RNTCP

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DR HASHMI S FAZLUULAH GUIDED BY DR D .G.MHAISEKAR SIR DEPARTMENT OF PULMONARY MEDICINE GMC NANDED :

Revised National Tuberculosis Control Program (RNTCP) DR HASHMI S FAZLUULAH GUIDED BY DR D .G.MHAISEKAR SIR DEPARTMENT OF PULMONARY MEDICINE GMC NANDED

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Category IV regimen RNTCP will be using a Standardised Treatment Regimen (Cat IV) for the treatment of MDR-TB cases (and those with rifampicin resistance) under the programme. Cat IV regimen comprises of 6 drugs- kanamycin, ofloxacin (levofloxacin)†, ethionamide, pyrazinamide, ethambutol and cycloserine during 6-9 months of the Intensive Phase and 4 drugs- ofloxacin (levofloxacin), ethionamide, ethambutol and cycloserine during the 18 months of the Continuation Phase. p-aminosalicylic acid (PAS) is included in the regimen as a substitute drug if any bactericidal drug (K, Ofl, Z and Eto) or 2 bacteriostatic (E and Cs) drugs are not tolerated. RNTCP CATEGORY IV REGIMEN: 6 (9) Km Ofx (Lvx) Eto Cs Z E / 18 Ofx (Lvx)Eto Cs E NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06

History of M. tuberculosis:

Tubercular decay has been found in the spines of mummies from 3000–2400 BC. Phthisis is a Greek term for tuberculosis; around 460 BC. History of M. tuberculosis

History of M. tuberculosis:

History of M. tuberculosis Aristotle was the first to say that tuberculosis is an airborne disease able to be passed from one person to another. Although his theory was correct scientists continued to search for different causes and treatment of TB.

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In 1865 Jean Antoine Villemin , put out the idea that TB was genetically inherited. This gave a sound piece of mind.

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This gave a sound piece of mind for all, until 1882 when Robert Koch proved her wrong by discovering Round Shaped Bacteria cause of the disease.

Revised National Tuberculosis Control Program (RNTCP):

1992 the Government of India, together with the World Health Organization (WHO) and Swedish International Development Agency (SIDA), reviewed the national programm & concluded that it suffered from Managerial weakness Inadequate funding Revised National Tuberculosis Control Program (RNTCP)

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c) Over-reliance on x-ray d) Non-standard treatment regimens e) Low rates of treatment completion f) Lack of systematic information on treatment outcomes . As a result, a Revised National Tuberculosis Control Programm (RNTCP) was designed.

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REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME ORIGIN NATIONAL TB PROGRAM (NTP) 1962 RNTCP IS THE REVIEWED FORM OF NTP NEED FOR REVISED STRATEGY -OVER EMPHASIS ON X-RAYS FOR DIAGNOSIS -INADEQUATE FUNDING,POOR QUALITY MICROSCOPY -NON-STANDARD TREATMENT REGIMENS -LOW RATES OF TREATMENT COMPLETION -LACK OF SYSTEMATIC INFORMATION ON TREATMENT OUTCOME -ONLY 30% OF ESTIMATED TB PATIENTS WERE DIAGONOSED -ONLY 30% OF THE DIAGONOSED CASES WERE TREATED SUCCESSFULLY RNTCP STARTED IN YEAR 1992 (GOVT. OF INDIA,WHO,WORLD BANK)

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GOAL TO REDUCE MORTALITY AND MORBIDITY FROM TB TO INTERRUPT CHAIN OF TRANSMISSSION OBJECTIVES ACHIEVEMENT OF AT LEAST 85%CURE RATE OF INFECTIOUS CASES DETECTION OF ATLEAST 70%OF ESTIMATED CASES INFORMATION, EDUCATION, COMMUNICATION AND IMPROVED OPERATIONAL RESEARCH ACTIVITIES. COMPONENTS POLITICAL COMMITMENT GOOD QUALITY SPUTUM MICROSCOPY UNINTERRUPTED SUPPLY OF GOOD QUALITY DRUGS DIRECTLY OBSERVED TREATMENT ACCOUNTABILITY

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ORGANIZATION-PROFILE AT STATE LEVEL STATE TUBERCULOSIS OFFICE - STATE TUBERCULOSIS OFFICER STATE TUBERCULOSIS TRAINING & DEMONSTRATION CENTRE - DIRECTOR DISTRICT TUBERCULOSIS CENTRE (DTC) - DISTRICT TUBERCULOSIS OFFICER TUBERCULOSIS UNIT - MEDICAL OFFICER - SENIOR TREATMENT SUPERVISOR(STS) - SENIOR TB LAB SUPERVISOR(STLS) MICROSCOPY CENTRES AND TREATMENT CENTRES DOTS PROVIDERS

Global burden of TB :

2 billion infected, i.e. 1 in 3 of global population 9.4 million (139/lakh) new cases in 2008, 80% in 22 high-burden countries 4 m new sm+ve PTB (61/lakh) cases in 2008 Global incidence of TB has peaked in 2004 and is declining. 1.77m deaths in 2007, 98% in low-income countries MDR-TB -prevalence in new cases around 3.6% NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Global burden of TB Ref: WHO Global Report, 2006

Millennium Development Goals:

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 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 NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Millennium Development Goals

Stop TB Partnership Targets:

By 2005: At least 70% people with sputum smear positive TB will be diagnosed. At least 85% cured. By 2015: Global burden of TB (prevalence and death rates) will be reduced by 50% relative to 1990 levels. Reduce prevalence to <150 per lakh population Reduce deaths to <15 per lakh population Number of people dying from TB in 2015 should be less than 1 million, including those co-infected with HIV By 2050: Global incidence of TB disease will be less than or equal to 1 case per million population per year NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Stop TB Partnership Targets

