REVISED NATIONAL TUBERCULOSIS PROGRAMME

1. Rahul.K.R
Dept. Of Swasthavritta
Amrita School of Ayurveda.
REVISED NATIONAL TUBERCULOSIS
PROGRAMME
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2. • Tuberculosis (TB) is an infectious disease
caused by a Mycobacterium tuberculosis.
• TB is a drop let infection and is highly
contagious.
• Patients are infective as long as they remain
untreated.
• An effective anti microbial treatment
reduces infectivity by 90% within 48 Hrs.
TUBERCULOSIS (TB)
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3. • Operational since 1962.
• Unacceptably low success rate.
• Spread of multidrug resistant TB.
• 1992 Govt. of India, WHO and SIDA reviewed TB situation
and concluded that
– NTP suffered managerial weakness
– Inadequate funding.
– Over-reliance of X-ray for diagnosis.
– Frequent interrupted supplies of drugs.
– Low rate of treatment completion.
NATIONAL TUBERCULOSIS PROGRAM (NTP)
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4. • 1993 Govt. of India revitalize NTP
with assistance from international
agencies.
• RNTCP thus formulated.
• Adopted Direct Observed
Treatment Short-course(DOTS)
• Political and Administrative
commitment for ensuring
adequate funds, staff and other
key inputs.
• Adoption of smear microscopy for
reliable and easy diagnosis in
decentralized manner.
REVISED NATIONAL TUBERCULOSIS CONTROL
PROGRAMME
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5. • Achievement of at least 85% cure
rate of infectious cases; through
DOTS.
• Augmentation of case finding
activities through quality sputum
microscopy to detect at least 70%
of estimated cases.
OBJECTIVES OF RNTCP
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Mycobacterium tuberculosis
Pure culture

6. • Introduced in 3 phases.
– Phase I (1992 – 2006)
– Phase II (2006 – 2011)
– Phase III
• 1998 it covers only 2% of the population.
• By the end of 2006 it covers whole India and enters to 2nd phase.
• Improve access to marginalised groups.
• RNTCP is built on the infrastructure of NTP.
• DOTS strategy is adopted.
PHASES OF RTNCP
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7. 1. Political will and administrative commitment.
2. Diagnosis by quality assured sputum smear microscopy.
3. Adequate supply of quality short course
chemotherapy(SCC).
4. Directly observed treatment.
5. Systemic monitoring and accountability.
FIVE COMPONENTS OF RNTCP
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8. • 2006 stop TB was announced by WHO
• Components are,
– Pursuing quality DOTS.
– Addressing TB/HIV and MDR-TB.
– Contributing to health system strengthening.
– Engaging all care providers.
– Empowering patients and communities.
– Enabling and promoting research.
STOP TB
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9. • State TB office – State tuberculosis officer.
• State TB training and demonstration centre – Director.
• District TB centre – District tuberculosis Officer.
• Tuberculosis Unit-
– Medical officer – TB control,
– Senior treatment supervisor
– Senior TB lab supervisor.
• Microscopy centre, Treatment centres.
• DOTS providers.
ORGANISATION (PROFILE OF RNTCP IN A STATE)
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10. • A nation–wide network of RNTCP quality assured
designated sputum smear microscopy labs has been
setup providing appropriate , available , affordable and
accessible diagnostic service for TB suspects.
• Carried out sputum microscopy with External Quality
Assessment (EQA) and Drug Resistance Surveillance (DRS).
• New protocols for microscopy and DRS prepared.
LABORATORY NETWORK
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11. • Consist of 4 NRLs
1. Tuberculosis Research centre, Chennai.
2. National Tuberculosis Institute, Bangalore.
3. Lala Ram Sarup Institute of TB and Allied Science, New Delhi.
4. JALMA Institute, Agra.
• A central laboratory committee, constituted with microbiologist from
3 NRLs and Central TB division with WHO representatives.
• 24 IRLs, 12750 Designated Microscopy Centres.
• State TB training and Demonstration Centre will be designated as
IRLs.
• Sputum analysis done in three stages – on-site evaluation, panel
testing, blinded rechecking.
LABORATORY NETWORK
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12. 12

