Universal access to TB care RNTCP DR.P.S.SARMA TECHNICAL CONSULTANT 9440118712; firstname.lastname@example.org
Aim• TO EDUCATE / SENSITISE PRIVATE HEALTH CARE PROVIDERS REG• TB CONTROL AND RNTCP – A NATIONAL HEALTH PROGRMME• OF G.O.I• SPECIAL EMPAHSIS ON TB NOTIFICATION & BANNING OF BLOOD TESTS FOR TB DIAGNOSIS
• The Union Health Ministrys notification was issued with on May 7. The notification clearly states that all healthcare providers (clinical establishments run or managed by government including local authorities, private or NGOs and/ or individual practitioners) in all the districts and towns in your concerned state/UT be immediately kept informed (through appropriate mechanism) on the contents of the Government Order on TB notification in India for their compliance with immediate effect.’
• The notification further said: "In order to ensure proper TB diagnosis and case management, reduce TB transmission and fight emergence of drug resistant TB, it is essential to have complete information of all TB cases. Therefore the healthcare providers shall notify every TB case to local authorities - district health officer/chief medical officer of a district and municipal health officer of a municipal corporation, every month
TB NOTIFICATION• Many options• The notification can be done through hard copy, email, mobile phones (IVRS or SMS), or by uploading the information directly on to the Nikshay portal ( http://nikshay.gov.in). They can also get in touch with the respective nearest nodal officers (http://tbcindia.nic.in) to notify the cases.• Contact your DTCO giving your details
New G.O• New Delhi, 18 June 2012: In a welcome step, a gazette notification by the Ministry of Health & Family Welfare banning serological test (commonly referred to as blood or antibody test) for TB, under the Drugs & Cosmetic Act, has finally been made public today. This gazette notification also, in particular bans the importation of the serological test kits.• The notification is online at https://picasaweb.google.com/101502226047950368947/GovernmentOfIndiaNotifi
G.O• The serological test for TB is widely used in the private sector, even though they are known to be inaccurate, inconsistent and with no clinical value for TB diagnosis. The World Health Organization (WHO) in its first-ever negative policy recommendation recently called on governments to immediately ban blood tests prescribed and used to detect TB.
RNTCP – Goal and Objectives• Goal – The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India.• Objectives: – To achieve and maintain a cure rate of at least 85% of new sputum positive TB patients – To achieve and maintain a case detection of at least 70% of new sputum positive TB patients
RNTCP (revised) Goals and Objectives• Goal: – To reduce the burden of Tuberculosis by providing universal access to TB care• Objectives: – 90/90 – Detection of at least 90% of all incident TB Cases – Successfully treat at least 90% of new smear positive cases
Population attributable fraction – PAF = P × ( RR − 1) P × ( RR − 1) + 1selected risk factors & determinants Relative risk for Weighted Population active TB disease prevalence Attributable (22 HBCs) Fraction HIV infection 20.6/26.7* 1.1% 19% Malnutrition 3.2** 16.5% 27% Diabetes 3.1 3.4% 6% Alcohol use 2.9 7.9% 13% (>40g / d) Active 2.6 18.2% 23% smoking Indoor Air 1.5 71.1% 26% PollutionSources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lönnroth etal. A consistent log-linear relationship between tuberculosis incidence and body-mass index. Submitted, 2009
“Diabetes makes a substantial contribution to the burden of incident tuberculosis in India…”
Universal Access to TB Care- Concept/Definition• 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.
Universal Access to TB Care-All TB patients• including women, elderly, children, 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.• All types- Smear positive, negative, EP, Drug Resistant TB
Early Diagnosis Approaching aOnset of Symptom Diagnosis health care facility Patient delay Diagnosis delay Treatment delay Initiation of treatment
Algorithm 1: Diagnostic Algorithm For Pediatric Pulmonary TB Pulmonary TB Suspect • Fever and / or cough 3 weeks • Loss of wt/No wt gain • History of contact with suspected Or diagnosed case of active TB Is expectoration present? If no, refer to Pediatrician If yes, examine 3 sputum smears2 or 3 Positives 3 Negatives Antibiotics 10-14 days Cough Persists Repeat 3 Sputum Examinations 1 Positive Negative 2 or 3 Positives X-Ray X-ray + Sputum Positive Mantoux TB (Anti TB Suggestive of TB Negative for TB Treatment) Sputum-Positive TB Negative for TB Suggestive of TB (Anti-TB Treatment) Refer to Pediatrician Sputum-Negative TB (Anti-TB Treatment)
PAEDIATRIC TB• 1.DIFFICULT TO BRING OUT SPUTUM IN CHILDREN• 2.RELY ON OTHER TESTS - MONTOUX ; & X RAY• 3.LOOK FOR HISTORY OF CONTACT WITH KNOWN TB CASE• 4.PAEDIATRICIAN’S DIAGNOSIS IS HONORED.
Two Types of Generic Boxes – 4 WEIGHT BANDS• 6 – 10 kg would require PC 13• 11 – 17 kg would require 14 PC PC 13 PC 14• 18 – 25 kg would require and PC 14 PC 14• 26 – 30 kg would require and
Delay in diagnosis• Cough as the presenting symptom• Awareness among patients• Awareness among providers• Accessibility to diagnostic facilities• ? Lack of “interest” in smear negative TB
Intensified Case Finding?• Settings – Contact investigation – HIV – DM – ?Smokers – ?Migrants – ?Slums – ?Mines – Other occupations – Prisoners…………………………
Intensive case finding among high risk groups:• HIV care centres • Active TB case finding should be implemented in all facilities providing HIV care, like ICTCs, ART Centres, Care and support centres etc. • Train Medical Officers in the algorithum for diagnosis of TB in HIV positive patients. • Involve NGOs working with HIV programme in TB case finding activities.
Intensive case finding among high risk groups: – Diabetic patients. • Sensitize medical officers to actively search for TB in diabetic patients. • Active TB case finding in diabetic clinics – Smokers • TB control programme to actively associate with anti smoking programme. • Chronic smokers attending OPDs with respiratory symptoms to be screened for TB.
OTHER POINTS• PREGNANT LADIES CAN TAKE ANTI TB DRUGS EXCEPT FOR INJ.STREPTOMYCIN.• ANTI TB DRUGS ARE TOXIC. PATIENTS WILL HAVE SIDE EFFECTS LIKE NAUSEA; VOMITINGSHEADACHE; JOINT PAINS ETC.• THEY NEED SYPTOMATIC TREATMENT.• IF THE PT DEVELOPES JAUNDICE – STOP ALL ANTI TB DRUGS ; TREAT JAUNDICE AND THEN RESTART ANTI TB DRUGS.• CO-INF OF TB & HIV NEEDS CPT ALSO.
PPM….• Involvement of NGOs and Private Practitioners – Schemes revised in 2008 – Presently ~19,000 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
Promote Universal access of care for TB in all Medical Colleges – State and Zonal Task force mechanism to further strengthen medical college involvement in RNTCP. – Medical colleges need • System of active screening and fast tracking of TB suspects • System of tracking patients both within the institution and outside for diagnosis as well as treatment. • Strengthening of interdepartmental collaboration and monitoring
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