Presentation 1 Introduction Contents • Global Tuberculosis Scenario Burden of Tuberculosis in India •RNTCP- Evolution, objectives, structure, achievements NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Global burden of TB 2 billion infected, i.e. 1 in 3 of global population 9.4 million (139/lakh) new cases in 2008, 80% in 22 high-burden countries 4 m new sm+ve PTB (61/lakh) cases in 2008 Global incidence of TB has peaked in 2004 and is declining. 1.77m deaths in 2007, 98% in low-income countries MDR-TB -prevalence in new cases around 3.6% Source of information (2006 report) NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Ref: WHO Global Report, 2006 3

Estimated TB incidence rate, 2007 :Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing

Millennium Development Goals Goal 6: “Combat HIV/AIDS, malaria and other diseases” Target 8: “By 2015, to have halted and begun to reverse the incidence of malaria and other major diseases…” Indicator 23: between 1990 and 2015 to halve prevalence of TB disease and deaths due to TB Indicator 24: to detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Stop TB Partnership Targets By 2005: At least 70% people with sputum smear positive TB will be diagnosed. At least 85% cured. By 2015: Global burden of TB (prevalence and death rates) will be reduced by 50% relative to 1990 levels. Reduce prevalence to <150 per lakh population Reduce deaths to <15 per lakh population Number of people dying from TB in 2015 should be less than 1 million, including those co-infected with HIV By 2050: Global incidence of TB disease will be less than or equal to 1 case per million population per year NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Stop TB Strategy, 2006 Vision: A world free of TB Goal: To dramatically reduce the global burden of TB by 2015 in line with Millennium Development Goals and the Stop TB Partnership targets NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Components of Stop TB Strategy, 2006 Pursuing high-quality DOTS expansion and enhancement Addressing TB/HIV, MDR-TB and other challenges Contributing to health system strengthening Engaging all health providers Empowering people with TB, and communities Enabling and promoting research NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Directly Observed Treatment, Short-course strategy (DOTS), 1994 Government commitment to TB control Diagnosis by smear microscopy mostly on self-reporting symptomatic patients Standardised short course chemotherapy (SCC) with direct observation of treatment (DOT) Efficient system of drug supply Efficient recording and reporting system with assessment of treatment results Five components were expanded in 2002 Stop TB Strategy and DOTs is part of it (SEARO AIIMS meeting) NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Global Situation Since 1995,over 21 million patients have been diagnosed and treated in DOTS programmes In 2007, 5.5 million new and relapse TB cases were initiated on treatment under DOTS strategy Of 2.5 million new smear positive patients registered in 2006, 85% were successfully treated under DOTS NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

International Standards for TB Care-2006-revised in 2009 Developed by Tuberculosis Coalition for Technical Assistance Members of TCTA American Thoracic Society WHO (World Health Organisation) CDC (Center for Disease Control and Prevention) KCNV(Dutch Tuberculosis Foundation), IUATLD (The International Union Against Tuberculosis and Lung Disease) Part of the new STOP TB Strategy and global plan to Stop TB NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

International Standards for TB Care The ISTC is designed to address the care of patients of all ages with any manifestation of the disease, including multi-drug resistant and extra-pulmonary tuberculosis and tuberculosis combined with HIV infection. The ISTC is also designed to guide providers everywhere, regardless of the circumstances of their practice. Consists of 21 standards for Public Health Responsibility NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 INDIA NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Problem of TB in India Estimated incidence 1.96 million new cases annually 0.8 million new smear positive cases annually 75 new smear positive PTB cases/1lakh population per year Estimated prevalence of TB disease 3.8 million bacillary cases in 2000 1.7 million new smear positive cases in 2000 Estimated mortality 330,000 deaths due to TB each year Over 1000 deaths a day 2 deaths every 3 minutes Divide into two slides Gopi P et al (TRC), IJMR, Sep 2005 NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Problem of TB in India (contd) Prevalence of TB infection 40% (~400m) infected with M. tuberculosis (with a 10% lifetime risk of TB disease in the absence of HIV) Estimated Multi-drug resistant TB < 3% in new cases 12% in re-treatment cases TB-HIV ~2.31 million people living with HIV (PLWHA) 10-15% annual risk (60% lifetime risk) of developing active TB disease in PLWHA Estimated ~ 5% of TB patients are HIV infected NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 India is the highest TB burden country accounting for more than one-fifth of the global incidence Global annual incidence = 9.4 million India annual incidence = 1.96 million India is 17th among 22 High Burden Countries (in terms of TB incidence rate) However, in terms of absolute numbers, India accounts for one fifth of the global Tuberculosis burden. Every year 1.9 million people in India develop tuberculosis (TB), of which 0.8 million are sputum positive cases that are infectious. Tuberculosis is unique among the main disease killers of the developing world in that it afflicts nearly all age groups. Tuberculosis has devastating social costs as well. This continued burden of disease is particularly tragic because TB is nearly 100% curable. Untreated patients can infect 10-15 persons each year; poorly treated patients develop drug resistant and potentially incurable TB. NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing

