RNTCP.pptx

Revised National Tuberculosis Control
Programme

What is Tuberculosis?
Tuberculosis (TB) is an infectious
disease caused by the bacterium
Mycobacterium tuberculosis
(MTB)
Tuberculosis generally affects the
lungs, but can also affect other
parts of the body
One patient with infectious
pulmonary TB if untreated can
infect 10-15 persons in a year

Risk factors
o Malnutrition
o Diabetes
o HIV infection
o Low body weight
o Severe kidney disease
o Other lung diseases (silicosis)
o Substance abuse etc.
o Overcrowding
o Inadequate ventilation
o Enclosed living/working
conditions
o Occupational risks
Environmental
Medical

Possible TB Disease Symptoms
Night Sweats Fever Chills
Weakness or
fatigue
Weight loss No appetite
Cough lasting
longer than
3 weeks
Pain in
the chest
Coughing up
blood or sputum
(phlegm from inside the
lungs)
4

Global TB Burden -2018
Global India
Incidence
1,00,00,000
(132/lakh)
26,90,000
(199/lakh)
Deaths
15,00,000
(16/lakh)
4,40,000
(32/lakh)
HIV TB
cases
8,62,000
(11/lakh)
92,000
(6.8/lakh)
HIV TB
deaths
3,74,000
(5.0/lakh)
12,000
(0.7/lakh)
Estimated
MDR/RR
cases
484000
(6.4/lakh
population)
1,30,000
(9.6/ lakh
population)

◾ India has highest burden of both TB and MDR
TB and second highest of HIV associated TB
based on estimates reported in Global TB report
2015.
◾ An estimated 71,000 cases of MDR TB emerge
annually from the notified cases of Pulmonary
TB in India.
◾ 3% among new TB cases, 12-17% among
previously treated TB cases have MDR TB.
◾ An estimated 1.1 Lac HIV associated TB
occurred in 2014 & 31,000 estimated number of
patient died among them.

⚫TB kills more adults in India than any other
infectious disease.
⚫In India every day –
⚫More than 6000 develop TB disease
⚫More than 600 people die of TB (i.e. 2 deaths
every 5 minutes)

EVOLUTION OF TB CONTROL IN INDIA
⚫ 1950s-60s
⚫ 1962
⚫ 1992
Important TB research at TRC and NTI
National TB Programme (NTP)
Programme Review
⚫ 1993
⚫ 1998
⚫ 2001
⚫ 2004
⚫ 2006
• only 30% of patients diagnosed;
• of these, only 30% treated successfully
RNTCP pilot began
RNTCP scale-up
450 million population covered
>80% of country covered
Entire country covered by RNTCP

STOP TB STRATEGY, 2006
⚫Vision:A world free of TB
⚫Goal: To dramatically reduce the global burden of
TB by 2015 in line with Millennium Development
Goals and the Stop TB Partnership targets

STOP TB PARTNERSHIP TARGETS
⚫By 2005:
⚫At least 70% people with sputum smear positive TB will be
diagnosed.
⚫At least 85% cured.
⚫By 2015:
⚫Global burden of TB (prevalence and death rates) will be
reduced by 50% relative to 1990 levels.
⚫ Reduce prevalence to <150 per lakh population
⚫ Reduce deaths to <15 per lakh population
⚫Number of people dying from TB in 2015 should be less
than 1 million, including those co-infected with HIV
⚫By 2035:
⚫Global incidence of TB disease will be less than or equal to
1 case per million population per year
Government of India preponed END TB Strategy

⚫Revised National TB Control
Programme (RNTCP) nomenclature
changed
To
⚫National TB Elimination Programme
(NTEP)
from January 2020

• At the start of 2020 the
central government of
India renamed
the RNTCP the
National
Tuberculosis
Elimination
Program (NTEP).
12

NATIONAL STRATEGIC PLAN 2017
- 2025
• The MOHFW in consultation with over 150
national and international experts working
in the field of public health, program
managers, donor agencies, technical
partners, civil societies, affected community
representatives and other stakeholders of
TB control both from public as well as
private sector finalized the new National
Strategic Plan for TB 2017-2025 (NSP).
14

