new rntcp guidelines 2016

1. NEW VISION FOR TB
CONTROL
- DR. PRAPULLA CHANDRA

2. India has highest TB burden
6%
5%
5%
4%
3%
3%
2%
2%
2%
1%
1%
India
Other
South Africa
Indonesia
Pakistan
Bangladeshd
Philippines
Ethiopia
DR Congo
Myanmar
Nigeria
Mozambique
Russian Federation
Vietnam
Kenya
23%
10%
10%
Data source: Global TB Report 2016, WHO
Global annual incidence = 10.4
million
India annual incidence = 2.84
million

3. TB Burden
Global India
Incidence
TB
104 lakh 28.4 lakh
Mortality
of TB *
14 lakh 4.8 lakh
Incidence
HIV TB
12 lakh 1.13lakh
Mortality
of HIV-TB
*
4.0 lakh 37,000
MDR-TB 5. 8 lakh 1.3 lakh

8. National Strategic Plan for TB Control
2012-2017
Universal Access
to quality TB
diagnosis and
treatment for all
TB patients in
the community
A TB FREE
INDIA Early and improved
diagnosis(90%)
Access to high-quality treatment(90%)
Scale-up access to effective
DR TB treatment
Decrease the morbidity and
Mortality in HIV TB
Extend RNTCP services to
patients in Private Sector

9. Evolving Strategies – Case Finding
Passive
Intensified
Active
ZN &
LED
Microsc
opy
Radiol
ogy
Molecu
lar
diagnos
tics
Culture
& DST
Linkage
s
Co
morbiditi
es
Key
Populati
ons
Slums
Migran
ts
Communi
ties

11. Evolution in TB Diagnosis
• LED microscopy.
• MODS-Microscopic Observation Drug Susceptibility
• LPA refinement for smear negative MDR TB suspects
• Rapid Identification of species by strip speciation test
• Breathalyzer screening test
• First generation loop mediated isothermal
amplification technology platform (LAMP)
• Urinary Lipo-arabinomannan (LAM) or any other
antigen detection tests
• Rapid automated 2nd and 3rd generation NAATs for
first and second line DST

13. PREVIOUS RECOMMENDATIONS :
• Commercial molecular line probe assays for 1st-line anti-TB drugs:
For use at central/regional reference laboratory level for rapid
detection of rifampicin (alone or with isoniazid) resistance. Suitable
for use on smearpositive specimens or culture isolates.
• NOT recommended for 2nd line drugs.

15. Automated NAAT
(GeneXpert / Xpert MTB/RIF)
• Result in 90m
• M TB – Y / N
• Rif res – Y / N
• 70% additional
yield in smear
negative TB
15Gokulam 21-03-2014

19. PREVIOUS RECOMMENDATIONS
• LAMP NOT recommended for use due to insufficient data.

21. URINARY LAM TEST
• Detection of lipoarabinomannan (a lipopolysaccharide
component of MTB cellwall) antigen in urine.
• Single clinical visit, results in ½ hr.
• sensitivity is 28.2 %
• But sensitivity increases to 66.7% when CD4 cell count <50
• In HIV pts, LAM + Smear microscopy increases sensitivity
comparable to GeneXpert MTB/RIF .

22. BREATHALYZER TEST
• Uses optical detection technology with fluorometry.
• The collection tube was designed to collect aerosols and
particles coughed out by the patient.
• Result can be obtained in 10min.
• Sensitivity is 74% and specificity is 79%

24. - TECHNICAL OPERATIONAL GUIDELINES FOR TB CONTROL IN INDIA 2016

25. 25

26. Current views leading to change in regime to
daily regime
• High rates of “relapse” in RNTCP ~ 12 - 15%
• Incidence rates remain high
26

27. Himachal Pradesh
Sikkim
Bihar
Maharashtra
Kerala
Daily Regimen
implementation
in 104 districts
Total population -
2690 Lakh

28. 28

31. MAIN CHANGES IN 2016 UPDATE
• A shorter MDR-tb treatment regimen under specific
conditions.
• Medicines used in the MDR tb treatment regimens are now
regrouped differently.
• MDR-tb treatment is recommended for all pts of RR-TB
regardless of confirmation of isoniazid resistance.
• Clarithromycin and other macrolides are no longer included
in the treatment of MDR-tb.

32. Earlier WHO classification of anti TB drugs
Group Drugs
Group 1. First line oral drugs Isoniazid, Rifampicin
Ethambutol, Pyrazinamide
Rifabutin, Rifapentine
Group 2. Injectable anti-TB drugs Streptomycin (First line)
Kanamycin, Amikacin, Capreomycin
Group 3. Fluoroquinolones Ofloxacin, Levofloxacin
Moxifloxacin
Group 4. Oral bacteriostatic second-line anti-TB
drugs
Ethionamide, Prothionamide
Cycloserine, Terizidone
Para-aminosalicylic acid
Group 5. Anti-TB drugs with limited
data on efficacy and/or long term
safety in the treatment of drug-resistant
TB
Bedaquiline
Delamanid
Linezolid
Clofazimine
Amoxicillin/ clavulanate
Imipenem/cilastatin; Meropenem
High-dose isoniazid
Thioacetazone
Clarithromycin

36. • The shorter MDR-TB treatment regimens were standardized in
content and duration and split into two distinct parts.
• The first was an intensive phase of four months (extended up to a
maximum of six months in case of lack of sputum smear conversion)
and included the following drugs: gatifloxacin (or moxifloxacin),
kanamycin, prothionamide, clofazimine, high-dose isoniazid,
pyrazinamide and ethambutol.

