NEW VISION FOR TB CONTROL

- DR. PRAPULLA CHANDRA

India has highest TB burden

6%

5%

5%

4%

3%

3%2%

2%

2%

1%1%

IndiaOtherSouth Africa IndonesiaPakistanBangladeshdPhilippinesEthiopiaDR CongoMyanmarNigeriaMozambiqueRussian FederationVietnamKenyaBrazil

23%

10%

10%

Data source: Global TB Report 2016, WHO

Global annual incidence = 10.4 millionIndia annual incidence = 2.84 million

TB Burden Global India

Incidence TB

104 lakh 28.4 lakh

Mortality of TB *

14 lakh 4.8 lakh

Incidence HIV TB

12 lakh 1.13lakh

Mortality of HIV-TB *

4.0 lakh 37,000

MDR-TB 5. 8 lakh 1.3 lakh

National Strategic Plan for TB Control2012-2017

Universal Access to quality TB diagnosis and treatment for all TB patients in the community

Vision

Goal

A TB FREE INDIA

Objectives

Early and improved diagnosis(90%)Access to high-quality treatment(90%)

Scale-up access to effective DR TB treatment

Decrease the morbidity andMortality in HIV TB

Extend RNTCP services to patients in Private Sector

Evolving Strategies – Case Finding

Passive

Intensified

Active

ZN & LED

Microscopy

Radiology

Molecular

diagnostics

Culture & DST

Linkages

Co morbiditi

es

Key Populati

ons

Slums

Migrants

Communities

Evolution in TB Diagnosis• LED microscopy.• MODS-Microscopic Observation Drug Susceptibility • LPA refinement for smear negative MDR TB suspects• Rapid Identification of species by strip speciation test• Breathalyzer screening test• First generation loop mediated isothermal

amplification technology platform (LAMP)• Urinary Lipo-arabinomannan (LAM) or any other

antigen detection tests• Rapid automated 2nd and 3rd generation NAATs for first

and second line DST

PREVIOUS RECOMMENDATIONS :• Commercial molecular line probe assays for 1st-line anti-TB drugs:

For use at central/regional reference laboratory level for rapid detection of rifampicin (alone or with isoniazid) resistance. Suitable for use on smearpositive specimens or culture isolates.

• NOT recommended for 2nd line drugs.

Automated NAAT(GeneXpert / Xpert MTB/RIF)

• Result in 90m• M TB – Y / N• Rif res – Y / N• 70% additional

yield in smear negative TB

15Gokulam 21-03-2014

PREVIOUS RECOMMENDATIONS• LAMP NOT recommended for use due to insufficient data.

URINARY LAM TEST• Detection of lipoarabinomannan (a lipopolysaccharide

component of MTB cellwall) antigen in urine.• Single clinical visit, results in ½ hr.• sensitivity is 28.2 %• But sensitivity increases to 66.7% when CD4 cell count <50• In HIV pts, LAM + Smear microscopy increases sensitivity

comparable to GeneXpert MTB/RIF .

BREATHALYZER TEST• Uses optical detection technology with fluorometry.• The collection tube was designed to collect aerosols and

particles coughed out by the patient.• Result can be obtained in 10min.• Sensitivity is 74% and specificity is 79%

- TECHNICAL OPERATIONAL GUIDELINES FOR TB CONTROL IN INDIA 2016

25

Current views leading to change in regime to daily regime• High rates of “relapse” in RNTCP ~ 12 - 15%• Incidence rates remain high

26

Himachal PradeshSikkimBihar MaharashtraKerala

Daily Regimen implementation in 104 districts

Total population -2690 Lakh

28

MAIN CHANGES IN 2016 UPDATE• A shorter MDR-tb treatment regimen under specific

conditions.• Medicines used in the MDR tb treatment regimens are now

regrouped differently.• MDR-tb treatment is recommended for all pts of RR-TB

regardless of confirmation of isoniazid resistance.• Clarithromycin and other macrolides are no longer included

in the treatment of MDR-tb.

Earlier WHO classification of anti TB drugs Group Drugs

Group 1. First line oral drugs Isoniazid, RifampicinEthambutol, PyrazinamideRifabutin, Rifapentine

Group 2. Injectable anti-TB drugs Streptomycin (First line)Kanamycin, Amikacin, Capreomycin

Group 3. Fluoroquinolones Ofloxacin, LevofloxacinMoxifloxacin

Group 4. Oral bacteriostatic second-line anti-TB drugs

Ethionamide, ProthionamideCycloserine, TerizidonePara-aminosalicylic acid

Group 5. Anti-TB drugs with limiteddata on efficacy and/or long termsafety in the treatment of drug-resistantTB

BedaquilineDelamanidLinezolidClofazimineAmoxicillin/ clavulanateImipenem/cilastatin; MeropenemHigh-dose isoniazidThioacetazoneClarithromycin

• The shorter MDR-TB treatment regimens were standardized in content and duration and split into two distinct parts.

