CME NTEP 28-12-2022 Dr Purabi.pdf

Overview of National TB Elimination
Programme and its Recent Updates
Dr Purabi Phukan
Professor and Head
Department of Community Medicine
Nodal Officer, Public Health (NTEP)
ESIC Medical College and Hospital Alwar.
11-01-2023 DR PURABI PHUKAN

TB Control to TB Elimination
Tuberculosis (TB) control activities implemented in
India for 60 years.
National TB Control Programme (NTCP), 1962
BCG Vaccination and Hospital Based TB care
Revised NTCP, 1997
shortcomings such as
1. managerial weaknesses,
2. inadequate funding,
3. over-reliance on x-ray,
4. non-standard treatment regimens,
5. low rates of treatment completion,
6. lack of systematic information on treatment outcomes.
1st Phase 1992 to 2005 – Nationwide DOTS coverage
2nd phase 2006-2011- Programme targets achieved by 2007
➢ TB epidemic persisted
➢ HIV –TB became leading cause of death
➢ Increase in MDR-TB every year

TB Free India (Strategic Plan for TB control, 2012 – 2017)-
universal access to quality TB diagnosis and treatment for
all TB patients
Initiatives under this strategy are
1. mandatory notification
2. programme integration with the general health services
(National Health Mission),
3. Expansion of diagnostics services,
4. programmatic management of drug resistant TB (PMDT)
5. single window service for TB-HIV cases,
6. national drug resistance surveillance and
7. revision of partnership guidelines.
National Strategic Plan for TB Elimination 2017-2025.
Eliminate TB in India by 2025, five years ahead of
the global target (SDG, 2030)
The 4 strategic pillars of TB elimination
“Detect – Treat – Prevent – Build”

NOTIFICATION OF TB CASES
• 2012
• 2015
• 2018
NIKSHAY: To facilitate TB notification, RNTCP developed a case-based
web-based TB surveillance system called “NIKSHAY”
(https://nikshay.gov.in ) for both government and private health care
facilities.
Medical Practitioners,
hospitals, NGOs,
private practitioners
Notify every
month to local
govt. health
authority -
DHO,CMO,
MHO/
Municipality
All laboratories
Public health staff,
Chemists dispensing TB
drugs
so that the incentives and support to patients, families
and communities can be properly extended.
D
E
T
E
C
T

TB treatment should not be started without
creation of NIKSHAY ID !!
• NIKSHAY VERSION 2 makes the following upgrades

INCENTIVES FOR TREATMENT
Direct beneficiary transfer
• Incentives for notification
• Incentives for ensuring treatment adherence
• Incentives for treatment completion
INCENTIVE TB RELATED SERVICE
Rs 250 On notification of a TB case diagnosed as per Standards for
TB Care in India (STCI)
Rs 250 On completion of every month of treatment
Rs 500 On completion of entire course of TB treatment
Rs 2750 On notification and management of a drug-sensitive
patient over 6-9 months as per STCI
Rs 6750 On notification and correct management of a drug-resistant
case over 24 months as per STCI
Private Sector TB Care Provider
D
E
T
E
C
T
T
R
E
A
T

Incentive for Nikshya Poshan
Yozana
• Centrally sponsored scheme under National Health
Mission (NHM)
• Financial incentive of Rs.500/- per month is provided
for nutritional support to each notified TB patient for
duration for which the patient is on anti-TB treatment.
• Incentives are delivered through Direct benefit transfer
(DBT) scheme to bank accounts of beneficiary.
T
R
E
A
T

DIAGNOSTIC AND TREATMENT SUPPORT
In private sector
• Free drugs and diagnostic test ensured through
1. Access to program-provided drugs and diagnostics through
attractive linkages;
2. Reimbursement of market- available drugs and diagnostics.
• Significant cost reduction of select diagnostics achieved
by ‘Initiative for Promoting Affordable and Quality TB
Tests’ (IPAQT)
D
E
T
E
C
T
T
R
E
A
T
Designated
Microscopy
Centers
Cartridge Based Nucleic
Acid Amplification Tests
(CBNAAT) / Line Probe
Assay (LPA) at district
levels for decentralised
molecular testing for drug
resistant TB.
Reference
laboratories at state
and national levels
which provide culture
and drug sensitivity
test (DST) services as
well as molecular
diagnosis.