WHAT IS NSP?
• The NSP for TB elimination 2017–25 is a framework to
guide the activities of all stakeholders including the
national and state governments, development partners,
civil society organizations, international agencies,
research institutions, private sector, and many others
whose work is relevant to TB elimination in India . It is a
3 year costed plan and a 8 year strategy document.
• It provides goals and strategies for the country’s
response to the disease during the period 2017 to 2025
and aims to direct the attention of all stakeholders on
the most important interventions or activities that the
RNTCP believes will bring about significant changes in
the incidence, prevalence and mortality of TB . • The
NSP will guide the development of the national project
implementation plan (PIP) and state PIPs, as well as
district health action plans (DHAP) under the national
health mission (NHM).
15

VISION,GOALS and TARGETS
• VISION:- TB-Free India with zero deaths,
disease and poverty due to tuberculosis.
• GOALS:- To achieve a rapid decline in
burden of TB, morbidity and mortality while
working towards elimination of TB in India
by 2025.
• TARGETS:- The requirements for moving
towards TB elimination have been
integrated into the four strategic pillars of
“Detect – Treat – Prevent – Build” (DTPB).
16

DETECT
• Early identification of presumptive TB cases,
at the first point of care be it private or
public sectors, and prompt diagnosis using
high sensitivity diagnostic tests to provide
universal access to quality TB diagnosis
including drug resistant TB in the country.
17

How it can be achieved?
• 1. LABORATORY SYSTEMS 2. CASE
FINDINGS 3. PATIENTS IN PRIVATE
SECTORS
18

TREAT
• What does it mean? Provide sustained,
equitable access to high quality TB
treatment, care and support services
responsive to the community needs
without financial loss thereby protecting
the population especially the poor and
vulnerable from TB related morbidity,
mortality and poverty.
19

What does it entail?
• 1. Providing daily regimen using FDCs to all
TB patients. 2. DST guided treatment for DR
TB. 3. Patient centric approach to treatment.
4. Prevent loss at cascade of TB care . How
it can be achieved? 1. Treatment services 2.
Key affected populations 3. Patient support
system
20

STRATEGIES
• 1. Initiation of appropriate treatment for all
diagnosed TB patients. • 2. Implementation
of TB treatment services in health facilities
and communities. • Regular and long term
follow up and rehabilitation of all treated
TB patients.
21

The principles of treatment
for TB
1. Screen all patients for Rifampicin
resistance and additional drugs wherever
indicated. 2. For drug sensitive TB,
administer daily fixed dose combinations of
first line Antituberculosis drugs in
appropriate weight bands for all forms of TB
and in all ages, including four drug FDC in
the intensive phase and three drug FDCs in
the continuation phase. 3. All Rifampicin
Resistant /Multi Drug Resistant TB patients
are subjected to baseline Kanamycin and
Levofloxacin all across the country. In
addition country has introduced extended
DST to all second line drugs in a phased 22

4. RR/MDR TB patients without additional
drug resistance are treated with standard
short course treatment regimen for MDR TB.
And in those with mixed patterns of
resistance, standard MDR TB regimens were
modified as per revised guidelines. 5. Where
DST patterns for extended DST are available,
the management protocol will follow
essential optimized regimen for patients
diagnosed with drug resistance other than
MDR and XDR TB. 6. Minimize leakage across
the care cascade and maximize adherence
through innovative patient support
strategies and real time monitoring. 23

PREVENT
• What does it entail? 1. Scale up air-borne
infection control measures at health care
facilities. 2. Treatment for latent TB
infection in contacts of bacteriologically-
confirmed cases . 3. Addressing social
determinants of TB through intersectoral
approach .
24

How it can be achieved?
• 1. AIR BORNE INFECTION CONTROL 2.
CONTACT TRACING 3. LTBI TREATMENT
25

AIR BORNE INFECTION
CONTROL
• CHALLENGES AT COMMUNITY LEVEL
- Social habits • Cough etiquettes not being
followed • Indiscriminate spitting • Sneezing
without covering face • Alcoholics and
mentally challenged patients • Delay in
reaching health facility for specific diagnosis
Special groups • Migrant population, back
ward areas and tribal pockets Old age
homes, poor homes, children homes, jails,
hard to reach areas • Delay in diagnosis in
co-morbid conditions like Diabetes, HIV,
Cancers, etc.
26

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, fast-tracking, 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
27

