CME_IMA_MNW(1).pptx

1. National TB Elimination Programme

2. Where we stand?

3. TB BURDEN – COMPARISON WITH OTHER DISEASES Tuberculosis is (India)- • Leading cause of death among communicable diseases- as a single infectious agent • 5th leading cause of death among all diseases Diarrheal diseases Tuberculosis Typhoid and paratyphoid Encephalitis HIV/AIDS Maternal disorders Meningitis Malaria 0 200 400 600 800 1000 1200 1400 1600 1800 DALY per 100000 Deaths attributed to disease Source: IHME, Global disease burden

4. Comparison of annual mortality of Infectious Diseases in India: 1.Malaria (2020), 2. Dengue (2019), 3. HIV (2020) , 4. COVID (2021) & 5.TB (2020) Data Sources: 1. NVBDCP Report: Countrywide Epidemiological Situation (1995 – 2020) 2. NVBDCP report: Dengue Cases and Deaths in the Country since 2015 3. NACO INDIA HIV ESTIMATES 2020 4. India Coronavirus COVID-19 Deaths (https://tradingeconomics.com/indi a/coronavirus-deaths) 5. WHO Global TB Report 2021 Malaria, 93 Dengue, 166 HIV,51000 COVID, 332000 TB, 504000

5. TB Epidemiology –India 2019-2021 Source: WHO Global TB Report 2016, 2020, 2021 & 2022 Parameters 2015 2019 2020 2021 Estimated TB incidence 28,40,000 26,40,000 25,90,0 00 29,50,00 0 Incidence per 100 000 population 217 193 188 210 Total TB Deaths 4,19,000 4,45,000 5,04,00 0 5,05,000 TB case fatality ratio (estimated mortality/estimated incidence) 15% 17% 20% 17% Total cases notified 17,40,000 23,91,022 18,12,6 43 21,16,97 6 11 lakhs

6. GAP BETWEEN ESTIMATES AND NOTIFICATION- INDIA (NUMBERS IN LAKHS) 28.40 27.90 27.4026.90 26.40 25.9 29.5 16.67 17.64 17.87 19.94 23.90 18.1 21.2 24.3 10.00 15.00 20.00 25.00 30.00 35.00 2015 2016 2017 2018 2019 2020 2021 2022 WHO estimated incident TB cases GAP Two significant causes of the GAP— Case presented with symptom but remain undiagnosed Diagnosed but NOT notified Gap has increased in huge proportion due to COVID in 2020

7. PROPORTION OF DRUG SALES IN PRIVATE AND CONSUMPTION IN NTEP- VS PROPORTION OF PRIVATE NOTIFICATION 1 1 1 1 1 1 0.8 0.9 0.7 0.5 0.4 0.5 0.02 0.06 0.12 0.18 0.30 0.28 0 0.2 0.4 0.6 0.8 1 1.2 2015 2016 2017 2018 2019 2020 Public Drug Consumption Private Drug Sale Private Notification IQVIA data- Calculated from Drug sales in private and consumption in NTEP. Notification We are still missing Notifications from Private

8. Where to go?

9. Few Public-health targets set by WHO Eradication (zero transmission at global level) • Polio • Dracunculiasis (Guinea worm disease) • Yaws Elimination (interruption of active transmission at country level) • Onchocerciasis • Human African trypanosomiasis (g) Elimination as a public-health problem (elimination of morbidity, mortality and/or reduction of transmission) • Tuberculosis • Human African trypanosomiasis (r) • Chagas disease • Lymphatic filariasis • Rabies Control (reduction of morbidity) • All the others • Trachoma • Visceral leishmaniasis • Schistosomiasis • Soil-transmitted helminthiases • Leprosy • Malaria

10. Where to go: India’s Commitment to End TB Vision: India free of TB TARGETS (for Reduction) INDIA (NSP) SDG WHO End TB 2025 2030 2035 Reduction in number of TB deaths Compared with 2015 (32 deaths per 1 lakh ) 90% (3 per lakh) 90% 95% Reduction in TB incidence rate Compared with 2015 (217 cases per 1 lakh) 80% (44 per lakh) 80% 90% Family affected with catastrophic costs due to TB 100% (0) 100% 100%