DRUG SENSITIVITY TESTING
•Screening of all patients for
Rifampicin resistance (and for
additional drugs wherever
indicated) is done.

TREATMENT FOR TB
Daily fixed dose combinations (FDCs) with
support of DOT provider
DOT is a specific strategy, to improve adherence by any
person observing the patient taking medications in real
time. The treatment observer does not need to be a
health-care worker, but could be a friend, a relative or a
lay person who works as a treatment supervisor or
supporter. If treatment is incomplete, patients may not
be cured and drug resistance may develop.
T
R
E
A
T

Drug Sensitive TB
• first-line anti-tuberculosis drugs
• in appropriate weight bands
• In daily dosage
• for all forms of TB and
• in all ages should be given.
Intensive phase Continuation phase
2 months (8weeks) with four
drug FDCs
4 months (16 Weeks) with
three drug FDCs.
Isoniazid (INH), Rifampicin,
Pyrazinamide and
Ethambutol (HRZE)
Rifampicin, Isoniazid, and
Ethambutol (HRE)
For new TB cases (6 months total duration)
T
R
E
A
T

Drug Resistant TB (pulmonary)
• first-line anti-tuberculosis drugs
• in appropriate weight bands
• In daily dosage
• for all forms of TB and
• in all ages should be given.
Intensive phase Continuation phase
3 months (12weeks) 5 months (20 Weeks)
8 weeks (5 drugs)
Inj streptomycin, INH, Rifampicin,
Pyrazinamide and Ethambutol)
4 weeks (4 drugs)
INH, Rifampicin, Pyrazinamide and
Ethambutol)
Rifampicin, Isoniazid,
and Ethambutol (HRE)
For previously treated TB cases ( total 8 months)
T
R
E
A
T

Drug Sensitive TB (Extrapulmonary)
Bone, disseminated TB
• The continuation phase in both new and
previously treated cases may be extended by
12-24 weeks (3 -6months) based on clinical
decision of the treating physician.
T
R
E
A
T

Retreatment Group
• Refer for Rapid Molecular test / DST to
determine at least Rifampicin resistance and
preferably also isoniazid resistance status.
• If no resistance documented a standard first-line
treatment regimen (2HRZE/4HR) can be repeated.
• If rifampicin resistance is present, WHO’s shorter
regimen for MDR-TB (multi drug resistant TB) regimen
should be prescribed
• In 2016 RNTCP introduced Bedaquiline CAP for MDR-
TB under conditional access programme across six
sites, with a country wide scale up in 2017-2020.
T
R
E
A
T

Global TB Report 2022

DRUG-RESISTANT TB • .
Increase of DR-TB
between 2020 and 2021.
450 000 new cases of rifampicin-
resistant TB (RR-TB) in 2021.
Decrease in the number of people who received
treatment for RR-TB and multidrug-resistant
MDR-TB between 2019 and 2020.
161 746 received
treatment in 2021,
covering only
about one in three
of those in need.
Low treatment success
rate for drug-resistant TB at 60% globally

Test result and treatment regime

DRUG RESISTANT TB TREATMENT
3 REGIMENS

TREATMENT OF EXTRAPULMONARY TB

TREATMENT OF EP TB

Sample collection for TB Test
FORMALIN NORMAL SALINE

Diagnosis and treatment of TB

Key populations addressed in NSP
• TB-HIV
• Diabetics, Tobacco use and Alcohol dependence
• Poor, undernourished, economically and socially
backward communities
• TB control in hilly and difficult terrains
• Substance dependence and sexual minorities
• TB and pregnancy
• Paediatrics population
• Prison Inmates and staff of prisons/jails
• management of extra pulmonary TB

Prevent emergence of TB in
susceptible population
• Scale up air-borne infection control measures at
health care facilities.
• Treatment for latent TB infection in contacts of
bacteriologically-confirmed cases
• Address social determinants of TB through
intersectoral approach (like poverty, malnutrition,
urbanization, indoor air pollution).
P
R
E
V
E
N
T

TB determinants
Global estimates of TB cases attributable to 5 risk factors in 2021
0.5
0 1.0 1.5 2.0
Millions
Undernourishment
HIV infection
Alcohol use disorders
Smoking
Diabetes

Contact tracing- Since transmission can occur from
index case to the contact any time (before diagnosis or
during treatment) all contacts of TB patients must be
evaluated. These groups include:
• All close contacts, especially household contacts
• In case of pediatric TB patients, reverse contact tracing
for search of any active TB case in the household of
the child must be undertaken.
• Particular attention will be paid to contacts with the
highest susceptibility to TB infection
P
R
E
V
E
N
T

