REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME Introduction TB is

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

Introduction: TB is one of most important public health problems worldwide. It has got high priority within the health sectors. It stands 7 th in the ten leading causes of global disability adjusted life years (DALYS) lost and expected to maintain its position even in 2020 AD. India accounts for nearly 1/3 rd of the global tuberculosis burden. Unfortunately the prevalence and incidence rates remain same as in 1954 -58 and with the increase in the country’s population, the absolute number of TB cases must have increased many fold but total cases detected in 1994 were more or less same as in 1987 which indicates poor case detection and case management. Tuberculosis in India continues to take a toll of 1, 000 per day or one every minute. It is estimated that there are 14 million TB cases in our country out of which 3. 5 million are sputum positive. About 1 million sputum cases are added every year. National Tuberculosis Control Programme was started in 1962. The objectives of the Programme were to reduce the morbidity and mortality, to reduce disease transmission and to diagnose as many cases of tuberculosis as possible and to provide free treatment. However, it could not make much of an impact on this dreaded disease. It was mainly due to incomplete treatment as treatment completion rate was less than 40 per cent along with some other causes such as inadequate budget; shortage of drugs; emphasis on x-ray diagnosis; poor quality sputum microscopy and multiplicity of treatment regimens. The crux of failure of TB control programme was: Lack of finances b) lack of commitment by the policy maker’s c) lack of urgency to achieve control and d) lack of compliance. CONTD…

A comprehensive review in 1992 determined that the programme had not achieved the desired results. There was urgent need in 1993 to design a policy and methodology, which will remove all these lacunae. In 1993, the WHO declared TB to be a global emergency. To intensify the efforts to control TB, the Government of India introduced the revised strategy known as the Revised National Tuberculosis Control Programme (RNTCP), which is based on Directly Observed Treatment –Short Course (DOTS) strategy. National Health policy 2002 has supported the Revised National Tuberculosis Control Programme (DOTS) with the goal of reducing 50% mortality by the year 2010. The World Tuberculosis Day is being observed on 24 th March every year. The theme chosen for World TB Day-2004 (WTBD) is “ Every Breath Counts- Stop TB Now”. The Prime Minister on March 25, 2004 said by 2005, the entire country would be covered by DOTS (directly observed treatment, short course, a comprehensive and cost-effective strategy for TB control. He said more than a decade ago, the WHO declared TB a global emergency and in India determined steps were taken to control this epidemic by launching the revised national TB control pro- gramme in 1997. The DOTS strategy adopted under this programme is one of the notable successes in public health in India, he said, adding that its coverage has increased from 130 million five years ago to 800 million of the population in the current year. He said the TB control programme in India has so far prevented 2. 6 million infections. It has also saved 5, 000 lives. 31 st December 2003, the total number of patients who had been treated under the RNTCP was 26, 39, 194.

Facts about TB: One third of the world's population is affected by TB Every year eight million people become sick with TB; of these 95 percent are in the developing world 26 percent of the avoidable adult deaths in the developing world are due to TB 40 percent of the world's TB cases lives in WHO's South. East Asia region TB kills 2 -3 million people each year; nearly 1 million deaths take place in South-East Asia TB causes more deaths than AIDS, malaria and diarrhoea combined TB kills more women than all cases of maternal mortality put together TB is the leading infectious killer of people living with HIV/AIDS

The 22 countries most affected by tuberculosis are Afghanistan, Bangladesh, Brazil, Cambodia, China, the Democratic Republic of Congo, Ethiopia, Indonesia, Kenya, Myanmar, Nigeria, Pakistan, Peru, the Philippines, Russia, South Africa, Thailand, Tanzania, Uganda, Vietnam and Zimbabwe, says WHO.

Reason for failure of National tuberculosis control programme Completion rate of treatment was 30% Inadequate budgetary outlay Shortage and irregular supply of anti-tuberculosis drugs Undue emphasis on x-ray diagnosis Poor quality of sputum microscopy More emphasis on case detection rather then cure Poor organizational setup and support Multiplicity of treatment regimes Poor awareness of TB patients about the disease Non availability of trained staff

Revised strategy: Augmentation of organizational support Increased budgetary outlay Use of sputum as a primary method of diagnosis Standardize treatment regimens Augmentation of the peripheral level supervision Ensuring a regular, uninterrupted supply of drugs up to the periphery health unit Emphasis on training, IEC, and Operational research

“WHO” goals for 2005: 1. To ensure that 70 per cent of TB cases would be detected. 2. 85 per cent would be treated successfully

PROGRAM REVISED NATIONAL CONTROL TUBERCULOSIS PROGRAMME

RNTCP-TARGET IN INDIA 2001 - 430 million population in 190 districts were covered 2004 - 800 million should be covered 2005 - the whole country should be covered

SUCCESS OF RNTCP “Instigating effective treatment regimens in a way that improves patient adherence is vital to tackling the global resurgence of tuberculosis”

GOAL To extend the RNTCP to cover the entire country by 2005

OBJECTIVE To cure 85% of the sputum positive cases To detect 70% of the estimated cases of T. B

TARGET Three million cases have to be treated and 1. 5 million cases have to be cured.

