2. 1. NTP: National Tuberculosis Control
Programme, 1962
• Reviewed in 1992: NTP had not achieved
its aims or targets
2. RNTCP: Revised National Tuberculosis
Control Programme, 1992
• Incorporating ‘Directly Observed
Treatment Short-course’ (DOTS) strategy
3. NTEP: The program has been renamed
as 'National Tuberculosis Elimination
Programme in 2020
• GOI (MoHFW )has committed to end TB
by 2025, – 5 years ahead of the global
target under Sustainable Development
Goals
3. Stop TB Strategy, 2006 Announced in 2006 by WHO and
adopted by RNTCP
• Continue and expand DOTS
• Addressing TB/HIV
• Addressing MDR-TB
• Health system strengthening
• Engaging pvt and alternative practitioners
• Empowering patients
• Promoting research
– Diagnostics
– Treatment
– Vaccine
• National Airborne Infection Control Guidelines
• Practical Approach to Lung Health
4. End TB Strategy, 2014
• Approved by WHO in 2014, as TB was still the
deadliest infectious disease globally – A 20 year
program
• Vision: Zero death, disease and suffering due to
TB
• Interventions are both: – Health related and –
Social (as TB is associated with social factors esp.
poverty)
• End-TB Strategy includes
1. Patient centered care and prevention
2. Bold policies & patient support
3. Intensified research and innovation
5. National Strategic Plan 2017-25 (NSP) has been made for
Tuberculosis Elimination by 2025
1. Detect: all drug sensitive cases
(DS-TB) and drug resistant TB cases
(DRTB) esp. from pvt providers and
undiagnosed TB cases in high-risk
groups (prisoners, migrant workers,
PLHIV/AIDS, contacts etc.). – And
report these
6. 2. 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 (DOT).
– Screening of all patients for rifampicin resistance
3. Prevent
– Air-borne infection control measures at health care facilities
– Treatment for latent TB infection in contacts of
bacteriologically-confirmed cases
– IPT
– BCG
– Address social determinants of TB through intersectoral
approach.
4. Build: Health system strengthening for TB control – enabling
policies, empowering institutions and human resources
7. Organization structure of NTEP
TB Laboratory
Services:
3-tier system
• The
peripheral
laboratories
• State level-
Intermediate
reference
laboratory
(IRL),
• Central level
For details,
click here
Supporting Facilities
• National Institutes (3)
• National Reference Laboratories
(6)
• Intermediate Reference
Laboratories (29)
• State TB Training and
Demonstration Centre (STDC)(26)
• Culture and DST Laboratories
(42)
• Nodal DR-TB Centre (154)
• CBNAAT Laboratories (1180)
8. Peripheral Health Institution (PHI)
PHI is a health facility, having at least 1 medical officer.
• Dispensaries, PHCs, CHCs, referral hospitals, major hospitals,
specialty clinics or hospitals, TB hospitals, ART Centres and
Medical colleges in the district.
• Even the private and NGO participating in NTEP are
considered as PHIs
• Some of these PHIs also function as DMCs.
• PHI has the main responsibility of case finding &
management.
• If > 1 MO is posted in a PHI, one is to be identified for the
responsibilities of the NTEP.
– Referral for screening for DM is the responsibility of the PHI
where TB Rx is initiated
• All Diabetic TB patients should be linked for diabetic care.
9. DMC
It is the most peripheral lab under RNTCP.
One DMC per 1 lac (50k in tribal and hilly areas) The lab
technician collects sputum, makes and stains smear and reports
the microscopic findings.
The Quality Assurance activities include: • On – site evaluation.
Tuberculosis Unit (TU)
Major organizational change: creation of a sub-district
administrative level i.e. at the Block/ PHC level
– MO-TC ( Tuberculosis Control) has the overall responsibility of
management of TB Control Program at the TU
– The team of STS (Senior TB supervisor) and STLS (ST Laboratory
S) are under the administrative supervision of the MO-TC and
the DTO ( District Tuberculosis Officer)
10. • State TB Training and Demonstration Centre (STDC):
– Training State workers in TB control,
– Translating educational material in local language
– Technical assistance to STO e.g. quality assurance of
sputum microscopy
– conducting Operational research
– AFB culture and sensitivity testing facilities etc.
• Culture and DST Laboratories – Advanced tests such as
the Line Probe Assay, Liquid and Solid Culture, and Drug
Susceptibility – located at a few select places in the state –
provide additional drug resistance/susceptibility testing
services
• Nodal DR-TB Centre : Mx of DR TB
11. TB Laboratory Services:
• Central level
– Six National Reference Laboratories (NRLs)
– External Quality Assurance of Lab network,
– Drug resistance surveillance,
– Training and research.
