Revised National Tuberculosis Control Program (RNTCP)

2. Revised National TuberculosisControl Program(RNTCP) Nithyashree B V Assistant Professor YNC

3. Specific objectives At the end of the class students will be able to • analyze the burden of disease of Tuberculosis in World and India • describe the background history of RNTCP • state the goals of RNTCP • enlist the objectives of RNTCP • discuss organizationalstructure ofRNTCP (2009)

4. Specific objectives contd…. • enumerate unique features ofRNTCP • recognize the Funding for RNTCP • explain the strategies of RNTCP • describe the Implementation of RNTCP • record RNTCP revised diagnostic algorithm

5. Introduction • Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis which was discovered by RobertKoch • Also known as “Koch’sBacillus” • The most common organ involved is lung(>80%) but it can involve any organ of the human body (except hair andnails) RobertKoch • It usually affects human in the age group of 15 to 59yrs

6. BURDEN OFDISEASE • WORLD: • TB continues to be one of the most important public health problems worldwide • In 2014, an estimated 9.6 million people developed TB and 1.5 million died from the disease, 400,000 of whom were HIVpositive • Worldwide the proportion of new cases with MDR-TB was 3.3% in 2014, whereas those for previously treated cases was20.0%

7. Of the estimated 9.6 million people who developed TB in 2014, more than half (58%) were in South-East Asia and Western Pacific regions and a further one quarter (28%) were in Africanregion • India, China and Indonesia alone accounted for 23%, 10% and 10% of total casesrespectively • In 2014, an estimated 3.2 million cases werewomen

8. An estimated 510,000 women died as a result of TB, more than 1/3rd of whom were HIVpositive • Globally,about 1.1million newcases and 130,000 deaths occur annually due to TB amongchildren • (Global TB report2015)

9. INDIA • Accounts for nearly 1/4th of the global burden ofTB • Around 2.2 million develop TB in 2013-14. During the same period, 0.27 million people died due toTB • Everyday about 20,000 people become infected, 5000 develop TB and more than 1000 die due to thedisease • In simple terms, 2 persons become sputum +vefor TB and almost 1 person is killed every minute due to the disease ( WHO2007) • The proportion of new cases with MDR-TB was 2.2% in 2014, whereas those for previously treated cases was15.0%

10. Background History ofRNTCP • 1906- First open air TB sanatorium foundedin India • 1939- TB association ofIndia • expert advice on the development of standard methods to deal with thedisease; • setting up model institutions for trainingTB workers; • - education of the public regarding preventive measures; • conceived the idea of domiciliary Rx ofTB in 1940

11. 1946- BhoreCommittee recommended to the GOI, setting up TB clinics in the districts and mobile TB clinics in rural areas. • 1947- GOI established a TB division under DGHS in the MoH, Planning and execution of anti-TB activities were greatly facilitated by thisDivision. • 1951- Mass BCG vaccination campaign covering 65 million children in collaboration withIUAT • 165 million tuberculin tests were administered to find the prevalence of TB inIndia

12. 1955-58-NationalSampleSurveyconductedunder ICMR to find the magnitude of TB problem inIndia • 1956- TRC established inChennai • - Provedtheefficacy ofdomiciliaryRxfor TB withchemotherapy • 1959- National TB Institute (NTI) established in Bangalore byGoI,withtheactivecooperation ofthe WHO, to develop a TB controlprogramme

13. 1962- National TB Control Program(NTCP)started • Managerial weakness, lack of supervision • Poor quality of sputummicroscopy • Multiplicity of treatmentregimens • Poor organizationalset-up • Inadequatefunding • Over dependence on X-ray fordiagnosis • Frequent interrupted supplies ofdrugs • Low rate of treatment completion (30%only)

14. 1992- ProgrammeReview showed - only 30% ofpatients diagnosed and only 30% of them treatedsuccessfully • 1993- WHO Declared TB as a global emergency,RNTCP was initiated applying the principles of DOTS as a pilot project • 1997- RNTCP started as a nationalprogramme • 1998- Massive RNTCP expansion began, RNTCP Istphase (1998-2005) • 1998 September- RNTCP Implemented in Imphal District, Manipur RNTCP programmecovered the State from 21stJan 2002

15. Early2000- 135millionpopulationcovered; Monitoring Missionconducted • Sept 2003 - 741 million population covered; Monitoring Mission appreciates rapid expansion and overallquality • End 2005- 97% population covered; next 5-year plan approved with additional activities, such as DOTS- Plus • March 2006- The entire country covered byDOTS • Oct 2006 - RNTCP phase II started for 5 years ( toSep’11) • 2007 - New sputum + case detection was 70%and treatment success rate was86%

16. 2007 - DOTS plus services for management ofMDR-TB patients have been rolled out in the states of Gujarat and Maharashtra • 2009: Prevalence of all forms of TB ↓ from 338 per 100,000 population (1990) to 249 per 100,000 population and TB mortality in the country ↓ from over 42 per 100,000 population in 1990 to 23 per 100,000 population (WHO global TB report2010) • May 2012- Notification of TB is made mandatory byGOI

17. 2012 -NIKSHAY, the web based reporting for TB programme has been another notable achievement initiated in 2012 and has enabled capture and transfer of individual patient data from the remotest health institutions of the country.

