critical review RNTCP

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  • MDG goal???? 1990?? (42per lakh)2006incidence??Stop TB Partnership targets set for 2015 and 2050By 2015: Reduce prevalence and death rates by 50%,compared with their levels in 19Symptomatic screening + CXR + Sputum Smear + Culture90Coordinated by NTI, Bangalore in association with New Delhi TB Centre (North Zone)MGIMS, Wardha (West Zone)LRS Institute, New Delhi (East Zone)CMC, Vellore (South Zone)By 2050(Public health problem) Reduce the global incidence of active TB cases to <1 case per 1 million population per yearMillennium Development Goals set for 2015 Goal 6: Combat HIV/AIDS, malaria and other diseasesTarget 6c: Halt and begin to reverse the incidence of malaria and other major diseases Indicator 6.9: Incidence, prevalence and death rates associated with TB Indicator 6.10: Proportion of TB cases detected and cured under DOTS.Targets linked to the MDGs and endorsed by the Stop TB Partnership:– 2015: reduce prevalence of and deaths due to TB by 50% compared with a baseline of 1990– 2050: eliminate TB as a public health problem
  • India and China together account for nearly 40 per cent of the global burden.In India, the prevalence is 3.1 million at best and 4.3 million at high. In China, the figures are 1.4 million and 1.6 million respectively. Even in prevalence rate (per one lakh population a year), India is 249 at best and 346 at high. China fares better: 104 at best and 119 at high. In 2011, India again topped the list for incidence (the number of new cases detected in a year). It had 2 million to 2.5 million, compared with China’s 0.9 million to 1.1 million. If global incidence during 2011 was 8.3 million to 9 million, “India and China accounted for 26 per cent and 12 per cent respectively,” the WHO report notes. Mortality is also high in India. About three lakh people will die this year. There are other differences between China and India. The percentage of TB patients who are also HIV positive is 6.5 in India; China’s figure is 2.3 per cent. This could be because only 23 per cent of TB patients were tested for HIV in China compared with India’s 45 per cent.
  • Source?/
  • It has been a century still TB has not become manageableTuberculosis was declared a global health emergency in 1993??, but it has been growing unchecked.Public health problem???
  • National institute?? 1993-95 pilot studyof Delhi, Kerala, Gujarat, Maharashtra and West Bengal1992- Government of India(GoI) and World Health Organization (WHO) and Swedish International Development Agency (SIDA)reviewed the TB situation and concluded NTP ‘s failure
  • Decrease the line?
  • http://www.hypothesisjournal.com/?p=989#sthash.h9Q1EY77.dpuf17. Singla N, Sharma PP, Singla R, Jain RC. Survey of knowledge, attitudes and practices for tuberculosis among general practitioners in Delhi, India. Int J Tuberc Lung Dis. 1998 May;2(5):384–9 - See more at: http://www.hypothesisjournal.com/?p=989#sthash.h9Q1EY77.dpufSource??22. Specter M. A deadly misdiagnosis. Is it possible to save the millions of people who die from TB? The New Yorker. 2010:48–5 - See more at: http://www.hypothesisjournal.com/?p=989#sthash.h9Q1EY77.dpufThere is a large amount of published literature that consistently show that serological tests for TB are inaccurate and have no clinical role in the diagnosis of either pulmonary or extra-pulmonary TB (18, 19). There are no international guidelines supporting their use; in fact, the International Standards for TB Care discourage the use of these tests (20). - See more at: http://www.hypothesisjournal.com/?p=989#sthash.h9Q1EY77.dpuf
  • VISION :A TB-free worldGOAL :To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals (MDGs)and the Stop TB Partnership targetsOBJECTIVES ■ Achieve universal access to high-quality care for all people with TB■ Reduce the human suffering and socioeconomic burden associated with TB■ Protect vulnerable populations from TB, TB/HIV and drug-resistant TB■ Support development of new tools and enable their timely and effective use■ Protect and promote human rights in TB prevention, care and control
  • 1993 & 1997??
