2. Maximum annual deaths than any other infectious disease in
the industrialized world
Most frequent cause of death for young adults
New outbreaks are increasing after almost 40 years of a steady
decline2 billion people (1/3 of the world's population) exposed
to TB
> 8 million cases & 2 million deaths annually
Rajyaroga (king of diseases) in ancient text
Global Burden
8/22/20132
3. 2 million develop TB & 5,00,000 die annually
> 1000 die of TB every day (2 every 3 minutes)
HIV , major risk factor for TB has already infected 4.8
million
Emergence of MDR-TB has added to TB epidemic
An untreated patient can infect 10-15 persons each year
TB Burden India
8/22/20133
4. Poorly treated patients develop drug-resistant and
potentially-incurable TB
A major barrier to economic development
> 300,000 children forced to leave school ,parents have TB
> 100,000 women with TB are rejected by their families
Tragic because TB is nearly 100% curable
TB Burden India
8/22/20134
5. Started in 1997
Lepra-India , NGO supporting under “Sahayog” & “Akshaya”
project to IEC & BCC activities in 12 districts
Catholic Bishop Conference of India & IMA also
Population covered 424 lakhs
Suspects examined in 2012 : 226305
Diagnosed new cases : 29728
Trained staff , MO 81 % & para staff 87 %
Laboratory : ILR Cuttack & RMRC Bhubaneswar
Odisha
8/22/20135
6. Back ground
Year Comments
1962 NTCP30 % diagnosed & 30 % treated
1993 pilot testing based on DOTS Strategy
1998 – 2005 RNTCP I Launched as a NP expanded in
1998
2000 30 %
2002 50 %
2003 778 million
2004 997 million
2005 1080 million 97 %
24th March 2006 Entire Country
2006 – 2010 RNTCP II 8/22/20136
7. 1. Evaluated 55 million & initiated treatment 15.8 million
2. Prevention of mortality : >2.8 million lives
3. National coverage ( unreached areas )
4. Well on track to achieve the MDG of halting & beginning to
reverse the spread of the disease
5. With NACP III : expanded joint TB/HIV services
6. RNTCP conforms to ISTC prescribed standards
7. All Medical colleges involved
Achievements of RNTCP:
8/22/20137
8. 78, 67,194 TB suspects examined for SSM
14, 67,585 initiated on treatment
Case detection rate of New Smear Positive TB was 68%
Treatment success rate of 88%
81,482 pediatric TB cases , accounting for 7% of all cases
8, 21,807 (56%) TB patients tested HIV
44,063 (5%) were positive
92% HIV infected TB patients were initiated on CPT and 74% ART
Achievements of RNTCP: 2012
8/22/20138
10. CTD & NIC develop a Case Based Web application : Nikshay to
improve TB surveillance
Notifiable disease on 7th May 2012 (trace contacts)
The revision of the OR agenda in 2012
The “National Standing Committee” was renamed as “National
Research Committee”
Ban on serological test
New initiatives in 2012
8/22/201310
11. 6.3 million treated (1997-2006)
Health benefit of 29.2 million DALYs gained including 1.3 million deaths averted
2006, burden of TB = 14.4 million DALYs (1.8 times higher) in absence RNTCP
8/22/201311
12. Theme : “Universal Access for quality diagnosis and
treatment for all TB patients in the community”
Target : “reaching the unreached”
Focus : early & complete detection of all cases (DR-TB ,HIV-TB)
Increase involvement of private sector
Higher commitment
4 fold increase in budget
RNTCP : NSP 2012-17 , 12th FYP
8/22/201312
13. Vision: “TB-free India - through achieving Universal Access by
provision of quality diagnosis and treatment for all TB patients
in the community”
Goal: to decrease the morbidity and mortality by early
diagnosis and early treatment to all TB cases thereby cutting
the chain of transmission
RNTCP : NSP 2012-17 , 12th FYP
8/22/201313
14. Early detection & Rx of 90% cases (DR-TB & HIV-TB)
Rx 90% of new TB patients, 85% of previously-treated
Reduce default rate : new TB cases to < 5%
re-treatment TB cases to < 10%
Initial screening of all re-treatment smear-positive till 2015
All Smear positive TB patients by 2017 for DR-TB
Provision of treatment for MDR-TB
Offer of HIV Counseling and testing for all patients
