fli6«o Ifo/f]u sfo{qmd National Tuberculosis Center National Tuberculosis Programme Nepal Dr. Rajendra Pant Director

/fli6«o Ifo/f]u sfo{qmdNational Tuberculosis Center

National Tuberculosis ProgrammeNepal

Dr. Rajendra PantDirector


Situation of Tuberculosis

Indicators

Expected Numbers

Each Year

Notified Cases

(069/70)

Still Missing Cases

Total TB Patients

45,000 36,908 8,092 (18%)

Sputum Positive Cases

20,580 15,094 5,486 (26%)

1 TB patient transmits TB bacilli to 10-15 persons annually!!!!!!


A glimpse of NTP

• Free diagnosis of TB through:

- 554 diagnosis centers

• Free anti-TB drug distribution

- 1,184 treatment centers

- 3,074 treatment sub-centers

- 84 DR center/sub-center

- 8 MDR hostel

• Directly Observe Treatment (DOT)

• Integrated health program


Vision

TB Free Nepal

Goal

To reduce the mortality, morbidity and transmission of tuberculosis until it is no longer a public health problem


MDG Target Vs. Achievements (NPC-2013)GOALS Achieved Likely Potent

ially likely

Unlikely

Lack of data

Strong Fair Weak but improving

Weak

6. Combat HIV/AIDs, Malaria and Other Diseases

Tuberculosis (j) Prevalence rate associated with TB (per 100,000 of population)

(k) Death rate associated with TB (per 100,000 of population)

(l) Proportion of tuberculosis cases detected (%) (m) Proportion of tuberculosis cases cured under directly observed treatment short course (%)


Post MDG and NSP 2015-20Mile stone for 2025• 75 % reduction in Tuberculosis deaths (compared with 2015)• 50% reduction in TB incidence ( compared with 2015)

– Less than 55/100000

–Targets for 2035– 95% reduction in TB deaths compared with 2015– 90% reduction in TB incidence compared with 2015

• Less than 10/100000

• NSP 2015-20• 85 % Case Finding Rate• Maintaining minimum 90% treatment success rate• Covering Hard to reach population


NTP Policy Updates• Active Case Finding • All Treatment centers as DOTS Center• Two sputum sample for sputum microscopy• Full implementation of HMIS for NTP

recording and reporting• Use of Master TB Register in district• HIV test of all TB patients• Redefined registration category and treatment

outcome


Annual Case Finding Trend

65/66 66/67 67/68 68/69 69/700%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

75% 76% 73% 73%78%


National Sputum Conversion Trend

2065/66 2066/67 2067/68 2068/69 2069/7050%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

89% 88% 89% 89% 90%

Chart Title


65/66 66/67 67/68 68/6950%55%60%65%70%75%80%85%90%95%

100%

90% 90% 90% 90%

National Treatment Success Trend


DRTB Management

Mountain

Hill

Terai

Legend

Treatment Centers : 13 Treatment Sub-Centers : 71Total Registered Cases : 1542Fiscal Year-068/069 : 262XDR TB : 52Fiscal Year 068/069 : 11


Cohort Report of Enrolled MDR TB

5

15

25

35

45

55

65

75

Trend of DR TB Treatment Rates

Cure Rate Died Rate Failed Rate Defaulted Rate


Progress on major indicators of NTP inline with Global Targets

Indicators Global Targets Achievements

Case finding 70% 78%

Treatment success rate

85% 90%

Programme coverage

Universal coverage 100%


Major Challenges for NTP

Economic challenge

Technical challenge

Managerialchallenge



Managerial Challege

No access to health care

Access, but don't go

Go, but not Diagnosed

Diagnosed, but Not Reported

Diagnosed and Recorded in notification data

Un-diagnosed cases

Un-notified

Notified cases

Miss-diagnosed

cases


Without faster progress, we face a tidal wave of preventable disease and death


KAPspeople at increased risk of TBdue to biological risks compromised immunity and exposure to pathogens

1

PLHIV DiabeticsSmokers

People with other health conditions that decrease immunity (e.g. people on long term therapeutic steroids, people on immune suppressant treatment, malnourished)

Silicosis and other dust related lung disorders

Alcohol abusers (>40 gm or 50 mL/day)


KAPs people who have increased exposure due to where they live or work – overcrowding, poor ventilation

