RNTCP

UPDATED RNTCP

1. Revised National Tuberculosis Control Program (RNTCP)

2. Presenters Masiya D ebbarma Naorem Kriyalaxmi D evi N. C hingei P hem Nevedita Das

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

4. Classification of TB TB Pulmonary (85-90%) Extra-pulmonary (10-15%) Sputum Positive TB (Those who have bacteria in sputum) Sputum Negative TB (Those who do not have bacteria in sputum) Lymph Nodes Joints Genitourinary tract Spinal tract Intestines

5. Symptoms of TB Most common symptom of TB Cough for 2 weeks or more Other symptoms of TB are: Fever, especially evening rise Pain in the chest Loss of weight Loss of appetite Coughing up blood-stained sputum Shortness of breath, Tiredness

6. How TB Spreads ? Those who have Tuberculosis of the lungs are the ones who can spread the disease to others When these infectious people cough, sneeze, talk or spit, they can spread TB bacteria into the air in the form of tiny droplets When these droplets are inhaled by a healthy person he/she can get infected with tuberculosis A sputum positive TB patient can infect 10-15 persons in a year

7. When to Suspect TB T B should be suspected in anyone with cough for 2 weeks or more These persons should have sputum examination in the nearest Microscopy Centre at the earliest

8. TB-HIV co-infection TB is the most common opportunistic infection amongst HIV infected individuals An HIV infected person newly infected with TB has 10-30 times higher chances of developing TB than those without HIV In India, 55-60% of AIDS cases reported had TB and TB is one of the leading causes of death in “People Living with HIV AIDS” (PLHA) Every TB patient should be referred to ICTC for HIV status and vice versa

9. Risk of infection About two persons infected in every 3 seconds About 50% are sputum smear positive and are infectious TB infected person will have a 10% lifetime risk of developing tuberculosis Infection of TB is 60 times more common in HIV + ve people than Non-HIV + ve Diabetes, malignancy, smoking tobacco, malnutrition and alcohol abuse also increase the risk of progression from infection to disease 2 out of every 5 Indians are infected with TB bacillus

10. BURDEN OF DISEASE 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 HIV positive Worldwide the proportion of new cases with MDR-TB was 3.3% in 2014, whereas those for previously treated cases was 20.0%

11. 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 African region India, China and Indonesia alone accounted for 23%, 10% and 10% of total cases respectively In 2014, an estimated 3.2 million cases were women

12. An estimated 510,000 women died as a result of TB, more than 1/3 rd of whom were HIV positive Globally , about 1.1 million new cases and 130,000 deaths occur annually due to TB among children (Global TB report 2015)

13. INDIA Accounts for nearly 1/4 th of the global burden of TB Around 2.2 million develop TB in 2013-14. During the same period, 0.27 million people died due to TB Everyday about 20,000 people become infected, 5000 develop TB and more than 1000 die due to the disease In simple terms, 2 persons become sputum + ve for TB and almost 1 person is killed every minute due to the disease ( WHO 2007 ) The proportion of new cases with MDR-TB was 2.2% in 2014, whereas those for previously treated cases was 15.0 %

14. Brief History of Tuberculosis (TB) 1865 Jean-Antoine Villemin : confirmed that TB is contagious Robert Koch : 1882: Isolated and cultured M. Tuberculosis(24 th March ) 1890: Announced the discovery of tuberculin D eveloped staining methods used to identify the bacteria 1905: R eceived Nobel Prize Visualization of M. tuberculosis using the Ziehl-Neelsen stain

15. Bacteriologist Paul Ehrlich developed Ziehl-Neelsen staining Before 1940 Sanatorium approach, good food, rest & fresh air 1948 Introduction of BCG vaccination 1950s-60s: Antibiotics available

16. Background History of RNTCP 1906- First open air TB sanatorium founded in India 1939- TB association of India - expert advice on the development of standard methods to deal with the disease; - setting up model institutions for training TB workers; - education of the public regarding preventive measures; - conceived the idea of domiciliary Rx of TB in 1940

17. 1946- Bhore Committee 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 this Division . 1951- Mass BCG vaccination campaign covering 65 million children in collaboration with IUAT 165 million tuberculin tests were administered to find the prevalence of TB in India

