1. 1
CRITICAL REVIEW ON RNTCP-INDIA
RELEVANCE
GLOBAL
• World Health Organisation (WHO) statistics for 2013-Global incidence of 9 million, 2 million die
each year
INDIAN SCENARIO
• India is the country with the highest burden of TB
• India- 2.6 million cases (incidence)
• India accounts for nearly 1/4th of global burden of TB (2010).
Mortality: 26 per 1 lac population.
Prevalence (old + new cases): 256 per 1 lac population.
Incidence (new cases only): 185 per 1 lac population
(http://gmch.gov.in/e-study/e%20lectures/Community%20Medicine/RNTCP.pdf)
Social and Economic Burden of TB in India
estimated burden per year
Indirect costs to society $3 billion
Direct costs to society $300 million
Productive work days lost due to TB illness 100 million
Productive work days lost due to TB deaths 1.3 billion
School drop-outs due to parental TB 300,000
Women rejected by families due to TB 100,000
2. 2
Before the Revised National Tuberculosis Program (NTCP) came into force the existing Tuberculosis
program had the following objectives:
1. To identify and treat as large a number of TB patients as possible so that infectious cases are
rendered non- infectious.
2. To reduce the magnitude of TB problem in the country to a level where it ceases to be a
public health problem
EVOLVING STRATEGIES OF TB CONTROL INN INDIA
• 1962 National TB Programme (NTP)
• 1992 Programme Review
» only 30% of patients diagnosed;
» of these, only 30% treated successfully
• 1993 RNTCP pilot began-DOTS strategy
• 1997 RNTCP large scale-implementation
• 1998-2005 RNTCP(phase 1)
• 2002 700 million population covered
• 2004 >80% of country covered
• 2006 Entire country covered by RNTCP/STOP TB strategy
• 2006-2011 RNTCP(phase 2)
3. 3
• 2010 Universal Access to TB Care
• 2012-2017 National Strategic Plan
NTP
• Ground-breaking research in the 1950s and early 1960s by the Tuberculosis Research Centre at
Chennai and the National TB Institute at Bangalore, a National Tuberculosis Programme (NTP) was
implemented by Government of India in 1962.
• The NTP was implemented on a 50:50 cost sharing basis between Centre and State.
• Use of a self-administered standard drug regimen of initially 12-18 months duration
• Treatment free of cost
• Priority to newly diagnosed patients over previously treated patient
• Treatment organization decentralized to district level.
• The NTP created an extensive infrastructure for TB control, with a network of 446 district TB
centres and 330 TB clinics.
FAILURE OF NTP
• Inadequate budget and insufficient managerial capacity
• Shortage of drugs
• Less than 40% of patients completed the treatment
• Emphasis on x-ray diagnosis resulting in inaccurate diagnosis
• Poor quality sputum microscopy
• Multiplicity of treatment regimens.
REVISED STRATEGY
• Augmentation of organizational support
• Increased budgetary outlay
• Use of sputum as a primary method of diagnosis
• Standardize treatment regimens
• Augmentation of the peripheral level supervision
• Ensuring a regular, uninterrupted supply of drugs up to the periphery health unit
• Emphasis on training, IEC, and Operational research
RNTCP
• GOI –WHO revised strategy for control of TB in India
• RNTCP application of WHO – DOTS launched in 1993 as pilot project covering 2.35 – 20 million
population (1993-1997)
THE BASIC PRINCIPLES OF RNTCP (1993)
4. 4
• Political commitment for ensuring adequate funds, staff and other key inputs.
• Establishment of diagnosis primarily by microscopic examination of specimens obtained from
patients presenting to health care facilities.
OBJECTIVES
• Achievement of at least 85% cure rate of infectious cases; through DOTS.
• Augmentation of case finding activities through quality sputum microscopy to detect at least 70% of
estimated cases
RNTCP in Phase I (1997-2006) RNTCP Phase II( 2006-11)
The core element of RNTCP in Phase I
(1997-2006)was to ensure high quality
DOTS expansion in the country, addressing
the five primary components of the DOTS
strategy
• Political and administrative
commitment
• Good Quality Diagnosis through
sputum Microscopy
• Directly observed treatment
• Systematic Monitoring and
Accountability
• Addressing stop TB strategy under
RNTCP
Consolidate the achievements of phase I
2006 - STOP TB
COMPONENTS OF STOP TB :
• Perusing quality DOTS expansion &
enhancement.
