1. Epidemiology and control of
tuberculosis and RNTCP
programme
JOSLITA D SOUZA

2. Problem statement
World
 1900-1980 death rate declined 199-0.5/100000 in
US
 2008
 Incidence- 9.4million(8.9-9.9)
 Prevalence-11.1million (9.6-13.3)
 HIV associated- 1.4 million
 Deaths- 1.8million (0.52 million HIV+)

7.  Multidrug resistant-0.5 million
 MDR deaths- 0.15million
 Extensively drug resistant- 50,000
 XDR deaths- 30,000
 SE Asia (34%), Africa(31%), Western Pacific (20%)

9. Achievements
 1995-2008
 Cured - 36 million
 Averted from death- 6million using DOTS
 Case fatality rate 7.6% to 4%
 Cure rate – 87%

10. India
 20% global burden
 2/3 rd cases in SEAR
 Incidence – 1.8million
 New smear+ -0.8 million
 Deaths – 0.32 million
 Annual risk – 1.5%

11. Tuberculosis estimate for India

13. Epidemiological indices
Prevalence of infection
% of individuals who show a positive reaction to
tuberculin test

14. Incidence of infection ( annual infection rate)
% of population under the study who will be newly
infected among the non infected of the preceding
survey during the course of 1yr
 “Tuberculin conversion index”

15.  Prevalence of disease/ case rate:
% of individuals whose sputum is positive for tubercle
bacilli
 “Case load”

16.  Incidence of new cases
The % of new TB cases/1,000 population in 1yr

17.  Prevalence of suspect cases
X ray examination

18.  Case detection rate:
The number of notification of new and relapse
cases in a year
Estimated incidence of such cases in the same year

19.  Mortality rate:
The number of deaths from tuberculosis every
year/1000 or 1,00,000 population

20. Natural history of tuberculosis
Agent factors:
 Agent
 Source of infection
 Communicability

21. Host factors:
 Age
 Sex
 Heredity
 Nutrition
 Immunity

22. Environmental and social factors

23. Mode of transmission
 Droplet infection

24. Pathogenesis

25. Clinical features
 Incubation period : 3-6 weeks

26. Control of TB
Case finding:
 Case
 Target group
 Case finding
a. Sputum examination
b. Mass miniature radiography
c. Tuberculin test

27. Sputum examination
 Collection of sample
 Slide reporting
 Sputum culture

28. Chemotherapy
First line drugs
 Isoniazid (H)
 Rifampicin (R)
 Pyrazinamide (Z)
 Ethambutol (E)
 Streptomycin (S)

29. Second line drugs:
 Thiacetazone(Tzn)
 Paraaminosalicylic acid(PAS)
 Ethionamide(Etm)
 Cycloserine(Cys)
 Kanamycin(Kmc)
 Amikacin(Am)
 Capreomycin (Cpr)

30. Newer drugs
 Ciprofloxacin
 Ofloxacin
 Clarithromycin
 Azithromycin
 Rifabutin

31. BCG vaccination
 Vaccine : „ Danish 1331‟ strain
 Types
1. Liquid
2. Freeze dried
Dosage :0.1ml

32. Administration :
Complications :

33. Protective value: 15-20yrs
Revaccination:?
Contraindications:
 Generalized eczema, infective dermatosis,
hypogammaglobulinemia, immunodeficiency

34. Chemoprophylaxis
 INH – 1yr
 INH + Ethambutol – 9months

35. Rehabilitation

36. Revised national tuberculosis control programme
 Govt. of India, WHO, world bank- 1992
 Features :
i. 85% cure rate through SCC
ii. Detecting 70% of the estimated cases
iii. Involvement of NGOs
iv. Direct Observed Treatment Short course (DOTS)

37. Pilot strategy
Phase
I
Phase
II
Phase
III

38. Organisation
State Tuberculosis office State tuberculosis officer
State TB training and Director
demonstration centre
District tuberculosis centre District tuberculosis officer
Tuberculosis unit Medical officer-TB control
Senior treatment supervisor
Senior TB laboratory
supervisor
Microscopy , treatment
centres
DOTS providers

39. Laboratory network
National
Central TB
reference
division
Lab
State TB cell Intermediate
reference lab
District TB
centre

40. TU TU TU
DMC1 DMC2 DMC3

41. Initiation of treatment
 Designated RNTCP microscopy centre
 Each centre
1. Skilled technician – ensure quality
2. Senior TB lab supervisor ( 5 microscopy centres)

42. cough for 2wks or more
2 sputum smears
2 negatives
1 or 2
positive Antibiotics 10-14
days
Symptoms persist
Repeat 2 smear
examination
2 negative
X ray
-ve
+ ve
Non TB Smear – ve TB

43. DOTS
 Political commitment
 Good quality sputum microscopy
 Directly observed treatment
 Uninterrupted supply of good quality drugs
 Accountability

44. Treatment regimen
TB category Initial phase Continuation Total duration
(daily/3 per wk) phase
I 2HRZE(S) 4HR/6HE 6/8
II 2HRZES+1HRZE 5HRE 8
III 2HRZ 4HR/6HE 6/8
IV RZE 18
ZE+S/Kmc/Am/C
pr+Cipro/Ofl+_Et
m

45. RNTCP phase II
 Approved for 5yrs Oct 2006 to Sept 2011
 Goal : decrease morbidity and mortality due to TB
 DOTS
 Access to tribal and marginalized groups

46. Drug resistance surveillance
 To determine the prevalence
 2005
 States : AP, Delhi, Gujarat, Kerala, Maharashtra,
Orissa, UP, West Bengal – 54%
 IRLs accredited

47. DOTS plus
 For management of MDR-TB
 MDR suspect
 Ofloxacin replaced to Levofloxacin
 Cat V regimen for XDR-TB patients

48. Achievements
 Cure rates -87% (25% in 1998)
 Death rate -4% (29%)
 DTC -650
 TB units -2596
 DMC -12,704
 NGOs-2,500
 Peripheral labs-12,750

49.  Public health carte providers- 5.5lacs
 Master trainers – 12 states
 Initiated treatment -1.1million patients
 Saved lives- 2million!!!

50.  Activities planned for 2011
  Supporting the development of a National Strategic Plan to control
 TB 2012–2017, with the planned and budgeted activities necessary
 to achieve the country‟s goal of universal access.
  Widening the network of quality assured laboratories and
strengthening capacity of all the state-level culture and DST laboratories to
undertake second-line DST.
  Expanding the delivery of services for MDR-TB cases to all states.
  Monitoring the implementation of the revised schemes for the
 involvement of NGOs and private practitioners across the country.
  Phased scale-up of the implementation of the intensified TB/HIV
 package for nationwide coverage by 2012.
  Review of all available studies and information on the TB burden, and
 re-estimation of TB incidence, prevalence, and mortality in cooperation
 with the Ministry of Health and national experts.
 . Developing and rolling out an integrated information system for
 MDR-TB services nationwide, and integrating laboratory results and
 patient management with outcome analysis and reporting.

52. THANK YOU