18. 1955-58 - National Sample Survey conducted under ICMR to find the magnitude of TB problem in India 1956- TRC established in Chennai - Proved the efficacy of domiciliary Rx for TB with chemotherapy 1959 - National TB Institute (NTI) established in Bangalore by GoI , with the active cooperation of the WHO, to develop a TB control programme

19. 1962- National TB Control Program(NTCP) started Managerial weakness, lack of supervision Poor quality of sputum microscopy Multiplicity of treatment regimens Poor organizational set-up Inadequate funding Over dependence on X-ray for diagnosis Frequent interrupted supplies of drugs Low rate of treatment completion (30% only)

20. 1992 - Programme Review showed - only 30% of patients diagnosed and only 30% of them treated successfully 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 national programme 1998- Massive RNTCP expansion began, RNTCP Ist phase (1998-2005 ) 1998 September- RNTCP Implemented in Imphal District, Manipur RNTCP programme covered the State from 21st Jan 2002

21. Early 2000 - 135 million population covered; Monitoring Mission conducted Sept 2003 - 741 million population covered; Monitoring Mission appreciates rapid expansion and overall quality End 2005- 97% population covered; next 5-year plan approved with additional activities, such as DOTS- Plus March 2006- The entire country covered by DOTS Oct 2006 - RNTCP phase II started for 5 years ( to Sep’11) 2007 - New sputum + case detection was 70% and treatment success rate was 86%

22. 2007 - DOTS plus services for management of MDR -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 report 2010 ) May 2012- Notification of TB is made mandatory by GOI

23. Revised National Tuberculosis Control Programme The National TB Programme (NTP) was started in 1962 for TB control in India. This programme was not able to give expected results in India The NTP was reviewed in 1992 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 24 th March 2006, the entire country was covered under the programme

24. Goal 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 Objectives To achieve and maintain: Cure rate of at least 90% among newly detected smear positive (infectious) pulmonary TB cases and Case detection of at least 85% of the expected new smear positive PTB cases in the community

25. Organisational structure of RNTCP Central TB Division, DGHS, MoH&FW Deputy Director General-TB State TB Cell District TB Centre Tuberculosis Unit DMC DOTS Centre National Institutes (NTI, TRC, LRS, JALMA) National Lab Committee, National TWG for TB-HIV, National DOTS Plus Committee, NTF for medical colleges, National OR Committee STO, MO, Epidemiologist, DEO etc State TB Training and Demonstration Centre/SDS/IRL DTO, MO-DTC, Support staff etc Nodal centre for TB control in the district MO-TC, STS, STLS 1 per 5 lakh population, 1 per 2.5 lakh in tribal, hilly and difficult areas 1 per 1 lakh population, 1 per 0.5 lakh in tribal, hilly and difficult areas MO, LT HW, ASHA, AWW, PPs, NGO, Comm vol etc

26. At each DTC - 1 dist TB officer - 1 second Medical Officer - 2 lab technicians - 1 X-ray technician - 2 health workers - 1 statistical assistant - 1 pharmacist Sub district level- - TB unit for 5 lakh population in one of the CHCs. PHC level- - Designated Microscopy center (DMC) for every 1 lakh population (50,000 in hilly areas)

27. Responsibilities of the Senior Treatment Supervisor (STS) 1. Ensure the quality of the DOTS services 2. Organize direct observation of treatment in the sub-district and ensure registration of all cases diagnosed and initiated on treatment in the sub-district 3. Maintain the Tuberculosis Register, updating the required information in respect of all cases diagnosed in the sub-district in a timely manner 4. Prepare Quarterly Reports on case-detection, sputum conversion, treatment outcome, and programme management and send them to the DTO after review and approval by MO-TC

28. Responsibilities of the Senior TB Laboratory Supervisor (STLS ) 1. Responsible for maintaining the quality of sputum microscopy including all activities under the QA guidelines, and for the smooth functioning of laboratory services. 2. To organise smear examination at the designated microscopy centres of the subdistrict . 3. To assess the training and retraining needs of Lab Technicians and to provide on the job training

29. 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

30. FUNDING 100 % central government sponsored The program is assisted by World bank and The Department for International Development (DFID) Other supporting agencies are Global TB Drug Facility(GDF ) Global Fund to Fight AIDS, TB, Malaria(GFATM ) United States Agency for International Development (USAID ) Danish International Development Agency ( DANIDA)