SOLUTIONS AT
INSTITUTIONAL LEVEL
• 1. Certification of Health facility for AIC
Compliance 2. Develop cough
corners/counters - Cough screening,
separation, fast-tracking, mask and counseling
3. Posting of specific staff for fast tracking and
providing masks 4. Providing N 95 masks to
the Hospital staff in High risk settings 5. ACSM
at OPD and other settings like Posters,
Clippings etc 6. Implementation of AIC in all
settings 7. In house AIC complaint facility for
treating nomads, destitutes, homeless patients
8. Separate IP facility for bacteriological
positive DS/DR TB patients and other airborne
infectious patients in major institutions
28

• 9. Proper infection control measures in ART
centres. 10. Proper follow up of daily
reported cases 11. Proper disposal of
sputum and infected materials 12. Early
diagnosis and initiation of treatment 13.
PPE for concerned staff 14. Wet mopping
and disinfection 15. Periodic screening of
staff 16. Proper ventilation, renovation if
necessary 17. Facility risk assessment and
reporting 18. Periodic trainings 19.
Ongoing monitoring dashboards/checklist
for AIC practices at all levels .
29

• CONTACT TRACING;- In RNTCP contact
screening has been a clinical function with
cursory programmatic monitoring. In this
NSP contact tracing will be made more
rigorous, expansive and accountable. The
end result expected is that most TB pts will
have their contacts screened, with
secondary cases detected and treated.
30

• PREVENTIVE THERAPY/ LATENT TB
INFECTION TREATMENT :- TB infection is
the seed bed for developing TB disease and
continued transmission. 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.
31

BUILD
• What does it means in term of NSP?
Undertake critical management reforms,
restructuring of HR and financial norms,
pathways for private sector participation, in
order to improve efficiency, effectiveness
and accountability of the health system for
an improved response to the TB epidemic.
32

• What does it entail? 1. Build synergies with
existing health service delivery mechanism
under Urban Health Mission and plan for
integration of services 2. Reform and
restructure HR in TB programme to align with
the enhanced programme needs for
surveillance, participation of private sector and
community participation. 3. Strengthen
RNTCP’s regulatory capacity to control TB
drugs through appropriate laws, regulations,
and policies. 4. Position TB high on the health
and development agenda of the nation to
ensure adequate resources, greater demand
for and universal access to TB care services
33

• How it can be achieved? • URBAN TB
CONTROL SYSTEMS • HEALTH SYSTEM
STRENGTHENING • ADVOCACY,
COMMUNICATIONS AND SOCIAL
MOBILIZATION • SURVEILLANCE,
MONITORING AND EVALUATION •
RESEARCH AND TECHNICAL ASSISTANCE
34

Tuberculosis unit
⚫It is the nodal point for TB control activities in the
sub-district.
⚫In urban areas 1 TU per 2,00,000 population
(range 1.5-2.5laks)
⚫Manned by designated
1. Medical Officer –Tuberculosis Control (MO-TC)
2. Senior Treatment Supervisor (STS)
3. Senior TB Laboratory Supervisor (STLS per 5
lakh population
4. 1 TBHV per 1 lakh urban population

Continued…..
⚫TU will have one Designated Microscopy Centre
(DMC) for every 1 lakh population (50,000 in
tribal, desert, remote and hilly region)
⚫Microscopy centres are also located in Medical
Colleges, Corporate Hospitals, ESI, Railways,
NGOs, private hospitals.

PRESUMPTIVE TB CASES
• Presumptive Pulmonary TB –
– Cough for > 2 weeks
– Fever for > 2 weeks
– Significant weight loss
– Haemoptysis
– Any abnormality in Chest Radiograph
Note – Contacts of Microbiologically confirmed TB patients,
PLHIV, Diabetics, Malnourished, Cancer patients, patients
on immune –suppressants or steroid should be regularly
screen for signs and symptoms of TB

Presumptive Extra Pulmonary TB
⚫Organ specific symptoms and signs like swelling
of Lymph node, pain and swelling in joints, neck
stiffness, disorientation.
⚫Constitutional symptoms like – significant weight
loss, persistent fever for ≥ 2 weeks, night sweats.

Presumptive Paediatric TB
⚫Persistent fever > 2 weeks
⚫Cough > 2 weeks
⚫Loss of weight / no weight gain
⚫History of contact with infectious TB case
Loss of weight is define as loss of > 5% body weight
as compared to highest weight recorded in last 3
months

Presumptive DRTB (As per TOG
2016)
⚫Patients who are found positive on any follow up
sputum smear examination during treatment with
FLD, previously treated TB cases
⚫ TB patients with HIV co–infection
⚫TB patients who failed treatment with FLD
⚫Paediatric TB non responders
⚫TB patients who are contact of DR-TB (or Rif
resistance)

CASE DEFINITIONS
⚫Microbiologically confirm TB case – Biological
specimen positive for AFB or positive for
Mycobacterium tuberculosis on culture or positive
for tuberculosis through quality assured rapid
diagnostic molecular test.

