Overview of the Presentation - Kamineni Institute of ... · Overview of the Presentation Definitions(TBCase, MDR-TB & XDR-TB) Global Tuberculosis (TB,HIV/TB,MDR & XDR)Scenario & Trend

Overview of the Presentation • Definitions(TBCase, MDR-TB & XDR-TB)

• Global Tuberculosis (TB,HIV/TB,MDR & XDR)Scenario & Trend

• Risk factor for TB

• Natural history of TB

• Types of TB & Trends of Extra Pulmonary TB

• RNTCP-Goals, Objectives, & Achievements

• Contribution of Medical institutions in TB Control

• Challenges

• Future Plans

Definition of TB case (Operational)

A patient diagnosed with at least one sputum specimen

positive for acid fast bacilli, or Culture-positive for

Mycobacterium tuberculosis, or RNTCP endorsed Rapid

Diagnostic molecular test positive for tuberculosis

OR

A patient diagnosed clinically as a case of tuberculosis,

without microbiologic confirmation, and initiated on

anti-TB drugs.

Source: Ministry of Health and Family Welfare, Govt of India.

www.tbcindia.nic.in

Definition of MDR / XDR

• MDR-TB is defined as resistance to isoniazid and

rifampicin, with or without resistance to other anti-TB drugs from an accredited RNTCP Laboratory

• XDR-TB is defined as resistance to at least Isoniazid

and Rifampicin (i.e. MDR-TB) with resistance to any of

the fluoroquinolones and any one of the second-line

injectable drugs (amikacin, kanamycin, or

capreomycin).

15%

24%

6%

5%

50%

TB cases Globally (2011)

China

India

South africa

Indonesia

All other countries

Total New TB cases

In the 22 high burden countries

7100000

India ranks 1st

2200000

Annual Global TB Report 2012-RNTCP

46%

5%

12%

26%

6% 5%

TB Prevalence

Other

Bangladesh

China

India

Indonesia

Pakistan

54%

4%

11%

25%

6%

TB Incidence

Other

Bangladesh

China

India

South africa

Global TB Report 2012

41%

7%

5% 4%

30%

7% 6%

TB Mortality Cases

Other

Bangladesh

China

DR Congo

India

Indonesia

6%

28%

6% 5%

55%

EPTB Cases

(Extra pulmonary TB)

Ehiopia

India

South Africa

Pakistan

All Other

countries

Annual Global TB Report 2012

Tuberculosis (TB) cases in India from

1999 to 2011

28%

3%

4% 5%

3% 4%

3% 9%

8%

30%

3%

TB HIV Cases

Other

DR Congo

India

Mozambique

Uganda

Zimbabwe

Brazil

Ethiopia

Kenya

South Africa

UR Tanzania

Global TB Report 2012

HIV on TB Incidence & TB Deaths(2008)

7%

13%

23%

17%

7%

33%

MDR TB Cases

India

Kazakhstan

Russian Federation

South Africa

Ukraine

Other countries

Global Tuberculosis report 2012

MDR-TB initial Drug resistance:0.6% - 3.2%

MDR-TB Acquired Drug resistance: 6% - 30%

India – ICMR Study

Annual multi-drug resistance (MDR) cases reported in India along with prevalence rate

of TB noti-fied. Numbers above the bars indicate total number of cases of MDR-TB

reported each year. Numbers above the red line notifies the estimated total TB cases

reported each year.

0

5

10

15

20

25

30

35

40

45

2008 2009 2010 2011(till sept)

4

29

43

36

No

of

Pa

tie

nts

Number of XDR-TB patients reported under RNTCP

Source: Annual report on TB 2011.

http://www.tbcindia.nic.in/pdfs/RNTCP

0% AMONG NEW CASES

0.5% AMONG RETREATMENT CASES

Natural History of untreated

smear + TB over a 5-8 year period

• 60-70% case-fatality rate for smear positive

cases, majority within the first 18 months

(50%-60% case-fatality rate, all forms)

• 30% self-cu e ate eve t to uiescent TB

• 20% chronic excretor rate

• For each untreated smear+ case, 10-14 new

infections/year can be expected

Risk factors for TB Risk factor Category Risk factors

Biomedical HIV infection, diabètes, Tobacco,

malnutrition, silicosis, malignancy

Environmental indoor air pollution, ventilation

Socioeconomic crowding, urbanization, migration,

poverty

• Diabetes accounts for 14.8% of all tuberculosis

• 20.8% of smear-positive TB & 4.85% of the incident TB cases in

India were HIV-positive.

