This document provides an overview of the global and Indian tuberculosis burden and the Revised National Tuberculosis Control Programme (RNTCP) in India. Some key points: - TB is a major global public health issue, with an estimated 8.8 million new cases and 1.1 million deaths in 2010. India accounts for 20% of the global TB burden. - The goals of RNTCP are to achieve an 85% cure rate for new sputum-positive TB patients and detect 70% of new sputum-positive cases. - RNTCP implements the DOTS strategy, which involves quality-assured diagnosis, supervised treatment, uninterrupted drug supply, and monitoring through a standardized recording and

1. by
Dr. Sridhar.D
2nd year PG
Department of Community Medicine
Osmania Medical College
Hyderabad

2. OVERVIEW
Global and Indian scenario
Control of tuberculosis
RNTCP

3. Estimated TB incidence rates 2010

4. Global TB disease burden
8.8 million incident cases of TB (range, 8.5million-9.2
million) globally in 2010
1.1 million deaths (range, 0.9 million-1.2 million) among HIV-
negative cases of TB and
An additional 0.35 million deaths (range, 0.32million-0.39
million) among people who were HIV positive In 2009
There were an estimated 9.7 million (range, 8.5-11 million)
children who were orphans as a result of parental deaths caused
by Tuberculosis.
The WHO Global TB Report 2011

5. Global estimation of burden of HIV positive incident
TB cases is 10,00,000 (11,00,000-12,00,000) while the
estimates of HIV positive incident TB cases in India is
75,000 (1,10,000 - 1,60,000), HIV prevalence amongst
incident TB cases is estimated to be 3.3% (5%-7.1%).
Globally, about 1 million cases of paediatric TB are
estimated to occur every year accounting for 10-15% of
all TB; with more than 100,000 estimated deaths every
year, it is one of the top 10 causes of childhood
mortality.
The WHO's Global TB Report of 2011

6. Estimated burden of tuberculosis in
India
Number (Millions)(95%CI) Rate Per 100000
persons(95 CI)
Incidence
All cases(2009 WHO 2.0(1.6-2.4) 168
estimates)
Period Prevalence (2000
GoI estimate)
AFB positive 1.7 (1.3-2.1) 165 (126-204)
Bacillary 3.8 (2.8-4.7) 369 (272-457)
Prevalence, all cases (2009 3.0 (1.3-5.0) 249
WHO estimate)

7. India is the highest TB burden country in the world
accounts 20% of global burden of TB and 2/3rd of cases
in SEAR.
Every year approximately 1.8million persons develop
tuberculosis, of which about 0.8 million are new cases.
Annual risk of becoming infected with tb is 1.5% and
once infected there is 10% life time risk of developing
TB disease.
Patients with infectious pulmonary tuberculosis disease
can infect 10-15 persons in a year.

8. Case notification 2010 in India
New cases Number(thousand Retreatment cases Number(thousand
s)& % s)& %
%
Smear +ve 630165(51) relapse 110691(38)
Smear -ve 366381(30) Treatment after 18463(6)
failure
Smear unknown Treatment after 72110(25)
default
extrapulmonary 231121(19) other 91708(31)
other 1508(<1)
Total new 1229175 Total rertretment 292972
Total <15 years 13415
Total new and relapse 1339866 88% of total
Total notified cases 1522147

9. The estimated MDR TB cases emerging annually in India are
reported to be 99,000 among incident total TB cases in India
in 2008 (range 79,000 - 1,20,000).
As per the WHO Global TB Report 2011, Estimated number
of MDR-TB cases out of notified Pulmonary TB cases in
India is 64,000 (range 44,000 to 84,000) emerge annually.
WHO Global TB Report 2010 and Multidrug and
extensively drug-resistant TB (M/XDR-TB) - 2010 Global
Report on Surveillance and Response

10. TB India annual report 2012.

11. The control of tuberculosis
Tuberculosis control means reduction in the prevalence
and incidence of the disease in the community.
The WHO defines that tuberculosis “control” is said to
be achieved when the prevalence of natural infection in
the age group 0-14 years is of the order of 1 %. This is
about 40% in India.
The control measures consists of a curative component-
namely case finding and treatment and prevention.

