Summary of changes in the RNTCP technical guidelines in 2008-09
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Summary of changes in the RNTCP technical guidelines in
2008-09
Dr. K S Sachdev, CMO Dr. K S Sachdev, CMO Central TB DivisionCentral TB Division
Directorate General of Health ServicesDirectorate General of Health ServicesMinistry of Health & Family WelfareMinistry of Health & Family Welfare
Nirman Bhavan, New DelhiNirman Bhavan, New Delhi
ZTF (South Zone) Workshop, Puducherry
27-28 August 2009
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(Newer) COMPONENTS OF THE STOP TB STRATEGY
• Pursue high-quality DOTS expansion and enhancement
• Secure political commitment, with adequate and sustained financing
• Ensure early case detection, and diagnosis through quality-assured bacteriology
• Provide standardized treatment with supervision, and patient support
• Ensure effective drug supply and management • Monitor and evaluate performance and impact
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Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
• Scale-up collaborative TB/HIV activities
• Scale-up prevention and management of multidrug-resistant TB (MDR-TB)
• Address the needs of TB contacts, and of poor and vulnerable populations
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Contribute to health system strengthening based on primary health care
• Help improve health policies, human resource development, financing, supplies, service delivery and information
• Strengthen infection control in health services, other congregate settings and households
• Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL)
• Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health
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Engage all care providers
• Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches
• Promote use of the International Standards for Tuberculosis Care (ISTC)
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Empower people with TB, and communities through partnership
• Pursue advocacy, communication and social mobilization
• Foster community participation in TB care
• Promote use of the Patients' Charter for Tuberculosis Care
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Enable and promote research
• Conduct programme-based operational research, and introduce new tools into practice
• Advocate for and participate in research to develop new diagnostics, drugs and vaccines
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Diagnosis of TB
• Change in the definition of PTB suspect- “Pulmonary TB suspect is any person with cough for 2 weeks, or more”
• Change in the number of sputum samples required for diagnosis of PTB from 3 to 2– Number of specimen required for diagnosis
is 2, with one of them being a morning sputum
– One specimen positive out of the two is enough to declare a patient as Sm+ PTB
Based on WHO STAG recommendations and further evidence from India
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Recording and reporting
• Revised PM report for PHI, TU, District and State– MDR-TB suspects– TB/HIV Activities– Revised PPM schemes– Involvement of other
sectors– ACSM (IEC)– Information on quality of
DOTS for all smear positive TB patients (not just NSP cases)
• New software phased in. Old software to be phased out in 2010
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TB/HIV
• Offer of VCT to all TB patients started in 9 states and planned to expand to the entire country by 2012
• Recording of HIV status in TB records in these states• Early start of ART in eligible HIV+ve TB patients (2 wks
following start of TB treatment; TB patients with CD4 <350/cc eligible for ART); also recording in TB records in these states
• Decentralized provision of CPT to all HIV+ve TB patients in these states
• Intensified TB case finding at ICTCs, ART centres & CCCs• Priority accorded to airborne infection control in ART centres
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WHO-recommended TB/HIV interventions
OngoingOngoingOngoingOngoing
Ongoing at VCTC; ARTPilot testingGuidelines in preparation
Ongoing (ICTCs)Ongoing (NACO)Ongoing Ongoing (NACO ART centres)Ongoing (NACO ART centres)
Indian TB/HIV Activities
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MDR-TB….1
• Recently implemented change in MDR-TB suspect definition– “any patient who fails a Cat I or III treatment regimen
or any Cat II patient who remains smear positive at the end of the fourth month of treatment or later”
• Future change of MDR-TB suspect definition planned to include all smear +ve retreatment cases
• Elimination of exclusion criteria (pregnancy, pediatric age-group, H/o SL ATT) for DOTS-Plus
• National DOTS-Plus committee has recommended– A Cat-V regimen for XDR-TB– To treat Rif mono-resistance with Cat-IV– Replace ofloxacin with levofloxacin in Cat-IV regimen
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MDR-TB….2
• Newer rapid diagnostics– Molecular technology based DST (Line Probe Assay)
• Advantages: rapid (result in 2 days), high throughput
• Status: Validation phase over; demonstration phase to start in Aug 2009
• 43 labs with LPA planned (these labs will also have solid media DST)
– Automated liquid culture• In 33 out of the 43 labs liquid culture systems
planned
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PPM
• New PPM schemes implemented
• Additional scheme on: – TB/HIV for high HIV risk
population– Purchase of DST services
from private accredited labs– Sputum collection and
transportation
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Other changes
• Operational research: New operational research agenda and guidelines (can be downloaded from www.tbcindia.org)
– RNTCP OR agenda 2009.pdf– RNTCP OR guidelines March2009.pdf
• Airborne infection control guidelines being developed
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Change is also happening in RNTCP policy
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Thanks