NTEP ( National TB elimination programme )

About national tuberculosis elimination programme

1. Central TB Division Ministry of health & Family welfare National Tuberculosis Elimination Program

2. PLAN OF PRESENTATION ROLL NO.s TOPICS COVERED 187 Introduction 188 Brief History of Tb Control in India 189 National Tuberculosis Elimination Program 190 Diagnostic Methods and revised case definition 191 Treatment Prevention and control 192 Newer Initiatives

3. Tuberculosis Introduction - Shimab Akhtar Roll no. -187

4. Tuberculosis Caused by M . tuberculosis complex M.tuberculosis complex includes majorly- 1. M . tuberculosis : It is the most common species to cause TB in man. 2. M . bovis (bovine tubercle bacillus)

5. Pathogenesis of TB Source of Infection - 1.human 2.bovine Mode of transmission- 1.Aerosols(mainly )generated while coughing and sneezing 2. Ingestion of sputum by infants or consumption of unpasteurised (infected) milk Source: Apurba Shastry textbook for microbiology

6. Important determinants of TB These risk factors together account for 44% of the total estimated incident TB in India Other Risk Factors include - Sputum positivity Bacillary load Overcrowding and poorly ventilated rooms Other comorbid conditions Source: NTB report 2023

7. Other contributory factors : The N ational TB Prevalence survey found that the majority (64%) of TB symptomatic individuals did not seek health care common reasons cited for not seeking care were: 1). Ignoring he symptoms (68%) 2).Not recognizing the symptoms to be that of TB (18%) 3). Self-treatment (12%) and 4).Not being able to afford care (2%) Source: NTB report 2023

8. Clinical manifestations of TB Extrapulmonary (miliary T.B.)

9. TB Characteristics The common sites of extra-pulmonary TB are - 1. lymph node (26.3%). 2. pleural (23.3%), 3. abdomen (17.4%) 4. spine (4.8%), 5. meninges (2.8%). 6. bone (excluding spine; 2.7%) 7.and genitourinary tract (1.6%). Source: NTB report 2023

10. Signs and symptoms of tuberculosis :

11. Epidemiology of TB Global An estimated global total of 10.6 million fell ill with TB in 2022, equivalent to 133 incident cases per 100 000 population. Among all TB cases, 6.3% were among people living with HIV. Source: NTB report 2023

12. TB Burden in India India accounts for the highest TB load in the world amounting to 27% according to the WHO. Source: NTB report 2023 TB case notifications in 2022: 2022 milestone year for TB surveillance efforts in India, recorded an increase of over 13% as compared to 2021 , approximately 172 cases per lakh population. The treatment initiation rate among the notified cases for 2022 was 95.5%. The highest case notification rate among States was seen in Delhi And the lowest among States was seen in Kerala

13. There has been an increased in the no. of cases reported in 2022 as compared to 2020 this reversal in of progress reflect the estimated impact of disruptions to essential TB services during the COVID-19 pandemic . The global goal was to reduce the TB incidence rate by 20% by 2020 . The cumulative fall in the TB incidence rate between 2015 and 2020 13.5% But in 2022 it was only 8.7%. This is only halfway to first end TB strategy goal and far below the goal to reduce TB incidence to 50% by 2025 Source: NTB report 2023

14. Annual case notification rate The year 2022 also saw the notification of highest number of TB cases at 24.2 lakhs So there was an in ACNR from 153 per in 2021 to 172 per lakh population in 2022. In the private sector, the CNR achieved for 2022 was 52 cases per case notification rate (ACNR) from 153 per lakh population, Source: NTB report 2023

15. TB Demography Age and Sex: TB affects more males (61%) as compared to females (39%) And vulnerable groups , the paediatric age group (5.6%) , and aged 55 years or above.(27%) Source: NTB report 2023

16. Drug Resistant TB in India The year 2022 saw an increase of 32% in the number of MDR/RR-TB cases detected under NTEP as compared to 2021. As one of the highest rates of MDR-TB in the world, TB with MDR-TB is a severe issue in India. DR-TB remains one of the primary obstacles to India's progress toward TB elimination Source: NTB report 2023

17. Catastrophic costs due to TB If the total costs incurred by a TB-affected household exceeds 20% of their household annual income, the costs are classified as catastrophic. As per the National TB report the median total cost incurred to participants currently on TB treatment was INR 7500 for public sector and INR 20000 for private sector. In India around 18% of the general population are experiencing such catastrophic healthcare expenditure in general. To address this, the End TB Strategy and the NSP for TB in India have set a target to eliminate the catastrophic cost due to TB care. Source: NTB report 2023

