Revised National Tuberculosis Control Programme (RNTCP)

Presenter

Anrud kumar Majhi

Batch-2017-18

Roll no -52

INDIA

• Accounts for nearly 1/4^th of the global burden of TB
• Around 2.2 million develop TB in 2013-14. During the same period, 0.27 million people died due to TB
• Everyday about 20,000 people become infected, 5000 develop TB and more than 1000 die due to the disease
• In simple terms, 2 persons become sputum +ve for TB and almost 1 person is killed every minute due to the disease ( WHO 2007)
• The proportion of new cases with MDR-TB was 2.2% in 2014, whereas those for previously treated cases was 15.0%

• 1962- National TB Control Program(NTCP) started
• Managerial weakness, lack of supervision
• Poor quality of sputum microscopy
• Multiplicity of treatment regimens
• Poor organizational set-up
• Inadequate funding
• Over dependence on X-ray for diagnosis
• Frequent interrupted supplies of drugs
• Low rate of treatment completion (30% only)

Revised National Tuberculosis Control Programme

• The National TB Programme (NTP) was started in 1962 for TB control in India. This programme was not able to give expected results in India
• The NTP was reviewed in 1992
• As a result of the review and pilot studies in 1993, the DOTS strategy was adopted in India under the Revised National TB control Programme - RNTCP
• The programme was implemented in a phase manner and by 24^th March 2006, the entire country was covered under the programme

Goal

The goal of RNTCP is to decrease the mortality and morbidity due to tuberculosis and cut down the chain of transmission of infection until TB ceases to be a public health problem

Objectives

To achieve and maintain:

• Cure rate of at least 90% among newly detected smear positive (infectious) pulmonary TB cases and
• Case detection of at least 85% of the expected new smear positive PTB cases in the community

Organisational structure of RNTCP

Central TB Division, DGHS, MoH&FW

Deputy Director General-TB

State TB Cell

District TB Centre

Tuberculosis Unit

DMC

DOTS Centre

National Institutes

(NTI, TRC, LRS, JALMA)

National Lab Committee, National TWG for TB-HIV, National DOTS Plus Committee, NTF for medical colleges, National OR Committee

STO, MO, Epidemiologist, DEO etc

State TB Training and Demonstration Centre/SDS/IRL

Nodal centre for TB control in the district

DTO, MO-DTC, Support staff etc

MO-TC, STS, STLS

1 per 5 lakh population, 1 per

2.5 lakh in tribal, hilly and difficult areas

1 per 1 lakh population, 1 per

0.5 lakh in tribal, hilly and difficult areas

MO, LT

HW, ASHA, AWW, PPs,

NGO, Comm vol etc

Unique features of RNTCP

• District TB Control Society
• Modular training
• Patient wise boxes
• Sub-district level supervisory staff (STS, STLS) for treatment & microscopy
• Robust reporting and recording system

FUNDING

• 100 % central government sponsored
• The program is assisted by World bank and The Department for International Development (DFID)
• Other supporting agencies are
• Global TB Drug Facility(GDF)
• Global Fund to Fight AIDS, TB, Malaria(GFATM)
• United States Agency for International Development(USAID)
• Danish International Development Agency (DANIDA)

Strategies

• Case finding and Diagnostics- Use of sputum testing as the primary method of diagnosis
• Patient friendly treatment services and ensuring a regular, uninterrupted supply of drugs up to the most peripheral level-DOTS
• Scale-up of Programmatic Management of Drug Resistance –TB (PMDT)
• Scale -up of Joint TB-HIV Collaborative Activities
• Integration with Health Systems

Strategies

• Engagement of Private Sector
• Human Resource Development
• Advocacy, Communication and Social Mobilization (ACSM)
• Monitoring and Evaluation, Surveillance and Impact Assessment
• Operational research to inform TB Control policy and practice

Strategies

1. Case finding and Diagnostics:

• Early identification of all infectious TB cases
• Improved integration with the general health system and leverage field staff for home-based case finding
• Improve communication and outreach

groups for

• Screening clinically & socially vulnerable risk TB
• Develop improved sputum collection and transportation systems

Strategies

• Deployment of higher-sensitivity diagnostic tests for TB suspects (and incorporate new tests) & decentralized DST services
• Catch patients already diagnosed through notification from all sources
• Improved referral for treatment mechanisms, and deployment of Laboratory & Private Provider notification

Strategies

2. Patient friendly treatment services: DOTS strategy

• Promptly and appropriately treating TB, increasingly guided by DST
• Making DOTS more patient friendly through ↑ communitization of DOT
• pilot incentives/offsets for patient costs to help patients complete treatment and better monitoring through IT
• Improving partnerships between public and private sector

