Recent advances in Revised National Tuberculosis Control Programme (RNTCP)

Dr Amol KingeEpidemiologist cum Assistant Professor,

Department of Community Medicine,SBHGMC, Dhule

Tuberculosis

Epidemiology• Agent: MycobacteriumTuberculosis, M.bovis, other

atypical Mb.

• Host: Age (Early childhood, adolescent and old age), Sex (Men), Nutrition, Social factors, illiteracy, Immunity

• Environment: overcrowding, sanitation etc

TuberculosisClassification

1. Anatomical site: Pulmonary & Extra-pulmonary2. History of Tt: - New case:- Previously treated case: a) Recurrent TB case (After Prev successful Tt.)

b) Tt after failure case c) Tt after loss to follow up d) Other previously treated

- Transferred in cases3. Drug resistance: Mono-DR, MDR (HR), XDR (1st line+FQ+2nd line injectables)

TuberculosisSigns and symptoms

1. Cough with /without expectoration >2 weeks2. Low grade fever3. Weight loss / general debility4. Generalised Weakness

Diagnosis

• Sputum Examination• X-ray chest• Detection of Antigens / Genexpert• Culture methods• Tuberculin Test

Estimated number of cases

Estimated number of deaths

1.5 million*• 140,000 in children• 480,000 in women• 890,000 in men

9.6 million• 1 million children• 3.2 million women• 5.4 million men

480,000

All forms of TB

Multidrug-resistant TB

HIV-associated TB 1.2 million (12.5%)

390,000

Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB

The Global Burden of TB, 2014

190,000

Estimated incidence, 2014

Estimated number of deaths, 2014

0.22 million*(0.15–0.25 million)

2.2 million(2.0–2.3 million)

(Rate 167)

All forms of TB

Multidrug-resistant TB

HIV-associated TB 0.11 million (0.09–0.12 million)

31,000(25,000–38,000)

India TB situation

71,000 amongst notified cases

Source: WHO Global TB Report 2015 * Including deaths attributed to HIV/TB

India is the highest TB burden country

Data source: Global TB Report 2015, WHO, Geneva

Evolution of TB Control Programme-Chronology

• 1946: Bhore Committee – Wide gap between TB patients and number of beds

• 1947: TB Division under the Directorate General of Health Services• 1951 : BCG Campaign• 1956: TRC Established, Madras study : domiciliary treatment as

effective as sanatorium treatment • 1959: NTI established• 1962 : National TB Programme • 1961 – 1986 : Era of Conventional Chemotherapy • 1986 -1993 : Era of Short course chemotherapy• 1993 : Directly Observed Treatment Short Course (DOTS) using

intermittent regimen tested• 1997: RNTCP roll-out

RNTCP – journey so far and way forward

8th Five Year Plan (1992-97)

TU 1

DMC 1

DMC 2

DMC 3

DMC 4

DMC 5

TU 2

DMC 1

DMC 2

DMC 3

DMC 4

DMC 5

Primary Healthcare infrastructure

3rd Five Year Plan (1961)

ASHA

ASHA

ASHA

ASHA

Health Subcentre

12th Five Year Plan (2012-17)

• PHCs ~4600• Centralized TB Services • Daily regimen • Long treatment (12-18 months)

• PHCs scaled-up ~22000• Health Sub-Centres manned by ANMs (~1,30,000)• Decentralized TB Services (TU’s, DMCs)

• PHCs >25000• >1,50,000 subcentres• >900,000 ASHA workers• PMDT following daily DOT• TB Units aligned to CD blocks• ICT tools (NIKSHAY)

Intermittent regimen under DOTS strategy

Daily (FDC) regimen feasible

Drugs

First Line DrugsH- Isoniazid

R- RifampicinZ- PyrazinamideE- Ethambutol

S- Streptomycin

Second Line Drugs Kanamycin

EthionamideLevofloxacinCycloserine

PAS

Daily Regimen: Adult Schedule

Daily Regimen: RNTCPPaediatric Schedule

Directly Observed Treatment, Short-course (DOTS) – a five point strategy

TB Register

Political and Administrative commitment

Good Quality Diagnosis by Sputum smear microscopy

Uninterrupted supply of good quality drugs

Directly observed treatment (DOT)

Systematic monitoring and accountability

Note: Directly Observed Treatment (DOT) is only one of the five components of DOTS strategy

RNTCP - AchievementsInfrastructure:• State TB Programme Management Units established in all

states/UTs• 728 District TB Programme Management Units established• 4117 TB Units established at Block level• >13,000 Designated Microscopy Centers established• > 6 lakh DOT centers established• 62 C&DST laboratories established for diagnosis of DR-TB• 135 DRTB Centers established for treatment of DR-TB