  • Controlled Clinical Trials for the Treatment of Sputum Positive Pulmonary Tuberculosis with Regimens Containing Ofloxacin" (TRC Annual Report 1999-2000:24), following durations of treatment ranging from the usual six months to just three, the two-month culture conversion rates ranged from 92 percent to 98 percent.TB Monitor (06.01.01) Vol 8; No 6: P 65-67. Info source :CDC HIV/STD/TB Prevention News Update
  • Misdiagnosis and management can result in only fraction of TB patients getting correct diagnosis, appropriate therapy and positive outcomesGive inference :::
  • REVIEW ARTICLEYear : 2012  |  Volume : 29  |  Issue : 2  |  Page : 147-153   DOTS for TB relapse in India: A systematic reviewMajority of relapses presented in the first year after completion of treatment, and the bulk of it occurs in the first 6 months itself.
  • A report from Pakistan indicated halving the default on switching from an intermittent to a daily regimen. [8]A study in Hong Kong found the intermittent regimen to be strongly associated with recurrence; poor adherence (particularly, during IP) emerged as an important factor. [A systematic review found that patients with INH resistance treated with a thrice-weekly regimen during IP had significantly higher risks of failure and acquired drug resistance (compared to daily dosing). With INH resistance in India currently estimated to be about 15-18%, a daily regimen in the IP is strongly indicated; Bangladesh implements a daily regimen during the continuation phase (CP) as well. [11Wells WA, Konduri N, Chen C, Ignatius HR, Gardiner E, Schwalbe NR. Implications of the current tuberculosis treatment landscape for future regimen change. Int J Tuberc Lung Dis 2011;15:746-53.  Back to cited text no. 9  [PUBMED]  [FULLTEXT] 10.Iseman MD. Good news and not such good news. Int J Tuberc Lung Dis 1999;3:87.  Back to cited text no. 10  [PUBMED]  [FULLTEXT] 11.World Health Organization. Anti-tuberculosis drug resistance in the world, Report No. 4. WHO.HTM/TB/2008.394 Geneva: World Health Organization Press; 2008.  Back to cited text no. 11     12.World Health Organization. Treatment of Tuberculosis: Guidelines. 4 th ed. Geneva: World Health Organization Press; 2010.  Back to cited text no. 12     13.Available from: http://www.nature.com/news/totally-drug-resistant-tb-emerges-in-india-1.9797. [Last accessed on 2012 Jan 12].  Back to cited text no. 13  Qayyum S, Ahmed I, Ansari G. Comparing Daily Versus partially Intermittent Regimen of ATT in non-HIV patients with new Pulmonary Tuberculosis (TB) in DOTS program. Availble from: http://www.pjcm.net/pdf-v16-n1-p3.pdf [Last accessed on 2012 Jan 12].
  • 10 states???
  • 42. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Anti-tuberculosis drug resistance in the world. Report No. 2. Geneva: WHO; 2000. 43. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Report No. 3. Geneva: WHO; 2003. 44. Paramasivan CN. Surveillance of Drug resistance in India. In: Agarwal SP, Chauhan LS, editors. Tuberculosis Control in India. India. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2005. p. 47-52. 42. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Anti-tuberculosis drug resistance in the world. Report No. 2. Geneva: WHO; 2000. 43. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Report No. 3. Geneva: WHO; 2003. 44. Paramasivan CN. Surveillance of Drug resistance in India. In: Agarwal SP, Chauhan LS, editors. Tuberculosis Control in India. India. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2005. p. 47-52. 42. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Anti-tuberculosis drug resistance in the world. Report No. 2. Geneva: WHO; 2000. 43. World Health Organization. The WHO/IUATLD Global Project on Anti-tuberculosis Drug Resistance Surveillance. Report No. 3. Geneva: WHO; 2003. Paramasivan CN. Surveillance of Drug resistance in India. In: Agarwal SP, Chauhan LS, editors. Tuberculosis Control in India. India. New Delhi, India: Directorate General of Health Services, Ministry of Health and Family Welfare; 2005. p. 47-52. WHO and the IUATLD have now replaced the term primary resistance with the term drug resistance among new cases; and acquired resistance, with the term drug resistance among previously treated cases.[42],[43]
  • Private or NGO laboratories which have been accredited for first-line DST include Hinduja Hospital (Mumbai), SRL (Mumbai and Gurgaon), Quest Diagnostics (Gurgaon), CMC (Vellore), BPRC (Hyderabad) and DFIT (Nellore).
  • Decrease lines!!