Strategies

3. Scale-up of Programmatic Management of Drug Resistance –TB (PMDT):

• Developing network of C&DST Laboratories & Strengthening of Reference Laboratories
• Decentralized DST at district level for early MDR detection
• Improved information system for PMDT

Implementation

• Case finding- by passive surveillance on patient with symptoms of
1. Persistent cough for 2weeks or more.
2. Haemoptysis
3. Night sweats
4. Evening rise of temperature
5. Chest pain In lab.-
• Sputum collection for diagnosis
• Radiography
• Tuberculin test

• Diagnosis of TB

Sputum examination is the best method to diagnose TB

• Pulmonary TB diagnosis can be confirmed by sputum examination. Two sputum samples are collected over one/two consecutive days
• If the health facility is a DMC, spot sample is collected immediately and the patient is given a sputum container to collect early morning sample & brought to the lab

• Alternatively the patient can be asked to collect a morning sample and go to a DMC where a spot sample can be taken
• In case the patient is not able to reach a DMC, both samples - morning and spot, can be collected and transported

• The sputum samples are subjected to microscopy examination as early as possible
• A patient is diagnosed positive if one or both the samples is positive for bacteria
• If the bacteria are not visible in any sputum sample, the patient is negative and should be referred to a medical officer for further evaluation
• TB of other organs is diagnosed by a medical officer

DOTS

Directly Observed Treatment Short Course

Directly Observed Treatment

Directly observed treatment (DOT) is one element of the DOTS strategy

An observer watches and helps the patient swallow the tablets

Direct observation

ensures treatment for the entire course

• with the right drugs
• in the right doses
• at the right

intervals

Components of DOTS

DOTS is a systemic strategy to control TB diseases. It has the following 5 components -

1. Political and administrative commitment

1. Good quality diagnosis, primarily microscopy
2. Uninterrupted supply of quality drugs
3. Directly observed treatment (DOT)
4. Systemic monitoring and accountability

by sputum smear

DOTS

Directly Observed Treatment Short Course There are two phases in DOTS treatment

1. Intensive Phase(IP):-
• Intensive phase is of 2 to 3 months duration
• Patient swallow medicine under the observation of a health worker during IP
• Medicines are taken 3 times a week on alternate days
• If the sputum is negative for bacteria after IP, continuation phase is started

DOTS

Directly Observed Treatment Short Course

2. Continuation Phase

• This phase is of 4 or 5 months duration
• The patient is provided with a weekly blister pack to take home
• The medicines from the blister pack are taken on alternate days, three times a week and in the remaining days, Vitamin tablets are taken
• The first dose of the weekly blister pack is taken under direct observation of the health worker
• Empty blister packs are collected to ensure that the

medicines are taken at home by the patient

Treatment Regimens

Category of Treatment

Type of Patient

Regimen

Category I

All new pulmonary (smear-positive

and

negative), extra pulmonary and ‘others’ TB patients.

2H₃R₃Z₃E₃+

4H₃R₃

Category II

TB patients who have had more than one month anti-tuberculosis treatment previously

Relapse , Failure, Treatment After

Default ,Others

2H₃R₃Z₃E₃S₃

+ 1H₃R₃Z₃E₃

+ 5H₃R₃E₃

ANTI-TUBERCULAR DRUGS

* Patients who weigh 60 kg or more at the start of treatment are given an extra 150mg dose of Rifampicin

** Patients over 50 years of age are given 0.5g of streptomycin

*** Adult patients weighing <30kg receive drugs in patients- wise from the weight band suggested for pediatric patients

DOTS Plus ?

• DOTS programme that add components for MDR-TB diagnosis, management and treatment

Drug resistant TB

Achievements

• RNTCP has been recognized for the fastest expansion of DOTS in the world
• During the year 2009 DOTS treatment success Rate was 87%
• Diagnostic facilities have been established in >13000 labs/ DMC throughout the country
• RNTCP has successfully involved 297 medical colleges

,over 1971 NGOs,10,984 private practitioners and over 150 corporate private sector health units

• Quality Assurance protocol for smear microscopy has been implemented in all the states
• 662 DTC, 2,698 TB units, >13000 DMC are functioning
• About 140 internal evaluations conducted in 2007
• > 60,0000 Dots Provider
• 38287 MDR TB suspects examined till the end of 2011,
• and 10267 MDR-TB patients diagnosed in 2011
• 6994 have been put on treatment

Thank you