1. Revised National Tuberculosis Control Programme Update and Challenges Dr. B Mahadev, CMO National Tuberculosis Institute Bangalore ZTF (South Zone) Workshop, Puducherry 27-28 August 2009

2. Overview of the presentation Burden of TB- Global and India Update on achievements of RNTCP –Case detection and treatment outcomes –TB-HIV Collaboration –Involving all care providers (NGOs and PPs) –Impact of RNTCP Challenges and Future plans

3. Estimated TB incidence per 100,000 population (2007) The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved Source: Global TB Report, 2009 World Health Organization

4. India is the highest TB burden country accounting more than one fifth of the global incidence Source: WHO Geneva; WHO Report 2009: Global Tuberculosis Control; Surveillance, Planning and Financing Global annual incidence = 9.23 million India annual incidence = 1.96 million India is 17 th among 22 High Burden Countries (in terms of TB incidence rate)

5. Problem of TB in India Incidence: 1.96 million new TB cases annually (2007) –Incidence more in north and in urban areas Prevalence: 3.8 million bacteriologically positive (2000)* Deaths: about 316,500 deaths due to TB each year (2007) 2.31 million population living with HIV; ~ 0.9 million co-infected –~4.85% of TB patients estimated to be HIV positive MDR-TB in new TB cases is ~3% and in previously treated cases is 12%-17% Affects predominantly economically productive age group leading to huge socio-economic impact *Source: National estimate 2000, published in IJMR, Sept, 2005; 243-48

6. Key Achievements of RNTCP

7. In the year 2008, more than 1.5 Million patients registered for treatment, every month more than 100,000 patients are registered on treatment. Whole country coverage achieved in March, 2006 372837

8. Achievements in line with the global targets New Smear Positive (NSP) case detection and treatment outcome targets achieved both in 2007 and 2008 Since implementation > 42 million TB suspects examined > 10 million pts placed on treatment > 1.8 million lives saved

9. Treatment Outcome of Smear Positive Cases registered under RNTCP DOTS, 1993-2007 NSP N = 3,589,838 Sp + Retreatment N = 1,312,710 The default rates (2007) among NSP is 6% and that of Re-treatment cases is 14.9%

10. Extra-pulmonary TB – By Site Source of pie-diagram: RNTCP Data from 13 Districts, Q3 2004 20042005200620072008 Total New Cases991,0101,067,7861,137,3361,198,2541,213,656 Extra-pulmonary TB15% (144,375) 16% (171,259) 16% (183,180) 17% (206,744) 18% (215,860)

11. Total cases (n =560,936) Treatment outcome of New Extra-Pulmonary Patients registered under RNTCP DOTS (2005-2007) (all forms of EP TB)

12. Quality diagnostic and treatment services ~12,500 decentralized designated microscopy centers established External Quality Assurance (EQA) system for sputum microscopy as per international guidelines Quality assured drugs Patient wise drug boxes Patient friendly DOT services

13. Network of nearly 0.4 million DOT providers: Quality of DOT ensured predominantly through Supervision by DTOs, MOTCs, STS Private doctor in Pune Unani doctor in Jaipur NGO Worker in Andhra Homeo doctor in Pune

14. Robust Programme Surveillance System Peripheral Health Institute (DMC and other PHIs) District TB Centre Electronic reports) Central TB Division State TB Cell Tuberculosis Unit Monthly PHI Report Quarterly CF, SC, RT, PM Reports Quarterly Reports CF, SC, RT, PM Additional Feedback Quarterly Feedback System electronic from district level upwards Cohort analysis

15. RNTCP “Supervision and Monitoring strategy” Programme has a well defined strategy for S & M It has checklists for all levels of staff It has a compendium of indicators

16. Total population of 1.1 billion 400 million TB infected ~2.31 million HIV-infected ≥0.9 million TB/HIV co-infected 1.9 million new TB cases 4.85% TB cases HIV-infected (~95,240 cases) HIV-associated TB disease in India 1.9 million new cases per year → But TB epidemic in India is being primarily driven by the 399 million TB infected non-HIV infected pool

17. TB-HIV activities in India TB-HIV collaboration began in 2001 –Joint training –Intensified case finding at ICTCs –HIV testing of TB patients with HIV risk factors 2004: Scale up of activities to ICTCs in 8 States 2006: Scale-up of activities to 14 states 2007: Piloted CPT & Routine Referral of TB patients for HIV testing (5 Districts) 2008: National Framework for Collaborative TB-HIV activities

