RNTCP

Revised National Tuberculosis Control Programme

1. Seminar on Revised National TB Control Programme Presented by : Nisha Yadav M.Sc. Nursing 2 nd year NINE, PGIMER Presented To : Mrs. Manjula Thakur Tutor, NINE PGIMER, Chandigarh

2. Learning Objectives Introduction to Tuberculosis Burden of Tuberculosis History of Tuberculosis National TB Control Programme RNTCP-I RNTCP-II National Strategic Plan for TB Control 2012-17 New National Strategic Plan for TB Elimination 2017-25.

3. INTRODUCTION Tuberculosis (TB) is a communicable disease One of the top 10 causes of death worldwide Globally, there were 1.2 million (range, 1.1–1.3 million) TB deaths among HIV-negative people in 2018 (a 27% reduction from 1.7 million in 2000) and an additional 251 000 deaths (range, 223 000–281 000) among HIV-positive people (a 60% reduction from 620 000 in 2000).

4. BURDEN In 2018, there were an estimated 10 (9.0—11.1) million new (incident) TB cases worldwide, of which 5.7 million were men, 3.2 million were women and 1.1 million were children. Eight countries accounted for 66% of the new cases: India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh, and South Africa. In 2018, 1.5 (1.4—1.6) million people died from TB, including 251 000 (223 000—281 000) people with HIV.

5. INCIDENCE OF TB VARIES AMONG COUNTRIES… Source: Global TB report, 2019

6. In 1880s it was widely believed that TB was an inherited disease. Incidence and prevalence are high Disease of social stigma and leads to isolation. A curse on family. History of Tuberculosis

7. Milestones… 1906- First open air TB sanatorium founded in India. 1939 - TB association of India 1946 - Bhore Committee recommended to the GOI, setting up TB clinics in the districts and mobile TB clinics in rural areas. 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 1955-58 - National Sample Survey conducted under ICMR to find the magnitude of TB problem in India 1962 - National TB Control Program(NTCP ) started 1992 - Programme Review showed - only 30% of patients diagnosed and only 30% of them treated successfully

8. 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) 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 May 2012- Notification of TB is made mandatory by GOI 

9. History The evolution of the national programme against tuberculosis is studied in 5 stages: Stage Year Programme I 1962- 92 National TB Programme II 1993- 05 RNTCP- Phase 1 III 2005- 11 RNTCP- Phase 2 IV 2012- 17 National Strategic Plan for TN Control V 2017- 25 National Strategic Plan for TB Elimination

10. National TB Programme Launched in 1962 Short term objective : To detect maximum number of TB Cases, giving them treatment and to vaccinate all the newborns and infants with BCG vaccine. Long term objective : To reduce the prevalence of TB infection among children below 14 years of age, to less than 1%, which was then about 30%.

11. DTC was identified as main structural unit of NTP with following activities: The TB cases were detected actively by the health workers male, by taking single sputum smear Registered sputum smear positive cases were instructed to collect the drugs from MO of PHC, for a month, on a Fixed day. Systematic mass BCG vaccination Weekly report to all the registered cases with details of treatment was sent by MO to District Hospital Officer. Supervisory visit by District TB team periodically

12. In 1972, Short Course Chemotherapy was introduced. (Rifampicin and Pyrazinamide included). In 1992, it was revealed that the magnitude of TB problem in country had not improved but there was increased incidence of Multi Drug Resistant TB cases and emergence of HIV infection made condition worse.

13. Reasons for failure

14. Weakness 1992 Govt. of India, WHO and SIDA reviewed TB situation and concluded that – NTP suffered managerial weakness – Inadequate funding. – Over-reliance of X-ray for diagnosis. – Frequent interrupted supplies of drugs. – Low rate of treatment completion. 

15. Revised National TB Control Programme Phase 1 Therefore it was recommended that NTP must be revised and revitalized with a new thrust to TB control activities by overcoming all the lacunae. So, GoI in 1993 renamed NTP and launched the programme as “ Revised National TB Programme ”. Started as a pilot project & expanded in 1997 , in phased manner, to cover the entire country by 2005.