• Isoniazid Preventive Therapy (IPT)- Recommended for
• Children < 6 years of age, who are close contacts of a TB patient. After
excluding active TB by a medical officer/ pediatrician.
• HIV infected children who either had a known exposure to an infectious
TB case or are Tuberculin skin test (TST) positive (>=5mm induration) but
have no active TB disease.
• All TST positive children who are receiving immunosuppressive therapy
(e.g. Children with nephrotic syndrome, acute leukemia, etc.).
• A child born to mother who was diagnosed to have TB in pregnancy will
receive prophylaxis for 6 months, provided congenital TB has been ruled
out. BCG vaccination can be given at birth even if INH preventive therapy
is planned.
• Close contacts of index cases with proven DR-TB (drug resistant-TB) will
be monitored closely for signs and symptoms of active TB as isoniazid
may not be prophylactic in these cases.
P
R
E
V
E
N
T

TPT

• BCG vaccination- It is provided at birth or as
early as possible till one year of age.
• BCG vaccine has a protective effect against
meningitis and disseminated TB in children.
P
R
E
V
E
N
T

Health system strengthening for TB control
under the National Strategic Plan 2017-2025
• Building and strengthening enabling policies
• Empowering institutions and human resources
with enhanced capacities.
Innovations and research
B
U
I
L
D

Elimination of TB

Pradhan Mantri TB Mukt Bharat Abhiyan,
2022
• Any person or organization can adopt TB patients and
the adopted patients will be taken care of.
• 66 % TB patients currently on treatment have given
their consent for adoption under this campaign
• The people and institutions who come forward to take
care of the patients will be called “Nikshay Mitras”.
• The period of Nikshay Mitra support can be chosen
from one year to three years. They can also choose
the state, district, block, health facilities.
• 13.5 lakh TB patients are registered in the NIKSHAY
portal, out of which 8.9 lakh active TB patients have
given their consent for adoption.

INDIA
2020 2021

Millions
Most obvious impact at global level
Big reductions (vs 2019) in reported number of people newly diagnosed
with TB
2019
2018
2017
2016
2015
6.0
7.0
6.5
5.5
7.5
7.1 million in 2019
6.4 million in 2021
5.8 million in 2020
18% drop,
2019-2020 Partial recovery,
2020-2021
2020 2021

END TB Strategy 2035

END TB Strategy, WHO
Reaching an equivalent 90% reduction in tuberculosis incidence rate from a
projected 110 cases/100 000 in 2015 to 10 cases/100 000 or less by 2035.

Tuberculosis -public health importance
• 2nd leading infectious killer after COVID-19 in 2022
• 13th leading cause of death worldwide.
• Leading killer of people with HIV
• A major cause of deaths related to antimicrobial
resistance.
• Covid PANDEMIC has reversed the achievements
made so far

GAP in TB Care
2000 and 2021
Saved 74 million lives
globally between 2000
and 2021.
2018 and 2021
Total TB patients treated between 2018 and
2021 was 26.3 million, equivalent to 66% of
the 5-year (2018–2022) UN High Level
Meeting TB target of 40 million.
2021
Rise in estimated
undiagnosed TB cases from
3.2 million in 2019 to 4.2
million in 2021.

GAP in Diagnostics and Drugs
• WHO-recommended rapid diagnostic test is one of
the main components of TB laboratory-
strengthening efforts under the End TB Strategy
• Only 38% of the 6.4 million people newly
diagnosed with TB in 2021, up from 33% in 2020
and 28% in 2019.

Progress towards Universal Health Coverage, better
levels of social protection and multisectoral actions of
broader TB determinants
Globally 48% of the households face catastrophic cost of TB care
Globally 2.2 million new cases of TB were attributable to
undernourishment, 0.86 million to HIV infection, 0.74 million to
alcohol use disorders, 0.63 million to smoking and 0.37 million to
diabetes. (Social Determinants)
The Global TB Report features a TB-SDG monitoring framework that
focuses attention on 14 indicators that are associated with TB
incidence. (Monitor and identify key influences on TB epidemic)

Subnational Certification (SNC) of
Districts/ States/ UTs for TB elimination
efforts

Role of Medical Colleges
• Provide overall leadership along with WHO and ICMR
institute during the whole certification process.
• IAPSM is major stakeholder in the activity, so medical
college needs to identify two faculties from the PSM
department and deploy them in the concerned district for
the prescribed duration.
• The nominated faculties will conduct field travel as and
when required. Detailed SoP and guideline for field travel
will be disseminated before the SNC activity.
• Faculty will support the district in conducting training of
the survey volunteers.
• Medical college faculty has major role in the analysis of
the secondary data i.e. TB score, NNT, drug
consumption/sale data, and epidemiological data.