13. RNTCP- LABORATORY NETWORK
Central TB Division National Reference Lab
State TB Cell Intermediate Reference Lab
District TB Centre
TU TU
DMC 2 DMC3
NATIONAL
LEVEL
STATE
LEVEL
DISTRICT LEVEL
TU TU
DIRECTION OF SUPERVISION
DIRECTION OF FEEDBACK
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DMC1

14. • Patient presenting with symptoms suspicious of
tuberculosis are screened with 2 sputum analysis.
– Chance of detecting TB +ve case is only 80% per sample.
• Done in RNTCP microscopy centres.
– In CHC, PHC, Taluk Hospitals or in TB dispensary.
• Sputum analysis indicates the degree of infectivity and
response to treatments.
• All patients are provided short course chemotherapy
(SCC) free of cost.
• Drugs are administered under direct supervision called
DOTS.
• DOTS is a community based TB treatment.
INITIATION OF TREATMENT
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15. • DOTS ensures high cure rate via 3 components
– Appropriate medical treatment.
– Supervision.
– Motivation.
• DOTS is given by peripheral health staff such as MPWs, or
through voluntary workers(DOTS Agents ) such as
teachers, anganawadi workers, dias, ex-patients, social
workers etc.
• DOTS Agents are paid Rs150/patient.
• Drugs are supplied in patient-wise box(PWBs) containing
the full course treatment.
INITIATION OF TREATMENT
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16. Cough for 2 weeks
1 or 2
positive
2 sputum smears 2 negative
Symptoms
persist
Antibiotic
10-14 days
2 negative
Negative TB
Positive TB X-ray
1or 2
positive
Repeat 2
smear
Smear
positive TB
Anti TB
treatment
Smear –ve TB
Non TB
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17. • Strategy to ensure cure by providing the
most effective medicine and confirming
that it is taken.
• Only strategy documented to be effective
worldwide.
• First dose is to be taken in the presence of
the health worker.
• During continuation the patient is issued
medicine for 1week in multi blister
combipack and need to return the empty
one to collect medicine for next week.
• Cases are divided into 3 catogeries.
DOTS
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18. • Category I (in red box)
– New sputum smear +ve.
– New sputum smear –ve.
– New extra pulmonary.
– New others.
• Category II (in blue box)(previously treated)
– Sputum smear +ve relapse.
– Sputum smear +ve failure.
– Sputum smear +ve treatment.
• Category III (in green box)
- sputum negative pulmonary tuberculosis with minimal involvement.
- Less severe form of extra pulmonary tuberculosis.
CATEGORY OF CASES
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19. Medicine code
Isoniazid-600mg H
Rifampicin-450mg R
Pyrazinamide-1500mg Z
Ethambutol-1200mg E
Steptomycin-500mg S
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a) Accuracy of TB diagnosis is more than
doubled
b) Treatment success rate is upto 95%.
c) Prevents the spread of TB infection.
d) Improves quality of health care and
remove stigma.
e) Prevents failure to treatment.
f) Helps alleviate poverty by saving lives,
reducing duration of illness and
preventing spread of infection.
g) Lends credibility to TB control efforts.
ADVANTAGES OF DOTS

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• Diagnosis and treatment for MDR-TB is complex and hence
its introduced by WHO.
• Diagnosis and treatment for MDR-TB are done at tertiary
care centres like medical colleges, large speciality hospitals
having qualified staffs.
• Use category IV regimen.
• Second line drugs are used.
• Ambulatory DOT after a short period of IP care to stabilize
the patient.
DOTS-PLUS

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• Treatment regimen:6(9) Kanamycin ofloxacin Ethinamide
Cycloserine Pyrazinamide Ethambutol + 18 Ofloxacin
Ethinamide Cycloserine Ethembutol
• Duration : at least 6months of intense phase extend up to
9months in patients with smear +ve after 4months, minimam
18 months continuation phase should be given.
• Smear examination done in 4,6,12,18,24 months of treatment
• Efforts made to administer treatment under DOTS over entire
period of treatment.
• Systemic documentation of the treatment should be
maintained.
DOTS-PLUS