16. Vision - TB free India Aim- Universal Access for quality diagnosis and treatment for all TB patients

17. Objectives To detect at least 70% of the estimated cases To achieve at least 85% cure rate among the newly detected sputum smear positive cases, initiated on treatment. Directly Observed Treatment Short Course Chemotherapy (DOTS) was identified as the KEY strategy to achieve these twin objectives

18. Targets Initial screening of all retreatment smear positive TB patient for drug resistant cases and provision of treatment services for MDR-TB patients. Offer HIV counseling and testing for all TB patients and linking HIV infected TB patients to HIV “care and support”. Treat all HIV infected TB patients with ART irrespective of CD4 count. Extend RNTCP services to patients diagnosed and treated in private sector.

19. DOTS Strategy

20. Political Commitment GoI borrowed a soft loan of US$ 142 million from World Bank for the implementation of RNTCP Celebration of World Stop TB Day on 24 th March every year by conducting rally especially by TB cured patients to create public awareness that TB is a curable disease .

21. Quality Microscopy Case finding is “ passive ” by microscopic examination of two sputa samples (spot & morning) Patients were categorized and treated accordingly with intermittent regimen (thrice weekly). Color of box Category Type of patient Intensive phase Continuation phase Red I New Sputum smear positive/ sputum smear negative extrapulmonary 2 (HRZE) 3 4(HR) 3 Blue II Previously treated Smear positive Relapse Failure Treatment after default Others 2(HRZES) 3 1(HRZE) 3 5(HRE) 3

22. Case Definitions New patient : A patient who has never taken anti TB treatment or has taken for less than 1 month Previously treated patients : A patient who has taken anti TB drugs for a month or more in past, further classified into- Relapse : A patient who has taken TB drugs & declared cured by doctor and the sputum smear has become positive. It may be true relapse or a new episode of TB infection.

23. Failure : A previously treated patient, whose sputum has remained positive, even after complete course of treatment. Treatment after default : A previously treated patient, who is lost to follow up at the end of treatment Others : These are pulmonary or extrapulmonary patients, whose sputum smear is negative and have relapse or failure.

24. Adequate supply of right drugs The entire course of drug supply is ensured free of cost , before beginning the treatment, thus ensuring regular supply without interruption. The drugs are supplied by patient-wise, colored coded boxes, red and blue , containing full course of treatment. Each box is ear marked for each registered patient. These patient-wise boxes helped to improve patient care, adherence, drug supply and stock management . Pediatric wise boxes were also available for children.

25. Directly Observed Treatment It envisages the direct observation, watching and supporting TB patients, swallowing every dose of anti TB (ATD), all at a time preferable in empty stomach, in the intensive phase and only first dose of the week during continuation phase, by the treatment observer. They are paid an incentive of Rs. 250 per patient completing the treatment. Thus DOTS is the strategy of RNTCP & DOT is the component of DOTS. DOTS- PLUS is the strategy for the diagnosis, management and treatment of MDR-TB cases.

26. Accountability RNTCP ensures systematic monitoring supervision and accountability at every level from national level to individual patient level. For effective supervision and monitoring, a sub district level “ Tuberculosis Unit” has been created.

27. Tuberculosis Unit A TB unit is established at sub-district level. Each TB unit covers a population of about 5 lakhs. It is staffed by one Senior Treatment Supervisor (STS) and one Senior TB Laboratory Supervisor (STLS) The designated medical officer of PHC supervises the work of the TB unit in addition to his/ her other responsibilities.

28. Accountability at various levels State VIP Health Worker (AWW) STS & STLS Medical Officer District TB Officer District PHC TB Unit Grass Root TB patient State TB Officer National Ministry of Health & Family Welfare

29. DOTS logo New logo of RNTCP has been in use from World TB Day 2011(24th March 2011). The visual icon of DOTS represents this major communication shifts. The visual icon, when deciphered, presents a graphic of human anatomy divided in two parts – half red and half orange.