Link HIV-infected TB patients to HIV care
Extend RNTCP services to patients in private sector
Objectives
8/22/201314
15. Detection , treatment of about 87 lakh TB patients
At least 2 lakh MDR-TB
Reduction in delay in diagnosis and treatment of all types of TB
Increase in access to services to hard to reach populations &
high risk & vulnerable groups
8/22/201315
Targets : 12th FYP
16. Over crowded living conditions Closeness of contacts
Absence of native resistance
Infectiousness of the source
Degree of sputum positivity
Pattern of coughing, lack of knowledge , nutrition
Resources : funds , trained manpower , infrastructure
Urbanization & migrations : slums
Unhygienic living conditions , poverty & indifferent attitude
towards health all these are high risk pockets 8/22/201316
Epidemiological factors
17. No financial constraints (best & 2nd largest)
multi factorial causation
Evidence from developed world
environmental condition & living standards
declined TB even before ATT
Social Stigma
Inhibits to come in early phase, even health workers behave
indifferently to them
72.4 % patients isolated with their utensils in their home
8/22/201317
18. Challenge peripheral area : lack of proper referral system
a chest symptomatic attends a health care provider, he is not
properly referred to DMC
Treatment facility to be accepted & utilized by community
Availability of all resources essential : drugs , needle syringe
,forms , chemical
8/22/201318
Organizational factors
19. Trained manpower still a big hindrance
General services still do not accept RNTCP strategies
In-service training must before merging it
Compulsory imposing of DOTS : resistance among doctors of
different discipline
8/22/201319
Organizational factors
20. RNTCP plans as NGO but implements as a government
department
Lack of coordination (intra & inter dept..)
DTO government post based on seniority
DTO : priority to clinical functions & failing to do justice with PH
8/22/201320
Organizational factors : District
21. Laboratory Supervisors STLs supervise the LTs but many times
they had far less experience than the technicians
Since they work on contractual basis ,ego problems may make
the technicians hostile
MO-TC , supervise STLs may not have necessary expertise
8/22/201321
Organizational factors : District
22. Computer literacy is still poor & networking not provided at all
levels
STDCs serve as hospitals instead of public health institutions
support training, monitoring, and supervision
State TB Officers don’t take action on DTO
STS ,treatment supervisor (1 lakh) population, has to observe
work by the health staff , no accountability
8/22/201322
State level
23. Patients reporting to big hospital not referred to DOTS center
due to fear of losing them
Social stigma of high SEC patients to visit DOTS
DOTS center restarts the investigation all again (don’t rely )
Often these centers are unattended so patients lose faith
8/22/201323
State level
24. Inconvenient (time / distance)
Observation may not be acceptable
Worse still : no accessible observer
Has to bear with cumulative side effects
No new drug in last 35 years
Universal coverage with DOTS not desirable
8/22/201324
DOTS : patients problem
25. 1% - 2% need non-DOTS regimen (intolerance, toxicity ,liver
disease, immcomp. & migration)
More common in reg. with alcoholism or drug abuse
DOTS should allow other reg. or provision to accommodate
Most pt. not recover of chest symptom sense of dissatisfaction
The drug combination & dosages changing over years creating
confusion among Physicians
8/22/201325
DOTS : patients problem
26. A study found that 60 % of dosages prescribed don’t correspond
to std. guidelines
Patients reluctant to visit DOTS center & take med for whole
month so the monthly doses are not supervised
Study by Bhatt 1998 showed SCC + HE = DOTS , but no
comparative study done
8/22/201326
DOTS : patients problem
27. RNTCP based on critical evaluation of NTC
Adopted a victim blaming approach ,
Rather than improving the policy & prog.
