About latest scenario of tuberculosis in India

1. REVISED NATIONAL
TUBERCULOSIS CONTROL
PROGRAMME
1
PRESENTER:
Dr. J.P. Rajliwal
Junior Resident
Community medicine
PGIMS Rohtak,
PGIMS, Rohtak

2. • INTRODUCTION
• PROBLEM STATEMENT
• RNTCP : EVOLUTION, ORGANIZATION & COMPONENT
• TB-HIV COLLABORATION
• ACHIEVEMENTS:RNTCP
• MONITORING AND SUPERVISION
• NATIONAL STRATEGIC PLAN
• ROHTAK SCENARIO
• PGIMS SCENARIO
• FINANCING TB CONTROL 2015
• RESEARCH AND DEVELOPMENT
• END TB STRATEGY
CONTENTS

3. Introduction
 Tuberculosis is one of the leading causes of mortality
in India- killing -2 persons every three minute, nearly
1,000 every day.
 Tuberculosis (TB) is an infectious
disease caused by
Mycobacterium tuberculosis
 If left untreated, a person with sputum positive TB
will infect an average of 10 to15 people in a year.
 Multi Drug Resistance and co-infection with HIV has
weakened our battle against the disease.

4. Estimated incidence,
2014
Estimated number of
deaths, 2014
1.1 million*9.6 millionAll forms of TB
Multidrug-
resistant TB
HIV-associated TB
1.2 million 390,000
Source: WHO Global Tuberculosis Report 2015 * Excluding deaths attributed to HIV/TB
The global TB situation
300,000

5. SEAR

6. Estimated incidence,
2014
Estimated number of
deaths, 2014
0.22 million*2.2 million
All forms of TB
Multidrug-
resistant TB
HIV-associated TB 0.11 million 31,000
Source: WHO Global Tuberculosis Report 2015 * Excluding deaths attributed to HIV/TB
India TB situation
71,000

7. ESTIMATED INCIDENCE OF TB IN TOP 10 HIGH BURDEN
COUNTRIES 2014

8. Evolution of TB Control in India
2/7/2016 8
• 1950s-60s Important TB research at TRC and NTI
• 1962 National TB Programme (NTP)
1992 NTP Reviewed and concluded its failure
• 1993 RNTCP pilot began
• 1997-2006 RNTCP I
National Strategic Policy: 2012-17
• 2006 -2011 RNTCP II

9. RNTCP
Before the Revised National Tuberculosis Control
Program (RNTCP) came into force the existing
National Tuberculosis program (NTP) had the following
objectives:
• To identify and treat as large a number of TB
patients as possible so that infectious cases are
rendered non- infectious.
• To reduce the magnitude of TB problem in the
country to a level where it ceases to be a public
health problem.

10. FAILURE OF NTP
 Results:
 low rates of case detection and treatment completion (30%),
 continuing high mortality (50 per 100,000)
 high rates of default (40–60%),
REASONS:
 More emphasis on detection rather than cure
 Inadequate budget and insufficient managerial capacity
 Shortage and interrupted supply of drugs
 Emphasis on x-ray diagnosis resulting in inaccurate
diagnosis
 Poor quality sputum microscopy
 Multiplicity of treatment regimens.

11. Revised National Tuberculosis Control
Programme(1993)
Goals
- To reduce mortality and morbidity from tuberculosis
- To interrupt chain of transmission.
Objectives
- Achievement of at least 85% cure rate of infectious cases of
tuberculosis through DOTS involving peripheral health
functionaries.
- Augmentation of case finding activities through quality
sputum microscopy to detect at least 70% of estimated
cases.

12. DOTS:
DOTS is a systematic strategy which
emphasizes on:
 Political and administrative commitment.
 Good quality diagnosis.
 Good quality microscopy is essential to identify the infectious patients
who need treatment the most.
 Good quality drugs.
 An uninterrupted supply of good quality anti-TB drugs must be available.
 Directly observed treatment short-course chemotherapy
 The DOTS strategy along with the other components of the Stop TB
strategy, implemented under the Revised National Tuberculosis Control
Programme (RNTCP) in India, is a comprehensive package for TB
control.
 Systematic monitoring and accountability.