18. Brief History of TB Control in India Roll no: 188

19. National tuberculosis programme Introduced in 1962 Primarily focused on BCG vaccination, X-Ray based diagnosis. Treatment success rate was unacceptably low and death and default rates were high. It lacked funding, information on health outcomes and consistency across management. Spread of multidrug resistant TB was threatening to worsen the situation. Source: Park’s Textbook of Preventive and Social Medicine

20. Revised National Tuberculosis Control Program In order to overcome these shortcomings of NTP highlighted by the 1992 joint review by government of India, The Swedish International Development Agency and WHO, RNTCP was established in 1993. New Programme based on internationally recommended strategy- DOTS was launched in 1997. It included flexible funding, decentralisation, quality assured drugs, better supervision, monitoring, evaluation and technical support. Source: www.who.int/tb

21. Achievement of at least 85 percent cure rate of infectious TB through DOTS, involving peripheral health functionaries. Augmentation of case finding activities through sputum microscopy to detect at least 70 percent of estimated cases. Objectives of RNTCP:

22. The Stop TB Strategy 2006 Vision: A TB-Free world. Goal: To Reduce Dramatically the global burden of TB by 2015 in line with Millennium Development Goals and the stop tb partnership targets. Source: stoptb.org

23. Achieve universal access to high-quality diagnosis and patient-centred treatment Reduce the human suffering and socioeconomic burden associated with TB Protect poor and vulnerable populations from TB, TB/HIV and multidrug-resistant TB Support development of new tools and enable their timely and effective use Objectives:

24. Targets: MDG 6, Target 8: halt and begin to reverse tb incidence by 2015. Targets linked to the MDGs and endorsed by Stop TB Partnership: By 2005: detect at least 70% of new sputum smear-positive TB cases and cure at least 85% of these cases. By 2015: reduce prevalence of and deaths due to TB by 50% relative to 1990 By 2050: eliminate TB as a public health problem ( <1 case per million population )

25. Components: Pursuing quality DOTS- Expansion and enhancement Addressing TB/HIV and MDR-TB contributing to health system strengthening Engaging all care providers Empowering patients and communities Enabling and promoting research.

26. End TB Strategy 2014 Vision : A world free of TB, zero deaths, disease and suffering due to TB. Goal : End the global TB epidemic. Source: www.who.int

27. Principles: Government stewardship and accountability with monitoring and evaluation. Strong coalition with civil society organisations and communities. Protection and promotion of human rights, ethics and equity. Adaptation of the strategy and targets at country level with global collaboration.

28. Pillars and components Integrated, patient-centred care and prevention

29. 2. Bold policies and supportive system

30. 3. Intensified research and innovation

31. In view of end TB Targets Revised National TB Control Programme (RNTCP) nomenclature changed to National Tuberculosis Elimination Program (NTEP)

32. NATIONAL TUBERCULOSIS ELIMINATION PROGRAMME rollno.189

33. NTEP ORGANOGRAM NTEP STRUCTURE COMPRISES OF FIVE LEVELS : 1. NATIONAL LEVEL 2. STATE LEVEL 3. DISTRICT LEVEL 4. SUB- DISTRICT LEVEL 5.PERIPHERAL HEALTH INSTITUTION LEVEL.

34. SUB-DISTRICT LEVEL- TB UNIT LEVEL- urban and rural areas -1 per (1.5-2.5 lakhs) population. Hilly / tribal/difficult areas- 1 per(0.75-1.25 lakhs) population. The TU has one microscopy centre for every 100,000 population(50,000 in tribal , desert, remote and hilly areas. PERIPHERAL HEALTH INSTITUTIONS(PHIs)- includes dispensaries, PHCs, CHCs, referral , major, speciality clinics/TB hospitals/ medical colleges. HEALTH AND WELLNESS CENTRES- serves as first point of care for continuation of treatment, adherence and for ancillary drugs.

35. NATIONAL STRATEGIC PLAN (2017-2025) FOR TB ELIMINATION VISION- TB free India with zero deaths , disease and poverty due to TB . OBJECTIVES - 1. Find all the drug sensitive TB and drug resistant TB cases with emphasis on reaching TB patients seeking care from private providers , And undiagnosed TB at high risk populations . 2. Initiate and sustain all the patients on appropriate Anti- TB treatment wherever the seek care , with patient friendly systems and social support.

