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Epidemiology and control of tuberculosis and rntcp programme


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Epidemiology and control of tuberculosis and rntcp programme

  1. 1. Epidemiology and control of tuberculosis and RNTCP programme JOSLITA D SOUZA
  2. 2. Problem statement World 1900-1980 death rate declined 199-0.5/100000 in US 2008 Incidence- 9.4million(8.9-9.9) Prevalence-11.1million (9.6-13.3) HIV associated- 1.4 million Deaths- 1.8million (0.52 million HIV+)
  3. 3.  Multidrug resistant-0.5 million MDR deaths- 0.15million Extensively drug resistant- 50,000 XDR deaths- 30,000 SE Asia (34%), Africa(31%), Western Pacific (20%)
  4. 4. Achievements 1995-2008 Cured - 36 million Averted from death- 6million using DOTS Case fatality rate 7.6% to 4% Cure rate – 87%
  5. 5. India 20% global burden 2/3 rd cases in SEAR Incidence – 1.8million New smear+ -0.8 million Deaths – 0.32 million Annual risk – 1.5%
  6. 6. Tuberculosis estimate for India
  7. 7. Epidemiological indicesPrevalence of infection % of individuals who show a positive reaction to tuberculin test
  8. 8. Incidence of infection ( annual infection rate) % of population under the study who will be newly infected among the non infected of the preceding survey during the course of 1yr “Tuberculin conversion index”
  9. 9.  Prevalence of disease/ case rate:% of individuals whose sputum is positive for tubercle bacilli “Case load”
  10. 10.  Incidence of new casesThe % of new TB cases/1,000 population in 1yr
  11. 11.  Prevalence of suspect casesX ray examination
  12. 12.  Case detection rate: The number of notification of new and relapse cases in a year Estimated incidence of such cases in the same year
  13. 13.  Mortality rate: The number of deaths from tuberculosis every year/1000 or 1,00,000 population
  14. 14. Natural history of tuberculosisAgent factors: Agent Source of infection Communicability
  15. 15. Host factors: Age Sex Heredity Nutrition Immunity
  16. 16. Environmental and social factors
  17. 17. Mode of transmission Droplet infection
  18. 18. Pathogenesis
  19. 19. Clinical features Incubation period : 3-6 weeks
  20. 20. Control of TBCase finding: Case Target group Case finding a. Sputum examination b. Mass miniature radiography c. Tuberculin test
  21. 21. Sputum examination Collection of sample Slide reporting Sputum culture
  22. 22. ChemotherapyFirst line drugs Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S)
  23. 23. Second line drugs: Thiacetazone(Tzn) Paraaminosalicylic acid(PAS) Ethionamide(Etm) Cycloserine(Cys) Kanamycin(Kmc) Amikacin(Am) Capreomycin (Cpr)
  24. 24. Newer drugs Ciprofloxacin Ofloxacin Clarithromycin Azithromycin Rifabutin
  25. 25. BCG vaccination Vaccine : „ Danish 1331‟ strain Types 1. Liquid 2. Freeze driedDosage :0.1ml
  26. 26. Administration :Complications :
  27. 27. Protective value: 15-20yrsRevaccination:?Contraindications:  Generalized eczema, infective dermatosis, hypogammaglobulinemia, immunodeficiency
  28. 28. Chemoprophylaxis INH – 1yr INH + Ethambutol – 9months
  29. 29. Rehabilitation
  30. 30. Revised national tuberculosis control programme Govt. of India, WHO, world bank- 1992 Features : i. 85% cure rate through SCC ii. Detecting 70% of the estimated cases iii. Involvement of NGOs iv. Direct Observed Treatment Short course (DOTS)
  31. 31. Pilot strategy Phase I Phase II Phase III
  32. 32. OrganisationState Tuberculosis office State tuberculosis officerState TB training and Directordemonstration centreDistrict tuberculosis centre District tuberculosis officerTuberculosis unit Medical officer-TB control Senior treatment supervisor Senior TB laboratory supervisorMicroscopy , treatmentcentresDOTS providers
  33. 33. Laboratory network NationalCentral TB reference division LabState TB cell Intermediate reference lab District TB centre
  34. 34. TU TU TU DMC1 DMC2 DMC3
  35. 35. Initiation of treatment Designated RNTCP microscopy centre Each centre1. Skilled technician – ensure quality2. Senior TB lab supervisor ( 5 microscopy centres)
  36. 36. cough for 2wks or more2 sputum smears 2 negatives 1 or 2 positive Antibiotics 10-14 days Symptoms persist Repeat 2 smear examination 2 negative X ray -ve + ve Non TB Smear – ve TB
  37. 37. DOTS Political commitment Good quality sputum microscopy Directly observed treatment Uninterrupted supply of good quality drugs Accountability
  38. 38. Treatment regimenTB category Initial phase Continuation Total duration (daily/3 per wk) phaseI 2HRZE(S) 4HR/6HE 6/8II 2HRZES+1HRZE 5HRE 8III 2HRZ 4HR/6HE 6/8IV RZE 18 ZE+S/Kmc/Am/C pr+Cipro/Ofl+_Et m
  39. 39. RNTCP phase II Approved for 5yrs Oct 2006 to Sept 2011 Goal : decrease morbidity and mortality due to TB DOTS Access to tribal and marginalized groups
  40. 40. Drug resistance surveillance To determine the prevalence 2005 States : AP, Delhi, Gujarat, Kerala, Maharashtra, Orissa, UP, West Bengal – 54% IRLs accredited
  41. 41. DOTS plus For management of MDR-TB MDR suspect Ofloxacin replaced to Levofloxacin Cat V regimen for XDR-TB patients
  42. 42. Achievements Cure rates -87% (25% in 1998) Death rate -4% (29%) DTC -650 TB units -2596 DMC -12,704 NGOs-2,500 Peripheral labs-12,750
  43. 43.  Public health carte providers- 5.5lacs Master trainers – 12 states Initiated treatment -1.1million patients Saved lives- 2million!!!
  44. 44.  Activities planned for 2011  Supporting the development of a National Strategic Plan to control TB 2012–2017, with the planned and budgeted activities necessary to achieve the country‟s goal of universal access.  Widening the network of quality assured laboratories and strengthening capacity of all the state-level culture and DST laboratories to undertake second-line DST.  Expanding the delivery of services for MDR-TB cases to all states.  Monitoring the implementation of the revised schemes for the involvement of NGOs and private practitioners across the country.  Phased scale-up of the implementation of the intensified TB/HIV package for nationwide coverage by 2012.  Review of all available studies and information on the TB burden, and re-estimation of TB incidence, prevalence, and mortality in cooperation with the Ministry of Health and national experts. . Developing and rolling out an integrated information system for MDR-TB services nationwide, and integrating laboratory results and patient management with outcome analysis and reporting.
  45. 45. THANK YOU 