Universal access to TB care

RNTCP

DR.P.S.SARMA

TECHNICAL CONSULTANT

9440118712; drpappuss@yahoo.co.in

Aim

• TO EDUCATE / SENSITISE PRIVATE HEALTH CARE PROVIDERS REG

• TB CONTROL AND RNTCP – A NATIONAL HEALTH PROGRMME

• OF G.O.I

• SPECIAL EMPAHSIS ON TB NOTIFICATION & BANNING OF BLOOD TESTS FOR TB DIAGNOSIS

• The Union Health Ministry's notification was issued with on May 7. The notification clearly states that 'all healthcare providers (clinical establishments run or managed by government including local authorities, private or NGOs and/ or individual practitioners) in all the districts and towns in your concerned state/UT be immediately kept informed (through appropriate mechanism) on the contents of the Government Order on TB notification in India for their compliance with immediate effect.’

• The notification further said: "In order to ensure proper TB diagnosis and case management, reduce TB transmission and fight emergence of drug resistant TB, it is essential to have complete information of all TB cases. Therefore the healthcare providers shall notify every TB case to local authorities - district health officer/chief medical officer of a district and municipal health officer of a municipal corporation, every month

TB NOTIFICATION• Many options

• The notification can be done through hard copy, email, mobile phones (IVRS or SMS), or by uploading the information directly on to the Nikshay portal (http://nikshay.gov.in). They can also get in touch with the respective nearest nodal officers (http://tbcindia.nic.in) to notify the cases.

• Contact your DTCO giving your details

New G.O• New Delhi, 18 June 2012: In a welcome

step, a gazette notification by the Ministry of Health & Family Welfare banning serological test (commonly referred to as blood or antibody test) for TB, under the Drugs & Cosmetic Act, has finally been made public today. This gazette notification also, in particular bans the importation of the serological test kits.

• The notification is online at https://picasaweb.google.com/101502226047950368947/GovernmentOfIndiaNotificationBanningTBSerologicalBloodTestsJune2012

G.O

• The serological test for TB is widely used in the private sector, even though they are known to be inaccurate, inconsistent and with no clinical value for TB diagnosis. The World Health Organization (WHO) in its first-ever negative policy recommendation recently called on governments to immediately ban blood tests prescribed and used to detect TB.

RNTCP – Goal and Objectives• Goal

– The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India.

• Objectives:– To achieve and maintain a cure rate of at least 85%

of new sputum positive TB patients – To achieve and maintain a case detection of at least

70% of new sputum positive TB patients

RNTCP (revised) Goals and Objectives

• Goal: – To reduce the burden of Tuberculosis by providing

universal access to TB care

• Objectives:

– 90/90– Detection of at least 90% of all incident TB Cases– Successfully treat at least 90% of new smear

positive cases

Population attributable fraction – selected risk factors & determinants

Relative risk for active TB disease

Weighted prevalence (22 HBCs)

Population Attributable

Fraction

HIV infection 20.6/26.7* 1.1% 19%Malnutrition 3.2** 16.5% 27%Diabetes 3.1 3.4% 6%Alcohol use (>40g / d)

2.9 7.9% 13%

Active smoking

2.6 18.2% 23%

Indoor Air Pollution

1.5 71.1% 26%

( )( )

1

1 1

P RRPAF

P RR

× −=

× − +

Sources: Lönnroth K, Raviglione M. Global Epidemiology of Tuberculosis: Prospects for Control. Semin Respir Crit Care Med 2008; 29: 481-491. *Updated data in GTR 2009. RR=26.7 used for countries with HIV <1%. **Updated data from Lönnroth et al. A consistent log-linear relationship between tuberculosis incidence and body-mass index. Submitted, 2009

“Diabetes makes a substantial contribution to the burden of incident tuberculosis in India…”

Universal Access to TB Care- Concept/Definition

• All TB patients in the community to have access to– early, good quality diagnosis and treatment services

• in a manner that is affordable and convenient to the patient in time, place and person.

• All affected communities must have full access to TB prevention, care and treatment, – including women, children, elderly, migrants, homeless

people, alcohol and other drug users, prison inmates, people living with HIV and other clinical risk factors, and those with other life-threatening diseases.

Universal Access to TB Care-

All TB patients

• including women, elderly, children, migrants, homeless people, alcohol and other drug users, prison inmates, people living with HIV and other clinical risk factors, and those with other life-threatening diseases.