  • the right number of people, with the right skills, in the right place, at the right time, who are motivated and supported to provide the right services to the right people. ( India -79% )
  • critical review RNTCP

    1. 1. Critical Review of Revised National Tuberculosis Control Programme(RNTCP) Presenter -Dr Har Ashish Jindal JR
    2. 2. Contents               Introduction Burden of disease Timeline of TB Control National Tuberculosis Programme Revised National Tuberculosis Control Programme(RNTCP) Directly Observed Treatment Short Course(DOTS) STOP TB Strategy RNTCP Funding Diagnosis Treatment Multi Drug Resistant TB TB-HIV Collaboration Recent Advances Conclusion
    3. 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 a contagious disease caused by Mycobacterium tuberculosis Left untreated, each person with infectious pulmonary TB will infect an average of between 10 and 15 people every year. With emergence of Multi Drug Resistance and coinfection with HIV has weakened our battle against the disease.
    4. 4. Burden of Disease  Globally, in 2011, there were an estimated 8.7 million new cases of TB (13% co-infected with HIV) and 1.4 million people died from TB.  New cases of TB have been falling for several years and fell at a rate of 2.2% between 2010 and 2011.  The TB mortality rate has decreased 41% since 1990 and the world is on track to achieve the global target of a 50% reduction by 2015.(MDG Target)
    5. 5. Global India Prevalence(million ) 12 3.1 Incidence rate(per 100 000 population) 125 181 Mortality rate(per 100 000 population) 14 24 HIV prevalence rate in incident TB cases (%)(per 100 000 population) 13% 4.2% 26%
    6. 6. TB in INDIA      Incidence rate(2011): 181 per lakh population Prevalence : 3.8million (2000) to 3.1million(2011) The Annual Risk of TB Infection (ARTI) has decreased from 1.5% in 2002-03 to 1.1% nationally in 2008-10 with the estimated decline of 3.7% per year (95% confidence interval, 2.4-5.1% per year). New Smear Positive(NSP) PTB cases in the country is estimated as 55 per 100,000 population. WHO estimated TB mortality in India as 280,000 (24/100,000 population) in 2011  Source: Global TB Report 2012
    7. 7. Achievements of RNTCP
    8. 8. Evolving Treatments of TB in India        1962 - National Tuberculosis Programme (NTP) started 1992- NTP Reviewed and concluded its failure 1993: RNTCP formulated, adopted Directly Observed Treatment Short-course (DOTS) strategy. 1997-Large-scale implementation of the RNTCP with DOTS RNTCP I: 1997-2006 RNTCP II: 2006-11 National Strategic Policy: 2012-17
    9. 9. National Tuberculosis Programme (1962)       Based on strategic principles of domiciliary treatment Use of a self-administered standard drug regimen of initially 12-18 months duration Treatment free of cost Priority to newly diagnosed patients over previously treated patient Treatment organization decentralized to district level. The NTP created an extensive infrastructure for TB control, with a network of 446 district TB
    10. 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 case detection rather than cure  Inadequate budget and insufficient managerial capacity  Shortage of drugs  Emphasis on x-ray diagnosis resulting in inaccurate diagnosis  Poor quality sputum microscopy  Multiplicity of treatment regimens. 
    11. 11. DELAYED POLICY REVISION in RNTCP and DOTS INITIATION  30 years had lapsed before RNTCP is implemented in 1993. why? why the policy not revised much earlier knowing that results are not good with NTP? why wasted 30 years?  HZES-1962 R -1982(leprosy). Led to accumulation of too many old and retreatment cases. 
    12. 12. Revised National Tuberculosis Control Programme(1993) Goals - To reduce mortality and morbidity from tuberculosis - To interrupt chain of transmission. Objectives - To cure at least 85% of all newly detected infectious(NSP) cases of Pulmonary tuberculosis - To detect at least 70% of estimated new smear positive pulmonary tuberculosis
    13. 13. Are the targets adequate?         Total net missed cases for treatment will be almost 40%. Is this ethical to leave the patients untreated when we have detected them with disease?? Have we done like this for any infectious disease with high communicability and longer period of communicability in the past? Why should we take a risk in leaving the known infected cases? What is the rationale behind leaving the detected infectious cases without treatment? Is it cost-effective to leave the detected cases? We have wasted our valuable resources also to detect those 15%.