• State level
- Intermediate reference laboratory (IRL),
– Usually situated in the State TB Training and Demonstration
Centre (STDC)
– Monitoring laboratory services across the state – CBNAAT sites
– DRTB Centres
12. • The peripheral laboratories
– The labs at dispensaries, PHCs, CHCs, referral hospitals,
major hospitals, specialty clinics / other sector hospitals /
TB hospitals / Medical colleges and in the private/NGO
sectors
– These laboratories are covered under quality assurance
mechanisms
– large hospitals and medical colleges have facilities of
digital X-Ray, rapid molecular test (Cartridge based
nucleic acid amplification test -CBNAAT & Line Probe
Assay - LPA), Fine Needle Aspiration Cytology (FNAC),
histopathology, and culture & DST for diagnostic services
of TB.
13. NTEP: Key activities include
1. Active TB case finding
2. Newer and shorter regimen
3. Financial/nutritional support to TB patients
4. Private sector engagement
5. IT enabled ( new initiative )
NIKSHAY-Surveillance, preventive and
awareness measures
15. As opposed to passive case finding, ACF means: Going out
and identifying TB in individuals who don’t come
themselves for health care using community volunteers
with proper training and supervision
• It’s planned to conduct 3 rounds of ACF/year
• 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
• TB patients detected during ACF are referred for Dx and
TB Rx
16. TB Comorbidities (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
– ICF is also to be done even among HIV high risk groups (HRG)
– Isoniazid preventive treatment (IPT) for all people living with HIV (PLHIV)
– TB pt. with HIV: same daily treatment for same duration as HIV-negative
TB pts.
17. TB and Diabetes
• Screening of TB patients for Diabetes – If DM
found, then linkage to DM care center
• Screening of Diabetes patients for TB (4
symptom complex/every visit) – If found to have
TB, linkage with TB management center
21. Treatment of Pediatric TB
• For pediatric patients, formulations with daily dosages as per 6
weight band categories are made available
– All adolescents up to 18 years of age and weighing less than 39
kg, are to be treated using pediatric weight bands and
– Children weighing more than 39 kg with adult weight bands
IPT (isoniazid preventive treatment) in children:
• Preventive chemotherapy with isoniazid (H)
• All children ≤ 5 years who are in contact with all forms of
Drug sensitive TB case.
– They are examined and investigated to rule out active TB
– If found to have TB, they are treated appropriately
– If active TB is ruled out, IPT given
• IPT dosage: INH 10 mg/kg body weight daily for 6 months.
22. TB in pregnant and lactating mother
• Consider age
• All 1st line
except
streptomycin
• Pyridoxine to
breast fed
baby too
24. Patient support for TB Elimination
1. Treatment Support
2. Adherence support strategy
3. Nutritional Support
4. Mitigating catastrophic expenditure (such as those
provided through DBT)
5. Airborne infection control in Community and Facility
6. Patient help desk and grievance redressal.
Treatment & Adherence Support
1. To Minimize delay in starting treatment
2. Maximize adherence by
– Monitoring & reporting dose administration
– Support for preventing treatment interruption
25. A support plan is developed right at time of diagnosis, in
consultation with the patient and the relevant health staff.
This plan should include:
1. A home visit for counseling of the patient and family members
2. Follow-up schedule at PHI and for lab investigations
3. Linkages for co-morbidity management – including assessment
of nutritional status and nutrition support
4. Adherence support using tools like
– 99DOTS,
– Retrieval of treatment interrupters,
– Screening for adverse reactions,
– Supervision of treatment supporter etc.
26. Nutritional support
• All individuals with active TB receive
(i) An assessment of their nutritional status and
(ii) Counseling based on their nutritional status – At
diagnosis and throughout their treatment.
(iii) Any malnutrition detected, is managed as per WHO
recommendations.
• NTEP guidelines for nutritional assessment and
counseling of TB patients are in the Document
Nikshay Poshan Yojana (NPY)
• DBT at notification and then during treatment
(DBT=Direct Benefit Transfer i.e. money credited directly
to the beneficiary’s account) – Rs. 500 each month of
treatment and – Up to Rs. 1000 as an advance.
27. Mitigating catastrophic expenditure
• Catastrophic expenditure: Includes expenses for tests,
medicines, travel, loss of wages etc.
