TUBERCULOSIS & RNTCP TUBERCULOSIS & RNTCP INTRODUCTIONINTRODUCTION

1111thth March March

DR . PRAJAKTA KADALEDR . PRAJAKTA KADALEMEDICAL OFFICER,MEDICAL OFFICER,

DISTRICT TB CENTRE PUNE (R)DISTRICT TB CENTRE PUNE (R)

Tuberculos is A Historical Tuberculos is A Historical Disease Progress to FutureDisease Progress to Future

HISTORY ofHISTORY ofTuberculosisTuberculosis

Tuberculosis Is an Tuberculosis Is an Ancient Disease Ancient Disease

Spinal Tuberculosis Spinal Tuberculosis in Egyptian in Egyptian Mummies Mummies

History dates to 1550 History dates to 1550

– 1080 BC– 1080 BC Identified by PCR Identified by PCR

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Robert Koch Robert Koch Discoverer of Discoverer of

MycobacteriumMycobacteriumTuberculosisTuberculosis

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A tribute to Robert KochA tribute to Robert Koch World TB Day is World TB Day is

March 24. This annual March 24. This annual event commemorates event commemorates the date in 1882 when the date in 1882 when Dr. Robert Koch Dr. Robert Koch announced his announced his discovery of discovery of Mycobacterium Mycobacterium tuberculosistuberculosis, the , the bacteria that cause bacteria that cause tuberculosis (TB) tuberculosis (TB)

TuberculosisTuberculosis ““TB" is short form of tuberculosis. TB TB" is short form of tuberculosis. TB

disease is caused by a bacterium called disease is caused by a bacterium called Mycobacterium tuberculosisMycobacterium tuberculosis. The bacteria . The bacteria usually attacks the lungs, but TB bacteria usually attacks the lungs, but TB bacteria can attack any part of the body such as can attack any part of the body such as the kidney, spine, and brain. If not treated the kidney, spine, and brain. If not treated properly, TB disease can be fatal.  properly, TB disease can be fatal. 

Tuberculosis can infect any oneTuberculosis can infect any one ? ?

Poverty and Crowded living Poverty and Crowded living spreads Tuberculosisspreads Tuberculosis

Dr.T.V.Rao MDDr.T.V.Rao MD 88

How TB is spreadHow TB is spread TB is spread through the TB is spread through the

air from one person to air from one person to another. The TB bacteria another. The TB bacteria are put into the air when are put into the air when a person with active TB a person with active TB disease of the lungs or disease of the lungs or throat coughs, sneezes, throat coughs, sneezes, speaks, or sings. People speaks, or sings. People nearby may breathe in nearby may breathe in these bacteria and these bacteria and become infected. become infected.

Multiorgan InvolvementMultiorgan Involvementin Tuberculosis.in Tuberculosis.

Dr.T.V.Rao MDDr.T.V.Rao MD 1010

SYMPTOMS OF TBSYMPTOMS OF TB

COUGH MORE THAN 2 WEEKS COUGH MORE THAN 2 WEEKS LOSS OF APPETITELOSS OF APPETITE WEAKNESSWEAKNESS PAIN IN CHESTPAIN IN CHEST RISING FEVER AT EVENINGRISING FEVER AT EVENING

Worldwide Distribution of New TB Cases, Worldwide Distribution of New TB Cases, 20062006

Global burden of TB Global burden of TB 2 billion infected, i.e. 1 in 3 of global population2 billion infected, i.e. 1 in 3 of global population 9.4 million (139/lakh) new cases in 2008, 80% in 9.4 million (139/lakh) new cases in 2008, 80% in

22 high-burden countries 22 high-burden countries 4 m new sm+ve PTB (61/lakh) cases4 m new sm+ve PTB (61/lakh) cases in 2008in 2008 Global incidence of TB has peaked in 2004 and Global incidence of TB has peaked in 2004 and

is declining.is declining. 1.77m deaths in 2007, 98% in low-income 1.77m deaths in 2007, 98% in low-income

countriescountries MDR-TB -prevalence in new cases around 3.6%MDR-TB -prevalence in new cases around 3.6%

