RNTCP: DOTS Expansion and plans for DOTS-Plus Central Tuberculosis Division Directorate General of Health Services Ministry of Health & Family Welfare.

RNTCP: DOTS Expansion and plans for DOTS-Plus

Central Tuberculosis DivisionDirectorate General of Health Services

Ministry of Health & Family WelfareGovernment of India

Status of DOTS expansion

Plans for DOTS-Plus

Contents

India: DOTS Implementation Status by District, 31st Mar 2005

Type of districts / reporting units

No. of districts / reporting

units

Projected population (in

million) *

Implementing 563 1001

Appraisal done 17 27

Ready for appraisal 8 14

Preparing 44 68

* 2005 projected population based on 2001 census.ImplementingAppraisal doneReady for appraisalPreparing

2 3 7 6 1 5

0

100

200

300

400

500

600

700

800

900

1000

I/94

III/9

4I/9

5III

/95

I/96

III/9

6I/9

7III

/97

I/98

III/9

8I/9

9III

/99

I/00

III/0

0I/0

1III

/01

I/02

III/0

2I/0

3III

/03

I/04

III/0

4

Quarter/Year

Po

pu

lati

on

co

ve

red

(m

illio

ns

)

0

50000

100000

150000

200000

250000

300000

To

tal p

ati

en

ts t

rea

ted

Total patients treatedPopulation coverage(in millions)

Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter

In 2004, a globally significant cohort of 1.2 million TB patients initiated on DOTS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Annualised New S+ve CDR Success rate

Case detection (New S+ve) and treatment success in DOTS areas, 1999-2004 *

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

State-wise Case-detection and treatment success rates in RNTCP areas for 2004/2003Case-detection and treatment success rates in RNTCP areas for 2004/2003

70%

75%

80%

85%

90%

95%

100%

40% 50% 60% 70% 80% 90% 100%Case detection

Suc

cess

rat

e

Target Zone

Bihar

Andhra Pr.

HaryanaManipur

MizoramDelhi

Gujarat

Arunachal Pr.

SikkimRajasthan

Chandigarh

2004

W Bengal

Tamil Nadu Himachal Pr.

Orissa

Karnataka

Madhya Pr.

Uttaranchal

Jharkhand

Maharashtra

Chhatisgarh

Punjab

Nagaland

Assam

Kerala

Uttar Pr.

Meghalaya

2000

2002

2001

2003

Treatment outcome of New Smear Positive patients in 2003

Cure, 84.9%

Died, 4.7%

Failure, 2.5%

Defaulted, 6.2%

Trans out, 0.3%

Completed1%

n=358,196

14%

35%

24%

0%

5%

10%

15%

20%

25%

30%

35%

40%

Orissa

Chhatis

garh

Kerala

Tamil

Nadu

Bihar

Jam

mu &

Kas

hmir

West

Ben

gal

Jhar

khan

d

Tripura

Andhra

Pra

desh

Maha

rash

tra

Assam

India

Tota

l

Karnat

aka

Mizo

ram

Uttar P

rade

sh

Chandig

arh

Madh

ya Pra

desh

Mani

pur

Pondiche

rry

Sikki

m

Punjab

Goa

Megh

alaya

Nagaland

Arunac

hal P

rades

h

Haryan

a

Himach

al Pra

desh

Rajast

han

Delhi

Uttara

nchal

Gujara

t

India: percentage of re-treatment cases out of all smear positive cases, 2004

Treatment outcome of Retreatment patients excluding ‘Others’ in 2003

Failure, 6%Cured,

66%

Transferred out, 0.6%

Defaulted, 15%

Completed, 4%

Died, 8%

n=112,304

Plans for DOTS-Plus RNTCP regimens highly effective, with low failure rates

(2% in CAT I , 6% in CAT II cases) However issue of PTB patients who remain positive

following a fully supervised CAT II regimen, has previously not been well addressed by the RNTCP

Although these cases represent a small minority of overall caseload of TB patients, they constitute an on-going problem for RNTCP managers, both from an epidemiological and human rights viewpoint

Now that RNTCP is well established in 90% of the country, it is timely to develop services to address the needs of this group of patients

Plans for DOTS-Plus (…2)