Clinically diagnosed TB case
⚫A presumptive TB patients who is not
microbiologically confirmed but diagnosed with a
active TB by a clinician on the basis of X-ray
abnormalities, Histopathology or Clinical signs
with a decision to treat the patient with a full
course of ATD.

It is same as the old one
Previously called relapse
Previously called only failure

New Pyramid of TB diagnostics
Characteristic
Symptom
Microbiologic
confirmation
with U-DST
Conventional
Radiology
Tuberculosi
s Skin Test/
IGRA
Specificit
y
Sensitivit
y
Yield of test and robustness of diagnosis can be improved by
better characterisation of symptoms and interpretation of radiology!!

NTEP Implementation
Arrangement
45

2
pills
5
4
3
pills
99DOTS Envelopes

99DOTS: Accurate Monitoring at Very Low Cost
101

How can the Patient data be
accessed?
Different ways of accessing the patient data –
⚫Web dashboard (www.99dots.org)
⚫Every center will be given their own login ID and
Password to access their patients
⚫Different logins for ART center, DTC and field staff (with
limited permissions)
⚫SMS Alerts for Staff and Treatment Supporters to
take immediate action in case of default.

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

Niksh
ay
Nikshay is an Integrated ICT (Information Communication
Technology) system for TB patient management and care in India
Real-time, case-based, web-based surveillance tool
Unified interface for public and private sector health care providers
Nikshay webpage - https://Nikshay.in
Android mobileApp - Google Play Store
Demo site – https://beta.nikshay.in

Modalities of
notification
Submission of
hardcopies to
DTO
Reporting into Nikshay web
portal/mobile application
Reporting via
Nikshay
Sampark
(1800 11
6666)

Incentives to Patients for Social Protection
⚫“Nikshay Poshan
Yojana”-
⚫Launched from 01st April
2018
⚫Nutritional support through
Direct Benefit Transfer of
500 INR per month
⚫For all patients on TB
treatment throughout
duration of treatment
⚫Patient need to be
registered in the Nikshay
portal
⚫Tribal patient incentive

Incentives to
Providers
⚫Private Provider Incentive
⚫500 INR at notification & 500 INR on reporting
treatment outcome
⚫Informant incentive
⚫Incentive of 500 INR to informant for notification of
patients in public sector
⚫Incentive for Treatment support
⚫New Case: 1000 INR at completion of treatment
⚫Drug Resistant Case: 2000 INR at completion of
intensive phase, 3000 INR at completion of treatment

Take Home Message………
⚫For microbiologically confirmed TB cases we
must follow Universal DST (Drug Susceptibility
Testing)
⚫For clinically diagnosed TB cases– it is the test of
experts not to over diagnose TB as well as not to
under diagnose TB cases
⚫Repeated counselling for regular adherence and
completion of ATD course is necessary

NIKSHAY
• Nikshay is an integrated Information and
Communication Technology system for
tuberculosis patient management and care in
India. Nikshay was launched in 2012 and has
evolved significantly to make patient
management easier and more effective for
health care providers and their support staff.
• NI-KSHAY-(Ni=End, Kshay=TB) is the web enabled
patient management system for TB control under
the National Tuberculosis Elimination
Programme (NTEP).
59

• It is developed and maintained by the Central TB
Division (CTD), Ministry of Health and Family Welfare,
Government of India, in collaboration with the National
Informatics Centre (NIC), and the World Health
Organization Country office for India.
• Ni-kshay is used by health functionaries at various
levels across the country both in the public and private
sector, to register cases under their care, order various
types of tests from Labs across the country, record
treatment details, monitor treatment adherence and to
transfer cases between care providers. It also functions
as the National TB Surveillance System and enables
reporting of various surveillance data to the
Government of India.
60

Salient Features of Nikshay 2.0
Nikshay is an Integrated ICT system for TB patient
management and care in India.
Nikshay was launched in 2012 and since then, various
improvements have been made in the system
Nikshay Version 2 has been launched in September 2018.
Nikshay provides-
1. A Unified interface for public and private sector health
care providers
2. Different types of Logins like State, District, TU, PHI,
Staff logins, Private providers, Chemist, Labs and
PPSA/JEET Logins
3. Integrates all adherence technologies such as 99DOTS
and MERM
4. Unified DSTB and DRTB data entry forms
5. Mobile friendly website with mobile app