13. Central TB Division, DGHS,
MoH & FW
Deputy Director
General-TB
Chief Medical Officers
National institutes
(NTI, TRC, LRS, JALMA)
National Lab Committee
National TWC for TB + HIV,
National DOTS Plus committee
NTF for medical colleges,
National OR committee
Organizational structure of RNTCP
STATE TB CELL
CENTRE

14. Health Minister
Health Secretary
MD NHM Director Health
Services
Additional / Deputy / Joint
Director
(State TB Officer)
State TB Cell
Deputy STO, MO, Accountant,
IEC Officer, SA,
DEO, TB HIV Coordinator etc.,
State Training and Demonstration
Center (TB)
Director, IRL Microbiologist, MO,
Epidemiologist/statistician, IRL LTs etc.,
14
ORGANISATION STATE

15. One/ 100,000
(50,000 in hilly/ difficult/
tribal area)
One/ 500,000
(250,000 in hilly/
difficult/ tribal area)
TB Health Visitors (TBHV),
DOT Provider
(MPW, NGO, PP, ASHA,
Community Volunteers)
Medical Officer, paramedical staff
And Laboratory Technician (20-50%)
Medical officer-TB Control,
Senior Treatment supervisor(STS),
Senior TB Laboratory Supervisor(STLS)
District Health Services
District TB Centre
Tuberculosis Unit
Microscopy Centre
DOT Centre
Nodal point for TB
control
Chief Medical Officer and
other supporting staff
District Administration District Magistrate/
District Collector
DTO, MO-DTC , LT, DEO,
Driver, Urban TB Coordinators,
TBHVs, Communication Facilitators
ORGANISATION DISTRICT

16. -OSE(On site evaluation) by NRL team – at least once a year.
-Panel testing of microbiologist & LTs of IRL
NRL
LAB STRUCTURE FUNCTIONS OF EQA
TU
IRL
DTC
-OSE by IRL team – at least once a year.
-Panel testing of all STLS
-OSE by DTO – at least once in quarter
- OSE by IRL Team (sample of DMCs)during OSE of
DTC
-OSE by STLS at least once every month.
-Collection of RBRC of routine slides.
-Unblinded rechecking (5 +ves and 5 –ves)
DMC
-OSE by DTO team – at least once a month.
-OSE by IRL Team-During annual district visit.
-RBRC of routine slides

17. A&N Islands
Arunachal Pradesh
Chandigarh
D&N Haveli
Daman & Diu
Goa
Karnataka
Lakshadweep
Meghalaya
Mizoram
Nagaland
Pondicherry
Sikkim
Tripura
Haryana
Delhi
Gujarat
Andhra Pradesh
Assam
Manipur
Punjab
Kerala
West Bengal
Jammu & Kashmir
Himachal Pradesh
Rajasthan
Maharashtra
Tamil Nadu
Orissa
Madhya Pradesh
Chhatisgarh
Uttar Pradesh
Uttaranchal
Jharkhand
Bihar
TRC
RNTCP culture and DST labs
network (October-2015)
NTI
JALMA
Med Col / NGO / Private Labs (Certified)
IRL (Certified )
IRL (Under Process)
Med Col / NGO / Private Labs (Under Process)
National Reference Labs
Gurgaon
By technology
- Solid culture: 46
- LPA: 51
- Liquid culture: 28
- CB-NAAT: 121
C-DST labs: 64
SL-DST: 24
CB-NAAT Sites

18. STOP TB Strategy(2006)
■ In DOTS collaboration ,STOP TB strategy was started
with additional six components-
1. Pursue high-quality DOTS expansion and enhancement
2. Address TB/HIV, MDR-TB, and the needs of poor and
vulnerable populations
3. Contribute to health system strengthening based on
primary health care
4. Engage all care providers
5. Empower people with TB, and communities through
partnership
6. Enable and promote research