Estimated Incidence of TB in India. (No Estimated Incidence of TB in India* (No. of NSP Cases per 100,000 population, per year) * Estimated from recent ARTI survey North West East National 75 North Zone 95 East Zone 75** West Zone 80 South Zone Legend to have same colour as map. Ref to be added South ** For programme monitoring purpose estimated cases in East & South zones have been kept at the national level of 75 and this is within the upper limit of CI or ARTI in these zones NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Source: Module 9, Managing the RNTCP in your area

Social and Economic Burden of TB in India Estimated burden per year Indirect costs to society $3 billion Direct costs to society $300 million Productive work days lost due to TB illness 100 million Productive work days lost due to TB deaths 1.3 billion School drop-outs due to parental TB 300,000 Women rejected by families due to TB 100,000 Estimates made in 1998-99. TRC, Socio-economic impact of TB on patients and family in India, Int J Tub Lung Dis 1999 3: 869-877 NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Evolution of TB Control in India 1950s-60s Important TB research at TRC and NTI 1962 National TB Programme (NTP) 1992 Programme Review only 30% of patients diagnosed; of these, only 30% treated successfully 1993 RNTCP pilot began 1998 RNTCP scale-up 2001 450 million population covered 2004 >80% of country covered 2006 Entire country covered by RNTCP Formattiing required..TURN 450 INTO PERCENTAGE NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Objectives of RNTCP To achieve and maintain a cure rate of at least 85% among newly detected infectious (new sputum smear positive) cases To achieve and maintain detection of at least 70% of such cases in the population Explanatory notes (brief and carefully written) NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

RNTCP Organization structure: State level Organizational Chart Ministry of Health and Family Welfare Directorate General of Health Services Central TB Division RNTCP Organization structure: State level Health Minister Health Secretary MD NRHM Director Health Services Additional / Deputy / Joint Director (State TB Officer) State TB Cell Deputy STO, MO, Accountant, IEC Officer, SA, DEO, TB HIV Coordinator etc., State Training and Demonstration Center (TB) Director, IRL Microbiologist, MO, Epidemiologist/statistician, IRL LTs etc., NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Structure of RNTCP at district levels District Magistrate/ District Collector District Administration Chief Medical Officer and other supporting staff District Health Services DTO, MO-DTC (15%), LT, DEO, Driver, Urban TB Coordinators, TBHVs, Communication Facilitators Nodal point for TB control District TB Centre One/ 500,000 (250,000 in hilly/ difficult/ tribal area) Medical officer-TB Control, Senior Treatment supervisor(STS), Senior TB Laboratory Supervisor(STLS) Tuberculosis Unit Medical Officer, paramedical staff And Laboratory Technician (20-50%) One/ 100,000 (50,000 in hilly/ difficult/ tribal area) Microscopy Centre TB Health Visitors (TBHV), DOT Provider (MPW, NGO, PP, ASHA, Community Volunteers) DOT Centre NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Unique features of RNTCP District TB Control Society Modular training Patient wise boxes Sub-district level supervisory staff (STS, STLS) for treatment & microscopy Robust reporting and recording system NTF Presentations for RNTCP Sensitization First edition 10th Nov 06

Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 2000-2009* Treatment success has recently exceeded the global target of 85% Case Detection in DOTS areas has recently attained global target of 70% Population projected from 2001 census Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report) NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 25

NTF Presentations for RNTCP Sensitization First edition 10th Nov 06 Impact of RNTCP Cure rate more than doubled compared with earlier NTP, 85% global target consistently achieved 2003 onwards Case detection rate is more than 70% Case fatality reduced from 29% to 4% in NSP cases, and deaths due to TB from 500,000 to <330,000 a year Over 11 million patients initiated on DOTS, and over 2 million additional lives saved Add slide of graphs (differential mortality) with reference NTF Presentations for RNTCP Sensitization First edition 10th Nov 06