36. 3.Prevent the emergence of TB in susceptible population. 4.Build and strengthen enabling policies , empowered institutions, additional human resources with enhanced capacities and provide adequate financial resources.

37. NSP FOR TB ELIMINATION 2017-2025 Aims to bring about significant changes in the incidence , prevalence and mortality of TB . It is in line with the global END TB TARGETS sustainable development goals to attain the vision of a TB FREE INDIA.

38. EXPECTED OUTCOMES AND TARGETS ELIMINATION OF TB BY 2025 80 PERCENT REDUCTION IN TB INCIDENCE 90 PERCENT REDUCTION IN TB MORTALITY 0 PERCENT PATIENTS HAVING CATASTROPHIC EXPENDITURE DUE TO TB

39. NATIONAL STRATEGIC PLAN 2017-2025 GOALS- To achieve rapid decline in burden of TB , mortality while working towards elimination of TB by 2025. DRIVEN BY: DETECT-TREAT-PREVENT-BUILD Approach.

40. DETECT ACTIVE CASE FINDING 1. A high visibility campaign – TB MUKT BHARAT Campaign for awareness generation to ensure early case finding . 2. community screening 3.institutinal screening 4.engagement of private sectors 5. scale up free, high sensitivity diagnostic tests and algorithms 6. systematic screening of high risk populations.

41. HIGH RISK POPULATION GROUP People who have increased exposure to TB due to where they live or work People who have limited access to quality TB services People at increased risk of TB because of biological or behavioural factors that compromise immune function. Slum dwellers, miners, prisoners, health care workers, hospital visitors. Children , physically challenged, tribals , refugees, people living in remote areas , migrants. People living with TB having diabetes , undernourished, uses tobacco, IV drug users, alcohol use disorders.

42. TREAT Provide sustained , access to high quality TB treatment , care and support services without financial loss. Universal daily regimen for TB cases and rapid scale up of short course regimens for drug-resistant TB and DST guided. Decentralization of DRTB treatment to initiate treatment faster and follow up patients better. Palliative care and rehabilitation for patients with extensive drug resistant. Empowering patients. pharmacovigilance activities.

43. PREVENT SCALE-UP AIR BORNE INFECTION CONTROL measures at health care facilities. Contact screening Testing and treatment for latent TB infection in contacts of bacteriologically-confirmed cases and in individual at high risk of getting TB disease.

44. BUILD Build and strengthen enabling policies , empowered institutions. HEALTH SYSTEM STRENGTHENING – National TB Elimination Board National TB Policy and Act Restructured TB Programme management Multisectoral approach and main steaming Case Based Routine Surveillance Burden estimation, Identify and describe vulnerable population Monitoring and evaluation.

45. DIAGNOSTIC METHODS AND REVISED CASE DEFINITIONS ROLL NO. 190

46. DIAGNOSTIC TOOLS FOR TB Sputum smear microscopy for AFB : Ziehl-Neelson staining Fluorescence staining. 2. Culture: Solid media - LJ media Automated liquid culture systems ( BACTEC MGIT 960) Drug sensitivity testing. 3. Rapid molecular diagnostic testing Line probe assay. NAAT (CBNAAT / TRUENAAT). MICROBIOLOGICAL CONFIRMATION

47. CLINICAL DIAGNOSIS OF TB Chest X ray abnormalities Tuberculin skin test IGRA Histopathology

48. Source - tbcindia.gov.in

49. Source - tbcindia.gov.in

50. Source - tbcindia.gov.in

51. Source- tbcindia.gov.in

52. CASE DEFINITIONS Presumptive case - Patients who presents with symptoms or signs suggestive of TB. Cough > 2 weeks, fever >2 weeks, significant weight loss, hemoptysis and any abnormality in chest x-ray . Bacteriologically confirmed case - Patients whose biological specimen is positive for smear microscopy, culture, gene Xpert. Source- WHO Global TB report (2014,2020)

53. Clinically Diagnosed Case - Does not fulfill criteria for bacteriological Confirmation but has been diagnosed with Active TB by clinician and should be given full course of TB treatment. Diagnosed on basis of x-ray abnormalities or suggestive histology and extrapulmonary cases without laboratory confirmation.

