For MDR-TB

Report
Current Status:
Tuberculosis in India
Dr Ashwini Kalantri
Moderator
Dr BS Garg
History of TB Control in India
• 1906 : Open air sanatorium in Ajmer
• 1929 : King George V Thanksgiving Fund
for TB control
• 1939 : TB Association of India (TAI)
• 1946 : Plan for TB Clinic in every district
• 1955 - 58 : National survey by ICMR
• 1959 : National TB Institute (NTI) to
develop the national TB control
programme.
History of TB Control in India
•
•
•
•
1961 : NTP pilot tested in Andhra Pradesh
1962 : NTP launched
1978 : NTP covered 390 districts (81%)
1983 : Short-course chemotherapy
(compliance improved only marginally)
• 1993 - 97 : DOTS pilot (RNTCP)
• 1997 : RNTCP launched
• 2007 : DOTS Plus (PMDT) for Drug
resistant TB
The Stop TB Strategy
• 2006 - 15 : Second Global Plan to Stop TB
• Roadmap and budget to reach MDGs
Microscopy vs X-ray
98%
90
Sputu
m AFB
80
70
60%
60
50
X-ray
30
40%
20
10
0
Specificity
True Positive
40
50%
False Positive
100
X-ray
NTI, Bangalore, 1974
Sanatorium vs Domiciliary care
Total
Patients
Favorabl
e
Respons
e (%)
Relapse
(%)
Total
contacts
Attack
rate (%)
Home
82
86
14
245
10.5
Sanatorium
81
92
12
264
11.5
Series
A concurrent comparison of home and sanatorium treatment of pulmonary
tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.
The Revised National TB
Control Programme
• 100% centrally sponsored
• Free of cost diagnosis and treatment with
anti-TB drugs
• 13,000+ microscopy centers
• 4,00,000+ DOTS treatment centers
• RNTCP an integral part if the NRHM
Components of DOTS
•
•
•
•
•
Political commitment
Diagnosis by microscopy
Adequate supply of the right drugs
Directly observed treatment
Accountability
Population Coverage and Patients
Registered
A brief history of tuberculosis control in India. Geneva, Switzerland: World
Health Organisation; 2010.
RNTCP Objectives
• To achieve 85% cure rate for the newly
diagnosed sputum smear positive TB
patients
• To detect at least 70% of the new smearpositive patients
Treatment outcomes
1994 to 2006
85
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
Unfavourable Treatment Outcomes
1994 to 2006
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.
Prevalence
A brief history of tuberculosis control in India. Geneva, Switzerland: World
Health Organisation; 2010.
3 vs 2 sputum samples
100
Cumulative Positivity
90
85
86
80
70
68
86
88
71
60
First
Second
Third
50
40
30
20
10
0
NTI, Bangalore
TRC
Revised National TB Control Programme
ACHIEVEMENTS
Achievements of RNTCP
• Evaluated 55 million+ persons for TB
• Initiated treatment for 15.8 million+ TB
patients.
• 2.8 million lives saved
• TB/HIV services in 18 states
• MDR-TB services in 132 districts
• Successful medical college involvement
• ARTI reduced from 1.5% to 1.1%
Achievements during 11th FYP
Indicators
Planned
Achieved
No of TB suspects examined
(millions)
23.72
27.5
Total number of patients to be
put on treatment (millions)
5.04
6.4
New Smear Positive patients to
be put on treatment (millions)
2.34
2.46
No of MDR TB patients to be
put on treatment (000)
5
4.2
Success Rate in New Smear
Positive patients in RNTCP (%)
≥85%
87%
Estimated Annual Prevalence per
lakh population
Reduced from 299 to 250
Annual Risk of TB Infection (%)
Reduced from 1.5% to 1.1%
Objectives for the 12th FYP
• Early detection and treatment of at least 90%
of all type of TB cases
• Reduction in default rate of new TB cases to
less than 5% and re-treatment TB cases to
less than 10%
• Screening for drug-resistant TB and provision
of treatment services for MDR-TB patients
• HIV Counseling and testing for all TB patients
• Extend RNTCP services to patients
diagnosed and treated in the private sector.
