Updates in RNTCP Universal access to TB care

Updates in RNTCP Universal access to TB care Central TB Division, Directorate General Of Health Services Ministry of Health & Family Welfare, Government of India

Outline Magnitude of TB Problem Update on achievements of RNTCP Case detection and treatment outcomes The Stop TB Strategy – 2009 SWOT analysis of RNTCP Need for Universal Access to TB Care Early and Complete case detection Role of Medical Colleges for Universal Access to TB Care OR opportunities in Universal Access to TB Care Impact of RNTCP

Magnitude of TB problem

Estimated TB incidence per 100, 000 population (2008) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2006. All rights reserved Source: Global TB Report, 2009 World Health Organization

India is the highest TB burden country accounting for one fifth of the global incidence Global annual incidence = 9. 4 million India annual incidence = 1. 98 million India is 17 th among 22 High Burden Countries (in terms of TB incidence rate)

Estimated TB problem in India (WHO 2008) Incidence of TB disease 1. 98 million / yr (168 / lac / year) Prevalence of TB disease 2. 18 million (185 / lac pop) Mortality due to TB 276, 512 / yr (>900/day) (24 / lac / year) HIV Positive TB patients MDR – TB in new cases MDR – TB in re-treatment cases (10% life time risk of TB disease; several factors increase this risk, e. g. HIV, diabetes, smoking, poor nutrition, etc) 4. 85% (95240 cases in 2007) 2 -3% 12 -17% (~99000 cases in 2008)

RNTCP – Goal and Objectives Goal The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. Objectives: To achieve and maintain a cure rate of at least 85% of new sputum positive TB patients To achieve and maintain a case detection of at least 70% of new sputum positive TB patients

The STOP TB Strategy, 2009 1. 2. 3. Pursue high-quality DOTS expansion and enhancement a. b. c. d. e. Secure political commitment, with adequate and sustained financing Ensure early case detection, and diagnosis through quality-assured bacteriology Provide standardised treatment with supervision, and patient support Ensure effective drug supply and management Monitor and evaluate performance and impact RNTCP is implementing all these components of The STOP TB Strategy Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations a. b. c. Scale–up collaborative TB/HIV activities Scale-up prevention and management of multidrug-resistant TB (MDR-TB) Address the needs of TB contacts, and poor and vulnerable populations a. b. c. d. Help improve health policies, human resources development, financing, supplies, service delivery and information Strengthen infection control in health services, other congregate settings and households Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) Adapt approaches from other fields and sectors, and foster action on the social determinants of health a. b. Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches Promote use of the International Standards for Tuberculosis Care (ISTC) a. b. c. Pursue advocacy, communication and social mobilization Foster community participation in TB care, prevention and health promotion Promote use of the Patients' Charter for Tuberculosis Care a. b. Conduct programme-based operational research, and introduce new tools into practice Advocate for and participate in research to develop new diagnostics, drugs and vaccines Contribute to health system strengthening based on primary health care 4. Engage all care providers 5. Empower people with TB, and communities through partnership 6. Enable and promote research 2006/rev. 2009

Key Achievements of RNTCP Case Detection & Treatment Outcomes

Key achievements Since implementation > 44 million TB suspects examined > 12 million TB patients placed on treatment > 2 million additional lives saved Achievements in line with the global targets

New Smear Positive (NSP) case detection and treatment success rate in areas covered under RNTCP

Quality diagnostic and treatment services � ~12, 800 decentralized designated microscopy centers established � External Quality Assurance (EQA) system for sputum microscopy as per international guidelines � Quality assured drugs � Patient wise drug boxes

Network of nearly 0. 43 million DOT providers: Private doctor in Pune Unani doctor in Jaipur NGO Worker in Andhra Homeo doctor in Pune Quality of DOT ensured predominantly through Supervision by DTOs, MOTCs, STS

Treatment Outcome of Smear Positive Cases registered under RNTCP DOTS, 1993 -2 Q 09 NSP Sp + Retreatment N = 4, 529, 030 N = 1, 613, 131 The default rates (2008) among NSP is 6% and that of Re-treatment cases is 13%

Treatment outcome of New Extra-Pulmonary Patients registered under RNTCP DOTS (20052 Q 2009) (all forms of EP TB) Total cases (n =9, 56, 515)

N=33649 N=25948

New Smear Positive (NSP) case detection and treatment success rate in areas covered under RNTCP Is this enough to control TB?

