4Introduction: TB is one of most important public health problems worldwide. It has got high priority within the health sectors. It stands 7th in the ten leading causes of global disability adjusted life years (DALYS) lost and expected to maintain its position even in 2020 AD. India accounts for nearly 1/3 rd of the global tuberculosis burden. Unfortunately the prevalence and incidence rates remain same as in and with the increase in the country’s population, the absolute number of TB cases must have increased many fold but total cases detected in 1994 were more or less same as in 1987 which indicates poor case detection and case management.Tuberculosis in India continues to take a toll of 1,000 per day or one every minute. It is estimated that there are 14 million TB cases in our country out of which 3.5 million are sputum positive. About 1 million sputum cases are added every year. National Tuberculosis Control Programme was started in The objectives of the Programme were to reduce the morbidity and mortality, to reduce disease transmission and to diagnose as many cases of tuberculosis as possible and to provide free treatment. However, it could not make much of an impact on this dreaded disease. It was mainly due to incomplete treatment as treatment completion rate was less than 40 per cent along with some other causes such as inadequate budget; shortage of drugs; emphasis on x-ray diagnosis; poor quality sputum microscopy and multiplicity of treatment regimens. The crux of failure of TB control programme was:Lack of finances b) lack of commitment by the policy maker’s c) lack of urgency to achieve control and d) lack of compliance CONTD…
5A comprehensive review in 1992 determined that the programme had not achieved the desired results. There was urgent need in 1993 to design a policy and methodology, which will remove all these lacunae. In 1993, the WHO declared TB to be a global emergency. To intensify the efforts to control TB, the Government of India introduced the revised strategy known as the Revised National Tuberculosis Control Programme (RNTCP), which is based on Directly Observed Treatment –Short Course (DOTS) strategy. National Health policy 2002 has supported the Revised National Tuberculosis Control Programme (DOTS) with the goal of reducing 50% mortality by the year 2010.The World Tuberculosis Day is being observed on 24th March every year. The theme chosen for World TB Day-2004 (WTBD) is “ Every Breath Counts- Stop TB Now”. The Prime Minister on March 25, 2004 said by 2005, the entire country would be covered by DOTS (directly observed treatment, short course, a comprehensive and cost-effective strategy for TB control. He said more than a decade ago, the WHO declared TB a global emergency and in India determined steps were taken to control this epidemic by launching the revised national TB control pro- gramme in The DOTS strategy adopted under this programme is one of the notable successes in public health in India, he said, adding that its coverage has increased from 130 million five years ago to 800 million of the population in the current year. He said the TB control programme in India has so far prevented 2.6 million infections. It has also saved 5,00,000 lives. 31st December 2003, the total number of patients who had been treated under the RNTCP was 26,39,194.
6Facts about TB:One third of the world's population is affected by TBEvery year eight million people become sick with TB; of these 95 percent are in the developing world26 percent of the avoidable adult deaths in the developing world are due to TB40 percent of the world's TB cases lives in WHO's South-East Asia regionTB kills 2-3 million people each year; nearly 1 million deaths take place in South-East AsiaTB causes more deaths than AIDS, malaria and diarrhoea combinedTB kills more women than all cases of maternal mortality put togetherTB is the leading infectious killer of people living with HIV/AIDSMore than 100,000 children die from TB every yearUp to 50 million people are likely to be infected with drug-resistant TB.
7The 22 countries most affected by tuberculosis are Afghanistan, Bangladesh, Brazil, Cambodia, China, the Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Myanmar, Nigeria, Pakistan, Peru, the Philippines, Russia, South Africa, Thailand, Tanzania, Uganda, Vietnam and Zimbabwe, says WHO.