Nikshay 2 is accessible either via web browser
(https://Nikshay.in ) or mobile App called ‘Nikshay’ that
can be downloaded from Google Play Store
( log in page in web browser) ( log in page in mobileApp)

Diagnostic work up
⚫Based on CBNAAT result patient will be
categorized as Microbiologically
confirmed drug sensitive TB or RIF
resistance TB

⚫In case of RIF indeterminate result an
additional CBNAAT will be done to get a
valid result. If indeterminate on second
occasion an additional specimen will be
sent to nearest IRL or C &DST centre for
LPA or liquid culture and DST as
appropriate

66
DIAGNOSTIC ALOGRYTHM FOR EXTRA PULMONARY TB

Recommendations for LTBI interventions under NTEP
3rd National Technical Working Group(TWG) on Latent TB
Infection Management in India held
on 12th May, 2020
Eligible population Strategy Treatment option
• People living with HIV
(Adults and children >12 months)
• Infants <12 months in contact
with active TB
• Household contacts below 5 years of
pulmonary TB patients
Treating all
after ruling out
active TB
• 6-months daily
isoniazid
• Three months of daily
rifampicin plus isoniazid
(Alternative in household
contacts 0 - 14 years (up to
25 kg weight) in limited
geographies)
• Household contacts 5 years
and above of pulmonary TB patients
(testing would be offered whenever
available)
Treating all
after ruling out
active TB
3-month weekly Isoniazid
and Rifapentine
• Children/Adult on
immunosuppressive therapy Testing and
3-month weekly Isoniazid
and Rifapentine

Ideally all presumptive TB patients have to
undergo HIV screening.
This is important to ensure all HIV positive TB
patients receive ART irrespective of CD4 count
and Chemo Prophylaxis (CPT).
HIV & Tuberculosis

First Line ART for HIV - TB
Second LineART for HIV - TB

TB-HIV Collaboration – Single
Window
Delivery of HIV-TB care at ART centres
Rapid molecular
diagnosis
CBNAAT
Daily FDC for HIV
and TB
ICT based
adherence support
(99 DOTS)
Pharmacovigilance
(AMC)
Isoniazid
Preventive Therapy
Progress
• Training completed by NACO and CTD
• Drugs supplied in Oct-Nov’16
• 10,031 HIV-TB patients initiated on treatment

Adjustment of Anti TB drugs in renal insufficiency
Drugs Recommended dose and frequency for patients with creatinine
clearance <30 ml/min or for patients receiving haemodialysis (unless
otherwise indicated dose after dialysis)
Isoniazid No adjustment necessary
Refiampicin No adjustment necessary
Pyrazinamide 25-35 mg/kg per dose three times per week ( not daily)
Ethambutol 15-25 mg/kg per dose three times per week ( not daily)
Rifabutin Normal dose can be used, if possible monitor drug concentrations to avoid
toxicity.
Streptomycin 12-15mg/kg per dose two or three times per week (not daily)
Capreomycin 12-15mg/kg per dose two or three times per week (not daily)
Kanamycin 12-15mg/kg per dose two or three times per week (not daily)
Amikacin 12-15mg/kg per dose two or three times per week (not daily)
Ofloxacin 600-800mg/kg per dose three times per week (not daily)
Levofloxacin 750-1000mg per dose three times per week (not daily)
Moxifloxacin No adjustment necessary
Cycloserine 250mg once daily or 500mg/ dose three times per week
Terizidone Recommendations not available

Torizidone Recommendations not available
Prothinamide No adjustment necessary
Ethionamide No adjustment necessary
Para-
aminosalicylicaci
d
4g/dose twice daily maximum dose
Bedaquiline No dosage adjustments required in patients with mild to moderate renal
impairment (dosing not established in severe renal impairment, use with
caution)
Linezolid No adjustment necessary
Clofazimine No adjustment necessary
Amoxicilin
/clavulanate
For creatinine clearance 10-30ml/min dose 1000mg as amoxiciline
component twice daily
For creatinine clearance <10ml/min dose 1000mg as amoxicilin
component once daily
Imipenem
/cilastin
For creatinine clearance 20-40ml/min dose 500mg every hours
For creatinine clearance <20-40ml/min dose 500mg every 12 hours
Meropenem For creatinine clearance 20-40/ml/min dose 750mg every 12 hours
For creatinine clearance <20/ml/min dose 500mg every 12 hours
High dose
isoniazid
Recommendations not available
Adjustment of Anti TB drugs in renal insufficiency

75
40 crore infected
35 lakh estimated
TB patients annually
4.2 lakh deaths
Due to TB annually
In India…….