    14. 14. RNTCP(1993)   The RNTCP was built on the infrastructure and systems built through the NTP. Major additions to the RNTCP:      a sub-district supervisory unit, known as a TB Unit decentralization of both diagnostic and treatment services with treatment given under DOTS (directly observed treatment). highest priority to the provision of quality assured sputum smear microscopy services. Patient-Wise Boxes, which contain the full course of treatment for one individual patient, ensuring that treatment of that patient cannot be interrupted due to a lack of drugs.
    15. 15. RNTCP Organization structure: State level
    16. 16. DOTS(1997) 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.
    17. 17. Weak Political Approach  Political commitment, the first requisite of dots management is only on paper.  Politicians were not serious and not actively involved in the crusade against tuberculosis.  Example TB was made Notifiable(May 7,2012) Other countries e.g China (2000) 
    18. 18. WHERE PATIENT OF TUBERCULOSIS GO FOR TREATMENT ? Private Sector Government Sector
    19. 19. Quality diagnosis? Quacks and Private Practioners  Tb is still a poor man's disease in India  Quacks And Private Practitioners : The First point of contact for a majority of patients  In India, 75% of doctors (6 million) are based in private practice and only 0.31% are implementing RNTCP.  In June 2012, the government banned serological tests for TB. based on Treatment in the private sector is often started serology results leading to wrong and/or delayed diagnosis.  inflate costs of care.  Thus, undiagnosed TB, delayed diagnosis and mismanaged TB continues to fuel the TB epidemic. 
    20. 20. Improvements    In 2009, WHO recommended that conventional Fluorescence Microscopy be replaced by LED microscopy in all settings and that LED microscopy be phased in as an alternative for conventional ZN microscopy in both high volume and low-volume laboratories. Success: Central TB Division is planning to replace the Binocular Microscopes with LED Microscopes in a phased manner over the next 5 years especially in the high work load settings. 200 LED Microscopes have already been procured by UNION for use in Projects in Medical Colleges
    21. 21. STOP TB Strategy(2006) ■ In DOTS collaboration ,STOP TB strategy was started with additional six components1. 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
    22. 22. RNTCP FUNDING Actual allocation as per planning commission 450 582 Rupees in crore 400 350 300 267 275 285 300 320 250 200 actual allocattion as per planning commision 150 100 50 0 1.8
    23. 23. World Bank Funding 175 170 170 165 $ in millions 160 155 150 145 World Bank Funding 142 140 135 130 125 1997-2005 2006-2012 Additional funding of $ 100 million for 2 years up to 2014 for Universal Access goals addressing MDR TB , Scaling up approach and New approaches
    24. 24. Category Type of Patient Regimen Duration in months Category I New Sputum Positive , sputum negative, extra pulmonary 2 (HRZE)3, 4 (HR)3 6 Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default 2 (HRZES)3, 1 (HRZE)3 5 (HRE)3 8 Color of box: RED Category II Color of box: BLUE
    25. 25. DOTS Treatment  Lengthy treatment: chemotherapy for six months duration is still a problem for the patient to comply.  Need to reduce the duration of treatment in view of patient’s compliance and side effects of drugs.  Ultra- short treatment regimens for three months duration using quinolones with rifampicin are on the anvil.
    26. 26. DOTS Treatment   Inadequate information and poor management of adverse events and toxicity continue to result in patients defaulting on treatment . Controversy regarding the efficacy of the 6-month regimen that is recommended under RNTCP in TB meningitis and TB of bones and joints cases compared with the 9–12 month regimen recommended by some experts.
    27. 27. DOTS Implementation Status 31st March 2006 Nationwide DOTS coverage -632 districts and 1164 million people covered under RNTCP
    28. 28. LARGE POPULATION The provision of quality TB services to a population of over 1 billion is a difficult task.  Providing an uninterrupted supply of Anti-TB drugs to more than 1.3 billion cases each year.  Quality????  Requires a large amount of resources to be mobilized ????   Human resource management ???
