Current Status:

Tuberculosis in India Dr Ashwini Kalantri

Moderator

Dr BS Garg

History of TB Control in India

• 1906 : Open air sanatorium in Ajmer• 1929 : King George V Thanksgiving

Fund for TB control• 1939 : TB Association of India (TAI)• 1946 : Plan for TB Clinic in every

district• 1955 - 58 : National survey by ICMR• 1959 : National TB Institute (NTI) to

develop the national TB control programme.

History of TB Control in India

• 1961 : NTP pilot tested in Andhra Pradesh

• 1962 : NTP launched• 1978 : NTP covered 390 districts

(81%)• 1983 : Short-course chemotherapy

(compliance improved only marginally)

• 1993 - 97 : DOTS pilot (RNTCP)• 1997 : RNTCP launched• 2007 : DOTS Plus (PMDT) for Drug

resistant TB

The Stop TB Strategy

• 2006 - 15 : Second Global Plan to Stop TB

• Roadmap and budget to reach MDGs

Microscopy vs X-ray

0

10

20

30

40

50

60

70

80

90

100 Sputum AFB

X-ray

X-ray

40%

False

Positiv

e Tru

e Po

sitive

60%

SpecificityNTI, Bangalore, 1974

98%

50%

Sanatorium vs Domiciliary care

SeriesTotal

Patients

Favorable

Response (%)

Relapse (%)

Total contact

s

Attack rate (%)

Home 82 86 14 245 10.5

Sanatorium 81 92 12 264 11.5

A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.

The Revised National TB Control Programme

• 100% centrally sponsored• Free of cost diagnosis and treatment

with anti-TB drugs• 13,000+ microscopy centers• 4,00,000+ DOTS treatment centers• RNTCP an integral part if the NRHM

Components of DOTS

• Political commitment • Diagnosis by microscopy• Adequate supply of the right drugs• Directly observed treatment• Accountability

Population Coverage and Patients Registered

A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

RNTCP Objectives

• To achieve 85% cure rate for the newly diagnosed sputum smear positive TB patients

• To detect at least 70% of the new smear-positive patients

Treatment outcomes1994 to 2006

85

A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

Unfavourable Treatment Outcomes1994 to 2006

A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

Prevalence

A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

3 vs 2 sputum samples

NTI, Bangalore TRC0

10

20

30

40

50

60

70

80

90

100

68 71

85 8686 88

FirstSecondThird

Cu

mu

lati

ve P

osit

ivit

y

ACHIEVEMENTSRevised National TB Control Programme

Achievements of RNTCP

• Evaluated 55 million+ persons for TB• Initiated treatment for 15.8 million+ TB

patients.• 2.8 million lives saved• TB/HIV services in 18 states• MDR-TB services in 132 districts• Successful medical college involvement• ARTI reduced from 1.5% to 1.1%

Achievements during 11th FYP

Indicators Planned Achieved

No of TB suspects examined(millions)

23.72 27.5

Total number of patients to beput on treatment (millions)

5.04 6.4

New Smear Positive patients tobe put on treatment (millions)

2.34 2.46

No of MDR TB patients to beput on treatment (000)

5 4.2

Success Rate in New SmearPositive patients in RNTCP (%)

≥85% 87%

Estimated Annual Prevalence perlakh population

Reduced from 299 to 250

Annual Risk of TB Infection (%) Reduced from 1.5% to 1.1%

Objectives for the 12th FYP

• Early detection and treatment of at least 90% of all type of TB cases

• Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10%

• Screening for drug-resistant TB and provision of treatment services for MDR-TB patients

• HIV Counseling and testing for all TB patients• Extend RNTCP services to patients diagnosed

and treated in the private sector.

Targets for the 12th FYP

• Detection & treatment of about 87 lakh Tuberculosis patients during 12th FYP

• Detection & treatment of at least 2 lakh MDR-TB patients during 12th FYP

• Reduction in delay in diagnosis and treatment of all types of TB cases

• Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups

Economic Impact of TB

• Each case of TB– US$ 12,235– 4.1 DALYs

• Each death due to TB– US$ 67,305– 21.3 DALYs

• 29.2 million DALYs and US$ 88.1 billion gained due to RNTCP

CURRENT STATUSTUBERCULOSIS

Annual Incidence of TB

Rest of the

World74%

India26%

Estimated burden of TB in India

Number (Millions) (95% CI)

Rate Per 100,000 (95% CI)

Incidence 2.3 (2.0–2.5) 185 (167–205)

Prevalence 3.1 (2.0–4.6) 256 (161–373)

Mortality 0.32 (0.21–0.47) 26 (17–39)

Number (Millions) (95% CI)

Percent(95% CI)

HIV among estimated incident TB patients

0.11 (0.075–0.16) 5% (3.3–7.1%)

MDR-TB among notified pulmonary TB patients

0.064 (0.044–0.075)

5.3% (3.6–6.2%)

National ARTI survey

Survey 1(2000-01)

Survey 2(2009-10)

Average annual decline

Zone Prevalence ARTI Prevalenc

e ARTI %

North 10.1 (9.1-11.1)

