Revised National TB Control Programme (RNTCP)-Overview

1. Revised National TB Control Programme (RNTCP)-Overview Central TB Division Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhawan,

2. Problem of TB in India • Incidence: 1.96 million new TB cases annually (2007) • Incidence more in north and in urban areas • Prevalence: 3.8 million bacteriologically positive (2000)* • Deaths: about 316,500 deaths due to TB each year (2007) • 2.31 million population living with HIV; ~ 0.9 million co-infected • ~5% of TB patients estimated to be HIV positive • MDR-TB in new TB cases is ~3% and in previously treated cases is 12%-17% • Affects predominantly economically productive age group leading to huge socio-economic impact *Source: National estimate 2000, published in IJMR, Sept, 2005; 243-48

3. 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 and maintain a cure rate of at least 85% of new sputum positive TB patients • To achieve and maintain a case detection of at least 70% of new sputum positive TB patients

4. Structure of RNTCP at district levels District Magistrate/ District Collector District Administration Chief Medical Officer and other supporting staff District Health Services Nodal Point for TB Control DTO, MO-DTC (15%), LT, DEO, Driver, Urban TB Coordinators, TBHVs, Communication Facilitators District TB Centre One/ 500,000 (250,000 in hilly/ difficult/ tribal area) Medical officer-TB Control, Senior Treatment supervisor(STS), Senior TB Laboratory Supervisor(STLS) Tuberculosis Unit One/ 100,000 (50,000 in hilly/ difficult/ tribal area) Medical Officer, paramedical staff And Laboratory Technician (20-50%) Microscopy Centre TB Health Visitors (TBHV), DOT Provider (MPW, NGO, PP, ASHA, Community Volunteers) DOT Centre

5. RNTCP Case finding • Sputum microscopy is the primary tool for diagnosing and monitoring of TB patients • Sputum microscopy is done only in “Designated Microscopy centers (DMCs)” • Diagnostic algorithms for diagnosis of • Pulmonary TB (Adult & Pediatric) • Extra Pulmonary TB (TB Lymphadenitis) • Referral linkages for secondary and tertiary hospitals for diagnosing and treating TB

6. 4 NRLs 27 IRLs ~12,500 DMCs (one per 50,000-100,000 population) DMC 2 DMC 3 DMC 1 RNTCP Laboratory Network for QA

7. A unique feature of RNTCP are the patient-wise drug boxes (for adult and paediatric cases), which improve patient care, adherence, and drug supply and drug stock management Patient-wise drug boxes

8. Components of treatment services under RNTCP • Patient counseling, categorization, appropriate dosage • Initial home address verification • Provision of convenient & quality DOT services • Hospitalization of seriously sick patients • Management of side effects • DOT provider: training and identification, honorarium • Linking of patients to welfare schemes • Follow-up sputum examination and timely declaration of outcome • Documentation and preservation of records

9. Ensuring uninterrupted supply of quality drugs • Central procurement • Patient Wise Boxes for 1st line drugs (Adult & Pediatric) • System for Quality assurance in place • Intensive and continuous monitoring through the Monthly and Quarterly Programme Management Reports • to regulate drug supply without overstocking or expiry • to identify potential problems in supply chain and address them in time

10. Stocking points within a state Reserve stock • SDS 3 months • DTC 3 months • TU 2 months • PHI 1 month + 1 month utilization

11. RNTCP: Records and Reports Records • Laboratory Form for Sputum Examination • Laboratory Register • Treatment Card and Patient ID card • Tuberculosis Register • Supervisory Register • Referral for Treatment Registers/Forms • Drug and lab consumables stock registers

12. RNTCP: Records and Reports (contd.) Reports • Quarterly Report on Case finding • Quarterly Report of Sputum Conversion • Quarterly Report on Results of Treatment • RNTCP Report on Programme Management and Logistics • Peripheral Health Institution Level (Monthly) • Tuberculosis Unit Level (quarterly) • District Level (quarterly) • State Level (quarterly)

13. Programme Surveillance System Peripheral Health Institute (DMC and other PHIs) Monthly PHI Report Tuberculosis Unit System electronic from district level upwards Quarterly CF, SC, RT, PM Reports Quarterly Feedback Additional Feedback District TB Centre Electronic reports) Quarterly Reports CF, SC, RT, PM State TB Cell Central TB Division Publication of quarterly and annual performance reports

14. RNTCP “Supervision and Monitoring strategy” • Strategy document developed and published in March 2005 • Contains checklists and indicators for monitoring • All states and districts implementing the strategy • All state/district programme staff trained in the strategy • Mechanism of internal evaluations from the state (2 districts per quarter) and central levels (1 state per month) • Annual joint donor missions and 6 monthly World Bank mission • External evaluations by partners & donors once every 3 years since 2000

15. TB-HIV activities in India • TB-HIV collaboration began in 2001 • Joint training • Intensified case finding at ICTCs • HIV testing of TB patients with HIV risk factors • 2004: Scale up of activities to ICTCs in 8 States • 2006: Scale-up of activities to 14 states • 2008: National Framework for Collaborative TB-HIV activities

16. India’s response: Comprehensive TB-HIV activities nationwide TB/HIV activities in all States • Coordination & Training on TB/HIV • Intensified Case Finding (ICF) at VCTs and HIV care settings • Risk-based referral of TB patients for VCT • Referral of all HIV- TB patients for HIV care and support (CPT & ART) • Involve NGOs: Include TB/HIV in “Targeted Interventions” for populations at risk of HIV

