Tb programme

MAGNITUDE OF THE PROBLEM

• TB is one of the most

important public health

problems worldwide.

• There are approximately 9

million new cases of all forms

of tuberculosis occurring

annually and 3 million people

die from it each year.

• India is the highest TB

burdened country in world

and accounts for nearly 20%

of the global burden of

Tuberculosis.

NATIONAL TB CONTROL PROGRAMME

SHORT-TERM OBJECTIVE:

• TO REDUCE T.B IN THE COMMUNITY.

LONG-TERM OBJECTIVE:

• TO DETECT MAXIMUM NO.OF T.B CASES

• TO VACCINATE NEW BORNS AND INFANTS WITH B.C.G

DISTRICT TUBERCULOSIS

PROGRAMME

• The National tuberculosis programme (NTP) operates

through the District Tuberculosis Programme (DTP)

which is the backbone of the NTP.

• Over 600 TB clinics have been set up in the country,

• Association with general health and medical

institutions.

• Monthly once patient received the drugs through

dispensary

DTC

CASE FINDING

BCG VACCINATION

HEALTH EDUCATION

TREATMENT

PROGRAMME ACHIEVEMENT

• NATIONAL TB CONTROL PROGRAMME DID NOT YIELD

GOOD RESULT.

• CASE DETECTION AND CASE HOLDING RESULT WAS

LOW(25%)

• DRUG SUPPLY NOT REGULAR

• RESPONSE FROM THE PATIENTS WAS POOR

• INCREASED INCIDENCE OF MDR-TB

• TREATMENT REGIMENS WERE MANY

• INADEQUATE BUDGET

• NO CHANGES IN MORBIDITY AND MORTALITY RATE

REVISED TB CONTROL PROGRAMME

• IN 1992 GOVERNMENT OF INDIA APPOINTED

EXPERT COMMITTEE TO REVIEW THE

STRATEGIES OF TUBERCULOSIS CONTROL

PROGRAMME.

• CASE FINDING MUST BE PASSIVE

• SYSTEMATIC REGISTRATION OF THE CASES

• CATEGORIZATION OF THE TB CASES INTO TWO TYPES

• ONLY INTERMITTENT REGIMEN NOT DAILY REGIMEN

• DRUGS MUST BE ENSURED FREE OF COST

• EFFECTIVE HEALTH EDUCATION

R.N.T.C.P

• IN 1993, GOVT OF INDIA INTENSIFIED AND REVISED THE NTCP AND

RENAMED AND LAUNCHED AS “ REVISED T.B CONTROL

PROGRAMME”.

• IT WAS LAUNCHED AS A PILOT PROJECT AND EXPANDED IN 1997.

• IT FUNDED BY W.H.O AND WORLD BANK.

• ACHIEVEMENT OF ATLEAST 85% CURE RATE THROUGH

SUPERVISED SHORT COURSE CHEMOTHERAPY.

• INVOLVEMENT OF NGO’S AND PRIVATE INSTITUTION.

• AUGMENTATION OF CASE FINDING ACTIVITIES

THROUGH QUALITY SPUTUM MICROSCOPY

EXAMINATION.

REVISED STRATEGIES:

• LABORATORY NETWORK

• SPUTUM EXAMINATION

• NEW PROTOCOL FOR DIAGNOSIS

• DOTS PROGRAMME

• DRUG RESISTANCE SURVEILLANCE

• DOTS PLUS

• PAEDIATRIC TUBERCULOSIS

• TB – HIV COORDINATION

• IEC ACTIVITIES

1. LABORATORY NETWORK

• A NATION WIDE NETWORK OF RNTCP

QUALITY ASSURED DESIGNATED

SPUTUM SMEAR MICROSCOPY

LABORATORIES HAS BEEN SETUP.

• THESE LABORATORIES CARRY OUT

SPUTUM MICROSCOPY WITH EXTERNAL

QUALITY ASSESSMENT (EQA) AND DRUG

RESISTANCE SURVEILLANCE (DRS)

RELATED ACTIVITIES.

• NEW PROTOCOLS FOR SPUTUM MICROSCOPY AND DRS HAVE BEEN

PREPARED.

• THE LABORATORY NETWORK FOR RNTCP IN INDIA CONSISTS OF THREE

DESIGNATED NRLS

• A CENTRAL LABORATORY COMMITTEE HAS BEEN CONSTITUTED WITH

THE MICROBIOLOGISTS OF THE THREE NATIONAL REFERENCE

LABORATORIES (NRLS) AND CENTRAL TB DIVISION WITH WHO

REPRESENTATIVES AS MEMBERS. THIS COMMITTEE GUIDES THE

LABORATORY RELATED ACTIVITIES OF THE PROGRAMME.

2. SPUTUM EXAMINATION

– Case finding is passive.

– Patients presenting themselves with symptoms suspicious

of tuberculosis are screened through two sputum smear

examinations. (ON THE SPOT – EARLY MORNING)

– Sputum positive

– Sputum negative

3. PROTOCOL FOR DIAGNOSIS

4. DOTS PROGRAMME

• The Directly Observed Treatment Short Course (DOTS) is

the distinguishing feature of RNTCP.

• It is directly observed chemotherapy because the drug

intake of every patient is supervised by programme

functionaries.

