Status of Revised National Tuberculosis Control Program (RNTCP)

in India

Dr Jitendra

Framework• TB burden• RNTCP implementation• RNTCP performance• Achievements Under RNTCP - Case Detection Rate - Cure Rate• Progress Towards MDGs• Cost Effectiveness of Program• RNTCP- DOTS-Plus• Changes in RNTCP policy• Challenges

Estimated epidemiological burden of TB

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

India is 17th among 22 High Burden Countries (in terms

of TB incidence rate)

India is Highest TB Burden Country

National ARTI- 75 NSP PTB cases/100,000 population

Global India

Annual incidence of TB (million)

9.3 1.9

HIV + among TB 15% 5%

Revised National TB Control Program (RNTCP)

• Launched in 1997 based on WHO DOTS Strategy

– Entire country covered in March’06 (632 districts/reporting units)

• Implemented as 100% centrally sponsored program

– GoI is committed to continue support till TB ceases to be a public health problem in country

Largest & fastest expanding program

RNTCP…All components of STOP TB Strategy-2006 are being implemented

1. Pursuing high-quality DOTS expansion and enhancement

2. Addressing TB/HIV, MDR-TB and other challenges

3. Contributing to health system strengthening

4. Engaging all health providers

5. Empowering people with TB, and communities

6. Enabling and promoting research

RNTCP performance- 2009

Continue to achieve twin objectives of NSP case detection and cure rate at the national level

New Sputum Positive Case Detection Rate ≥ 70%

Cure rate≥ 85%

Suspects Examined/ lakh pop

Annualized new sm+ CDR (%)

Cure rate of new Sm+ pt

T/t success rate of new Sm+ pt

India 154 59(78) 85% 87%

MH 137 48(60) 83% 85%

WR 147 40(50) 67% 82%

RNTCP performance…

TB Suspects Examined per 100,000 Population(2000-2009)

Achievements Under RNTCP

Achievements …Case Detection Rate and Treatment Success Rate

CDR- 72% 78% Treatment success rate- 85% 87%

Achievements in line with the global targets

Achievements since implementation > 40 million TB suspects examined > 9 million patients placed on treatment > 1.6 million lives saved (deaths averted)

Annualized new smear (+) case detection rate and T/t success rate

Progress Towards MDGsGoal 6: “Combat HIV/AIDS, malaria and other diseases”

- Target 8: “By 2015, to have halted and begun to reverse the incidence of malaria and other major diseases…”

• Indicator 23: between 1990 & 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

33%?

47%?

WHO Global TB Report 2008

Global (2006) India

NSP CDR 61% 70% (2007 onwards)

T/t success rate 85% 85% (2003 onwards)

Cost Effectiveness of Program in India

• Total cost 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 High Burden Countries (HBCs)

• India remains the country with lowest cost per patient treated (US $ 84) compared to US $ 274 (median) for HBCs

Source: WHO Report 2008, Global Tuberculosis Control; pg 71 &112

RNTCP- DOTS-Plus• RNTCP regimens highly effective, with low failure rates (2% in

CAT I , 6% in CAT II cases)

MDR-TB: 3% in new cases 12-17% in retreatment cases

India- Highest burden country in world On verge of MDR-TB epidemic

• Failure cases- previously not been well addressed by RNTCP, now have been addressed in RNTCP under DOTS-Plus

DOTS-Plus…Strategy to prevent MDR-TB1. Through sustained high-quality DOTS implementation (DOTS-

Plus) - MH and GJ: 2007 - AP, DL, HR, KE and WB: 2008 - Remaining states: 2009-2010

2. Improve lab capacity- 27 Accredited culture and DST IRLs are being established across country in a phased manner

DOTS-Plus in MH:Nagpur circle- 7district (2007)Akola circle- 6 district (2008)

100% coverage across MH state by 2012

3. Effective t/t of MDR-TB

• 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

RNTCP- DOTS-Plus Vision

Changes in RNTCP policy on diagnosis of smear positive pulmonary TB

1. Number of sputum specimen required for diagnosis is 2, with one of them being a morning sputum

2. Diagnosis of PTB suspect- One smear specimen positive out of the two is enough to declare a patient as Sm+ PTB

3. Definition of PTB suspect- any person with cough for 2 weeks, or more

Challenges…

• Wide variation in capacity of health systems in states

• Burden due to TB-HIV co-infection• Ensure adherence of treatment• Large & unregulated private system

References

• Global tuberculosis control : epidemiology, strategy, financing : WHO report 2009.

• TB INDIA 2009. RNTCP Status Report. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi.

• RNTCP Performance Report, India. Second Quarter, 2009. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi.

• RNTCP Performance Report, India. Second Quarter, 2008. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi.

• Global Tuberculosis Control: Surveillance, Planning and Financing: WHO Report 2008.

• TBC India. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi. [Online]. 2009. [cited 2009 Dec 7]; Available from: URL: http://www.tbcindia.org.

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