19. SYMPTOMATOLOGY OF T.B.

21. • Persistent Fever >2wk, without a known cause and/or
• Unremitting Cough for >2w and/or
• Wt loss of 5% in 3m or no wt gain in past 3 m
Sputum Smear (2 samples),
X-ray Chest (XRC), TST
Smear +ve
Bacteriological
confirmed TB Case
Smear –ve or
Sputum not available
XRC highly suggestive*
XRC NS shadows
TST -ve
XRC Normal
TST +ve
XRC Normal
TST -ve
Sputum/GA/IS for smear
and CB NAAT
+ve -ve
No other likely alternative diagnosis
Clinically Diagnosed TB case
Persistent shadow
and symptoms
Sputum/GA/IS for
smear and CB NAAT
+ve -ve
Refer to expert for
work up of persistent
pneumonia
Evaluate for EPTB
Refer to expert
Look for
alternate cause
Give course of
Antibiotics
Presumptive TB
21
PAEDIATRIC
T.B.

22. MDR-TB & XDR-TB
 MDR-TB is defined as resistance to isoniazid and
rifampicin, with or without resistance to other anti-TB
drugs.
 XDR-TB is defined as resistance to at least Isoniazid
and Rifampicin (i.e. MDR-TB) plus resistance to any
of the fluoro-quinolones and any one of the second
line injectable drugs (amikacin, kanamycin or
capreomycin).

23. Revised National TB Control Programme

24. Category Type of Patient Regimen Duration in
months
Category I
Color of box:
RED
New Sputum Positive Seriously
ill sputum negative, Seriously ill
extra pulmonary,
2 (HRZE)3,
4 (HR)3
6
Category II
Color of box:
BLUE
Sputum Positive relapse Sputum
Positive failure
Sputum Positive treatment after
default
2 (HRZES)3,
1 (HRZE)3
5 (HRE)3
8
TREATMENT REGIMEN

25. Interim guidance on using existing PWBs till
newer formulations available
Revised National TB Control Programme

26. TREATEMENT OF MDR T.B.
RNTCP Regimen for MDR TB: 6 (9) Km Lvx Eto Cs Z E / 18 Lvx Eto Cs E
[Reserve/Substitute drugs: PAS, Mfx, Cm]
TREATEMENT OF XDR T.B.
RNTCP Regimen for XDR TB: 6-12 Cm, PAS, Mfx, High dose-H, Cfz, Lzd, Amx/Clv
/ 18 PAS, Mfx, High dose-H, Cfz, Lzd, Amx/Clv [Reserve/Substitute drugs:
Clarithromycin, Thiacetazone]

29. TB HIV Collaboration
 In 2007, the first National Framework for joint TB-HIV
collaborative activities was developed which endorsed a
differential strategy reflective of the heterogeneity of TB-
HIV epidemic.
 Coordinated TB-HIV interventions were implemented
including establishment of a coordinating body at national
and state level, dedicated human resources, integration of
surveillance, joint monitoring and evaluation, capacity
building and operational research.
 Interventions have focused on improving services for HIV-
infected patients, with intensified TB case finding at HIV
care settings and linking with TB treatment; and for TB
patients with provider initiated HIV testing and counseling,
provision of ART and decentralized CPT.

30. ESTIMATED HIV-POSTIVE INCIDENT TB CASES: 0.11 MILLION IN 2014
PERCENTAGE OF NOTIFIED TB PATIENTS WITH TESTING OF HIV : 72%
% OF TB PATIENTS WITH AN HIV TEST RESULT WHO WERE HIV-
POSITIVE: 4.3%
% OF NOTIFIED HIV-POSITIVE TB PATIENTS STARTED ON ART: 91%
TB HIV Collaboration…
94% HIV INFECTED TB PATIENTS WERE INITIATED ON CPT.

31. 0
10
20
30
40
50
60
70
80
Treatment
Success
Died
Failure
TAD
Transfer
Out Switch to
CAT 4
71
14
2
8
3
2
74
16
1
8
0 1
INDIA HARYANA
TB HIV Collaboration : Haryana
ANNUAL TB REPORT 2015

33. • Ineffective and delayed diagnosis of TB in both the private and public sector;
• Practitioners do not stick to standard RNTCP treatment protocol.
• Patients accessing private providers not linked or engaged with RNTCP;
• Large-scale expansion of patient notification from the private sector;
• Inadequate staffing at all levels, to be addressed through improved HRD, to
reduce reliance on a limited pool of TB-dedicated staff.
• Enforcement of regulations for prescribing and sale of anti-TB drugs; promoting
rational use of first- and second-line anti-TB drugs outside the programme to
prevent MDR and XDR TB;
• Developing and implementing airborne infection control measures in health
facilities.
• Major challenges : RNTCP

