Revised national tuberculosis elimination program pro.pptx

Rntcp

1. Revised National Tuberculosis Control Programme

2. Objectives describe Revised National Tuberculosis Control Programme explain organization describe laboratory network list new initiatives explain National strategic plan (2012-2017

3. Introduction TB is one of the most ancient diseases. It has been referred in the Vedas and Ayurvedic Samhitas. It is caused by Mycobacterium tuberculosis In India, the first open air sanatorium was founded in 1906

4. TB surveys -(1939) and Introduction of BCG vaccination (1948) Under Dr Frimodt Moller First TB dispensary established in Bombay in 1917 India became a member of the International Union Against Tuberculosis (IUAT) in 1929.

5. Incident in India(2016) Estimates of TB burden*, 2016 Rate (per 100 000 population) Mortality (excludes HIV+TB) 32(24–40) Mortality (HIV+TB only) 0.92(0.5–1.5) Incidence  (includes HIV+TB) 211(109–345) Incidence (HIV+TB only) 6.6(4.3–9.4) Incidence (MDR/RR-TB)** 11(7.2–15)

6. National Tuberculosis Programme (NTP) National Tuberculosis Programme (NTP) has been in operation since 1962. However, the treatment success rates were unacceptably low and the death and default rates remained high. Spread of multidrug resistant TB was threatening to further worsen the situation.

7. In view of this, 1992 GOI along with WHO and SIDA reviewed the TB situation in the country and came up with following conclusion: -NTP, though technically sound, suffered from managerial weakness. - Inadequate funding - Over-reliance on X- Ray for diagnosis - Frequent interrupted supplies of drugs - Low rates of treatment completion

8. In 1993, in order to overcome these, RNTCP started with the assistance from international agencies. adopted the internationally recommend Directly Observed Short-Course(DOTS) strategy

9. Objectives Achievement of at least 85 % cure rate of infectious cases of TB, through DOTS involving peripheral health functionaries; and Augmentation of case finding activities through quality sputum microscopy to detect at least 70% of estimated cases.

10. The revised strategy was introduced in the country in a phased manner as Pilot phase I, Pilot phase II and pilot phase III.

11. DOTS strategy: Components Political will and administrative commitment Diagnosis by quality assured sputum smear microscopy Adequate supply of quality assured short course chemotherapy drugs. Directly Observed treatment Systematic monitoring and accountability

12. The Stop TB Strategy 2006 Vision: A TB-FREE WORLD Goal: To dramatically reduce the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets

13. Objectives Achieve universal access to high-quality care for all people with TB Reduce the human suffering and socioeconomic burden associated with TB Protect vulnerable populations from TB, TB/HIV and multidrug-resistant TB

14. Support development of new tools and enable their timely and effective use Protect and promote human rights in TB prevention, care and control

15. Targets MDG 6, Target 8: Halt and begin to reverse the incidence of TB by 2015 Targets linked to the MDGs and endorsed by the Stop TB Partnership: – by 2015: reduce prevalence and deaths due to TB by 50% compared with a baseline of 1990 – by 2050: eliminate TB as a public health problem

16. Stratergy 1. Pursue high-quality DOTS expansion and enhancement Secure political commitment, with adequate and sustained financing Ensure early case detection, and diagnosis through quality-assured bacteriology Provide standardized treatment with supervision, and patient support

17. 2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations Scale-up collaborative TB/HIV activities Scale-up prevention and management of multidrug-resistant TB (MDR-TB) Address the needs of TB contacts, and of poor and vulnerable populations

18. 3. Contribute to health system strengthening based on primary health care Help improve health policies, human resource development, financing, supplies, service delivery and information Strengthen infection control in health services, other congregate settings and households Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL)

19. 4. Engage all care providers Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches Promote use of the International Standards for Tuberculosis Care (ISTC)

20. 5. Empower people with TB, and communities through partnership Pursue advocacy, communication and social mobilization Foster community participation in TB care, prevention and health promotion Promote use of the Patients' Charter for Tuberculosis Care

21. 6. Enable and promote research Conduct programme-based operational research Advocate for and participate in research to develop new diagnostics, drugs and vaccines

22. The End TB Strategy 2014 Vision A world free of TB. Zero deaths, disease and suffering due to TB. Goal End the global tuberculosis epidemic.