23. • Introduced under RNTCP in 2003.
• TB paediatric cases are treated with PWBs
like in adults.
• Treatment based on the child’s body
weight, there is 2 generic PWBs
– 6-10kg weight band.
– 11-17kg weight band.
• This is the worlds first DOTS therapy for
children.
• Children weighing less than 6kg are
treated with loose anti-TB drugs.
PAEDIATRIC TB
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24. • Drug resistance TB prevalence is an indicator of
effectiveness of control activities over a period of time.
• Aim of DRS is to determine the prevalence of
antimycobacterial drug resistance among new sputum
smear positive pulmonary tuberculosis.
• The results of survey indicates MDR-TB is less than 3%
among new cases and 12-17% in treated cases.
• These results show the prevalence of MDR-TB is stable in
the country.
• Surveys are conducted periodically to monitor and study
the trend prevalence of MDR-TB in community.
DRUG RESISTANCE SURVEILLANCE (DRS)
UNDER RNTCP
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Mono-resistant:-Resistant to any one TB treatment drug.
Poly-resistant:-Resistant to at least any two TB drugs (but not
both isoniazid and rifampicin).
Multidrug- resistant(MDR TB):-Resistant to at least isoniazid and
rifampicin, the two best first-line TB treatment drugs.
Extensively drug-resistant (XDR TB):-Resistant to isoniazid and
rifampicin, plus resistant to any fluoroquinolone AND at least 1
of the 3 injectable second-line drugs (e.g., amikacin,
kanamycin, or capreomycin)
TYPES OF DRUG-RESISTANT TB

26. DOTS-Plus
• PMDT services for quality diagnosis and treatment of drug
resistant TB initiated in 2007 in Gujarat and Maharashtra
• By 2012 aimed drug susceptibility testing to all smear positive
retreatment cases upon diagnosis and all new cases who
are smear positive after first line of anti-TB treatment.
• By 2015 test will be made to all smear +ve cases.
PROGRAMMATIC MANAGEMENT OF DRUG
RESISTANT TB (PMDT)
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27. 1. Definition of MDR suspect has been revised to include
contact of MDR cases who are found to be smear positive
besides Category I failure and category I patient who are
smear positive at 4 months or later.
2. A new weight band has been added (16kg-25kg) for
treatment of paediatric MDR patients.
3. In order to cat IV regimen, more effective Ofloxacin is
replaced with levofloxacin.
4. Guidelines for the management of MDR patients with
pregnancy have been finalised.
POLICY CHANGES RELATED TO DOT-plus
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28. • RNTCP and NACO devised a joint
action plan for TB-HIV coordination.
• Objective is to reduce the TB related
morbidity and mortality of people
living with HIV.
• Effective prevention of both the
diseases.
• Initiated in 2001 in 6 high HIV
prevalent states.
TB-HIV coordination.
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29. • Newer strategies have been developed as a
comprehensive National Strategic plan under 12th five
year plan, includes
– Strengthening and improving the quality of basic DOTS
service.
– Further strengthen and align with health system under NRHM.
– Deploying rapid diagnosis at the field level.
– Expand effort to engage all care providers.
– Strengthen urban TB control.
– Expand diagnosis and treatment of drug resistant TB.
– Promote research for development and implementation of
improved tools and strategies.
NATIONAL STRATEGIC PLAN (2012-2017)
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30. • Objectives of programme proposed are
1. To achieve 90%notification rate for all cases.
2. 90% success rate for all new and 85% for retreated
cases.
3. Improve the successful outcomes of treatment of MDR
cases.
4. Decrease mortality and morbidity of HIV associated
TB.
5. Improve out come of TB care in private sector.
• Notification of TB cases
• According to govt of India it is mandatory for all healthcare
providers to notify every TB case to local authorities.
STRATEGIC VISION TO MOVE TOWARDS
UNIVERSAL ACCESS.
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31. • Covers whole country since march 2006.
• Phase II has been launched from 1st October 2006.
• Increased treatment success rate from 25% in 1988 to
88% in 2010.
• Reduced death rate from 29% to 4%.
• More than 15million patients have been treated saving
almost 2.5million lives.
• Four urban DOTS project have also been launched.
ACHIEVEMENTS OF RNTCP
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32. • India receives assistance from:
1.World Bank, in first phase.
2.DFID & World Bank in second phase.
3.DANIDA , GDF & USAID
FINANCIAL RESOURCES
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• One big reason is that it can live in animals. As hard as it
is to eradicate in humans, it's much much harder to
eradicate a disease in animals. Also, there's no good
vaccine, which is an absolutely vital tool in the
eradication of a disease.
WHY HAS TB NOT BEEN ERADICATED?

34. THANK YOU
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