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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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