RNTCP

RNTCP
DOTS Pilot 1993
and Gujarat) (Delhi, Kerala, West Bengal, Maharashtra,

RNTCP launched - 1997.

(Phased Manner)

Rapid RNTCP - late 1998. 100% coverage - 24th March 2006. Targets Reached 2007
treatment success rate > 85%) (70% case detection with

Components of DOTS (Directly Observed Treatment, Short-course) Political and administrative commitment. Good quality diagnosis. Good quality drugs. An uninterrupted supply of good quality anti-TB drugs Supervised treatment treatment to ensure the right

Systematic monitoring and accountability.

2nd Phase of RNTCP

1st Phase - 1998-2005 - focus on expansion of quality DOTS. 2nd Phase Consolidate the gains made to date. Addressing challenges to achieve the TB-related MDG targets. All components of new Stop TB Strategy are incorporated in the second phase of RNTCP.

Stop TB Strategy - 2006

DOTS Address TB/HIV and MDR-TB Health system strengthening Involvement of all care providers Engaging people with TB and affected communities Enabling/promoting research.

Five and administrative commitment components of dots-plus 1. Sustained political

A well functioning DOTS programme Long term investment of staff and resources Coordination efforts between community, local governments, and international Agencies Addressing the factors leading to the emergence of MDR-TB

1. Diagnosis of MDR-TB through quality-assured culture and drug susceptibility testing

Proper triage of patients for Culture & DST testing and management under DOTS-Plus Co-ordination with National and Supra-National Reference Laboratories

1. Appropriate treatment strategies that utilize second-line drugs under proper management conditions
Rational standardized treatment design (evidence-based) Directly observed therapy (DOT) ensuring long-term adherence Monitoring and management of adverse drug reactions Adequate human resources.

1. Uninterrupted supply of quality assured anti-TB drugs. 2. Recording and reporting system designed for DOTS-Plus programmes that enable performance monitoring and evaluation of treatment outcome

TB & HIV
M.C. opportunistic infection risk of TB 50% with HIV as to 10% without HIV - progression from TB infection to TB disease. TB - accelerates the progression of HIV to AIDS and shortens the survival of patients with HIV infection. DOTS similar effective as non-infected with HIV.

MDRTB
Lab proven resistant to Isoniazid and Rifampicin. Treatment extremely expensive, toxic, arduous, and often unsuccessful. DOTS - proven to prevent the emergence of MDRTB, and also to reverse the incidence of MDRTB where it has emerged. MDRTB - a symptom of poor TB management.

Types of Drug-Resistant TB
Mono-resistant: treatment drug Resistant to any one TB

Poly-resistant: Resistant to at least any two TB drugs (but not both isoniazid and rifampicin) Multidrug- resistant (MDRTB): Resistant to at least isoniazid and rifampicin, the two best firstline TB treatment drugs Extensively drug-resistant (XDR TB): Resistant to isoniazid and rifampicin + resistant to any fluoroquinolone & at least 1 of the 3 injectable second-line drugs (e.g. amikacin, kanamycin, or capreomycin)

PPM Activities
ACSM Scheme: TB advocacy, communication, and social mobilization Mobilization of local political commitment and resources for TB Improved case detection and treatment adherence. Empower people and communities affected by TB. Reduced stigma and discrimination against persons and families affected by TB. SC Scheme: Sputum Collection Centre/s Transport Scheme: Sputum Pick-Up and Transport Service DMC Scheme: Designated Microscopy Cum Treatment Centre (A & B) A. Designated Microscopy and Treatment Centre for a NGO/Private lab B.Designated Microscopy Centre - Microscopy only LT Scheme: Strengthening RNTCP diagnostic services Culture and DST Scheme: Providing Quality Assured Culture and Drug Susceptibility Testing Services Adherence scheme: Promoting treatment adherence DOT services Awareness generation Counseling services for patients and families Additional services: Transportation of patient wise boxes and treatment cards, Maintain records of such transfers Slum Scheme: Improving TB control in Urban Slums Tuberculosis Unit Model TB-HIV Scheme: Delivering TB-HIV interventions to high HIV Risk groups (HRGs)

Data management

Data Management in RNTCP

Programme Surveillance System

Peripheral Health Institute
Monthly Report

Tuberculosis Unit System electronic from district level upwards Quarterly Feedback
Quarterly Report

District TB Centre

Quarterly Feedback

Quarterly Report

Central TB Division

State TB Cell

Programme Monitoring

Programme Monitoring
RNTCP monitoring strategy is based on:
Supervision: fixed no. of days for different staff and standard checklists

Review meetings: using standard indicators and checklists

Internal evaluation: 2 disticts per month per state using standard protocol

Monitoring indicators: Exhaustive list of indicators for all levels of monitoringr

Key programme monitoring indicators

TB suspects / chest symptomatics (subjects with cough >2 weeks) examined for sputum examination Proportion of symptomatics with positive smear New smear positive case detection rate Proportion of smear positive out of total new PTB cases Proportion of diagnosed smear-positive patients who were initiated on treatment Smear conversion at the end of 2/3 months of treatment Treatment outcome at the end of treatment

When do we evaluate
Evaluations should be done at regular intervals In India, RNTCP evaluation is being done at three levels Inter-district evaluations by the state at

quarterly intervals (2 districts each quarter) External evaluation by a central team (>2 districts each quarter) International evaluation at 3-yearly interval

Progress so far.

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)

Key achievements of RNTCP

100 % 90% 80 % 70 % 60 % 50 % 40 % 30% 20 % 10 % 0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
A nnualisedN S+ve C R ew D Success rate

84 %

85 %

87 %

86%

86 % 72 %

86 %

86%

87 %

87%

87 % 72 %

55 % 56%

69% 59 % 66 % 66 %

70 %

72%

72 %

450 Million population coverage

Full country coverage

Since implementation >48 million TB suspects examined >13 million pts placed on treatment >2.3 million lives saved

Achievements in line with the global

Diagnostic & Treatment Protocol

Diagnostic Algorithm

A pulmonary TB suspect is any person with cough for 2 weeks, or more. The number of specimen required for diagnosis of smear positive pulmonary TB is two, with one of them being a morning sputum specimen. One specimen positive out of the two is enough to declare a patient as smear positive TB. New/ Retreatment based on Rx h/o. Categorize into 3 categories

Classification of Patients in Categories for Standardized Treatment Regimen

Category Category I Color of box: RED Category II Color of box: BLUE Type of Patient Regimen Duration in months 6

New Sputum Positive, 2 (HRZE)3 Seriously ill sputum negative, Seriously 4 (HR)3 ill extra pulmonary,

Sputum Positive relapse Sputum Positive failure Sputum Positive treatment after default

2 (HRZES)3 1 (HRZE)3 5 (HRE)3

Category III Color of box: GREEN

Sputum Negative, extra pulmonary not Seriously ill

2 (HRZ)3 4 (HR)3