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Current Status:
Tuberculosis in India Dr Ashwini Kalantri
Moderator
Dr BS Garg
History of TB Control in India
• 1906 : Open air sanatorium in Ajmer• 1929 : King George V Thanksgiving
Fund for TB control• 1939 : TB Association of India (TAI)• 1946 : Plan for TB Clinic in every
district• 1955 - 58 : National survey by ICMR• 1959 : National TB Institute (NTI) to
develop the national TB control programme.
History of TB Control in India
• 1961 : NTP pilot tested in Andhra Pradesh
• 1962 : NTP launched• 1978 : NTP covered 390 districts
(81%)• 1983 : Short-course chemotherapy
(compliance improved only marginally)
• 1993 - 97 : DOTS pilot (RNTCP)• 1997 : RNTCP launched• 2007 : DOTS Plus (PMDT) for Drug
resistant TB
The Stop TB Strategy
• 2006 - 15 : Second Global Plan to Stop TB
• Roadmap and budget to reach MDGs
Microscopy vs X-ray
0
10
20
30
40
50
60
70
80
90
100 Sputum AFB
X-ray
X-ray
40%
False
Positiv
e Tru
e Po
sitive
60%
SpecificityNTI, Bangalore, 1974
98%
50%
Sanatorium vs Domiciliary care
SeriesTotal
Patients
Favorable
Response (%)
Relapse (%)
Total contact
s
Attack rate (%)
Home 82 86 14 245 10.5
Sanatorium 81 92 12 264 11.5
A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.
The Revised National TB Control Programme
• 100% centrally sponsored• Free of cost diagnosis and treatment
with anti-TB drugs• 13,000+ microscopy centers• 4,00,000+ DOTS treatment centers• RNTCP an integral part if the NRHM
Components of DOTS
• Political commitment • Diagnosis by microscopy• Adequate supply of the right drugs• Directly observed treatment• Accountability
Population Coverage and Patients Registered
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
RNTCP Objectives
• To achieve 85% cure rate for the newly diagnosed sputum smear positive TB patients
• To detect at least 70% of the new smear-positive patients
Treatment outcomes1994 to 2006
85
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
Unfavourable Treatment Outcomes1994 to 2006
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
Prevalence
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
3 vs 2 sputum samples
NTI, Bangalore TRC0
10
20
30
40
50
60
70
80
90
100
68 71
85 8686 88
FirstSecondThird
Cu
mu
lati
ve P
osit
ivit
y
ACHIEVEMENTSRevised National TB Control Programme
Achievements of RNTCP
• Evaluated 55 million+ persons for TB• Initiated treatment for 15.8 million+ TB
patients.• 2.8 million lives saved• TB/HIV services in 18 states• MDR-TB services in 132 districts• Successful medical college involvement• ARTI reduced from 1.5% to 1.1%
Achievements during 11th FYP
Indicators Planned Achieved
No of TB suspects examined(millions)
23.72 27.5
Total number of patients to beput on treatment (millions)
5.04 6.4
New Smear Positive patients tobe put on treatment (millions)
2.34 2.46
No of MDR TB patients to beput on treatment (000)
5 4.2
Success Rate in New SmearPositive patients in RNTCP (%)
≥85% 87%
Estimated Annual Prevalence perlakh population
Reduced from 299 to 250
Annual Risk of TB Infection (%) Reduced from 1.5% to 1.1%
Objectives for the 12th FYP
• Early detection and treatment of at least 90% of all type of TB cases
• Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%
• Screening for drug-resistant TB and provision of treatment services for MDR-TB patients
• HIV Counseling and testing for all TB patients• Extend RNTCP services to patients diagnosed
and treated in the private sector.
