1. Epidemiology and Evolving
strategies of TB Control in India
17/04/2013
Dr. Priyamadhaba Behera
Junior Resident, AIIMS
1

2. Outline of presentation
• Epidemiology
• Evolving strategies of TB Control in India
1.National Tuberculosis Programme (NTP)
2.RNTCP phase I
3.RNTCP phase II
4.STOP TB strategy
5.Universal Access to TB Care
6.National Strategic Plan (2012-2017)

3. Epidemiology
TB is an infectious disease caused by the bacillus
Mycobacterium tuberculosis
It typically affects the lungs (pulmonary TB) but can affect
other sites as well (extrapulmonary TB)
The disease is spread in the air when people who are sick
with pulmonary TB expel bacteria, for example by coughing
In general, a relatively small proportion of people infected
with Mycobacterium tuberculosis will develop TB disease

4. Continued
• TB is also more common among men than
women, and affects mostly adults in the
economically productive age groups
• Risk factors-
• Biomedical- HIV, DM, silicosis, malnutrition,
malignancy, tobacco
• Environmental-ventilation, indoor air pollution
• Socioeconomic –crowding, urbanisation, poverty,
migration

5. Continued
• Without treatment, mortality rates are high. In studies of
the natural history of the disease among sputum smear-
positive and HIV-negative cases of pulmonary TB, around
70% died within 10 years; among culture-positive (but
smear-negative) cases, 20% died within 10 years
• The World Health Organization (WHO) declared TB a
global public health emergency in 1993
• 9 million new cases in 2011 and 1.4 million TB deaths
(990 000 among HIV negative people and 430 000 HIV-
associated TB deaths)

6. Annual risk of infection
• ARI is the most informative index of magnitude of
problem of tuberculosis
• For ARI=1%
1. new Smear positive cases=50/lakh/year
2. new Smear negative cases=50/lakh/year
3. Retreatment cases=50% new smear positive
(25/lakh/year)
4. Extrapulmonary and smear negative seriously ill=20% of
new smear positive (10/lakh/year)
5. Total=135/lakh/year
• ARI for India 1-2%

7. Continued

8. Continued
In India 2deaths occur in every 3minute due to TB

10. Globally, 3.7% (2.1–5.2%) of new cases and
20% (13–26%) of previously treated cases
are estimated to have MDR-TB.
IN INDIA IN WORLD

14. Evolution of TB Control in India
• 1962 National TB Programme (NTP)
• 1992 Programme Review
» only 30% of patients diagnosed;
» of these, only 30% treated successfully
• 1993 RNTCP pilot began
• 1997 RNTCP large scale-implementation
• 2002 700 million population covered
• 2004 >80% of country covered
• 2006 Entire country covered by RNTCP/STOP TB strategy
• 2010 Universal Access to TB Care
• 2012-2017 National Strategic Plan

15. National Tuberculosis Programme
(NTP)
• India has had a National Tuberculosis Programme (NTP) in place since 1962
• The treatment success rates were unacceptably low and the death & default
rates remained high
• HIV-AIDS epidemic and the spread of multi-drug resistance TB were
threatening to further worsen the situation.
• In 1992, GOI, with WHO and SIDA reviewed the TB situation and the following
were concluded:
In order to overcome these lacunae, the Government decided to give a new thrust to TB
control activities by revitalising the NTP, with assistance from international agencies, in
1993

16. Revised National TB Control Program
(RNTCP)
• Pilots were conducted between 1993- 1995 to test the operational
feasibility in a population of 2.35 million in 5 pilot sites in the states
of Delhi, Kerala, Gujarat, Maharashtra and West Bengal
• success of these pilot sites, the programme was expanded to a
population of 13.85 million in 1995 and 20 million in 1996
• Large-scale implementation of the RNTCP began in 1997, following
the successful negotiation of a World Bank credit of US$ 142 million
• The initial 5-year project plan was to implement the RNTCP in 102
districts of the country and strengthen another 203 Short Course
Chemotherapy (SCC) districts for introduction of the revised strategy
at a later stage.
• In early 2002, the World Bank assisted TB control project

