Dr. Priyamadhaba BeheraJunior Resident, AIIMS

Epidemiology and Evolving strategies of TB Control in India 17/04/2013

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Outline of presentation

• Epidemiology • Evolving strategies of TB Control in India1.National Tuberculosis Programme (NTP)2.RNTCP phase I3.RNTCP phase II4.STOP TB strategy5.Universal Access to TB Care6.National Strategic Plan (2012-2017)

Epidemiology

TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis

It typically affects the lungs (pulmonary TB) but can affect other sites as well (extrapulmonary TB)

The disease is spread in the air when people who are sick with pulmonary TB expel bacteria, for example by coughing

In general, a relatively small proportion of people infected with Mycobacterium tuberculosis will develop TB disease

Continued

• TB is also more common among men than women, and affects mostly adults in the economically productive age groups

• Risk factors-• Biomedical- HIV, DM, silicosis, malnutrition,

malignancy, tobacco• Environmental-ventilation, indoor air pollution• Socioeconomic –crowding, urbanisation, poverty,

migration

Continued• Without treatment, mortality rates are high. In studies of

the natural history of the disease among sputum smear-positive and HIV-negative cases of pulmonary TB, around 70% died within 10 years; among culture-positive (but smear-negative) cases, 20% died within 10 years

• The World Health Organization (WHO) declared TB a global public health emergency in 1993

• 9 million new cases in 2011 and 1.4 million TB deaths (990 000 among HIV negative people and 430 000 HIV-associated TB deaths)

Annual risk of infection• ARI is the most informative index of magnitude of

problem of tuberculosis• For ARI=1%

1. new Smear positive cases=50/lakh/year2. new Smear negative cases=50/lakh/year3. Retreatment cases=50% new smear positive

(25/lakh/year)4. Extrapulmonary and smear negative seriously ill=20% of

new smear positive (10/lakh/year)5. Total=135/lakh/year

• ARI for India 1-2%

Continued

Continued

In India 2deaths occur in every 3minute due to TB

IN INDIA

Globally, 3.7% (2.1–5.2%) of new cases and 20% (13–26%) of previously treated cases are estimated to have MDR-TB.

IN WORLD

Evolution of TB Control in India

• 1962 National TB Programme (NTP)• 1992 Programme Review

» only 30% of patients diagnosed; » of these, only 30% treated successfully

• 1993 RNTCP pilot began• 1997 RNTCP large scale-implementation• 2002 700 million population covered• 2004 >80% of country covered • 2006 Entire country covered by RNTCP/STOP TB strategy• 2010 Universal Access to TB Care• 2012-2017 National Strategic Plan

National Tuberculosis Programme (NTP)

• India has had a National Tuberculosis Programme (NTP) in place since 1962 • The treatment success rates were unacceptably low and the death & default

rates remained high• HIV-AIDS epidemic and the spread of multi-drug resistance TB were

threatening to further worsen the situation. • In 1992, GOI, with WHO and SIDA reviewed the TB situation and the following

were concluded:

In order to overcome these lacunae, the Government decided to give a new thrust to TB control activities by revitalising the NTP, with assistance from international agencies, in 1993

Revised National TB Control Program (RNTCP)

• Pilots were conducted between 1993- 1995 to test the operational feasibility in a population of 2.35 million in 5 pilot sites in the states of Delhi, Kerala, Gujarat, Maharashtra and West Bengal

• success of these pilot sites, the programme was expanded to a population of 13.85 million in 1995 and 20 million in 1996

• Large-scale implementation of the RNTCP began in 1997, following the successful negotiation of a World Bank credit of US$ 142 million

• The initial 5-year project plan was to implement the RNTCP in 102 districts of the country and strengthen another 203 Short Course Chemotherapy (SCC) districts for introduction of the revised strategy at a later stage.

