Updates in RNTCPUniversal access to TB

care

Central TB Division, Directorate General Of Health Services

Ministry of Health & Family Welfare,Government of India

OutlineMagnitude of TB ProblemUpdate on achievements of RNTCP

Case detection and treatment outcomesThe Stop TB Strategy – 2009SWOT analysis of RNTCP

Need for Universal Access to TB CareEarly and Complete case detectionRole of Medical Colleges for Universal Access to TB CareOR 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

Non-HBCs20%

Pakistan3%

Ethiopia3%

Philippines3%

South Africa5%

Bangladesh4%

Nigeria5%

Indonesia6%

China14%

India20%

Other 13 HBCs16%

Global annual incidence = 9.4 million

India annual incidence = 1.98 million

India is 17th 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 TB276,512 / yr (>900/day)

(24 / lac / year)

HIV Positive TB patients 4.85% (95240 cases in 2007)

MDR – TB in new casesMDR – TB in re-treatment cases

2-3%12-17%(~99000 cases in 2008)

(10% life time risk of TB disease; several factors increase this risk, e.g. HIV, diabetes, smoking, poor nutrition, etc)

RNTCP – Goal and Objectives

GoalThe 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

2006/rev. 2009

1. Pursue high-quality DOTS expansion and enhancementa. Secure political commitment, with adequate and sustained financing b. Ensure early case detection, and diagnosis through quality-assured bacteriologyc. Provide standardised treatment with supervision, and patient supportd. Ensure effective drug supply and management e. Monitor and evaluate performance and impact

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populationsa. Scale–up collaborative TB/HIV activitiesb. Scale-up prevention and management of multidrug-resistant TB (MDR-TB)c. Address the needs of TB contacts, and poor and vulnerable populations

3. Contribute to health system strengthening based on primary health care a. Help improve health policies, human resources development, financing, supplies, service

delivery and informationb. Strengthen infection control in health services, other congregate settings and householdsc. Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) d. Adapt approaches from other fields and sectors, and foster action on the social determinants

of health4. Engage all care providers

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

b. Promote use of the International Standards for Tuberculosis Care (ISTC)5. Empower people with TB, and communities through partnership

a. Pursue advocacy, communication and social mobilizationb. Foster community participation in TB care, prevention and health promotionc. Promote use of the Patients' Charter for Tuberculosis Care

6. Enable and promote researcha. Conduct programme-based operational research, and introduce new tools into practiceb. Advocate for and participate in research to develop new diagnostics, drugs and vaccines

RNTCP is implementing all these components of The STOP TB Strategy

Key Achievements of RNTCP

Case Detection & Treatment Outcomes

Key achievementsSince implementation > 44 million TB suspects examined > 12 million TB patients placed on

treatment > 2 million additional lives savedAchievements in line with the

global targets

55% 56%59%

69%72%

66% 66%70% 72% 72%

84% 85% 87% 86% 86% 86% 86% 87% 87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%20

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

Annualised New S+ve CDR Success rate

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

Patient friendly DOT services

Network of nearly 0.43 million DOT providers:

Quality of DOT ensured predominantly through Supervision by DTOs, MOTCs, STS

Private doctor in Pune Unani doctor in Jaipur

NGO Worker in Andhra Homeo doctor in Pune

Treatment Outcome of Smear Positive Cases registered under RNTCP DOTS, 1993-2Q09

NSP

N = 4,529,030

Sp + Retreatment

N = 1,613,131

The default rates (2008) among NSP is 6% and that of Re-treatment cases is 13%

Cured ; 3,806,049; 84%

Treatment Completed ; 94,990; 2%

Died ; 203,440; 5%

Failed ; 103,472; 2%

Default ; 291,196; 6%

Transferred out ; 29,883;

1%Cured ; 955,144;

59%

Treatment Completed ;

185,254; 12%

Died ; 119,616; 8%

Failed ; 84,950; 5%

Default ; 246,771;

15%

Transferred out ; 21,396;

1%

Total cases (n =9,56,515)

Treatment outcome of New Extra-Pulmonary Patients registered under RNTCP DOTS (2005- 2Q

2009) (all forms of EP TB)

Died, 23,641, 2%

Failure, 1469, 0%

Defaulted, 44,860, 5%

Tran Out, 12,366, 1%

Completed, 874,179, 92%

N=33649 N=25948

New Smear Positive (NSP) case detection and treatment success

rate in areas covered under RNTCP

55% 56%59%

69%72%

66% 66%70% 72% 72%

84% 85% 87% 86% 86% 86% 86% 87% 87%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%20

00

2001

2002

2003

2004

2005

2006

2007

2008

2009

Annualised New S+ve CDR Success rate

Is this enough to control TB?

SWOT Analysis - RNTCPStrengths:•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

Weaknesses:•Unorganized private sector•Weak general health systems in some states.•Shortage of key Managerial staff (one person handling multiple portfolio)

Opportunities:•Universal Access •Airborne Infection Control Guidelines developed•Newer diagnostics under RNTCP in collaboration with FIND

–Pan Sensitive TB - LED Microscopy, GeneXper–M/XDR TB diagnosis - LPA, Liquid culture, Capillia test, GeneXpert

Threats:•HR turnover•Sustainability of finances•Irrational use of 1st & 2nd line drugs due to market forces

Vision

To provide universal access toquality diagnosis and treatment for all TB patients in the community

Active TB

Symptoms recognised

Health care utilisation

Diagnosis

Notification

Health education

Improve referral and notification

systems

Improve diagnostic

quality, new tools

Infected

Patie

nt d

elay

Health services delay

Access delay

Effective TB screening in health services and on

broader indication

ACSMDOTS / MDR-TB

Expansion

HRD

PAL

Lab str.