54. OTHER CLASSIFICATION OF TB CASES Based on - Anatomical site of disease History of previous TB treatment Drug resistance HIV status

55. ANATOMICAL SITE OF DISEASE Pulmonary Tuberculosis (PTB): Refers to any bacteriologically confirmed or clinically diagnosed case of TB involving lung parenchyma or tracheobronchial tree. Ex - miliary TB in lungs. Extrapulmonary TB (EPTB) : Refers to any bacteriological or clinically diagnosed TB case involving organs other than lungs. Ex - pleura, lymph nodes, abdomen, skin, genitourinary tract, skin and bones.

56. HISTORY OF PREVIOUS TB TREATMENT New Patients : Have never been treated for TB or have taken anti-TB drugs for less than 1 month . Previously Treated Patients : Have received 1 month or more of anti-TB drugs in the past.

57. PREVIOUSLY TREATED TB PATIENTS Relapse patients : previously been treated for TB and declared cured or treatment completed at their most recent course of treatment and now diagnosed with recurrent TB episode. Treatment after failure patients : Have previously been treated for TB and treatment failed at their most recent course of treatment. Treatment after loss to follow up patients : previously been treated for TB and declared lost to follow up at end of most recent course of treatment. Other previously treated patients : previously been treated for TB but outcome after most recent course of treatment is unknown/undocumented. Patients with unknown previous TB treatment history

58. BASED ON DRUG RESISTANCE Monoresistance : Resistance to any 1 first line anti - TB drug. Polydrug resistance : Resistance to more than 1 first line anti-TB drug. (Other than both H and R). Multidrug resistance (MDR): Resistance to atleast both H and R. Pre-extensive drug resistant (pre-XDR) : Resistant to H,R and any FQs. Extensively drug resistant (XDR) : MDR patient resistant to any FQ and one of three 2nd line injectable drugs addition to MDR. Rifampicin resistant : Resistance to rifampicin with or without resistance to any other anti-TB drugs.

59. BASED ON HIV STATUS HIV positive TB patients. HIV negative TB patients. HIV status unknown TB Patients.

60. CASE FINDING IN TB Passive case finding - Passive surveillance from the hospital records. Patients having symptoms of pulmonary TB like persistent Cough and fever seek medical advice on their own initiative. Intensified case finding - Provider initiated screening for TB symptoms in OPD patients and hospital attendees. Screening people presenting to health facilities with other co-morbidities for TB.

61. Active case finding - Actively searching for TB patients in the community among vulnerable groups. ASHA Workers are involved and an incentive of Rs.500 is given to them for finding any presumptive case. Any member in community who helps in identification of presumptive TB case get an Rs.500 incentive. Vulnerability mapping - It is followed by periodic screening of vulnerable Population.

62. VULNERABLE POPULATION

63. SCREENING STRATEGIES FOR TB Community screening - Inviting people to attend screening at a mobile or fixed facility targeting people specifically in vulnerable groups, those who recent contact with a TB case or having symptoms of TB and going door to door to screen households. Institutional Screening - Health care facilities - Active screening of vulnerable individuals attending health care institution and hospitals. Congregate settings - Active screening of vulnerable individuals in shelters, old age homes, work places.

64. TREATMENT , PREVENTION AND CONTROL Shreya Chopra , 191

65. PRE TREATMENT : Counselling and Evaluation The patient and family members should be counselled about the : type of disease , mode of spread, treatment duration and dosage schedule , side effects, methods of prevention etc HIV testing for all TB patients PRE TREATMENT EVALUATION: Detailed history Weight and height CBC blood sugar level to screen for diabetes LFT Blood urea and creatinine Chest x day Pregnancy test

66. TREATMENT What does it mean in the context of this NSP for TB elimination in India? Provide sustained, equitable access to high quality TB treatment, care and support services responsive to the community needs without financial loss thereby protecting the population especially the poor and vulnerable from TB related morbidity, mortality and poverty.. What does it entail? 1. Providing daily regimen using FDCs to all TB patients. 2. DST guided treatment for DR TB. 3. Patient centric approach to treatment. 4. Prevent loss at cascade of TB care

67. ANTI- TUBERCULAR DRUGS

68. TWO PHASE CHEMOTHERAPY INTENSIVE PHASE CONTINUATION PHASE Short, aggressive or intense phase 1-3 months INH, rifampicin, pyrazinamide, ethambutol Aims to sterilise the persistent bacteria 6-9 months INH plus rifampicin and ethambutol