Targets for the 12th FYP
• Detection & treatment of about 87 lakh Tuberculosis patients during 12th FYP
• Detection & treatment of at least 2 lakh MDR-TB patients during 12th FYP
• Reduction in delay in diagnosis and treatment of all types of TB cases
• Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups
Economic Impact of TB
• Each case of TB– US$ 12,235– 4.1 DALYs
• Each death due to TB– US$ 67,305– 21.3 DALYs
• 29.2 million DALYs and US$ 88.1 billion gained due to RNTCP
CURRENT STATUSTUBERCULOSIS
Annual Incidence of TB
Rest of the
World74%
India26%
Estimated burden of TB in India
Number (Millions) (95% CI)
Rate Per 100,000 (95% CI)
Incidence 2.3 (2.0–2.5) 185 (167–205)
Prevalence 3.1 (2.0–4.6) 256 (161–373)
Mortality 0.32 (0.21–0.47) 26 (17–39)
Number (Millions) (95% CI)
Percent(95% CI)
HIV among estimated incident TB patients
0.11 (0.075–0.16) 5% (3.3–7.1%)
MDR-TB among notified pulmonary TB patients
0.064 (0.044–0.075)
5.3% (3.6–6.2%)
National ARTI survey
Survey 1(2000-01)
Survey 2(2009-10)
Average annual decline
Zone Prevalence ARTI Prevalenc
e ARTI %
North 10.1 (9.1-11.1)
1.9 (1.7-2.1)
5.9 (4.7-7.0)
1.1 (0.8-1.3) 6%
East 6.2 (5.5-7.0)
1.2 (1.0-1.3)
6.5 (4.8-6.2)
1.2 (0.9-1.5) —
West 8.7 (7.7-9.6)
1.7 (1.5-1.9)
4.0 (3.2-4.9)
0.8 (0.8-0.9) 8%
South 6.1 (5.4-6.7)
1.1 (1.0-1.2)
6.8 (5.9-7.7)
1.3 (1.1-1.5) —
Total 1.5 (1.4-1.6)
1.1 (1.0-1.2) 3.6%
RNTCP, Annual Status Report 2013
Annual New Smear Positive Case Detection Rate, 2012
RNTCP, Annual Status Report 2013
Cure Rate of New Smear Positive Cases, 2011
RNTCP, Annual Status Report 2013
Composite Indicators
India
Maharashtra
Wardha
Human Resources (65) 68% 54% 87%
Financial Management (20)
71% 79% 100%
Drugs and Logistics (30)
67% 64% 0%
Case Finding Efforts (20)
30% 39% 40%
Quality of Service (115) 57% 64% 59%
Composite Score (250)
59% 66% 63%RNTCP, Annual Status Report 2013
Case Detection
• RNTCP Designated Microscopy Center (DMC)
• 2 Sputum smear examination (spot and morning)
• ZN smear exam under bright field binocular microscopes
• Drug resistant TB – solid/liquid culture DSTs
• CBNAAT being used in 18 sites
Treatment
• INH (H), Rifampicin(R), Pyrazinamide (Z), Ethambutol (E) and streptomycin (S)
• Category I : 6 months– 2 months Intensive Phase: HRZE thrice
weekly– 4 months Continuation Phase: HR
• Category II : 8 months– 3 months Intensive Phase: 2 months HRZES
and 1 month HRZE– 5 months Continuation Phase: HRE
Treatment
• All doses of intensive phase and first dose of each week of continuation phase are given under supervision.
• Follow-up sputum examination at the end of intensive phase, 2 months into the continuation phase and at the end of treatment
Drug Resistant TB
• By 2015: DST for all smear positive cases
• MGIMS, Sevagram certified for solid culture and DST.
• Genexpert (CBNAAT) introduced in 12 TUs
Drug Resistant TB Treatment
• For MDR-TB : Daily DOT includes (6-9m) Kanamycin, Levofloxacin, Cycloserine, Ethionamide, Pyrazinamide, Ethambutol / (18m) Levofloxacin, Cycloserine, Ethionamide, Ethambutol
• For XDR-TB : (6-12m) Capreomycin, PAS, Moxifloxacin, High dose INH, Clofazimine, Linezolid, Amoxy- Clavulanic Acid / (18m) all the above drugs except Capreomycin
PMDT Services
RNTCP, Annual Status Report 2013
TB/HIV
• Latent TB Active TB• 2001: TB/HIV collaboration• ICTC : Intensified TB case finding has
been implemented nationwide at all HIV testing and ART centres
• HIV testing of TB patients is now routine through provider initiated testing and counselling (PITC)
TB/HIV
• 2012 : 56% TB patients screened, 5% positive
• HIV-positive given free HIV care at the antiretroviral treatment (ART) centres
• Policy decision taken expand coverage of whole blood finger prick HIV screening test at all DMC
TB and Diabetes
• People with a weak immune system, as a result of chronic diseases such as diabetes, are at a higher risk of progressing from latent to active TB.
• Diabetics have a 2-3 times higher risk of TB
• 10% of TB cases globally are linked to Diabetes
• Longer time of sputum conversion
TB and Diabetes
• High chances of drug resistance, mortality and relapse
• Good glycemic control in TB patients has better outcome
• Policy to screen all TB patients for DM in the 100 districts where NPCDCS has been implemented
Childhood TB
• The newer weight bands are 6-8 kg, 9-12 kg, 13-16 kg, 17-20 kg, 21-24 kg and 25-30 kg.
• Chemoprophylaxis for children under 6 years: isoniazid (5mg/kg) for 6 monthsRifampicin 10-12 mg/kg (max 600
mg/day)
Isoniazid 10 mg/kg (max 300 mg/day)
Ethambutol 20-25mg/kg (max 1500 mg/day)
PZA 30-35mg/kg (max 2000 mg/day)
Streptomycin 15 mg/kg (max 1gm/day)
Childhood TB
• If sputum sample not available, alternative specimen (Gastric lavage, Induced sputum, bronco-alveolar lavage) should be collected under pediatric supervision.
• Tuberculin skin test / Mantoux : 10 mm or more induration
NEWER INITIATIVESRevised National TB Control Programme
Notifiable Disease
www.nikshay.gov.in
Other Initiatives
• Composite Indicator• Ban of sero-diagnostic tests• Availability of free quality assured
anti-TB drugs through local chemists
References
1. A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
2. Revised National TB Control Program : Annual Status Report 2013. New Delhi: Central TB Division, 2013.
3. A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.