critical review of RNTCP

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  • Since inception of RNTCP till 4th qr 2011, total462749 tb cases have been detected and treated.349425 cases have been cured & successfully completed treatment. In the 4th quarter 2011, the annualized new sputumpositive case detection rate of Odisha was 58%against the norm of 70% and the success rate 88% asagainst the norm of 85%.AchievementsIntensified TB-HIV Package• TB HIV Intensive Package is implemented in allthe districts since 2010 in collaboration withthe OSACS.• During 4th Quarter 2011, 3513 TB patients havebeen tested for HIV out of which 93 have beendiagnosed as TB-HIV co-infected.Progress of DOTS-Plus Programmes• Intermediate Reference laboratory (IRL) at AntiTB Demonstration & Training Centre, Cuttackaccredited on 10th Aug’ 2009.• Four RNTCP districts of Cuttack, Ganjam,Khurda and Bhubaneswar taken up for DOTS Plus activity in 2009-10 in 1st phase. The DOTSPlus services has been rolled out in 11 nearbydistricts of Anugul, Dhenkanal, Keonjhar,Mayurbhanj, Balasore, Bhadrak, Jajpur,Jagatsinghpur, Kendrapada, Puri, Nayagarh inphase-2. Central Appraisal has been plannedfor the phase-3 districts of Kandhamal,Kalahandi, Rayagada, Gajapati, Koraput,Malkangiri and Nabrangpur during February2012. Preparatory activities are in progress toexpand DOTS Plus Programme to other districts.• CAT-IV services (treatment of MDR-TB patients)initiated in the State from 11th Nov, 2009 atDOTS-PLUS SITE (SCB Medical College). So farthe sputum specimen of 230 Suspects have beenexamined for MDR out of which, 115 diagnosedas MDR-TB and 76 MDR-TB patients put underDOTS plus treatment (Cat-IV) patients fromabove four districts.• Line Probe Assay (LPA) at IntermediateReference Laboratory (IRL) Cuttack has been established and the Laboratory is waiting foraccreditation from National ReferenceLaboratory (NRL). This would dramatically cutdown diagnosis time of MDR-TB suspects fromthe current 60 days to 3 days.
  • Pathak et al , 2008 , Jharkhand
  • Pathak et al , 2008 , Jharkhand
  • Pathak et al , 2008 , Jharkhand
  • Pathak et al , 2008 , Jharkhand
  • Pathak et al , 2008 , Jharkhand


  • 1. Critical Review of RNTCP Dr. Abhishek Tiwari
  • 2. Maximum annual deaths than any other infectious disease in the industrialized world Most frequent cause of death for young adults New outbreaks are increasing after almost 40 years of a steady decline2 billion people (1/3 of the world's population) exposed to TB > 8 million cases & 2 million deaths annually Rajyaroga (king of diseases) in ancient text Global Burden 8/22/20132
  • 3. 2 million develop TB & 5,00,000 die annually > 1000 die of TB every day (2 every 3 minutes) HIV , major risk factor for TB has already infected 4.8 million Emergence of MDR-TB has added to TB epidemic An untreated patient can infect 10-15 persons each year TB Burden India 8/22/20133
  • 4. Poorly treated patients develop drug-resistant and potentially-incurable TB A major barrier to economic development > 300,000 children forced to leave school ,parents have TB > 100,000 women with TB are rejected by their families Tragic because TB is nearly 100% curable TB Burden India 8/22/20134
  • 5. Started in 1997 Lepra-India , NGO supporting under “Sahayog” & “Akshaya” project to IEC & BCC activities in 12 districts Catholic Bishop Conference of India & IMA also Population covered 424 lakhs Suspects examined in 2012 : 226305 Diagnosed new cases : 29728 Trained staff , MO 81 % & para staff 87 % Laboratory : ILR Cuttack & RMRC Bhubaneswar Odisha 8/22/20135
  • 6. Back ground Year Comments 1962 NTCP30 % diagnosed & 30 % treated 1993 pilot testing based on DOTS Strategy 1998 – 2005 RNTCP I Launched as a NP expanded in 1998 2000 30 % 2002 50 % 2003 778 million 2004 997 million 2005 1080 million 97 % 24th March 2006 Entire Country 2006 – 2010 RNTCP II 8/22/20136
  • 7. 1. Evaluated 55 million & initiated treatment 15.8 million 2. Prevention of mortality : >2.8 million lives 3. National coverage ( unreached areas ) 4. Well on track to achieve the MDG of halting & beginning to reverse the spread of the disease 5. With NACP III : expanded joint TB/HIV services 6. RNTCP conforms to ISTC prescribed standards 7. All Medical colleges involved Achievements of RNTCP: 8/22/20137