    29. 29. DOTS in India      TB as a disease and its treatment may be viewed differently in the various socio-cultural-economic conditions prevailing in India today. E.g. Muslims during Roza Socioeconomic factors that have been identified in studies done among patients on DOTS in India include smoking, alcoholism, old age, poverty with default and malnutrition etc. It is unclear to what extent these factors affect the functioning of DOTS treatment. Poverty, social upheaval and crowded living conditions Inadequate health coverage and poor access to health services Reluctance to report TB suspects leading to poorly administered programmes
    30. 30. POOR PATRONAGE OF DOTS REGIMENS  Most Indian doctors/health workers are not aware of DOTS, its success in TB control in other countries and how it is being implemented in the country.  All doctors, some knowingly and some unknowingly are prescribing anti-tuberculosis drugs as they like. Even pulmonologists are not sticking on to dots regimens as recommended in the national program.  The knowledge regarding the treatment guidelines among the residents and consultants is low, points to the fact that re-education of faculty members regarding recent trends or guidelines is essential if we want this knowledge to percolate to the periphery.
    31. 31. RNTCP has consistently shown treatment success rates of around 87%, whilst case detection rates have generally risen to now stand at around 72%.
    32. 32. Progress towards MDG indicator 23 Prevalence rate of TB Cases per 1,00,000 population Prevalence rate of TB 500 450 400 350 300 250 200 150 100 50 0 459 249 1990 2011 230 2015
    33. 33. Progress towards MDG indicator 23 Mortality rate of TB Cases per 1,00,000 population Mortality rate of TB 45 40 42 41% 35 30 24 25 19.5 20 15 10 5 0 1990 2011 2015
    34. 34. Programme Performance Indicator Norm Achievement Annual case detection rate 135/lakh population 129/lakh (145/lakh) Case detection rate 70% 71%(Haryana-71.4%) % of smear positive among total new pulmonary TB cases 50% 62%(Haryana-51.9%) Proportion of new smear positive cases on DOTS within 7 days of diagnosis >90% 86%(Haryana-89%) New sputum positive conversion rate at three months > 90% 90%(Haryana-90%) Cure rate >85% 86% (Haryana-84.6%) Default rate <5% 6% Haryana (6.4%) Death rate <5% 4%(Haryana -4.4%)
    35. 35. Reasons for Unachieved targets •Migratory population??? • Poor commitment of DOTS providers and supervisory staff •Defaulter correction activities need to be more effective
    36. 36. Patients with TB symptoms Patients investigated Patients with appropriate TB test is ordered Patients qualityWhy is TB a big problem in India, despite assured results the success of the DOTS program? Patients width diagnoses Patients who get correct TB therapy Patients who get therapy and cured Misdiagnosis and management can result in only fraction of TB patients getting correct diagnosis, appropriate therapy and positive outcomes
    37. 37. High Relapse Rate     Irregularity in treatment and presence of initial drug resistance. There is a choice of providers for the patient and he is free to discontinue and start treatment from whichever provider he likes, based on his perception of getting benefit for treatment. Thus, patients can be over treated or started with intensive phase again when they switch providers. This previous treatment history is poorly documented. Retreatment cases not followed up after treatment for any length of time, there is very less information about relapse
    38. 38. Why intermittent regimen was opted?     In a high-burden country as India intermittent regimen was never critically reviewed. The current WHO guidelines, based on "strong/high grade evidence" recommends "wherever feasible, the optimal dosing frequency for new patients with pulmonary TB is daily throughout the course of therapy"; Studies have been documented rates of acquired drug resistance were higher among patients receiving three times weekly dosing throughout therapy than among patients who received daily drug administration throughout treatment. Missed dose in Intermittent Regimen leads to no medicine for 3 or 4 straight days ?????
    39. 39. Recommendations   The model of DOT being implemented in India needs to be reconsidered ,which enable access to treatment and maximize adherence. There is a need for operational research into alternative models of DOT, especially in urban areas, which do not impede access to care under the RNTCP, and which minimize the indirect costs of DOT based treatment.
    40. 40. Challenges Ahead!!!!! “If detecting and treating all TB patients who are not drug resistant is challenging enough, detecting and treating drug-resistant TB is riddled with problems.”
    41. 41. MDR-TB & XDR-TB MDR-TB is defined as resistance to isoniazid and India, China, the Russian or without resistance to other60% of the rifampicin, with Federation and South Africa have almost anti-TB world’s cases of MDR-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). 