11. THE STATE STRATEGIC PLAN FOR TUBERCULOSIS ELIMINATION 2020 – 2025 Treat Prevent Build Detect Find all TB cases through quality assured Diagnostics with an emphasis on reaching every TB patient in the private sector Treat all TB cases with high quality anti TB drugs Prevent the emergence of TB in susceptible populations and stop catastrophic expenditure due to TB Build & strengthen supportive systems including enabling policies, empowered institutions & human resources

12. 100% Notification from the entire Private Sector Registration in TB Surveillance portal(Nikshay) Notificationcan be done in 3 ways— A) Using registered ID inNikshaydirectly B) Through Patient Provider Support Agencies C) Inform District TB officer in prescribed format Use Molecular Diagnostic Technology. Establish Microbiological confirmation All TB cases has to undergo Drug Susceptibility testing Nikshayrecords all events of a TB patient, hence has to be updated real time regularly) Scale up of Technology Govt Sector- WB 2021 Microscopy 1029 Rapid Molecular Test 276 Culture lab (for drug resistance test) 5 GAP-- Quantum of TB Diagnostic modalities present in Private is Unknown. Urgent need to line list ALL PRIVATE HEALTH FACILITIES along with the D E T E C T

13. When we suspect TB? Presumptive TB : Sign & symptoms of Pulmonary TB in adult 1. Cough for 2 weeks or more 2. Any Chest X-ray abnormality 3. Fever for 2 weeks or more 4. Significant weight loss (>5% wt. loss in last 3 month) 5. Blood in sputum 6. Abnormal night sweat Any one of the above qualify for TB testing Presumptive TB : Sign & symptoms of TB in Children (<15 years) 1. H/o Cough or fever for 14 days or abnormal chest X-ray or hemoptysis or weight loss or no weight gain 2. H/o contact with active TB within two years in case of under six years • For extra-pulmonary TB- symptoms depend on organ affected • Socially and clinically vulnerable populations needs to be screened for TB at regular intervals • In case of PLHIV , cough for any duration qualify for TB testing In a Health Facility around 3-5% of total OPD footfall is referred for TB testing

15. ANTIBIOTICS TO AVOID IN PATIENT HAVING ANY SIGN/SYMPTOM OF TB , TILL TB STATUS IS KNOWN Fluoroquinolones Macrolides Rifamycins Aminoglycosides Ciprofloxacin Azithromycin Rifampicin Streptomycin Ofloxacin Clarithromycin Rifabutin Amikacin Levofloxacin Erythromycin Kanamycin Moxifloxacin Roxithromycin

16. 0.5% 5.8% 12.9% 17.0% 19.9% 23.5% 22.9% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 2017 2018 2019 2020 2021 2022 2023 % Private Notification in Paschim Medinipur

17. PUBLIC VS PRIVATE- KEY INDICATORS: PASCHIM MEDINIPUR (2022) Indicators Norms /Target /National Average Public (%) Private (%) % Pediatric Cases 6-8% 1.6 3.5 % Female Cases 35-40% 24.6 34.5 Drug Susceptibility testing offered 90% 72.4 37.3 Microbiological confirmation 80% 71.3 36.1 % DRTB detected 6% 2.3 0.3 Proportion of Treatment Days monitored/reported adherence 50% 33 20 HIV status known 100% 97.9 95.4 Treatment Success Rate (2020) 90% 87.2 86.2 Better surveillance indicator for women & child Public health action? Status of Treatment Adherence? Are we missing DRTB Patients from the Private Sector?

