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Rahul.K.RDept. Of Swasthavritta

Amrita School of Ayurveda.

REVISED NATIONAL TUBERCULOSIS PROGRAMME

• Tuberculosis (TB) is an infectious disease caused by a Mycobacterium tuberculosis.

• TB is a drop let infection and is highly contagious. 

• Patients are infective as long as they remain untreated.

• An effective anti microbial treatment reduces infectivity by 90% within 48 Hrs.

TUBERCULOSIS (TB)

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• Operational since 1962.

• Unacceptably low success rate.

• Spread of multidrug resistant TB.

• 1992 Govt. of India, WHO and SIDA reviewed TB situation and concluded that– NTP suffered managerial weakness– Inadequate funding.– Over-reliance of X-ray for diagnosis.– Frequent interrupted supplies of drugs.– Low rate of treatment completion.

NATIONAL TUBERCULOSIS PROGRAM (NTP)

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• 1993 Govt. of India revitalize NTP with assistance from international agencies.

• RNTCP thus formulated.

• Adopted Direct Observed Treatment Short-course(DOTS)

• Political and Administrative commitment for ensuring adequate funds, staff and other key inputs.

• Adoption of smear microscopy for reliable and easy diagnosis in decentralized manner.

REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

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• Achievement of at least 85% cure rate of infectious cases; through DOTS.

• Augmentation of case finding activities through quality sputum microscopy to detect at least 70% of estimated cases.

OBJECTIVES OF RNTCP

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Mycobacterium tuberculosis Pure culture

• Introduced in 3 phases.– Phase I (1992 – 2006)

– Phase II (2006 – 2011)– Phase III

• 1998 it covers only 2% of the population.• By the end of 2006 it covers whole India and enters to 2nd

phase.• Improve access to marginalised groups.• RNTCP is built on the infrastructure of NTP.• DOTS strategy is adopted.

PHASES OF RTNCP

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1. Political will and administrative commitment.

2. Diagnosis by quality assured sputum smear microscopy.

3. Adequate supply of quality short course chemotherapy(SCC).

4. Directly observed treatment.

5. Systemic monitoring and accountability.

FIVE COMPONENTS OF RNTCP

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• 2006 stop TB was announced by WHO

• Components are,– Pursuing quality DOTS.– Addressing TB/HIV and MDR-TB.– Contributing to health system strengthening.– Engaging all care providers.– Empowering patients and communities.– Enabling and promoting research.

STOP TB

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• State TB office – State tuberculosis officer.

• State TB training and demonstration centre – Director.

• District TB centre – District tuberculosis Officer.

• Tuberculosis Unit- – Medical officer – TB control,– Senior treatment supervisor– Senior TB lab supervisor.

• Microscopy centre, Treatment centres.• DOTS providers.

ORGANISATION (PROFILE OF RNTCP IN A STATE)

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• A nation–wide network of RNTCP quality assured designated sputum smear microscopy labs has been setup providing appropriate , available , affordable and accessible diagnostic service for TB suspects.

• Carried out sputum microscopy with External Quality Assessment (EQA) and Drug Resistance Surveillance (DRS).

• New protocols for microscopy and DRS prepared.

LABORATORY NETWORK

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• Consist of 4 NRLs1. Tuberculosis Research centre, Chennai.2. National Tuberculosis Institute, Bangalore.3. Lala Ram Sarup Institute of TB and Allied Science, New Delhi.4. JALMA Institute, Agra.

• A central laboratory committee, constituted with microbiologist from 3 NRLs and Central TB division with WHO representatives.

• 24 IRLs, 12750 Designated Microscopy Centres.• State TB training and Demonstration Centre will be designated as

IRLs.• Sputum analysis done in three stages – on-site evaluation, panel

testing, blinded rechecking.