30. Rationale for new Logo Building on Existing Foundation Change with Continuity ‘DOTS: Pura course, pakka ilaaj ’

31. Comparison between NTCP & RNTCP S.No . NTCP RNTCP- I 1 Launched in 1962 Launched in 1993 & expanded in 1997 2 Objective was case detection & treatment Objectives were two: 70% case detection & 85% cure rate 3 Strategy: Case detective was “Active” by health worker District TB center was functional unit Strategy: DOTS and case detection is Passive by quality microscopy. TB unit is functional unit. 4 Patients were not categorized Patients were categorized into I & II. 5 Chemotherapy was not supervised Chemotherapy was supervised by DOTS provider 6 Treatment regimens were many & not standardized Treatment regimens were standardized 7 Drug supply & follow up was not regular. Drug supply & follow up was regular.

32. RNTCP Phase 2 (2006-2011) RNTCP phase 1 lasted till September 2006 The second phase of RNTCP commenced on 1 st October 2006 for a further period of 5 years Aim of RNTCP phase II is to consolidate the gains achieved in Phase I (1993-05) and to further improve the achievements . Phase II was designed to initiate the services to address TB-HIV . It also included DOTS- Plus strategy for diagnosis, treatment & management of MDR-TB and XDR-TB .

33. RNTCP Phase II emphasized on : To strengthen the quality of DOTS through quality assurance protocol for sputum microscopy Decentralized accessible and patient friendly DOTS services through intersectoral collaboration, e.g., Medical colleges, NGOs, etc. To provide services for marginalized groups such as urban slum dwellers and tribals by strengthening IEC activities Rational use of standardized first and second line anti- TB drugs. Need based advocacy communication and social mobilization to generate awareness and demand for quality services.

34. Advanced techniques of diagnostic tools Genotypic methods PCR TMA- NAA CBNAAT GeneXpert MTB/RIF

35. CONT… Polymerase Chain Reaction : With this the sequence of DNA present in the mycobacterium can be visualized and identified. It is rapid method and the result is obtained within a day or two. Transcription and mediated amplification and nucleic acid amplification (TMA & NAA) : This test helps to differentiate between tuberculous and non tuberculous mycobacterium.

36. Cartridge based nuclei acid amplification test (CBNAAT): It is rapid molecular test helps not only in rapid and accurate diagnosis of tuberculosis; but also helps in finding out Rifampicin resistance confessing mutations, in the sputum specimen as well as specimen from extrapulmonary sites. This is preferably helpful among children, people living with HIV (PLHIV) and extrapulmonary TB.

37. GeneXpert Test : This is a new rapid molecular test, not only helps in making a diagnosis of TB by detecting DNA, but also in testing for resistance to Rifampicin. It gives result within two hours. WHO recommended that the test should be used as a diagnostic test in individuals suspected of having MDR- TB or HIV associated TB.

38. Laboratory Network in RNTCP The credibility, success and sustainability of the programme depend upon the strength of the laboratory network. Providing high quality smear microscopy services is of the highest priority for RNTCP. Therefore, for effective quality assurance (QA) system of RNTCP, sputum smear microscopy network is crucial important. To optimize QA, decentralization of the supervision and monitoring of the lab network is essential.

39. Designated Microscopy Center (DMC) is the most peripheral laboratory under RNTCP. Internal Quality Control : it is the process of systematic monitoring and checking of the work in microscopy center such as equipments (microscope) External Quality Assessment : it is a process of assessing the lab performance by evaluation of entire process of microscopy such as unblinded reading of smears.

40. Organization of Lab Network National level State level TB unit level At each level, EQA is carried out by three activities: Onsite evaluation Panel testing Random blinded rechecking

41. Strategy of Case Detection under RNTCP New guidelines effective from April 2009 : Every patient who has cough for 2 weeks or more with or without other symptoms should have 2 sputum samples examined(spot and early morning). Ideally all the 2 specimen should be collected within 2 days. Screening of all patients with TB risk factors, change of TB suspect definition in high risk groups to cough of any duration or fever with night sweats. The number of specimen required for diagnosis of smear positive pulmonary TB is two, compared to three in the previous guidelines, with one of the two, being a morning sputum specimen. One specimen out of the two is enough to declare a patient as smear positive TB as against two out of three samples as per the previous guidelines.