18. WHY NOTIFICATION? PUBLIC HEALTH ACTIONS FOR THE NOTIFIED TB PATIENTS ! Components— 1. Patient home visit as per convenience of patient 2. Counselling of patient and family members 3. Treatment adherence and follow up support to ensure treatment completion 4. Contact tracing -- Symptoms screening -- Evaluation of TB symptomatics 5. Offering TB preventive treatment to all contacts after ruling out TB 6. Offering HIV counselling and testing 7. Offering Diabetes testing 8. Offering drug susceptibility testing 9. Linking with available social welfare schemes and Nikshay Poshan Yojana

19. INCENTIVE TO PRIVATE PROVIDERS & TREATMENT SUPPORTERS Health Establishment are expected to utilise these incentives in recordkeeping, facilitating notification, for storing NTEP drugs, dispensing them to patients as per norms, counselling, ensuring adherence, timely follow up, recordkeeping, updating Nikshay portal and liasoning with Govt Patients Private Providers Beneficiary All TB patients (Private, Public, DS, DR) All types of Private providers. Private provider who notifies the earliest Benefits Rs 500/- per treatment month. Travel allowance for DRTB patient. Locally managed additional nutrition, Social support scheme etc 500 for notifying, 500 for declaring outcome Mode Payment is made through direct bank transfer

20. GAZETTE ON TB NOTIFICATION Mandatory Notification and Public Health Actions of TB patients Private Clinics---Hospitals---Laboratories--- Chemists  Latest version of the Gazette dated 19th March 2018 has the following provision— Failure to take the mandated steps may attract the provisions of Sections 269 and 270 of the Indian Penal Code (IPC)

21. Follow STANDARDISED Treatment Protocol for Drug Sensitive and Drug Resistant TB cases Use 2ndline Anti TB Drugs like Linezolid, Kanamycin only for Microbiologically confirmed Drug Resistant TB cases Use injection free regimens with latest Anti TB drugs Store NTEP drugs in Private Pharmacies for periodic dispensation to private TB patients Use IT based adherence technology to monitor compliance Sustain treatment success rate of 95% and more T R E A T STOP empirical treatmen t/ Trial ATD

22. First-line regimen Drug Susceptible TB (Both New & Previously treated TB patient) IP CP 2 H 4 H R R Z E E

23. Adult weight bands

24. Regimen class Intensive phase Continuation phase H mono/poly DR TB (R resistance not detected and H resistance) All oral H mono-poly DR TB regimen (6) Lfx R E Z MDR/RR TB Shorter Oral MDR TB regimen (4-6) BDQ(6) Lxf Eto Cfz Z Hh E (5) Lxf Cfz Z E All oral longer MDR TB regimen (18-20) Bdq(6) Lfx Lzd# Cfz Cs Treatment regimens for DRTB

25. DOSAGE DISPARITY Daily dosage according to Standards of TB Care in NTEP are— FDCs are prepared in such a way that they can cater to all age groups. Even paediatric formulations are present. Weight band Number of tablets Intensive phase Continuation phase HRZE HRE 75/150/400/275 mg 75/150/275 mg 25-39 kg 2 2 40-54 kg 3 3 55-69 kg 4 4 ≥70 5 5

26. Sustain COVID appropriate behavior Contact Tracing & TB Preventive Treatment for all contacts of TB patients–GAME CHANGER TB preventive treatment after testing for TB infection among clinically vulnerable Airborne Infection Control in Health Facilities Contact tracing and screening of all household contacts and TB Preventive Treatment P R E V E N T Clinical risk groups- Patients on anti-TNF treatment Receiving dialysis Preparing for organ or hematological transplantation Those with silicosis On immune suppressants Patients with cancer Having HIV infection Cross

27. Display Information material on TB in Hospital premise Strengthening workforce in the hospital for TB awareness and counselling among staff and patients, Notification techniques Formation of Private Hospitals Consortium for TB elimination.Member of State TB Forum Apply for NTEP certification for TB diagnosis and Drug susceptibility testing. Join IPAQT labs Establish dedicated DR-TB, Pediatric TB wards/ ICU Avail Partnership Options Or apply CSR Mobilize Brand Ambassador for TB, Organize High Visibility Event, Support Mass Media Activity, Social Media Campaign, Community B U I L D Plenty of Partnership options available Invest to Eliminate TB Make India TB Free by 2025 #TBHaregaDeshJeetega

28. IT’S TIME TO COME TOGETHER TO END TB Thank You

CME_IMA_MNW(1).pptx

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