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Magnitude of the ProblemMagnitude 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 22 High Burden

Countries (in terms of TB incidence rate)

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Problem of TB in IndiaProblem of TB in India Estimated incidenceEstimated incidence

1.96 million new cases annually1.96 million new cases annually 0.8 million new smear positive cases annually0.8 million new smear positive cases annually 75 new smear positive PTB cases/1lakh population 75 new smear positive PTB cases/1lakh population

per year per year Estimated prevalence of TB diseaseEstimated prevalence of TB disease

3.8 million bacillary cases in 2000 3.8 million bacillary cases in 2000 1.7 million new smear positive cases in 20001.7 million new smear positive cases in 2000

Estimated mortalityEstimated mortality 330,000 deaths due to TB each year330,000 deaths due to TB each year Over 1000 deaths a dayOver 1000 deaths a day 2 deaths every 3 minutes2 deaths every 3 minutes05/01/2305/01/23 1616

Problem of TB in India (contd)Problem of TB in India (contd) Prevalence of TB infection Prevalence of TB infection

40% (~400m) infected with 40% (~400m) infected with M. tuberculosis M. tuberculosis (with a 10% lifetime (with a 10% lifetime risk of TB disease in the absence of HIV)risk of TB disease in the absence of HIV)

Estimated Multi-drug resistant TBEstimated Multi-drug resistant TB < 3% in new cases< 3% in new cases 12% in re-treatment cases12% in re-treatment cases

TB-HIVTB-HIV ~~2.312.31 million people living with HIV (PLWHA) million people living with HIV (PLWHA) 10-15% annual risk (60% lifetime risk) of developing 10-15% annual risk (60% lifetime risk) of developing

active TB disease in PLWHAactive TB disease in PLWHA Estimated Estimated ~~ 5% of TB patients are HIV infected 5% of TB patients are HIV infected

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Dr.T.V.Rao MDDr.T.V.Rao MD

Social and Economic Burden of TB in Social and Economic Burden of TB in IndiaIndia

Estimated burden per yearEstimated burden per year

Indirect costs to society Indirect costs to society $3 billion$3 billion

Direct costs to societyDirect costs to society $300 million$300 million

Productive work days lost due to TB illness Productive work days lost due to TB illness 100 million100 million

Productive work days lost due to TB deathsProductive work days lost due to TB deaths 1.3 billion 1.3 billion

School drop-outs due to parental TBSchool drop-outs due to parental TB 300,000 300,000

Women rejected by families due to TBWomen rejected by families due to TB 100,000 100,000

TRC, Socio-economic impact of TB on patients and family in India, Int J Tub Lung Dis 1999 3: 869-87705/01/2305/01/23 1818

Do You KnowDo You Know • • That someone in the world is newly infected with That someone in the world is newly infected with

TB bacilli every second? TB bacilli every second?

• • That one-third of the world population is currently That one-third of the world population is currently infected by TB?infected by TB?

• • That over six lakhs Indians are unaware that they That over six lakhs Indians are unaware that they suffer from TB? suffer from TB?

• • That every TB patient infects 10-15 new persons That every TB patient infects 10-15 new persons on an average every year? on an average every year?

Tuberculosis – A major cause of Tuberculosis – A major cause of Morbidity and Mortality in IndiaMorbidity and Mortality in India

In India today, two In India today, two deaths occur every deaths occur every three minutes from three minutes from tuberculosis (TB). But tuberculosis (TB). But these deaths can be these deaths can be prevented. With prevented. With proper care and proper care and treatment, TB patients treatment, TB patients can be cured and the can be cured and the battle against TB can battle against TB can be won be won

Diagnosis of Diagnosis of Tuberculosis Tuberculosis

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How are TB cases diagnosed?How are TB cases diagnosed? Cough for ≥2 weeks (Cough for ≥2 weeks (TB suspectsTB suspects) screened from ) screened from

OPD/clinics and referred for sputum microscopyOPD/clinics and referred for sputum microscopy Sputum microscopy performed at quality assured Sputum microscopy performed at quality assured