12. Case finding
A “case” is defined by WHO as a patient whose sputum
is positive for TB bacilli and such cases are the target of
case finding.
All other possible sufferers from TB whose sputum is
negative but who show suggestive shadows in chest x-
ray’s are reckoned as “suspects”.
Park’s text book of Preventive and Social Medicine 21st
edition
AFMC Text book of Public Health and Community Medicine
www.WHO.int

13. Target group-pulmonary TB patients because pulmonary
TB is most common and causes pool of infection every
year.
Case finding tools:-
{1}sputum examination: direct microscopy
Collection of samples- 2samples
day1 sample1 Patient provides an
“on the spot “
sample
day2 sample2 Patient brings an
early morning sample

14. Slide reporting
Number of bacilli Results reported
No AFB per 100 oil 0
Slide reporting immersion fields
1-9 AFB per 100 oil Scanty( number AFB
immersion fields seen)
10-99 AFB per 100 oil +(1+)
immersion fields
1-10 AFB oil immersion fields ++(2+)
>10 AFB oil immersion fields +++(3+)

15. RNTCP Laboratory Network
4 NRLs
27 IRLs
>12,000 DMCs
(one per 50,000-100,000
population)

16. Quality Assurance (QA)
External Quality Internal Quality Quality
Assessment (EQA) Assurance Improvement
(Quality Control) (QI)
1. On Site Evaluation
(OSE) 1. Instrument
1. Data
checks
2. Panel Testing Collection
2. Reagent
3. Random Blinded 2. Data Analysis
quality check
Rechecking 3. Solving
(RBRC) problems

17. One specimen out two is enough to declare positive TB.
Patients in whom both specimens are smear negative
should be prescribed symptomatic treatment and broad
spectrum antibiotic for 10-14 days.
If symptoms persists after treatment repeat sputum smear .
if one smear is positive label as smear positive and none of
the repeated smear positive take chest x-ray if it suggests
pulmonary TB label as sputum negative pulmonary TB .

18. Sputum culture: it is only second in importance in case
finding.
Available at district and regional chest clinics
Necessary for carrying out sensitivity tests and
monitoring drug treatment.
{2}mass miniature radiography : stopped as general
measure of case finding due to lack of definitiveness,
high cost , erroneous interpretation of films, very low
yield of cases.
{3}tuberculin test: invalidated as case finding tool.

19. Treatment
1st line drugs 2nd line drugs
Bactericidal Bacteriostatic Fluroquinolones
Rifampicin(RMP) Ethambutol Ethionamide
Isoniazide(INH) Thioacetazone Capreomycin
Streptomycin Kanamycin and Amikacin
Pyraxinamide Cycloserine
Macrolides
Two phase chemo therapy: 1st is short , aggressive or
intensive phase fo 1-3 months 2nd is continuation phase

20. Long course regimens:
daily regimens
bi-weekly regimens
Short course chemotherapy: 1972 Wallace Fox
advantages- rapid bacteriological conversion, lower
failure rates, and reduction in frequency of emergence of
drug resistant bacilli. Patient compliance will improve
disadvantage- high cost of short –term chemotherapy.

21. DOTS
cost effective approach to tuberculosis control.
(a) accuracy of diagnosis is more than doubled
(b) treatment success rate is upto95%
(c) prevents the spread of infection thus reducing the incidence
and prevalence of tb.
(d)improves quality of health care and removes stigma
associated with Tb
(e) prevents failure of treatment and the emergence of MDR-TB
by ensuring patient adherence and uninterrupted drug supply
(f) helps alleviate poverty by saving lives , reducing duration of
illness and preventing spread of infection
(g) lends credibility to TB control efforts

22. The success of DOTS depends on five components:
- Political commitment
- Good quality sputum microscopy
- Directly observed treatment
- Uninterrupted supply of good quality drugs, and
- Accountability

24. Revised Categories
Treatment groups Type of Patient Regimen
Intensive Continuation
Phase(IP) Phase(CP)
New (Cat I) New Sputum smear-positive 2(HRZE)3 4(HR)3
New Sputum smear-negative
New Extra-pulmonary
New Others
Previously Treated (Cat II) Smear-positive relapse 2 (HRZES)3/ 5(HRE)3
Smear-positive failure 1(HRZE)3
Smear-positive treatment after
default
Others
MDR-TB Cases(Cat IV) 6 (9) Km Ofx 18 Ofx
(Lvx) Eto Cs Z (Lvx)Eto Cs
E E

25. MDR / XDR
MDR-TB is defined as resistance to isoniazid and rifampicin,
with or without resistance to other anti-TB drugs from an
accredited RNTCP Laboratory
XDR-TB is defined as resistance to at least Isoniazid and
Rifampicin (i.e. MDR-TB) with resistance to any of the
fluoroquinolones and any one of the second-line injectable drugs
(amikacin, kanamycin, or capreomycin).
NTM is Non-Tuberculous Mycobacteria reported in the sputum
specimen by an accredited RNTCP Laboratory

26. DOTS-plus
It refers to DOTS programs that add components for
MDR-TB diagnosis, management and treatment
DOTS-plus strategy promotes full integration of DOTS
and DOTS-plus activities under the RNTCP
1. Sustained government commitment
2. Accurate , timely diagnosis through quality assured
culture and drug susceptibility testing
3. Appropriate treatment utilizing second line drugs
under strict supervision
4. Uninterrupted supply of quality assured anti-TB drugs
5. Standardized recording and reporting.

