Medical College Task Force Workshop on NTEP

1. National Workshop for Medical Colleges Task Force to
Accelerate Ending TB in India
NTEP Policy updates and plans for Ending TB - 2025
Dr Rajendra P Joshi
Deputy Director General ( TB )
Central TB Division, MoHFW, GOI

2. Outline
• National commitment towards TB Mukt Bharat
• What is our SDG and Where are we?
• Bending the curve – Know how?
• Strategies/Interventions by the programme (DTPB)
• Newer initiatives – SNC, PMTBMBA
• Role of medical college

3. National Commitment: TB Mukt Bharat
• Prime Minister of India launched
TB Free India campaign at ‘Delhi
End TB Summit’ on 13th March,
2018
• India has committed to End TB by
2025, 5 years ahead of the global
SDG target
• The campaign calls for a patient-
centric and holistic care driven by
integrated actions for TB Free India

4. NTEP – India 2022 (Jan-Sep*)
127
91
104
123
50
40
49 52
177
131
153
175
0
20
40
60
80
100
120
140
160
180
200
2019 2020 2021 2022*
Public Private Total
*Jan-Sep 2022 annualized. $ - among microbiologically confirmed TB. Incidence from Interim report of Global TB report, 2022.
Rf sensitivity testing
coverage$: 84.7%
Total TPT initiations:
6.1L
NPY payment status:
58%
2022*
Treatment success
rate: 84.2%
Case Notification rate
Incidence 2021:
210/lakh
population

5. Drivers of the epidemic
India*
1
2
3
2
5 5
4
3
4
1
*Global TB Report, 2022 – Interim report for India

6. Burden – Current
Scenario
• As per the Global TB Report, the estimated incidence of all
forms of TB in India for the year 2021 was 210 per 100,000
population (178-244 per 100,000 population)
• How to bend the curve*?
TB Epidemic dynamics under different intervention
scenarios
Incidence slope Mortality slope
6
*Arinaminpathy N, Mandal S, Bhatia V, McLeod R, Sharma M, Swaminathan S, et al. Strategies for ending tuberculosis in the South-East Asian Region: A modelling approach. Indian J Med Res.
2019;149(4):517.

7. Strategies and Initiatives by the programme: NSP 2017-2025

8. Build - updates

9. Private Sector Engagement
TB Notification made mandatory- Gazette
Notification
Incentives to private providers- INR 500-
notification, INR 500-outcome reporting
Schedule H1 implementation
Collaboration with professional medical
associations
‘National Forum of Professional Associations in Health’
constituted in 2020
Failure to take the mandated steps may
attract the provisions of Sections 269 and
270 of the Indian Penal Code (IPC)
Section 269. Negligent act likely to spread
infection of disease dangerous to life
Section 270. Malignant act likely to spread
infection of disease dangerous to life

10. NTEP collaborations for addressing determinants (Clinical and social)
National AIDS Control Program
National Tobacco
Control Program
Rashtriya Bal Swasthya
Karyakram + Rashtruya Kishor
Swasthya Karyakram
National Programme for Prevention
and Control of :
 Cancer,
 Diabetes
 Cardiovascular Diseases
 and Stroke
Poshan Abhiyaan
Ayushman Bharat –
Health and Wellness Centres
Bi-directional screening
of TB-COVID

11. Collaboration with Directorate of Medical Education (DME)
 Gazette Notification – June 2019
 DO- DME to National Medical Commission-
5Jan’21
 DO- JS VS to PS Health (all States/UTs)-
14Jan’21
 “Every Teaching Hospital should have Anti-
Retroviral Treatment (ART) Centre and facility for
management of MDR-TB by the time of 3rd
renewal (admission of 4th Batch of MBBS
students)” .

