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ControlProgramme
(RNTCP)
Dr.NAVPREET
AssistantProf.,Deptt.ofCommunityMedicine
GMCHChandigarh
ProblemStatementofTBinIndia
India accounts for nearly 1/4th of global burden of TB
(2010).
Mortality: 26per1lacpopulation.
Prevalence(old+newcases):256per1lacpopulation.
Incidence(newcasesonly):185per1lacpopulation.
MillenniumDevelopmentGoals
Goal 6: Combat HIV/AIDS, malaria and other
diseases
Target 8: By 2015, to have halted and begun to
reverse the incidence of malaria and other major
diseases
Indicator 23: between 1990 and 2015 to halve
prevalenceofTBdiseaseanddeathsduetoTB
Indicator24:todetect70%ofnewinfectiouscasesand
tosuccessfully treat 85% of detected sputum positive
patients
EvolutionofTBControlinIndia
1950s60s ImportantTBresearchatTRCandNTI
1962
NationalTBProgramme(NTP)
1992
ProgrammeReview
only30%ofpatientsdiagnosed;
ofthese,only30%treatedsuccessfully
1993
RNTCP pilotbegan
1998
RNTCPscaleup
2000
>30%ofcountrycovered
2004
>80%ofcountrycovered
2006
EntirecountrycoveredbyRNTCP
NationalTuberculosisControl
Programme
NTCPwasstartedin1962withaimtodetectcasesat
theearliest&treatthem.
However,
Treatmentsuccessrate
:unacceptablylow
Death&defaultrate :high
NeedForRevisedStartegy
in 1992, nation wise review was conducted with
assistanceofSIDA&WHO.
NTPsufferedfrommanagerialweakness
Inadequatefunding
OverrelianceonXraysfordiagnosis
Frequentinterruptedsuppliesofdrugs
Lowratesoftreatmentcompletion.
RevisedNational TuberculosisControlProgramme
ObjectivesofRNTCP:
1. To achieve and maintain a cure rate of at least 85%
amongnewlydetectedinfectious(newsputumsmear
positive)cases
2.Toachieveandmaintaindetectionofatleast70%of
suchcasesinthepopulation.
Revisedstrategy:
1. Augmentation of organizational support at centre
andstatelevel.
2. Usesputumtestingasprimarymethodofdiagnosis
3. Standardizedtreatmentregimen
4. Ensuringregular,uninterruptedsupplyofdrugs
5. Emphasis on training, IEC, operational research &
NGOinvolvement.
6. Increasedbudgetoutlay
ComponentsofDOTS:
1. Political will ensures financial support and
sustainability.
2. Case detection with the help of quality assured
sputumsmearmicroscopy.
3. Regularanduninterruptedsupplyofdrugs
patientwiseboxes
4. Directlyobservedtreatment
directobservationwhilepatientisgettingtreatment.
5. Systemicmonitoringandaccountability.
StructureofRNTCPatStatelevel
State TB Cell
District TB Centre
Tuberculosis Unit
Microscopy Centre
DOT Centre
MO-TC
STS, STLS
MO, LT
RecommendationoftheRNTCPNationalLaboratory
Committee(Oct2008)
Strongly recommended that RNTCP changes diagnostic
criteriaofSmear+vePTBasbelow:
TB suspect is any person with cough for 2 weeks, or
more
Number of specimen required for diagnosis is 2, with
oneofthembeingamorningsputum
One specimen positive out of the two is enough to
declareapatientasSm+PTB
Basisofchanges
The revised definition of a new sputum smear
positivepulmonaryTBcaseisbasedonthepresence
ofatleastoneacidfastbacillus(AFB)inatleastone
sputum sample in countries with a well functioning
EQAsystem.
The reduction of the number of specimens to be
examined for screening of TB cases from three to
two, in places where workload is very high and
humanresourcesarelimited.