Role of Medical Colleges
• Entry of the verified secondary data in the ICMR portal designed
for SNC activity.
• Field monitoring and supervision of the survey teams.
• Conducting group discussions and key informant interviews with
the private sector stakeholders (Doctors, chemist, distributors and
drug inspectors), collection of the qualitative data, script writing
and preliminary analysis of the qualitative data.
• Preparation of the final report for the SNC activity in the district
and submission of the report to IAPSM, ICMR and central TB
division.

SOP for Medical College Core committee (MCCC) - 3
1. Recording the administration of diagnosis, treatment and referral for treatment in
the NTEP prescribed format for Medical Colleges.
2. Coordination between various departments so that the patients get the services in
respect of their TB problem under one roof.
3. Ensure submission of Medical College quarterly report to the STF . This needs to be
done within the 15 days of the quarter end i.e. the quarterly report for the Ist
quarter (Jan - March) are to be submitted before April 15.
Functions of Medical College Core Committee (MCCC)

4. Hold a quarterly review meeting of the core committee to review performance of
the NTEP activities in the medical college and share the minutes of the same with
the STF/DTO.
5. Training of Medical College faculty/ staff, which includes Training of the faculty
coordinator in Training of trainers, Master trainers (MO TC modular training at
state/national level), Heads of department/nominated core committee members
in concise modular training at state level, other interested faculty in MO modular
training at College level and nurses and para-medical staff in Multi-Purpose
Worker training at Medical College level.
6. Organize sensitization workshops/ trainings for other faculty members/ PGs/ UGs/
Interns/ paramedical staff in the Medical College.

7. Ensure that teaching on TB/NTEP form a part of the curriculum for PG
students/ Residents / Interns/ UG students.
• Teaching should include practical training through regular
postings/ visits to treatment (DOT) centre as well as
classes/lectures taken by departments of Medicine, TB & Chest
Medicine, Microbiology, PSM etc.
8. Coordinate with the district TB programme for participation in the
quality assurance network of sputum microscopy, referral for treatment
network, management of complicated cases of TB, and submission of
monthly PHI report.
9. Undertake Operational Research for NTEP on the priority areas defined
by the STF for the State. Encourage research on TB by faculty
members as well as by PG students for their thesis, etc.

10.Undertake advocacy for the programme by publishing articles on TB,
newsletters, giving radio/ TV talks, etc and participate in NTEP related
activities carried out by the state/district whenever requested.
11.Support District TB Officer in Active Case Finding (ACF).
12.Conducting meeting with Standard agenda and template
13.Realtime Ni-kshay entry
14.Any other activity to augment end TB efforts

Key Issues
• A Large number of physicians are yet to be familiarized with NTEP
which is an ongoing activity under NTEP.
• 560 / 605* medical colleges ( as per NMC* ) are participating in NTEP & still a
significant number of medical colleges are yet to implement NTEP ( ongoing ).
• 30 Medical colleges in Rajasthan
• Continuing success of NTEP requires the involvement of all large
providers of care including medical colleges because still TB patients
continue to be treated outside NTEP with:
• X rays as the primary basis of diagnosis
• Non-supervised non-NTEP regimens, many not compliant with STCI
• No system for tracking ‘lost to follow up’ cases
• Undesirable effect on the learning experience and attitude of
undergraduate and postgraduate medical students.

