National Health Programmes for TB control in India

National Health Programmes for TB control in India
B.Pharm 8th Semester, BP802T

1. Dr Jyoti Prasad Pattnaik MBBS, PGDMCH, PGDHM Asst Professor National Health Programmes for TB control in India 1 Dr Jyoti Prasad Pattnaik, MBBS

2. Since independence in 1947 many measures have been taken to improve the health of the people and the society at large and the most effective of all these programmes is National health Programmes . 2 Dr Jyoti Prasad Pattnaik, MBBS

3. National Health Programmes These programmes are launched by the central government from time to time To control/eradicate communicable diseases Improve environmental sanitation Raising the standards of nutrition Control of population Improving rural health scenario 3 Dr Jyoti Prasad Pattnaik, MBBS

4. International Assistance International agencies like WHO, UNICEF, UNFPA, World Bank Foreign aid agencies like SIDA, DANIDA, NORAD, USAID etc have been providing technical and material assistance in the implementation of these programmes . 4 Dr Jyoti Prasad Pattnaik, MBBS

5. Some programmes list… Integrated disease surveillance programme National leprosy eradication programme National tuberculosis programme Revised national tb control programme National mental health programme National AIDS control programme National programme for prevention and control of deafness Universal immunization programme National programme for control of blindness Pulse polio programme 5 Dr Jyoti Prasad Pattnaik, MBBS

6. TB in India TB has existed in India for several thousand years. TB in India around 1500 BCE TB in India is an ancient disease. In Indian literature there are passages from around 1500 BCE in which consumption is mentioned, and the disease is attributed to excessive fatigue, worries, hunger, pregnancy and chest wounds. Dr Jyoti Prasad Pattnaik, MBBS 6

7. TB in India around 500 BCE Then from around 500 BCE there are a number of Sanskrit manuscripts which are the texts from which the Ayurveda system of general Indian medical practice is derived. In at least one of these there is a group of diseases referred to as Sosha . These are diseases with a prominent feature of wasting, and there are other symptoms such as “cough and blood-spitting”. It is also said that the Moon-god, the king of the Brahmanas was the first to become a victim of this disease, which is as a result also known as Rajayakshma , or king’s disease. Dr Jyoti Prasad Pattnaik, MBBS 7

8. TB in India around 900 CE A subsequent important compendium on Indian medicine is the Rogaviniscaya , usually referred to as the Madhavanidana , and one of a number of commentaries on it is the Madhukosa . Neither the date of the Madhavanidana or the Madhukosa is absolutely clear but both are likely to have been written around 800 - 1000 CE. The Madhukosa describes the disease referred to in a number of different texts as yaksman , consumption or rajayaksman (kingly consumption) and it also refers to how it has been identified by many as being what is in the twenty first century called Tuberculosis. However, the Madhukosa also says that the texts are clear that the ancient disease had a much wider range than TB, and covers a number of conditions between physical exhaustion through to cachexia or physical wasting. Dr Jyoti Prasad Pattnaik, MBBS 8

9. Indian Research Fund Association The Indian Research Fund Association was created by the Government of India in 1911. A sum of 5 lakhs rupees was provided by the Government as an endowment for research in connection with the Central Research Institute in Kasauli . The objects of the Association were: ( a) the cause and mode of spread of epidemic diseases; ( b) the prevention of epidemic diseases by direct attack upon the casual micro-organisms.” The work of the Association included the holding of an annual conference and the publishing of its official journal, the Indian Journal of Medical Research, which was first published in 1913. The early work of the Association did not include significant work on Tuberculosis, because of the perceived urgent need for work on other diseases such as Malaria, Cholera, Plague, Yellow Fever and Leprosy. Dr Jyoti Prasad Pattnaik, MBBS 9

10. The All-India Sanitary Conferences The first All-India Sanitary Conference, Bombay 1911 The second All-India Sanitary Conference, Madras, 1912 The third All-India Sanitary Conference, Lucknow , 1914 Dr Jyoti Prasad Pattnaik, MBBS 10

