, Shipping Corporate sector q ~150 Corporate Houses participating Involvement of FBOs like CBCI Involvement of Medical Colleges n Task Forces and Core Committees formed n 260 Medical colleges involved 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Well Defined IEC Strategy n n n 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 12/1/2020 Dr. KANUPRIYA CHATURVEDI

RNTCP: Assessment of Impact n Nation wide ARTI Survey – 2008 -10 n Coordinated by NTI, Bangalore in association with n New Delhi TB Centre (North Zone) n MGIMS, Wardha (West Zone) n LRS Institute, New Delhi (East Zone) n CMC, Vellore (South Zone) Symptomatic screening + CXR + Sputum Smear + Culture 12/1/2020 Dr. KANUPRIYA CHATURVEDI

External Evaluations Undertaken n Joint Monitoring Mission (JMM) by WHO and other development partners in 2000, 2003 and 2006 Conclusions n JMM 2000 n RNTCP is succeeding and its results have been excellent n JMM 2003 n Extra-ordinarily rapid expansion of the programme & highly economical n JMM 2006 n Excellent system of recording & reporting with indicators for monitoring & evaluation; well integrated into general health system Future plan n JMMs planned in 2009 and 2012 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Contd. n Disease prevalence Surveys – 2007 -09 n n n n TRC Chennai – MDP project NTI, Bangalore MGIMS, Wardha PGI, Chandigarh AIIMS, New Delhi JALMA, Agra RMRCT, Jabalpur Symptomatic screening + Sputum Smear + Culture Repeat ARTI and Disease prevalence surveys planned in 2015 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Impact of RNTCP Trends in prevalence of culture-positive and smear-positive tuberculosis in south India(5 Blocks), 1968 -2006 RNTCP era Pre-SCC treatment era 12/1/2020 SCC treatment era Dr. KANUPRIYA CHATURVEDI

Achievements Under RNTCP 412766 Since implementation n > 40 million TB suspects examined n > 9 million patients placed on treatment n > 1. 6 million lives saved (deaths averted) Achievements in line with the global 12/1/2020 targets Dr. KANUPRIYA CHATURVEDI

Progress Towards Millennium Development Goals n n Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients n n The global NSP case detection rate is 61% (2006) and treatment success rate is 85% RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and case detection rate 70% (2007) 12/1/2020 Dr. KANUPRIYA CHATURVEDI

Cost Effectiveness of Program in India* n n n Total costs of TB control per capita is US $ 0. 1 (2007) Cost of first line drugs per patient treated in India is US $ 14 compared to US $ 30 (median) for HBCs India remains the country with the lowest cost per patient treated (US $ 84) compared to US $ 274 (median) for HBCs *Source: WHO Report 2008, Global Tuberculosis Control; pg 71 &112; HBCs= High Burden Countries 12/1/2020 Dr. KANUPRIYA CHATURVEDI

TB-HIV: Accomplishments n Developed and implemented mechanism for TB & HIV program collaboration at all levels (National, State, District) n Conducted surveillance and determined national burden of HIV in TB patients n Mainstreamed TB-HIV activities as core responsibility of both programs (training & monitoring) 12/1/2020 Dr. KANUPRIYA CHATURVEDI

TB-HIV: Current Policies (2008) TB/HIV activities in all States n n Coordination & Training on TB/HIV Intensified Case Finding (ICF) Referral of all HIV- TB patients for HIV care and support (CPT & ART) Involve NGOs Activities in high-HIV states n n n 12/1/2020 Provider-initiated HIV counseling and testing for all TB patients Decentralized provision of Co-trimoxazole Expanded TB-HIV monitoring Dr. KANUPRIYA CHATURVEDI

RNTCP- DOTS-Plus Vision n n By 2010 DOTS-Plus services available in all states By 2012, universal access under RNTCP to laboratory based quality assured MDR-TB diagnosis for all retreatment TB cases and new cases who have failed treatment By 2012, free and quality assured treatment to all MDR-TB cases diagnosed under RNTCP (~30, 000 annually) By 2015, universal access to MDR diagnosis and treatment for all smear positive TB cases under RNTCP 12/1/2020 Dr. KANUPRIYA CHATURVEDI