SWOT Analysis - RNTCP Strengths: Weaknesses: • Strong political and administrative commitment. • Secured medium to long term financing. • Wide network of TUs and quality assured DMCs across the country. • Decentralized DOTs (~ 0. 43 million DOT centers ) • Consistently achieving Global targets for past few years. • TBHIV & DOT plus services introduced-Nation vide scale up by 2012. • Wide participation of NGOs, PPs, Corporate, Professional bodies and other Government departments. • Engaged CS Partners viz. Union, WV, CBCI to enhance reach & empower TB cases / communities • Unorganized private sector • Weak general health systems in some states. • Shortage of key Managerial staff (one person handling multiple portfolio) Opportunities: Threats: • Universal Access • Airborne Infection Control Guidelines developed • Newer diagnostics under RNTCP in collaboration with FIND • HR turnover • Sustainability of finances • Irrational use of 1 st & 2 nd line drugs due to market forces –Pan Sensitive TB - LED Microscopy, Gene. Xper –M/XDR TB diagnosis - LPA, Liquid culture, Capillia test, Gene. Xpert

Vision �To provide universal access to quality diagnosis and treatment for all TB patients in the community

Thinking Beyond - 70 / 85 ! Community engagement ACSM Minimize access barriers Symptoms recognised Access delay Pediatric. TB Health care utilisation tie nt TB determinants lth se rv s Pa Infected PPM HRD HSS PAL Contact investig Clinical risk Vulnerable groups populations -Children -Other risk groups -All household -Workplace -HIV -Previous TB -Malnourished -Smokers -Diabetics -Drug abusers -Prisons -Urban slums -Poor areas -Migrants -Workplace -Elderly Improve diagnostic quality, new tools He a ice Intensified case finding Active TB Infection control Effective TB screening in health services and on broader indication de l ay Health education DOTS / MDR-TB/HIV TB Expansion de l Lab str. ay Diagnosis Notification Improve referral and notification systems New diagnostic tools

Universal Access to TB Care Early and Complete case detection

Universal Access to TB Care. Concept/Definition All TB patients in the community to have access to early, good quality diagnosis and treatment services in a manner that is affordable and convenient to the patient in time, place and person. All affected communities must have full access to TB prevention, care and treatment, including women, children, elderly, migrants, homeless people, alcohol and other drug users, prison inmates, people living with HIV and other clinical risk factors, and those with other life-threatening diseases. All types- Smear positive, negative, EP, Drug Resistant TB

Steps to Universal access Most of the un-reached cases are seeking health care but not being treated under the programme. They can be reached by Increasing suspects examination rate National level- 160/lakh/qtr District level- wide variations Ensure adequate infrastructure – Health system strengthening DMCs-trained LTs TUs Sputum collection and Transport facilities Medical Colleges Involving all departments in Medical Colleges Strengthening Quality through Supervision and Monitoring Filling up of vacant posts Proactive programme review at all levels Implementing Tribal Action Plan

Steps to Universal access Other Health Care providers Other Govt health sectors, corporate sector, ESI, Mines etc NGO/PP involvement IMA, CBCI GF Rd-9 Project ACSM-374 district o IUATLD o World Vision

Steps to Universal access Contact Tracing Contact tracing of sputum positive patients Intensified case finding activities in High risk population (evidences) HIV Smokers Diabetes Other vulnerable groups – migrants, slum dwellers

Role of Medical Colleges for Universal Access to TB Care

Colleges • Started in 1997, gained momentum in 2001 -02 • 7 leading medical colleges as nodal centers • National/Zonal/State Task Forces and Core Committees in MCs –Quarterly meeting of Core committee and STF –Annual NTF and ZTF workshops since 2002 onwards • RNTCP supports medical colleges by provision of contractual manpower, lab consumables, ATT drugs, trainings/sensitizations, OR • Quarterly reporting system and monitored by the task forces in collaboration with the programme managers at all levels

Medical College Involvement NTF - 2009 endorsed “RNTCP’s proposed change in the regimen and nomenclature from the existing categories (CAT I, II & III) to ‘new’ and ‘previously treated’. ” Quarterly reporting formats revised for MC/STF/ZTF 273 out of 286 medical colleges involved by the end of 3 Q 09 > 185 contractual MOs, > 255 Contractual LTs and > 255 TBHVs have been sanctioned for medical colleges During the period 3 Q 08 -2 Q 09, > 0. 57 million TB suspects examined > 85, 400 sputum smear positive cases diagnosed > 45, 600 sputum smear negative TB cases & > 71, 500 extra-pulmonary cases have been diagnosed

Promotion of Universal access of care for TB in all Medical Colleges Utilize State and Zonal Task Force mechanism to further strengthen medical college involvement in RNTCP. Medical colleges need System of intensified screening of TB suspects from all departments Strengthening of interdepartmental collaboration and monitoring System of tracking patients both within the institution and outside for diagnosis as well as treatment. Mechanism to conduct Internal Evaluation of Medical Colleges to further strengthen medical college involvement in RNTCP is being developed.