India: MDG6 TB target
TB REVERSED
Rate
per
100,000
population
50%
35 lakh
additional
lives saved
50%
New cases
declining
All cases reduced
by half
Deaths reduced
by half
HIV
WHO Global TB Report 2016
465  195 per lakh pop
(58% reduction) 38  17 per lakh pop
(55% reduction)
216  167 per lakh pop
(23% reduction)

Vision: A world free of TB
Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB Epidemic (<10 cases per 100,000 population)
Sustainable Development Goals (SDG)
INDICATORS
TARGETS
SDG 2030
Reduction in number of TB deaths
compared with 2015 (%)
90%
Reduction in TB incidence (new case) rate
compared with 2015 (%)
80%
TB-affected families facing catastrophic
expenditures due to TB (%)
Zero

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

79
Strategies
Private
sector
engagement
Active Case
Finding
TB
Co-
morbidities
Multi-
sectoral
response
Drug
Resistant TB
ICT Tools for
adherence
and
monitoring
Preventive
Measures
Community
Engagemen
t
National
Strategic Plan
(2017-25)

Organizational
structure
Ministry of Health & Family Welfare
Central TB Division
State TB Cell
36 States / UTs
District TB Centre
733 Districts
TB Unit
One per 1.5 – 2.5 lakh
population
Designated Microscopy
Centre
One per 1 lakh
population
Peripheral Health Institute
Supporting Facilities
 National Institutes (6)
 National Reference Laboratories (6)
 Intermediate Reference Laboratories (29)
 State TB Training and Demonstration Centres (26)
 Culture and DST Laboratories (49)
 DR-TB Centres (148)
 CBNAAT Laboratories (1180)

Key Services
1. Free diagnosis and treatment for TB patient
2. Provision of rapid diagnostics
3. Testing of all TB patients for drug resistance
and HIV
4. Management of associated diseases
5. Treatment adherence support
6. Nutrition assistance to TB patients
7. Preventive measures

Strategy to find
Active TB
Case Finding
Reaching
patients
seeking care
in Private
Sector
High
Sensitive
Diagnostic
tool

Treat
Treatment
Patient Centric Care
Reduce Out-of-pocket
Expenditure
• Daily Regimen
• Shorter Regimen
• Newer Drugs
• IT Enabled Adherence
Support
• Comorbidity
management
• Financial incentives
• Direct Benefit Transfer

Direct Benefit Transfer (DBT) schemes
Existing schemes:
1. Honorarium to Treatment Supporters – For provision of
treatment support to TB patients (Adherence, ADR
monitoring, counselling @Rs.1000/- to Rs.5000/-)
2. Patient Support to Tribal TB Patients (Financial Patient
Support @Rs750/-)
New Schemes:
1. Nutritional Support to All TB patients (Financial Support to
Patients @Rs.500/-month)
2. Incentives to Private Providers (Rs.500/- for Notification &
Rs.500/- for Follow-up with Treatment Outcome @Rs. 500)
3. Incentives to Informant (Rs. 500/- is given on diagnosis of TB
among referrals from community to public sector health
facility)

Prevent
• Air borne infection control measures
• Strengthen Contact Investigation
• Preventive treatment in high risk groups
• Manage Latent TB Infection
• Address determinants of disease

Increased Access to Diagnostic
Services
 Expansion of microscopy centres to improve
access
 Phase 1 - PHCs where a Laboratory Technician (LT) is
available
 Phase 2 – Other PHCs
Current Status –
Policy Update in RNTCP, 2018
14,576
16758
Microscopy Centres in 2018
Microscopy Centres in 2017
16.1 lakh TB patients notified in
public sector (12% in 2018)
1 microscopy centre at ~75,000
population

Universal Drug Susceptibility
Testing
 All TB patients to be tested for Rifampicin Resistance
Current Status – 60% of target
 DR-TB patients diagnosed
(54% from 2017)
Testing for Rifampicin to All
Rif
Resistance
MDR-TB
Testing for INH
Mono/Poly
DR-TB
Testing for Second line
FQ/SLI Resistance XDR
38,605
59544
2018 2017

