Population Attributable Fraction (PAF) Quantifying the contribution of risk factors to the Burden of Disease Definition The contribution of a risk factor to a disease or a death is quantified using the population attributable fraction (PAF). PAF is the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario (eg. no tobacco use). Many diseases are caused by multiple risk factors, and individual risk factors may interact in their impact on overall risk of disease. As a result, PAFs for individual risk factors often overlap and add up to more than 100 percent. Calculating PAF Pi = proportion of population at exposure level i, current exposure P'i = proportion of population at exposure level i, counterfactual or ideal level of exposure RR = the relative risk at exposure level i n = the number of exposure levels For risk factors with continuous rather than discrete exposure levels there is an analogous formula for PAF involving integration of the exposure level distribution.
Extensively drug resistant TB (XDR-TB), subset of MDR-TB with resistance to second line drugs i.e. any fluoroquinolone and to at least 1 of the 3 second line injectable drugs (capreomycin, kanamycin and amikacin), To obtain a more precise estimate of Multi-Drug ResistantTB (MDR-TB) burden in the country, RNTCP carried out drug resistance surveillance (DRS) surveys in accordance with global guidelines in selected states, Gujarat (56 million population) and Maharashtra (107 million) in 2005-2006 and Andhra Pradesh (81 million) in 2007-2008. The results of these surveys indicate prevalence of MDR-TB to be low i.e. less than 3% amongst new cases and 12-17% in re-treatment cases
Swedish International Development Cooperation Agency ( SIDA ), Government of India
Sputum microscopy continues to be the primary tool for detection of infectious cases. Apart from sputum microscopy, RNTCP also uses standardized diagnostic algorithms to diagnose and treat all forms of TB wherein X-ray plays a supporting role. However in line with the stop TB strategy the program is exploring all possible avenues with newer and innovative technologies for early detection of TB including use of LED fluorescent microscopes, liquid culture and line probe assay for diagnosis drug resistant TB etc. Sufficient anti-TB drugs in patient wise boxes are made available at all the appropriate levels (Peripheral Health Institution/TB unit/District/State/National). The uninterrupted supply of drugs to teach patient is made possible through the “patient wise box.” Patient-wise drug boxes (both adult and pediatric) are an innovation of RNTCP wherein a box of medications for the entire duration of the treatment is earmarked for every patient registered. Directly observed treatment (DOT) is one of the key elements of the DOTS strategy. In DOT, an observer (health worker or trained community volunteer who is not a family member) watches and supports the patient in taking drugs. The DOT provider ensures that the patient takes the right drugs, in the right doses, at the right intervals, for the right duration. RNTCP has a systematic monitoring mechanism which accounts for/tracks the outcome of every patient put-on treatment. There is a standardized recording and reporting structure in place. The cure rate and other key indicators are monitored regularly at every level of the health system and regular supervision ensures quality of the program. RNTCP shifts the responsibility for cure from the patient to the health system.
The RNTCP Phase II of the World Bank project has been approved by the CCEA for the period Oct 2006 to Sep 2011 for a total outlay of USD 256.9 million which includes credit from World Bank of USD 170 million and commodity assistance of anti-TB drugs from DFID through WHO for USD 62.5 million, and the balance by GoI. New financial norms in respect of certain expenditure heads have been approved by Cabinet Committee on Economic Affairs which have been implemented with effect from April 01, 2009. Global Fund Support: The Global Fund has supported by grants) DOTS expansion in India under different rounds. DOTS expansion in the 3 States of Chhattisgarh, Jharkhand, and Uttarakhand (56 million populations) was supported by grants for USD 8.78 million under Round 1 of GFATM from April 2003-September 2006. In addition, the Round 2 of GFATM supported DOTS expansion in 56 districts of Bihar and Uttar Pradesh with a population of 110 million for USD 29.10 million (April 2004 to March 2009). Round 4 of GFATM is supporting strengthening of RNTCP implementation in the states of Andhra Pradesh and Orissa w.e.f November 05 and January 2006 respectively for USD 26.63 million till March 2010.