42. Cont.. Smear positive TB is further classified as a new or retreatment case based on their previous treatment history and appropriate therapy is prescribed. Patients in whom both specimen are smear negative should be prescribed symptomatic treatment and broad spectrum antibiotics for 10-14 days. In such cases, antibiotics such fluroquinolones (ciprofloxacin) which are active against TB should not be used. If the symptoms persist after a course of broad spectrum antibiotics, repeat sputum examination (2 samples) must be done for such patients. Patients suspected of extrapulmonary TB, and patients who are contacts of sputum smear positive patients, should have their sputum examined for AFB if they have cough of any duration. Extrapulmonary TB cases will be diagnosed by the physicians and referred to DTC chest clinic or MO TB control. Procedure undertaken to arrive at the diagnosis must e mentioned on the treatment card.

43. Treatment Outcome and Type of Patients Cured- Initially sputum smear positive patient who have completed treatment and had negative sputum smear on two, one of which was at completion of treatment. New- a patient who has never had treatment for TB or has anti TB drugs for less than one month. Relapse- A patient cured for TB by a physician or completed treatment but who reports to the health service and is found to be bacteriologically positive. Transfer Out- a patient who has been transferred to another TB unit/ district and whose treatment outcome is still not known.

44. Cont … Failure - a smear positive patient who remain smear positive at 5 months or more after starting treatment. Failure also includes a patient who was initially smear negative but who becomes smear positive during treatment. Treatment after default- a patient who received anti TB treatment for one month or more from any source and returns from treatment after having defaulted . Others - Patients who do not fit into above mentioned type. Reasons for defining a patient a patient as “ other must be specified”.

45. Cont … Defaulted - a patient after treatment initiation has interrupted treatment consecutively for >2 months. Died - A patient who died during the course of treatment.

46. First Line Drugs Class Side Effect Isoniazid Antibiotic Increased levels of liver enzymes and Numbness in the hands and feet,  Liver inflammation Rifampicin Antibiotic Hepatitis   nausea , vomiting, Abdominal cramps,  Diarrhea Malaise and  dysphoria Redness and watering of eyes Pyrizinamide Antibiotic nausea, loss of appetite, muscle pains, and rash sensitivity to sunlight gout ,  liver toxicity Ethambutol Antibiotic Optic neuritis  (hence contraindicated in children below six years of age) Red-green color blindness Peripheral neuropathy Arthralgia Hyperuricaemia Vertical  nystagmus Milk skin reaction Inj. Streptomycin Antibiotic Ototoxic , Nephrotoxic tinnitus ,  vertigo ,  ataxia

47. Second Line Drugs Aminoglycosides : e.g., amikacin (AMK), kanamycin (KM) Polypeptides e.g., capreomycin, viomycin,  enviomycin Fluoroquinolones : e.g., ciprofloxacin (CIP), levofloxacin, moxifloxacin(MXF) Thioamides: e.g.  Ethionamide ,  Prothionamide Cycloserine Terizidone Third line Drugs Rifabutin macrolides : e.g.,  clarithromycin  (CLR) Linezolid(LZD) Thioacetazone (T) thioridazine arginine vitamin D bedaquiline

48. Category of Treatment Treatment Groups Type of Patients Regimen Intensive Phase Continuation Phase New (Category 1) New sputum smear positive New sputum smear negative New extrapulmonary New others 2(HRZE) 3 4(HR) 3 Previously Treated (Category 2) Smear positive relapse Smear positive failure Smear positive treatment after default and others 2(HRZES) 3 1(HRZE) 3 5(HRE) 3

49. Patient wise box Drugs are supplied in patient wise boxes container Intensive Phase= blister pack = One day medication Continuation Phase= blister pack = One week medication

50. TB/HIV Collaboration The joint HIV/TB activities in India started in 2001 with 6 states The first national policy framework was developed based on experience gained during programme implementation in initial years Overall purpose is to articulate the national policy for TB/HIV Collaborative Activities between RNTCP and NACP so as to ensure reduction of TB and HIV burden in India.

51. Objectives: To maintain close coordination between RNTCP and NACP at National, State and District levels. To decrease morbidity and mortality due to TB among persons living with HIV/AIDS. To decrease impact of HIV in TB patients and provide access to HIV related care and support to HIV-infected TB patients. To significantly reduce morbidity and mortality due to HIV/TB through prevention, early detection and prompt management of HIV and TB together.