RNTCP - Achievements

Since implementation:• 86 million TB suspects examined, • 19 million patients placed on treatment, • > 3.4 million additional lives saved• 70,000 MDR-TB patients put on treatment • 2000 XDR-TB patients put on treatment

Trends in suspects examined per smear positive TB case diagnosed (2000-2015)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 20156.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

10.0

6.4

7.1 7.0 7.1 7.27.5 7.4 7.4 7.5

7.88.0

8.3 8.48.7

8.9

9.6

f(x) = 0.164270267213748 x + 6.37721007327756R² = 0.906759682751551

Progress towards MDG

Year Incidence(per lakh population)

Prevalence(per lakh population)

Mortality(per lakh population)

1990 216 465 38

1995 216 465 38

2000 216 438 39

2005 209 365 36

2009 190 289 29

2010 185 269 27

2011 181 249 24

2012 176 230 22

2013 171 211 19

2014 167 195 17

Achieved…. based on WHO estimates….

Maharashtra: State profile Population 1194 Lakhs

STDCs 2

State Drug Stores 3

Districts 79

Tuberculosis Units 444

DMCs 1448

DOT Centres 35,339

C&DST Labs 10

CBNAAT Labs 72DR TB Centres 16

Dist DR TB Centres 9

ART Centres 86

Stand Alone ICTCs 657

F-ICTCs 1,645

Evolution of global strategies to control TB 1994 2006 2014

Moving from halting TB to ending TB by 2030

Global commitment to End TB

The End TB Strategy: Vision, Targets and Pillars

Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering

Goal: End the Global TB Epidemic

Global projections to 2035 compared with current trends

India’s Address to TB Situation

12th Five Year Plan (2012-17)

• To achieve 90% notification for all cases• To achieve 90% success rate for all new & 85% for re-

treatment cases• To significantly improve the successful outcome of

treatment of DR-TB cases• To achieve decreased morbidity and mortality of HIV-

TB• To improve outcomes of TB care in the private sector

Action for 12th Plan Objectives

• Strengthened & improved basic DOTS services• TU alignment with BPMU’s of NHM• Availability of rapid diagnostics to field level• Increase efforts for engaging all care providers• Strengthen Urban TB Control• Expansion of PMDT services

• Gazette notification prohibiting import, manufacture, sale, distribution of sero-diagnostic tools for diagnosing TB

• Government Order mandating notification about TB to local health authorities

• Strengthen TB Surveillance using a case based web based system NIKSHAY

Action for 12th Plan Objectives

Standard 7: Treatment with first-line regimen

7.1 Treatment of New TB patients: • The initial phase - H, R, Z, E for two months • The continuation phase - H, R, E for at least four months

7.2 Extension of Continuation Phase: Extend CP by 3 to 6 months in special situations like Bone & Joint TB, Spinal TB with neurological involvement and neuro-tuberculosis.

7.3 Drug Dosages: As per body weight in weight bands

7.4 Bioavailability of Drugs: ensured for every batch

7.5 Dosage frequency: • Daily/ Intermittent regimen• OR to assess the feasibility of daily observed therapy under programmatic settings.

7.6 Drug formulations: FDCs may be considered if the recommendations are accepted.

7.7 Previously treated TB patients: No MDR :- 2HREZS/1HREZ/5HRE or 2H3R3E3Z3S3/1H3R3E3Z3/5H3R3E3

Standards of TB Care in India..

Private sector

• The private sector holds a factual predominance of health care service delivery in India

• Very little information about the TB patient from the private sector available to the programme

• Little is known about quality of treatment, including treatment outcomes in the private sector

• Engaging the private sector effectively is the single most important intervention required for India to achieve the overall goal of universal access to quality TB care

• Himachal Pradesh• Sikkim• Bihar • Maharashtra• Kerala

Rollout of Daily Regimen in 104 districts/5 States Total population

coverage - 2,690 Lakh

Rajasthan

Gujarat

MaharashtraOrissa

Karnataka

Madhya Pradesh

Bihar

Uttar Pradesh

Jammu & Kashmir

Tamil Nadu

Assam

Telangana

Chhattisgarh

Andhra Pradesh

Jharkhand

Punjab

West Bengal

Kerala

Haryana

Himachal Pradesh

Manipur

Mizoram

Andaman & Nicobar

Daman & Diu

UttarakhandSikkim

Arunachal Pradesh

Nagaland

Tripura

Way-forward for 2015-16

• Rolling out of daily regimen in 5 states• Involvement of Private sector • TB Surveillance • Social support • Urban TB control• Special population

Thanks