RevisedCategories
Treatmen Typeofpatient
tgroups
Regimen
Intensive Continuation
phase(IP) phase(CP)
4
New
Newsputumsmearpositive 2
(CatI)
Newsputumsmearnegative H3R3Z3E3 H3R3
Newextrapulmonary
Newothers
5
2
Previously Smearpositiverelapse
H3R3Z3E3 H3R3E3
Smearpositivefailure
treated
S3/
Smearpositivetreatment
(CatII)
1
afterdefault
H3R3Z3E3
Others
QualityAssurance
RNTCPLabnetworkhasthreelevels:
NationalReferenceLaboratories
NTIBangalore
TRCChennai
LRSNewDelhi
IntermediateReferenceLaboratories
Statelevel
NetworkofDesignatedMicroscopyCenters(>11,000)
Includesmicroscopycentersinmedicalcolleges
OneDMCcoversapopulationofabout1lakh
Providequalityassuredacidfastsputumsmearmicroscopy
services
RNTCPExternalQualityAssessment
Components
Paneltesting
Onsiteevaluation
Randomblindedrecheckingofroutineslides
ExternalQualityAssessmentactivitiesofRNTCP
ReportingProcedure
HIV&TB
HIV coinfection strongest known risk factor for the
progressionoflatentTBinfectiontoactiveTBdisease
Estimated710%annualriskofreactivation,with60%lifetime
risk (cf. 10% lifetime risk in TB infected, nonHIV infected
individual)
Conversely, TB amongst the most common causes of
morbidityandmortalityinpeoplelivingwithHIV/AIDS
Immune response to TB bacilli increases HIV replication
leadingtoarapidprogressionofHIVdisease
Optimal access to DOTS will significantly reduce morbidity
andmortalityinPLWHA
TB/HIVcollaborativeactivities
TB/HIV Action Plan implemented by RNTCP and NACP
jointly,focusingon:
Trainingofserviceproviders
Servicedeliverylinkages(ICTCRNTCPCrossreferrals)
Monitoring
Information,Education,andCommunication
Implementationstarted:
in 2001, in 6 high HIV prevalent States (population 311
million)
expanded in 2004, to 8 additional States (population 323
million)
TB/HIVcollaboratingactivities
National, State and District level coordination committees to
monitorlinkages
Guidelinesandtrainingmaterialdevelopedjointly
OngoingtrainingofstaffonTB/HIV
Crossreferral between ICTC and DOTS services developed,
pilotedandimplemented
InvolvementofNGOsandPPs
CollaborativeIECactivities
Jointmonitoringofactivities
TreatmentofTBinHIV
TBcanbesuccessfullytreatedeveninHIVinfectedpts.
But,cannotalonepreventpeoplefromdyingofAIDS
InadditiontoTBtreatment,ARTandCPTneededforthose
eligible
DOTSisthetreatmentofchoice
IntermittentSCCiseffective
NationalpolicyistoprovideRNTCPCatItonewcasesand
CatIItoretreatmentcases
Higher relapse rates have been observed especially in those
treatedwithnonRifampicincontainingregimen
Whethertruerelapseorreinfection?
DruginteractionsbetweenRifampicinandARVs
National policy is to start ART after completing antiTB
treatment, or modify ART by replacing Nevirapine with
EfavirenzforthedurationofTBtreatment
LikelyimpactofHIVonTBinIndia?
ScenariowithoutRNTCP
HIV would increase TB prevalence (by 1%), incidence (by
12%), and mortality rates (by 33%) between 1990 and
2015
ScenariowithRNTCP
Expect substantial reductions in prevalence (by 68%),
incidence(by41%),andmortality(by39%)between1990
and2015
PediatricTuberculosis
RelatedtoadultTB
Canoccuratanyage
Diseasedevelopswithinoneyearofinfection
Younger,earlier= disseminated
PTB:EPTB::55:45
PTBpaucibacillary,usuallyspneg
TreatmentofPediatricTB
DOTS
Categorization SAME
Dosesperkgbodyweight
Drugs to be made available as combipacks in patient wise
boxes, linked to child's weight ( 610kg,1117kg, 1825kg,26
30kg)
PWB beingmadeavailable
PC13yellow(610kg)
PC14orange(1117kg)
Prolongationpouches
Pink(1825kg)
Gray(2630kg)
MDRTBandDOTSPlus
MDRTBisalabdiagnosis,NOTaclinicalone
MDRTBlevelsoflessthan1%to3%innewcasesandof12%
inretreatmentcases.
EmergenceofresistancetoRifampicin inonly2%ofpatients,
despite a high level (8%) of initial resistance to Isoniazid,
eitheraloneorincombinationwithotherantiTB
Quality assured laboratory facility for culture and Drug
SusceptibilityTestmustbeavailable(NB:2 4monthsdelay
beforeDSTresultsseen)
RNTCPCatIVtreatmentisa24monthstandardized2ndline
regimengivenunderdailyDOT:
6KmOfxEtoCsZE/18OfxEtoCsE
MDRTBpatientadmittedtoindoorfacilityatDOTSPlussite
forupto1monthfor:
pretreatmentassessment;
initiationofCategoryIVtreatmentafterdecisionofDOTS
Plussitecommittee;
monitoringtolerancetotreatmentregimen;
counselingandhealtheducationtopatientandfamily;
developinglinkagestodistrictservices;and
contacttracing
AchievementsofRNTCP
Treatmentsuccessrate:25%(1998)to88%(2010)
Deathrate:29%(1998)to4%(2010)
662DTCs
2,698TUs
13,039DMCs
1,971NGOs
>10,894Privatepractitioner
297Medicalcolleges
>13,000peripherallaboratories
Thanks.