31. Strategies Case finding and Diagnostics - Use of sputum testing as the primary method of diagnosis Patient friendly treatment services and ensuring a regular, uninterrupted supply of drugs up to the most peripheral level- DOTS Scale -up of Programmatic Management of Drug Resistance –TB ( PMDT ) Scale -up of Joint TB-HIV Collaborative Activities Integration with Health Systems

32. Strategies Engagement of Private Sector Human Resource Development Advocacy, Communication and Social Mobilization (ACSM) Monitoring and Evaluation, Surveillance and Impact Assessment Operational research to inform TB Control policy and practice

33. Strategies Case finding and Diagnostics : Early identification of all infectious TB cases Improved integration with the general health system and leverage field staff for home-based case finding Improve communication and outreach Screening clinically & socially vulnerable risk groups for TB Develop improved sputum collection and transportation systems

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

35. Strategies 2. Patient friendly treatment services: DOTS strategy Promptly and appropriately treating TB, increasingly guided by DST Making DOTS more patient friendly through ↑ communitization of DOT pilot incentives/offsets for patient costs to help patients complete treatment and better monitoring through IT Improving partnerships between public and private sector

36. Strategies 3. Scale-up of Programmatic Management of Drug Resistance –TB (PMDT) : Developing network of C&DST Laboratories & Strengthening of Reference Laboratories Decentralized DST at district level for early MDR detection Improved information system for PMDT

37. Implementation Case finding - by passive surveillance on patient with symptoms of i ) Persistent cough for 2weeks or more. ii) Haemoptysis iii) Night sweats iv) Evening rise of temperature v) Chest pain In lab.- i ) Sputum collection for diagnosis ii) Radiography iii) Tuberculin test

38. Diagnosis of TB Sputum examination is the best method to diagnose TB Pulmonary TB diagnosis can be confirmed by sputum examination. Two sputum samples are collected over one/two consecutive days 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 the lab

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

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

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

42. DOTS Directly Observed Treatment Short Course

43. Directly Observed Treatment

44. Components of DOTS DOTS is a systemic strategy to control TB diseases. It has the following 5 components - Political and administrative commitment Good quality diagnosis, primarily by sputum smear microscopy Uninterrupted supply of quality drugs Directly observed treatment (DOT) Systemic monitoring and accountability

45. DOTS 1 - Intensive Phase(IP):- Intensive phase is of 2 to 3 months duration Patient swallow medicine under the observation of a health worker during IP Medicines are taken 3 times a week on alternate days If the sputum is negative for bacteria after IP, continuation phase is started Directly Observed Treatment Short Course There are two phases in DOTS treatment

46. DOTS 2. Continuation Phase This phase is of 4 or 5 months duration The patient is provided with a weekly blister pack to take home The medicines from the blister pack are taken on alternate days, three times a week and in the remaining days, Vitamin tablets are taken The first dose of the weekly blister pack is taken under direct observation of the health worker Empty blister packs are collected to ensure that the medicines are taken at home by the patient Directly Observed Treatment Short Course

47. Treatment Regimens Category of Treatment Type of Patient Regimen Category I All new pulmonary (smear-positive and negative), extra pulmonary and ‘others’ TB patients . 2H 3 R 3 Z 3 E 3 + 4H 3 R 3 Category II TB patients who have had more than one month anti-tuberculosis treatment previously Relapse , Failure, Treatment After Default ,Others 2H 3 R 3 Z 3 E 3 S 3 + 1H 3 R 3 Z 3 E 3 + 5H 3 R 3 E 3

48. NEW CATEGORY The medicine box of this category-Red Treatment Box contains 2 packets of IP & CP It contains 24 blister doses for 2 months IP It contains 18 weekly combipack doses for 4 months CP All medicines of the blister pack have to be taken under observation, thrice weekly on alternate days 1 st dose of this combipack should be swallowed by patient under direct observation The remaining medicines are taken home by patient & taken thrice weekly on alternate days Vitamin tablets in the combipack are taken on remaining days Towards A World Free From TB…

49. NEW CATEGORY Patient is sent for follow up sputum examination after 22 blister in the IP. The 23 rd and 24 th blisters should be taken as per the scheduled time If the follow up examination is negative after the IP, the patient is put on Continuous phase as per the schedule After 2 months in the CP (8 weekly strips) and at the end of the treatment (17 th weekly strip), follow up sputum examination is done