  • 8. 78, 67,194 TB suspects examined for SSM 14, 67,585 initiated on treatment Case detection rate of New Smear Positive TB was 68% Treatment success rate of 88% 81,482 pediatric TB cases , accounting for 7% of all cases 8, 21,807 (56%) TB patients tested HIV 44,063 (5%) were positive 92% HIV infected TB patients were initiated on CPT and 74% ART Achievements of RNTCP: 2012 8/22/20138
  • 9. 8/22/20139
  • 10. CTD & NIC develop a Case Based Web application : Nikshay to improve TB surveillance Notifiable disease on 7th May 2012 (trace contacts) The revision of the OR agenda in 2012 The “National Standing Committee” was renamed as “National Research Committee” Ban on serological test New initiatives in 2012 8/22/201310
  • 11. 6.3 million treated (1997-2006) Health benefit of 29.2 million DALYs gained including 1.3 million deaths averted 2006, burden of TB = 14.4 million DALYs (1.8 times higher) in absence RNTCP 8/22/201311
  • 12. Theme : “Universal Access for quality diagnosis and treatment for all TB patients in the community” Target : “reaching the unreached” Focus : early & complete detection of all cases (DR-TB ,HIV-TB) Increase involvement of private sector Higher commitment 4 fold increase in budget RNTCP : NSP 2012-17 , 12th FYP 8/22/201312
  • 13. Vision: “TB-free India - through achieving Universal Access by provision of quality diagnosis and treatment for all TB patients in the community” Goal: to decrease the morbidity and mortality by early diagnosis and early treatment to all TB cases thereby cutting the chain of transmission RNTCP : NSP 2012-17 , 12th FYP 8/22/201313
  • 14. Early detection & Rx of 90% cases (DR-TB & HIV-TB) Rx 90% of new TB patients, 85% of previously-treated Reduce default rate : new TB cases to < 5% re-treatment TB cases to < 10% Initial screening of all re-treatment smear-positive till 2015 All Smear positive TB patients by 2017 for DR-TB Provision of treatment for MDR-TB Offer of HIV Counseling and testing for all patients Link HIV-infected TB patients to HIV care Extend RNTCP services to patients in private sector Objectives 8/22/201314
  • 15. Detection , treatment of about 87 lakh TB patients At least 2 lakh MDR-TB Reduction in delay in diagnosis and treatment of all types of TB Increase in access to services to hard to reach populations & high risk & vulnerable groups 8/22/201315 Targets : 12th FYP
  • 16. Over crowded living conditions Closeness of contacts Absence of native resistance Infectiousness of the source Degree of sputum positivity Pattern of coughing, lack of knowledge , nutrition Resources : funds , trained manpower , infrastructure Urbanization & migrations : slums Unhygienic living conditions , poverty & indifferent attitude towards health all these are high risk pockets 8/22/201316 Epidemiological factors
  • 17. No financial constraints (best & 2nd largest) multi factorial causation Evidence from developed world environmental condition & living standards declined TB even before ATT Social Stigma Inhibits to come in early phase, even health workers behave indifferently to them 72.4 % patients isolated with their utensils in their home 8/22/201317
  • 18. Challenge peripheral area : lack of proper referral system a chest symptomatic attends a health care provider, he is not properly referred to DMC Treatment facility to be accepted & utilized by community Availability of all resources essential : drugs , needle syringe ,forms , chemical 8/22/201318 Organizational factors
  • 19. Trained manpower still a big hindrance General services still do not accept RNTCP strategies In-service training must before merging it Compulsory imposing of DOTS : resistance among doctors of different discipline 8/22/201319 Organizational factors
  • 20. RNTCP plans as NGO but implements as a government department Lack of coordination (intra & inter dept..) DTO government post based on seniority DTO : priority to clinical functions & failing to do justice with PH 8/22/201320 Organizational factors : District
