Revised National Tuberculosis Control Program- Dr. Atul MD, PGIMER

REVISED NATIONAL TUBERCULOSIS
CONTROL PROGRAMME
Presenter – Dr. Atul Gupta
Moderator – Dr. J.S. Thakur

OUTLINE OF PRESENTATION
 Introduction
 Burden of disease
 Evolution of TB control in India
 National Tuberculosis Programme
 Revised National Tuberculosis Control Programme (RNTCP)
 Paradigm Shift in Tuberculosis Control
 National Strategic Plan (NSP) 2017-25
 Status in Punjab and Chandigarh
 Challenges

INTRODUCTION
 Tuberculosis is one of the leading causes of mortality in India-
killing - 2 persons every three minute, nearly 1,000 every day.
 Tuberculosis (TB) is a contagious disease caused by
Mycobacterium tuberculosis.
 Left untreated, each person with infectious pulmonary TB will
infect an average of between 10 and 15 people every year.
 Emergence of Multi Drug Resistance and co-infection with HIV
has weakened the battle against the disease.
Source- The global tuberculosis situation and the new control strategy of the World Health Organization

BRIEF HISTORY OF TUBERCULOSIS
 Robert Koch:
- 1882 : Isolated and cultured M.
Tuberculosis (24th March)
- 1890: Developed staining
methods used to identify
the bacteria
- 1905: Received Nobel Prize
Kumar P. Journey of tuberculosis control movement in India: National tuberculosis programme to
revised national tuberculosis control programme. Indian J tuberc. 2005;52:63-71.

BURDEN OF DISEASE
Indicator India Global
statistics
Incidence of TB
(including HIV)
27,90,000 1,04,00,000
Mortality due to TB
(Excluding HIV)
4,23,000 13,00,000
Incidence of
MDRTB / RR
1,47,000 6,01,000
Incidence of
HIV-TB
87,000 10,30,000
Mortality due to
HIV-TB co-morbidity
12,000 3,74,000

SOURCE: GLOBAL TB REPORT 2018
Series1, India,
2,740,000, 31%
Series1,
China,
889,000,
10%
Series1, Indonesia,
842,000, 10%
Series1,
Philippines,
581,000, 7%
Series1, Pakistan,
525,000, 6%
Series1, Nigeria,
418,000, 5%
Series1,
Bangladesh,
364,000, 4%
Series1, South
Africa, 322,000, 4%
Series1, Other
10 HBC,
1,570,000, 18%
Series1, Non HBC,
468,000, 5%
Global burden of TB

BURDEN OF DISEASE …CONTD…
 Globally, TB incidence is falling at about 2% per year. This needs to
accelerate to a 4–5% annual decline to reach the 2020 milestones of
the End TB Strategy.
 An estimated 54 million lives were saved through TB diagnosis and
treatment between 2000 and 2017.
 Ending the TB epidemic by 2030 is among the health targets of the
Sustainable Development Goals.
SOURCE: GLOBAL TB REPORT 2018

EVOLUTION OF TB CONTROL IN INDIA
 1962 - National Tuberculosis Programme (NTP) started
 1992 - NTP Reviewed
 1993 - RNTCP formulated, adopted Directly Observed Treatment
Short course (DOTS) strategy.
 1997 - Large-scale implementation of the RNTCP with DOTS
 2006 - Entire country covered by RNTCP on 24th march

EVOLUTION OF TB CONTROL IN INDIA - CONTD….
 2006 - India adopts the STOP TB Strategy
 2008 - NACP & RNTCP have developed “National framework of
TB/HIV Collaborative activities”
 2012-17 - National Strategic Policy
 2017-22 - National Strategic Policy

NATIONAL TUBERCULOSIS PROGRAMME (1962)
 Based on strategic principles of domiciliary treatment
 Use of a self-administered standard drug regimen of initially 12-18
months duration. --------- Treatment free of cost
 Priority to newly diagnosed patients over previously treated patient
 Treatment organization decentralized to district level.
 The NTP created an extensive infrastructure for TB control, with a
network of 446 district TB centres and 330 TB clinics.
Kumar P. Journey of tuberculosis control movement in India: National tuberculosis programme to revised
national tuberculosis control programme. Indian J tuberc. 2005;52:63-71.

FAILURE OF NTP
Results:
 Low rates of case detection and treatment completion (30%),
 Continuing high mortality (50 per 100,000)
 High rates of default (40–60%)
Reasons
 More emphasis on case detection rather than cure
 Shortage of drugs
 Emphasis on x-ray diagnosis resulting in inaccurate diagnosis
 Poor quality sputum microscopy
 Multiplicity of treatment regimens.
Kumar P. Journey of tuberculosis control movement in India: National tuberculosis programme to revised
national tuberculosis control programme. Indian J tuberc. 2005;52:63-71.