12. NTEP collaborations for addressing determinants (Clinical and social)
Prioritised 23 Key Ministries of
Govt. of India for Collaboration
& Convergent Action
• Formalized Partnership with 08
Ministries.
• Letters have been sent by Hon’ble
HFM to Hon’ble Union Ministers
of 23 Key Ministries and NITI
Aayog for multisectoral
collaboration and convergent
actions.
• Meeting held with MoWCD,
MSME, MoRTH MoHI, MEITY,
Corporate Affairs, MoCOAL etc
Support provided to Corporates under CTP
Access to specifically designed materials for Workplace and CSR projects on TB
Support in monitoring and documentation of outputs,
achievements and learnings
Facilitate for Kits and consumables for TB testing
Training for corporate health team/NGO partner on TB
Linkages of TB patients for Free of cost TB medicine from Govt
Technical support in designing your CSR/Workplace projects.
Healthier communities and workforce
Recognition at State, national and international forums
High visibility and goodwill
Coordination support with district and state health
department
More than 250 corporates including 12 business associations have joined
the fight to end-TB

13. Incentives – Recent updates
Incentive for
Informant
Incentive for TB Preventive
Treatment support
Incentive for
Bank account seeding of patients
• An Informant is eligible for
incentive of Rs. 500/- for a
confirmed TB case
(new module launched)
• Provision of financial
incentive to
ASHA/Community volunteer
of Rs. 250/- per individual
for successful completion of
TB preventive treatment
• Provision of incentive at rate of Rs.
50/- ASHA/Community volunteer for
facilitating seeding of bank account
information of notified TB patient in
Ni-kshay portal within 15 days of
treatment initiation for enabling DBT
payments under NTEP

14. TB digital ecosystem: Ni-kshay
1962
Paper based
reporting
1998
DOS based
Epi-centre
2007
Windows
based Epi-
centre
2012
Web –based
Ni-kshay 1.0
2018
Web & App
based
Ni-kshay 2.0
Application subsumed in Ni-kshay platform
e-Nikshay, UATBC
Aggregate data from districts/block level
(quarterly data submission)
Individual patient data from health
facility level (online real-time patient
tracking and care cascade monitoring)

15. The e-learning tools – Knowledge building
Swasth e-Gurukul
WHO India’s
knowledge platform
platform for
e-learning
Expanded Clinical
Health Outcomes
Tele-mentoring
platform for learning
learning and capacity
capacity building
National
Programme on
Technology
Enhanced
Learning
ICMR-NIRT online
course “Manage TB”
Integrated
Government
Online Training
Integrated courses
across diseases and
different healthcare
providers

16. The Artificial Intelligence tools – Developed and under pipeline
Cough sound based Pulmonary TB screening tool
• Cough sounds collected and model trained - Sensitivity ~84%
• Presently under validation
Automated reading of Line Probe Assay strips
• Image database created and model trained
• Independent validation planned
Automated Chest X-ray reading tool
• For detecting abnormalities on Chest X-ray
• Model being trained with Chest X-ray images - accuracy ~73%
Prediction of Loss to Follow up
• Tool being developed to assess patient-wise risk of Loss to Follow up

17. Detect - Updates

18. Strengthening Case Finding in the Public Sector
Upfront CXR
screening and
coverage
improvement
Revised Diagnostic
Algorithm: Upfront
& NAAT testing
coverage
improvement
Intensive Case Finding in
Health facilities – To be
strengthened
Active Case Finding in
vulnerable population –
Hotspot mapping and TPT
integration
Leveraging Outreach of
other Healthcare
Programmes: CBAC and
AB-HWC linkage
strengthening
PASSIVE APPROACH TO CASE FINDING ACTIVE APPROACH TO CASE FINDING

19. Strengthening Case Finding in the Private Sector
Schedule H1 Implementation
Provision of Govt. supplied Free FDCs for private
sector patients
Mandatory Notification by private providers
Patient Provider Support Agency through JEET and
Domestic Resources:
Guidance Document on Partnerships (2019)
92% Increase
in private
sector
notification
from 3.8 lakhs
in 2017 to 7.3
L in 2022*.
*Jan-Sep Private sector
notifications annualized

20. Treat

21. PMDT guidelines – 2021: Key updates
Updated UDST definitions
Shorter oral MDR-TB regimen
No “Injectible containing regimens” + Updated guidance on longer oral M/XDR-TB
regimen
Training of DR-TB counsellors by TISS – 13/15 batches completed
TB preventive treatment for contacts of DR-TB
BPaL regimen in research mode and in exceptional cases
Improving access and quality of DR-TB care to patients seeking care in private
sector

22. Policy – updates
• Introduction of shorter oral MDR/RR-TB regimen selected
7 states – May 2021
• Pan-country roll-out of shorter oral MDR/RR-TB regimen
– April 2022
• Use of Bedaquiline in MDR-TB patients in the age group 5
years and above weighing atleast 15 kg
• Use of Delamanid in MDR-TB patients in all age groups
weighing atleast 10 kg (DCGI recently approved)
• Use of Bedaquiline during pregnancy (off-label use)
• Introduction of preventive treatment in contacts of DR-
TB in 12 selected states
• BPaL regimen has been introduced under pragmatic
clinical trial in collaboration with NIRT-ICMR, Central TB
Division and WHO country office for India in selected
sites.

