India moving ahead from tuberculosis control to tuberculosis elimination: status and challenges

1. India moving ahead from tuberculosis
control to tuberculosis elimination: status
and challenges
DR. NISHANT MISHRA

2. Contents :-
1.Introduction
2.Evolution of programme
3.National tuberculosis elimination programme
4. Current status
5. Key challenges.

3. National TB Control Programme (NTCP)
launched by Government of India during 1962
two survey
reports
ICMR, done during 1955-58,
that TB was a major public
health problem, 1.5 percent of
the population above 5 years
was suffering from
radiologically active TB and
0.4 percent of them infectious
National TB Institute (NTC)
Bangalore during 1955 to 56 :
1. That nearly 50 percent of the cases
do not come to health care facility
for treatment
2. That domiciliary treatment is as
effective as institutional treatment
3. That the expenditure incurred for
treating 20-25 TB cases in the
sanitorium, can suffice to serve the
population of about 1500 through
establishment of TB clinics.

4. Objectives of NTCP
• Short-term objectives: –
- To detect and treat as many cases of TB as possible among outpatients
- To vaccinate the newborns with BCG
• Long-term objectives: –
-To reduce the problem of TB in the community to such a low level that it ceases to be a
public health problem, i.e. one infectious case should infect less than one new person
annually and the prevalence of infection among children below 14 years should be brought
down to les than 1 percent from 30 percent level then.

5.  The organizations established for NTCP has 3 tiers: central, district and peripheral.
 Five treatment regimen (R1-R5). long course chemotherapy for at least 1.5 years.
 Short course chemotherapy was introduced during 1972.
 It was centered around Rifampicin and INH.(regimen A & B).
 Success rate was unacceptably low and death and default rates was high.
 Inspite of a nation wide network of facilities, NTCP failed to yield satisfactory results.
 Situation of TB remained same. It remained as a major public health problem .
 On the other hand, there was increased incidence of MDR-TB cases and also the emergence of
HIV infection made the situation still worst.

6. In 1992, Government Of India (GOI) along with WHO and SIDA reviewed the TB situation
in the country. and came up with following conclusions : -
1. NTP had managerial weaknesses
2. Inadequate funding
3. Over-reliance on X-ray for diagnosis
4. Frequent interrupted supplies of drugs
5. Low rates of treatment completion

7.  In 1993, because of emergence of HIV pandemic and increased incidence of MDR-TB
cases, WHO declared tuberculosis as ‘Global Emergency’.
 In 1993, GOI intensified and revised the NTCP and renamed and launched as ‘revised
national tuberculosis control program’(RNTCP) . It was launched in 1993 as a pilot
project and expanded in 1997, with a plan to cover the entire country by 2004, in a
phased manner.
‘Revised National Tuberculosis Control Program’

8. The objectives of the RNTCP are :
1. Achievement of at least 85 % cure rate of infectious cases of tuberculosis, through
DOTS involving peripheral health functionaries.
2. Augmentation of case finding activities through quality sputum microscopy to
detect at least 70 % of estimated cases.

9. Directly Observed Treatment Short-course (DOTS) strategy adopted by RNTCP initially had
the following five main components:
1. Political will and administrative commitment.
2. Diagnosis by quality assured sputum smear microscopy.
3. Adequate supply of quality assured short course chemotherapy drugs.
4. Directly observed treatment.
5. Systematic monitoring and accountability.

10. SN NTP RNTCP
1 NAME National TB Control Program Revised National TB Control Program
2 Objective The objective was case detection
and treatment
70% case detection and 85% cure rate
3 Functional unit District TB center Tuberculosis unit
4 Case finding Active by health care worker ‘passive’ by quality microscopy.
5 sputum smear
examination
one two
6 Treatment regimen Many standardized
7 Supervision of
chemotherapy
No Yes by DOTS agent.
8 Drug supply Not regular “patient wise boxes”
9 Follow up Not regular regular
10 Case detection rate and
success rate
<50% >85%

11. In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP.
The components are as follows :
1. Pursuing quality DOTS - expansion and enhancement.
2. Addressing TB/HIV and MOR-TB.
3. Contributing to health system strengthening.
4. Engaging all care providers.
5. Empowering patients and communities.
6. Enabling and promoting research (diagnosis, treatment, vaccine).