Paradigm shift in management of Drug
Resistant TB
> 20,000 patients on Shorter regimen
> 4,600 patients on BDQ containing regimen
62 patients on DLM containing regimen
Shorter
Regimen
• All
MDR/RR-
TB
patients
without
resistant
to addl.
SLD
BDQ
• MDR/RR-
TB
patients
with
resistance
to addl.
SLD &
eligible
DLM
• 7 States
• Children 6
to 17
years in all
States

Injection Free Regimen
2HRZES
1HRZE
3HRE
Injection Free
regimen for
4,20,000
patients
2HRZE
4HRE
(3-6) Km Lfx R E Z
Injection Free regimen
for ~1,00,000 patients Lfx R E Z
Treatment for Previously Treated TB Patients
Treatment for INH Resistant TB Patients

Gazette on TB Notification
Mandatory Notification of TB
patients
 Public Health Actions
Provisions of Sections 269 and 270 of the
Indian Penal Code (IPC)
Pharmac
ies
Laborato
ries
Clinics /
Hospital
s
FIR
1
Notices
519 Policy Update in RNTCP, 2018
Provider
RNTCP
Patient
48 Cities in JEET & others
90 Cities approved in PIP

Multi-sectoral Engagement
TB care services in
health
infrastructure
Socio-economic
support &
Empowerment
Infection
Prevention
Address
Determinants
Information
Education
Communication
Prevention and
Care at Work Place
Corporate Social
Responsibility
TB - A social problem & needs multi-sectoral approach

Community Engagement
Transformation of TB survivors to
TB champions
Capacity building and mentoring
programme
Engagement of existing
community groups like PRI, SHG,
VHSNC, MAS, Youth Club
Grievance redressal mechanism
Involvement of community
representatives in different
forums
National
22 States
351 Districts
TB Patients | Community
4 lakh Treatment supporters

Call Centre
 1800-11-6666
 Outbound & Inbound
 Time – 7 to 11
 Languages – 14
 100 call centre agents
 Pan-India coverage
 Citizen – Patient - Providers
Counselli
ng Treatme
nt
Adheren
ce
Grievance
Redressal
Follow
Up
TB
Notificati
on
Informat
ion
Nikshay
Poshan
Yojana

Subnational Certification for TB
Free District / State
 Accelerate efforts
 Contextual strategies
 Generate healthy competition
 Recognition for achieving “Disease Free” status through
monetary and non-monetary awards
TB
Free

Award Categories Criteria
Decline in incidence rate
compared to 2015
Monetary Award for
District (in Rs.)
Non-Monetary
Recognition
Bronze 20% 2 lakhs Certification and
Felicitation at the
National Level
Silver 40% 3 lakhs
Gold 60% 5 lakhs
TB Free Status 80% 10 lakhs
State
District
Award
Categories
State/Uts with
population <50 lakh
State/Uts with
population 50 lakh –
5 Cr
State/Uts with
population >5 Cr
Non-Monetary
Recognition
Bronze 10 lakhs 15 lakhs 25 lakhs Certification and
Felicitation at
the National
Level
Silver 20 lakhs 35 lakhs 50 lakhs
Gold 40 lakhs 60 lakhs 75 lakhs
TB Free Status 60 lakhs 75 lakhs 1 Crore

State TB Index

1. Under reporting and uncertain care of TB patients in
private sector
2. Reaching the unreached – Slums, Tribal, vulnerable
3. Drug Resistant TB
4. Co-morbidities – HIV, Diabetes
5. Undernutrition, overcrowding
6. Lack of awareness and poor health seeking behaviour lead
to delay in diagnosis
Key Challenges

Key Take Away
• Improve TB notification rate Ensure mandatory TB
notification from private sector
• Active TB Case Finding to reach the unreached
• Optimum utilization of CBNAAT machines
• Expand Universal Drug Susceptibility Testing coverage
• Expansion of newer treatment regimens (daily regimen,
bedaquiline, delamanid, shorter MDR TB regimen)
• NIKSHAY Poshan Yojana to every TB patients
• 100% reporting through NIKSHAY
• Collaboration with Line Ministries to tackle social
determinants of TB
• Community participation for TB Elimination

Thank You
Bending the Curve
Accelerating towards a TB free India
Thank You

RNTCP.pptx

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