REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME (RNTCP) IN INDIA (1993)

DR. MAHESWARI JAIKUMAR

CLIENT WITH TB

CHILD WITH TB

MAGNITUDE OF THE PROBLEM

• The WHO report on Global Tuberculosis Control in 2005 remarks that "India, the country with the greatest burden of TB”

• In India today, two deaths occur every three minutes from tuberculosis (TB). But these deaths can be prevented. With proper care and treatment, TB patients can be cured and the battle against TB can be won

• Tuberculosis (TB) is an infectious disease caused by a Bacterium, Mycobacterium tuberculosis. It is spread through the air by a person suffering from TB. A single patient can infect 10 or more people in a year.

TUBERCULOSIS BACTERIA

ROBERT KOCK

SOURCE OF INFECTION

1. HUMAN SOURCE.2. BOVINE SOURCE.

COMMUNICABILITY• Clients are infective as long as

they remain untreated.• An effective anti microbial

treatment reduces infectivity by 90% within 48 Hrs.

MODE OF TRANSMISSION

1. Mainly by droplet infection.2. Coughing generates the largest

number of droplets of all sizes.

INFECTED LUNG

INCUBATION PERIOD• 1. Development of a positive

tuberculin test -3 To 6 wks.• 2. Development of disease depends

upon the closeness of contact, extent of disease and sputum positivity of the case. (Several weeks, months or years)

REVISED NATIONAL

TUBERCULOSIS CONTROL PROGRAMME IN INDIA

RNTCP (1993)

THE BASIC PRINCIPLES OF RNTCP

• Political commitment for ensuring adequate funds, staff and other key inputs.• Establishment of diagnosis primarily

by microscopic examination of specimens obtained from patients presenting to health care facilities.

OBJECTIVES• Achievement of at least 85% cure

rate of infectious cases; through DOTS.• Augmentation of case finding

activities through quality sputum microscopy to detect at least 70% of estimated cases.

FIRST PHASE OF RNTCP (1998-2005)

• In the first phase of RNTCP (1998-2005), the programme’s focus was on ensuring expansion of quality DOTS services to the entire country.

• Regular and uninterrupted supply of anti-TB drugs in the form of a patient-specific box that contains the medicines for the entire course of treatment so that no patient is subjected to interruption of treatment for lack of medicines.

• Direct observation of every dose of treatment in the intensive phase and of at least the first dose in the continuation phase of treatment.

• Systematic monitoring, supervision and cohort analysis-one Senior Treatment Laboratory Supervisor (STLS) is responsible for organization of uninterrupted treatment and one Senior Tuberculosis Laboratory Supervisor for ensuring quality laboratory service for every 5,00,000 population.

PROGRAMME EXPANSION AND CURRENT COVERAGE

• The initial implementation of RNTCP started in 1993 with a population coverage of 2.35 million at 5 sites in different states (Delhi, Kerala, West Bengal, Maharashtra and Gujarat). Its expansion continued in the following years with population coverage reaching 13.85 million in 1995.

• The Revised National Tuberculosis Control Programme (RNTCP), based on the DOTS strategy, began as a pilot in 1993 and was launched as a national programme in 1997.

• Rapid RNTCP expansion began in late 1998. By the end of 2000, 30%of the country’s population was covered, and by the end of 2002, 50%of the country’s population was covered under the RNTCP.

• The entire country was covered under DOTS by 24th March 2006.

2006 - STOP TB• “STOP TB” strategy was announced

by WHO and was adopted by India.• COMPONENTS OF STOP TB :1.Persuing quality DOTS expansion

& enhancement.

2. Addressing TB/HIV & MDR-TB

3. Contributing to Health Care Strengthening.

4.Engaging all care providers.

5.Empowering patients and communities.

6. Enabling and promoting research (diagnosis, treatment, vaccine)

ORGANIZATION• PROFILE OF RNTCP IN A STATE :• State TB office-State tuberculosis

Officer• State TB Training & Demonstration

Centre

STATE TB TRAINING & DEMONSTRATION CENTRE

DISTRICT TB CENTRE – DISTRICT TB OFFICER

TUBERCULOSIS UNIT

MICROSCOPY CENTRES, TREATMENT CENTRES

DOTS PROVIDERS

STATE TUBERCULOSIS OFFICE –STATE TB OFFICER

DIRECTLY OBSERVED TREATMENT, SHORT-COURSE (DOTS)

• The DOTS strategy is cost-effective and is today the international standard for TB control programmes. To date, more than 180 countries are implementing the DOTS strategy.

• The DOTS strategy along with the other components of the Stop TB strategy, implemented under the Revised National Tuberculosis Control Programme (RNTCP) in India, is a comprehensive package for TB control.

