Summary of changes in the RNTCP technical guidelines in 2008-09 ZTF (South Zone) Workshop, Puducherry 27-28 August 2009 Dr. K S Sachdev, CMO Central TB Division Directorate General of Health Services Ministry of Health & Family Welfare Nirman Bhavan, New Delhi

(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

Scale-up collaborative TB/HIV activities 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

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

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)

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

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

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

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

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

WHO-recommended TB/HIV interventions Indian TB/HIV Activities Ongoing Ongoing at VCTC; ART Pilot testing Guidelines in preparation Collaborative TB/HIV activities jointly implemented by RNTCP and NACP in India include all the TB/HIV interventions recommended by WHO. Ongoing (ICTCs) Ongoing (NACO) Ongoing Ongoing (NACO ART centres) 14

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

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

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

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

Change is also happening in RNTCP policy

Thanks