LABORATORY NETWORK

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RNTCP- LABORATORY NETWORK

Central TB Division

National Reference Lab

State TB Cell

Intermediate Reference Lab

District TB Centre

TU

TU

DMC 2

DMC3

NATIONAL

LEVELSTATE LEVEL

DISTRICT LEVEL

TU

TU

DIRECTION OF SUPERVISIONDIRECTION OF FEEDBACK

13DMC1

• Patient presenting with symptoms suspicious of tuberculosis are screened with 2 sputum analysis.– Chance of detecting TB +ve case is only 80% per sample.

• Done in RNTCP microscopy centres.– In CHC, PHC, Taluk Hospitals or in TB dispensary.

• Sputum analysis indicates the degree of infectivity and response to treatments.

• All patients are provided short course chemotherapy (SCC) free of cost.

• Drugs are administered under direct supervision called DOTS.

• DOTS is a community based TB treatment.

INITIATION OF TREATMENT

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• DOTS ensures high cure rate via 3 components– Appropriate medical treatment.– Supervision.– Motivation.

• DOTS is given by peripheral health staff such as MPWs, or through voluntary workers(DOTS Agents ) such as teachers, anganawadi workers, dias, ex-patients, social workers etc.

• DOTS Agents are paid Rs150/patient.• Drugs are supplied in patient-wise box(PWBs)

containing the full course treatment.

INITIATION OF TREATMENT

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Cough for 2 weeks

1 or 2 positive

2 sputum smears 2 negative

Symptoms persist

Antibiotic 10-14 days

2 negative

Negative TB

Positive TB X-ray

1or 2 positive

Repeat 2 smear

Smear positive TB

Anti TB treatment

Smear –ve TB

Non TB

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• Strategy to ensure cure by providing the most effective medicine and confirming that it is taken.

• Only strategy documented to be effective worldwide.

• First dose is to be taken in the presence of the health worker.

• During continuation the patient is issued medicine for 1week in multi blister combipack and need to return the empty one to collect medicine for next week.

• Cases are divided into 3 catogeries.

DOTS

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• Category I (in red box)– New sputum smear +ve.– New sputum smear –ve.– New extra pulmonary.– New others.

• Category II (in blue box)(previously treated)– Sputum smear +ve relapse.– Sputum smear +ve failure.– Sputum smear +ve treatment.

• Category III (in green box)- sputum negative pulmonary tuberculosis with minimal involvement.- Less severe form of extra pulmonary tuberculosis.

CATEGORY OF CASES

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Medicine code

Isoniazid-600mg H

Rifampicin-450mg R

Pyrazinamide-1500mg Z

Ethambutol-1200mg E

Steptomycin-500mg S

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a) Accuracy of TB diagnosis is more than doubled

b) Treatment success rate is upto 95%.

c) Prevents the spread of TB infection.

d) Improves quality of health care and remove stigma.

e) Prevents failure to treatment.

f) Helps alleviate poverty by saving lives, reducing duration of illness and preventing spread of infection.

g) Lends credibility to TB control efforts.

ADVANTAGES OF DOTS

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• Diagnosis and treatment for MDR-TB is complex and hence its introduced by WHO.

• Diagnosis and treatment for MDR-TB are done at tertiary care centres like medical colleges, large speciality hospitals having qualified staffs.

• Use category IV regimen.

• Second line drugs are used.

• Ambulatory DOT after a short period of IP care to stabilize the patient.

DOTS-PLUS

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• Treatment regimen:6(9) Kanamycin ofloxacin Ethinamide Cycloserine Pyrazinamide Ethambutol + 18 Ofloxacin Ethinamide Cycloserine Ethembutol

• Duration : at least 6months of intense phase extend up to 9months in patients with smear +ve after 4months, minimam 18 months continuation phase should be given.

• Smear examination done in 4,6,12,18,24 months of treatment

• Efforts made to administer treatment under DOTS over entire period of treatment.

• Systemic documentation of the treatment should be maintained.

DOTS-PLUS

• Introduced under RNTCP in 2003.

• TB paediatric cases are treated with PWBs like in adults.

• Treatment based on the child’s body weight, there is 2 generic PWBs

– 6-10kg weight band.– 11-17kg weight band.

• This is the worlds first DOTS therapy for children.