Risk Factors for the Development of Active

Tuberculosis Among Persons Infected with

Mycobacterium Tuberculosis

Estimated increased risk of active

Risk Factor tuberculosis persons infected

with Mycobacterium tuberculosis

Acquired immunodeficiency syndrome 170.0

Human immunodeficiency virus infections 113.0

Other Immuno-compromising conditions* 3.6 – 16.0

Recentness of infection (<2 years) 15.0

Age of contact (< 5 years and >60 years) 2.2 – 5.0

For example, diabetes mellitus type 1, renal failure, carcinoma of the head or neck, iatrogenic immuno-suppression

Causes of inadequate treatment which can lead to drug

resistance TB

Providers/ Programmes:

Inadequate regimens

Drugs:Inadequate supply/quality

Patients:Inadequate drug intake

Absence of guidelines

or inappropriate

guidelines

Non-compliance with

guidelines

Inadequate training of

health staff

No monitoring of treatment

Poorly organized or funded TB control

programmes

Non-availability of

certain drugs (stock-

outs or delivery

disruptions)

Poor quality

Poor storage

conditions

Wrong dosages or combination

Poor adherence (or

poor DOT)

Lack of information

Non-availability of free

drugs

Adverse drug reactions

Social and economic

barriers

Malabsorption

Substance abuse disorders

Communicability :

• patients are infective as long as they remain

untreated.

• Effective treatment reduces infectivity by

90% within 48 hours

Incubation period

• Ranges from 3 – 6 weeks

• Depends on closeness of contacts

• Extent of the disease

• Sputum positivity of the source case

• Host parasite relationship

• May be weeks , o ths, or years…

Relative proportion of various forms of TB in immunocompetent (a) and HIV-infected individuals (b)

a

The Goal and Objectives of the RNTCP-1st phase

• Goal:

– Decrease mortality and morbidity due to TB

– cut transmission until TB ceases to be a major public health problem in India.

• Objectives:

85% cure rate

70% case detection rate

Directly Observed Treatment,

Short Course (DOTS)

• The success of DOTS depends on five

components:

- Political commitment

- Good quality sputum microscopy

- Directly observed treatment

- Uninterrupted supply of good quality drugs, and

- Accountability.

Second Phase of RNTCP (2006-2011)

• All components of new STOP TB Strategy(DOTS+)

are incorporated:

1. Pursue quality DOTS expansion and enhancement

2. Address TB-HIV, MDR-TB and other challenges

3. Contribute to Health system strengthening

4. Involve all health care providers

5. Engage people with TB, and affected communities

6. Enable and promote research

Changes in RNTCP policy on diagnosis of smear

positive pulmonary TB

1. Number of sputum specimen required for

diagnosis is 2.

2. One smear specimen positive out of the two is

enough to declare a patient as Sm+ PTB

3. Definition of PTB suspect- any person with

cough for 2 weeks, or more

Changes in RNTCP treatment

Guidelines

• Discontinuation of Cat III regimen under RNTCP

• Further, these regimens will be called regimen for

“New” (Category I) and “Previously treated” (Category II) cases.