12. DOTS-Plus
• This was launched by WHO during the year 2000 and by RNTCP in India during 2007.
• DOTS-plus program should strengthen the basic DOTS strategy. Since the treatment of
MDR-TB cases is very complex, treatment is given as per the internationally recommended
DOTS-Plus guidelines, in the designated RNTCP DOTS-Plus sites, one for each state that
will have ready access to sputum culture and susceptibility testing laboratory, i.e. IRL.

16. In 2014, the World
Health Assembly
unanimously approved
to end global TB
epidemic by "End TB
Strategy" , a 20 year
programme with
vision of a world with
zero death, disease
and suffering due to
TB.

17. NATIONAL STRATEGIC PLAN FOR TB ELIMINATION (2017-2025)
VISION
The VISION is - TB free India with zero deaths, disease and poverty due to
TB
OBJECTIVE
1. Find all drug sensitive TB and drug resistant TB cases with an emphasis on
reaching TB patients seeking care from private providers, and undiagnosed TB
in high-risk populations.
2. Initiate and sustain all patients on appropriate anti-TB treatment wherever
they seek care, with patient friendly systems and social support.
3. Prevent the emergence of TB in susceptible populations.
4. Build and strengthen enabling policies, empowered institutions, additional
human resources with enhanced capacities, and provide adequate financial
resources.

18. KEY STRATEGIES
1. Private sector engagement
2. Active case finding
3. Drug resistant TB case management
4. Addresssing social determinants including nutrition.
5. Robust surveillance system.
6. Community engagement and multisector approach.
EXPECTED
OUTCOME
The aim of the National Strategic Plan is to achieve elimination of TB
by 2025. During plan period, targets for TB are:
1. 80% reduction in TB incidence (i.e . reduction from 211 per lakh to
43 per lakh)
2. 90% reduction in TB mortality (i.e. reduction from 32 per lakh to 3
per lakh
3. 0% patient having catastrophic expenditure due to TB

19. 19
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)

20. S
N
IMPACT INDICATORS 2015 2020 2023 2025
1 Estimated TB incidence rate ( per lakh) 217 142 77 44
2 Estimated TB mortality (per lakh) 32 15 6 3
3 Estimated TB prevalence (per lakh) 320 170 90 65
4 Families suffering catastrophic cost due to TB 35% 0% 0% 0%
5 Total TB patient notifications (in millions) 1.74 3.6 2.7 2
6 Total TB patients private provider notifications (in
millions)
0.19 2 1.5 1.2

21. National AIDS Control Program
National Tobacco
Control Program
Rashtriya Bal
Swasthya
Karyakram
National Programme for
Prevention and Control
of Cancer, Diabetes,
Cardiovascular Diseases
and Stroke
Poshan Abhiyaan
Ayushman Bharat –
Health and Wellness
Centres
Collaborations to address risk factors of TB

22. ENDTB SUMMIT
13TH MARCH 2018
• Landmark event towards compete
elimination of TB from the country
• Hon’ble Prime Minister announced
targets for Ending TB by 2025, much
ahead of the global SDG targets of
2030.
• Emphasized importance of working
together for the cause as the
disease is inked to the betterment
of the lives of the poor .

23. Strengthening Case Finding in the Private Sector
Schedule H1 Implementation: The number of
chemists registered in Nikshay increased from
15221 in 2017 to over 43000 chemists notifying
20,609 TB cases in 2019.
Mandatory Notification of TB: Gazette
notification issued in March 2018; Provisions
of Sections 269 and 270 of the Indian Penal
Code (IPC) in 2019
Patient Provider Support Agency through JEET
and Domestic Resources: From 48 PPSAs in 2017
to 220 PPSAs in 2019 and 266 PPSAs in 2020.
67.8%
Increase in
private sector
notification
from 3.8
lakhs in 2017
to 5.6 lakhs in
2020.

24. NIKSHAY
NIKSHAY : TB surveillance using case based web based IT system (19) Central TB Division
in collaboration with National Informatics Centre has undertaken the initiative to develop a
case based web based application named Nikshay. The word is combination of two Hindi
words NI and KSHAY, meaning eradication of TB.