23. Indicators 95% reduction by 2035 in number of TB deaths  compared with 2015. 90% reduction by 2035 in  TB incidence  rate compared with 2015. Zero TB-affected families facing  catastrophic costs  due to TB by 2035.

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

25. Pillars and components Integrated, patient-centred care and prevention Early diagnosis of tuberculosis including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups. Treatment of all people with tuberculosis Collaborative tuberculosis/HIV activities,

26. Bold policies and supportive systems Political commitment with adequate resources for tuberculosis care and prevention. Engagement of communities Universal health coverage policy, and regulatory frameworks for case notification, Social protection,

27. Intensified research and innovation Discovery, development and rapid uptake of new tools, interventions and strategies. Research to optimize implementation and impact, and promote innovations.

28. Ending the TB epidemic Ending the global TB epidemic is feasible with dramatic decline in TB deaths and cases, and elimination of economic and social burden of TB. Failure to do so will carry serious individual and global public health consequences.

29. Organization

30. Laboratory Network

31. National reference laboratories NRLs works closely with IRLs, monitor and supervise the IRL staff in EQA, culture and DST, LPA and CBNAAT activities. Three microbiologist four laboratory technicians The NRL microbiologist and laboratory supervisor/ technician Quality improvement workshop

32. Immediate reference laboratory The functions of IRL are supervision and monitoring of EQA activities, mycobacterial culture and DST and also drug resistance surveillance in selected states. Technical training to laboratory technicians and senior TB laboratory supervisor. The ILR undertake on site evaluation (district in the state)

33. Designated microscopy Centres (DMC): DMC which serves a population of around 100000 The quality assurance activities include: - onsite evaluation -panel testing -Random blinded rechecking Culture and DST laboratory

34. In addition to IRLs, Microbiology department of medical colleges 64 C and DST laboratories Solid culture certifications: 45. Liquid culture certifications: 28 laboratories.

35. Line probe assay: Rapid diagnosis of MDR-TB by LPA. Second line DST: 25 laboratory Expanding CBNAAT service: The time to diagnosis of TB and drug resistant TB has been significantly reduced with the availability of CBNAAT, which is a rapid molecular assay that detects M. Tuberculosis and Rifampicin resistance. The test is fully automated and provides results in two hours. Currently there are 121 machines.

36. TB diagnostic Smear microscopy for acid fast bacilli. - sputum smear stained with ZN staining - Fluorescence stains and examined under direct or indirect microscopy with or without LED. 2. Culture - solid media -liquid media

37. 3 . Rapid diagnostic molecular test. - Conventional PCR based line probe assay for MTB complex -Real-time PCR based nucleic acid amplification test NAAT for MTB complex. 4. Radiography 5. Tuberculin skin test

38. TB diagnostic algorithm Adult Paediatric

39. Standard Drug regimen New case Intensive phase 2 months of HRZE Continuation phase 4 months of HRE

40. Standard Drug regimen Previously treated Intensive phase 2 months of HRZES and 1 Month of HRZE Continuation phase 5 months of HRE

41. Paediatric dose

42. Dose Drug Dose and range (mg/kg body weight) Maximum(mg) isoniazid 5(4–6) 300 rifampicin 10 (8–12) 600 pyrazinamide 25 (20–30) ethambutol 15 (15–20) Streptomycina 15 (12–18)

43. New initiatives

44. 1. Nikshay TB surveillance using case based web IT system. Central TB division in collaboration with National informatics centre launched in May 2012

45. TB patient registration and details of diagnosis, DOT provider, HIV status, follow up, contact tracing, outcomes. Details of solid and liquid culture and DST, LPA, CBNAAT details. DR-TB patient registration Referral and transfer of patients. Private health facility registration and TB notification

46. Mobile application for TB notification SMS alert to patients on registration SMS alerts to Programme officers. Automated period report - case finding -sputum conservation -treatment outcome.

47. 2. TB notification According to the government of India notification dated 7th May 2012, it is now mandatory for all healthcare providers to notify every TB cases to local authorities. 3. Ban on TB serology The serology tests are based on antibody response, which is highly variable in TB and may reflect remote infection rather than active disease.