50. NEW CATEGORY If the follow up sputum examination after the IP is positive, the IP is extended for 1 month(12 blisters strip). Sputum examinations is done again at the end of this phase (11 th blister strip) If the follow up sputum examination is positive after the extended phase, CP is started irrespective of the sputum result

51. Previously Treated Category Medici ne box of this category - Blue Treatment Box contains 2 packets of IP & CP Contains 36 blisters for 3 months & 24 injection Contains 22 weekly combipacks for 5 month CP All medicines of the blister to be taken thrice weekly on alternate days under direct observation and Injection also on the same days 1 st dose of the weekly combipack should be swallowed by patient under direct observation Remaining part of combipack is taken home by the patients and taken on alternate days Vitamin tablets are taken in the remaining days

52. Previously Treated Patient is sent for follow up sputum examination after 34 blister strips in the IP. The 35 th and 36 th blisters strips should be taken as per the scheduled time If the follow up examination is negative after the IP, the patient is put on Continuous phase as per the schedule After 2 months in the CP (8 weekly strips) and at the end of the treatment (21st weekly strip), follow up sputum examination is done

53. Previously Treated If the follow up sputum examination after the IP is positive, the IP is extended for 1 month(12 blisters strip). Sputum examinations is done again at the end of this phase (11 th blister strip) If the follow up sputum examination is positive after the extended phase, CP is started irrespective of the sputum result

54. ANTI-TUBERCULAR DRUGS Medication Drug action Dose(Thrice a week)*** Dose in children(mg/kg) Isoniazid Bactericidal 600 mg 10-15 Rifampicin Bactericidal 450 mg* 10 Pyrazinamide Bactericidal 1500 mg 30-35 Ethambutol Bacteriostatic 1200 mg 20-25 Streptomycin Bactericidal 0.75 g** 15 * Patients who weigh 60 kg or more at the start of treatment are given an extra 150mg dose of R ifampicin ** Patients over 50 years of age are given 0.5g of streptomycin *** Adult patients weighing <30kg receive drugs in patients-wise from the weight band suggested for pediatric patients

55. Treatment Outcomes

56. DIED Patient who died during the course of treatment regardless of cause FAILURE Any TB patient who is smear positive at 5 months or more after starting treatment . Default A patient who has not taken anti-TB drugs for 2 months or more consecutively after starting treatment . Transferred out A patient who has been transferred to another Tuberculosis Unit/ District and his/ her treatment result (outcome) is not known.

57. WHO definitions of TB cases recommended for use since March 2013 Bacteriologically confirmed case of TB: A patient from whom a biological specimen is positive by smear microscopy, culture or WHO-approved rapid diagnostic test (such as Xpert MTB/RIF ) Clinically diagnosed case of TB: A patient who does not fulfil the criteria for bacteriologically confirmed TB but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment

58. Case of pulmonary TB: Any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or the tracheobronchial tree. Miliary TB is classified as pulmonary TB because there are lesions in the lungs. Tuberculous intra-thoracic lymphadenopathy ( mediastinal and/or hilar ) or tuberculous pleural effusion, without radiographic abnormalities in the lungs, constitute a case of extrapulmonary TB. A patient with both pulmonary and extrapulmonary TB should be classified as a case of pulmonary TB.

59. Case of extrapulmonary TB: Any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs, e.g. abdomen, genitourinary tract, joints and bones, lymph nodes, meninges, pleura, skin New case of TB: A patient who has never been treated for TB or has taken anti-TB drugs for less than one month Retreatment case of TB: A patient who has been treated for one month or more with anti-TB drugs in the past. Retreatment cases are further classified by the outcome of their most recent course of treatment into four categories.