The Practical Approach to Lung Health (PAL) is one of the strategies intended to overcome the challenge posed by weak health systems. This initiative is aimed at managing respiratory patients in primary health care settings while expanding TB detection and good-quality TB services. PAL focuses on the most prevalent respiratory diseases at first-level health facilities – pneumonia, acute bronchitis and other acute respiratory infections, TB, and chronic respiratory conditions including chronic bronchitis, asthma and chronic obstructive pulmonary disease. PAL uses two main approaches to achieve integrated case-management of respiratory patients in primary health care: standardization of diagnosis and treatment of respiratory conditions, and coordination among health workers of different levels.
Tb control in india
Epidemiology and Evolvingstrategies of TB Control in India 17/04/2013 Dr. Priyamadhaba Behera Junior Resident, AIIMS 1
Outline of presentation• Epidemiology• Evolving strategies of TB Control in India1.National Tuberculosis Programme (NTP)2.RNTCP phase I3.RNTCP phase II4.STOP TB strategy5.Universal Access to TB Care6.National Strategic Plan (2012-2017)
EpidemiologyTB is an infectious disease caused by the bacillusMycobacterium tuberculosisIt typically affects the lungs (pulmonary TB) but can affectother sites as well (extrapulmonary TB)The disease is spread in the air when people who are sickwith pulmonary TB expel bacteria, for example by coughingIn general, a relatively small proportion of people infectedwith Mycobacterium tuberculosis will develop TB disease
Continued• TB is also more common among men than women, and affects mostly adults in the economically productive age groups• Risk factors-• Biomedical- HIV, DM, silicosis, malnutrition, malignancy, tobacco• Environmental-ventilation, indoor air pollution• Socioeconomic –crowding, urbanisation, poverty, migration
Continued• Without treatment, mortality rates are high. In studies of the natural history of the disease among sputum smear- positive and HIV-negative cases of pulmonary TB, around 70% died within 10 years; among culture-positive (but smear-negative) cases, 20% died within 10 years• The World Health Organization (WHO) declared TB a global public health emergency in 1993• 9 million new cases in 2011 and 1.4 million TB deaths (990 000 among HIV negative people and 430 000 HIV- associated TB deaths)
Annual risk of infection• ARI is the most informative index of magnitude of problem of tuberculosis• For ARI=1% 1. new Smear positive cases=50/lakh/year 2. new Smear negative cases=50/lakh/year 3. Retreatment cases=50% new smear positive (25/lakh/year) 4. Extrapulmonary and smear negative seriously ill=20% of new smear positive (10/lakh/year) 5. Total=135/lakh/year• ARI for India 1-2%
ContinuedIn India 2deaths occur in every 3minute due to 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 INDIA IN WORLD
Evolution of TB Control in India• 1962 National TB Programme (NTP)• 1992 Programme Review » only 30% of patients diagnosed; » of these, only 30% treated successfully• 1993 RNTCP pilot began• 1997 RNTCP large scale-implementation• 2002 700 million population covered• 2004 >80% of country covered• 2006 Entire country covered by RNTCP/STOP TB strategy• 2010 Universal Access to TB Care• 2012-2017 National Strategic Plan
National Tuberculosis Programme (NTP)• India has had a National Tuberculosis Programme (NTP) in place since 1962• The treatment success rates were unacceptably low and the death & default rates remained high• HIV-AIDS epidemic and the spread of multi-drug resistance TB were threatening to further worsen the situation.• In 1992, GOI, with WHO and SIDA reviewed the TB situation and the following were concluded: In order to overcome these lacunae, the Government decided to give a new thrust to TB control activities by revitalising the NTP, with assistance from international agencies, in 1993
Revised National TB Control Program (RNTCP)• Pilots were conducted between 1993- 1995 to test the operational feasibility in a population of 2.35 million in 5 pilot sites in the states of Delhi, Kerala, Gujarat, Maharashtra and West Bengal• success of these pilot sites, the programme was expanded to a population of 13.85 million in 1995 and 20 million in 1996• Large-scale implementation of the RNTCP began in 1997, following the successful negotiation of a World Bank credit of US$ 142 million• The initial 5-year project plan was to implement the RNTCP in 102 districts of the country and strengthen another 203 Short Course Chemotherapy (SCC) districts for introduction of the revised strategy at a later stage.• In early 2002, the World Bank assisted TB control project
Revised National TB Control Program (RNTCP)• Launched in 1997 based on WHO DOTS Strategy – Entire country covered in March’06 through an unprecedented rapid expansion of DOTS• Implemented as 100% centrally sponsored program – Govt. of India is committed to continue the support till TB ceases to be a public health problem in the country
Objectives of RNTCP• To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases• To achieve and maintain detection of at least 70% of such cases in the population
Strategy1. Augmentation of organizational support at the central and state level for meaningful coordination2. Increase in budgetary outlay3. Use of Sputum microscopy as a primary method of diagnosis among self reporting patients4. Standardized treatment regimens.