8Reason for failure of National tuberculosis control programme Completion rate of treatment was 30% Inadequate budgetary outlay Shortage and irregular supply of anti-tuberculosis drugs Undue emphasis on x-ray diagnosis Poor quality of sputum microscopy More emphasis on case detection rather then cure Poor organizational setup and support Multiplicity of treatment regimes Poor awareness of TB patients about the diseaseNon availability of trained staff
9Revised strategy: Augmentation of organizational support Increased budgetary outlayUse of sputum as a primary method of diagnosisStandardize treatment regimensAugmentation of the peripheral level supervisionEnsuring a regular, uninterrupted supply of drugs up to the periphery health unitEmphasis on training, IEC, and Operational research
10“WHO” goals for 2005:To ensure that 70 per cent of TB cases would be detected.per cent would be treated successfully
11PROGRAMREVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
12RNTCP-TARGET IN INDIAmillion population in 190 districts were coveredmillion should be covered2005- the whole country should be covered
13SUCCESS OF RNTCP“Instigating effective treatment regimens in a way that improves patient adherence is vital to tackling the global resurgence of tuberculosis”
20“THE DOTS STRATEGY REPRESENTS THE MOST IMPORTANT PUBLIC HEALTH BREAKTHOUGH OF THE DECADE, IN TERMS OF LIVES WHICH WILL BE SAVED”. DIRECTOR GENERAL WORLD HEALTH ORGANISATION MARCH 24, 1997
21Components of DOTSCase detection with help of microscopy with a system of multi-tier cross-checking and quality assurance of sputum smear.Regular and uninterrupted supply of drugs(patient-wise boxes)Direct observation while patient is getting chemotherapy by the health worker and community volunteersSystematic evaluation and monitoringPolitical will
22Treatment observes or Drug providers or Dots agent Health inspectorsPharmacistsMalaria field workersWork place supervisorsRailway school teachersSJAB personalsCured patientsWife of medical officersSelf help group volunteersMid-wifeSenior dressersMulti purpose health workersAnd H & FW personnel
23TYPE OF TUBERCULOSIS PATIENT UNDER RNTCP NEW CASERELAPSEDEFAULTERFAILURE CASECHRONIC CASE
32MONITORING INDICATORS 1. Annualized detection of New Smear Positive Cases Detection rate of new sputum smear-positive (infectious) tuberculosis cases per 100,000 populations. It is estimated that the national average rate of new cases is 85 per 100,000. The global and national target is to detect at least 70% of the total estimated cases – i.e. 60 cases per 100,000 per year contd…
33MONITORING INDICATORS 2. Ratio of New S-ve cases to S+ve Cases In a well performing area, there will be no more than approximately 1 smear-negative case (not laboratory confirmed) for every smear-positive (infectious, confirmed in the laboratory) case. The accepted ratio under RNTCP between smear-negative and smear positive cases ranges from 0.4 to Contd….
34MONITORING INDICATORS 3. Smear Conversion Rate Percentage of new smear-positive (infectious) patients who are documented to become non-infectious within 3 months of starting treatment. In a well-performing area, a conversion rate of at least 85-90% will be achieved. This indicator is reported one quarter after patients begin treatment, and applies to every patient started on treatment, without exceptions contd…
35MONITORING INDICATORS 4. Treatment Success Rate Percentage of new smear-positive (infectious) patients who are documented to either be cured, or to successfully complete treatment. In a well-performing area, at least 80-85% of patients will be successfully treated. The global and national target is 85% treatment success. This indicator is reported months after patients begin treatment, and applies to every patient started on treatment, without exceptions.
36Sputum smear examination form Culture/sensitivity form RECORDS AND REGISTERSputum smear examination formCulture/sensitivity formLaboratory registerTB registerQuarterly report form
37THE STRATEGY FOR IMPROVING THE PERFORMANCE OF RNTCP PROGRAMME Paramedical personnel to be nominated as DOTS agentsMotivation of the patients by Health EducationEarly reportingTo create awareness about T.BTo take the treatment regularly, completelyTo bring 3 consecutive day sputum for examinationTo provide diagnostic and treatment facility in all sub- divisional, divisional and zonal hospitalsContd..
38THE STRATEGY FOR IMPROVING THE PERFORMANCE OF RNTCP PROGRAMME .The paramedical and H&FW staffs to be trained to improve their intercommunication skill. T.B Association has to provide cash assistance to prepare the I.E.C Materials in the local languages. Discourage to conduct diagnostic camp, as it is counter productive in T.B cases.The medical officers instead of finding fault, they have to encourage the field workers to improve their performance.
39CONCLUSIONTuberculosis is a major public health problem in India.This serious situation will further worsen with TB/HIV co-infection and multidrug resistant TB.Several members in India have begun to implement the revised strategy but there are many constrains which require both national and regional efforts.Strong and sustainable revised RNTCPs must be established in order to achieve the global targets at a 85% cure and 70% case finding by the year 2010.Without DOTS it is highly unlikely that countries will be able to develop effective and sustainable national tuberculosis programme.With the introduction of DOTS, achieving the global targets for tuberculosis control has now become a realistic proposition.“Is it not time for DOTS to become the standard of care in tuberculosis worldwide”.
41The immediate challenges for the control of tuberculosis include developing curative regimens that are shorter or that require patients to take drugs less frequently, ideally, future regimens would have both features that is, a once weekly regimen requiring that patients be treated for only four months. Such regimens would greatly facilitate monitoring compliance. The more compelling long-term issue is the development of an improved vaccine that would have an epidemiological impact. BCG does reduce morbidity and mortality in infants but has little effect on adult pulmonary disease, which is the primary cause of death and virtually the only source of transmission. Unfortunately, because the reservoir of currently infected people is so huge, the benefits of an improved vaccine would not have substantive impact for decades. Finally, it is crucial that new, affordable and non-toxic drugs be developed to replace those lost to drug resistance.