Revised National Tuberculosis Control Programme Status, Challenges

1
Revised National Tuberculosis Control
ProgrammeStatus, Challenges Achievements

• Dr L S Chauhan
• Deputy Director General (TB)
• Central TB DivisionMinistry of Health Family
  WelfareNew Delhi

2
Global Burden

• Of the 22 High burden countries are
• 12 are in Asian continent
• 8 in Africa

3
India is the highest TB burden country globally
accounting for one fifth of the global incidence
Global annual incidence 8.9 million
Source WHO Geneva WHO Report 2004 Global
Tuberculosis Control Surveillance, Planning and
Financing
4
Problem of TB in India

• Incidence of TB disease 1.8 million new TB cases
  annually (0.8 million new infectious cases)
• Prevalence of TB disease 3.8 million
  bacteriologically positive (2000)
• Deaths about 370,000 deaths due to TB each year
• TB/HIV 2.5 million people with HIV
• About 5 of TB patients estimated to be HIV
  positive
• MDR-TB in new TB cases 3
• Substantial socio- economic impact

5
RNTCP Goal and Objectives

• Goal
• The goal of TB control Programme is to decrease
  mortality and morbidity due to TB and cut
  transmission of infection until TB ceases to be a
  major public health problem in India.
• Objectives
• To achieve a case detection of at least 70 of
  new sputum positive TB patients
• To achieve a cure rate of at least 85 in such
  patients

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Achievements of RNTCP 1993-2007
7
Population in India covered under DOTS and Total
Tuberculosis Patients put on treatment each
quarter
346566
8
Annualized New Smear-Positive Case Detection Rate
and Treatment Success Rate in DOTS Areas, India,
1999-2007

• Population projected from 2001 census
• Estimated no. of NSP cases - 75/100,000
  population per year (based on recent ARTI report)

9
Treatment Outcome of Smear Positive Cases
registered under RNTCP DOTS, 1993-2006
Sp Retreatment 1,119,369
NSP 2,997,753
10
Extra-pulmonary TB By Site
Source of pie-diagram RNTCP Data from 13
Districts, Q3 2004
11
Treatment outcome of New Extra-Pulmonary Patients
registered under RNTCP DOTS (2005-2006) (all
forms of EP TB)
Total cases (n 354,025)
12
Other Sector involvement

• gt2400 NGOs involved under RNTCP
• 17,000 PPs involved
• 150 Corporate Houses participating
• Involvement of professional bodies
• IAP involved in development of Pediatric
  guidelines 2005
• IMA actively collaborating in 167 districts/ 6
  states under Rd 6 GFATM Project
• Coalition of professional bodies established
  (2007)
• Assoc. of Physicians of India (API)/ Indian
  Academy of Pediatricians (IAP)/ National College
  of Chest Physicians (NCCP)/ Indian Chest Society
  (ICS) / Federation of Family Physicians of India
  (FFPI)

13
Contribution of Various Sectors 14 intensified
urban PPM sites summary of contributionby
different health sectors (1st Qtr 06 4th Qtr 06)
N788381
N52111
N26649
N77884
14
TB suspects referred from ICTC for evaluation,
2005-2007
gt 5 fold increase in referrals
(Jan-Nov)
(Jan-Nov)
(Jan-Nov)
15
TB patients Newly HIV Tested, 2005-2007
gt 3 fold increase in last 3 years
Jan-Nov
Jan-Nov
Jan-Nov
16
MDG Goals Progress

• Indicator 23 between 1990 and 2015 to halve
  prevalence of TB disease and deaths due to TB
• Studies by NTI, TRC suggest annual decline in
  prevalence by 9-11.
• Mortality rates have declined from 42 per 100,000
  population in 1990 to 29 per 100,000 population
  in 2005
• Trends in Incidence to be measured by repeat
  national ARTI survey in 2007-09
• Indicator 24 to detect 70 of new infectious
  cases and to successfully treat 85 of detected
  sputum positive patients
• The global NSP case detection rate is 60 and
  treatment success rate is 84
• RNTCP consistently achieving global bench mark of
  85 treatment success rate and case detection
  rate close to 70 (2006 66)

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Challenges Road ahead
18
Implement all components of the newStop TB
Strategy
19
Component 1 Pursue high quality DOTS expansion
and enhancement
20
New Smear Positive Case Detection Rate,
India Third Quarter, 2007
gt70
50 - 69.9
30 49.9
lt30
21
Cure Rate by district, India Third Quarter, 2006
gt85
80 84.9
lt80
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Component 2 Address TBHIV, MDR TB (1)

