National Tuberculosis Elimination Programme

1. Dr Neha Dhingra
Assistant Professor
Community Medicine
National TB Elimination Programme
Overview - Key Priorities

2. Revised National TB Control Programme
(RNTCP)
renamed as
National Tuberculosis Elimination
Programme
(NTEP)
2

3. What is Tuberculosis?
Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium
tuberculosis (MTB) which generally affects the lungs, but can also affect other parts
of the body
One patient with infectious
pulmonary TB if untreated can
infect 10-15 persons in a year
o Malnutrition
o Diabetes
o HIV infection
o Poor immunity
o Severe kidney disease
o Other lung diseases
e.g. silicosis
o Substance abuse etc.
o Overcrowding
o Inadequate
ventilation
o Enclosed living/
working conditions
o Occupational risks
Risk factors:

4. 4

5. Objectives
RNTCP
1. To achieve high cure rate of 85% among new smear
positive cases.
2. To detect at least 70% of TB cases
3. To reduce morbidity and mortality by 50% by 2015
These objectives have been replaced by NSP -2017-2025
5

6. • In view of End TB targets, the programme has been
renamed from RNTCP to NTEP.
• Revised National Tuberculosis control Programme to
National Tuberculosis Elimination Programme
6

7. Organizational structure
Supporting Facilities
 National Reference Laboratories
(6)
 Intermediate Reference
Laboratories (31)
 Culture and DST Laboratories (81
including IRL/NRL)
 CBNAAT Laboratories (1268)
 DRTB Centres- 703

8. Components of NTEP
DOTS – Directly Observed Treatment Short Course
Strategy
8

9. DOTS
1. The heart of DOTS is, treatment by a person who
is not a family member but is accountable,
accessible and acceptable such as health worker.
2. Good quality of Anti TB drugs.
3. Good quality of diagnosis
4. Political and administrative commitment
5. Monitoring
6. Organization
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10. NTEP
• Key activities include
1. Active TB case finding
2. Newer and shorter regimen
3. Private sector engagement
4. Financial/nutritional support to TB patients
5. IT enabled
• surveillance,
• preventive and
• awareness measures
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11. • Active Case Finding (ACF):
Active case finding means:
Going out and identifying TB in individuals who don’t come
themselves for health care using community volunteers with
proper training and supervision.
To reach the unreached
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12. • ACF is to be done in among high-risk groups (HRGs) which
have been identified as:
1. PLHIV (people living with HIV)
2. All contacts of bacteriologically confirmed pulmonary TB
patient
3. Other risk groups (silicosis, immuno-compromised, organ
transplant, hemodialysis, anti TNF-therapy, etc).
4. Migrants
5. People living in
– urban slums,
– construction sites, and
– hard-to-reach areas
12

13. • TB Co-morbidities
(Detecting TB in patients with other Morbidities)
TB and HIV
• HIV Testing for TB Patients (including Presumptive TB
cases)
• Screening for TB among HIV patients (Intensive Case
Finding /ICF)
– using 4 symptom complex
1. Cough of any duration,
2. Fever,
3. Weight loss,
4. Night sweat
• ICF is to be done at ICTC, ART center and Link ART Centers
•
13

14. • Isoniazid preventive treatment (IPT) for all people living
with HIV (PLHIV)
• TB and Diabetes
• Screening of TB patients for Diabetes
– If DM found, then linkage to DM care center
14

15. 15
Strategies
Private
sector
engagement
Active
Case
Finding
TB
Co-
morbidities
Multi-
sectoral
response
Drug
Resistant
TB
ICT Tools for
adherence
and
monitoring
Preventive
Measures
Community
Engagement
National Strategic Plan (2017-25)

16. • Eliminating TB by 2025: India is committed to eliminating
tuberculosis from the country by 2025, five years ahead of
the global target by the World Health Organisation
(WHO) i.e. 2030. (AIM OF National Strategic Plan)
• Targets:
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1) 80 % reduction in TB incidence
2) 80% reduction of Prevalence
3) 90% reduction in TB mortality
4) 0% patient having catastrophic
expenditure due to TB

17. 17
TB Mukt
Bharat

18. • DETECT:
All Drug Sensitive Cases (DS-TB) and Drug Resistant TB cases
(DRTB) esp. from Private providers and undiagnosed TB cases
in high-risk groups (prisoners, migrant workers, PLHIV/AIDS,
contacts etc.).
– And report these
• TREAT: Provision of free TB drugs in the form of Daily Fixed
Dose Combinations (FDCs) for all TB cases is advised with
the support of directly observed treatment (DOTS).
– Screening of all patients for Rifampicin resistance
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19. • PREVENT
– Air-borne infection control measures at health care
facilities
– Treatment for latent TB infection in contacts of
bacteriologically-confirmed cases
– BCG
– Address social determinants of TB through intersectoral
approach
• BUILD: Health system strengthening for TB control
– enabling policies, empowering institutions and human
resources
19

20. Key Services
1. Free diagnosis and treatment for TB patient
2. Public health action- contact tracing, testing for co-
morbidities etc.
3. Treatment adherence support
4. Nutrition assistance to TB patients (DBT-Nikshay
Poshan Yojana)
5. Preventive measures
6. CBNAAT sites