• Addressing TB/HIV & MDR-TB
• Contributing to Health Care
Strengthening.
• Engaging all care providers.
• Empowering patients and
communities.
• Enabling and promoting research
(diagnosis, treatment, vaccine)
Regular and uninterrupted supply of anti-TB
drugs in the form of a patient-specific box
that contains the medicines for the entire
course of treatment so that no patient is
subjected to interruption of treatment for
lack of medicines.
Maintain its progressive trend and effect
further improvement in its functioning
Achieve TB related MDG goals while
retaining DOTS as its core strategy
Direct observation of every dose of
treatment in the intensive phase and of at
least the first dose in the continuation
phase of treatment.
Implementation of DOTS-PLUS for MDR-TB
cases in a phased manner
Systematic monitoring, supervision and
cohort analysis-one Senior Treatment
Laboratory Supervisor (STLS) is responsible
for organization of uninterrupted treatment
and one Senior Tuberculosis Laboratory
Supervisor for ensuring quality laboratory
service for every 5,00,000 population
Institutional strengthening at national ,state
and district level
Distribution of pediatric drug boxes
6. 6
TARGETS
By 2005:
• At least 70% people with sputum smear positive TB will be diagnosed.
• At least 85% cured.
By 2015:
• Global burden of TB (prevalence and death rates) will be reduced by 50% relative to 1990
levels.
• Reduce prevalence to <150 per lakh population
• Reduce deaths to <15 per lakh population
• Number of people dying from TB in 2015 should be less than 1 million, including those co-
infected with HIV
By 2050:
Global incidence of TB disease will be less than or equal to 1 case per million population per year
Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB
Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected
sputum positive patients
• The global NSP case detection rate is 61% (2006) and treatment success rate is 85%
• RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and
case detection rate 70% (2007)
STRATEGY
• Augmentation of organizational support at the central and state level for meaningful coordination
• Increase in budgetary outlay
• Use of Sputum microscopy as a primary method of diagnosis among self-reporting patients
• Standardized treatment regimens
• Augmentation of the peripheral level supervision through the creation of a sub district supervisory
unit
• Ensuring a regular uninterrupted supply of drugs up to the most peripheral level
• Emphasis on training, IEC, operational research and NGO involvement in the program
COMPONENTS OF NEW STOP TB STRATEGY
• Pursue quality DOTS expansion and enhancement, by improving the case finding are cure through
an effective patient-centered approach to reach all patients, especially the poor.
7. 7
• Address TB-HIV, MDR-TB and other challenges, by scaling up TB-HIV joint activities, DOTS Plus, and
other relevant approaches.
• Contribute to health system strengthening, by collaborating with other health programmes and
general services
• Involve all health care providers, public, nongovernmental and private, by scaling up approaches
based on a public-private mix (PPM), to ensure adherence to the International Standards of TB care.
• Engage people with TB, and affected communities to demand, and contribute to effective care. This
will involve scaling-up of community TB care; creating demand through context-specific advocacy,
communication and social mobilization.
• Enable and promote research for the development of new drugs, diagnostic and vaccines.
Operational Research will also be needed to improve programme performance.
INPUT & OUTPUT INDICATORS
1. Logic model for evaluation of revised national tuberculosis control program (RNTCP), District
Kangra, Himachal Pradesh, India, 2006. (Case detection)
8. 8
2. logical model for evaluation of Revised National Tuberculosis Program, Kangra, Himachal Pr adesh,
India, 2006 (IEC)
9. 9
3. Logic model for evaluation of revised national tuberculosis program, Kangra, Himachal Pradesh, India,
2006 (case management)
OUTCOME
10. 10
• Prevalence of all forms of TB has been brought down from 586/lakh population (1990) to 283/lakh
population in 2007 and TBmortality in the country has reduced from over 42/lakh population in 1990
to 28/lakh population in 2007 as per the WHO global report 2009.