69. DOSAGE SCHEDULE

70. CLASSIFICATION Abbreviations: DS-TB, drug sensitive TB; H mono/poly, mono-resistance or poly-resistance to isoniazid; MDR-TB; multidrug resistant TB; RR-TB, rifampicin resistant TB; XDR-TB, extensively drug-resistant TB; R/FQ, resistant to fluoroquinolones; R/ SLI, resistant to second-line injectable agents; H, isoniazid; R, rifampicin; E, ethambutol; Z, pyrazinamide; Lfx, levofloxacin; Km, kanamycin; Mfx, moxifloxacin; Eto, ethionamide; Cfz, clofazimine; Hh, high-dose isoniazid; Cs, cycloserine; Lzd, linezolid; Bdq, bedaquiline; Cm, capreomycin.

71. NEW DRUGS NEW TREATMENT REGIMENS The following group of patients are eligible for BDQ therapy : 1. MDR/RR TB with resistance to any/all fluoroquinolones (FQ) or to any/all second-line injectable agents (SLI) 2. XDR-TB 3. Mixed pattern resistant TB (XDR-TB + additional first line / second line resistant TB) 4. Treatment failure of MDR-TB + FQ/SLI resistance or XDR-TB BEDAQUILINE (BDQ) AND DELAMANID Shorter oral BEDAQUILINE containing MDR/ RR-TB Regimen Shorter injectable containing regimen H resistant TB regimen Longer oral M/XDR-TB treatment regimen

72. NIKSHAY ENTRY Once the treatment regimen is finalised all patients should be initiated on treatment after opening the treatment card and entries are done in Nikshay FOLLOW UP OF TREATMENT Clinical follow up Done at monthly Interval Improvement in chest symptoms ,increase in weight may indicate good prognosis 2. . Laboratory investigations Sputum smear microscopy should be done at the end of intensive phase and end of treatment Negative Sputum smear at the end of IP indicate good prognosis.

73. DIRECT BENEFITS TRANSFER

74. PREVENTION What does it mean in the context of this NSP for TB elimination in India? Prevent the emergence of TB in susceptible populations What does it entail? 1. Scale up air-borne infection control measures at health care facilities 2. Treatment for latent TB infection in contacts of bacteriologically-confirmed cases 3. Contact screening

75. AIRBORNE INFECTION CONTROL

76. 2. PREVENTIVE THERAPY/ LATENT TB INFECTION TREATMENT Isoniazid Preventive Therapy Children are more susceptible to TB infection, more likely to develop active TB disease soon after infection, and more likely to develop severe forms of disseminated TB. Children < 6 years of age, who are close contacts of a TB patient, will be evaluated for active TB by a medical officer/ pediatrician. After excluding active TB he/she will be given INH preventive therapy irrespective of their BCG or nutritional status. The dose of INH for preventive therapy is 10 mg/kg body weight administered daily for a minimum period of six months. The INH tablets will be collected on monthly basis. The contacts will be closely monitored for TB symptoms.

77. Isoniazid Preventive Therapy (IPT) For PLHIVs Children living with HIV who are more than 12 months of age and who are unlikely to have active TB on symptom-based screening, and have no contact with a TB case will receive six months of IPT (10 mg/kg/ day) as part of a comprehensive package of HIV prevention and care services Systematic recording and reporting: All events in the cascade of IPT implementation including symptom screening at all contacts, IPT eligibility assessment, investigations, and the compliance with regimen will be systematically recorded and reported.

78. THE BCG VACCINATION ‘ Bacille Calmette Guerin’ Avirulent strain Live attenuated bacterial vaccine Vaccine strain : Mycobacterium bovis Is reconstituted with normal saline (NaCl), used within 1 hour Dose: 0.05mL (neonates) 0.1mL (infant & children) Strength: 0.1mg in 0.1mL volume Route: intradermal site: above the insertion of left deltoid (fig.5.) Administration: at birth or at 6th week Protective value: 15-20 years Fig.4. BCG vaccine Fig.5.

