National Tuberculosis Control

Program

DR. KANUPRIYA CHATURVEDI

Lesson Objectives

To know about the magnitude of TB

problem
To know about the evolution of TB
control in India
To learn about the goals, objectives
and strategies
To know about the achievements and
progress

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Magnitude of the Problem
Global annual incidence = 9.1 million
India annual incidence = 1.9 million

India is 17th among 22

High Burden
Countries (in terms of
TB incidence rate)

Source: WHO Geneva; WHO Report 2008: Global Tuberculosis Control; Surveillance, Planning and Financing

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Global Burden of Tuberculosis

TB is one of the leading causes of death

due to infectious disease in the world
Almost 2 billion people are infected with M.
tuberculosis
Each year about:
9 million people develop TB disease

2 million people die of TB

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Contribution of India to Global TB
Control*
5.28 m
4.92 m

23%
23%

*WHO Global TB Report 2007 & 2008

7/27/2017 Dr. KANUPRIYA CHATURVEDI
 The Beginning :National Tuberculosis
Control Program
Before the Revised National Tuberculosis
Program (NTCP) came into force the existing
Tuberculosis program had the following
objectives:
To identify and treat as large a number of TB
patients as possible so that infectious cases are
rendered non- infectious.
To reduce the magnitude of TB problem in the
country to a level where it ceases to be a public
health problem.

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Organization and administration

Central level
Besides the Tuberculosis Division in the Directorate
General Health services, National Tuberculosis Institute,
Bangalore and Tuberculosis Research centre at Chennai
District level
A district constitutes a functional unit of the NTCP and
is called District Tuberculosis Control Program
Peripheral level
Comprises of chest clinics and Primary Health Centers
(PHC)

7/27/2017 Dr. KANUPRIYA CHATURVEDI

Program Implementation( prior to
RNTCP)

Program activities were:

Case detection
Case treatment
Health education
BCG vaccination

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Program performance and evolution
of RNTCP
Despite a nationwide network of facilities , NTCP failed to
yield satisfactory results. The situation did not change
much.
The case finding efficiency was only 30 of the expected
level although the mortality rate decreased to 53/100,00
population
Government of India launched the Revised
National Tuberculosis Control Program(RNTCP) in
1997 encouraged by the results of Pilot studies
were tested in 1993-94

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Evolution of TB Control in India
1950s-60s Important TB research at TRC and NTI
1962 National TB Programme (NTP)
1992 Programme Review
only 30% of patients diagnosed;
of these, only 30% treated successfully
1993 RNTCP pilot began
1998 RNTCP scale-up
2001 450 million population covered
2004 >80% of country covered
2006 Entire country covered by RNTCP

7/27/2017 Dr. KANUPRIYA CHATURVEDI

Revised National TB Control Program
(RNTCP)

Launched in 1997 based on WHO DOTS

Strategy
Entire country covered in March06 through an
unprecedented rapid expansion of DOTS

Implemented as 100% centrally sponsored

program
Govt. of India is committed to continue the support till TB
ceases to be a public health problem in the country

All components of the STOP TB Strategy-

2006 are being implemented

7/27/2017 Dr. KANUPRIYA CHATURVEDI

Objectives of RNTCP

To achieve and maintain a cure rate of at

least 85% among newly detected
infectious (new sputum smear positive)
cases

To achieve and maintain detection of at

least 70% of such cases in the population

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Strategy
1. Augmentation of organizational support at
the central and state level for meaningful
coordination
2. Increase in budgetary outlay
3. Use of Sputum microscopy as a primary
method of diagnosis among self reporting
patients
4. Standardized treatment regimens.