Designated Microscopy Centres (DMCs)Designated Microscopy Centres (DMCs) If sputum is initially negative and remains so after a If sputum is initially negative and remains so after a

course of antibiotic, despite persisting symptoms, course of antibiotic, despite persisting symptoms, then X-ray chest is donethen X-ray chest is done

Standard diagnostic algorithm for pulmonary TBStandard diagnostic algorithm for pulmonary TB Patients diagnosed as Sputum +ve and Sputum –ve PTBPatients diagnosed as Sputum +ve and Sputum –ve PTB

Extra-Pulmonary TB is diagnosed based on clinical Extra-Pulmonary TB is diagnosed based on clinical evaluation and histopathological evidenceevaluation and histopathological evidence

Why Sputum MicroscopyWhy Sputum Microscopy

Sputum smear microscopy is an essential tool of case-finding in Tuberculosis control. Tuberculosis control, aiming at the prevention of the transmission of infection, imparts a clear priority to the sputum positives which are the sources of infection in the community. Hence the need to detect as many sputum positives as possible

Dr.T.V.Rao MDDr.T.V.Rao MD

Evolution of TB Control in IndiaEvolution of TB Control in India

1950s-60s 1950s-60s Important TB research at TRC and NTIImportant TB research at TRC and NTI 1962 1962 National TB Programme (NTP)National TB Programme (NTP) 1992 1992 Programme ReviewProgramme Review

• only 30% of patients diagnosed; only 30% of patients diagnosed; • of these, only 30% treated successfullyof these, only 30% treated successfully

1993 1993 RNTCP pilot beganRNTCP pilot began 1998 1998 RNTCP scale-up RNTCP scale-up 2001 2001 450 million population covered450 million population covered 2004 2004 >80% of country covered >80% of country covered 20062006 Entire country covered by RNTCPEntire country covered by RNTCP

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WHO WHO - Working - Working WHO is working to WHO is working to

dramatically reduce dramatically reduce the burden of TB, and the burden of TB, and halve TB deaths and halve TB deaths and prevalence by 2015, prevalence by 2015, through its Stop TB through its Stop TB Strategy and Strategy and supporting the Global supporting the Global Plan to Stop TB. Plan to Stop TB.

WHO - DOTSWHO - DOTS The WHO-recommended The WHO-recommended

Directly Observed Directly Observed Treatment, Short Course Treatment, Short Course (DOTS) strategy was (DOTS) strategy was launched formally as launched formally as Revised National TB Revised National TB Control programme in Control programme in India in 1997 after pilot India in 1997 after pilot testing from 1993-1996. testing from 1993-1996. Since then DOTS has Since then DOTS has been widely advocated been widely advocated and successfully and successfully applied. .... applied. ....

State TB Cell

District TB Centre

Tuberculosis Unit

Microscopy Centre

DOT Centre

STO, Deputy STOMO, Accountant, IEC Officer, SA, DEO

DTO, MO-DTC, LT, DEO, Driver

MO-TCSTS, STLS

MO, LT

DOT Provider – MPW, NGO, PP, Comm Vol

Nodal point for TB control

One/ 5 lakh (2.5 lakh in hilly/ difficult/ tribal area)

One/ lakh (0.5 lakh in hilly/ difficult/ tribal area)

Structure of RNTCP at State level

Imitation to Imitation to Revised National TB Revised National TB ControlControl

India had switched over to the Revised India had switched over to the Revised National TB Control Programme (RNTCP), National TB Control Programme (RNTCP), which concentrates on the personal which concentrates on the personal attention of the health staff on each TB attention of the health staff on each TB patient. Thus, India hopes to cut down TB patient. Thus, India hopes to cut down TB prevalence and death rate by half, by the prevalence and death rate by half, by the year 2015. year 2015.