REVISED NATIONAL TUBERCULOSIS CONTROL
PROGRAMME(1993)
Goals
• To reduce mortality and morbidity from tuberculosis
• To interrupt chain of transmission.
Objectives
• To cure at least 85% of all newly detected infectious (NSP)
cases of Pulmonary tuberculosis
• To detect at least 70% of estimated new smear positive
pulmonary tuberculosis

RNTCP (1993)
Major additions to the RNTCP:
 Sub-district supervisory unit, known as a TB Unit.
 Decentralization of diagnostic and treatment services.
 Treatment given under DOTS (directly observed treatment).
 Provision of quality assured sputum smear microscopy services.
 Patient-Wise Boxes

DOTS (1997)
Emphasizes on:
 Political and administrative commitment.
 Good quality diagnosis.
 Good quality drugs.
 Directly observed treatment short-course chemotherapy
 Systematic monitoring and accountability.
Kumar P. Journey of tuberculosis control movement in India: National tuberculosis programme to revised national
tuberculosis control programme. Indian J tuberc. 2005;52:63-71.

PARADIGM SHIFT IN TUBERCULOSIS CONTROL
Significant changes in the definition of cases as per New
Guidelines:
Microbiologically confirmed : : Presumptive TB patient with
1. Biological specimen positive for AFB
2. Positive for M.tuberculosis on culture
3. Positive for TB through quality assured rapid diagnostic
molecular test
Technical and operational guidelines for TB control in India, 2016

Clinically diagnosed TB case
 Presumptive TB who is not microbiologically confirmed
 Has been diagnosed with active TB by a clinician on the basis of
 X ray abnormalities
 Histopathology
 Clinical signs
 With decision to treat the patient with full course of ATT
CONTD…

CONTD..
 Mono-resistance: Resistant to one first line anti - TB drug only.
 Poly drug resistance : More than one first line anti -TB drug,
other than both INH and Rifampicin.
 Rifampicin resistance (RR) : Resistance to Rifampicin
 MDR : Both INH and Rifampicin with or without resistance
other first line ATD
 XDR : MDR TB + Fluroquinolone (FQ) and a second line
injectable ATD.

PARADIGM SHIFT IN TUBERCULOSIS CONTROL
CONTD..
Previous Guidelines New Guidelines
3 categories for treatment (I , II ,
III )
2 categories ( New and
Previously treated )
Extension of IP No extension of IP
Intermittent regimen FDC Daily regimen as per
weight bands
Streptomycin in Cat II , IP No streptomycin*
Introduction of new medicines
( Bedaquiline and Delamanid )
* Notification / MOHFW dated 18 / 12 / 2018

Revised National Tuberculosis Control Program- Dr. Atul MD, PGIMER

NSP 2017- 2025
Goal :
 To achieve a rapid decline in burden of TB, morbidity and mortality
while working towards elimination of TB in India.
Objectives:
 1. Find all Drug Sensitive TB and Drug Resistant TB cases with an
emphasis on reaching TB patients seeking care from private
providers and undiagnosed TB in high-risk populations
Source - National strategic plan for tuberculosis elimination 2017–2025

NSP 2017- 2025
2. Initiate and sustain all patients on appropriate anti-TB treatment
wherever they seek care, with patient friendly systems and social
support.
3. Prevent the emergence of TB in susceptible populations.
4. Build and strengthen enabling policies, empowered institutions,
additional human resources with enhanced capacities, and provide
adequate financial resources.

NSP 2017- 2025
Key Strategies:
 1. Private sector engagement
 2. Active Case finding
 3. Drug resistant TB case management
 4. Addressing social determinants including nutrition
 5. Robust Surveillance system
 6. Community engagement & Multi- sectoral approach

NSP 2017- 2025
Expected Outcomes:
 80% reduction in TB incidence (i.e. reduction from 211 per lakh
to 43 per lakh)
 90% reduction in TB mortality (i.e. reduction from 32 per lakh to
3 per lakh)
 0% patient having catastrophic expenditure due to TB

NSP 2017- 2025
 Four strategic pillars of TB elimination
Detect Treat
Prevent Build

DETECT HOW DO WE DO IT?
Find all DS-TB and DR-TB cases
with an emphasis on reaching TB
patients seeking care from
private providers and
undiagnosed TB in high-risk
populations.
Laboratory systems
Case findings
Patients in private sectors

STRATEGIES
 1. To use high efficiency diagnostic tools for early and accurate
diagnosis linked treatment across the country
 2. Purchasing services and ensuring notification through
laboratories from the private sector and link to laboratory
surveillance
 3. To promote research for new diagnostic tools
 4. To build capacity for diagnosis of LTBI

DRTB CASE DETECTION AND INITIATION
2007 - 2017
 India TB Report 2018

CASE FINDINGS
 Early identification of people with a high probability of having
active TB (presumptive TB) is the most important activity of the
case finding strategy.
 Screening and diagnosing patients with appropriate tests and
strategies will largely determine the response to appropriate
treatment.
 ACF - primary objective of detecting TB cases early in targeted
groups and to initiate treatment promptly.
Active case finding guidelines – MOHFW June 2017

ACTIVE CASE FINDING
Screening strategies
 1. Community screening can be done by:
a. Inviting people to attend screening at a mobile facility or a
fixed facility. Invitations may target specifically people
within a given vulnerable group, those who have had recent
close contact with someone who has TB and people with
symptoms of TB.
b. Going door to door to screen households .