48. Newer initiatives 1. Daily regimen for pediatric TB 2. Daily regimen for all forms of TB in five States. 3. Daily regimen for all TB/ HIV co-infected patients across the country. 4. Pilots for universal access to TB cases. 5. Bedaquilline conditional access program. Drug resistance surveillance under RNTCP

49. TB-HIV coordination dedicated human resources, integration of surveillance, joint monitoring and evaluation, capacity building and operational research. Activities as follows Intensified TB case finding has been extended to all ART centres. HIV testing of TB patients is now routine through provider initiated testing and counseling,

50. free HIV care at (ART) centre. Policy decisions has been taken by National technical working group on TB/HIV collaborative activities to expand coverage of whole blood finger prick HIV screening test at all DMC without a stand alone. Provider initiated HIV testing and counseling among presumptive TB cases is now a policy

51. . Intensified case finding activities to be specifically monitored among HIV infected pregnant women and children living with HIV infected pregnant women and children with HIV.

52. 7. The national aids control programme and RNTCP have taken the policy decision to adopt isoniazid prophylaxis therapy as a strategy for prevention of TB among PLHIV. The implementation will be in a phased manner.  

53. ,8. The RNTCP has prioritized presumptive TB cases among people living with HIV for diagnosis of TB and Rifampicin resistance with rapid diagnostic tools having high sensitivity .

54. National strategic plan (2012-2017 Target : universal access to TB care. Strategic vision to move towards universal access Vision: TB free India

55. Areas: Strengthening and improving the quality of basic DOTS service. Further strengthen and align with health system under NRHM Deploying improved rapid diagnosis at the field level. Exapand efforts to engage all care providers

56. Strengthen urban TB control Expand diagnosis and treatment of drug resistant TB Improve communication and outreach Promote research for development and implementation of improved tools and strategy.

57. Objective: are Early detection and treatment of at least 90 % estimated all type of TB cases in community including drug resistant and HIV associated TB. Successful treatment of at least 90% of new TB patients, and at least 85% of previously-treated TB patients. Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%.

58. Initial screening of all re-treatment smear positive till 2015, and all smear positive TB patients by year 2017 for drug resistance TB and provision of treatment services for MDR-TB patients Offering counseling Expand RNTCP service to private sector.

59. Targets Detections and treatment if about 87 lakh TB patients during 12th five year plan. Detections and treatment of at least 2 lakh MDR-TB patients during the 12th five year plan. Reduction in delay in diagnosis and treatment of all types of TB cases. Increase in access to service to marginalized and hard to reach population, and high risk and vulnerable groups.

60. Achievement The treatment success rate has more than treblrd from 25% in 1998 to 88% in 2015. Death rates reduced to 4% from 29%> 731 DTCs, 4888 TB units and 13886 DMC are functional in the country.

61. Financial resources - world bank and department for international development via WHO Global TB drug facility Global fund to fight AIDS, Tuberculosis and malaria, the United States agencies for international development and DANIDA. Government of India provides 100% grant in aid to the implementing agencies. State/ UTs, besides free drugs. The states are expected to use the existing infrastructure and also to provide some manpower resources.

62. NTI The NTI had believed in assessment and evaluation as an ongoing process. It welcomed the idea of periodic assessment, especially from experts, on scientific lines as they are vital to the growth and improvement in the programme.

63. Active case finding This is initiated to identify the TB cases in the community by conducting survey. Health care professionals gathers the history, and assess for the signs and symptom of TB among the general population.

64. Conclusion

65. REFERENCES Park, K. (2015). Park's textbook of preventive and social medicine (23rd ed.). Jabalpur: M/S Banarsidas Bhanot. Lal, S., A., & P. (2014). Textbook of community medicine: preventive and social medicine (3rd ed.). New Delhi: CBS & Distributors Pvt. Ltd. Ministry of Health & Family Welfare-Government of India. (n.d.). About us. Retrieved November 09, 2017, from https://tbcindia.gov.in/index4.php?lang=1&level=0&linkid=399&lid=2768 Soyam, V., & Boro, P. (2015). Newer initiatives in revised national tuberculosis control programme and its current implementation status.  Asian Journal of Medical Sciences,   6 (5). doi:10.3126/ajms.v6i5.11945