1. Recent advances in
Revised National Tuberculosis
Control Programme (RNTCP)
Dr Amol Kinge
Epidemiologist cum Assistant Professor,
Department of Community Medicine,
SBHGMC, Dhule
2. 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
3. Tuberculosis
Classification
1. Anatomical site: Pulmonary & Extra-pulmonary
2. 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 cases
3. Drug resistance: Mono-DR, MDR (HR), XDR (1st line+FQ+2nd line
injectables)
4. Tuberculosis
Signs and symptoms
1. Cough with /without expectoration >2 weeks
2. Low grade fever
3. Weight loss / general debility
4. Generalised Weakness
6. 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
7. 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
8. India is the highest TB burden country
Data source: Global TB Report 2015, WHO, Geneva
9. 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
11. 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)
DTC
PHC
1
PHC
2
PHC
3
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
12. Drugs
First Line Drugs
H- Isoniazid
R- Rifampicin
Z- Pyrazinamide
E- Ethambutol
S- Streptomycin
Second Line Drugs
Kanamycin
Ethionamide
Levofloxacin
Cycloserine
PAS
15. 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
16. RNTCP - Achievements
Infrastructure:
• 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
17. 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
20. 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 72
DR TB Centres 16
Dist DR TB Centres 9
ART Centres 86
Stand Alone ICTCs 657
F-ICTCs 1,645
21. The DOTS Strategy
1. Government commitment
2. Case detection through
predominantly passive case
finding
3. Standardized short-course
chemotherapy to at least all
confirmed sputum smear
positive cases of TB under proper
case management conditions
4. Establishment of a system of
regular drug supply of all
essential anti-TB drugs
5. Establishment and
maintenance of a monitoring
system, for both programme
supervision and evaluation
The Stop TB Strategy
1. Pursue high-quality DOTS
expansion and enhancement
2. Address TB/HIV, MDR-TB
and other challenges
3. Contribute to health
system strengthening
4. Engage all care providers
5. Empower people with TB
and communities
6. Enable and promote
research
The Post-2015
End TB Strategy
1. Integrated, patient-
centred TB care and
prevention
2. Bold policies and
supportive systems
3. Intensified research
and innovation
Evolution of global strategies to control TB
1994 2006 2014
23. 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
26. 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
27. 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
28. • 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
29. 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..
30. 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
31. • Himachal Pradesh
• Sikkim
• Bihar
• Maharashtra
• Kerala
Rollout of Daily Regimen
in 104 districts/5 States Total population
coverage - 2,690 Lakh
Rajas than
Gujarat
Maharas htra
Oriss a
Karnataka
Madhya Prades h
Bihar
Uttar
Pradesh
Jam m u &
Kas hm ir
Tam il Nadu
Assam
Telangana
Chhattis garh
Andhra Pradesh
Jhark hand
Punjab
W est B engal
Kerala
Haryana
Himac hal
Pradesh
Manipur
Mizoram
Andam an & N icobar
Dam an & Diu
Uttarakhand
Sikkim
Arunachal
Pradesh
N aga lan d
Tripura
32. 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
