REVISED NATIONAL TUBERCULOSIS

CONTROL PROGRAM
(RNTCP)

DOTS STRATEGY INCLUDING DOTS PLUS

 Introduction

 Tuberculosis is an ancient disease described in

Vedic Medicine as Yakshma
 Belief based concept eventually entered reason

based Ayurvedic treatises with a redefined

name Rajayakshma
 In western world it was known as phthisis
 TB is caused by Mycobacterium tuberculosis,

commonly known as “Koch’s Bacillus” or

tubercle bacillus or Acid Fast Bacillus (AFB)
 Global Burden of Disease
 In 2008 an estimated 9.4 million incident cases
of TB globally with 11.1 million prevalent cases
with 5.7 million notified cases of TB
 1.4 million cases of HIV associated with TB;

and 1.8 million deaths including 0.52 million

deaths in HIV +ve patients
 Using DOTS 36 million patients were cured

between 1995-2008
 Burden of Disease - India
 Yearly 1.8 million persons (5000/day) develop TB
out of which 0.8 million are new smear +ve cases
and 0.13 million cases of multi drug resistance
 Mortality of 0.32 million cases each year
 Annual risk of being infected with TB is 1.5%
and once infected 10% life time risk of developing
TB
 2 out of every 5 Indians are infected with TB
bacillus and patients with PTB can infect 10-15
persons in a year
 5% of TB patients are HIV +ve
 Direct and indirect cost of TB to India amount to
Rs. 13,000 crore per year (US$ 3 billion)
“Tuberculosis is defined as an infectious
disease caused by a bacterium; that most
commonly affects the lungs.”
Currently, it kills “three million people” a year
and could claim up to 30 million lives if not
controlled.
Mycobacterium tuberculosis as
causative
agent for tuberculosis

Robert Koch
1886
How Are TB Germs Spread?
TB germs are passed through the air when a
person who is sick with TB disease coughs, sings,
sneezes, or laughs
To become infected with TB germs, a person
usually needs to share air space with someone
sick with TB disease (e.g., live, work, or play
together)
The amount of time, the environment, and
how sick the person is all contribute to whether
or not you get infected.
 How Are TB Germs NOT Spread?
Through quick, casual contact, like passing
someone on the street
By sharing utensils or food
By sharing cigarettes or drinking containers
By exchanging saliva or other body fluids
By shaking hands
Using public telephones
 Common Symptoms of TB Disease
 Cough (2-3 weeks or more)
 Coughing up blood
 Chest pains
 Evening raising Fever
 Night sweats
 Feeling weak and tired

(general weakness)
 Losing weight without trying
 Decreased or no appetite
 If you have TB outside the lungs, you may have
 Tuberculosis
 Mycobacterium tuberculosis which is
carried by humans.
 Mycobacterium T.B. can present it self
in the human body in different forms
effecting any where from “the
intestines, bones, joints, skin, and the
genitourinary, lymphatic, and nervous
system.
 Incubation period- From infection to
development of a positive TB skin test
reaction (the incubation period) is
approximately 2 to 12 weeks. The risk
for developing active disease is the
highest in the first two years after
infection and development of a positive
TB skin test reaction.
Source of infection-
1. Human source
2. Bovine source
 communicability- infection as long as
not treated communicability reduces by
90% within 48 hr’s of treatment.
 Age- under 5 age group 1%
15 years above 30%
 Sex- more prevalent in male than

females.
 Mode of transmission-
 Droplet infection
 Droplet nuclei
RNTCP (revised national tuberculosis
control program).

 National tuberculosis programme (NTP) has

been in operation since 1962.
 It’s two objectives

1. Long term objectives.

2. Short term objectives.
 1. Long term objectives.-
 one case infects less than one new

person annually
 The prevalence of infection in the age

group below 14 years is brought down

to less than 1 percent.
 2. Short term objectives.-
 To detect maximum number of T.B.

cases among the out patients attending

any health institution with symptoms
suggestive of tuberculosis & treat them
effectively
 To vaccinate new born & infant with

BCG.
 To undertake the above objectives in an

integrated manner through all the

exiting health institutions in the
country.
Diagnosis of TB in RNTCP: Smear
examination
Cough for 3 weeks or More

3 sputum smears 3 Negative

3 or 2 positives
1 positive Antibiotics
smear 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
Dr. KANUPRIYA CHATURVEDI 01/28/2024
 RNTCP (revised national tuberculosis control
program)
 The government of India WHO & world
Bank together reviewed the NTP in the
year 1992. based on the findings a
revised strategy for NTP was evolved.
 The salient features of this strategy are