• Children weighing less than 6kg are treated with loose anti-TB drugs.

PAEDIATRIC TB

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• Drug resistance TB prevalence is an indicator of effectiveness of control activities over a period of time.

• Aim of DRS is to determine the prevalence of antimycobacterial drug resistance among new sputum smear positive pulmonary tuberculosis.

• The results of survey indicates MDR-TB is less than 3% among new cases and 12-17% in treated cases.

• These results show the prevalence of MDR-TB is stable in the country.

• Surveys are conducted periodically to monitor and study the trend prevalence of MDR-TB in community.

DRUG RESISTANCE SURVEILLANCE (DRS) UNDER RNTCP

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Mono-resistant:-Resistant to any one TB treatment drug.

Poly-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 drugs.

Extensively drug-resistant (XDR TB):-Resistant to isoniazid and rifampicin, plus resistant to any fluoroquinolone AND at least 1 of the 3 injectable second-line drugs (e.g., amikacin, kanamycin, or capreomycin)

TYPES OF DRUG-RESISTANT TB

DOTS-Plus

• PMDT services for quality diagnosis and treatment of drug resistant TB initiated in 2007 in Gujarat and Maharashtra

• By 2012 aimed drug susceptibility testing to all smear positive retreatment cases upon diagnosis and all new cases who are smear positive after first line of anti-TB treatment.

• By 2015 test will be made to all smear +ve cases.

PROGRAMMATIC MANAGEMENT OF DRUG RESISTANT TB (PMDT)

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1. Definition of MDR suspect has been revised to include contact of MDR cases who are found to be smear positive besides Category I failure and category I patient who are smear positive at 4 months or later.

2. A new weight band has been added (16kg-25kg) for treatment of paediatric MDR patients.

3. In order to cat IV regimen, more effective Ofloxacin is replaced with levofloxacin.

4. Guidelines for the management of MDR patients with pregnancy have been finalised.

POLICY CHANGES RELATED TO DOT-plus

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• RNTCP and NACO devised a joint action plan for TB-HIV coordination.

• Objective is to reduce the TB related morbidity and mortality of people living with HIV.

• Effective prevention of both the diseases.

• Initiated in 2001 in 6 high HIV prevalent states.

TB-HIV coordination.

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• Newer strategies have been developed as a comprehensive National Strategic plan under 12th five year plan, includes– Strengthening and improving the quality of basic DOTS

service.– Further strengthen and align with health system under

NRHM.– Deploying rapid diagnosis at the field level.– Expand effort to engage all care providers.– Strengthen urban TB control.– Expand diagnosis and treatment of drug resistant TB.– Promote research for development and implementation of

improved tools and strategies.

NATIONAL STRATEGIC PLAN (2012-2017)

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• Objectives of programme proposed are1. To achieve 90%notification rate for all cases.2. 90% success rate for all new and 85% for retreated

cases.3. Improve the successful outcomes of treatment of

MDR cases.4. Decrease mortality and morbidity of HIV associated

TB.5. Improve out come of TB care in private sector.• Notification of TB cases• According to govt of India it is mandatory for all healthcare

providers to notify every TB case to local authorities.

STRATEGIC VISION TO MOVE TOWARDS UNIVERSAL ACCESS.

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• Covers whole country since march 2006.

• Phase II has been launched from 1st October 2006.

• Increased treatment success rate from 25% in 1988 to 88% in 2010.

• Reduced death rate from 29% to 4%.

• More than 15million patients have been treated saving almost 2.5million lives.

• Four urban DOTS project have also been launched.

ACHIEVEMENTS OF RNTCP

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• India receives assistance from:

1.World Bank, in first phase.

2.DFID & World Bank in second phase.

3.DANIDA , GDF & USAID

FINANCIAL RESOURCES

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• One big reason is that it can live in animals. As hard as it is to eradicate in humans, it's much much harder to eradicate a disease in animals. Also, there's no good vaccine, which is an absolutely vital tool in the eradication of a disease.

WHY HAS TB NOT BEEN ERADICATED?

THANK YOU

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