MDR-TB is a laboratory diagnosis, NOT a clinical one Hence quality assured culture and DST lab facilities must

be available For RNTCP to provide MDR-TB treatment, RNTCP will

start establishing network of state-level IRLs Aim is to have 1 such state-level IRL in each large state

by 2009-10 Requires a planned and phased programme of capacity

building of such an IRL network

Plans for DOTS-Plus (…3) RNTCP views treatment of MDR-TB patients as a

“standard of care” issue Recognizing that MDR-TB treatment is complex,

treatment will follow the international DOTS Plus guidelines and will be done only in designated RNTCP DOTS Plus sites:

sites will be in a limited number of highly specialized centres, at least 1 in each large state;

sites will have ready access to an RNTCP accredited IRL; will have adequate number of qualified staff available to manage

patients; use standardized second-line drug regimens given under daily

DOT and with standardized follow-up protocols; systems in place to deliver ambulatory DOT after an initial short

period of in-patient care to stabilise patient on the second-line drug regimen; and

with a logistics system and standardized MIS in place

Plans for DOTS-Plus (…4) Activities to be undertaken for DOTS Plus:

Formation of a national level MDR-TB / DOTS Plus Committee; Develop national management guidelines for treatment of MDR-

TB cases and DOTS Plus; Establish procurement mechanism for second-line drugs,

including systems for quality assurance of the drugs; Identify sites for DOTS Plus; and Enrol MDR-TB patients for treatment

DOTS Plus sites will be initiated in a phased manner similar to that for establishment of state-level IRL network, and sites will be geographically linked to the establishment of the IRLs

By 2010, plan is for 24 DOTS Plus sites, with the capacity to annually enroll 5,000 new MDR-TB cases for treatment

Planned to enroll first 100 cases in Gujarat and Maharashtra in early 2006

Year Nos. of DOTS Plus sites initiated

Location of new DOTS Plus sites

Annual nos. of new MDR-TB patients put on Rx *

Annual total nos. of MDR-TB patients on treatment

2005-06 2 Gujarat and Maharashtra 100 -

2006-07 5 (+2) Delhi, Kerala, Rajasthan, Tamil Nadu & W Bengal (plus Andhra Pradesh and Orissa under GFATM R4)

450 550

2007-08 7 Chandigarh, Chhattisgarh, Harayana, Himachal, Jharkhand, Karnataka and Uttaranchal

1250 1700

2008-09 5 Assam, Goa, Madhya Pradesh, Punjab and UP

2350 3600

2009-10 3 Bihar, J&K and Manipur 3450 5800

Total 22 (+2) 22 (+2) states 7600 (+1100) -

•In 1st Year of a new DOTS Plus site, 50 new patients enrolled per site for treatment. In 2nd Year, 100 patients enrolled. From 3rd Year onwards, 200 new patients enrolled for treatment annually in each DOTS Plus site.

Summary

Rapid expansion – nearly 90% covered; 100% by end 2005

Case detection and treatment success meeting global targets within DOTS areas

Next 5-year plan includes, DRS and DOTS-Plus Challenges for DOTS-Plus include laboratory

capacity at State level, procurement of drugs, in-hospital care and follow-up/monitoring of patients, and a system for daily DOT

THANK YOU

Multiyear DOTS expansion plan for India *31st March 2005

Total Population 1111

* Projected population based on 2001 census.

0

200

400

600

800

1000

1200

Quarter/Year

Po

pu

lati

on

in

mil

lio

n .

Country population Actual DOTS coverage Planned DOTS coverage

0%

10%

20%

30%

40%

50%

60%

70%

80%

1999 2000 2001 2002 2003 2004 2005 2006 2007

Year

% C

ases

det

ecte

d o

f to

tal e

stim

ated

fo

r In

dia

.

Target 70%

Progress Towards 70% Case Detection Target*

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

RNTCP Treatment Regimen

Category I

New smear-positive; seriously ill smear negative; seriously ill extrapulmonary, New TB case with known HIV positive status

2 H3R3Z3E3 / 4 H3R3

Category II

Previously treated smear-positive (relapse, failure, treatment after default)

2 H3R3Z3E3S3 / 1 H3R3Z3E3 /

5 H3R3E3

Category III New smear-negative; and extrapulmonary, not seriously ill

2 H3R3Z3 / 4 H3R3

All treatment thrice weekly. Cat I and Cat II extended onemonth if smear+ at end of initial intensive phase.