STRATEGY DOTS

“THE DOTS STRATEGY REPRESENTS THE MOST IMPORTANT PUBLIC HEALTH BREAKTHOUGH OF THE DECADE, IN TERMS OF LIVES WHICH WILL BE SAVED”. DIRECTOR GENERAL WORLD HEALTH ORGANISATION MARCH 24, 1997

Components of DOTS Case detection with help of microscopy with a system of multi-tier cross-checking and quality assurance of sputum smear. Regular and uninterrupted supply of drugs(patient-wise boxes) Direct observation while patient is getting chemotherapy by the health worker and community volunteers Systematic evaluation and monitoring Political will

Treatment observes or Drug providers or Dots agent Health inspectors Pharmacists Malaria field workers Work place supervisors Railway school teachers SJAB personals Cured patients Wife of medical officers Self help group volunteers Mid-wife Senior dressers Multi purpose health workers And H & FW personnel

TYPE OF TUBERCULOSIS PATIENT UNDER RNTCP NEW CASE RELAPSE DEFAULTER FAILURE CASE CHRONIC CASE

CATEGORY I TREATMENT TYPE OF PATIENT New sputum positive New sputum negative and seriously ill New extra pulmonary seriously ill

CATEGORY - II TREATMENT TYPE OF PATIENT SPUTUM POSITIVE RELAPSE CASE SPUTUM NEGATIVE RELAPSE OR FAILURE SPUTUM POSITIVE TREATMENT AFTER DEFAULT

CATEGORY III TREATMENT TYPE OF PATIENT New sputum negative and not seriously ill New extra pulmonary and not seriously ill

COLOUR OF BOXES AND QUANTITY OF DRUGS RED COLOURED BOX 24 DOSES FOR TWO MONTHS OF INTENSIVE PHASE 18 CALENTERED WEEKLY MULTIBLISTER COMBI PACK FOR FOUR MONTHSOF CONTINUATION PHASE

COLOUR OF BOXES AND QUANTITY OF DRUGS BLUE COLOURED BOX 36 DOSES FOR THREE MONTH OF INTENSIVE PHASE 22 CALENDERED WEEKLY MULTIBLISTER COMBI PACK FOR FIVE MONTHS OF CONTINUATION PHASE

COLOUR OF BOXES AND QUANTITY OF DRUGS GREEN COLOURED BOX 24 DOSES FOR TWO MONTHS OF INTENSIVE PHASE 18 CALENTERED WEEKLY MULTIBLISTER COMBIBACK FOR FOUR MONTH OF CONTINUATION PHASE

MONITORING & EVALUATION Sputum conversion rate Cure rate

MONITORING INDICATORS 1. Annualized detection of New Smear Positive Cases Detection rate of new sputum smear-positive (infectious) tuberculosis cases per 100, 000 populations. It is estimated that the national average rate of new cases is 85 per 100, 000. The global and national target is to detect at least 70% of the total estimated cases – i. e. 60 cases per 100, 000 per year. … contd

MONITORING INDICATORS 2. Ratio of New S-ve cases to S+ve Cases In a well performing area, there will be no more than approximately 1 smear-negative case (not laboratory confirmed) for every smear-positive (infectious, confirmed in the laboratory) case. The accepted ratio under RNTCP between smear-negative and smear positive cases ranges from 0. 4 to 1. 2. Contd….

MONITORING INDICATORS 3. Smear Conversion Rate Percentage of new smear-positive (infectious) patients who are documented to become noninfectious within 3 months of starting treatment. In a well-performing area, a conversion rate of at least 85 -90% will be achieved. This indicator is reported one quarter after patients begin treatment, and applies to every patient started on treatment, without exceptions. contd…

MONITORING INDICATORS 4. Treatment Success Rate Percentage of new smear-positive (infectious) patients who are documented to either be cured, or to successfully complete treatment. In a well-performing area, at least 80 -85% of patients will be successfully treated. The global and national target is 85% treatment success. This indicator is reported 12 -15 months after patients begin treatment, and applies to every patient started on treatment, without exceptions.

RECORDS AND REGISTER Sputum smear examination form Culture/sensitivity form Laboratory register TB register Quarterly report form

THE STRATEGY FOR IMPROVING THE PERFORMANCE OF RNTCP PROGRAMME Paramedical personnel to be nominated as DOTS agents Motivation of the patients by Health Education Early reporting To create awareness about T. B To take the treatment regularly, completely To bring 3 consecutive day sputum for examination To provide diagnostic and treatment facility in all sub- divisional, divisional and zonal hospitals ntd. . Co

THE STRATEGY FOR IMPROVING THE PERFORMANCE OF RNTCP PROGRAMME . The paramedical and H&FW staffs to be trained to improve their intercommunication skill . T. B Association has to provide cash assistance to prepare the I. E. C Materials in the local languages . Discourage to conduct diagnostic camp, as it is counter productive in T. B cases . The medical officers instead of finding fault, they have to encourage the field workers to improve their performance.

CONCLUSION Tuberculosis is a major public health problem in India. This serious situation will further worsen with TB/HIV co-infection and multidrug resistant TB. Several members in India have begun to implement the revised strategy but there are many constrains which require both national and regional efforts. Strong and sustainable revised RNTCPs must be established in order to achieve the global targets at a 85% cure and 70% case finding by the year 2010. Without DOTS it is highly unlikely that countries will be able to develop effective and sustainable national tuberculosis programme. With the introduction of DOTS, achieving the global targets for tuberculosis control has now become a realistic proposition. “Is it not time for DOTS to become the standard of care in tuberculosis worldwide”.

FUTURE DIRECTION

The immediate challenges for the control of tuberculosis include developing curative regimens that are shorter or that require patients to take drugs less frequently, ideally, future regimens would have both features that is, a once weekly regimen requiring that patients be treated for only four months. Such regimens would greatly facilitate monitoring compliance. The more compelling long-term issue is the development of an improved vaccine that would have an epidemiological impact. BCG does reduce morbidity and mortality in infants but has little effect on adult pulmonary disease, which is the primary cause of death and virtually the only source of transmission. Unfortunately, because the reservoir of currently infected people is so huge, the benefits of an improved vaccine would not have substantive impact for decades. Finally, it is crucial that new, affordable and non-toxic drugs be developed to replace those lost to drug resistance.