Targets for the 12th FYP
• Detection & treatment of about 87 lakh
Tuberculosis patients during 12th FYP
• Detection & treatment of at least 2 lakh
MDR-TB patients during 12th FYP
• Reduction in delay in diagnosis and treatment
of all types of TB cases
• Increase in access to services to
marginalized and hard to reach populations
and high risk and vulnerable groups
Economic Impact of TB
• Each case of TB
– US$ 12,235
– 4.1 DALYs
• Each death due to TB
– US$ 67,305
– 21.3 DALYs
• 29.2 million DALYs and US$ 88.1 billion
gained due to RNTCP
TUBERCULOSIS
CURRENT STATUS
Annual Incidence of TB
Rest of the
World
74%
India
26%
Estimated burden of TB in India
Number (Millions)
(95% CI)
Rate Per 100,000
(95% CI)
Incidence
2.3 (2.0–2.5)
185 (167–205)
Prevalence
3.1 (2.0–4.6)
256 (161–373)
Mortality
0.32 (0.21–0.47)
26 (17–39)
Number (Millions)
(95% CI)
Percent
(95% CI)
0.11 (0.075–0.16)
5% (3.3–7.1%)
HIV among estimated
incident TB patients
MDR-TB among notified
pulmonary TB patients
0.064 (0.044–0.075) 5.3% (3.6–6.2%)
National ARTI survey
Zone
North
East
West
South
Total
Survey 1
Survey 2
(2000-01)
(2009-10)
Prevalence
10.1 (9.111.1)
6.2 (5.57.0)
8.7 (7.79.6)
6.1 (5.46.7)
ARTI
1.9 (1.72.1)
1.2 (1.01.3)
1.7 (1.51.9)
1.1 (1.01.2)
1.5 (1.41.6)
Prevalence
5.9 (4.77.0)
6.5 (4.86.2)
4.0 (3.24.9)
6.8 (5.97.7)
ARTI
1.1 (0.81.3)
1.2 (0.91.5)
0.8 (0.80.9)
1.3 (1.11.5)
1.1 (1.01.2)
Average
annual
decline
%
6%
—
8%
—
3.6%
RNTCP, Annual Status Report 2013
Annual New Smear Positive Case
Detection Rate, 2012
RNTCP, Annual Status Report 2013
Cure Rate of New Smear Positive
Cases, 2011
RNTCP, Annual Status Report 2013
Composite Indicators
India Maharashtra Wardha
Human Resources (65)
68%
54%
87%
Financial Management
(20)
71%
79%
100%
Drugs and Logistics (30)
67%
64%
0%
Case Finding Efforts (20)
30%
39%
40%
Quality of Service (115)
57%
64%
59%
Composite Score (250)
59%
66%
63%
RNTCP, Annual Status Report 2013
Case Detection
• RNTCP Designated Microscopy Center
(DMC)
• 2 Sputum smear examination (spot and
morning)
• ZN smear exam under bright field
binocular microscopes
• Drug resistant TB – solid/liquid culture
DSTs
• CBNAAT being used in 18 sites
Treatment
• INH (H), Rifampicin(R), Pyrazinamide (Z),
Ethambutol (E) and streptomycin (S)
• Category I : 6 months
– 2 months Intensive Phase: HRZE thrice
weekly
– 4 months Continuation Phase: HR
• Category II : 8 months
– 3 months Intensive Phase: 2 months HRZES
and 1 month HRZE
– 5 months Continuation Phase: HRE
Treatment
• All doses of intensive phase and first dose
of each week of continuation phase are
given under supervision.
• Follow-up sputum examination at the end
of intensive phase, 2 months into the
continuation phase and at the end of
treatment
Drug Resistant TB
• By 2015: DST for all smear positive cases
• MGIMS, Sevagram certified for solid
culture and DST.
• Genexpert (CBNAAT) introduced in 12
TUs
Drug Resistant TB Treatment
• For MDR-TB : Daily DOT includes (6-9m)
Kanamycin, Levofloxacin, Cycloserine,
Ethionamide, Pyrazinamide, Ethambutol /
(18m) Levofloxacin, Cycloserine,
Ethionamide, Ethambutol
• For XDR-TB : (6-12m) Capreomycin, PAS,
Moxifloxacin, High dose INH, Clofazimine,
Linezolid, Amoxy- Clavulanic Acid / (18m)
all the above drugs except Capreomycin
PMDT Services
RNTCP, Annual Status Report 2013
TB/HIV
• Latent TB  Active TB
• 2001: TB/HIV collaboration
• ICTC : Intensified TB case finding has
been implemented nationwide at all HIV
testing and ART centres
• HIV testing of TB patients is now routine
through provider initiated testing and
counselling (PITC)
TB/HIV
• 2012 : 56% TB patients screened, 5%
positive
• HIV-positive given free HIV care at the
antiretroviral treatment (ART) centres
• Policy decision taken expand coverage of
whole blood finger prick HIV screening test
at all DMC
TB and Diabetes
• People with a weak immune system, as a
result of chronic diseases such as
diabetes, are at a higher risk of
progressing from latent to active TB.
• Diabetics have a 2-3 times higher risk of
TB
• 10% of TB cases globally are linked to
Diabetes
• Longer time of sputum conversion
TB and Diabetes
• High chances of drug resistance, mortality
and relapse
• Good glycemic control in TB patients has
better outcome
• Policy to screen all TB patients for DM in
the 100 districts where NPCDCS has been
implemented
Childhood TB
• The newer weight bands are 6-8 kg, 9-12 kg,
13-16 kg, 17-20 kg, 21-24 kg and 25-30 kg.
• Chemoprophylaxis for children under 6 years:
isoniazid (5mg/kg) for 6 months
Rifampicin
Isoniazid
10-12 mg/kg (max 600 mg/day)
10 mg/kg (max 300 mg/day)
Ethambutol
PZA
Streptomycin
20-25mg/kg (max 1500 mg/day)
30-35mg/kg (max 2000 mg/day)
15 mg/kg (max 1gm/day)
Childhood TB
• If sputum sample not available, alternative
specimen (Gastric lavage, Induced
sputum, bronco-alveolar lavage) should be
collected under pediatric supervision.
• Tuberculin skin test / Mantoux : 10 mm or
more induration
Revised National TB Control Programme
NEWER INITIATIVES
Notifiable Disease
www.nikshay.gov.in
Other Initiatives
• Composite Indicator
• Ban of sero-diagnostic tests
• Availability of free quality assured anti-TB
drugs through local chemists
References
1. A brief history of tuberculosis control in
India. Geneva, Switzerland: World Health
Organisation; 2010.
2. Revised National TB Control Program :
Annual Status Report 2013. New Delhi:
Central TB Division, 2013.
3. A concurrent comparison of home and
sanatorium treatment of pulmonary
tuberculosis in South India. Bull World
Health Organ. 1959;21(1):51-144.

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