17. RNTCP Response Plan to MDR/XDR-TB • MDR-TB prevention through sustained high-quality DOTS implementation • XDR-TB prevention: Effective treatment of MDR-TB patients through RNTCP Category IV services • Improve laboratory capacity: Diagnosing MDR-TB • Evaluate the extent of the threat of second-line anti-TB drug resistance / XDR-TB • Review the supply and availability of second-line anti-TB drugs in India

18. RNTCP Revised DOTS Plus- Vision • By 2010, RNTCP Category IV services introduced in all states • By 2012, universal access under RNTCP to laboratory based quality assured MDR-TB diagnosis and treatment for • all smear positive re-treatment TB cases and • new cases who have failed an initial first-line drug treatment • By 2015, universal access to MDR-TB diagnosis and treatment for all smear positive TB (new and re-treatment) cases registered under RNTCP

19. RNTCP DOTS Plus Status and Plan Plan Status • Accredited labs • 7 Government labs (IRLs) • Gujarat, Maharashtra, Andhra Pradesh, Delhi, Kerala, Tamil Nadu and Rajasthan • 2 private labs (BPRC, Hyderabad & CMC Vellore) • Treatment services • 7 states have initiated treatment services in identified districts (~133 million pop) • Gujarat, Maharashtra, Andhra Pradesh, Delhi*, Haryana, Kerala*, Tamil Nadu and West Bengal • Rajasthanhas initiated diagnostic services will commence treatment services shortly • Orissa and Uttar Pradesh are in the process of initiating DOTS-Plus services • Till date ~900 patients have been initiated on Category IV treatment *Whole State is covered

20. Other steps for preventing drug resistance-1 • Ensuring quality DOTS services • Infection control measures • National Airborne Infection Control Committee constituted • Infection control guidelines for all levels of healthcare facilities under development • Provision of support to upgrade Infection Control measures at • DOTS-Plus site indoor facilities and Intermediate Reference laboratories • Collaboration with NACP to ensure infection control measures at ICTCs and ART centres • Encouraging Medical Colleges (through NTF, ZTF and STF mechanism) to develop and implement infection control measures

21. Other steps for preventing drug resistance-2 • Promte rational use of anti-TB drugs • “Chennai Consensus Statement on the Management of MDR-TB outside of RNTCP” developed and disseminated • Interacting with MCI for guidelines to all healthcare providers on rational use of anti TB drugs • Interacting with DCGI to ensure sale of anti-TB drugs against valid prescription only

22. PPM activities for involvement of all health care providers • Involvement of NGOs and Private Practitioners • Presently > 2500 NGOs, 19,500 PPs involved • Involvement of professional bodies like IMA, IAP • Other Central government departments/PSUs • CGHS, Railways, ESI, Mining, Shipping • Corporate sector • ~150 Corporate Houses participating • Involvement of FBOs like CBCI • Involvement of Medical Colleges • 267 Medical colleges involved by the end of 2008

23. Revised NGO/PP schemes for involvement of NGOs and PPs (2008) • Scheme for ACSM      • Scheme for Sputum Collection • Scheme for Sputum Transport • Scheme for Microscopy center • LT Scheme • Culture and DST Scheme • Scheme for Treatment Adherence • Scheme for Urban Slums • Scheme for the Tuberculosis Unit • Scheme for TB/HIV

24. Intensified PPM DOTS in Urban Areas • Started in 14 districts in 2003 with WHO support • Being continued as sentinel sites for measurement of disaggregated PPM contribution through • Integration into the existing RNTCP delivery system • Additional Human resource support discontinued in 2008 • Modified surveillance system implemented • Key staff of NTP trained in PPM surveillance • Staff of other sectors trained in DOTS

25. Advocacy, Communication & Social Mobilization (ACSM) • Well defined ACSM strategy in place clearly defining: • Target audiences, communication needs, media options • Roles and responsibilities at National. State and District levels • National Level strategy: • Provides leadership and direction • Develop partnership with other stakeholder e.g. ICAT, NTC, IMA, CBCI • Supporting States • Development of prototype material – Web based IEC resource centre developed and updated regularly • Hiring Media agency and handing mass media • Capacity building for the Key programme staff in the states and district • Training modules for all health staff included training on Inter Personal Communication (CTD is drawing support from “Centres of Excellence” in the field of communication, media and research. This support has been formalized as ‘IEC Advisory Group”)

26. Achievements of RNTCP

27. Progress towards Millennium Development Goals Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients The global new case detection rate is 64% (2007) and treatment success rate is 85% RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and case detection rate 72% (2008) Prevalence rate of TB Mortality rate of TB 33.3% 51.7%

28. Challenges of RNTCP • Maintaining and further improving the quality of services across the country • Maintaining and increasing the commitment for funding from the international, national and state partners • Promoting rational use of first line and second line anti-TB drugs outside the programme for prevention of MDR and XDR TB • Scaling up culture & DST and treatment services for MDR-TB. • Scaling up of PPM activities to link all providers to the national programme • TB-HIV collaboration • ART-DOTS linkages `for improving access • Operationalisation of CPT prophylaxis to co-infected patients • Provider initiated routine referrals of TB patients for VCT • Promote operational research to address the local challenges • Introduction of new tools for diagnosis and drugs for treatment

29. Future plan • Maintaining/improving quality and reach of DOTS with special focus on improving programme performance in underperforming areas • Scaling up of MDR-TB management • Engaging all care providers • Promoting community involvement and ownership • Further strengthening TB-HIV collaborative activities • Eg: implementation of intensified package in the high prevalence states • Introduction of newer diagnostics • Eg., introduction of LPA tests in RNTCP accredited labs

30. Indicators to be reviewed • State level • District level • DMC level • Patient interview