CONTD….
 2. Institutional screening:
a. In Health care facilities : Active screening of vulnerable
individuals attending hospitals and other health care
institution.
b. In congregate settings: Active screening of vulnerable
individuals in shelters, old age homes, refugee camps,
correctional facilities and other specific locations such as
workplaces.

PATIENTS IN PRIVATE SECTORS
 80% of people with TB first attend the private sector or Quacks
 Diagnosis and treatment are of variable quality.
Diagnostic delays occur,
 Patients from low-income households lose several months of
their income in the process of paying for inappropriate
diagnostics and treatments before starting approved therapy.

THE INCENTIVES
 Rs 250/- on notification of a TB case diagnosed as per Standards
for TB Care in India.
 Rs 500/- on completion of entire course of TB treatment.
 For notification and correct management of a drug-resistant case
over 24 months as per STCI, a private provider will be eligible to
receive Rs 6750/-

THE INCENTIVES
 For Patients :
 500/- month for nutritional
support for DS TB cases
 1000/- month for nutritional
support for MDR TB

TREAT HOW DO WE DO IT?
Initiate and sustain all
patients on appropriate anti-
TB treatment wherever they
seek care, with patient
friendly systems and social
support.
A. Providing daily regimen using FDCs
to all TB patients
B. DST guided treatment for DR TB.
C. Patient centric approach to
treatment.

THE PRINCIPLES OF TREATMENT FOR TB IS:
 1. Screen all patients for RR and additional drugs wherever
indicated.
 2. For drug sensitive TB ---- daily FDC of first line ATT drugs in
appropriate weight bands for all forms of TB and in all ages.
 4 drug FDC in IP and 3 FDC in the CP.
 3. All RR /MDR TB patients are subjected to baseline Levofloxacin
sensitivity. In addition extended DST to all second line drugs in a
phased manner.

FDC DRUGS BY WEIGHT
WEIGHT
CLASS
# OF PILLS
# STRIPS FOR 28
DAYS
< 25 kgs
Does not receive FDCs or
99DOTS
0
25 – 39 kgs 2 pills per day 2
> 70 kgs 5 pills per day 5
Operational Guidelines Daily Regimen in first-line TB treatment under RNTCP

 Using mobile phones to monitor and improve adherence to
tuberculosis medications
 Goal: to provide 99% of the benefits of dots at a fraction of the
cost and inconvenience to patients
Source - National strategic plan for tuberculosis elimination 2017–2025.

 Anti-TB drugs wrapped in envelopes printed
with hidden numbers behind the pills
 Patients dispense a dose, reveal a hidden
TOLL FREE number ----- call
 Call reflects on the 99DOTS dashboard and
the 99 DOTS Android Mobile App
immediately as a taken dose.
Training module 99 DOTS - 2018

SMS ALERTS FROM 99DOTS
Analytics and Reports for Program
SMSMessage:
[0000] Please
takepills
Notification of new patients
New patient
(740XXXXXX) enrolled,
Yelahanka district
Two of your
patients have
missed doses
Raj (979XXXXXX)
& Om (812XXXXXX)
SMSMessage:
Twoof your
patientshave
misseddoses
today: Raj&
Om
[0000]
Please
take pills
SMSMessage:
[0000] Please
takepills
Reminders to Patients Alerts to Staff

Benefits of 99DOTS
• Less travel
• Increased convenience
Patients
• Focused and more efficient care
Field Staff /
Supervisors
• Easy monitoring
• Accurate reports
Program Officers

PREVENT HOW DO WE DO IT ??
Prevent the emergence
of TB in susceptible
populations
 Scale up air-borne infection control
measures at health care facilities.
 Testing and treatment for latent TB
infection in contacts of bacteriologically
confirmed cases and in individuals at
high risk of getting TB disease
 Address social determinants of TB
through intersectoral approach

AIR BORNE INFECTION CONTROL:
CHALLENGES AT COMMUNITY LEVEL :-
 Cough etiquettes not being followed
 Indiscriminate spitting
 Sneezing without covering face
 Alcoholics and mentally challenged patients
 Delay in reaching health facility for specific diagnosis
 Delay in diagnosis in co-morbid conditions like Diabetes, HIV,
Cancers etc.