52. Strategies Existing HIV/TB Collaborative Activities Strong NACP-RNTCP coordination mechanisms at national, state and district level Joint monitoring and evaluation with standardized reporting shared between NACP and RNTCP Joint training of key programme and field staff in HIV/TB activities Operational research to strengthen implementation of HIV/TB Collaborative Activities Implementation of basic infection control measures at ART centres e.g. fast tracking

53. Cont … Activities to reduce burden of HIV among TB patients: Provider initiated HIV testing and counselling (PITC) among TB patients Provision of co-trimoxazole preventive therapy (CPT) for HIV infected TB patients Provision of Anti-Retroviral Therapy (ART) for HIV infected TB patients Provision of HIV prevention education for patients with presumptive or diagnosed TB cases

54. Cont … Activities to reduce burden of TB among HIV infected individuals: Intensified (TB) case finding (ICF) at ICTC Intensified (TB) case finding (ICF) at ART centres and Link ART centres Air borne infection control measures for prevention of TB transmission at HIV care settings Implementation of Isoniazid preventive treatment (IPT) for all PLHIV (On ART + Pre-ART)

55. What is new in National Framework 2013? Emphasis on Integrated TB and HIV services e.g. HIV screening at RNTCP DMC Focus on early detection and early care: a. Early detection of TB in PLHIV: Early suspicion of TB–symptoms of any duration among PLHIV Use of an expanded clinical algorithm for TB screening that relies on presence of four clinical symptoms (current cough, weight loss, fever or night sweats) instead of only cough, to identify patients with presumptive TB Strengthen ICF at ART, Link ART centre (LAC) and Targeted intervention projects (TI) for High Risk Group (HRG) specially Injection Drug Users (IDU)

56. b. Early detection HIV/TB: Enhance HIV testing facilities in settings with lack of co-located HIV and TB testing facilities, by establishing HIV screening services using whole blood finger prick test (WBT) Strengthen HIV testing of TB patients in high HIV prevalent settings by promoting establishment of Facility Integrated Counselling and Testing Centre(F-ICTC) where DMC exists PITC among patients being evaluated by diagnostic smear microscopy presumptive TB cases in high HIV prevalent settings. 3. Early detection and care of HIV infected Drug Resistant TB patients (DR-TB/HIV): Strengthen HIV testing in presumptive DR-TB cases (Criteria C) Ensure access to culture and drug susceptibility testing for HIV infected TB patients Prompt linkage of HIV infected DR-TB cases to ART centres Prompt initiation of ART in HIV infected DR-TB cases

57. Prevention of TB among HIV infected adults and children: Implementation of IPT for all PLHIV (On ART + Pre-ART) Strengthen implementation of air borne infection control strategies. Strengthen HIV/TB activities among children and pregnant women Promotion of participation of private, NGO, CBO health facilities and affected communities working with NACP and RNTCP to strengthen HIV/TB Collaborative Activities.

58. TB Notification Since 2012, TB is a notifiable disease in India As to estimate the number of TB cases in the community more correctly Help policy makers to make rational and evidence-based planning with regard to strengthening of the existing infrastructure

59. Nikshay Web-based, care-based, software application/ solution developed by National Informatics Center, in 2012, to effectively monitor the TB patients under RNTCP. Used by health functionaries at various levels across the country in association with Central TB division, Ministry of Family & Welfare, GoI. Nikshay involves better surveillance and tracking of all TB patients, including those in private sector. It enables proper care, management, treatment adherence, HIV status, drug resistance, culture report, different outcomes, thus various aspects of controlling TB using technological innovations .

60. Cont … Apart from web-based technology, SMS services (mobile applications) have been used effectively for communication with patients and monitoring the programme on day to day basis thereby Nikshay enables better surveillance and treatment of TB cases. Thus, Nikshay provides a platform to support notification of every TB case diagnosed and treated by public and private sector and thus strengthen TB surveillance, decreases lead time of data transmission and increases the use of information for betterment of care delivery services.