• National estimates of ARTI prior to 2000 were 1.7 and estimates based on National ARTI survey in
2001-03 is 1.5.
• Repeat population surveys conducted by TRC indicate an annual decline in prevalence of disease by
12%.
• Death rate has been brought down seven folds (29% to 4%).
• 662 DTCs, 2698 TB units, 13,039 DMCs are functional in the country.
• The programme involves more than 1971 NGOs, >10894 private practitioners, >297 medical
colleges & >150 corporate health facilities are involved
• >13,000 peripheral labs & designated microscopy centres have been established.
• > 6 lakh public health care providers are trained under the progamme
• >15 million patients have been initiated on treatment.
THE NATIONAL STRATEGIC PLAN 2012-2017
• Strengthening and improving the quality of basic DOTS services
• Further strengthen and align with the health systemunder National Rural Health Mission (NRHM)
• Improve communication and outreach and social mobilization
• Promote research for development and implementation of improved tools and strategies
Vision: "TB-free India“
Goal: Universal Access to quality TB diagnosis & treatment for all pulmonary & extra pulmonary TB
patients including drug resistant and HIV associated TB.
OBJECTIVES
• To achieve 90% notification rate for all cases.
• To achieve 90% success rate for all new & 85% for re treatment cases.
• To achieve decreased morbidity & mortality if HIV associated TB.
• To improve outcomes of TB care in private sector.
• To significantly improve the successful outcomes of treatment for drug resistant cases.
DOTS services
• Further strengthen and align with health system under NRHM
• Deploying improved rapid diagnosis at the field level
• Expand efforts to engage all care providers
11. 11
• Strengthen urban TB Control
• Expand diagnosis and treatment of drug resistant TB
• Improve communication and outreach
• Promote research for development and implementation of improved tools and strategies
TARGETS
• Early detection and treatment of at least 90 %of estimated TB case in the community, including
HIV-associated TB
• Initial screening of all re treatment smear positive cases for drug resistant TB & appropriate
treatment
• Offer of HIV counselling and testing for all TB patients and linking HIV-infected TB patients to
HIV care and support
• Successful treatment of at least 90 percent of all new TB patients
• Extend RNTCP services to patients diagnosed and treated in the private sector
TARGET PLANS FOR 2012-2017:
BUDGET ALLOCATION
Allocation under the XIth plan (2007-12)
Total budget of Rs. 1447.00 Crores has been approved by the planning commission for the
implementation of RNTCP under the XIth plan.
YEAR BUDGET(IN CRORES) EXPENDITURE(INCRORES)
2007-08 267.00 262.12
2008-09 275.00* 279.9
2009-10 297.25 72.5
* Provision increased to Rs. 280.00 crores at RE Stage.
12. 12
SWOT
ANALYSIS
Strength
• Quality of care
• Strong political and administrative commitment.
• Secured medium to long term financing.
• Intersectoral coordination
• Grass root level penetration of the programme
13. 13
• Wide network of TUs and quality assured DMCs across the country.
• Decentralized DOTs (~ 0.43 million DOT centers )
• Consistently achieving Global targets for past few years.
• TBHIV & DOT plus services introduced-Nation vide scale up by 2012.
• Wide participation of NGOs, PPs, Corporate, Professional bodies and other Government
departments .
• Engaged CS Partners viz. Union, WV, CBCI to enhance reach & empower TB cases / communities
• DOTS is a proven cost-effective TB treatment strategy
• Dots results in success rates up to 95%.
Weakness
• Unorganized private sector
• Weak general health systems in some states.
• Shortage of key Managerial staff (one person handling multiple portfolio)
Opportunities
• Universal Access
• Airborne Infection Control Guidelines developed
• Newer diagnostics under RNTCP in collaboration with FIND
• Pan Sensitive TB - LED Microscopy
• M/XDR TB diagnosis - LPA, Liquid culture, Capillary test, Gene pert
Threats
• Social stigma
• Sustainability of finances
• Irrational use of 1st & 2nd line drugs due to market force
MULTI-DRUG-RESISTANT TUBERCULOSIS (MDR-TB)
• MDRTB refers to strains of the bacterium which are proven in a laboratory to be resistant to the
two most active anti-TB drugs, isoniazid and rifampicin. Treatment of MDRTB is extremely
expensive, toxic, arduous, and often unsuccessful.
