Summary of changes in the RNTCP technical guidelines in

2008-09

Dr. K S Sachdev, CMO Dr. K S Sachdev, CMO Central TB DivisionCentral TB Division

Directorate General of Health ServicesDirectorate General of Health ServicesMinistry of Health & Family WelfareMinistry of Health & Family Welfare

Nirman Bhavan, New DelhiNirman Bhavan, New Delhi

ZTF (South Zone) Workshop, Puducherry

27-28 August 2009

(Newer) COMPONENTS OF THE STOP TB STRATEGY

• Pursue high-quality DOTS expansion and enhancement

• Secure political commitment, with adequate and sustained financing

• Ensure early case detection, and diagnosis through quality-assured bacteriology

• Provide standardized treatment with supervision, and patient support

• Ensure effective drug supply and management • Monitor and evaluate performance and impact

Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations

• Scale-up collaborative TB/HIV activities

• Scale-up prevention and management of multidrug-resistant TB (MDR-TB)

• Address the needs of TB contacts, and of poor and vulnerable populations

Contribute to health system strengthening based on primary health care

• Help improve health policies, human resource 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 successful approaches from other fields and sectors, and foster action on the social determinants of health

Engage all care providers

• Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches

• Promote use of the International Standards for Tuberculosis Care (ISTC)

Empower people with TB, and communities through partnership

• Pursue advocacy, communication and social mobilization

• Foster community participation in TB care

• Promote use of the Patients' Charter for Tuberculosis Care

Enable and promote research

• Conduct programme-based operational research, and introduce new tools into practice

• Advocate for and participate in research to develop new diagnostics, drugs and vaccines

Diagnosis of TB

• Change in the definition of PTB suspect- “Pulmonary TB suspect is any person with cough for 2 weeks, or more”

• Change in the number of sputum samples required for diagnosis of PTB from 3 to 2– Number of specimen required for diagnosis

is 2, with one of them being a morning sputum

– One specimen positive out of the two is enough to declare a patient as Sm+ PTB

Based on WHO STAG recommendations and further evidence from India

Recording and reporting

• Revised PM report for PHI, TU, District and State– MDR-TB suspects– TB/HIV Activities– Revised PPM schemes– Involvement of other

sectors– ACSM (IEC)– Information on quality of

DOTS for all smear positive TB patients (not just NSP cases)

• New software phased in. Old software to be phased out in 2010

TB/HIV

• Offer of VCT to all TB patients started in 9 states and planned to expand to the entire country by 2012

• Recording of HIV status in TB records in these states• Early start of ART in eligible HIV+ve TB patients (2 wks

following start of TB treatment; TB patients with CD4 <350/cc eligible for ART); also recording in TB records in these states

• Decentralized provision of CPT to all HIV+ve TB patients in these states

• Intensified TB case finding at ICTCs, ART centres & CCCs• Priority accorded to airborne infection control in ART centres

WHO-recommended TB/HIV interventions

OngoingOngoingOngoingOngoing

Ongoing at VCTC; ARTPilot testingGuidelines in preparation

Ongoing (ICTCs)Ongoing (NACO)Ongoing Ongoing (NACO ART centres)Ongoing (NACO ART centres)

Indian TB/HIV Activities

MDR-TB….1

• Recently implemented change in MDR-TB suspect definition– “any patient who fails a Cat I or III treatment regimen

or any Cat II patient who remains smear positive at the end of the fourth month of treatment or later”

• Future change of MDR-TB suspect definition planned to include all smear +ve retreatment cases

• Elimination of exclusion criteria (pregnancy, pediatric age-group, H/o SL ATT) for DOTS-Plus

• National DOTS-Plus committee has recommended– A Cat-V regimen for XDR-TB– To treat Rif mono-resistance with Cat-IV– Replace ofloxacin with levofloxacin in Cat-IV regimen

MDR-TB….2

• Newer rapid diagnostics– Molecular technology based DST (Line Probe Assay)

• Advantages: rapid (result in 2 days), high throughput

• Status: Validation phase over; demonstration phase to start in Aug 2009

• 43 labs with LPA planned (these labs will also have solid media DST)

– Automated liquid culture• In 33 out of the 43 labs liquid culture systems

planned

PPM

• New PPM schemes implemented

• Additional scheme on: – TB/HIV for high HIV risk

population– Purchase of DST services

from private accredited labs– Sputum collection and

transportation

Other changes

• Operational research: New operational research agenda and guidelines (can be downloaded from www.tbcindia.org)

– RNTCP OR agenda 2009.pdf– RNTCP OR guidelines March2009.pdf

• Airborne infection control guidelines being developed

Change is also happening in RNTCP policy

Thanks