RNTCP shift responsibility for cure from RNTCP shift responsibility for cure from patient to health system…patient to health system…

DOTS is a systematic strategy DOTS is a systematic strategy which has various componentswhich has various components

Political and administrative commitment.Political and administrative commitment. Good quality diagnosis.Good quality diagnosis. Good quality drugs. An uninterrupted Good quality drugs. An uninterrupted

supply of good quality anti-TB drugsupply of good quality anti-TB drug Directly observed treatment short course Directly observed treatment short course

chemotherapychemotherapy Monitoring and accountabilityMonitoring and accountability

India – DOTS largestIndia – DOTS largest

India now has the second largest DOTS India now has the second largest DOTS (Directly Observed Treatment, Short (Directly Observed Treatment, Short course) programme in the world. However, course) programme in the world. However, India's DOTS programme is the fastest India's DOTS programme is the fastest expanding programme, and the largest in expanding programme, and the largest in the world in terms of patients initiated on the world in terms of patients initiated on treatment, placing more than 100,000 treatment, placing more than 100,000 patients on treatment every month. patients on treatment every month.

DOTS in 2009DOTS in 2009

By June 2009, more than 10.2 million By June 2009, more than 10.2 million patients have been initiated on treatment, patients have been initiated on treatment, saving more than 1.9 million additional saving more than 1.9 million additional lives. lives.

The success of DOTS in India has The success of DOTS in India has contributed substantially to the success of contributed substantially to the success of TB control in the world. TB control in the world.

Concern for TB patients is the Concern for TB patients is the Backbone of the Control Backbone of the Control

ProgrammeProgramme

MDR TuberculosisMDR Tuberculosis The emergence of The emergence of

resistance to drugs resistance to drugs used to treat TB, and used to treat TB, and particularly multi-particularly multi-drug-resistant TB drug-resistant TB (MDR TB), has (MDR TB), has become a significant become a significant public health problem public health problem and an obstacle to and an obstacle to effective TB control.effective TB control.

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DOTS Can reduce MDR DOTS Can reduce MDR TuberculosisTuberculosis

DOTS has been proven to prevent the DOTS has been proven to prevent the emergence of MDRTB, and also to emergence of MDRTB, and also to reverse the incidence of MDRTB where it reverse the incidence of MDRTB where it has emerged. MDRTB is a tragedy for has emerged. MDRTB is a tragedy for individual patients and a symptom of poor individual patients and a symptom of poor TB management. The best way to confront TB management. The best way to confront this challenge is to improve TB treatment this challenge is to improve TB treatment and implement DOTS. and implement DOTS.

DOTS PlusDOTS Plus DOTS Plus refers to a DOTS program that adds DOTS Plus refers to a DOTS program that adds

components for MDR TB diagnosis, components for MDR TB diagnosis, management, and treatment. The WHO-management, and treatment. The WHO-endorsed DOTS Plus program began in 2000s. endorsed DOTS Plus program began in 2000s. In 2002, the Global Fund to fight AIDS, TB, and In 2002, the Global Fund to fight AIDS, TB, and Malaria (GFATM) started financing TB control Malaria (GFATM) started financing TB control programs, including MDR TB, greatly reducing programs, including MDR TB, greatly reducing the economic barrier to MDR TB control.the economic barrier to MDR TB control.

DOTS-Plus programs can and should DOTS-Plus programs can and should strengthen the basic DOTS strategystrengthen the basic DOTS strategy

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Current Experience withCurrent Experience withDOTSDOTS

DOTS is a proven cost-effective TB DOTS is a proven cost-effective TB treatment strategy. A combination of treatment strategy. A combination of technical and managerial components, technical and managerial components, DOTS quickly makes infectious cases DOTS quickly makes infectious cases non-infectious and breaks the cycle of non-infectious and breaks the cycle of transmission. Using DOTS also prevents transmission. Using DOTS also prevents the development of drug-resistant strains the development of drug-resistant strains of TB that are often fatal and very of TB that are often fatal and very expensive to cure.expensive to cure.

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World TB Day celebrated with a World TB Day celebrated with a New Theme Every YearNew Theme Every Year

The 2014 World TB Day campaign “Reach “Reach the three million, A TB the three million, A TB test, treatment and cure for all”test, treatment and cure for all”..

The key message is that TB is curable..The key message is that TB is curable.. World TB Day is held each year on 24

March.

Control of TB is a Team WorkControl of TB is a Team Work

“Let us all join hands in transforming the fight against TB towards elimination of Tuberculosis”

 

THANK YOU…THANK YOU…