• All types- Smear positive, negative, EP, Drug Resistant TB

Early Diagnosis

Onset of SymptomApproaching a

health care facilityDiagnosis

Initiation of treatment

Patient delay Diagnosis delay

Treatment delay

NTF Presentations for RNTCP Sensitization First edition 10th

Nov 06

Algorithm 1: Diagnostic Algorithm For Pediatric Pulmonary TB

X-ray + Mantoux

Sputum Positive TB (Anti TB Treatment)

If yes, examine 3 sputum smears

Is expectoration present?

If no, refer to Pediatrician

Pulmonary TB Suspect • Fever and / or cough 3 weeks • Loss of wt/No wt gain • History of contact with suspected

Or diagnosed case of active TB

Refer to Pediatrician

Negative

Antibiotics

10-14 days

1 Positive

X-Ray

Cough Persists

2 or 3 Positives

2 or 3 Positives 3 Negatives

Negative for TB

Suggestive of TB

Repeat 3 Sputum Examinations

Sputum-Positive TB

(Anti-TB Treatment)

Suggestive of TB

Negative for TB

Sputum-Negative TB (Anti-TB Treatment)

PAEDIATRIC TB

• 1.DIFFICULT TO BRING OUT SPUTUM IN CHILDREN

• 2.RELY ON OTHER TESTS - MONTOUX ; & X RAY

• 3.LOOK FOR HISTORY OF CONTACT WITH KNOWN TB CASE

• 4.PAEDIATRICIAN’S DIAGNOSIS IS HONORED.

Two Types of Generic Boxes –4 WEIGHT BANDS

• 6 – 10 kg would require

• 11 – 17 kg would require

• 18 – 25 kg would require and

• 26 – 30 kg would require and

PC 13

PC 14

PC 13 PC 14

PC 14 PC 14

PAEDIATRIC UPDATE

• 6 WEIGHT BANDS & 3 generic

• Patient wise boxes

• 6-8 Kgs – Product -1

• 9-12 Kgs – Product -2

• 13-16 Kgs – Product -3

• 17-20 Kgs – Product -1 +2

• 21-24 Kgs – Product – 2+ 2

• 25-30 Kgs – Product - 3+3

Treatment Regimens -new

2H3R3Z3E3S3 /

1H3R3Z3E3 /

5H3R3E3

Previously treated smear positive (relapse, failure,

treatment after default)

PT

2H3R3Z3E3 /

4H3R3

New smear positive; seriously ill smear negative; all extra-pulmonary

NT

Delay in diagnosis• Cough as the presenting symptom• Awareness among patients• Awareness among providers• Accessibility to diagnostic facilities• ? Lack of “interest” in smear negative TB

Intensified Case Finding?

• Settings– Contact investigation– HIV– DM

– ?Smokers

– ?Migrants

– ?Slums– ?Mines– Other occupations

– Prisoners…………………………

Intensive case finding among high risk groups:

• HIV care centres• Active TB case finding should be implemented in all

facilities providing HIV care, like ICTCs, ART Centres, Care and support centres etc.

• Train Medical Officers in the algorithum for diagnosis of TB in HIV positive patients.

• Involve NGOs working with HIV programme in TB case finding activities.

Intensive case finding among high risk groups:

– Diabetic patients.• Sensitize medical officers to actively search for

TB in diabetic patients. • Active TB case finding in diabetic clinics

– Smokers• TB control programme to actively associate

with anti smoking programme.• Chronic smokers attending OPDs with

respiratory symptoms to be screened for TB.

OTHER POINTS

• PREGNANT LADIES CAN TAKE ANTI TB DRUGS EXCEPT FOR INJ.STREPTOMYCIN.

• ANTI TB DRUGS ARE TOXIC. PATIENTS WILL HAVE SIDE EFFECTS LIKE NAUSEA; VOMITINGSHEADACHE; JOINT PAINS ETC.

• THEY NEED SYPTOMATIC TREATMENT.• IF THE PT DEVELOPES JAUNDICE – STOP ALL

ANTI TB DRUGS ; TREAT JAUNDICE AND THEN RESTART ANTI TB DRUGS.

• CO-INF OF TB & HIV NEEDS CPT ALSO.

• Involvement of NGOs and Private Practitioners – Schemes revised in 2008

– Presently ~19,000 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

PPM….

Promote Universal access of care for TB in all Medical Colleges

– State and Zonal Task force mechanism to further strengthen medical college involvement in RNTCP.

– Medical colleges need • System of active screening and fast tracking of TB

suspects• System of tracking patients both within the

institution and outside for diagnosis as well as treatment.

• Strengthening of interdepartmental collaboration and monitoring

Thanking you all!!!

www.tbcindia.nic.inwww.stoptb.org