Status of Revised National Tuberculosis Control Program (RNTCP) in India

1. Status of Revised National Tuberculosis Control Program (RNTCP) in India Dr Jitendra

2. Framework • TB burden • RNTCP implementation • RNTCP performance • Achievements Under RNTCP - Case Detection Rate - Cure Rate • Progress Towards MDGs • Cost Effectiveness of Program • RNTCP- DOTS-Plus • Changes in RNTCP policy • Challenges

3. Estimated epidemiological burden of TB India is Highest TB Burden Country India is 17th among 22 High Burden Countries (in terms of TB incidence rate) National ARTI- 75 NSP PTB cases/100,000 population Source: WHO Report 2008: Global Tuberculosis Control; Surveillance, Planning and Financing

4. Revised National TB Control Program (RNTCP) • Launched in 1997 based on WHO DOTS Strategy • Entire country covered in March’06 (632 districts/reporting units) • Implemented as 100% centrally sponsored program • GoI is committed to continue support till TB ceases to be a public health problem in country Largest & fastest expanding program

5. RNTCP… All components of STOP TB Strategy-2006 are being implemented • Pursuing high-quality DOTS expansion and enhancement • Addressing TB/HIV, MDR-TB and other challenges • Contributing to health system strengthening • Engaging all health providers • Empowering people with TB, and communities • Enabling and promoting research

6. RNTCP performance- 2009 • Continue to achieve twin objectives of NSP case detection and cure rate at the national level • New Sputum Positive Case Detection Rate ≥ 70% • Cure rate≥ 85%

7. RNTCP performance…

8. Achievements Under RNTCP TB Suspects Examined per 100,000 Population(2000-2009)

9. Achievements …Case Detection Rate and Treatment Success Rate CDR- 72% 78% Treatment success rate- 85%  87%

10. Achievements in line with the global targets Annualized new smear (+) case detection rate and T/t success rate Achievements since implementation • > 40 million TB suspects examined • > 9 million patients placed on treatment • > 1.6 million lives saved (deaths averted)

11. Progress Towards MDGs 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 & 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 33% 47% ? ? WHO Global TB Report 2008

12. Cost Effectiveness of Program in India • Total cost of TB control per capita is US $ 0.1 (2007) • Cost of first line drugs per patient treated in India is US $ 14 compared to US $ 30 (median) for High Burden Countries (HBCs) • India remains the country with lowest cost per patient treated (US $ 84) compared to US $ 274 (median) for HBCs Source: WHO Report 2008, Global Tuberculosis Control; pg 71 &112

13. RNTCP- DOTS-Plus • RNTCP regimens highly effective, with low failure rates (2% in CAT I , 6% in CAT II cases) India- Highest burden country in world On verge of MDR-TB epidemic MDR-TB: 3% in new cases 12-17% in retreatment cases • Failure cases- previously not been well addressed by RNTCP, now have been addressed in RNTCP under DOTS-Plus

14. DOTS-Plus… Strategy to prevent MDR-TB 1. Through sustained high-quality DOTS implementation (DOTS- Plus) - MH and GJ: 2007 - AP, DL, HR, KE and WB: 2008 - Remaining states: 2009-2010 2. Improve lab capacity- 27 Accredited culture and DST IRLs are being established across country in a phased manner 3. Effective t/t of MDR-TB DOTS-Plus in MH: Nagpur circle- 7district (2007) Akola circle- 6 district (2008) 100% coverage across MH state by 2012

15. RNTCP- DOTS-Plus Vision • By 2010 DOTS-Plus services available in all states • By 2012, universal access under RNTCP to laboratory based quality assured MDR-TB diagnosis for all retreatment TB cases and new cases who have failed treatment • By 2012, free and quality assured treatment to all MDR-TB cases diagnosed under RNTCP (~30,000 annually) • By 2015, universal access to MDR diagnosis and treatment for all smear positive TB cases under RNTCP

16. Changes in RNTCP policy on diagnosis of smear positive pulmonary TB • Number of sputum specimen required for diagnosis is 2, with one of them being a morning sputum • Diagnosis of PTB suspect- One smear specimen positive out of the two is enough to declare a patient as Sm+ PTB • Definition of PTB suspect- any person with cough for 2 weeks, or more

17. Challenges… • Wide variation in capacity of health systems in states • Burden due toTB-HIV co-infection • Ensure adherence of treatment • Large & unregulated private system

18. References • Global tuberculosis control : epidemiology, strategy, financing : WHO report 2009. • TB INDIA 2009. RNTCP Status Report. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi. • RNTCP Performance Report, India. Second Quarter, 2009. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi. • RNTCP Performance Report, India. Second Quarter, 2008. Central TB Division. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi. • Global Tuberculosis Control: Surveillance, Planning and Financing: WHO Report 2008. • TBC India. Directorate General of Health Services. Ministry of Health and Family Welfare. New Delhi. [Online]. 2009. [cited 2009 Dec 7]; Available from: URL: http://www.tbcindia.org.

19. THANK YOU