• DOTS has been proven to prevent the emergence of MDRTB, and also to reverse the incidence of
MDRTB
EXTREME DRUG RESISTANT TUBERCULOSIS (XDR-TB)
14. 14
• XDR TB is strains of TB that are resistant to at least rifampicin and isoniazid (which means that it is
MDR TB), and also resistant to a fluoroquinolone and to at least one of the three injectable TB
drugs, capreomycin, kanamycin and amikacin.3 XDR TB is also sometimes referred to as
extensively drug resistant TB
40% cases of MDR-TB converts into XDR-TB & 70% of XDR-TB patients die.
MDR-TB & XDR-TB
THE 2008 REPORT
% of MDR-TB among new TB cases 1994-2007
15. 15
Drug susceptible TB MDR-TB XDR-TB Total DR
limited resistance
manageable with 4
drug regimen –
DOTS
Resistance to H&R –
Treatment with 2nd
line drugs
Resistance to 2nd
line drugs-
Treatment options
restricted
Resistance to all
available drugs-
No treatment
options
Five priorities action to address global MDR-TB crisis
DOTS PLUS
DOTS Plus refers to a DOTS program that adds components for MDR TB diagnosis, management,
and treatment. WHO-endorsed DOTS Plus program began in 2000. At that time, the Green Light
Classification Estimated
Number of
Cases
Estimated
Number
of Deaths
All forms TB 8.8 million 1.6
million
MDR TB 4,24,000 1,16,000,
XDR TB 27,000 16,000
16. 16
Committee (GLC) was established to promote access to high quality second line drugs for
appropriate use in TB control programs. In 2002, the Global Fund to fight AIDS, TB, and Malaria
(GFATM) started financing TB control programs, including MDR TB, greatly reducing the economic
barrier to MDR TB control. DOTS-Plus programs can and should strengthen the basic DOTS strategy
TB: ACCOMPLISHMENTS
• Program innovations
• Creation of sub district level supervisory and monitoring unit “TB Unit”
• Patient-wise individual drug boxes for entire course of treatment
• Community involvement in DOTs – shopkeepers, teachers, postmen, cured patients, etc
• Continuous Internal Evaluation of districts
• Monitoring strategy document with checklists
• NGO & PP (Private Provider) schemes
• Task Force mechanism for involvement of Medical colleges
• Web based IEC/ ACSM resource centre
• District TB Control Society
• Modular training
• Patient wise boxes
• Sub-district level supervisory staff (STS, STLS) for
• Treatment & microscopy
• Robust reporting and recording system
• Public Private Mix (PPM) Activities for Involvement of All Health Care Providers
• Involvement of NGOs and Private Practitioners
Schemes revised in 2008
Presently > 2500 NGOs, 17,000 PPs involved
• Involvement of professional bodies like IMA, IAP
• Other Central government departments/PSUs
• CGHS, Railways, ESI, Mining, Shipping
• Corporate sector
• ~150 Corporate Houses participating
• Involvement of FBOs like CBCI
• Involvement of Medical Colleges
RECOMMENDATIONS
• Receive daily TB treatment at least during the intensive phase
17. 17
• For the continuation phase, the optimal dosing frequency is also daily
• Three times weekly dosing during the continuation phase is an acceptable alternative
• TB patients who are living with HIV should receive at least the same duration of TB treatment as
HIV-negative TB patients
• Co-trimoxazole preventive therapy
• Susceptibility testing as component of control programme
REFERENCES
http://www.ijcm.org.in/viewimage.asp?img=India nJCommunityMed_2011_36_2_146_84136_t1.jp
http://www.who.int/tb/publications/global_report/gtbr14_supplement_web_v3.pdf
http://medind.nic.in/ibr/t12/i1/ibrt12i1p18.pdf
http://tbcindia.nic.in/index1.php?sublinkid=4160&level=1&lid=2807&lang=1
http://www.who.int/tb/publications/global_report/en/
http://www.12thplan.gov.in/