    42. 42. Burden of MDR TB     Globally, 3.7% (2.1–5.2%) of new cases and 20% (13– 26%) of previously treated cases are estimated to have MDR-TB in 2011 In India, 2.1% have been estimated to be MDR in New TB cases , and 15% in Retreatment cases. respectively(2011) Extensively drug-resistant TB (XDR-TB) has been identified in 84 countries globally. Combining data from 65 countries and 3 union territories, the proportion of MDR-TB cases with XDR-TB was 9.0% (95% confidence interval, 6.7%–11.2%).
    43. 43. Drug Resistant TB • In December 2011 , 4 patients from Mumbai, “totally drug resistant” tuberculosis i.e. resistant to all first -line and second-line drugs tested. • Media reports have added reports of further cases in Mumbai and in Bangalore. • Such cases have been reported sporadically in Europe and 15 cases in Iran in 2009. Audit Reveals: Unsupervised second line drugs Incorrect doses Multiple private practitioners (on average from 4 physicians during a 18-month period) (an attempt to cure their (MDR)tuberculosis.)
    44. 44. Treatment Of MDR-TB Cases  RNTCP will be using a Standardised Treatment Regimen (Cat IV) for the treatment of MDR-TB cases (and those with rifampicin resistance) under the programme. Category Intensive Phase IV  Category of Patients Continuation phase MDR TB Cases 6-9(kmOfxEtoCsZE) 18(OfxEtoCsE ) Km – Kanamycin ;Ofx- Ofloxacin; Eto-Ethionamide ; Cs- Cycloserin; Z- Pyrazinamide ; E- Ethambutol
    45. 45. Gaps in the MDR TB management  Diagnosed with TB and MDR TB in the private sector  No notification done to public health authorities, who would be able to take actions to confirm diagnoses, offer supportive services, and offer free treatment to patients from public sources or at least supervise the quality of care in the private sector. Inadequate or inefficient administration of effective treatment. Poor case holding . Frequent use of Second line drugs in treatment common ailments. inadequate or irregular drug supply. Ignorance of health care workers in the treatment and control of TB. Interruption of chemotherapy due to side effects.      
    46. 46. Gaps in the MDR TB management    Anti-TB drugs available without prescription and subsequent widespread irrational and irresponsible use Insufficient public sector MDR and XDR TB diagnosis and treatment services Only in recent years has a public sector option for free diagnosis and treatment of MDR TB become available;
    47. 47. Success   In 2008 were only 17 accredited facilities for doing culture and DST (which works out to 0.1 facility per 10 million residents, against a minimum of 1 per 10 million), although efforts are underway to increases the number to 43 laboratories with DST capacity. Indeed, by 2011, 27 accredited laboratories are operational, including 8 private/NGO sector laboratories. Expansion of laboratory capacity is critical to ensure that patients with suspected drug resistant TB can be diagnosed early and. The RNTCP has begun to incorporate recent, more rapid methods of performing culture and DST (e.g. liquid culture and molecular assays) and this is important to avoid unnecessary delays in the management of patients with MDR–TB
    48. 48. New lines of diagnosis    Xpert MTB/RIF has 72 per cent sensitivity with one test, and 90 per cent with three tests in the case of smear-negative patients. The sensitivity goes up to 98 per cent in the case of smear-positive and culturepositive patients. Xpert MTB/RIF has 99 per cent specificity. It can turn in results in less than two hours compared with four to six weeks in the case of the culture process. But the most important advantage is its ability to diagnose rifampicin drug resistance.
    49. 49. Recommendation  Need for continuous surveying of drug resistance by a network of investigators in different regions of the country, by employing a common protocol, with an emphasis on quality control, which will serve as a useful parameter in the evaluation of current and past chemotherapy programs
    50. 50. TB-HIV collaboration  In comparison to 19 states in 2010, in 2011 23 states are implementing the intensified TBHIV package for at least 2 quarters with close to 6 lakh TB patients were ascertained for their HIV status (67% of TB patients registered) and about 44,000 HIV-infected TB patients In 2011, 1.1 million (13%) were diagnosed. of the 8.7 million people who developed TB worldwide were HIV-positive ; 79% of these HIV-positive TB cases were in the African Region. Globally, there were an estimated 0.4 million HIV-associated TB deaths in 2011, with  Till December 2011, more thanand women centres were approximately equal numbers among men 300 ART operating in the country, and 550 link- ART centres.