Very low targets were set for coverage & cure (85%)
But only 50% -60 % attend Gov. facility
Short comings : policy
8/22/201327
28. Targets achieved are not uniform , some areas need greater
effort as case detection is passive
(i) lack of participation of other health care providers like CGHS,
Railways, Corporate sector, private practitioners
(ii) lack of community participation
Short comings : policy
8/22/201328
29. 40 % - 50 % of active pulmonary TB (culture positive ) can not be
detected by microscopy ( Nagpaul 1968 )
Improve quality of sputum microscopy
Undetected smear negative pt will get Cat III or left untreated
if x ray are also neg, but will continue to infect community
Not providing : leads to loss of faith in Gov. services
RNTCP has quality assured laboratory network NRL,IRL, & DMC
Short comings : diagnostic
8/22/201329
30. During 2012, RNTCP finalized protocol & guidelines for
certification for second line Drug Susceptibility testing (DST)
Some recent advantages in case detection
African giant pouched rats trained to detect pul. TB
Alt tool to enhance case detection in resource limited
setting
Fast , cheap & low skill
Lab 40 sample in a day , HeroRAT same in 7 min
With 86 % sensitivity ,89 % specificity ( overall 87 % vs 37 % )
Short comings : diagnostic
8/22/201330
31. Sputum microscopy instead of X-ray avoids over diagnosis and
identifies infectious cases
Sputum test still not taken seriously
Depends on skill & commitment of technician
IQA & EQA cannot guarantee quality of monitoring
SSM – high tech job needs training & re-training
8/22/201331
32. Initial drug resistance : effects success
Most of pt. receiving ATT outside are potential for DR
37.3 % TB pt. develop resistance to rifampcin
Cat II pt. put on 5 drugs without C & DS
DST should be included as one of the diagnostic criteria in
tertiary center rather than changing all center to DOTS
Short comings : resistance
8/22/201332
33. In case of CAT I failure , one more drug added but at least 3
should be added after sensitivity testing
2nd line drugs to be added for MDR-TB
Majority of these are poor & left (DOTS-PLUS not yet 100%)
Freely available in market , frequently used by PP
All these increase MDR-TB
Short comings : resistance
8/22/201333
34. Community Participation & Role of NGO
CP essential to achieve targets
Best prog. : makes people realize the imp of health
Does the community thinks same way as health expert ?
Felt need has to be generated
NGOs should be acknowledged & supervised
PP should be trained on differential diagnosis as silicosis ,
asbestosis
Short comings : integration
8/22/201334
35. No National IEC program , needed to change the attitude
Effective for illiterate population with strong political
leadership , as seen in case of polio prog.
WHO Report 2005 : political commitment not uniform
Political leaders needed at all stage to mobilize the resources
With corruption this is hard to be found
IEC , BCC ,training
8/22/201335
36. RNTCP training modules updated with latest policy changes
Videos training modules for training DEO in Nikshay
Relapse more common in smokers
Focus on Anti smoking campaign & counseling of smoker Tb
patient
IEC , BCC ,training
8/22/201336
37. Recording & Reporting :
3 forms : SSE / C&S / Transfer
2 cards : id & treatment
2 registers : Lab & TB
4 copies of quarterly report TU has to submit (S/C/NTI/Rec.)