CONTD….
CHALLENGES AT INSTITUTIONAL LEVEL
 Outpatient facility
• Patients with chest infection at outpatient settings
• Overcrowding - mixing of patients in queues and waiting areas
• Poor ventilation in the facilities
 In patient facility
• Cough screening, separation, mask and counseling provision
missing
• Infectious patients getting admitted at General wards
• Cough etiquettes not followed in wards
• Overcrowding in the wards – no restricted entries

CONTACT TRACING
 All close contacts, especially household contacts will be
screened for TB using Chest X Rays.
 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.
 Since transmission can happen from index case to the contact
any time (before diagnosis or during treatment) all contacts of TB
patients must be evaluated.

LTBI TREATMENT
 The lifetime risk of reactivation of LTBI in healthy HIV-uninfected
individuals is 10%, with 5% developing TB disease during the first
2 to 5 years after infection.
 ART reduces the risk of TB by approximately two thirds.

BUILD HOW DO WE DO IT ??
Build and strengthen
enabling policies,
empowered institutions,
human resources with
enhanced capacities, and
financial resources to
match the plan.
•Urban TB control systems
• Health system strengthening
• Advocacy, communications and
social mobilization
• Surveillance, monitoring and
evaluation
• Research and technical assistance

 A web based solution for monitoring of TB patients launced on
15th May 2012 by
 Developed by NIC (National Informatics Centre)
 The data entry of the individual TB cases at the block level
DEOs (data entry operator) of NHM
 The system has been extended to include drug resistant TB
cases, online referral and transfer of patients

TB-HIV COLLABORATIVE ACTIVITIES
 Establishment/Strengthening NACP-RNTCP coordination
mechanisms at national, state and district level in 2001
 Joint M&E including standardized reporting shared between the
two programmes
 Training of the programme and field staff on HIV/TB
 TB and HIV service delivery co-ordination
India TB Report 2018

TB AND DIABETES CO-MORBIDITY
 About 10% of TB cases globally are linked to diabetes.
 People with a weak immune system (diabetes) are at a higher risk
of progressing from latent to active TB.
 People with diabetes have a two to three times higher risk of
getting infected with TB, compared to people without diabetes.
 People with TB and coexisting diabetes have a four times higher
risk of death during TB treatment and higher risk of TB relapse
after treatment.
National framework for joint TB-Diabetes collaborative activities

PUBLIC PRIVATE PARTNERSHIP
 Several organizations and Projects like Programme for
Appropriate Technology in Health (PATH), The Union, Foundation
for Innovative New Diagnostics (FIND), World Vision India –
Project Axshya, Project Saksham Pravaah etc are actively
involved in the programme.
 At present around 1,900 NGOs collaborations are involved in the
programmes in different schemes.
 India TB Report 2018

STATUS IN PUNJAB
 District TB Centers ( DTCs) - 22
 TB units (TU) - 134
 Designated Microscopy Centers (DMCs) - 274
 Culture and Drug Sensitivity lab ( C& DST ) - GMC Faridkot
 Liquid Culture Labs for 2nd line DST - TB Hospital Patiala
 CBNAAT labs - 29
 Bedaquiline treatment for DR TB - All 3 medical Colleges

STATUS IN CHANDIGARH
with HIV testing
 CBNAAT labs - 2 ( PGI and GMCH 32)
 Bedaquiline & Delamanid treatment for DR TB - GMCH 32
 Total notification of TB cases in 2018 - Around 6000

STATUS IN PGIMER
DMC (Designated Microscopy Centre) (New OPD/1)

STATUS IN PGIMER
 Culture & DST Laboratory (Research Block A)
 Gene Xpert and LPA - available
 Solid culture and DST for First Line DST (RIF + INH + STR + ETM) - 2011
 Line Probe Assay For First Line DST (RIF+ INH) - April 2013
 Liquid culture and DST for First Line DST (RIF + INH + STR + ETM) – Feb
2015
 Liquid culture and DST for Second Line DST (OFLx + AMK + KAN + CAP)
– Sept 2015

CHALLENGES
 Collection of appropriate specimens from children and EPTB.
 Transportation of specimens from hard to reach areas (hilly,
tribal, deserts, etc.)
 The paper based system of monitoring (recording and reporting)
is tedious leading to delayed reporting.
 Retention of trained staff and compensation packages is a barrier
for sustainability for ensuring consistent performance.

CHALLENGES
 Lack of awareness in the community on TB diagnostic facilities in
the programme
 Case finding is largely passive
 New diagnostic algorithm will require additional resources for
CXR, and molecular tests.
 Ensuring active case finding in at risk groups and repeating the
activity periodically.

Revised National Tuberculosis Control Program- Dr. Atul MD, PGIMER

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