    51. 51. 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 TBHIV 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 HIVinfected 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.
    52. 52. Challenges    Treatment outcomes among HIV-infected TB patients: low failure rates but high case-fatality; death has been associated with lack of ART. . Only about 50% of TB patients know their HIV status and of those identified as HIV positive, only about 60% are linked to ART as the majority are poor and unable to reach centralized ART centres. Thus, gap between RNTCP and NACP infrastructure results in suboptimal linkages.
    53. 53. POOR DIAGNOSIS and POOR POLICY     Sputum smear microscopy is not a sensitive tool to diagnose TB among PLHIV, and access to a culture based diagnosis (or equivalent technology) is lacking. Implementation of airborne infection control measures in health care settings is also limited. Revised National TB Control Programme (RNTCP) in India uses a fully intermittent thrice-weekly rifampicin containing regimen for all TB patients including those who are HIV-infected; whereas, WHO recommends daily TB treatment at least during the intensive phase. The WHO recommendation was based on the results of a meta-analysis demonstrating increased risk of recurrence and failure among HIV-infected TB patients receiving intermittent TB treatment, compared to a daily regimen.
    54. 54. Human Resource   Vision A world where every person, everywhere has access to a motivated and supported health worker, who is skilled in TB control. Goal Health workers at different levels of the health system have the skills, knowledge, and attitudes (professional competence) necessary to successfully implement and sustain comprehensive TB control services based on the Stop TB Strategy.
    55. 55. NEED FOR HUMAN RESOURCE PLANNING     Unprecedented programme expansion in the last five years has outpaced capacity at central, state and district level to ensure quality of services. Members of the staff at state and district levels : perform multiple functions , being overburdened. New Recruits necessitates frequent trainings, which is neglected at times. Hence, there is an urgent need for national HRD planning that strategically and comprehensively addresses the overall staffing issues related to recruitment, capacity development, performance .
    56. 56. NEED FOR HUMAN RESOURCE PLANNING     Advanced training on management aspects such as health financing, leadership/governance, business planning, organizational development Engage in strategic partnerships for health workforce development with other Training divisions/ institutions, inservice training for programmes, Ministry of Education and other relevant ministries, Professional associations, Private sector including NGOs and bilateral and international organizations Monitor and supervise health worker performance to detect performance deficiencies; identify new staff in need of training; identify additional staff needs for current interventions and for new interventions/strategies. Quality assessment of Training.
    57. 57. National Strategic Plan (NSP)(2012-17) Vision TB-free India RNTCP defined newer objectives of 'Universal Access to TB Care' for TB control in Goal  Decrease the morbidity and mortality by early diagnosis and treatment to all TB cases thereby cutting the chain of transmission. India in 2010.
    58. 58. Objectives Case detection NSP objective: RNTCP Objective : To 70% of estimated New Smear for all cases cases Achieve 90% Notification rate Positive TB Treatment RNTCP Objective: success NSP Objective: 85% of all New amongst New TB cases 90% success rateSmear positive & 85% amongst retreatment TB cases registered under RNTCP Drug resistant NSP Objective: TB Improve the successful outcome of treatment of MDR cases
    59. 59. Objectives TB-HIV Collaboration NSP Objective: Decrease Mortality and morbidity of HIV associated TB Private Sector NSP Objective: Improve the outcome of TB care in Private sector
    60. 60. Targets planned for 2012 to2017
    61. 61. TB Made Notifiable (May 7,2012)     Mandatory for laboratories, hospitals, nursing homes and doctors, both in the public and private sector, to report every TB case detected. Once a case is notified govt. will ensure correct diagnosis and complete adherence to treatment during the entire duration of treatment. This is where the approaches that India and China adopted to fighting TB diverged. Of the 37 notifiable diseases in China, TB ranks No. 1. It pulled out all the stops by 2000. “The concept of acceptance of the problem, identifying its requirement and the political will of TB eradication has set China on a progressive path,” notes a paper published in the journal Interdisciplinary Perspectives on Infectious Diseases.
    62. 62. Conclusion         Join Hands Strong Commitment from TB control Staff Human Resource Management Strong Political Commitment Proper IEC Activities Decentralization of the resources Research HELP US COMBAT TUBERCULOSIS
    63. 63. Thank you

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