contd.5 Augmentation of the peripheral level supervision through the creation of a sub district supervisory unit6 Ensuring a regular uninterrupted supply of drugs up to the most peripheral level7 Emphasis on training, IEC, operational research and NGO involvement in the program
Core elements of Phase I• The core element of RNTCP in Phase I (1997-2006)was to ensure high quality DOTS expansion in the country, addressing the five primary components of the DOTS strategy
RNTCP Phase II( 2006-11) Consolidate the achievements of phase I Maintain its progressive trend and effect further improvement in its functioning MPLEMENTATIOIN OF DOTS-PLUS FOR MDR-TB CASES IN A PHASED MANNER DISRIBUTION OF PAEDIATRIC DRUG BOXES INSTITUTIONAL STRENGHTHENING AT NATIONAL, STATE AND DISTRICT LEVEL INTRODUCTION OF TB-HIV CO-ORDINATOR ,URBAN CO- ORDINATOR AND COMMUNICATION FACILITATOR.
STOP TB STRATEGY• In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP• Many of the National Airborne Infection Control guidelines, developing and piloting strategy for Practical Approach to Lung Health are the examples of initiatives taken by RNTCP under the comprehensive strategy of STOP TB
Universal Access to TB Care• The twin objectives of 70/85 alone is not enough to achieve adequate reduction of TB transmission and reduction in disease with which epidemiological impact is expected.• RNTCP defined newer objectives of Universal Access to TB Care for TB control in India in 2010• All TB patients in the community to have access to early, good quality diagnosis and treatment services in a manner that is affordable and convenient to the patient in time, place and person• All affected communities must have full access to TB prevention, care and treatment, including women, children, elderly, migrants, homeless people, alcohol and other drug users, prison inmates, people living with HIV and other clinical risk factors, and those with other life-threatening diseases
Specific actions to achieve early and complete case detection, towards universal access to TB diagnosis• Improve suspects identification• Follow up of the sputum negative symptomatic• Reduce initial defaulters• Screening for TB among high risk groups1. HIV2. Diabetic patients3. Elderly4. Smokers5. Malnutrition, patients with silicosis and other chronic diseases
Universal access to TB care in Medical Colleges
-------Improve the TB notification system by registering all cases treated underDOTS and non-DOTS (irrespective of the source of drugs and the regimen used)in the RNTCP TB register.------ Conduct operational research to identify local barriers to early casedetection,including care seeking behavior, missed opportunities for diagnosis,etc. -----Collaborate with the local authorities to implement pharmacovigilance for anti-TB drugs sold in the district/state with a view to develop locallyinnovativestrategies for improvements in notification of TB cases and promotion ofrational use of drugs.
National Strategic Plan (2012- 2017)12th Five Year Plan: RNTCP has developed National Strategic Plan to be implemented during 2012-2017Vision: "TB-free India“Goal: Universal Access to quality TB diagnosis & treatment for all pulmonary & extra pulmonary TB patients including drug resistant and HIV associated TB.
Objectives• To achieve 90% notification rate for all types of TB cases• To achieve 90% success rate for all new and 85% for re-treatment cases• To significantly improve the successful outcomes of treatment of Drug Resistant TB• To achieve decreased morbidity and mortality of HIV associated TB• To improve outcomes of TB care in the private sector
AREAS• Strengthening and improving the quality of basic DOTS services• Further strengthen and align with health system under NRHM• Deploying improved rapid diagnosis at the field level• Expand efforts to engage all care providers• Strengthen urban TB Control• Expand diagnosis and treatment of drug resistant TB• Improve communication and outreach• Promote research for development and implementation of improved tools and strategies