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Control of tb

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Dayyala Sridhar

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

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by Dr. Sridhar.D 2nd year PG Department of Community Medicine Osmania Medical College Hyderabad
OVERVIEW Global and Indian scenario Control of tuberculosis RNTCP
Estimated TB incidence rates 2010
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
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
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)
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.
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
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
TB India annual report 2012.
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.
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
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
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+)
RNTCP Laboratory Network 4 NRLs 27 IRLs >12,000 DMCs (one per 50,000-100,000 population)
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
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 .
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.
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
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.
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
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
Control of tb
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
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
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.
Treatment during pregnancy in place of Streptomycin Ethambutol added INH , RMP , Pyrazinamide and Ethambutol are safe Ethionamide and Protionamide are teratogenic.
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
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
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
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
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.
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.
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.
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.
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.
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
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.
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.
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)
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
Control of tb
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
WHO-recommended Stop TB Strategy (2006) to Reach the 2015 MDGs
Control of tb
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.
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
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,
Control of tb
Control of tb
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.
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
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.
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
Control of tb
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.
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
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.
Control of tb

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Control of tb

  • 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
  • 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.