11. Tuberculosis Association of India In 1937 the wife of the Governor General, the Marchioness of Linlithgow issued a public appeal, “in the name of the King Emperor” for an anti tuberculosis fund, and nearly a crore of rupees was collected. Five per cent of this money was retained and the balance distributed to the Provinces and States. The Tuberculosis Association of India was formed in February 1939 using mainly the retained money. The King George V Thanksgiving Anti Tuberculosis Fund was merged into the funds of the Tuberculosis Association of India. In May 1939 Dr Frimodt Moller became the Association’s first Medical Commissioner. During the time that he held office three major measures were carried out by the Association. These were the establishment of the TB clinic in New Delhi, the creation of the Lady Linlithgow Sanatorium at Kasauli , and the formation of a scheme for organizing home treatment as an essential part of India’s anti TB campaign. Dr Jyoti Prasad Pattnaik, MBBS 11

12. History of TB programs in India India has had a TB Control Program since 1962. Since then it has re-organized itself two times; first into the Revised National Tuberculosis Control Program (RNTCP) in 1997 and then into the National Tuberculosis Elimination program in 2020. Dr Jyoti Prasad Pattnaik, MBBS 12

13. National TB Program- NTP (1962-1997 ) TB control efforts got organized with the National TB program (NTP) primarily focusing on BCG vaccinations as a preventive measure. At that time, the Indian government lacked the financial backing to meet its public health goals. Therefore, external sources of funding and administration, often from the WHO and UN, became common in the realm of public health. In 1992, the WHO and Swedish International Development Agency evaluated the NTCP, finding that it lacked funding, information on health outcomes, consistency across management and treatment regimens, and efficient diagnostic techniques. Dr Jyoti Prasad Pattnaik, MBBS 13

14. National Tuberculosis Control Program In 1962, the government of India launched a National Tuberculosis Control Program to detect as many tuberculosis cases as possible, provide effective treatment, establish district tuberculosis centers, extend short-course chemotherapy, and strengthen existing state tuberculosis training and demonstration centers.  Dr Jyoti Prasad Pattnaik, MBBS 14

15. A 1992 review of the national program revealed inadequate budgetary outlays and drug shortages, an overemphasis on clinical and radiologic diagnosis, insufficient utilization of sputum microscopy facilities, an emphasis on case detection rather than cure, and a lack of consensus on treatment regimens. On the basis of these findings, the national strategy has been revised to achieve an 85% cure rate through administration of short-course (6-8 months) chemotherapy and to detect 70% of estimated cases. Dr Jyoti Prasad Pattnaik, MBBS 15

16. Strategies for achieving these objectives include use of sputum testing as the primary diagnostic method among self-referred cases, a standardized treatment regimen, an uninterrupted supply of drugs at all levels of the health system, increased budgetary outlays, creation of a sub-district supervisory unit, and greater emphasis on training and operations research. Dr Jyoti Prasad Pattnaik, MBBS 16

17. Revised National TB Control Program- RNTCP (1997-2020) The large scale implementation of the Indian government’s Revised National TB Control Program (RNTCP) (sometimes known as RNTCP 1) was started in 1997. The RNTCP was then expanded across India until the entire nation was covered by the RNTCP in March 2006. At this time the RNTCP also became known as RNTCP II. RNTCP II was designed to consolidate the gains achieved in RNTCP I, and to initiate services to address TB/HIV, MDR-TB and to extend RNTCP to the private sector. Dr Jyoti Prasad Pattnaik, MBBS 17

18. RNTCP in India RNTCP uses the World Health Organisation (WHO) recommended Directly Observed Treatment Short Course (DOTS) strategy and reaches over a billion people in 632 districts/reporting units. The RNTCP is responsible for carrying out the Government of India five year TB National Strategic Plans . With the RNTCP both diagnosis and treatment of TB are free. There is also, at least in theory, no waiting period for patients seeking treatment and TB drugs. Dr Jyoti Prasad Pattnaik, MBBS 18

19. RNTCP in India The initial objectives of the RNTCP in India were : to achieve and maintain a TB treatment success rate of at least 85% among new sputum positive (NSP) patients. to achieve and maintain detection of at least 70% of the estimated new sputum positive people in the community. New sputum positive patients are those people who have never received TB treatment before, or who have taken TB drugs for less than a month. They have also had a positive result to a sputum test, which diagnoses them as having TB Dr Jyoti Prasad Pattnaik, MBBS 19