COMPONENTS OF DOTS PROGRAMME

POLITICAL COMMITTMENT

GOOD QUALITY SPUTUM SMEAR

DIRECT OBSERVATION

UNINTERUPTED SUPPLY OF DRUGS

ACCOUNTABILITY

DOTS AGENTS

• MULTI PURPOSE HEALTH

WORKERS

• ANGANWADI WORKERS

• DAIS

• EX-PATIENTS

• SOCIAL WORKERS

• TEACHERS

• OTHERS

DRUGS REGIMEN

• ISONIAZID – 600 mg

• RIFAMPICIN – 450 mg

• PYRAZINAMIDE – 1500 mg

• ETHAMBUTOL – 1200 mg

• STREPTOMYCIN – 0.75 g

CATEGORY TYPE OF PATIENT

REGIMEN DURATION IN MONTHS

CATEGORY I

Color of box: RED

New Sputum

Positive

Seriously ill sputum negative,

Seriously ill extra pulmonary,

INTENSIVE:

2 (HRZE)3

CONTINUOUS:

4 (HR)3

6

CATEGORY II

Color of box: BLUE

Sputum Positive relapse

Sputum Positive failure

Sputum Positive treatment after

default

INTENSIVE:

2 (HRZES)3,

1 (HRZE)3

CONTINUOUS:

5 (HRE)3

8

5. DRUG RESISTANCE SURVEILLANCE

(DRS)

• A new protocol for state-wide DRS under RNTCP has been

developed in 2005.

• Over the next five years, RNTCP plans to systematically

carry out state-wide DRS surveys in the states of Andhra

Pradesh, Delhi, Gujarat, Kerala, Maharashtra, Orissa, Uttar

Pradesh and West Bengal.

DRS ACTIVITIES

6. DOTS PLUS

• DOTS-Plus, conceived by the WHO and several of its partners, is

a strategy currently under development for the management of

multi-drug resistant TB(MDR-TB).

• Recognizing that the treatment of MDR-TB cases is very

complex, treatment is to follow the internationally recommended

DOTS-Plus guidelines and will be done in designated RNTCP

DOTS-Plus sites.

• IT LAUNCHED IN INDIA DURING 2007

• DIAGNOSIS IS CONFIRMED BY SPUTUM CULTURE AND SUSCEPTIBILITY TEST DONE IN IRL

• TREATMENT IS DAILY REGIMEN WITH SECOND LINE DRUGS

• PATIENTS ARE ADMITTED AND TREATED IN THE RNTCP DESIGNATED SITES

• TOTAL DURATION OF TREATMENT IS MINIMUM 2 YEARS

• I.P FOR 6-9 MONTHS C.P IS FOR 18 MONTHS

RECOMMENDED DOSAGE FOR DOTS PLUS

DRUGS < 45 KG >45 KG

KANAMYCIN 500 mg 750 mg

OFLOXCIN 600 mg 800 mg

ETHIONAMIDE 500 mg 750 mg

ETHAMBUTOL 800 mg 1000 mg

PYRAZINAMIDE 1250 mg 1500 mg

CYCLOSERINE 500 mg 750 mg

PARA AMINO SALICYLIC ACID

10 mg 12 mg

7. PAEDIATRIC TUBERCULOSIS

• MODIFICATION OF THE EXISTING

RNTCP GUIDELINES FOR THE

DIAGNOSIS AND TREATMENT OF

PAEDIATRIC PATIENTS.

• DRUGS FOR PAEDIATRIC TB CASES

UNDER RNTCP SHOULD BE

SUPPLIED IN PATIENT-WISE BOXES

(PWBS),

8. TB – HIV COORDINATION

• RNTCP and the National AIDS Control Organization (NACO)

have devised a Joint Action Plan for TB-HIV coordination.

• The objective of TB-HIV coordination is to reduce TB-

associated morbidity and mortality in People Living With

HIV/AIDS (PLWHA) through collaboration between NACP and

RNTCP.

• The basic purpose of the Joint Action Plan is to ensure optimum

synergy between the two national programmes for effective

prevention and control of both the diseases.

ACTIVITIES IN TB – HIV COORDINATION

Sensitization of key policy makers to address theimportance of TB-HIV co-ordination

Co-ordination of service delivery and cross-referrals;

A joint training programme for service providersinvolved in RNTCP and NACP

VCTC-RNTCP co-ordination for cross-referrals

· Use of universal precaution to prevent the spread of tuberculosis in facilities caring for HIV infected persons, and to prevent the spread of HIV through safe injection practices in RNTCP

· Joint efforts at IEC and at establishing a monitoring and evaluation system at district, state and national levels to assess the co-ordination and treatment services for people living with HIV/AIDS; and

· Active involvement of NGOs, private practitioners and corporate sector.

9. IEC ACTIVITIES

• Intensive IEC activities are

carried out at various levels to

promote utilization of RNTCP

services in the country. A mass

media agency has been

envisaged at the national level.

• IEC material is being prepared

by the states in local languages.

ORGANISATIONAL PATTERN OF RNTCP

• CENTRAL LEVEL :

• CENTRAL TB DIVISION

• STATE LEVEL

• STATE TUBERCULOSIS OFFICE• STATE TB TRAINING AND DEMONSTRATION CENTRE

• DISTRICT LEVEL:

• DISTRICT TUBERCULOSIS CENTRE

• SUB DISTRICT LEVEL:

• T.B UNIT

• PERIPHERAL LEVEL:

• HEALTH UNITS• RURAL HOSPITALS

ROLE OF NURSE

ESSENTIAL CARE

HEALTH EDUCATION

CLINICAL EXAMINATION

BCG VACCINATION

PROGRAMME ACHIEVEMENT:

• Despite rapid expansion, the overall performance of theprogramme remains consistently good.

• Death rate has been brought down seven folds from 29 per centto 4 per cent.

• Master trainers on TB/HIV have been trained on TB/HIV relatedissues in 12 states.