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Tuberculosis in India Dr Ashwini Kalantri Current Status: Dr BS Garg

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Presentation on theme: "Tuberculosis in India Dr Ashwini Kalantri Current Status: Dr BS Garg"— Presentation transcript:

1 Tuberculosis in India Dr Ashwini Kalantri Current Status: Dr BS Garg
Moderator Dr BS Garg

2 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 : National survey by ICMR 1959 : National TB Institute (NTI) to develop the national TB control programme.

3 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) : DOTS pilot (RNTCP) 1997 : RNTCP launched 2007 : DOTS Plus (PMDT) for Drug resistant TB Programmatic Management of Drug-resistant TB

4 The Stop TB Strategy 2006 - 15 : Second Global Plan to Stop TB
Roadmap and budget to reach MDGs

5 Microscopy vs X-ray Specificity X-ray False Positive True Positive 98%
60% 50% False Positive True Positive 40% Specificity X-ray NTI, Bangalore, 1974

6 Sanatorium vs Domiciliary care
Series Total Patients Favorable Response (%) Relapse (%) Total contacts Attack rate (%) Home 82 86 14 245 10.5 Sanatorium 81 92 12 264 11.5 This was a land mark study in the management of tuberculosis. All patients with smear positive tuberculosis and their contacts who were living with the patients were systematically followed up for a period of 5 years and as can be seen in the slide, there was no difference either in terms of immediate response to treatment, relapse during a follow up period of 4 years. Also the close contacts of patients who were treated at home were at no additional risk of developing disease. A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):

7 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

8 Components of DOTS Political commitment Diagnosis by microscopy
Adequate supply of the right drugs Directly observed treatment Accountability

9 Population Coverage and Patients Registered
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

10 RNTCP Objectives To achieve 85% cure rate for the newly diagnosed sputum smear positive TB patients To detect at least 70% of the new smear-positive patients

11 Treatment outcomes 1994 to 2006 85 A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

12 Unfavourable Treatment Outcomes 1994 to 2006
A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

13 Prevalence A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

14 3 vs 2 sputum samples

15 Revised National TB Control Programme
Achievements

16 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%

17 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%

18 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. National Strategic Plan for the 12th five year plan 4 times the budgetary allowance.

19 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

20 Economic Impact of TB Each case of TB Each death due to 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

21 TUBERCULOSIS Current Status

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23 Annual Incidence of TB

24 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) Percent (95% CI) HIV among estimated incident TB patients 0.11 (0.075–0.16) 5% (3.3–7.1%) MDR-TB among notified pulmonary TB patients 0.064 (0.044–0.075) 5.3% (3.6–6.2%) Prevalence 1990 – 583/100,000

25 Average annual decline
National ARTI survey Survey 1 ( ) Survey 2 ( ) Average annual decline Zone Prevalence ARTI % North 10.1 ( ) 1.9 ( ) 5.9 ( ) 1.1 ( ) 6% East 6.2 ( ) 1.2 ( ) 6.5 ( ) 1.2 ( ) West 8.7 ( ) 1.7 ( ) 4.0 ( ) 0.8 ( ) 8% South 6.1 ( ) 1.1 ( ) 6.8 ( ) 1.3 ( ) Total 1.5 ( ) 3.6% RNTCP, Annual Status Report 2013

26 Annual New Smear Positive Case Detection Rate, 2012
RNTCP, Annual Status Report 2013

27 Cure Rate of New Smear Positive Cases, 2011
RNTCP, Annual Status Report 2013

28 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% 59% Composite Score (250) 66% 63% RNTCP, Annual Status Report 2013

29 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

30 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

31 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

32 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 Rational Use of anti-TB drugs

33 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

34 PMDT Services RNTCP, Annual Status Report 2013

35 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)

36 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

37 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

38 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

39 Childhood TB The newer weight bands are 6-8 kg, 9-12 kg, kg, kg, kg and kg. Chemoprophylaxis for children under 6 years: isoniazid (5mg/kg) for 6 months Rifampicin 10-12 mg/kg (max 600 mg/day) Isoniazid 10 mg/kg (max 300 mg/day) Ethambutol 20-25mg/kg (max 1500 mg/day) PZA 30-35mg/kg (max 2000 mg/day) Streptomycin 15 mg/kg (max 1gm/day)

40 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

41 Revised National TB Control Programme
Newer initiatives

42 Notifiable Disease

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44 Other Initiatives Composite Indicator Ban of sero-diagnostic tests
Availability of free quality assured anti-TB drugs through local chemists

45 References A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010. Revised National TB Control Program : Annual Status Report New Delhi: Central TB Division, 2013. A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):

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