• An END TB Goal is: reducing catastrophic expenditure
1.Free diagnostic and treatment for the private sector too
2. Financial support to patients and care providers (DBT)
a. Nutritional Support (Rs.500/-month)
b. Travel support to Tribal Patients (Rs750/-)
c. Private Practitioners incentives (Rs.500/- for
Notification & Rs.500/- for reporting of Treatment
Outcome )
d. Treatment supporters Honorarium (Rs.1000/- to
Rs.5000/-)
28. Support for airborne infection control
• TB patients are educated on prevention of
airborne infection
– At home and at work place.
– E.g. cough hygiene
• Airborne infection control measures are
implemented in Health Facilities, Community, and
at household level.
• Health facilities
– Increased ventilation,
– Reduced crowding,
– Faster processing of patients’ and samples (fast
tracking),
– Wet mopping – Cough etiquette
29. • Patients are provided with
– Spittoon , Disinfectant and Reusable masks
and educated on their use.
• During house visits, the health workers
observe for cough hygiene and reinforce AIC
information.
• Details can be found the ‘Guidelines for
Airborne infection control’. Patient Grievance
Redressal
31. Supporting TB Patients under Private Providers
• TB control officers mustn’t attempt to divert
patients from private providers to the public system
– Regulatory measures must also be used
judiciously.
• The approach includes:
– Engagement and prioritization of providers
– Linkage of services
– Patient support/ Public health actions
– Process of engagement of PPs
– Regulatory Measures
32. Engagement of providers
Mapping of private providers-
• Allopathy and AYUSH
• Chemists
• Laboratories
• NGO, corporate sector, health facilities under other
Ministries, Public Sector Enterprises etc.
Prioritization of providers by DTO
• Following is considered for prioritization
1. allopathic practice
2. Patient load (Respiratory or TB patient load)
3. AYUSH providers
4. Pharmacies and their TB prescription load.
5. Diagnostic laboratories with TB diagnostic services and their
test load
33. Collaborate with Private Providers
• All providers should be registered in NIKSHAY
• DTO can involve an NGO/agency to reach out to private
providers.
• The private providers are sensitized through
1. Clinic visits, peer pressure or professional associations
2. Scientific and clinical information about TB management
Then an onboarding kit is provided to the doctor
1. Notification formats
2. List of diagnostic/treatment services free & paid
• E.g. free X-ray, smear microscopy, CBNAAT, TrueNat etc. 3.
Free anti-TB drugs
4. Sputum collection containers/falcon tubes
34. TB in the Private Sector
• Standards for TB care in India: Guidelines made
available for treatment & follow-up of TB patients
• Mandatory TB notification
• NIKSHAY: a web enabled application to facilitate
monitoring of universal access to TB patients data
by all concerned
• Ban on Sero-diagnostics and
• Regulatory tools are limited.
35. Involvement of Medical colleges in NTEP
• Facilities like
– DMC/CBNAAT lab,
– Treatment centre,
– Drug resistant TB centre etc. in Medical Colleges.
• It also facilitates research pertaining to TB in
Medical colleges.
• Core Committees in medical colleges for inter-
departmental coordination
– Operational research is one of the important
activities of Medical Colleges.
36. Regulatory measures
GOI has made notification of TB cases mandatory
on 7th May 2012.
– Legal backing for not notifying a TB patient.
– punitive measures as per IPC 269 & IPC 270.
– Use clinical establishment act (CEA) wherever it is
being implemented.
– This will help to identify providers who are
registered under the CEA and not registered with
NIKSHAY
37. Patient support/ Public health actions
• Patients can provide feedback and report
grievances to the DTO on – Paper or email or –
Through the National Call Centre (Nikshay –
Sampark).
• If the request/grievance is not addressed at a
particular level it will be escalated to the next
higher level.
• At all points, the patient should be informed of
the status of his/her submission
38. NI-KSHAY-(Ni=End, Kshay=TB)
• It is the web enabled patient management system for TB control
under the National Tuberculosis Elimination Programme (NTEP). It is
developed and maintained by the Central TB Division (CTD),
Ministry of Health and Family Welfare, Government of India, in
collaboration with the National Informatics Centre (NIC), and the
World Health Organization Country office for India.
• Ni-kshay is used by health functionaries at various levels across the
country both in the public and private sector, to register cases
under their care, order various types of tests from Labs across the
country, record treatment details, monitor treatment adherence
and to transfer cases between care providers. It also functions as
the National TB Surveillance System and enables reporting of
various surveillance data to the Government of India.