23. Prevent

24. Prevent - PMTPT policy related update
PMTPT policy Update
Target
population
Household contacts of pulmonary
TB*
Expansion of target population
PLHIV
NTEG meeting (23-24 Sep 2022): Malnourished,
Alcohol abusers, smokers and diabetics
Other risk groups - dialysis, silicosis,
initiated on Immunosuppresant or
anti-TNF, transplant recipients
NTEG meeting (23-24 Sep 2022): TPT intervention
to be merged with ACF and community level
intervention [next slide]
Testing
option
IGRA or TST
• IGRA or TST or Cy-TB
• DCGI approval for use of Cy-TB in age >/=18 years
• ICMR study is ongoing to validate feasibility of
Cy-TB in age <18 years [likely to get approval
from DCGI following study findings by year end]
Treatment
option
• 6H or 3HP
o 6H or 3HP
o 3RH expanded in 1+5 states
TPT in DR-
TB contact
• 6Lfx or 4R On-going and need to improve coverage

25. Newer initiatives

26. PRADHAN MANTRI TB MUKT BHARAT ABHIYAAN
– VIRTUAL LAUNCH EVENT : 9 Sept 2022
More than 2.25 lakh people witnessed the live proceeding across the
country.

27. The digital interface for community support to TB patients

28. Newer initiatives: Subnational Certification for TB Free India
Criteria
(Incidence decline)
20% 40% 60% 80%
State Rs. 25 Lakh Rs. 50 Lakh Rs. 75 Lakh Rs. 100 Lakh
District Rs. 2 Lakh Rs. 3 Lakh Rs. 5 Lakh Rs. 10 Lakh
TB FREE
2020 State 2 0 0 1
District 29 4 1 1
2021 State 5 3 Nil Nil
District 56 27 8 Nil
Bronze Silver Gold

29. Towards 2025: Thrust from Medical Colleges

30. Framework and Strategies for action
Training
Implementation Monitoring

31. Training – through “Task Force”
• Curriculum of Undergraduates – NTEP centric updates to be included
• NTEP modular training – mandatory part of the clinical rotations of interns
and postgraduates from all the departments
• Satellite sites establishment – Periodic visits by Pulmonary medicine and
Internal medicine department faculties/residents to catering CHCs/PHCs for
training and patients services (paediatric and extra-pulmonary TB, sample
collection and transport related services)
• Difficult to Treat TB Clinics – in geographies in rotation to be lead by medical
colleges
• NTEP updates – a component of CMEs/Lectures to be taken up by every
professional medical associations across geographies

32. Implementation
• Single window system establishment – for TB and Lung Health
• OPD triaging for ‘4S’ symptom complex
• Air-borne infection control – both at individual and facility level
• Quality assessment of Lung Health services initiative – to assess the missed
opportunities of the beneficiaries coming to facilities in all colleges (eg: Exit
interview)
• Curriculum – of “Clinico-psycho-social case study - TB” part of examination of
3rd year/4th year final MBBS examination
• Differentiated TB care for all presumptive TB patients accessing the Pulmonary
medicine department
• Medical college collaboration – through innovative approaches
• Geography adoption – “Health and Demographic Surveillance System”
development by every medical colleges in the catering rural/urban areas

33. Monitoring
• Core committee meetings – calendar based approach
• Meetings to be followed by CME/Lectures on the updates in NTEP
• Ni-kshay based review on the key performance indicators plus departmental
contribution by various OPD & IPDs
• Department of Pharmacology and Community Medicine – annual Prescription
audit and schedule H1 audit of nearby pharmacies: Collaboration with NTEP
and District/State Drug controller office
• Implementation of death audits – monthly audits for all TB deaths in the facilities
(address the gaps in 3 delay framework)
• Zonal centres/Regional centres for NTEP research collaboration
identification – for Operational and Implementation research (evidence
generation and feasibility)

34. Thank you