79. Phenomenon after vaccination: a)After 2-3 weeks- Papule formation b)After 5 weeks- 4-8mm of diameter of papule c)After 6-8 weeks- Breaks into a shallow ulcer, seen covered with a crust d)After 6-12 weeks- Permanent tiny, round scar, typically 4-8mm diameter e)After 8-14 weeks- Mantoux test becomes positive Complications : a)Prolonged severe ulceration at site of vaccination b)Disseminated BCG infection c)Suppurative lymphadenitis d)Osteomyelitis e)Death Fig.6. scar formation

80. BUILD What does it mean in the context of this NSP for TB elimination in India? Undertake critical management reforms, restructuring of HR and financial norms , pathways for private sector participation, in order to improve efficiency , effectiveness and accountability of the health system for an improved response to the TB epidemic. It includes : Urban TB control systems Health system strengthening Advocacy , communication and social mobilisation Surveillance, Monitoring and Evaluation Research Technical Assistance

81. ADVOCACY , COMMUNICATION AND SOCIAL MOBILISATION (ACSM) A) Advocacy is an activity by an individual or a group that aims to influence the decisions within political, economic and social institutions. Target audience- Decision-makers at national, regional and district levels Policy-makers Professional groups Funders Media Fig.17 ACSM handbook by WHO

82. Fig.18 celebrity endorsement

83. B) Communication aims to favourably change knowledge, attitudes and practices among various groups of people. Target audience- General public, including different vulnerable groups, healthcare workers TB patients currently on treatment as well as cured TB patients Contacts of patients with active TB People at high risk of developing TB C) Social mobilisation is the process of bringing together different stakeholders and building partnerships to prevent, detect, and cure TB. Target audience includes- Communities Community groups, e.g., mahila mandals, youth groups National and local level leaders Local Non-government Organisations (NGOs), Youth organizations, Community-based Organisations ( CBOs) Fig.19 public interaction Fig.20 community group participation

84. SUPERVISION AND MONITORING Routine monitoring is conducted under the supervision of the District TB Programme Officer by- Senior TB Treatment Supervisor, Senior TB Laboratory Supervisor, and The designated Medical Officer for TB Control Staff from the state and central governments also make regular site visits to identify problems and facilitate improvements, particularly in districts that are seen to be performing poorly. A monthly programme management and logistics report is provided by all health facilities to monitor facility performance, and manage drug supply and laboratory consumables. Tuberculosis units submit quarterly reports to the district on case detection, treatment outcomes, and programme logistics. The respective district enters these reports into the RNTCP electronic information management system and sends them to the respective state government TB cells and to the Central TB Division in the Ministry of Health and Family Welfare.

85. Newer Initiatives 192

86. Nikshay TB surveillance using case based web based IT system Central TB Division in collaboration with National Informatics Centre has undertaken the initiative to develop a case based web based application named Nikshay. This software was launched in May 2012 it was upgraded to Version2 pan-India in 2018 into an Integrated Web and mobile based ICT solution with support from partner organizations.

87. Functionalities of Nikshay 1. Direct Benefit Transfers (DBT) through Nikshay PFMS interface. 2. Ability to follow-up patients from the presumptive TB stage 3. Transaction based information system, where the primary function is to exchange information (diagnosis, adherence, Transfer, outcome, DBT etc) between various users logged into Nikshay.

88. 4. Institutional level login decentralised to PHIs: Now all public and private health facilities have separate user credentials which they can use to manage their own patients. 5. Nikshay has an Android based mobile app for the programme staff as well as private sector users that increases performance and accessibility on mobile devices. 6. TB Aarogya Saathi is a citizen- facing Android based mobile app providing basic information about TB disease as well as serves as a TB Self-Screening and enrolment tool.

89. Nikshay Dashboards

90. 99 DOTS: The programme has started using IT enabled adherence tools like 99 DOTS for HIV-TB patients.This will be expanded to all TB patients with implementation of daily regimen TB Notifications: According to the Government of India notification dated 7th May 2012, it is now mandatory for all healthcare providers to notify every TB case to local authorities i.e. District Health Officer/Chief Medical Officer of a district and Municipal health officer, every month in a given format

91. Ban To TB Serology The serological tests are based on antibody response, which is highly variable in TB and may reflect remote infection rather than active disease Currently available serological tests are having poor specificity and should not be used for the diagnosis of pulmonary or extra-pulmonary TB Their import, manufacturing, sale, distribution and use is banned by the Government of India

92. Patient Support Systems Direct Benefit Transfer Schemes Direct beneficiary transfer systems are being established by linking TB patients reported in NIKSHAY with AADHAR and PEMS to effectively deliver benefits to TB patients and their provider

93. B.Call Centre Support - Nikshay SAMPARK (1800-11-6666) is managed by the Central TB Division and is operational 7 days in a week, from 7am to 11pm. The operations of the Call Centre commenced in May-2018 and is currently operating from two sites - Noida & Pune. It provides inbound and outbound call services in 14 languages for all States & UTs.