35. Major Achievements:RNTCP
• Since its inception, the programme has initiated more than 19
million
patients on treatment, thus saving more than 3.1 million additional
lives
• Since 2007, RNTCP has also achieved the new smear-positive case-
detection rate of more than 70% in line with the global targets for TB
control while maintaining the treatment success rate of >85%.
• Treatment services were decentralized through a network of more than
640 000 DOT centres/providers using patient-wise boxes both for adults
and paediatric patients.
• Successful involvement of 330 medical colleges, 2569 NGOs, 13 150
private
practitioners and over 150 corporate sector health units was achieved

36. • By March 2013, all districts in the country were covered by PMDT services.
Major Achievements:RNTCP…
• In a workshop “TB-India Vision 2020”, RNTCP has developed strategies for
intensified TB control activities for achieving 2020 TB targets.

37. Progress towards MDG indicator 23
459
211
230
0
50
100
150
200
250
300
350
400
450
500
1990 2013 2015
Casesper1,00,000population
Prevalence rate of TB
Prevalence rate of TB
TARGET

38. Progress towards MDG indicator 23
39.1
19 19.5
0
5
10
15
20
25
30
35
40
45
1990 2013 2015
Casesper1,00,000population
Mortality rate of TB
Mortality rate of TB
TARGE

39. NIKSHAY
CASE BASED WEB BASED APPLICATION LAUNCHED ON MAY 2012

40. NIKSHAY
TB Patients Registered under RNTCP Till 18th March 2014 : 38,61,201
Peripheral Health Institutes (PHI) registered : 47,461
Patients notified : 20,8617
Culture & Drug Resistant Labs Patients registered : 1,20,717
Drug Resistant Tuberculosis Patients registered : 10,788
Till 18th March 2014
By end-2014, 82 309 private health facilities were registered for TB notification in
Nikshay and cumulatively 1 643 521 TB patients were notified from the private sector
through this tool.

41. IMA GFATM RNTCP
PROJECT
IMA RNTCP
GFATM PPM
Started in April 2008
Under the IMA GFATM RNTCP Project and IMA TB initiative IMA has been engaged in
the following activities:
1. Sensitization of doctors about Standards of TB care through State and District Level
Workshops
2. Need for notification - follow up and cure
3. Training of general practitioners in standards of TB care through District Level
Workshops
4. Establishment of Private Sector Peripheral Health Institution
5. IEC activities, e-IMA NEWS, IMA NEWS, JIMA, TB Newsletter
6. Media Advocacy
7. Celebrity endorsement
8. Medico-Legal Protection
9. Policy Making
10. IMA Slogan

42. • IMA in its 207th meeting of the Central Working
Committee held on 22nd April, 2012 in Mumbai resolved
as under
• “In conformity with the requirements of international standards for TB
care, IMA desires that Notifications of TB patients to the national
program be made mandatory. IMA also recommends to the General
Practitioners to follow the ISTC in diagnosis and management of TB
patients.” Subsequently, Govt. of India, MoHFW Letter No.Z-
28015/2/2012/TB dt. 7th May 2012 mandated Notification of TB Cases.
The Govt Order said “……therefore, the healthcare providers shall notify
every TB case to the local authorities……..”
” I have notified a TB patient today: have you. Do it today”
IMA RNTCP
GFATM PPM
TB: A NOTIFIABLE
DISEASE

43. ADVOCACY, COMMUNICATION AND
SOCIAL MOBILIZATION
 Mobilizing political administrative commitment resulting in
availability of better resources for TB
 Early case detection and early complete treatment
 Combating stigma and discrimination
 Generate awareness and demand in community through
well-informed and reasoned dialogue.
 Reaching the unreached

44. HARYANA

45. LAUNCH OF MISSED CALL CAMPAIGN TOLL FREE TB NO. 1800116666

46. Monitoring and supervision
• To review the performance of states and districts
regarding the implementation of ACSM, Nine
states and sixteen district were reviewed through
the structured mechanism of Central Internal
Evaluations (CIE) during the year 2014:
• RNTCP Central Internal Evaluation (CIE) of
Haryana was organized from 24th to 28th
November 2014; during the CIE, two districts
(Sonepat and Sirsa) were visited along with State
level RNTCP Institution.