20. National Tuberculosis Elimination Program, RNTCP RNTCP renamed as NTEP At the start of 2020 the central government renamed the RNTCP the National Tuberculosis Elimination Program (NTEP). In a lettter to all the State Chief Secretaries of states and UTs, the commitment is emphasised of the Union government achieving the sustainable development goal of ending TB by 2025, five years ahead of the global targets. Dr Jyoti Prasad Pattnaik, MBBS 20

21. National Tuberculosis Elimination Program (NTEP) The National Tuberculosis Elimination Program (NTEP) is the Public Health initiative of the Government of India that organizes its anti-Tuberculosis efforts. It functions as a flagship component of the National Health Mission (NHM) and provides technical and managerial leadership to anti-tuberculosis activities in the country. As per the National Strategic Plan 2012–17, the program has a vision of achieving a "TB free India", and aims to provide Universal Access to TB control services. The program provides, various free of cost, quality tuberculosis diagnosis and treatment services across the country through the government health system. Dr Jyoti Prasad Pattnaik, MBBS 21

22. India National Strategic Plan (NSP) for TB 2017 - 2025 The Indian TB National Strategic Plan (NSP) 2017 - 2025 is the plan produced by the government of India ( GoI ) which sets out what the government believes is needed to eliminate TB in India. The NSP 2017 - 2025 describes the activities and interventions that the GoI believes will bring about significant change in the incidence, prevalence and mortality from TB. This is in addition to what is already going on in the country. The NSP sets out the recommendations of the GoI . However, the rate at which these recommendations are implemented, will largely depend on the action taken by individual states. The state of Uttar Pradesh has the highest number of TB patients notified by both the public and private sector. Dr Jyoti Prasad Pattnaik, MBBS 22

23. Visions & Goals of the National Strategic Plan The Vision is of a TB free India with zero deaths, disease and poverty due to tuberculosis The Goal is to achieve a rapid decline in the burden of TB, mortality and morbidity, while working towards the elimination of TB in India by 2025. The requirements for moving towards TB elimination in India have been arranged in four strategic areas of Detect, Treat, Prevent & Build.There is also across all four areas, an overarching theme of the Private Sector. Another overarching theme is that of Key Populations. Dr Jyoti Prasad Pattnaik, MBBS 23

24. Targets The targets of the National Strategic Plan are set out as consisting of both outcome and impact indicators. There are also four main “thrust” or priority areas in the NSP which are: Private sector engagement; Plugging the “leak” from the TB care cascade (i.e. people with TB going missing from care); Active case finding among key populations; and for people in “high risk” groups, preventing the development of active TB in people with latent TB. Another “thrust” area is that of the Programmatic Management of Drug Resistant TB (PMDT). Dr Jyoti Prasad Pattnaik, MBBS 24

25. Detect The aim is to detect all those people with drug sensitive TB as well as those with drug resistant TB. The emphasis is to be on reaching TB patients seeking care from private providers and also finding people with undiagnosed TB in “high risk” or key populations. This is to be done through: Scaling up free, high sensitivity TB diagnostic tests such as CBNAAT; Scaling up private provider engagement approaches; Universal testing for drug resistant TB; & Systematic screening of high risk populations. Dr Jyoti Prasad Pattnaik, MBBS 25

26. Diagnosis The Technical & Operational Guidelines for TB Control (TOG) describes how various tests should be used to diagnose anyone who has signs and symptoms suggesting that they might have TB. The tests to be used are sputum smear microscopy, chest X ray and the new CB-NAAT test. The CB-NAAT test is beginning to be made available throughout India. There is a diagram, or set of rules, which shows which tests should be used for different groups of people. Dr Jyoti Prasad Pattnaik, MBBS 26

27. Active case finding The main objective of active case finding (ACF) is to detect TB cases early and to initiate treatment promptly. The NSP emphasizes the need to shift from passive case finding, which is waiting for people to seek care, to ACF which involves seeking out people in targeted groups. In Karnataka 1,150 cases of TB were identified in just the first week of active case finding . Dr Jyoti Prasad Pattnaik, MBBS 27