HSS

Community engagement

Contact investig-Children

-Other risk groups

-All household

-Workplace

Clinical risk groups-HIV

-Previous TB

-Malnourished

-Smokers

-Diabetics

-Drug abusers

Vulnerable populations-Prisons

-Urban slums

-Poor areas

-Migrants

-Workplace

-Elderly

TB/HIV Pediatric. TB

TB determinants

Infection control

Thinking Beyond - 70 / 85 !

Intensified case finding

Minimize access barriers

New diagnostic tools

PPM

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 toearly, 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 accessMost of the un-reached cases are seeking health care but not

being treated under the programme.They can be reached by

Increasing suspects examination rateNational level- 160/lakh/qtrDistrict level- wide variations

Ensure adequate infrastructure – Health system strengtheningDMCs-trained LTsTUsSputum collection and Transport facilities

Medical Colleges Involving all departments in Medical Colleges

Strengthening Quality through Supervision and MonitoringFilling up of vacant postsProactive programme review at all levels

Implementing Tribal Action Plan

Steps to Universal accessOther Health Care providers

Other Govt health sectors, corporate sector, ESI, Mines etc

NGO/PP involvementIMA, CBCIGF Rd-9 Project-

ACSM-374 districto IUATLDo World Vision

Contact TracingContact tracing of sputum positive patients

Intensified case finding activities in High risk population (evidences)HIVSmokersDiabetesOther vulnerable groups – migrants, slum dwellers

Steps to Universal access

Role of Medical Colleges for Universal Access to TB Care

Initiatives to Involve Medical 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

RAJASTHAN

ORISSA

GUJARAT

MAHARASHTRA

MADHYA PRADESH

BIHAR

KARNATAKA

UTTAR PRADESH

ANDHRA PRADESH

JAMMU & KASHMIR

ASSAM

TAMIL NADU

CHHATISGARH

PUNJAB

JHARKHANDWEST

BENGAL

HARYANA

KERALA

UTTARANCHAL

ARUNACHAL PRADESH

HIMACHAL PRADESH

MANIPUR

MIZORAM

MEGHALAYANAGALAND

TRIPURA

SIKKIM

GOA

A&N ISLANDS

D&N HAVELI

PONDICHERRY

LAKSHADWEEP

DELHI

West Zone

East Zone

South Zone

North Zone

North-East Zone

ORISSA

#

#

#

#

#

#

#

Guwahati

Kolkata

Vellore

Chandigarh

AIIMS,Delhi

Jaipur

Mumbai

Medical Colleges asRNTCP Nodal centres

RG Kar Medical College, CalcuttaLokmanya Tilak Municipal Medical College and Hospital, MumbaiSMS Medical College, JaipurAll India Institute of Medical Sciences, N DelhiPost Graduate Institute of Medical Education and Research, ChandigarhChristian Medical College, Vellore, Tamil NaduGuwahati Medical College, Guwahati, Assam

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 3Q09 > 185 contractual MOs, > 255 Contractual LTs and > 255 TBHVs have been

sanctioned for medical colleges During the period 3Q08-2Q09,

> 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

SmokersTB 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

Trends in prevalence of culture-positive and smear-positive tuberculosis in south India

(5 Blocks), 1968-2006

7.0

8.0

9.0

10.0

11.0

1968-70 1971-73 1973-75 1976-78 1979-81 1981-83 1984-86 1987-89 1990-92 1993-95 1996-98 1999-01 2001-03 2004-06

Year

256

512

1024

Smear +ve

Culture +ve

128

Pre-SCC treatment era SCC treatment era

RNTCP era

Impact of RNTCP

Progress towards Millennium Development Goals

Indicator 6.9: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB

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)

586

185

293

0

200

400

600

800

1990 2009 2015 (MDG-Target)

Cases p

er

100,0

00 p

op

ula

tio

n

42

2421

0

20

40

60

1990 2009 2015 (MDG-Target)

Cas

es p

er 1

00,0

00 p

op

ula

tio

n

68%43%

Prevalence rate of TB Mortality rate of TB

Progress towards Millennium Development Goals

Indicator 6.9: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB

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)

586

185

293

0

200

400

600

800

1990 2009 2015 (MDG-Target)

Cases p

er

100,0

00 p

op

ula

tio

n

42

2421

0

20

40

60

1990 2009 2015 (MDG-Target)

Cas

es p

er 1

00,0

00 p

op

ula

tio

n

68%43%

Prevalence rate of TB Mortality rate of TB

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

Repeat ARTI and Disease prevalence surveys planned in 2015

Symptomatic screening + CXR + Sputum Smear + Culture

Symptomatic screening + Sputum Smear + Culture

The way forwardVision

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 TBOffer 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 (%) 1Q2010

>= 70% (14 states)60 - 69% (7 states)< 60% (14 states)

National Level- 70%

NSP Case Detection Rate (%) 1Q2010

National Level- 70%

< 30% 21

30% – 49.9% 11450% - 69.9% 263

> 70%, 255

< 30% 16

30% – 49.9% 13350% - 69.9% 231

> 70%, 260

1Q2009

National Level- 70%

Back

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% 19%Malnutrition 3.2** 16.5% 27%Diabetes 3.1 3.4% 6%Alcohol use (>40g / 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…”

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