1. Achievement of at least 85 percent cure

rate of infectious cases through
supervised short course chemotherapy
involving peripheral health functionaries.
2. Augmentation of case finding
activities through quality sputum
microscopy to detect at least 70%
estimated cases.
3. Involvement of NGO’s information,
education & communication &
improved operational research.
 Revised Strategy
1. Augmentation of organizational support at Central
and State levels for meaningful coordination
2. Increased budgetary outlay
3. Use sputum testing as the primary method of
diagnosis among self reported patients
4. Standardized treatment regimens
5. Augmentation of the peripheral level supervision
through the creation of a sub district supervisory
unit
6. Ensuring a regular, uninterrupted supply of drugs
up to the most peripheral level
7. Emphasis on training, IEC, Operational research
and NGO involvement in the program
 Prevention and Control of TB
 Medical interventions
 Chemotherapy
 Immunoprophylaxis
 Chemoprophylaxis-isoniazid 5mg/kg body wt

daily x 6 months
 Treatment of HIV-infected / AIDS cases
 Strategies for prevention of HIV infection as

per NACO guidelines

 Silicosis: Screen patients with silicosis once

in 6 months and treat for TB when necessary

 For extrapulmonary TB surgery sometimes

required
 Prevention and Control of TB
 Non-Medical interventions
 Exercise – lifestyle modifications
 Nutrition – to prevent malnutrition in chilren

and adults
 Others

i. Health education to increase community

awareness, role of BCG vaccination etc.
ii. Intervention to reduce poverty and economic
condition
iii. Training
iv. Incentives
v. Monitoring and evaluation
 Difference in National Tuberculosis Program (NTP) and
Revised NTCP

NTP RNTCP
Objective Early diagnosis & Breaking the chain of
Treatment transmission
Operational 1. Not defined 1. Cure rate 85%
Targets 2. Case finding 70% of
estimated cases

Strategy 1. Short Course 1. DOTS (Directly Observed

Chemotherapy (SCC) Treatment Short Course
unsupervised Chemotherapy
2. Conventional 2. Uninterrupted drug supply

Diagnosis 1. More emphasis on X- 1. Mainly sputum microscopy

rays 2. Three sputum smears
2. Two sputum smears 3. One positive is not a case
3. One sputum positive is
considered a case
Direct Observed Therapy
Short-term (DOTS)

DOTS is a community based TB

treatment and care strategy which
combines the benefits of supervised
treatment, and the benefits of
community based care and support.
DOTS (direct observed therapy short
term )-
 DOTS is given by peripheral health staff such as
MPWs or through voluntary workers such as
teachers, anganwadi workers, Dais, Ex-patients,
Social workers etc.
 They known as DOT ‘agent’ & ‘paid’ incentive/

honorarium of 150 per patient completing the

treatment
 Components of DOTS
1) Case detection with the help of microscopy with
a system of multi-tier cross-checking and
quality assurance of sputum smear
2) Regular and uninterrupted supply of drugs:
Patient wise box
3) Direct observation while the patient is getting
Chemotherapy by the health worker or
community volunteers
4) Systemic evaluation and monitoring to ensure
cure
5) Political and administrative commitment to
ensure financial support and sustainability
General model of the Health Care
delivery for the TB patients

Chest symptomatic

Microscopy centre (1 lakha population)

(DTC/CHC/PHC)

DOTS
Subcenter – Multipurpose worker
Village level – Anganwadi Worker/ Dai
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 Diagnosis
Sputum examination

Overnight/
Spot Early morning
Spot

First Day Second Day Second Day

 3 samples of sputum stained with Zeihl Neelsen

technique under microscope collected on two days

 Culture, BACTEC, ELISA Test, PCR Test, Restriction

Fragment Length Polymorpism (RFPL), FTB (Fast

Plaque TB), QTB-G (Quantiferon TB Gold), Tuberculin
Test can be used for diagnosis
 Drugs and regimen used in RNTCP
 All the drugs are administered thrice weekly
 The number before the letters refers to the

number of months of treatment

 R = Rifampicin
 E = Ethambutol
 H = INH
 S = Streptomycin
 Z = Pyrazinamide
 K = Kanamycin
 O = Ofloxacin
 Et = Ethionamide

 Treatment under RNTCP
Category I (Red Box-high priority)
Type of patients:
 New cases sputum smear +ve
 Seriously ill sputum –ve
 Seriously ill extra-pulmonary

Regimen: 6 months
 Intensive phase: 2(HRZE)
3
 Continuation phase: 4(HR)
3

H = INH R = Rifampicin Z = Pyrazinamide

E = Ethambutol
 Sputum testing done on 2, 4 and 6
months of treatment
 If sputum +ve at 4 months then

another sputum smear test is done on

5 months
 If +ve the patient is declared failure
 Registered as a fresh case on the

category II regimen
Category II (Blue Box-High priority)
Type of patients:
 Sputum +ve relapse
 Sputum +ve failure
 Sputum +ve treatment after default