18. India’s response: Comprehensive TB-HIV activities nationwide TB/HIV activities in all States Coordination & Training on TB/HIV Intensified Case Finding (ICF) at ICTCs, ART Centres and CCCs Risk-based referral of TB patients for VCT Referral of all HIV- TB patients for HIV care and support (CPT & ART) Involve NGOs: Include TB/HIV in “Targeted Interventions” for populations at risk of HIV

19. Intensified TB-HIV package for high HIV burden states (2009), All states by 2012 Additional activities Additional training on TB-HIV for all health staff Provider-initiated HIV counseling and testing for all TB patients Decentralized provision of Co- trimoxazole by local health centres for co-infected patients Expanded TB-HIV monitoring and evaluation: inclusion of HIV status, co-trimoxazole, and ART in TB programme records and reports Implemented in AP, MH, TN, KA, MN, NG, MZ, GA & PD (Delhi & Gujarat - 2009) Entire country by 2012

20. Training Modules for Intensified TB/HIV Package

21. Intensified Case Finding - TB suspects referred from ICTC for evaluation, 2005-2008 > 8 fold increase in referrals Source: Monthly reports from ICTCs collated and reported by respective State AIDS Control Societies

22. Total TB patients registered No. with known HIV status Known to be HIV infected

23. Revised NGO/PP schemes for involvement of NGOs and PPs Scheme for ACSM* Scheme for Sputum Collection Scheme for Transport Scheme for Microscopy centre Laboratory Technician Scheme Culture and DST**Scheme Scheme for Treatment Adherence Scheme for Urban Slums Scheme for the Tuberculosis Unit Scheme for TB/HIV * Advocacy, Communication and Social Mobilization **Drug Susceptibility Testing

24. PPM activities for involvement of all health care providers Involvement of NGOs and Private Practitioners –Schemes revised in 2008 –Presently > 2500 NGOs, 17,000 PPs involved Involvement of professional bodies like IMA, IAP Other Central government departments/PSUs  CGHS, Railways, ESI, Mining, Shipping Corporate sector  ~150 Corporate Houses participating Involvement of FBOs like CBCI Involvement of Medical Colleges –Task Forces and Core Committees formed –263 Medical colleges involved

25. Well defined IEC Strategy IEC officers and communication facilitators have been appointed at State and Districts respectively to support the programme

26. Impact of RNTCP

27. Trends in prevalence of culture-positive and smear-positive tuberculosis in south India (5 Blocks), 1968-2006 Pre-SCC treatment eraSCC treatment era RNTCP era Impact of RNTCP

28. Progress towards Millennium Development Goals 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 –The global new case detection rate is 64% (2007) and treatment success rate is 85% –RNTCP consistently achieving global bench mark of 85% treatment success rate for NSP; and case detection rate 72% (2008) 51.7% 33.3% Prevalence rate of TBMortality rate of TB

29. RNTCP: Studies for assessment of Impact Nation wide ARTI Survey – 2008-10 –Coordinated by NTI, Bangalore in association with New Delhi TB Centre (North Zone) MGIMS, Wardha (West Zone) LRS Institute, New Delhi (East Zone) CMC, Vellore (South Zone) Disease prevalence Surveys – 2007-09 –TRC Chennai – MDP project –NTI, Bangalore –MGIMS, Wardha –PGI, Chandigarh –AIIMS, New Delhi –JALMA, Agra –RMRCT, Jabalpur Repeat ARTI and Disease prevalence surveys planned in 2015 Symptomatic screening + CXR + Sputum Smear + Culture Symptomatic screening + Sputum Smear + Culture

30. Challenges and Future plan

31. Challenges of RNTCP Maintaining and further improving the quality of services across the country Promoting rational use of first line and second line anti-TB drugs outside the programme for prevention of MDR and XDR TB Scaling up culture & DST and treatment services for MDR-TB. Scaling up of PPM activities to link all providers to the national programme TB-HIV collaboration –ART-DOTS linkages `for improving access –Operationalisation of CPT prophylaxis to co-infected patients Promote operational research to address the local challenges Introduction of new tools for diagnosis and drugs for treatment

32. Future plan Maintaining/improving quality and reach of DOTS with special focus on improving programme performance in underperforming areas Scaling up of MDR-TB management Engaging all care providers Promoting community involvement and ownership Further strengthening TB-HIV collaborative activities –Expansion of intensified TB/HIV package to entire country by 2012 Introduction of newer diagnostics –Eg., introduction of LPA tests in RNTCP accredited labs

33. Thank you