2

Contacts of TB patients (in households, workplaces, educational facilities)

Slum dwellers in urban settingsPeople living in hostelsHealth care workers

Incarcerated people (prisoners) and staff working in correctional facilities

Miners, peri-mining or mining-affected population


KAPs

Geography • Remote populations• Deep sea fishermen Limited mobility

• Homeless• Elderly• People living with

physical and mental disabilities

Women and children in settings of poverty

people who have limited access to health servicesdue to gender, geography, limited mobility, legal status, stigma

3

Migrants, refugees and internally displaced people

Indigenous peoples and ethnic minoritiesStigmatised

• Sex workers and victims of sex trafficking• People who use drugs* (fit in biological as

well?)• Men who have sex with men


SummaryScreen Fast track transport systemsDiagnose Use Xpert more, it’s cheaperCollaborate Providers for high risk groupsCommunity EmpowerSocial protect Transport, cash transfersLegislation Ban drugs, serological testsNew ways Active, enhanced case finding


Managerial Challege

No access to health care

Access, but don't go

Go, but not Diagnosed

Diagnosed, but Not Reported

Diagnosed and Recorded in notification data

Un-diagnosed cases

Un-notified

Notified cases

Miss-diagnosed

cases

•ACSM•Active case finding- Lab

•PAL•TB HIV•Lab

•PPM

• ISTC•Pt. Charter


Technical Issue: Improper Estimation

Because of use of ARI (Annual Risk of Infection): • observed prevalence of infection, approximating the incidence of infection• Developed and adopted in 1992• Has been discarded by many nations as estimate

Need revision of estimation find the true prevalence for true estimation.

Prevalence Survey


What is Prevalence Survey?

• cross-sectional and population-based survey of a representative sample of the population in which the number of people with TB disease is measured.


Objective of Prevalence survey

• To measure prevalence of bacteriologically-positive (smear and/or culture positive) pulmonary TB

• To understand health seeking behavior of TB symptomatic and TB cases


Thank you


Implementation Modality

• Internal:• NTC

• Outsourcing of Research Management Agency • External

– RIT/JATA will provide technical support through out the survey period

– WHO


Duration and Budget

• Duration– Approximately 3 years- To produce full survey

report (2013 to 2016)• Required Budget

– 2,011,295 US$– Funding available

• GFATM- 1,292,795 USD

– Funding required from Nepal govt & other agengies- 716,500 USD


Way forward………..

• Assurance of budget from MoHP to address budget gaps

• Protocol Approval• Outsourcing Research Management Agency• Tendering of equipments (Lab, x-ray)• Training• Piloting• Field operation


Major Recommendations of In-depth Review-2013

• Introduce “sputum courier system”, .• Expand PAL to urban HPs and sub-HPs • Nominate TB-Infection Control focal person and revise

guidelines.• Enhance the quality of existing DR-TB programme through

e.g., dcentralizing DOT in DR-TB management.• Expand Open MRS system.• Integrate TB guideline within guidelines of IMCI and PPM• Introduce stricter controls/ban and adequate measures for

restricting distribution of anti-TB drugs in the open market.• Further integrate the TB reporting into the HMIS.• Conduct TB prevalence survey to measure burden of disease

immediately.


Major plan- (2013-2015)

• NSA phase 2 Application (GFATM -23 million)- Signed with GF

• Active Case Finding

• Microscopic camps -75 districts( prisons, slum, hard to reach area)

• FCHV door to door mobilization – Contact tracing

• Transportation of sputum slides- DOTS center/Sub canters to MC in mountainous districts

• Piloting of community DOTS- 5 Districts (Kaski)

• Prevalence survey

• Data integration- complete data via HMIS.


Major planning …….• Expansion of Gene Xpert machines -14 places (NTC-17,HERD-5)

• Establish of culture facilities in 3 regions

• Construction of TB Hospital

• Establish of DR Home in Bandipur

• Establish MDR Hostels in 5 places with in Hospitals premise

• DOT Provider at Districts- 15 HA/Staff Nurse(4 in WDR)

• Annual workshop with districts finance, Statistics and store staff at regional level.

• National TB Conference• Recording reporting format revised. implemention from IInd

Trimester.

Documents

fli6«o Ifo/f]u sfo{qmd National Tuberculosis Center National Tuberculosis Programme Nepal Dr. Rajendra Pant Director