60. Relapse patients have previously been treated for TB, were declared cured or treatment completed at the end of their most recent course of treatment, and are now diagnosed with a recurrent episode of TB (either a true relapse or a new episode of TB caused by reinfection ) 2. Treatment after failure patients have previously been treated for TB and their most recent course of treatment failed i.e. they had a positive sputum smear or culture result at month 5 or later during treatment

61. 3. Treatment after loss to follow-up patients have previously been treated for TB and were declared ‘lost to follow-up’ at the end of their most recent course of treatment 4. Other previously treated patients are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented

62. DOTS Plus ? DOTS programme that add components for MDR-TB diagnosis, management and treatment

63. Drug resistant TB

64. Causes of drug resistance Programme related - Poor treatment Drug related - Poor drugs Patient related - Poor drug intake by the patient Scientific basis of drug resistance Genetic Mutation in bacteria due to continuous exposure to low concentration of drugs

65. Methods of Sputum C&DST Solid Culture – ( LJ Method) -2 -3 months Used both for diagnosis & follow up Liquid Culture: - 2-4 weeks for diagnosis - only used for diagnosis LPA – Line Probe Assay (Molecular test) 3 days for diagnosis Only used for diagnosis CBNAAT (Cartridge Based Nucleic Acid Amplification Test)- can diagnose TB and Rifampicin resistance within 2 hours

66. CAT IV – MDR TB INITIAL INTENSIVE PHASE :6 - 9 months Tab. Pyrazinamide Tab Ethionamide Tab . Ethambutol Cap Cycloserine Tab Ofloxacin Inj. Kanamycin CONTINUATION PHASE :18 months Tab Ethionamide Tab Ofloxacin Tab Ethambutol Cap Cycloserine DOT – 6 days a Week Sunday – Unsupervised Oral Medicines Inj Kanamycin OMITTED

67. CAT V- XDR TB XDR TB- MDR TB+ Resistant to Second line injectable Anti TB drug & Fluroquinolone The Intensive Phase (6-12 months) will consist of 7 drugs Capreomycin (Cm), PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav The Continuation Phase (18 months) will consist of 6 drugs PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid , and Amoxyclav

68. Preventive chemotherapy with isoniazid (H) 10mg/kg body weight daily for 6 months is administered to all the children aged 6 years and below who are in contact with smear positive pulmonary TB case PROPHYLAXIS

69. TB-HIV collaborative activities Specific TB-HIV collaborative activities undertaken are: Establishment/Strengthening NACP-RNTCP co-ordination mechanisms at national, state and district level Scaling up of intensified TB/HIV package of services across the country Joint M&E including standardized reporting shared between the two programmes Training of the programme and field staff on HIV/TB TB and HIV service delivery co-ordination

70. Offer of HIV testing to TB patients Intensified TB case finding at ICTCs & ART Linking of HIV-infected TB patients to NACP for HIV care and support and to RNTCP for TB treatment Provision of Co- trimoxazole Prophylactic Treatment (CPT) for HIV infected TB patients Involvement of NGOs/CBOs and affected communities working with NACP and RNTCP for all activities on TB/HIV collaboration Operational research to improve the implementation and impact of TB/HIV collaborative activities

71. Public Private Partnership Intensified Public Private Mix Project is being undertaken with IMA in 16 states and with CBCI- CARD(catholic bishop conference of india -coalition for AIDS & related disease) Several organizations and Projects like Programme for Appropriate Technology in Health (PATH), The Union, Foundation for Innovative New Diagnostics (FIND), Improving Health Behavior Project (IHBP), World Vision India etc are actively involved in the programme At present 2,708 NGOs collaborations and 13,311 private practitioners are involved in the programmes in different schemes

72. Monitoring and Evaluation

73. Structure of RNTCP laboratory network 3 tier system National Reference Labs (NRL): 6 NRLs at present Tuberculosis Research Centre (TRC), Chennai National TB Institute, Bangalore LRS Institute of TB and Respiratory Diseases, New Delhi and JALMA Institute, Agra Regional Medical Research Centre, Bhubaneswar and Bhopal Memorial Hospital and Research Centre, Bhopal

74. Intermediate Reference Labs: At State TB Training and Demonstration Centres (STDCs) Designated Microscopy Centres (DMCs): At the periphery Each NRL will supervise sputum microscopy EQA of states designated under them The NRL will ensure proficiency of RNTCP staff for carrying out good quality diagnosis by providing technical training to the STOs, STDC Directors, Microbiologists and Lab Technicians of States

75. The states will designate 1 IRLs in the STDC or Medical Colleges or in any Public Health Laboratory of the State The designated IRL will conduct sputum microscopy EQA for the state and occasionally for a neighbouring state or union territory The IRL will provide technical training to district and sub-district technicians and STLS