  • 21. Laboratory Supervisors STLs supervise the LTs but many times they had far less experience than the technicians Since they work on contractual basis ,ego problems may make the technicians hostile MO-TC , supervise STLs may not have necessary expertise 8/22/201321 Organizational factors : District
  • 22. Computer literacy is still poor & networking not provided at all levels STDCs serve as hospitals instead of public health institutions support training, monitoring, and supervision State TB Officers don’t take action on DTO STS ,treatment supervisor (1 lakh) population, has to observe work by the health staff , no accountability 8/22/201322 State level
  • 23. Patients reporting to big hospital not referred to DOTS center due to fear of losing them Social stigma of high SEC patients to visit DOTS DOTS center restarts the investigation all again (don’t rely ) Often these centers are unattended so patients lose faith 8/22/201323 State level
  • 24. Inconvenient (time / distance) Observation may not be acceptable Worse still : no accessible observer Has to bear with cumulative side effects No new drug in last 35 years Universal coverage with DOTS not desirable 8/22/201324 DOTS : patients problem
  • 25. 1% - 2% need non-DOTS regimen (intolerance, toxicity ,liver disease, immcomp. & migration) More common in reg. with alcoholism or drug abuse DOTS should allow other reg. or provision to accommodate Most pt. not recover of chest symptom sense of dissatisfaction The drug combination & dosages changing over years creating confusion among Physicians 8/22/201325 DOTS : patients problem
  • 26. A study found that 60 % of dosages prescribed don’t correspond to std. guidelines Patients reluctant to visit DOTS center & take med for whole month so the monthly doses are not supervised Study by Bhatt 1998 showed SCC + HE = DOTS , but no comparative study done 8/22/201326 DOTS : patients problem
  • 27. RNTCP based on critical evaluation of NTC Adopted a victim blaming approach , Rather than improving the policy & prog. Very low targets were set for coverage & cure (85%) But only 50% -60 % attend Gov. facility Short comings : policy 8/22/201327
  • 28.  Targets achieved are not uniform , some areas need greater effort as case detection is passive (i) lack of participation of other health care providers like CGHS, Railways, Corporate sector, private practitioners (ii) lack of community participation Short comings : policy 8/22/201328
  • 29. 40 % - 50 % of active pulmonary TB (culture positive ) can not be detected by microscopy ( Nagpaul 1968 ) Improve quality of sputum microscopy Undetected smear negative pt will get Cat III or left untreated if x ray are also neg, but will continue to infect community Not providing : leads to loss of faith in Gov. services RNTCP has quality assured laboratory network NRL,IRL, & DMC Short comings : diagnostic 8/22/201329
  • 30. During 2012, RNTCP finalized protocol & guidelines for certification for second line Drug Susceptibility testing (DST) Some recent advantages in case detection African giant pouched rats trained to detect pul. TB  Alt tool to enhance case detection in resource limited setting  Fast , cheap & low skill  Lab 40 sample in a day , HeroRAT same in 7 min  With 86 % sensitivity ,89 % specificity ( overall 87 % vs 37 % ) Short comings : diagnostic 8/22/201330
  • 31. Sputum microscopy instead of X-ray avoids over diagnosis and identifies infectious cases Sputum test still not taken seriously Depends on skill & commitment of technician IQA & EQA cannot guarantee quality of monitoring SSM – high tech job needs training & re-training 8/22/201331
  • 32. Initial drug resistance : effects success Most of pt. receiving ATT outside are potential for DR 37.3 % TB pt. develop resistance to rifampcin Cat II pt. put on 5 drugs without C & DS DST should be included as one of the diagnostic criteria in tertiary center rather than changing all center to DOTS Short comings : resistance 8/22/201332
