Status of RNTCP in Gujarat Dr. PV Dave State TB Officer Gujarat 2nd Quarter 2013

What is Tuberculosis ? Tuberculosis (TB) is a highly infectious bacterial disease caused by Mycobacterium tuberculosis. TB can affect any part of the body. When it affects the lungs it is called pulmonary TB. The commonest form of TB is pulmonary TB. TB in any other part of the body (i.e. other than lungs) is called extra pulmonary TB.

HEALTH IN THE MILLENNIUM DEVELOPMENT GOALS Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6c: Halt and begin to reverse the incidence of malaria and other major diseases including TB. Indicator 6.9: Incidence, prevalence and death rates associated with TB Indicator 6.10: Proportion of TB cases detected and cured under DOTS Stop TB Partnership targets By 2005: At least 70% of people with sputum smear-positive TB will be diagnosed (i.e. under the DOTS strategy), and at least 85% successfully treated. The targets of a case detection rate of at least 70% and a treatment success rate of at least 85% were first set by the World Health Assembly of WHO in 1991. By 2015: The global burden of TB (per capita prevalence and death rates) will be reduced by 50% relative to 1990 levels. By 2050: The global incidence of active TB will be less than 1 case per million population per year.

RNTCP – Goal and Objectives The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. Objectives: To achieve and maintain a case detection of at least 70% of new sputum positive TB patients To achieve and maintain a cure rate of at least 85% in such patients 5

Directly Observed Treatment, Short-course (DOTS) – a five point strategy Political and Administrative commitment Good Quality Diagnosis by Sputum smear microscopy Uninterrupted supply of good quality drugs Directly observed treatment (DOT) TB Register Systematic monitoring and accountability Note: Directly Observed Treatment (DOT) is only one of the five components of DOTS strategy 6

Annual Risk of TB Infection (ARTI) - 1 One of the key epidemiological indicators of the tuberculosis situation in a community It represents the proportion of population that gets newly infected (or re-infected) with tubercle bacilli over the course of one year. Currently the average ARTI in the country as a whole is estimated to be 1.5%.

Annual Risk of TB Infection (ARTI) - 2 It has been estimated that for every one percent annual risk of tuberculosis infection, there are about 50 new pulmonary sputum smear positive (NSP) cases 50 new pulmonary sputum smear negative (NSN) cases 25 re-treatment pulmonary cases 10 extra-pulmonary cases Totaling to 135 cases …………..per 100,000 population per year. This means that, with an ARTI of 1.6% for West Zone (including Gujarat), there will be 80 new smear positive cases, 80 new smear-negative cases, 40 re-treatment cases, and 16 extra-pulmonary cases, totaling to 216 cases ……………per 100,000 population per year.

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 ARTI survey North West East National 75 North Zone 95 East Zone 65** West Zone 80 South Zone 50** South ** For programme monitoring purpose estimated cases in East & South zones have been kept at the national level of 75

Structure of RNTCP State TB Cell District TB Centre Central TB Division, DGHS, New Delhi DDG-TB, CMO-TB STO, Deputy STO, MO, Accountant, ,IEC Officer, TB-HIV Coordinator, SA, DEO Designated IRL and DOTS-Plus site State TB Cell DTO, MO-DTC, LT, DEO, Driver Nodal point for TB control District TB Centre Urban TB Coordinators, Communication Facilitator One/ 5 lakh (2.5 lakh in hilly/ difficult/ tribal area) Tuberculosis Unit MO-TC STS, STLS One/ lakh (0.5 lakh in hilly/ difficult/ tribal area) Designated Microscopy Centre MO, LT DOT Provider – MPW, NGO, PP, Community Volunteer TBHV DOT Centre

RNTCP Infrastructure in Gujarat State TB Cell, Gandhinagar 1 State TB Training & Demonstration Centre / Intermediate Reference Laboratory - Ahmedabad District TB Centers (reporting units) 30 TB Units 144 Designated Microscopy Centers 749 Peripheral Health Institutes (PHIs) 1940 DOTS providers 43618