27. Treatment during pregnancy
in place of Streptomycin Ethambutol added
INH , RMP , Pyrazinamide and Ethambutol are safe
Ethionamide and Protionamide are teratogenic.

28. Childhood tuberculosis
10-20% of all tb cases
Usally sputum smear –ve
Children under 5years of age ae more prone to develop the disase mostly
with in 2years following infection
The commonest age is 1-4 years.
drugs dosage
Isoniazide 10-15mg/kg
Rifampicin 10mg/kg
Pyrazinamide 35mg/kg
Streptomycin 15mg/kg
Ethambutol 30mg/kg
Ethambutol should not be given to children below 6years of age

29. For infants if the mother or any other household member
is smear positive then chemoprophylaxis should be
given for 3 months then do mantoux test. If test is
negetive stop chempprophylaxis and give BCG
(if previously not vaccinated). If test is positive continue
chemoprophylaxis for a total duration of 6months

30. BCG vaccination
Aim: to reduce morbidity mortality from primary
infection.
Vaccine: Danish 1331 strain
Types of vaccine: liquid(fresh) vaccine
freeze dried vaccine
Dosage: 0.1mg in 0.1ml volume
administration: tuberculin syringe
intra dermal
just above the insertion of deltoid

31. Age: either at birth or at 6weeks of age (tuberculosis high
prevalent countries)
high risk groups ( low prevalent countries).
Phenomena after vaccination:
2-3 wks - develops papule
5 weeks - 4-8mm diameter
develops into shallow ulcer
6-12 weeks - permanent scar
Complications: prolonged ulceration
suppurative lymphadenitis
osteomyelitis
disseminated infection

32. Protective value: 15-20 years
protection offered by BCG varies from 0-80%.
Because prior exposure to non tuberculous
environmental mycobacteria.
Contra indications: generalized eczema, infective
dermatosis, hypogammaglobulinaemia, history of
deficient immunity, patients under immuno suppressive
treatment.

33. Chemoprophylaxis
(preventive treatment)
With INH for 1year or INH + Ethambutol for 9months
It is costly exercise , not effective, causes drug induced
hepatitis.
Chemoprophylaxis with INH can prevent the
development of tb in infected individuals, but impact on
the community will be minimal because it cannot
applied on mass scale.

34. surveillance
It is an integral part of any effective tuberculosis
programme
By annual infection rates
Surveillance of control measures applied such as BCG
vaccination and chemotherapy.

35. Revised National Tuberculosis
Control Programme (RNTCP)
The Goal and Objectives of the RNTCP
Goal: The goal of RNTCP is to decrease mortality and
morbidity due to TB and cut transmission until TB ceases
to be a major public health problem in India.
Objectives:
1) To achieve at least 85% cure rate of the newly
diagnosed sputum smear-positive TB patients; and
2) To detect at least 70% of new sputum smear-positive
patients after the 1st goal is met.
Strategy: DOTS is a systematic strategy which has five
components.

36. Cont…
The revised strategy was introduced in the country as a
pilot project since 1993 in a phased manner as Pilot
Phase I, II, III.
RNTCP has expanded rapidly over the years and now it
covers the whole country.
It has now entered into its second phase.

37. Technical Organization of the Tuberculosis Programme in India
National level
Deputy Director General, TB
National Institutes
State level
(State TB Officer)
State TB Training and
Demonstration Centre
District level Metropolitan City
(District TB Officer) (City TB Officer)
District TB Centre
Sub-district level Municipal Ward
(Medical Officer-TB Control) (Chest Clinic)
Tuberculosis Unit
Peripheral health level Primary Health Centre Health Post /
Medical Officer Microscopy Centres Microscopy Centres

38. RNTCP Structure and Service Delivery
Mechanisms
At the Center: The Central TB Division (CTD) is
responsible for developing technical policies, procuring
drugs, preparing training modules, quality assurance,
advocacy, operational research priorities and mobilizing
funds.
At the State: State Tuberculosis Officer ( STO) is
responsible for planning, training, supervising and
monitoring the programme in their states as per
guidelines.

39. Cont..
At the District: District TB Centre(DTC) is the key
organizational unit for implementation of the programme. It’s
the nodal point for TB control activities in the district.
In RNTCP, the primary role of DTC has shifted from a
clinical one to a managerial one.
District TB Officer (DTO) has overall responsibility of
management of RNTCP at district level.