Revised Categories

Treatment Regimes Type of Patient Regimen

Intensive

Phase(IP)

Continuation

Phase(CP)

New (Cat I)

New Sputum smear-positive

New Sputum smear-negative

New Extra-pulmonary

New Others

2(HRZE)3 4(HR)3

Previously Treated (Cat II) Smear-positive relapse

Smear-positive failure

Smear-positive treatment

after default

Others

2 (HRZES)3/

1(HRZE)3

5(HRE)3

MDR-TB Cases(Cat IV) 6 (9) Km, Ofx,

Eto, Cs , Z, E

18 Ofx, Eto,

Cs, E

C&DST-MDR-TB(Diagnosis)

Andhra Pradesh State TB Demonstration &

Training Centre, Irramnuma,

Besides AP Chest Hospital,

HYDERABAD-500 038.

Blue Peter Research Centre,

Near TEC Building,

Cherlapally,

HYDERABAD 501 301.

DOTS PLUS sites(Treatment)

Hyderabad AP Chest Hospital, Hyderabad

Guntur Govt.Fever Hospital

Achievements of RNTCP

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

110%

120%

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Annualised New S+ve CDR Success rate

•Population projected from 2001 census •Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 2000-2009*

Progress towards MDG’s-India

• Indicator 23: between 1990 and 2015, to

halve the prevalence of TB disease and deaths

due to TB.

459

256 230

0

100

200

300

400

500

1990 2010 2015(MDG-Target)

pe

r 1

Lak

h P

op

ula

tio

n

Prevalence

Progress towards MDG’s-India

39.1

29.4

19.5

0

5

10

15

20

25

30

35

40

45

1990 2010 2015(MDG-Target)

Ra

te p

er

1La

kh

Po

pu

lati

on

Mortality

RNTCP-REVISED GOALS 12th Five year plan(2012 – 2017)

• Vision: "TB-free India“

• Goal: Universal Access to quality TB diagnosis & treatment for all pulmonary & extra pulmonary TB patients including drug resistant and HIV associated TB.

RNTCP-REVISED OBJECTIVES 12th Five year plan(2012 – 2017)

Objectives:

• To achieve 90% notification rate for all types of TB

cases

• To achieve 90% success rate for all new and 85% for

re-treatment cases

• To significantly improve the successful outcomes of

treatment of Drug Resistant TB

• To achieve decreased morbidity and mortality of HIV associated TB

• To improve outcomes of TB care in the private sector

6%

3% 1%

25%

8%

57%

Contribution to referral of TB

suspects (n=430908)

NGO

Private

Corporate

Medical

colleges

Govt.Other

than Health

Health Dept.

5% 5%

1%

23%

10%

56%

Contribution to New smear

case detection(n=35025)

NGO

Private

Corporate

Medical

colleges

Govt.Other

than Health

Health Dept.

Contribution of Medical Institutions in TB Control

8% 9% 1%

7%

4% 71%

Contribution to DOT

Provision(n=25833)

NGO

Private

Corporate

Medical

colleges

Govt.Other

than Health

Health

Dept.

8% 10%

1%

6%

3%

72%

Contribution to Treatment

Success of NSP Case

Reg.(n=26388)

NGO

Private

Corporate

Medical

colleges

Govt.Other

than Health

Health

Dept.

Contribution of Medical Institutions in TB Control

Chemoprophylaxis

• TB chemoprophylaxis with Isoniazid daily for a period of six months. This is regardless of BCG vaccination.

• Close contacts of MDR TB patients should receive careful clinical follow-up for a period of at least 2years. During this stage, no prophylactic treatment of MDR TB contacts is recommended.

Challenges

References

1)WHO & AFMC Textbook of Public Health and Community

Medicine, 1st edition, 2009.

2) Textbook of Community Medicine by Dr.Sunder lal, 2nd

edition, 2009.

3) Park’s Textbook of Preventive and Social Medicine by K.Park, 21st edition, 2011.

4) TB Control of India, http://www.tbcindia.nic.in/

5) Ministry of Health and family welfare,

http://www.mohfw.nic.in/NRHM.htm

6) World Health Organization(WHO)

http://www.who.int/publications/guidelines/tuberculosis/e

n/index.html

Thank you

Evaluation

• Define TB case

• Define MDR-TB

• Current case detection rate & cure rate for

INDIA

• Treatment duration of

– New treatment regime

– Previous treatment regime

– Dots plus treatment regime