Human Resource – State level, 2nd Quarter 2013 Name of the post Number sanctioned Number in Place Percentage in Place & trained STO 1 100% Medical Officer STC 1(regular) STDC Director Assistant Program Officer/Epidemiologist NA TB –HIV coordinator IEC officer State Accountant 2 State DEO IRL Microbiologist Urban TB –Coordinators DEO (IRL) Sr LT - IRL Statistician * Statistical Assistant * 3 Highlight vacancies with Bold & red colour Data source: 3q11 State PMR * STC+STDC 12

Other Human Resource in the state under TB cadre Name of the post Level * Number sanctioned Number (%) in Place Percentage in place & trained TB Supervisor State TB Cell 3 100.00 Research Officer STDC 1 NA Research Assistant Statistical Assistant Computer 2 Treatment Organizer District TB Centre/ADTC 9 66 57 23 14 Health Visitor 28 15 Level: STC/ STDC/DTC/ADTC/periphery This will include regular posts under state govt. including the staff sanctioned for clinical activities e.g. ward in STDC may have posts of nursing staff, Statisticians, statistical assistants, social workers, field workers, BCG technicians, BCG leaders, treatment Organizers, Computer, * Level: STC/ STDC/DTC/ADTC/periphery 13

Human Resource – District Level, 1st Quarter 2013 Name of the post Number sanctioned Number in Place % vacant Percentage in place & trained DTO 30 17 43% 100 Senior DOTS Plus TB-HIV Supervisor 29 3% 90 District DEO 0% Part time Accountant MOTC 144 143 0.6% 97 STS 134 7% 88 STLS 140 96 TBHV 203 185 4% 98 LT 748 708 5.3% Highlight vacancies with Bold & red colour Data source: 3q11 State PMR & district PMRs 14

Composite Score – 1 Q 2013 State - Gujarat S.No. Thematic Area Scores Remarks 1 Human resource management 41/45 (91%) 2 Financial management 20/20 (100%) 3 Case finding efforts 28/40 (70%) 4 Quality of services 85/145 (58%) Total 174/250 (70%)

District – wise Composite Score – 1Q 2013

Achievements at a Glance 2nd Quarter 2013 Gujarat state has been in the target zone, consecutively since last more than Seven Years 26 / 30 (87%) reporting units are in the target zone 113/143 (79%) TUs in target zone TB Suspects Examined – 2Q13 : 1,06,668 New Smear Positive Case Detection Rate – 2Q13 : 75% New Smear Positive Cure Rate – 2Q12 : 86% Total TB patients put on treatment : 18,864 New Smear Positive Cases put on treatment : 9334 Since the inception of RNTCP up to 30-6-13 Total TB suspect Examined : 45,56,096 Total TB Patients put on DOTS treatment, : 9,69,093 New Smear Positive patients put on treatment : 4,15,995 Additional lives saved : 1,74,437 Identification of MDR TB Suspects : 38,421 Diagnosis of MDR TB Cases : 5,301 MDR TB Cases Put on CAT – IV : 4,173 XDR TB Cases Put on CAT – V : 56 18 18

Annualized New Smear Positive Case Detection Rate and Treatment Success Rate in DOTS areas of Gujarat, 2000-2Q13 19 19

Success Rate Vs Case Detection Rate (2Q12/2Q13)

TB Suspects Examined per lac per quarter 2nd Quarter 2013 Expected : 150 / Lac / Qtr Gujarat: 162 2nd Quarter 2012 Gujarat: 171 Gujarat: 159 21

TB Suspects Examined per lakh per quarter Gujarat: 171 Expected : 150 / Lac / Qtr TB Units – Gujarat 2nd Quarter 2013 Gujarat: 171

NSP Case Detection Rate 2Q 2011 NSP Case Detection Rate 2Q 2013 Expected : 70% Gujarat State: 77% 2Q 2012 Gujarat State: 75% Gujarat: 75% 23