18. Revised National TuberculosisControl Programme • The National TB Programme (NTP) was started in 1962 for TB control in India. This programme was not able to give expected results inIndia • The NTP was reviewed in1992 • 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 24th March 2006, the entire country was covered under theprogramme

19. Goal- RNTCP 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

20. Objectives- RNTCP • To achieve andmaintain: • Cure rate of at least 90% among newly detected smear positive (infectious) pulmonary TB casesand • Case detection of at least 85% of the expected new smear positive PTB cases in thecommunity

21. Organisational structure ofRNTCP Central TB Division, DGHS,MoH&FW Deputy DirectorGeneral-TB National Lab Committee, National TWG for TB-HIV, National DOTS Plus Committee, NTF for medical colleges, National OR Committee STO, MO, Epidemiologist, DEOetc NationalInstitutes (NTI, TRC, LRS,JALMA) State TB Trainingand Demonstration Centre/SDS/IRL Nodal centre for TB control in thedistrict State TBCell District TBCentre DTO, MO-DTC, Support staffetc 1 per 5 lakhpopulation, 1per 2.5 lakhin tribal, hilly and difficultareas Tuberculosis Unit MO-TC, STS,STLS 1 per 1 lakh population, 1per 0.5 lakhin tribal, hilly and difficultareas DMC MO,LT HW, ASHA, AWW,PPs, NGO, Comm voletc DOTSCentre

22. Unique features ofRNTCP • District TB ControlSociety • Modulartraining • Patient wiseboxes • Sub-district level supervisory staff (STS, STLS)for treatment &microscopy • Robust reporting and recordingsystem

23. FUNDING • 100 %centralgovernment sponsored • The programisassistedbyWorldbankandThe Department for International Development(DFID) • Other supporting agenciesare • Global TB DrugFacility(GDF) • Global Fund to Fight AIDS, TB,Malaria(GFATM) • United States Agency for InternationalDevelopment(USAID) • Danish International Development Agency(DANIDA)

24. Strategies • Case finding and Diagnostics- Use of sputum testing as the primary method ofdiagnosis • Patient friendly treatment services and ensuring a regular, uninterrupted supply of drugs up to the most peripherallevel-DOTS • Scale-up of Programmatic Management of Drug Resistance –TB(PMDT) • Scale -up of Joint TB-HIV CollaborativeActivities • Integration with HealthSystems

25. Strategies • Engagement of PrivateSector • Human ResourceDevelopment • Advocacy, Communication and Social Mobilization (ACSM) • Monitoring and Evaluation, Surveillance andImpact Assessment • Operational research to inform TB Control policyand practice

26. Strategies • 1. Case finding andDiagnostics: • Early identification of all infectious TBcases • Improved integration with the general health system and leverage field staff for home-based casefinding • Improve communication andoutreach • Screening clinically & socially vulnerable risk TB • Develop improved sputum collection and transportation systems groupsfor

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

28. Strategies • 2. Patient friendly treatment services: DOTSstrategy • PromptlyandappropriatelytreatingTB,increasingly guided byDST • Making DOTS morepatientfriendlythrough↑ communitization ofDOT • pilot incentives/offsets for patient costs to help patients complete treatment and better monitoring throughIT • Improvingpartnershipsbetweenpublicandprivate sector

29. Strategies • 3. Scale-up of Programmatic Management of Drug Resistance –TB(PMDT): • DevelopingnetworkofC&DSTLaboratories& Strengthening of ReferenceLaboratories • DecentralizedDSTatdistrictlevelforearlyMDR detection • Improved information system forPMDT

30. Implementation • Case finding- by passive surveillance on patient with symptomsof • Persistent cough for 2weeks ormore. • Haemoptysis • Nightsweats • Evening rise oftemperature • Chestpain Inlab.- • Sputum collection fordiagnosis • Radiography • Tuberculintest

31. Diagnosis ofTB • Sputum examination is the best method to diagnoseTB • Pulmonary TB diagnosis can be confirmed by sputum examination. Two sputum samples are collected over one/two consecutivedays • 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 thelab

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

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

34. RNTCP revised diagnostic algorithm(2009) Note: RNTCP has separate diagnostic algorithm for pediatric pulmonary TB and common forms of extra- pulmonaryTB

35. Summary

36. CONCLUSION

37. RECAPTUALIZATION • 1. When the RNTCP programme launched? • 2. List the strategies of RNTCP programme

38. Evaluation • ……………is the web based reporting for TB programme • ……………which was discovered by RobertKoch

39. Answer • NIKSHAY • Mycobacterium tuberculosis