94. Role of Nikshay Sampark 1. Resolving queries related to TB for citizens, patients, public health providers and private health providers. 2. Resolving queries of citizens/patients related to Hepatitis under National Viral Hepatitis Control Programme (NVHCP). 3. Tele-counselling to persons affected with TB. 4. Satisfaction Survey of persons affected with TB on NTEP services.

95. 5. TB grievance management : National TB Call Centre has launched a new online TB Grievance Management System (TB-GMS) pan India for improved transparency on TB grievances. TB-GMS provides real-time online visibility on the status of grievances and their pendency. It is used by the Call Centre-Grievance Team/District TB Officers (DTO)/ State TB Officers (STO)/Central TB Division (CTD). 6. IVRS (Interactive Voice Response System) : National TB Call Centre has launched Origin Dependent Routing (ODR) IVRS. ODR IVRS provides facility to callers to choose to talk in their regional language along with options of Hindi and English languages, and thus provides better interaction experience for callers.

96. MERM Container : Medicine Event Reminder Monitoring Systems is a GPS enabled box which detect when the tablet are taken from the container and inform onto the nikshay portal. Dare2erad TB : Uses AI to predict loss of follow ups

97. Pradhan Mantri TB Mukt Bharat Abhiyaan ( PMTBMBA)

98. Smt. Droupadi Murmu, Hon’ble President of India on 9th September 2022 launched “Pradhan Mantri TB Mukt Bharat Abhiyan ‘’ for community support to TB patients to provide people with TB and their families increased nutritional, diagnostic, and vocational support, delivered within the community.

99. The three-fold objectives of the initiative are: • Provide additional patient support to improve treatment outcome of TB patients • Augment community involvement in meeting India’s commitment to end TB • Leverage Corporate Social Responsibility (CSR) activities

100. The expected outputs of the initiative are: 1. This initiative will increase the active involvement of society in the fight against tuberculosis 2. This activity aims at increasing awareness among the public regarding tuberculosis 3. Involvement of the community in supporting the treatment cascade shall also help in the reduction of stigma

101. 4. Provision of additional support to the TB patient shall also result in the reduction of the out-of-pocket expenditure for the family of the TB patient 5. Ultimately improved nutrition for the TB patient shall result in better treatment outcomes

102. Nikshay Mitra Certificates : Each donor/Ni-kshay Mitra receives a certificate as a token of appreciation.

103. TB - HIV coordination 1. Intensified TB case finding has been implemented nationwide at all HIV testing centers (known as integrated counselling and testing centres, or ICTCs), and has now been extended to all ART centres. 2. HIV testing of TB patients is now routine through provider initiated testing and counselling (PITC), implemented in all states with the intensified TB-HIV package. 3. Persons found to be HIV-positive are eligible for free HIV care at a network of ART centres.

104. 4. Policy decision has been taken by National Technical Working Group on TB/HIV collaborative activities (NTWG on TB/HIV) to expand coverage of whole blood finger prick HIV screening test at all DMC without a stand-alone or F-ICTC. 5. Provider initiated HIV testing and counselling (PIC) among presumptive TB cases (TB suspects) is now a policy - A. In high HIV prevalent states/settings The implementation will be done in a phased manner, starting with high prevalent states and then in A and B category districts in rest of the country. B. In low HIV prevalent states/settings HIV testing among presumptive TB cases should be routinely implemented in the age-group of 25-54 years in low HIV prevalent districts (C & D) at places where there are co-located TB and HIV testing facilities.

105. 6. Intensified case finding activities to be specifically monitored among HIV infected pregnant women and children living with HIV. 7. The National AIDS Control Programme (NACP) and RNTCP have taken the policy decision to adopt isoniazid prophylaxis therapy (IPT) as a strategy for prevention of TB among PLHIV. The implementation will be in phased manner. 8. The RNTCP has prioritized presumptive TB cases among people living with HIV for diagnosis and Rifampicin resistance with rapid diagnostic tools having high sensitivity e.g. Xpert MTB/RIF.

106. THANK YOU