47. National Strategic Plan (NSP)(2012-17)
RNTCP defined newer objectives of 'Universal Access to TB Care' for TB control in
India in 2010.
Vision
TB-free India
Goal
 Decrease the morbidity and mortality by
early diagnosis and treatment to all TB
cases thereby cutting the chain of
transmission.

48. Objectives
Case detection
RNTCP Objective :
70% of estimated New Smear Positive TB cases
NSP objective:
To Achieve 90% Notification rate for all cases
Treatment
successRNTCP Objective:
85% of all New Smear positive TB cases
NSP Objective:
90% success rate amongst New & 85% amongst retreatment TB
cases registered under RNTCP
Drug resistant
TBNSP Objective:
Improve the successful outcome of treatment of MDR
cases

49. Objectives
TB-HIV
Collaboration
Private
Sector
NSP Objective:
Decrease Mortality and morbidity of HIV associated
TB
NSP Objective:
Improve the outcome of TB care in Private
sector

50. ROHTAK SCENARIO
2 FUNCTIONAL TU: MEHAM & ROHTAK
3 more TU are under process.
Total number of DMCs:12 excluding PGIMS ,Rohtak
Till now in 2015 ,33 patients are registered under
category IV treatment & one patient is on XDR
treatment.
DTO: Dr Indu
In 2014, 30 MDR patients were registered out of
them 3 died

51. PGIMS SCENARIO
DOTS CUM REFERRAL
CENTRE
Out of district :1379 cases were reported positive.
In 2015 up till 23th November 997 cases were reported
positive in Rohtak.Out of these 680 were referred to TU
Rohtak and 317 were referred to TU MEHAM
REFERRAL STAMP

52. PGIMS SCENARIO …..
FLUORESCENT MICROSCOPE is used for sputum smear examination since 2 years.
Auramine –O stain is used instead of ZN stain
2 lab technician's are there (1 from RNTCP,1 from PGI)
< 20 𝐴𝐹𝐵 𝑖𝑛 40 𝑓𝑖𝑒𝑙𝑑𝑠 𝑠𝑐𝑎𝑛𝑡𝑦
>20 AFB in 40 fields 1+
2-5 per field 2+
> 5 per field 3+
1 MOTC –CUM-MO-DRTB

53. 2509 13887

54. PGIMS SCENARIO …..
Till now 517 MDR Cases & 30 XDR cases have been registered .
1 TDR case was found in 2013 but no follow up was done for that case.
5 Districts Rohtak, Jhajjar, Bhiwani, Jind, Narnaul are attached to PGI Rohtak
for CB-NAAT.
LPA is done at karnal for all Haryana except 5 Districts Ambala, Panchkula,
Yamunanagar, Kaithal, Kurukshetra which are linked to GMCH, Chd.

55. CB-NAAT MACHINE
SOLVENT
CARTRIDGE
FALCON TUBE
TEMP SHOULD BE < 20° C
4 SAMPLES AT A TIME, 12 SAMPLES IN A DAY
TIME 1 HR 50 MIN. SAMPLE: SOLVENT 1:2

56. 46%
54%
INDIA FINANCING TB STRATEGY 2015

57. RESEARCH & DEVELOPMENT
A diagnostic platform called the GeneXpert Omni® is in development.
A next-generation cartridge called Xpert UltraR is also in development.
Eight new or repurposed anti-TB drugs are in advanced phases of clinical
development. An anti-TB drug candidate (TBA-354) is in Phase I.
testing.
Fifteen vaccine candidates are in clinical trials. Their emphasis has shifted from
children to adolescents and adults.

59. TB India 2015 annual status report.
WHO Global Tuberculosis Report 2015.
Tuberculosis control in the South East Asia Region. Annual TB Report 2015.
Park’s Text Book of community medicine 23rd edition.
REFERENCES
Revised National TB Programme Training Course for program managers

60. T
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