28. Treatment Initiate and sustain all patients on appropriate anti- tb treatment wherever they seek care. Provide patient friendly systems and social support. This is to be done through: Preventing the loss of TB cases in the cascade of care by providing support systems. The “cascade of care” means every step in the provision of treatment, from when it is first started, to the point at which the patient finishes their treatment and is cured of TB; Providing free TB drugs for all patients with TB; Provide daily TB drugs for all patients with TB and a rapid scale up of short course regimens for drug resistant TB. Provide treatment approaches guided by drug sensitivity testing. Providing patient friendly adherence monitoring and social support in order to sustain TB treatment; & The elimination of catastrophic costs by linking eligible TB patients with social welfare schemes including providing nutritional support. Dr Jyoti Prasad Pattnaik, MBBS 28

29. Nutritional support It has now been announced that patients with TB will receive R500 ($8) a month for food. There is more about all the Direct Benefit Transfer schemes for TB. Under nutrition is a risk factor for TB in India. Under nutrition worsens the nutritional status, generating a vicious cycle which can lead to adverse outcomes during and after treatment for patients with active TB. This includes those with MDR-TB. So this payment is partially to ensure that patients with TB have adequate food. There is more about food and TB and nutrition & TB. Dr Jyoti Prasad Pattnaik, MBBS 29

30. Prevention Preventing the emergence of TB in susceptible populations. This is to be done through Scaling up air-borne infection control measures at health care facilities; Providing treatment for latent TB infection for the contacts of people with confirmed TB; & Addressing the social determinants of TB through an approach across different sectors. The social determinants of health are generally considered to be the conditions in which people live and work that affect their health. Dr Jyoti Prasad Pattnaik, MBBS 30

31. Build Build and strengthen relevant policies. Provide extra capacity for institutions and extra human resources capacity. This is to be done through: Translating high level political commitment into action; Restructuring the RNTCP and other institutional arrangements; Building supportive structures for surveillance, research and innovations. Providing a range of interventions based on the local situation; Scaling up technical assistance at national and state levels; & Preventing the duplication of partners’ activities Dr Jyoti Prasad Pattnaik, MBBS 31

32. Private provider engagement At least half of those treated for TB in India first attend the largely unorganized and unregulated private sector. Patients from low income households will often lose several months of their income in the process of paying for inappropriate diagnostics and treatments before starting approved therapy. Patients treated by private providers have often not been notified to the RNTCP, despite government orders to that effect. Patients cared for by private providers rarely receive sputum testing, and DST. Similarly, public health services such as surveillance, adherence monitoring, contact investigation, and outcome recording rarely reach privately treated patients. Dr Jyoti Prasad Pattnaik, MBBS 32

33. National Strategic Plan To End TB in India 2020-25 This NSP is an update of the NSP 2017 2025 which is necessitated by the rapidly changing environment within which NTEP operates. Knowledge and insights generated from the Joint Monitoring mission in 2019, 16 large scale programme evaluations (Central Internal Evaluations) during 2017-2019; implementation of the past NSP especially scale up of private sector involvement strategies, roll out of rapid molecular tests, LTBI treatment rollout; and updated recommendations from WHO sets the direction for this NSP. As in the past, the NSP 2020 2025 is a framework to guide the activities of all stakeholders including the national and state governments, development partners, civil society organizations, international agencies, research institutions, private sector, and many others whose work is relevant to TB elimination in India. This NSP is a five year strategy document that provides goals, strategies and interventions for the country’s response to the disease and aims to direct the attention of all stakeholders to the most important interventions that the NTEP believes will bring about significant changes in the incidence, prevalence and mortality of TB. These strategies and interventions are in addition to the processes and activities already ongoing in the country. Dr Jyoti Prasad Pattnaik, MBBS 33

34. Dr Jyoti Prasad Pattanayak MBBS, PGDMCH, PGDHM Asst Professor Dept of Pharmacology Roland Institute of Pharmaceutical Sciences Khodasingi , Berhampur , 760010, Odisha 34 Dr Jyoti Prasad Pattnaik, MBBS