• The first was an intensive phase of four months (extended up to a maximum of six months in case of lack of sputum smear conversion) and included the following drugs: gatifloxacin (or moxifloxacin), kanamycin, prothionamide, clofazimine, high-dose isoniazid, pyrazinamide and ethambutol.

• This was followed by a continuation phase of five months with the following medicines:

• gatifloxacin (or moxifloxacin), clofazimine, pyrazinamide and ethambutol.

Introduction of Bedaquiline BDQ-CAP (Conditional access programme)

• Six sites identified to roll out BDQ CAP

• Guidelines have been prepared

• National Training of trainers(TOT) done at NTI Bangalore in Jan 2016

• BDQ CAP rolled out in six pilot sites in 2016.

Rajasthan

Gujarat

MaharashtraOrissa

Karnataka

Madhya Pradesh

Bihar

Uttar Pradesh

Jammu & Kashmir

Tamil Nadu

Assam

Telangana

Chhattisgarh

Andhra Pradesh

Jharkhand

Punjab

West B engal

Kerala

Haryana

Himachal Pradesh

Manipur

Mizoram

Andaman & Nicobar

Daman & Diu

UttarakhandSikkim

Arunachal Pradesh

Nagaland

Tripura

TB-HIV Collaborative Activities

TB – HIV co-morbidity

Status 2015• 79% TB patients know their HIV status• 92% TB HIV patients are receiving ART• 93% TBHIV patients receiving CPT

3 I’s• Intensified case finding (ICF)• Isoniazid preventive therapy (IPT)• Infection control for Tuberculosis (IC)

Intensified TB case finding and treatment at high burden Anti-Retroviral Therapy (ART) centres

Single window service delivery for TB & HIV

Intensified case finding TB diagnosis through CBNAAT Daily Regimen Better management of side

effects- Pharmacovigilance Use of newer technology for

treatment monitoring Isoniazid Preventive Therapy Air Borne Infection control

Progress so far 45419 PLHIV tested for TB 6389 diagnosed as TB 185 diagnosed as Rif

Resistance 6073 put on Daily Anti TB

treatment 149 Rif /R put on CAT IV

Country-wide expansion by 2nd October 2016

ISONIAZID PREVENTIVT THERAPY

Reaching the unreached

Groups• Socially vulnerable• Clinically high risk

Screening TB patients for DMTertiary Care Centers

Screening DM patients for TB Tertiary Care Centers

DM Patients screened for TB DM Patients diagnosed as TB

(68%)

(13%)

TB –Diabetes and Tobacco Collaborative Activities

TB-DM• A national collaborative workshop was

held between RNTCP and NPCDCS• The joint framework aims at reduction in

morbidity and mortality by doing bi-directional screening, early detection and prompt management of DM and TB.

• Activities to improve diagnosis and management of DM among TB pts :

-Screening of all registered TB pts for DM -DM management among TB ptsTB among DM patients : - intensified detection of active TB among DM pts -TB infection control measures -TB treatment and management in comorbid pts

TB AND TOBACCO

TB AND TOBACCO• Main intervention will be counselling of tobacco users at TB

facilities and referral of tobacco users coming at Tobacco Cessation Centre to DMC for TB screening.

VACCINES

INDEX TB Guidelines 2016• New guidelines

developed for management of Extra pulmonary TB by Central TB Division , AIIMS, New Delhi , WHO and GHA

• Dissemination Workshop held on 09th July 2016 at AIIMS New Delhi

• Dissemination and further develop a training module

SKELETAL TB

NOTIFICATION OF TB CASES

NIKSHAYCase Based Web Based TB Notification System

Developed & powered by CTD & NIC

TB Notification (private)

Laboratory Single-PP clinic Multi-Hospital0

10000

20000

30000

40000

50000

60000

70000

3 420 10273563 4732

1803

24226

29395

12620

56101

64908

24875

38571

51879

Before 2012 2012 20132014 2015

Total 3.2 lakh till date

Source: Global TB Report 2015, WHO, Geneva

Missed Call Server

Missed Call

Missed call List

Call Center Agent

Agent call to Patient

Server

Patie

nt

Feed

back

Patie

nt Fe

edba

ck

upda

ted t

o Ser

ver

Patient Category wise List

Information about diagnosis

General information TB

Adverse drug reactions due to TB drugs

Missed Call Campaign

Information about treatment facilities

Missed call server will be linked with NIKSHAY platform

DTO

Web based Monitoring for DR TB patients

e-Smart

Electronic Surveillance and Management of Drug Resistant Tuberculosis System

- An innovative approach towards better patient management

Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering

Goal: End the Global TB epidemic

Vision, goal, targets, milestones

(2,2 million)

(2.2 lakh)

Global TB projections to 2035 compared with current trends

Next Seminar on WEDNESDAY 26/10/16

MEDIASTINUM by DR. SATISH & NON-INVASIVE VENTILATION by DR. SANDEEP