• In early 2002, the World Bank assisted TB control project

Revised National TB Control Program (RNTCP)

• Launched in 1997 based on WHO DOTS Strategy– Entire country covered in March’06 through an unprecedented

rapid expansion of DOTS

• Implemented as 100% centrally sponsored program– Govt. of India is committed to continue the support till TB ceases

to be a public health problem in the country

Objectives of RNTCP

• To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases

• To achieve and maintain detection of at least 70% of such cases in the population

Strategy

1. Augmentation of organizational support at the central and state level for meaningful coordination

2. Increase in budgetary outlay3. Use of Sputum microscopy as a primary method

of diagnosis among self reporting patients4. Standardized treatment regimens.

contd.

5 Augmentation of the peripheral level supervision through the creation of a sub district supervisory unit

6 Ensuring a regular uninterrupted supply of drugs up to the most peripheral level

7 Emphasis on training, IEC, operational research and NGO involvement in the program

Core elements of Phase I

• The core element of RNTCP in Phase I (1997-2006)was to ensure high quality DOTS expansion in the country, addressing the five primary components of the DOTS strategy

RNTCP Phase II( 2006-11)

Consolidate the achievements of phase I Maintain its progressive trend and effect further

improvement in its functioning MPLEMENTATIOIN OF DOTS-PLUS FOR MDR-TB CASES IN A PHASED

MANNER

DISRIBUTION OF PAEDIATRIC DRUG BOXES

INSTITUTIONAL STRENGHTHENING AT NATIONAL, STATE AND DISTRICT LEVEL

INTRODUCTION OF TB-HIV CO-ORDINATOR ,URBAN CO-ORDINATOR AND COMMUNICATION FACILITATOR.

STOP TB STRATEGY• In 2006, STOP TB strategy was announced by WHO and adopted by RNTCP• Many of the National Airborne Infection Control guidelines, developing and

piloting strategy for 'Practical Approach to Lung Health' are the examples of initiatives taken by RNTCP under the comprehensive strategy of STOP TB

Universal Access to TB Care

• The twin objectives of 70/85 alone is not enough to achieve adequate reduction of TB transmission and reduction in disease with which epidemiological impact is expected.

• RNTCP defined newer objectives of 'Universal Access to TB Care' for TB control in India in 2010

• All TB patients in the community to have access to early, good quality diagnosis and treatment services in a manner that is affordable and convenient to the patient in time, place and person

• All affected communities must have full access to TB prevention, care and treatment, including women, children, elderly, migrants, homeless people, alcohol and other drug users, prison inmates, people living with HIV and other clinical risk factors, and those with other life threatening ‐diseases

Specific actions to achieve early and complete case detection, towards universal access to TB diagnosis

• Improve suspects identification• Follow up of the sputum negative symptomatic• Reduce initial defaulters• Screening for TB among high risk groups1. HIV2. Diabetic patients3. Elderly4. Smokers 5. Malnutrition, patients with silicosis and other chronic diseases

Universal access to TB care in Medical Colleges

-------Improve the TB notification system by registering all cases treated under DOTS and non DOTS (irrespective of the source of drugs and the regimen used) ‐in the RNTCP TB register.

------ Conduct operational research to identify local barriers to early case detection,including care seeking behavior, missed opportunities for diagnosis, etc.

-----Collaborate with the local authorities to implement pharmacovigilance for anti TB drugs sold in the district/state with a view to develop locally ‐innovativestrategies for improvements in notification of TB cases and promotion of rational use of drugs.

National Strategic Plan (2012-2017)

12th Five Year Plan: RNTCP has developed National Strategic Plan to be implemented during 2012-2017

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.

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

AREAS• Strengthening and improving the quality of basic DOTS services• Further strengthen and align with health system under

NRHM• Deploying improved rapid diagnosis at the field level• Expand efforts to engage all care providers• Strengthen urban TB Control• Expand diagnosis and treatment of drug resistant TB• Improve communication and outreach• Promote research for development and

implementation of improved tools and strategies