61. New strategies

62. Changes in definitions As per the previous guidelines, a pulmonary TB suspect was defined as: • An individual having cough for 2 weeks or more • Contacts of smear‑positive TB patients having cough for any duration • Suspected/confirmed extra‑pulmonary TB having cough for any duration • HIV‑positive patient having cough for any duration. But according to the new guidelines Presumptive pulmonary TB refers to a person with any of the symptoms or signs suggestive of TB: • cough >2 weeks, • fever >2 weeks, • significant weight loss, • haemoptysis , • any abnormalities in chest radiography In addition, contact of microbiologically confirmed TB patients, PL HIV, diabetics, malnourished, cancer patients, patients on immunosuppressive therapy or steroid should be regularly screened for signs and symptoms of TB.

63. Previously treated patients have received one month or more ATD in the past. This may be: Recurrent TB case – A TB patient previously declared as successfully treated (cured/treatment completed) and who is subsequently found to be microbiologically confirmed TB case is a recurrent TB case. ( Previously called relapse . ) Treatment after failure – Patients are those who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment. Previously, it was called failure where a TB patient is sputum‑positive at 5 months or more after initiation of treatment. Treatment after loss to follow‑up – A TB patient previously treated for TB for one month or more and who was declared lost to follow‑up in their most recent course of treatment and subsequently found microbiologically confirmed TB cases. Previously called treatment after default – a patient who has received treatment for TB for a month or more from any source and return for treatment after having defaulted, that is, not taking ATD consecutively for 2 months or more and found to have smear‑positive.

64. Diagnostic Algorithm For Pulmonary TB For Adults (Previous Guidelines)

65. Diagnostic Algorithm For Pediatric TB(Previous Guidelines)

66. Drug Regimen According to the previous guidelines Standard intermittent regimen with 2 categories of treatment Treatment under direct observation of DP Category decided by MO (category I/II) Drugs to be taken three times a week under direct observation of the DP Intensive phase (IP) for 2–3 months – all doses given under supervision Continuation phase (CP) for 4–5 months – first dose of the week given under supervision. According to the new guidelines Principle of treatment of TB has been shifted towards daily regimen with administration of daily fixed dose combination of first‑line ATD

67. Treatment Regimen

68. Drug Dosage for Adult TB(New Guidelines)

69. Difference of RNTCP regimen between new and previous guidelines

70. Bedaquiline : A new drug approved for treatment of multidrug-resistant tuberculosis

71. The Food and Drug Administration (FDA), on 28 December 2012, granted accelerated approval to SIRTURO™ ( bedaquiline ) Tablets as a part of combination therapy in adults with multi-drug-resistant TB (MDR-TB). Bedaquiline is available as 100 mg tablet for oral administration. Bedaquiline should be administered as directly observed therapy (DOT) along with standard MDR-TB regimen. The most common side-effects reported with bedaquiline therapy are nausea (30%), arthralgia (26%), headache (22%), hemoptysis (14%), chest pain (9%), anorexia (7%), and rash (6%). Important cardiovascular adverse effect is QT prolongation . Other important adverse effect is elevation of hepatic transaminases , which is moderate and reversible on discontinuation of therapy. There are no clinical data in pediatric patients, adolescents (<18 yrs), and pregnant and lactating women. The safety and efficacy of bedaquiline for treatment of drug-sensitive TB, extra-pulmonary TB, and HIV-infected patients is not established. Therefore, use of bedaquiline is not recommended in these settings. Criteria- Adult Age > 18 years having Pulmonary MDR TB. Female should not be pregnant.

72. Introduction India’s ambitious National Strategic Plan (NSP) to achieve Universal Access to quality TB diagnosis and treatment has guided activities and created accountability against results. India achieved complete geographical coverage for diagnostic and treatment services for multi-drug resistant TB (MDR-TB) in 2013 93,000 persons with MDR-TB diagnosed and put on treatment till 2015

73. OBJECTIVES 1. To ensure early and improved diagnosis of all TB patients including drug and HIV-associated TB 2. To provide access to high-quality treatment for all diagnosed cases of TB 3. To scale-up access to effective treatment for drug-resistant TB 4. To decrease the morbidity and mortality of HIV-associated TB 5. To extend RNTCP services to patients diagnosed and treated in the private sector.