Possible areas for intervention Active identification of chest symptomatics in all out patient departments (OPD) Smear Negative cases Follow up of smear negative chest symptomatics Chest X-ray as part of the diagnostic algorithm Referral services

Intensive case finding among high risk groups: HIV care centres - - Active TB case finding should be implemented in all facilities providing HIV care, like ICTCs, ART Centres, Care and support centres etc. Train Medical Officers in the algorithm for diagnosis of TB in HIV positive patients. Early initiation of CPT and ART along with DOTS in HIV positive TB cases Involve NGOs working with HIV programme in TB case finding activities.

Intensive case finding among high risk groups: Diabetic patients. Sensitize medical officers to actively search for TB in diabetic patients. Active TB case finding in diabetic clinics Smokers TB control programme to actively associate with anti smoking programme. Chronic smokers attending OPDs with respiratory symptoms to be screened for TB.

Operational Research on Universal Access Medical colleges are encouraged and funded to conduct OR on RNTCP priority agenda topics for research. Download RNTCP OR Agenda, Guidelines and format for proposal submission from http: //www. tbcindia. org/documents - 7. research in RNTCP

Impact of RNTCP

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

Progress towards Millennium Development Goals � Indicator 6. 9: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB Prevalence rate of TB 68% Mortality rate of TB 43% � Indicator 6. 10: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients � The global NSP case detection rate is 62% (2009) and treatment success rate is 85% � RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and case detection rate 72% (2007, 2008 and 2009)

RNTCP: Studies for assessment of Impact � Nation wide ARTI Survey – 2008 -10 � Coordinated by NTI, Bangalore in association with � � New Delhi TB Centre (North Zone) MGIMS, Wardha (West Zone) LRS Institute, New Delhi (East Zone) CMC, Vellore (South Zone) � Disease prevalence Surveys – 2007 -09 � TRC Chennai – MDP project � NTI, Bangalore � MGIMS, Wardha � PGI, Chandigarh � AIIMS, New Delhi � JALMA, Agra � RMRCT, Jabalpur Symptomatic screening + CXR + Sputum Smear + Culture Symptomatic screening + Sputum Smear + Culture � Repeat ARTI and Disease prevalence surveys planned in 2015

The way forward �Vision �To provide universal access to quality diagnosis and treatment for all TB patients in the community �By 2015 �Detection of at least 90% of all TB patients in the community, including HIV-associated TB and DR-TB �Initial screening of all smear-positive TB patients for drug resistant TB �Offer of HIV Counseling and testing for all TB patients �Successful treatment of � at least 90% of all new TB patients, � at least 85% of all previously-treated �Promote rational use of anti TB drugs

Thank you

NSP Case Detection Rate (%) 1 Q 2010 National Level- 70% >= 70% (14 states) 60 - 69% (7 states) < 60% (14 states)

1 Q 2009 NSP Case Detection Rate (%) 1 Q 2010 National Level- 70% > 70%, 260 231 30% – 49. 9% 133 < 30% 16 50% - 69. 9% Back > 70%, 255 263 30% – 49. 9% 114 < 30% 21 50% - 69. 9%

$Population attributable fraction – selected risk factors & determinants Relative risk for active TB$

Population attributable fraction – selected risk factors & determinants Relative risk for active TB disease Weighted prevalence (22 HBCs) Population Attributable Fraction HIV infection 20. 6/26. 7* 1. 1% Malnutrition 3. 2** 16. 5% Diabetes 3. 1 3. 4% 19% 27% 6% Alcohol use (>40 g / d) 2. 9 7. 9% 13% Active smoking 2. 6 18. 2% 23% Indoor Air Pollution 1. 5 71. 1% 26% Sources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481 -491. *Updated data in GTR 2009. RR=26. 7 used for countries with HIV <1%. **Updated data from Lönnroth et al. A consistent log-linear relationship between tuberculosis incidence and body-mass index. Submitted, 2009

“Diabetes makes a substantial contribution to the burden of incident tuberculosis in India…” Back