21. NTEP endorsed TB diagnostics
• Smear microscopy for acid fast bacilli
• Culture –( L-J media, Bactec, MGIT etc)
• Line probe assay
• CBNAAT
• Gene Xpert
• Radiography
• Tuberculin sensitive test
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22. Strengthening Case Finding in the Public Sector
Chest X Ray:
Clinically diagnosed TB
increased from 8.8 lakhs in
2017 to 12.7 lakhs in 2019
Revised Diagnostic
Algorithm for TB: Increase
in DR-TB cases from 38,000
in 2017 to 66,000 in 2019
Upfront Rapid Molecular
Testing: Increased from
5.23 lakhs upfront tests in
2017 (16% yield) to 11.34
lakhs in 2019 (17% yield)
Intensive Case Finding in Health
facilities- Screening for TB
among:
-DM patients increased from
11.5 L in 2018 to ~20 L in 2019
- ICTC/ART referrals increased
from 3.35 L in 2017 to 3.94 L in
2019
Active Case Finding in vulnerable
population: from 5.5 crore
population screened in 2017 to
28 crores screened in 2019. Yield
increasing from ~27,000 to
~63,000 TB patients.
Leveraging Outreach of other
Healthcare Programmes: 8.3
lakhs referrals from Health &
Wellness Centres .
PASSIVE APPROACH TO CASE FINDING
ACTIVE APPROACH TO CASE FINDING

23. Treat
Treatment
Patient Centric Care
Reduce Out-of-pocket
Expenditure
• Daily Regimen
• Shorter Regimen
• Newer Drugs
• IT Enabled Adherence
Support
• Comorbidity
management
• Financial incentives
• Direct Benefit Transfer

24. Direct Benefit Transfer (DBT) schemes
1. Honorarium to Treatment Supporters – For provision of treatment
support to TB patients (Adherence, ADR monitoring, counselling
@Rs.1000/- to Rs.5000/-)
2. Patient Support to Tribal TB Patients (Financial Patient Support
@Rs750/-)
3. Nutritional Support to All TB patients (Financial Support to
Patients @Rs.500/-month)
4. Incentives to Private Providers (Rs.500/- for Notification &
Rs.500/- for reporting of Treatment Outcome
5. Incentives to Informant (Rs. 500/- is given on diagnosis of TB
among referrals from community to public sector health facility)

25. Prevent
• Air borne infection
control measures
• Strengthen Contact
Investigation
• Preventive
treatment in high
risk groups
• Manage Latent TB
Infection
• Address
determinants of
disease

26. Multi-sectoral Engagement
TB care services in
health
infrastructure
Socio-economic
support &
Empowerment
Infection
Prevention
Address
Determinants
Information
Education
Communication
Prevention and
Care at Work Place
Corporate
Social
Responsibility
TB - A social problem & needs multi-sectoral approach

27. Inter-Ministerial Coordination
AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and
Homoeopathy)
•1st meeting of National Technical Expert Group on NTEP-AYUSH Collaboration &
e-consultation of experts held
•2nd draft of Policy Document and Joint Letter drafted
Railways
•Joint Working Group to be formed to monitor implementation
Defence
•Action Plan developed.
•95 Ex- Servicemen Contributory Health Scheme (ECHS) Polyclinics registered in
Nikshay, remaining underway
Labour and Employment
• MoU signed in September 2020

28. Community Engagement
Transformation of TB survivors to TB
champions
Capacity building and mentoring
programme
Engagement of existing community
groups like PRI, SHG, VHSNC, MAS,
Youth Club
Grievance redressal mechanism
Involvement of community
representatives in different forums
TB Forums at the National, State
and District level to provide a
platform for all stakeholders,
including the community, to voice
their views

29. New Initiatives
• NIKSHAY – Case based Web based IT system
• TB Notification
• Ban on TB serology- based on antibody response
• Direct Benefit Transfer
• Universal Drug Susceptibility testing
• Shorter Regimen and Bedaquilin
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30. Call Centre- Nikshay Sampark
 1800-11-6666
 Outbound & Inbound
 Time – 7 to 11
 Languages – 14
 100 call centre agents
 Pan-India coverage
 Citizen – Patient - Providers
Counselling
Treatment
Adherence
Grievance
Redressal
Follow
Up
TB
Notification
Information
Nikshay
Poshan
Yojana
Policy Update in RNTCP, 2018

31. State TB Index
Policy Update in RNTCP, 2018

32. 1. Under reporting and uncertain care of TB patients in
private sector
2. Reaching the unreached – Slums, Tribal, vulnerable
3. Drug Resistant TB
4. Co-morbidities – HIV, Diabetes
5. Undernutrition, overcrowding
6. Lack of awareness and poor health seeking behaviour lead
to delay in diagnosis
Key Challenges

33. Key Take Away
• Improve TB notification rate Ensure mandatory TB
notification from private sector
• Active TB Case Finding to reach the unreached
• Optimum utilization of CBNAAT machines
• Expand Universal Drug Susceptibility Testing coverage
• NIKSHAY Poshan Yojana to every TB patients
• 100% reporting through NIKSHAY
• Collaboration with Line Ministries to tackle social
determinants of TB
• Community participation for TB Elimination

34. Vision: A world free of TB
Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB Epidemic (<10 cases per 100,000 population)
Sustainable Development Goals (SDG)
INDICATORS
TARGETS
SDG 2030
Reduction in number of TB deaths
compared with 2015 (%)
90%
Reduction in TB incidence (new case) rate
compared with 2015 (%)
80%
TB-affected families facing catastrophic
expenditures due to TB (%)
Zero

35. TB Free India
• India has committed to End TB by
2025, 5 years ahead of the global
SDG target
• Prime Minister of India launched
TB Free India campaign at ‘Delhi
End TB Summit’ on 13th March,
2018
• The campaign calls for a social
movement focused on patient-
centric and holistic care driven by
integrated actions for TB Free
India

36. Thank You
Bending the Curve
Accelerating towards a TB free India
Thank You