74. Strategies Import of sero - diagnostic test kits for tuberculosis an innovative and visionary electronic recording and reporting system ( Nikshay ) across the country in 2012, Modern media are being creatively used for TB control with India’s leading actor, Amitabh Bachchan’s campaign, “TB Harega , Desh Jeetega ”, Case Finding and Diagnostics Patient Friendly Treatment Services Scale-up of Programmatic Management of Drug Resistant TB Scale –up of Joint TB-HIV Collaborative Activities Integration with Health Systems

75. Case Finding and Diagnostics

76. Introduction Focus on to  eliminate TB in India describes the activities and interventions bring about significant change in the incidence, prevalence and mortality from TB. 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

77. Targets 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

78. Strategies

79. CHALLENGES Collection of appropriate specimens from children and EPTB. The capacity for specimen collection (children and EPTB) at district level is also deficient. Transportation of specimens from hard to reach areas (hilly, tribal, deserts, etc.) continues to be challenging despite local efforts to improve the sputum collection and transport system. Establishment of TB containment labs at state level.

80. Retention of trained staff and compensation Procurement of equipments with original manufacturers from outside the country having no or restricted post sales services in the country threatens unhindered lab operations. With only a limited number of firms in country with capacity to provide AMC services in select locations, the cost of AMC is high. AMC for equipments is an issue due to limited technical knowledge and availability of funds Packages is a barrier for sustainability for ensuring consistent performance.

81. RNTCP IN CHANDIGARH

82. In Chandigarh, RNTCP was launched on 25th January 2002. Chandigarh has been ranking among the top performing states Case detection rate of more than 90% and among those, the cure rate being more than 85% each year.

83. Infrastructure: RNTCP in Chandigarh covers the whole UT including the Urban, Rural and Slum population falling under the map -3 Tuberculosis Units (TU) -17 Designated Microscopy Centres (DMC) + 1 DMC in private sector under Public Private Mix. - More than 171 DOTS centers including Government as well as Private DOTS Centres .

84. 1. Programmatic management of Drug Resistant Tuberculosis (PMDT) DOTS- Plus program has been launched in Chandigarh in October 2010 to address the emerging issue of Drug Resistant Tuberculosis (DRTB). The diagnostic services were launched in Oct 2010 The treatment services were initiated from Jan 2011. DOTS plus site has been created at GMCH-32 For the diagnosis of DR-TB, RNTCP lab at the Microbiology Department of PGIMER- Chd has been accredited for Line Probe Assay (LPA) testing.

85. TB/HIV Co-infection: In Chandigarh, this TB/HIV Intensified Package of services was launched in April 2010. Since then, RNTCP and NACP are working hand in hand by means of: Referral of all TB patients to nearest ICTC for HIV counselling and testing. Linking all the Co-infected patients to ART centre at PGIMER.

86. TB- A Notifiable Disease From 7th May 2012, TB has been declared as a notifiable disease . NIKSHAY

87. NGOs Area Of Work Schemes YUVSATTA Colony No.4 Slum Scheme & Adherence Scheme Mother Teresa Home Sector-23 Adherence Scheme Pingalwara Charitable Society Palsora Adherence Scheme Surya Foundation Vikas Nagar, Maulijagran Adherence Scheme Godwine Education Society Hallo Majra Slum Scheme Bharat Vikas Parishad (Mani Majra) Indira Colony, Mani Majra Transport Scheme

88. Innovations Self addressed post cards are given to each patient who is being referred out of Chandigarh for intimation regarding the start of treatment. Self inking stamps for the OPD cards with message of TB has been circulated among the dispensaries. Pamphlets in Hindi, Punjabi and Urdu are being circulated. Wall paintings in Urdu on the message on Tuberculosis have been developed at Mosque in Mani Majra and Bapu Dham colony for the Urdu speaking population.

89. Role of Nurse in RNTCP

90. Care Provider Nurse providing Care to TB patients in physical, Mental and social aspect. Nurses provides DOTS Treatment to patients. Identify Side effects of treatment quickly. Make home visits. Prevent Infections. Provide Counselling and explore feelings. Socialize the patient.

91. Nurse provide education to students on RNTCP and its functions Diagnosis and Treatment of TB patients Care of TB patients in hospital as well as community setting Health education to patients

92. Advocate Nurses can advocate rights of patients regarding their incentives through Nikshay scheme and free treatment from private practioners and various arising through social stigma related to disease.

93. Take home message

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