76. Sputum microscopy diagnostic services under RNTCP are provided by DMCs established for every 1 lakh population (50,000 population in tribal, hilly and remote areas) In addition, the DMCs are also established at Medical Colleges, Corporate hospitals, ESI, Railways, NGOs, large private hospitals and other major hospitals

77. Quality Assurance (QA) for smear microscopy: It includes Internal Quality Control (IQC) External Quality Assessment ((EQA) Quality Improvement (QI) Internal Quality Control (IQC): It’s a systematic internal monitoring of working practices It includes technical procedures, checking instruments, quality of new batches of staining solution, smear preparation, grading etc

78. External Quality Assessment (EQA): A process to assess laboratory performance. It includes 1 On -Site Evaluation (OSE): Conducted at least once a month by STLS to the DMCs Once a year by STDC/IRL lab supervisors to DTCs and TUs Once a year by lab supervisors of NRLs to STDCs/ IRLs 2 Panel testing: This determine whether a lab technician can adequately perform AFB smear microscopy This method evaluate individual performance in staining and reading

79. Panel testing is not performed as a routine in the DMCs 3 Random Blinded Re-Checking (RBRC) of routine slides: It’s a process of re-reading a statistically valid sample of slides from a laboratory to assess whether that laboratory has an acceptable level of performance Performed once a month for every DMCs Quality Improvement (QI): A process by which all components of smear microscopy diagnostic services are carefully analyzed with the aim of looking for ways to permanently remove obstacles to success

80. Technical and managerial indicators for case finding and management Indicator Norm Proportion of symptomatic patients who are smear positive 8-12% Two smears taken from suspect cases 100% Percent of smear positive among new TB cases >50% Proportion of new smear positive patients found in the lab register being on treatment >95% Proportion of new smear positive cases placed on DOTS (within seven days of diagnosis) >90% Sputum conversion for new smear positive cases at three months >90% Percent of new smear positive patients who are cured >85%

81. Improving TB surveillance by transitioning to case based web based recording and reporting ( Nikshay ) This ICT(information communication technology) application ( Nikshay ) was launced on 15 th May 2012 by NIC(national informatics centre ) (HQ) and Central TB Division The data entry of the individual TB cases is being done at the block level DEOs(data entry operator) of NHM The system has been extended to include drug resistant TB cases, online referral and transfer of patients

82. Achievements RNTCP has been recognized for the fastest expansion of DOTS in the world During the year 2009 DOTS treatment success Rate was 87% Diagnostic facilities have been established in >13000 labs/ DMC throughout the country RNTCP has successfully involved 297 medical colleges ,over 1971 NGOs,10,984 private practitioners and over 150 corporate private sector health units

83. Quality Assurance protocol for smear microscopy has been implemented in all the states 662 DTC, 2,698 TB units, >13000 DMC are functioning About 140 internal evaluations conducted in 2007 > 60,0000 Dots Provider 38287 MDR TB suspects examined till the end of 2011, and 10267 MDR-TB patients diagnosed in 2011 6994 have been put on treatment

84. Programme performance Indicator Norm Achievement Annual case detection rate 135/ lakh pop. 176/ lakh pop. Annual new sputum positive case detection rate 70% 72% % of smear positives among total new pulmonary TB cases 50% 62% Proportion of new smear positive cases placed on DOTS within 7 days of diagnosis >90% 88% New sputum positive conversion rate at 3 months >90% 90% Cure rate >85% 87% Default rate <5% 6% Death rate <5% 4% Source: MOHFW. RNTCP. Annual report 2013-14. Central TB Division, MOHFW, GOI, TB India 2012 status report. Central TB Division, TB India 2014, RNTCP Annual Status Report.

85. MANIPUR TB case detected 30,895 (1998-2008) Treated successfully – 28,072 (1998-2008) No. of patients put on DOTS - 2061( 2008 ) (2011 )Manipur 27-lakhs, suspects examined- 13083 ; No of Smear positive patients Diagnosed – 1360; Total patients registered for treatment- 3080 ; Annual total case notification rate- 113 ; Annual new smear positive case notification rate -39 ; Annual new smear negative case notification Rate 30; Annual new extra pulmonary case notification rate -25