Year
Total TB case
Notified
Medical college
notified
%
contribution
Total TB case
Notified
Medical
college
notified
%
contribution
2018 2101970 219124 10 148549 23426 16
2019 2401351 330486 14 173120 22439 13
2020 1812560 219274 12 137387 19831 14
2021 2120133 257062 12 149553 22984 15
Medical Colleges Contribution
Issues
INDIA RAJASTHAN

100750
166041
109487 111720
118374
164445
109787
96111
54.0%
49.8% 50.1%
46.2%
42.0%
44.0%
46.0%
48.0%
50.0%
52.0%
54.0%
56.0%
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
2018 2019 2020 2021
Total TB cases (National level)
Clinical TB vs Microbiological
Confirmed TB
Clinically diagnosed
Microbiologically confirmed
32028
45199
28560 30871
99743
134257
87843
76631
75.7%
74.8%
75.5%
71.3%
68.0%
70.0%
72.0%
74.0%
76.0%
78.0%
0
50000
100000
150000
2018 2019 2020 2021
Pulmonary TB (National level)
Clinical TB v/s Microbiological
Confirmed TB
Microbiologically confirmed TB
% Microbiologically confirmed TB
Medical Colleges: Issues

66801
123833
84782 82169
5312 10751 8719 7388
8%
9%
10%
9%
0%
2%
4%
6%
8%
10%
12%
0
20000
40000
60000
80000
100000
120000
140000
2018 2019 2020 2021
Grand Total
100670
165639
109333
111573
118374
164427
109757
96111
54.0%
49.8% 50.1%
46.3%
42.0%
44.0%
46.0%
48.0%
50.0%
52.0%
54.0%
56.0%
0
20000
40000
60000
80000
100000
120000
140000
160000
180000
2018 2019 2020 2021
% Microbiologically confirmed TB
EP TB (National level)
Clinical vs Microbiological Confirmed TB
Paediatric TB (National level)
Clinical vs Microbiological Confirmed TB
Medical Colleges: Issues

Rajasthan Picture- TB notification on Nikshay (Jan-Sept22)
Sl no District name
No of Medical
college/Associated
Med. College
Total Patients
ENROLLED
on Nikshay (Jan-Sept
22
1 Rajasthan 54 7889
2 Udaipur 10 2272
3 Jodhpur 9 1791
4 Ajmer 2 1181
5 Jaipur 1 5 954
6 Kota 6 829
7 Jaipur 2 4 364
8 Pali 1 255
9 Rajsamand 1 144
10 Bikaner 6 63
11 Jhalawar 1 31
12 Dungarpur 2 5
13 Bhilwara 1 0
14 Churu 1 0
15 Sikar 1 0
16 Alwar 1 0
17 Barmer 2 0
18 Bharatpur 1 0
Medical College
contribution as
per reports :
26051

Sl no District name
No of Medical
college/Associated Med.
College
Total ADULT OPD
Total Tested for
TB
% tested
1 Bhilwara 1 0 0 0%
2 Churu 1 0 0 0%
3 Sikar 1 232600 0 0%
4 Dungarpur 2 195465 282 0%
5 Alwar 1 15893 28 0%
6 Rajsamand 1 266967 1050 0%
7 Kota 6 291943 3003 1%
8 Barmer 2 105755 1989 2%
9 Bikaner 6 303923 5759 2%
10 Rajasthan 54 2770248 59079 2%
11 Ajmer 2 156055 4210 3%
12 Jaipur 1 5 380022 11230 3%
13 Jodhpur 9 430913 12756 3%
14 Pali 1 50643 1586 3%
15 Bharatpur 1 73312 2576 4%
16 Udaipur 10 198924 9721 5%
17 Jaipur 2 4 57150 3760 7%
18 Jhalawar 1 10683 1129 11%
TB Testing in medical college hospitals (Jan-Sept 22)

NTEP efforts to strengthen the mechanism
1. Deployment of NAAT machine in each medical college hospital
2. Cover all NAAT & CDST equipment under centralized maintenance
3. Procurement & supply of NAAT & CDST consumables
4. Access to newer drugs-bedaquline & Delamanid
5. Guidance to all medical college hospitals to start OPD /IPD based DRTB
treatment as per latest PMDT guidelines.

Way forward
• Test at least 4-5% of our OPD for TB.
• Mandatory TB screening of In-door patients
• Establish & strengthen rapid molecular testing facility at all HF
• Strive for microbiological evidence of TB diagnosis
• Ensure Drug susceptibility-based treatment- DST
• Say NO to empirical therapy & therapeutic trial
• Initiate & counsel the patient timely.
• Record & report through NI-KSHAY- Establish a single window system at all medical
college hospitals.

Required training?
In place
Trained in 2022
No. Trained No. Sensitized
Number of Faculties
Number of PG
students & residents
Number of Interns
Number of UG
students
Number of Staff
Nurse
Number of LT

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