17. Revised National TB Control Program
(RNTCP)
• Launched in 1997 based on WHO DOTS Strategy
– Entire country covered in March’06 through an unprecedented
rapid expansion of DOTS
• Implemented as 100% centrally sponsored
program
– Govt. of India is committed to continue the support till TB ceases
to be a public health problem in the country

18. Objectives of RNTCP
• To achieve and maintain a cure rate of at
least 85% among newly detected infectious
(new sputum smear positive) cases
• To achieve and maintain detection of at least
70% of such cases in the population

19. Strategy
1. Augmentation of organizational support at the
central and state level for meaningful
coordination
2. Increase in budgetary outlay
3. Use of Sputum microscopy as a primary method
of diagnosis among self reporting patients
4. Standardized treatment regimens.

20. contd.
5 Augmentation of the peripheral level supervision
through the creation of a sub district supervisory
unit
6 Ensuring a regular uninterrupted supply of drugs
up to the most peripheral level
7 Emphasis on training, IEC, operational research
and NGO involvement in the program

21. Core elements of Phase I
• 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

22. RNTCP Phase II( 2006-11)
Consolidate the achievements of phase I
Maintain its progressive trend and effect
further improvement in its functioning
 MPLEMENTATIOIN OF DOTS-PLUS FOR MDR-TB CASES IN A
PHASED MANNER
 DISRIBUTION OF PAEDIATRIC DRUG BOXES
 INSTITUTIONAL STRENGHTHENING AT NATIONAL, STATE AND
DISTRICT LEVEL
 INTRODUCTION OF TB-HIV CO-ORDINATOR ,URBAN CO-
ORDINATOR AND COMMUNICATION FACILITATOR.

23. STOP TB STRATEGY
• In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP
• Many of the National Airborne Infection Control guidelines, developing and
piloting strategy for 'Practical Approach to Lung Health' are the examples of
initiatives taken by RNTCP under the comprehensive strategy of STOP TB

25. Universal Access to TB Care
• The twin objectives of 70/85 alone is not enough to achieve adequate
reduction of TB transmission and reduction in disease with which
epidemiological impact is expected.
• RNTCP defined newer objectives of 'Universal Access to TB Care' for TB
control in India in 2010
• All TB patients in the community to have access to early, good quality
diagnosis and treatment services in a manner that is affordable and
convenient to the patient in time, place and person
• All affected communities must have full access to TB prevention, care
and treatment, including women, children, elderly, migrants, homeless
people, alcohol and other drug users, prison inmates, people living with
HIV and other clinical risk factors, and those with other life-threatening
diseases

26. Specific actions to achieve early and complete case
detection, towards universal access to TB diagnosis
• Improve suspects identification
• Follow up of the sputum negative symptomatic
• Reduce initial defaulters
• Screening for TB among high risk groups
1. HIV
2. Diabetic patients
3. Elderly
4. Smokers
5. Malnutrition, patients with silicosis and other chronic diseases

27. Universal access to TB care in Medical Colleges

28. -------Improve the TB notification system by registering all cases treated under
DOTS and non-DOTS (irrespective of the source of drugs and the regimen used)
in the RNTCP TB register.
------ Conduct operational research to identify local barriers to early case
detection,including care seeking behavior, missed opportunities for diagnosis,
etc.
-----Collaborate with the local authorities to implement pharmacovigilance for
anti-TB drugs sold in the district/state with a view to develop locally
innovative
strategies for improvements in notification of TB cases and promotion of
rational use of drugs.

30. National Strategic Plan (2012-
2017)
12th Five Year Plan: RNTCP has developed
National Strategic Plan to be implemented
during 2012-2017
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.

31. Objectives
• To achieve 90% notification rate for all types of
TB cases
• To achieve 90% success rate for all new and 85%
for re-treatment cases
• To significantly improve the successful outcomes
of treatment of Drug Resistant TB
• To achieve decreased morbidity and mortality
of HIV associated TB
• To improve outcomes of TB care in the private
sector

32. AREAS
• Strengthening and improving the quality of basic
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
• 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