37. • This was followed by a continuation phase of five months with the
following medicines:
• gatifloxacin (or moxifloxacin), clofazimine, pyrazinamide and
ethambutol.

38. Introduction of Bedaquiline
BDQ-CAP (Conditional access programme)
• Six sites identified to roll
out BDQ CAP
• Guidelines have been
prepared
• National Training of
trainers(TOT) done at
NTI Bangalore in Jan
2016
• BDQ CAP rolled out in six
pilot sites in 2016.
Rajas than
Gujarat
Maharas htra
Oriss a
Karnataka
Madhya Prades h
Bihar
Uttar
Pradesh
Jam m u &
Kas hm ir
Tam il Nadu
Assam
Telangana
Chhattis garh
Andhra Pradesh
Jhark hand
Punjab
W est B engal
Kerala
Haryana
Himac hal
Pradesh
Manipur
Mizoram
Andam an & N icobar
Dam an & Diu
Uttarakhand
Sikkim
Arunachal
Pradesh
N aga lan d
Tripura

40. TB-HIV Collaborative Activities

41. TB – HIV co-morbidity
Status 2015
• 79% TB patients know their HIV status
• 92% TB HIV patients are receiving ART
• 93% TBHIV patients receiving CPT

42. 3 I’s
• Intensified case finding (ICF)
• Isoniazid preventive therapy (IPT)
• Infection control for Tuberculosis (IC)

43. Intensified TB case finding and treatment at high
burden Anti-Retroviral Therapy (ART) centres
 Single window service delivery
for TB & HIV
 Intensified case finding
 TB diagnosis through CBNAAT
 Daily Regimen
 Better management of side
effects- Pharmacovigilance
 Use of newer technology for
treatment monitoring
 Isoniazid Preventive Therapy
 Air Borne Infection control
Progress so far
 45419 PLHIV tested for TB
 6389 diagnosed as TB
 185 diagnosed as Rif
Resistance
 6073 put on Daily Anti TB
treatment
 149 Rif /R put on CAT IV
Country-wide expansion by 2nd October
2016

46. ISONIAZID PREVENTIVT THERAPY

49. Reaching the unreached
Groups
• Socially vulnerable
• Clinically high risk

50. Screening TB patients for DM
Tertiary Care Centers

51. Screening DM patients for TB
Tertiary Care Centers
DM Patients screened for TB DM Patients diagnosed as TB
(68%)
(13%)

52. TB –Diabetes and Tobacco Collaborative Activities
TB-DM
• A national collaborative workshop was
held between RNTCP and NPCDCS
• The joint framework aims at reduction in
morbidity and mortality by doing
bi-directional screening, early detection
and prompt management of DM and TB.

53. • Activities to improve diagnosis and management of DM
among TB pts :
-Screening of all registered TB pts for DM
-DM management among TB pts
TB among DM patients :
- intensified detection of active TB among DM pts
-TB infection control measures
-TB treatment and management in comorbid pts

54. TB AND TOBACCO

56. TB AND TOBACCO
• Main intervention will be counselling of tobacco users at TB
facilities and referral of tobacco users coming at Tobacco
Cessation Centre to DMC for TB screening.

57. VACCINES

59. INDEX TB Guidelines 2016
• New guidelines
developed for
management of
Extra pulmonary TB
by Central TB
Division , AIIMS, New
Delhi , WHO and
GHA
• Dissemination
Workshop held on
09th July 2016 at
AIIMS New Delhi
• Dissemination and
further develop a
training module

64. SKELETAL TB

65. NOTIFICATION OF TB CASES

66. NIKSHAY
Case Based Web Based TB Notification System
Public TB
notification
system
DR-TB
lab & RX
centres
Private TB
notification system
Special
projects for
adherence
Developed & powered by CTD & NIC

67. TB Notification (private)
3 420 1027
3563 4732
1803
24226
29395
12620
56101
64908
24875
38571
51879
0
10000
20000
30000
40000
50000
60000
70000
Laboratory Single-PP clinic Multi-Hospital
Before 2012 2012 2013 2014 2015
Total 3.2 lakh till date

68. Source: Global TB Report 2015, WHO, Geneva

69. Missed Call Server
Missed Call
Missed call List
Call Center Agent
Agent call to Patient
Server
PatientFeedback
Patient Category wise List
Information
about diagnosis
General
information TB
Adverse drug
reactions due to
TB drugs
Missed Call Campaign
Information about
treatment facilities
Missed call server will be linked with NIKSHAY platform
DTO

70. Web based Monitoring for DR TB patients
e-Smart
Electronic Surveillance and Management of
Drug Resistant Tuberculosis System
- An innovative approach towards better patient
management

71. Vision:
A world free of TB
Zero TB deaths,
Zero TB disease, and
Zero TB suffering
Goal:
End the Global TB
epidemic
Vision, goal, targets, milestones
(2,2 million)
(2.2 lakh)

74. Global TB projections to 2035 compared with current trends

77. Next Seminar on WEDNESDAY 26/10/16
MEDIASTINUM by DR. SATISH
&
NON-INVASIVE VENTILATION by DR. SANDEEP