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 contd.
7 Augmentation of the peripheral level
supervision through the creation of a sub
district supervisory unit
8. Ensuring a regular uninterrupted supply of
drugs up to the most peripheral level
9. Emphasis on training, IEC, operational
research and NGO involvement in the
program

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Core elements of Phase I
The core element of RNTCP in Phase I (1997-
2006)was to ensure high quality DOTS expansion in
the country, addressing the five primary components
of the DOTS strategy
Political and administrative commitment

Good Quality Diagnosis through sputum

Microscopy
Directly observed treatment

Systematic Monitoring and Accountability

Addressing stop TB strategy under RNTCP

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 RNTCP Phase II( 2006-11)
The RNTCP phase II is envisaged to:

Consolidate the achievements of phase I

Maintain its progressive trend and effect
further improvement in its functioning
Achieve TB related MDG goals while
retaining DOTS as its core strategy

7/27/2017 Dr. KANUPRIYA CHATURVEDI

Diagnosis of TB in RNTCP: Smear
examination
Cough for 3 weeks or More

3 sputum smears 3 Negative

3 or 2 positives
1 positive smear Antibiotics
1-2 weeks
X- ray
Symptoms
positive smear negative persist

Smear-Positive X-ray
TB

Negative Positive
For TB
Anti-TB Treatment
Non-TB Smear-Negative TB

Anti-TB Treatment
7/27/2017 Dr. KANUPRIYA CHATURVEDI
 Classification of Patients in Categories
for Standardized Treatment Regimen
Category Type of Patient Regimen Duration in
months
Category I New Sputum Positive 2 (HRZE)3, 6
Seriously ill sputum negative, 4 (HR)3
Seriously ill extra pulmonary,
Color of
box: RED
Category II Sputum Positive relapse 2 HRZES)3, 8
Sputum Positive failure 1 (HRZE)3
Color of Sputum Positive treatment 5 (HRE)3
box: BLUE after default

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Contd.
Category Type of Patient Regimen Duration
in
months

Category Sputum Negative, 2 6

III extra pulmonary not Seriously (HRZ)3,
ill 4 (HR)3

Color of
box:
GREEN

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Types of Drug-Resistant TB
Mono-resistant Resistant to any one TB treatment
drug
Poly-resistant Resistant to at least any two TB
drugs (but not both isoniazid and rifampicin)
Multidrug- resistant
(MDR TB) Resistant to at least isoniazid and
rifampicin, the two best first-line TB treatment drugs
Extensively drug-resistant
(XDR TB)
Resistant to isoniazid and rifampicin, PLUS resistant to
any fluoroquinolone AND at least 1 of the 3 injectable
second-line drugs (e.g., amikacin, kanamycin, or
capreomycin)

7/27/2017 Dr. KANUPRIYA CHATURVEDI

RNTCP Organization structure: State
level
Health Minister

Health Secretary

MD NRHM Director Health

Services

Additional / Deputy / Joint

Director
(State TB Officer)

State TB Cell
State Training and Demonstration
Center (TB) Deputy STO, MO, Accountant,
Director, IRL Microbiologist, MO, IEC Officer, SA,
Epidemiologist/statistician, IRL LTs etc., DEO, TB HIV Coordinator etc.,

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Program innovations
Creation of sub district level supervisory and monitoring
unit TB Unit
Patient-wise individual drug boxes for entire course of
treatment
Community involvement in DOTs shopkeepers, teachers,
postmen, cured patients, etc
Continuous Internal Evaluation of districts
Monitoring strategy document with checklists
NGO & PP (Private Provider) schemes
Task Force mechanism for involvement of Medical colleges
Web based IEC/ ACSM resource centre

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Contd.
District TB Control Society
Modular training
Patient wise boxes
Sub-district level supervisory staff (STS,
STLS) for
Treatment & microscopy
Robust reporting and recording system

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Quality Diagnostic and Treatment
Services

~12,500 decentralized designated microscopy

centers established
External Quality Assurance (EQA) system for
sputum microscopy as per international
guidelines
Quality assured anti-TB drugs
Patient friendly DOT services

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Data Management System: RNTCP

7/27/2017 Dr. KANUPRIYA CHATURVEDI

Public Private Mix (PPM) Activities for
Involvement of All Health Care Providers
Involvement of NGOs and Private Practitioners
Schemes revised in 2008
Presently > 2500 NGOs, 17,000 PPs involved
Involvement of professional bodies like IMA, IAP
Other Central government departments/PSUs
CGHS, Railways, ESI, Mining, Shipping

Corporate sector
~150 Corporate Houses participating

Involvement of FBOs like CBCI

Involvement of Medical Colleges
Task Forces and Core Committees formed
260 Medical colleges involved