Regimen: 8 months
 Intensive phase: 2(HRZES) + 1(HRZE)
3 3
 Continuation phase: 5(HRE)
3

 If sputum smear is +ve even after 3 months of the start

of treatment in category II patients
 Then four drugs (HRZE) excluding streptomycin is
3
extended for one more month
Category III (Green Box-Low priority)
Type of patients:
 Sputum –ve
 Extra-pulmonary not seriously ill

Regimen: 6 months
 Intensive phase: 2(HRZ)3

 Continuation phase: 4(HR)3

 Two smears are examined for follow
up at the end of two months of
treatment
 Also at the end of treatment

(6months)
 If patients become sputum +ve during

the treatment he is started on a

treatment regimen afresh
 Registered as “others” in category II
Category IV: Multi-Drug Resistant TB
Type of patients:
 Multidrug resistant TB cases

Regimen: 24 months
 Intensive phase: 6(KOCZEEt)
 Continuation phase: 18(OCEEt)

All drugs are to be administered daily

under direct observation by a trained
DOT provider accompanied by regular
follow up taking smear and culture
examination as per the protocol based on
international guidelines
 Multi-Drug Resistant TB

WHO defines a multi-drug resistant

(MDR) strain as one tat is at least
resistant to Isoniazid and Rifampicin,
with or without resistance to other
anti-TB drugs
 Extensively Drug Resistant TB
 Cases of TB that are resistant to almost all
second line drugs are termed extensively drug
resistant tuberculosis (XDR-TB)
 Defined as occurring when M. tuberculosis is

resistant to
I. At least Rifampicin and Isoniazid (i.e. MDR-TB)
II. Resistant to a Fluoroquinolone
III. Resistant to one or more of the following 2nd
line injectable drugs: Amikacin, Capreomycin,
Kanamycin
 DOTS-Plus
 DOTS-Plus for MDR-TB is a comprehensive
management initiative build upon 5 elements of
DOTS strategy
 Takes into account specific issues, such as use

of second-line anti-TB drugs

 Goal : prevent further development and spread

of MDR-TB
 Aim of implementation of DOTS-Plus in selected

areas with significant level of MDR-TB is to

combat an emerging epidemic
 7 point plan of action to limit the
impact of MDR-TB & XDR-TB
 In short term
1. Develop national emergency response and ensure
basic TB control measures meet international
standards for TB care and are fully implemented
2. Conduct rapid surveys of MDR TB & XDR TB
using standardized protocol to assess
geographical and temporal distribution in
vulnerable population
3. Strengthen and expand TB laboratory capacity
4. Implement infection control precautions in health
care facilities according to WHO guidelines, with
special emphasis on those facilities providing care
 7 point plan of action to limit the
impact of MDR-TB & XDR-TB
 In long term
5. Establish capacity for clinical and public health
managers to respond effectively to MDR-TB &
XDR-TB
6. Promote universal access to antiretroviral therapy
for all TB patients through close collaborations
with treatment and care programs for people
living with HIV/AIDS
7. Support and increase funding for research into
the development of new anti-TB drugs and rapid
diagnostic tests for MDR-TB & XDR-TB
 RNTCP Phase II
 RNTCP Phase-II of the World Bank Project
approved for a period of 5 yrs from Oct 2005-Sept
2011
 Phase-II is a step towards achieving TB related

MDG’s
 Goal is to ↓ mortality and morbidity and cut

transmission of TB
 DOTS remain the core strategy
 Phase II will consolidate, maintain and further

improve the achievements of first phase

 RNTCP II is expected to maintain atleast 70%

case detection of new smear +ve

 Maintain cure rate of 85%
 Monitoring and Supervision
Central National National level
TB Reference Lab
division

State TB Intermediate
State level
Cell Reference Lab

District TB centre

Supervision TU TU
TU
District level

Feedback DMC 1 DMC 2 DMC 3

 Achievements of RNTCP
 Treatment success rate ↑ from 25% in 1998 to 87% in
2009
 Death rate ↓ to 4% from 29%
 650 DTC, 2596 TB units and 12704 DMC are
functional
 Involves more then 2500 NGO’s, 19000 private
practitioners, 273 medical colleges and 150 corporate
health facilities
 More than 12750 peripheral laboratories/ Designated
Microscopy Centers have been established
 More then 5.5 lacs public health care providers have
been trained
 11 million patients initiated for treatment, saving