NSP Case Detection Rate TB Units – Gujarat 2nd Quarter 2013 Expected : 70% Gujarat: 75%

NSP Conversion Rate 3Q 2012 1Q 2013 4Q 2012 Gujarat State: 92% Expected : 90% Gujarat State: 92% 4Q 2012 Gujarat: 92% Gujarat: 91% 25

NSP Conversion Rate TB Units – Gujarat Gujarat: 91% 1st Quarter 2013 Expected : 90% Gujarat: 91%

NSP Success Rate 4Q 2011 2Q 2012 1Q 2012 Gujarat State: 88% Expected : 85% 2Q 2012 Gujarat State: 88% 1Q 2012 Gujarat State: 87% Gujarat: 86% 27

NSP Success Rate TB Units – Gujarat Gujarat: 86% 2nd Quarter 2012 Expected : 85% Gujarat: 86%

Rate of change in suspects examined per lakh population (compared to same quarter in previous year) 2Q13 Vs 2Q12 Gujarat State : 7.2% 29

Rate of change in suspects examined per s+ case diagnosed (compared to same quarter in previous year) 2Q13 Vs 2Q12 Gujarat State : 8.1% 30

Sputum conversion of NSP patients registered in 4th quarter 2012

% of PHIs referring 2-3% of new adult OPD Gujarat 2nd Quarter 2013 32

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Major indicators – Internal Evaluations-2Q13 District Dahod Junagadh Bharuch Navsari Apr-13 May-13 June-13 Difference in NSP Cure rate b/w TB register and Quarterly Reports 0.9% 2.1% 0.3% 0% Difference in SP-RT Cure rate b/w TB register and Quarterly Reports 1.1% 0.1% DOT Rate in NSP interviewed 100% 90% 85% 95% Place & Timing of DOT Convenient Proportion of patients aware of their illness Wrong Categorization 10% 5% Aware about duration of Treatment 89% Attended a PP interaction meeting or community meeting 11% 30% Initial home visit has done 80% 63% Eligible children received chemoprophylaxis 56% Practicing proper cough etiquettes 37% 72% 71% Know their HIV status 21% 35%% 32% 34

PP Involvement – Gujarat - since 2006 Contribution of PPs in RNTCP 1st Q 13 Patients (no) % of total of state PPs involved 4858 Referral of suspects 3018 2.1% NSP patients put on DOTS 726 7.1% Total TB patients put on DOTS 1455 37

Referral of TB Suspects from Health Facilities Gujarat 1st Quarter 2013

ESIS Referral of TB Suspects Gujarat 1st Quarter 2013

NGOs Involvement – Gujarat Reporting format changed

Involvement - as a DOT Provider in RNTCP 2Q13

Status of Staffing No. of MOTCs vacant (5 / 144) Jamnagar (2), Kheda (1), Narmada (1), VMC (1) No. of Contractual STSs vacant (5 / 144) Kheda (2), Surendranagar (2), VMC (1) No. of Contractual STLSs vacant (4 / 144) Bharuch (2), Panchmahals (1), Valsad (1) No. of Contractual TBHVs vacant (17/203) AMC (9), Banaskantha (1), Bharuch (1), Dahod (1), Panchmahals (1), Porbandar (1), Rajkot (1), VMC (2)

Status of Training Untrained MO-TCs (6) Bhavnagar (1), Junagadh (1), Porbandar (1), The Dangs (1), VMC (2) Untrained STS (5) AMC (1), Anand (1), Chhotaudepur (1), Surat-R (1), Vadodara-R (1) Untrained STLS (7) Anand (1), Bhavnagar (1), Dahod (1), Narmada (1), Navsari (1), Panchmahals (1), Surat-R (1) Number of DMC LTs untrained (14) Banaskantha (2), Navsari (5), Sabarkantha (4), The Dangs (1), VMC (2)

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