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Well Defined IEC Strategy

Web based resource centre

Communication facilitators provided to support IEC at district level
Ongoing capacity building of program managers for planning and
implementing need based IEC activities

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 RNTCP: Assessment of Impact

Nation wide ARTI Survey 2008-10

Coordinated by NTI, Bangalore in association with

New Delhi TB Centre (North Zone)
MGIMS, Wardha (West Zone)
LRS Institute, New Delhi (East Zone)
CMC, Vellore (South Zone)
Symptomatic screening + CXR +
Sputum Smear + Culture

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 External Evaluations Undertaken
Joint Monitoring Mission (JMM) by WHO and other
development partners in 2000, 2003 and 2006
Conclusions
JMM 2000
RNTCP is succeeding and its results have been
excellent
JMM 2003
Extra-ordinarily rapid expansion of the programme &
highly economical
JMM 2006
Excellent system of recording & reporting with
indicators for monitoring & evaluation; well integrated
into general health system
Future plan
JMMs planned in 2009 and 2012

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Contd.
Disease prevalence Surveys 2007-09
TRC Chennai MDP project
NTI, Bangalore
MGIMS, Wardha

PGI, Chandigarh
AIIMS, New Delhi Symptomatic screening + Sputum
JALMA, Agra Smear + Culture
RMRCT, Jabalpur

Repeat ARTI and Disease prevalence surveys

planned in 2015

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Impact of RNTCP
Trends in prevalence of culture-positive and smear-positive
tuberculosis in south India(5 Blocks), 1968-2006

RNTCP era

Pre-SCC treatment era SCC treatment era

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 Achievements Under RNTCP
412766

Since implementation
> 40 million TB suspects examined
> 9 million patients placed on treatment
> 1.6 million lives saved (deaths averted)
Achievements in line with
the global 7/27/2017
targets Dr. KANUPRIYA CHATURVEDI
 Progress Towards Millennium
Development Goals

Indicator 23: between 1990 and 2015 to halve

prevalence of TB disease and deaths due to TB
Indicator 24: to detect 70% of new infectious cases
and to successfully treat 85% of detected sputum
positive patients
The global NSP case detection rate is 61% (2006) and
treatment success rate is 85%
RNTCP consistently achieving global bench mark of
85% treatment success rate for NSP; and case
detection rate 70% (2007)
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 Cost Effectiveness of Program in India*

Total costs of TB control per capita is US $ 0.1

(2007)

Cost of first line drugs per patient treated in India

is US $ 14 compared to US $ 30 (median) for
HBCs

India remains the country with the lowest cost

per patient treated (US $ 84) compared to US $
274 (median) for HBCs

*Source: WHO Report 2008, Global Tuberculosis Control; pg 71 &112; HBCs=

High Burden Countries

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 TB-HIV: Accomplishments

Developed and implemented mechanism for TB & HIV

program collaboration at all levels (National, State,
District)

Conducted surveillance and determined national burden

of HIV in TB patients

Mainstreamed TB-HIV activities as core responsibility of

both programs (training & monitoring)

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 TB-HIV: Current Policies (2008)

TB/HIV activities in all States

Coordination & Training on TB/HIV
Intensified Case Finding (ICF)
Referral of all HIV- TB patients for HIV care and
support (CPT & ART)
Involve NGOs

Activities in high-HIV states

Provider-initiated HIV counseling and testing for all
TB patients
Decentralized provision of Co-trimoxazole
Expanded TB-HIV monitoring

7/27/2017 Dr. KANUPRIYA CHATURVEDI

 RNTCP- DOTS-Plus Vision

By 2010 DOTS-Plus services available in all states

By 2012, universal access under RNTCP to
laboratory based quality assured MDR-TB
diagnosis for all retreatment TB cases and new
cases who have failed treatment
By 2012, free and quality assured treatment to all
MDR-TB cases diagnosed under RNTCP (~30,000
annually)
By 2015, universal access to MDR diagnosis and
treatment for all smear positive TB cases under
RNTCP

7/27/2017 Dr. KANUPRIYA CHATURVEDI