national TB control

7/30/2019 national TB control

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National Tuberculosis ControlProgram


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Lesson Objectives To know about the magnitude of TB

problem

To know about the evolution of TBcontrol in India

To learn about the goals, objectivesand strategies

To know about the achievements andprogress


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Magnitude of the Problem

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

Global annual incidence = 9.1 million

India annual incidence = 1.9 million

India is 17th among 22High Burden

Countries (in terms ofTB incidence rate)


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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


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23%

5.28 m

Contribution of India to Global TBControl*

*WHO Global TB Report 2007 & 2008

?

?

4.92 m

23%


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The Beginning :National Tuberculosis

Control ProgramBefore the Revised National Tuberculosis

Program (NTCP) came into force the existingTuberculosis program had the followingobjectives:

To identify and treat as large a number of TBpatients as possible so that infectious cases arerendered non- infectious.

To reduce the magnitude of TB problem in thecountry to a level where it ceases to be a publichealth problem.


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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 District level

A district constitutes a functional unit of the NTCP andis called District Tuberculosis Control Program

Peripheral level Comprises of chest clinics and Primary Health Centers

(PHC)


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Program Implementation( prior to

RNTCP)Program activities were:

Case detection

Case treatment

Health education

BCG vaccination


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Program performance and evolutionof RNTCP

Despite a nationwide network of facilities , NTCP failed toyield satisfactory results. The situation did not changemuch.

The case finding efficiency was only 30 of the expectedlevel although the mortality rate decreased to 53/100,00population

Government of India launched the RevisedNational Tuberculosis Control Program(RNTCP) in1997 encouraged by the results of Pilot studieswere tested in 1993-94


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Evolution of TB Control in India 1950s-60s Important TB research at TRC and NTI 1962 National TB Programme (NTP) 1992 Programme Review

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

1993 RNTCP pilot began 1998 RNTCP scale-up

2001 450 million population covered 2004 >80% of country covered 2006 Entire country covered by RNTCP


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Revised National TB Control Program(RNTCP)

Launched in 1997 based on WHO DOTSStrategy Entire country covered in March06 through an

unprecedented rapid expansion of DOTS

Implemented as 100% centrally sponsoredprogram 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


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Objectives of RNTCP

To achieve and maintain a cure rate of atleast 85% among newly detected

infectious (new sputum smear positive)cases

To achieve and maintain detection of atleast 70% of such cases in the population


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Strategy1. Augmentation of organizational support at

the central and state level for meaningfulcoordination

2. Increase in budgetary outlay

3. Use of Sputum microscopy as a primarymethod of diagnosis among self reporting

patients

4. Standardized treatment regimens.


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contd.7 Augmentation of the peripheral level

supervision through the creation of a sub

district supervisory unit8. Ensuring a regular uninterrupted supply of

drugs up to the most peripheral level

9. Emphasis on training, IEC, operationalresearch and NGO involvement in theprogram


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Core elements of Phase I The core element of RNTCP in Phase I (1997-

2006)was to ensure high quality DOTS expansion inthe country, addressing the five primary componentsof the DOTS strategy

Political and administrative commitment

Good Quality Diagnosis through sputumMicroscopy

Directly observed treatment

Systematic Monitoring and Accountability

Addressing stop TB strategy under RNTCP


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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


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Diagnosis of TB in RNTCP: Smearexamination

Cough for 3 weeks or More

3 sputum smears

1 positive smear

X- ray

positive smear negative

3 Negative

Antibiotics1-2 weeks

Symptoms

persist

X-ray

Negative

For TBPositive

Smear-Negative TB

Anti-TB Treatment

Non-TB

Smear-Positive

TB

Anti-TB Treatment

3 or 2 positives


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Classification of Patients in Categoriesfor Standardized Treatment Regimen

Category Type of Patient Regimen Duration inmonths

Category I

Color ofbox: RED

New Sputum Positive

Seriously ill sputum negative,Seriously ill extra pulmonary,

2 (HRZE)3,

4 (HR)3

6

Category II

Color ofbox: BLUE

Sputum Positive relapseSputum Positive failure

Sputum Positive treatmentafter default

2 HRZES)3,1 (HRZE)35 (HRE)3

8


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Contd.

Category Type of Patient Regimen Durationinmonths

CategoryIII

Color ofbox:GREEN

Sputum Negative,

extra pulmonary not Seriouslyill

2(HRZ)3,

4 (HR)3

6


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Types of Drug-Resistant TBMono-resistant Resistant to any one TB treatment

drugPoly-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 drugsExtensively drug-resistant(XDR TB)

Resistant to isoniazid and rifampicin, PLUS resistant toany fluoroquinolone AND at least 1 of the 3 injectablesecond-line drugs (e.g., amikacin, kanamycin, orcapreomycin)


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RNTCP Organization structure: Statelevel

Health Minister

Health Secretary

MD NRHM Director HealthServices

Additional / Deputy / JointDirector

(State TB Officer)

State TB CellDeputy STO, MO, Accountant,

IEC Officer, SA,DEO, TB HIV Coordinator etc.,

State Training and DemonstrationCenter (TB)

Director, IRL Microbiologist, MO,Epidemiologist/statistician, IRL LTs etc.,


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Program innovations

Creation of sub district level supervisory and monitoringunit 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


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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


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Quality Diagnostic and TreatmentServices

~12,500 decentralized designated microscopy

centers established External Quality Assurance (EQA) system for

sputum microscopy as per internationalguidelines

Quality assured anti-TB drugs Patient friendly DOT services


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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 andimplementing need based IEC activities

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