  • 33. In case of CAT I failure , one more drug added but at least 3 should be added after sensitivity testing 2nd line drugs to be added for MDR-TB Majority of these are poor & left (DOTS-PLUS not yet 100%) Freely available in market , frequently used by PP All these increase MDR-TB Short comings : resistance 8/22/201333
  • 34. Community Participation & Role of NGO CP essential to achieve targets Best prog. : makes people realize the imp of health Does the community thinks same way as health expert ? Felt need has to be generated NGOs should be acknowledged & supervised PP should be trained on differential diagnosis as silicosis , asbestosis Short comings : integration 8/22/201334
  • 35. No National IEC program , needed to change the attitude Effective for illiterate population with strong political leadership , as seen in case of polio prog. WHO Report 2005 : political commitment not uniform Political leaders needed at all stage to mobilize the resources With corruption this is hard to be found IEC , BCC ,training 8/22/201335
  • 36. RNTCP training modules updated with latest policy changes Videos training modules for training DEO in Nikshay Relapse more common in smokers Focus on Anti smoking campaign & counseling of smoker Tb patient IEC , BCC ,training 8/22/201336
  • 37. Recording & Reporting : 3 forms : SSE / C&S / Transfer 2 cards : id & treatment 2 registers : Lab & TB 4 copies of quarterly report TU has to submit (S/C/NTI/Rec.) New patient , sputum conversion , Rx outcome Data analyzed at Dist. to get age, sex , CAT distribution of cases , done by technical experts In reality little or no role of CDMO & DM in general & in supervision & monitoring Short comings : reporting 8/22/201337
  • 38. Need huge funding Improved diagnostic tests New vaccine in early phases of clinical trials New drugs : Shorten Rx for drug-susceptible disease Refine Rx in special populations (with HIV, children & elderly) Short comings : research 8/22/201338
  • 39. whole blood (finger prick) HIV screening test to all DMCs and Provider Initiated HIV Testing and Counseling (PITC) among presumptive TB cases in all “high” HIV prevalent settings Isoniazid prophylaxis therapy (IPT) has also been accepted for prevention of TB among PLHIV Future 8/22/201339
  • 40. To screen all TB patients for DM in the 100 districts where NPCDCS implemented Universal Access, school awareness programme RNTCP field personnel to generate awareness among students and teachers of all school and colleges in all the States/UT's > 3.5 lakh schools visited, 4.5 lakh teachers, 9 lakh students covered Future 8/22/201340
  • 41. Extensive training, supervision and monitoring needed at all levels Ensuring treatment adherence and timely follow-up, and uninterrupted supply of second line drugs Unsupervised and uncontrolled private sector Almost 100% of second line drugs were sold and used outside of RNTCP Conclusion 8/22/201341
  • 42. Risk of failure of treatment and development of drug resistance This large unregulated private sector, conflict of interest, and easy availability of anti-TB drugs are important hindrances to a successful programme Guidelines to all healthcare providers (IMA ,MCI ,DCGI) to draft Need urgent attention : infection control practices in Hospitals National guidelines on Airborne Infection control in context of TB Conclusion 8/22/201342
  • 43. 1. factsheets/fs104/en/index.html 2. 3. Lambregts-van Wezenbeek CSB, Veen J. Control of drug-resistant tuberculosis. Tubercle and Lung Disease 1995: 76; 455-458. 4. DOTS PLUS guidelines, Central TB Division, Directorate General of Health Services. GOI,2010 References
  • 44. Development & dissemination of different schemes for the involvement of private practitioners, NGO’s etc. Conduct sensitization & training Programmes for medical personnel in other sectors including corporate sector Awareness generation activities for health providers in the community Recommendations 8/22/201344
  • 45. Change mindset of doctors & patients Prog. Does not emphasize on active health education and counseling of pt. in treatment & follow up Convince them of RNTCP Supervise & monitor the programme activities , address shortcomings so quality services provided Recommendations 8/22/201345
  • 46. Thanks a lot for your cooperation 8/22/201346