1.9 (1.7-2.1)

5.9 (4.7-7.0)

1.1 (0.8-1.3) 6%

East 6.2 (5.5-7.0)

1.2 (1.0-1.3)

6.5 (4.8-6.2)

1.2 (0.9-1.5) —

West 8.7 (7.7-9.6)

1.7 (1.5-1.9)

4.0 (3.2-4.9)

0.8 (0.8-0.9) 8%

South 6.1 (5.4-6.7)

1.1 (1.0-1.2)

6.8 (5.9-7.7)

1.3 (1.1-1.5) —

Total 1.5 (1.4-1.6)

1.1 (1.0-1.2) 3.6%

RNTCP, Annual Status Report 2013

Annual New Smear Positive Case Detection Rate, 2012

RNTCP, Annual Status Report 2013

Cure Rate of New Smear Positive Cases, 2011

RNTCP, Annual Status Report 2013

Composite Indicators

India

Maharashtra

Wardha

Human Resources (65) 68% 54% 87%

Financial Management (20)

71% 79% 100%

Drugs and Logistics (30)

67% 64% 0%

Case Finding Efforts (20)

30% 39% 40%

Quality of Service (115) 57% 64% 59%

Composite Score (250)

59% 66% 63%RNTCP, Annual Status Report 2013

Case Detection

• RNTCP Designated Microscopy Center (DMC)

• 2 Sputum smear examination (spot and morning)

• ZN smear exam under bright field binocular microscopes

• Drug resistant TB – solid/liquid culture DSTs

• CBNAAT being used in 18 sites

Treatment

• INH (H), Rifampicin(R), Pyrazinamide (Z), Ethambutol (E) and streptomycin (S)

• Category I : 6 months– 2 months Intensive Phase: HRZE thrice

weekly– 4 months Continuation Phase: HR

• Category II : 8 months– 3 months Intensive Phase: 2 months HRZES

and 1 month HRZE– 5 months Continuation Phase: HRE

Treatment

• All doses of intensive phase and first dose of each week of continuation phase are given under supervision.

• Follow-up sputum examination at the end of intensive phase, 2 months into the continuation phase and at the end of treatment

Drug Resistant TB

• By 2015: DST for all smear positive cases

• MGIMS, Sevagram certified for solid culture and DST.

• Genexpert (CBNAAT) introduced in 12 TUs

Drug Resistant TB Treatment

• For MDR-TB : Daily DOT includes (6-9m) Kanamycin, Levofloxacin, Cycloserine, Ethionamide, Pyrazinamide, Ethambutol / (18m) Levofloxacin, Cycloserine, Ethionamide, Ethambutol

• For XDR-TB : (6-12m) Capreomycin, PAS, Moxifloxacin, High dose INH, Clofazimine, Linezolid, Amoxy- Clavulanic Acid / (18m) all the above drugs except Capreomycin

PMDT Services

RNTCP, Annual Status Report 2013

TB/HIV

• Latent TB Active TB• 2001: TB/HIV collaboration• ICTC : Intensified TB case finding has

been implemented nationwide at all HIV testing and ART centres

• HIV testing of TB patients is now routine through provider initiated testing and counselling (PITC)

TB/HIV

• 2012 : 56% TB patients screened, 5% positive

• HIV-positive given free HIV care at the antiretroviral treatment (ART) centres

• Policy decision taken expand coverage of whole blood finger prick HIV screening test at all DMC

TB and Diabetes

• People with a weak immune system, as a result of chronic diseases such as diabetes, are at a higher risk of progressing from latent to active TB.

• Diabetics have a 2-3 times higher risk of TB

• 10% of TB cases globally are linked to Diabetes

• Longer time of sputum conversion

TB and Diabetes

• High chances of drug resistance, mortality and relapse

• Good glycemic control in TB patients has better outcome

• Policy to screen all TB patients for DM in the 100 districts where NPCDCS has been implemented

Childhood TB

• The newer weight bands are 6-8 kg, 9-12 kg, 13-16 kg, 17-20 kg, 21-24 kg and 25-30 kg.

• Chemoprophylaxis for children under 6 years: isoniazid (5mg/kg) for 6 monthsRifampicin 10-12 mg/kg (max 600

mg/day)

Isoniazid 10 mg/kg (max 300 mg/day)

Ethambutol 20-25mg/kg (max 1500 mg/day)

PZA 30-35mg/kg (max 2000 mg/day)

Streptomycin 15 mg/kg (max 1gm/day)

Childhood TB

• If sputum sample not available, alternative specimen (Gastric lavage, Induced sputum, bronco-alveolar lavage) should be collected under pediatric supervision.

• Tuberculin skin test / Mantoux : 10 mm or more induration

NEWER INITIATIVESRevised National TB Control Programme

Notifiable Disease

www.nikshay.gov.in

Other Initiatives

• Composite Indicator• Ban of sero-diagnostic tests• Availability of free quality assured

anti-TB drugs through local chemists

References

1. A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

2. Revised National TB Control Program : Annual Status Report 2013. New Delhi: Central TB Division, 2013.

3. A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.