25. This software was launched in May 2012 and has following functional components.
- Master management
- User details
- TB Patient registration and details of diagnosis. DOT provider, HIV status, follow-up, contact tracing,
outcomes.
- Details of solid and liquid culture and DST, LPA, CBNAAT details.
- DR-TB patient registration with details.
- Referral and transfer of patients.
- Private health facility registration and TB notification.
- Mobile application for TB notification.
- SMS alerts to patients on registration.
- SMS alerts to programme officers.
- Automated periodic reports:
a. Case finding
b. Sputum conversion
c. Treatment outcome.

26.  Registered enteries till dec 2020-
1. Public health sector – 39136
2. Private health sector- 244508
3. Staff -267714
 Number of TB PATIENTS NOTIFIED IN NIKSHAY FROM 2017 TO 2020-
80,42,008
 Number of beneficiaries paid atleast 1 benefit since inception of npy in april 2018 to
dec 2020- 39,37,719

27. NIKSHAY DASHBOARD
 Dashboard portal was launched in 2020.
 Dashboard provide a visual representation of the various NTEP indicators to
users across all levels .
 Allows monitoring and review of all levels against selected indicator.

29. DIRECT BENEFIT TRANSFER (DBT)
 DBT schemes under NTEP are as follows :
1. Nikshay Poshan Yojana (NPY)
2. Incentive to treatment supporters/ DOTS providers
3. Notification incentive to private providers.
4. Transport incentive to tribal TB patients

30. NIKSHAY PFMS
Bank
Patient
TB patients
provided
benefit
39
lakh
Public sector –
90%,
•Private – 23%
Covera
ge
• Rs. 500/- per month given to
every TB patient through DBT for
duration of treatment
• Scheme rolled out from April
2018
• Rs. 990.4 Cr amount disbursed to
beneficiaries from Apr’18 till date
30
Period - April 2018 till date
DBT: Direct Beneficiary Transfer; PFMS- Public Financial Management System
NIKSHAY Poshan Yojana

31. Incentive for Treatment
supporter
Incentive for
Informant
Travel support in Tribal
blocks
• Drug sensitive TB :
Rs. 1000/- at completion of
treatment
• Drug Resistant Case:
Rs.5000/- during treatment
• An Informant is
eligible for
incentive of
Rs. 500/- for a
confirmed TB case
• Rs. 750/- as travel
support for all TB
patients of tribal
blocks
Incentives

32. INCENTIVE TO PRIVATE SECTOR PROVIDERS FOR NOTIFICATION OF TB
PATIENTS
BENEFICIARY:-
 Private Providers ( Private Practioner, Hospital, Laboratory And Chemist ) who notify
TB patients to National TB Elimination Programme .
INCENTIVE :-
 INR 500 as a one time payment on notification.
 INR 500 to Private Practitioner or Hospital for updating the patients’s treatment
outcome.

33. 33
Call Centre- NIKSHAY SAMPARK
 TOLL FREE 1800-11-6666
 Outbound & Inbound
 Time – 7 to 11
 Languages – 14
 100 call centre agents
 Pan-India coverage
 Citizen – Patient – Providers
Counselli
ng Treatme
nt
Adheren
ce
Grievance
Redressal
Follow
Up
TB
Notificati
on
Informat
ion
Nikshay
Poshan
Yojana
Total Calls at TB Call Centre
May-18 to June-20
TB inbound Calls answered 719103
TB outbound calls dialled 1576963
COVID-19 inbound Call
answered 529413

34. INDICATOR STATUS
TOTAL NOTIFICATION (2020) 18,05,670
PRIVATE NOTIFICATION(2020) 4,79,905
PUBLIC NOTIFIVCSTION(2020) 13,25,765
ON TREATMENT (2020) 17,10,923
DIED (2019) 89,823
TREATMENT SUCCESS (2019) 19,05,920
LOST TO FOLLOW UP(2019) 81,306
TREATMENT FAILURE (2019) 13,781

35. 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. Under nutrition, overcrowding.
6. Lack of awareness and poor health seeking behaviour lead to delay in diagnosis.
Key Challenges

36. Bending the Curve
Accelerating towards a TB free India