Stop TB Strategy, 2006:

Vision: A world free of TB Goal: To dramatically reduce the global burden of TB by 2015 in line with Millennium Development Goals and the Stop TB Partnership targets NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Stop TB Strategy, 2006

Components of Stop TB Strategy, 2006:

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 NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Components of Stop TB Strategy, 2006

Directly Observed Treatment, Short-course strategy (DOTS), 1994 :

Directly Observed Treatment, Short-course strategy (DOTS), 1994 Government commitment to TB control Diagnosis by smear microscopy mostly on self-reporting symptomatic patients Standardised short course chemotherapy (SCC) with direct observation of treatment (DOT) Efficient system of drug supply Efficient recording and reporting system with assessment of treatment results Five components were expanded in 2002

Global Situation:

Since 1995,over 21 million patients have been diagnosed and treated in DOTS programmes In 2007, 5.5 million new and relapse TB cases were initiated on treatment under DOTS strategy Of 2.5 million new smear positive patients registered in 2006, 85% were successfully treated under DOTS Global Situation

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NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06

International Standards for TB Care-2006-revised in 2009:

Developed by Tuberculosis Coalition for Technical Assistance Members of TCTA American Thoracic Society WHO (World Health Organisation) CDC (Center for Disease Control and Prevention) KCNV(Dutch Tuberculosis Foundation), IUATLD (The International Union Against Tuberculosis and Lung Disease) Part of the new STOP TB Strategy and global plan to Stop TB NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 International Standards for TB Care-2006-revised in 2009

International Standards for TB Care:

The ISTC is designed to address the care of patients of all ages with any manifestation of the disease, including multi-drug resistant and extra-pulmonary tuberculosis and tuberculosis combined with HIV infection. The ISTC is also designed to guide providers everywhere, regardless of the circumstances of their practice. Consists of 21 standards for Public Health Responsibility International Standards for TB Care

INDIA:

INDIA

Problem of TB in India:

Estimated incidence 1.96 million new cases annually 0.8 million new smear positive cases annually 75 new smear positive PTB cases/1lakh population per year Estimated prevalence of TB disease 3.8 million bacillary cases in 2000 1.7 million new smear positive cases in 2000 Estimated mortality 330,000 deaths due to TB each year Over 1000 deaths a day 2 deaths every 3 minutes Problem of TB in India

Problem of TB in India (contd):

Prevalence of TB infection 40% (~400m) infected with M. tuberculosis (with a 10% lifetime risk of TB disease in the absence of HIV) Estimated Multi-drug resistant TB < 3% in new cases 12% in re-treatment cases TB-HIV ~ 2.31 million people living with HIV (PLWHA) 10-15% annual risk (60% lifetime risk) of developing active TB disease in PLWHA Estimated ~ 5% of TB patients are HIV infected Problem of TB in India (contd)

India is the highest TB burden country accounting for more than one-fifth of the global incidence :

India is the highest TB burden country accounting for more than one-fifth of the global incidence NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing Global annual incidence = 9.4 million India annual incidence = 1.96 million India is 17 th among 22 High Burden Countries (in terms of TB incidence rate)

Estimated Incidence of TB in India* (No. of NSP Cases per 100,000 population, per year):

National 75 North Zone 95 East Zone 75** West Zone 80 South Zone 75** Estimated Incidence of TB in India* (No. of NSP Cases per 100,000 population, per year) North West East South ** For programme monitoring purpose estimated cases in East & South zones have been kept at the national level of 75 and this is within the upper limit of CI or ARTI in these zones

Social and Economic Burden of TB in India:

Estimated burden per year Indirect costs to society $3 billion Direct costs to society $300 million Productive work days lost due to TB illness 100 million Productive work days lost due to TB deaths 1.3 billion School drop-outs due to parental TB 300,000 Women rejected by families due to TB 100,000 Social and Economic Burden of TB in India

RNTCP:

RNTCP NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06

Evolution of TB Control in India:

1950s-60s Important TB research at TRC and NTI 1962 National TB Programme (NTP) 1992 Programme Review only 30% of patients diagnosed; of these, only 30% treated successfully 1993 RNTCP pilot began 1998 RNTCP scale-up 2001 450 million population covered 2004 >80% of country covered 2006 Entire country covered by RNTCP NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Evolution of TB Control in India

Objectives of RNTCP :

To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases To achieve and maintain detection of at least 70% of such cases in the population NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Objectives of RNTCP

RNTCP Organization structure: State level:

RNTCP Organization structure: State level Health Minister Health Secretary Director Health Services Additional / Deputy / Joint Director (State TB Officer) Organizational Chart Ministry of Health and Family Welfare Directorate General of Health Services Central TB Division State TB Cell Deputy STO, MO, Accountant, IEC Officer, SA, DEO, TB HIV Coordinator etc., STDC State Training and Demonstration Center (TB) Director, IRL Microbiologist, MO, Epidemiologist/statistician, IRL LTs etc.,

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

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NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Unique features of RNTCP District TB Control Society Modular training Patient wise boxes Sub-district level supervisory staff (STS, STLS) for treatment & microscopy Robust reporting and recording system

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NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Population projected from 2001 census Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report) Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 2000-2009*

Impact of RNTCP:

Cure rate more than doubled compared with earlier NTP, 85% global target consistently achieved 2003 onwards Case detection rate is more than 70% Case fatality reduced from 29% to 4% in NSP cases, and deaths due to TB from 500,000 to <330,000 a year Over 11 million patients initiated on DOTS, and over 2 million additional lives saved NTF Presentations for RNTCP Sensitization First edition 10 th Nov 06 Impact of RNTCP