40. Cont..
Tuberculosis Unit(TU): A major organizational change in
RNTCP is the creation of a sub-district level Tuberculosis
Unit.
TU consists of a designated Medical Officer-Tuberculosis
Control(MO-TC), as well as a Senior Treatment Officer(STS)
and a Senior Tuberculosis Laboratory Supervisor(STLS).
TU covers a population of approximately 5lakh or it covers 5
Designated Microscopic Centres(DMC)

41. Key Functions of the TU
Maintain the TB Register which contains
information on the diagnosis and treatment of
every patient
Ensure effective diagnosis by microscopy and
directly observed treatment
Complete quarterly reports on diagnosis, sputum
conversion, treatment outcome, and programme
management

43. Programme Surveillance System
Peripheral Health
Institute (DMC and other PHIs)
Monthly PHI Report
Tuberculosis Unit Cohort analysis
System electronic
from district level
Quarterly CF, SC, RT, PM Reports
upwards
Additional District TB Centre Quarterly
Feedback Electronic reports) Feedback
Quarterly Reports
CF, SC, RT, PM
Central TB Division State TB Cell

44. WHO-recommended Stop TB Strategy (2006)
to Reach the 2015 MDGs

46. Millennium Development Goals
related to Tuberculosis
Goal 6--to combat HIV/AIDS, malaria and other diseases.
Target 8– to have halted by 2015 and begun to reverse the
incidence of malaria and other major diseases, including
tuberculosis.
Indicators for Target 8 to be used to evaluate the
implementation and impact of TB control (derived from STOP TB
strategy)
Indicator 23: Between 1990 and 2015, to halve the prevalence
and death rates associated with tuberculosis; and
Indicator 24: By 2005, to detect 70% of new smear positive TB
cases arising annually, and to successfully treat 85% of these
cases.

47. Programmatic management of drug
resistant TB(PMDT)
The RNTCP PMDT Vision is as follows:
By end 2011, basic RNTCP PMDT services will be initially
introduced in all states, with complete geographical coverage
by end 2012
By 2013, access to laboratory based quality assured DST and
appropriate treatment for at least
all smear-positive re-treatment TB cases at diagnosis, and
all cases who remain smear-positive after first-line drug
treatment
By 2015, access to MDR-TB diagnosis and treatment for
all smear-positive TB (new and retreatment) cases
registered under RNTCP early during their treatment
RNTCP plans to initiate at least 30,000 MDR cases on
treatment annually by 2013

48. GoI commitment at Beijing Ministerial Meeting –
2009
Plan for patients to be tested and treated for MDR-
TB
*Based on RNTCP 2012 goal of MDR diagnosis for all S+ retreatment patients,

51. 12th Five year plan
12th Five Year Plan: RNTCP has developed National
Strategic Plan to be implemented during 2012-2017, the
national 12th Five Year plan period, with following Vision
and objectives for RNTCP:
Vision: "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.

52. Cont…
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

53. TB/HIV Collaborative Efforts
Central TB Division(CTD) & National AIDS Control
Organization(NACO) have revised the “National framework
for joint TB-HIV collaborative activities” in Oct 2009.
All the WHO recommended TB/HIV collaborative activities
have been incorporated and include the following:
1) Strengthen NACP-RNTCP coordination mechanisms at
national, state and district levels.
2) Joint Monitoring and Evaluation between 2 programmes.

54. Cont..
3) Training of Programme and field staff
4) Scaling up of Intensified TB/HIV Package of services
across the country
5) Activities to reduce the burden of TB among HIV-
infected individuals
6) Involvement of NGO’s
7) Operational research

56. World TB day
Falling on March 24th each year, is designed to build
public awareness that TB today remains an epidemic in
much of the day, causing deaths of several million
people each year.
It commemorates the day in 1882 when Dr.Robert
Koch astounded the scientific community by
announcing that he had discovered the cause of
tuberculosis, the TB bacillus.

57. Theme for 2012
Theme for 2012’s world TB day is
“Stop TB--- in my life time”
Some hopes people of different ages and living in
different countries may have for stopping TB in their
lifetimes…
Zero deaths from TB
Faster treatment
A quick, cheap, low-tech test
An effective vaccine
A world free of TB

58. References
WHO's Global TB Report of 2011.
Multidrug and extensively drug-resistant TB (M/XDR-TB) - 2010
Global Report on Surveillance and Response.
TB India annual report 2012.
Park’s text book of Preventive and Social Medicine 21st edition.
AFMC Text book of Public Health and Community Medicine.
J . Kishore’s National Health Programs of India 10th edition.
www.WHO.int
National Scale-up Plan for the Programmatic Management of Drug
Resistant Tuberculosis (PMDT)2011 – 2012.
http://www.stoptb.org/
Tuberculosis Control Laws and Policies: A Handbook for Public
Health and Legal Practitioners by CDC.