• Strengthening of collaborative activities across
  the country
• National Framework for Joint TB HIV Collaborative
  activities
• Establish collaborative mechanisms
• Service delivery coordination Intensified TB
  case finding at ICTCs ART centers
• Documentation and reporting
• ACSM involevment of NGOs
• Operational issues
• ART-DOTS linkages improving access
• CPT prophylaxis to co-infected patients -
  operationalisation
• Provider initiated routine referrals of TB
  patients for VCT
• INH prophylaxis to at ART centers efficacy/
  feasibility
• Assess impact of HIV burden on TB epidemiology
• Periodic surveillance of HIV prevalence among TB
  patients

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Component 2 Address TBHIV, MDR TB (2)

• National DOTS Plus Guidelines framed and
  disseminated
• Gujarat and Maharashtra initiated DOTS Plus
  services in 2007.
• Plan to expand to 5 additional states in 2008
• Challenges
• Non standardized regimen being practiced for 1st
  line anti TB treatment
• Irrational use of 2nd line drugs
• Looming threat of XDR TB

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Component 3 Contribute to Health Systems
Strengthening

• NRHM - window of opportunity for strengthening
  existing health systems
• Indian Public Health Standards for all health
  care facilities
• Improved Human Resource management
• Strengthening of community outreach through ASHA
  workers
• Innovative collaborations with NGO and Private
  sector

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Component 4 Engage all care providers

• Need for strengthening involvement of PPs
• IMA involved in 167 districts in 6 states under
  Rd 6 GFATM project starting July 2007
• Coalition of Professional Organisations - IMPACT
• Expand scope of involvement of NGOs, especially
  in hard to reach areas/ areas with weak
  government health system
• Consortium of NGOs
• Systematic involvement of other sectors-
  Railways/ Coal/ ESI/ Faith based organizations
• Varying administrative control and geographical
  spread
• Definite role of Medical Colleges
• In seeking involvement of all health care
  providers, promoting rational use of anti TB
  drugs
• Role envisaged by NTF and echoed by JMM 2006
• Addressing competing interests of private
  providers/ market forces
• Regulation/ Legislation

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Component 5 Empower people with TB and
Communities

• Mass media important to generate awareness
• Local/ Focal ACSM strategy to increase awareness
  and thus address community needs and generate
  demand
• Generate demand for quality services
• sharing information through different media (mass
  media, schools, organized groups)
• Increase utilization of services
• informing patients and communities,
• promoting neighbourhood DOT provision,
• motivating patients with the support of cured
  persons,
• involving other care providers in the community
• Enhancing patient satisfaction
• patient provider counselling,
• using traditional healer/ cured persons for DOT
  provision,

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Component 6 Enable and promote research

• RNTCP to pro-actively participate in national and
  international trials on
• New diagnostic tools
• Operational feasibility of MGIT liquid culture
  method in states - PATH supported
• New drugs/ vaccines
• Promote operational research on RNTCP
• 6 large scale OR projects undertaken by Medical
  Colleges were approved by the National OR
  Committee in 2006-07.
• Over 20 more OR proposals from Medical Colleges
  are in process for approvals.
• Post Graduate Thesis by Medical College
  residents, being undertaken on RNTCP topics

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Assessment of Impact

• Nation wide ARTI Survey 2007-09
• Co-ordinated by NTI, Bangalore in association
  with
• New Delhi TB Centre (North Zone)
• MGIMS, Wardha (West Zone)
• LRS Institute, New Delhi (East Zone)
• CMC, Vellore (South Zone)
• Disease prevalence Surveys 2007-09
• TRC Chennai MDP project
• NTI, Bangalore
• MGIMS, Wardha
• PGI, Chandigarh
• AIIMS, New Delhi
• JALMA, Agra
• RMRCT, Jabalpur

Symptomatic screening CXR Sputum Smear
Culture
Symptomatic screening Sputum Smear Culture
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Impact Assessment surveys

• TB Mortality Surveys
• AP Orissa field survey completed/ results
  awaited
• Uttarakhand in 2008-09
• Drug Resistance Surveillance
• Pilot study in AP completed/ survey in 2007-08
• UP DRS underway
• Impact of HIV
• Periodic HIV surveillance

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Conclusions

• Significant progress since 1993
• 30 million suspects examined
• Over 7.7 million patients registered on
  treatment thus saving gt1.4 million lives
• Global benchmarks almost achieved
• Challenges
• Expand reach of standardized treatment/ ISTC
  across all care providers
• Establish systems for diagnosis and management of
  MDR TB
• Promote rational use of 2nd line drugs
• Prevent emergence of XDR TB
• Achieve TB related MDGs by 2015
• Limit impact of HIV and MDR on TB epidemiology

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Thanks

• www.tbcindia.org