New patient , sputum conversion , Rx outcome
Data analyzed at Dist. to get age, sex , CAT distribution of
cases , done by technical experts
In reality little or no role of CDMO & DM in general & in
supervision & monitoring
Short comings : reporting
8/22/201337
38. Need huge funding
Improved diagnostic tests
New vaccine in early phases of clinical trials
New drugs : Shorten Rx for drug-susceptible disease
Refine Rx in special populations (with HIV, children & elderly)
Short comings : research
8/22/201338
39. whole blood (finger prick) HIV screening test to all DMCs and
Provider Initiated HIV Testing and Counseling (PITC)
among presumptive TB cases in all “high” HIV prevalent settings
Isoniazid prophylaxis therapy (IPT) has also been accepted for
prevention of TB among PLHIV
Future
8/22/201339
40. To screen all TB patients for DM in the 100 districts where
NPCDCS implemented
Universal Access, school awareness programme
RNTCP field personnel to generate awareness among students
and teachers of all school and colleges in all the States/UT's
> 3.5 lakh schools visited, 4.5 lakh teachers, 9 lakh students
covered
Future
8/22/201340
41. Extensive training, supervision and monitoring needed at all
levels
Ensuring treatment adherence and timely follow-up, and
uninterrupted supply of second line drugs
Unsupervised and uncontrolled private sector
Almost 100% of second line drugs were sold and used outside of
RNTCP
Conclusion
8/22/201341
42. Risk of failure of treatment and development of drug resistance
This large unregulated private sector, conflict of interest, and
easy availability of anti-TB drugs are important hindrances to a
successful programme
Guidelines to all healthcare providers (IMA ,MCI ,DCGI) to draft
Need urgent attention : infection control practices in Hospitals
National guidelines on Airborne Infection control in context of
TB
Conclusion
8/22/201342
44. Development & dissemination of different schemes for the
involvement of private practitioners, NGO’s etc.
Conduct sensitization & training Programmes for medical
personnel in other sectors including corporate sector
Awareness generation activities for health providers in the
community
Recommendations
8/22/201344
45. Change mindset of doctors & patients
Prog. Does not emphasize on active health education and
counseling of pt. in treatment & follow up
Convince them of RNTCP
Supervise & monitor the programme activities , address
shortcomings so quality services provided
Recommendations
8/22/201345
Since inception of RNTCP till 4th qr 2011, total462749 tb cases have been detected and treated.349425 cases have been cured & successfully completed treatment. In the 4th quarter 2011, the annualized new sputumpositive case detection rate of Odisha was 58%against the norm of 70% and the success rate 88% asagainst the norm of 85%.AchievementsIntensified TB-HIV Package• TB HIV Intensive Package is implemented in allthe districts since 2010 in collaboration withthe OSACS.• During 4th Quarter 2011, 3513 TB patients havebeen tested for HIV out of which 93 have beendiagnosed as TB-HIV co-infected.Progress of DOTS-Plus Programmes• Intermediate Reference laboratory (IRL) at AntiTB Demonstration & Training Centre, Cuttackaccredited on 10th Aug’ 2009.• Four RNTCP districts of Cuttack, Ganjam,Khurda and Bhubaneswar taken up for DOTS Plus activity in 2009-10 in 1st phase. The DOTSPlus services has been rolled out in 11 nearbydistricts of Anugul, Dhenkanal, Keonjhar,Mayurbhanj, Balasore, Bhadrak, Jajpur,Jagatsinghpur, Kendrapada, Puri, Nayagarh inphase-2. Central Appraisal has been plannedfor the phase-3 districts of Kandhamal,Kalahandi, Rayagada, Gajapati, Koraput,Malkangiri and Nabrangpur during February2012. Preparatory activities are in progress toexpand DOTS Plus Programme to other districts.• CAT-IV services (treatment of MDR-TB patients)initiated in the State from 11th Nov, 2009 atDOTS-PLUS SITE (SCB Medical College). So farthe sputum specimen of 230 Suspects have beenexamined for MDR out of which, 115 diagnosedas MDR-TB and 76 MDR-TB patients put underDOTS plus treatment (Cat-IV) patients fromabove four districts.• Line Probe Assay (LPA) at IntermediateReference Laboratory (IRL) Cuttack has been established and the Laboratory is waiting foraccreditation from National ReferenceLaboratory (NRL). This would dramatically cutdown diagnosis time of MDR-TB suspects fromthe current 60 days to 3 days.