DOTS IS A SYSTEMATIC STRATEGY WHICH HAS FIVE COMPONENTS

• Political and administrative commitment.• Good quality diagnosis.• Good quality drugs. An uninterrupted

supply of good quality anti-TB drugs• Supervised treatment to ensure the right

treatment• Systematic monitoring and

accountability. 

RNTCP- LABORATORY NETWORKCentral TB Division National Reference Lab

State TB Cell Intermediate Reference Lab

District TB Centre

TU TU

TU

DMC 1 DMC 2 DMC 3

NATIONAL

STATE

DISTRICT

PERIPHERY

TB and HIV• TB is the most common

opportunistic infection in people living with HIV virus. As the HIV breaks down the immune system, HIV- infected people are at greatly increased risk of TB.

• TB in turn accelerates the progression of HIV to AIDS and shortens the survival of patients with HIV infection. Thus, TB and HIV are closely interlinked. In India there are an estimated over 5 million HIV-infected persons.• Directly Observed Treatment, Short-

course (DOTS) is as effective among HIV- infected TB patients as among those who are HIV negative.

MULTI-DRUG-RESISTANT TUBERCULOSIS (MDRTB)

• MDRTB refers to strains of the bacterium which are proven in a laboratory to be resistant to the two most active anti-TB drugs, isoniazid and rifampicin. Treatment of MDRTB is extremely expensive, toxic, arduous, and often unsuccessful.

• DOTS has been proven to prevent the emergence of MDRTB, and also to reverse the incidence of MDRTB

SECOND PHASE OF RNTCP• The RNTCP has now entered its second

phase in which the programme aims to firstly consolidate the gains made to date, to widen services both in terms of activities and access, and

• To sustain the achievements for decades to come in order to achieve ultimate objective of TB control in the country.

All components of new Stop TB Strategy are incorporated in the

second phase of RNTCP

COMPONENTS OF NEW STOP TB STRATEGY• • Pursue quality DOTS expansion and

enhancement, by improving the case finding are cure through an effective patient-centred approach to reach all patients, especially the poor.

• Address TB-HIV, MDR-TB and other challenges, by scaling up TB-HIV joint activities, DOTS Plus, and other relevant approaches.

• Contribute to health system strengthening, by collaborating with other health programmes and general services

• Involve all health care providers, public, nongovernmental and private, by scaling up approaches based on a public-private mix (PPM), to ensure adherence to the International Standards of TB care.

• Engage people with TB, and affected communities to demand, and contribute to effective care. This will involve scaling-up of community TB care; creating demand thorugh context-specific advocacy, communication and social mobilization.

• Enable and promote research for the development of new drugs, diagnostic and vaccines. Operational Research will also be needed to improve programme performance.

VISION AND TARGETS FOR RNTCP DURING THE 12th FIVE YEAR PLAN (2012-2017)

• Vision and targets for RNTCP during the 12th Five Year Plan (2012-2017)

TARGETS

• Early detection and treatment of at least 90 %of estimated TB case in the community, including HIV-associated TB• Initial screening of all re treatment

smear positive cases for drug resistant TB & appropriate treatment

• Offer of HIV counselling and testing for all TB patients and linking HIV-infected TB patients to HIV care and support

• Successful treatment of at least 90 percent of all new TB patients

• Extend RNTCP services to patients diagnosed and treated in the private sector

PROGRAMME ACTIVITIES NECESSARY TO ACHIEVE RNTCP (2012-2017) TARGETS

THE NATIONAL STRATEGIC PLAN 2012-2017

• Strengthening and improving the quality of basic DOTS services

• Further strengthen and align with the health system under National Rural Health Mission (NRHM)

• Improve communication and outreach and social mobilization

• Promote research for development and implementation of improved tools and strategies

OBJECTIVES • To achieve 90% notification rate for

all cases.

• To achieve 90% success rate for all new & 85% for re treatment cases.

• To achieve decreased morbidity & mortality if HIV associated TB.

• To improve outcomes of TB care in private sector.

• To significantly improve the successful outcomes of treatment for drug resistant cases.

ACHIEVEMENTS• Death rate has been brought down seven folds

(29% to 4%).

• 662 DTCs, 2698 TB units, 13,039 DMCs are functional in the country.

• The programme involves more than 1971 NGOs, >10894 private practitioners, >297 medical colleges & >150 corporate health facilities are involved

• >13,000 peripheral labs & designated microscopy centres have been established.

• > 6 lakh public health care providers are trained under the prog.

• >15 million patients have been initiated on treatment.

FINANCIAL RESOURCES• India receives assistance from:1.World Bank.

2.USAID.

3. DANIDA