1. Summary of changes in the RNTCP technical guidelines in 2008-09
ZTF (South Zone) Workshop, Puducherry
27-28 August 2009
Dr. K S Sachdev, CMO
Central TB Division Directorate General of Health Services
Ministry of Health & Family Welfare Nirman Bhavan, New Delhi

3. (Newer) COMPONENTS OF THE STOP TB STRATEGY
Pursue high-quality DOTS expansion and enhancement
Secure political commitment, with adequate and sustained financing
Ensure early case detection, and diagnosis through quality-assured bacteriology
Provide standardized treatment with supervision, and patient support
Ensure effective drug supply and management
Monitor and evaluate performance and impact

4. Scale-up collaborative TB/HIV activities
Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
Scale-up collaborative TB/HIV activities
Scale-up prevention and management of multidrug-resistant TB (MDR-TB)
Address the needs of TB contacts, and of poor and vulnerable populations

5. Contribute to health system strengthening based on primary health care
Help improve health policies, human resource development, financing, supplies, service delivery and information
Strengthen infection control in health services, other congregate settings and households
Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL)
Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health

6. Engage all care providers
Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches
Promote use of the International Standards for Tuberculosis Care (ISTC)

7. Empower people with TB, and communities through partnership
Pursue advocacy, communication and social mobilization
Foster community participation in TB care
Promote use of the Patients' Charter for Tuberculosis Care

8. Enable and promote research
Conduct programme-based operational research, and introduce new tools into practice
Advocate for and participate in research to develop new diagnostics, drugs and vaccines

9. Diagnosis of TB Change in the definition of PTB suspect
- “Pulmonary TB suspect is any person with cough for 2 weeks, or more”
Change in the number of sputum samples required for diagnosis of PTB from 3 to 2
Number of specimen required for diagnosis is 2, with one of them being a morning sputum
One specimen positive out of the two is enough to declare a patient as Sm+ PTB
Based on WHO STAG recommendations and further evidence from India

12. Recording and reporting
Revised PM report for PHI, TU, District and State
MDR-TB suspects
TB/HIV Activities
Revised PPM schemes
Involvement of other sectors
ACSM (IEC)
Information on quality of DOTS for all smear positive TB patients (not just NSP cases)
New software phased in. Old software to be phased out in 2010

13. TB/HIV
Offer of VCT to all TB patients started in 9 states and planned to expand to the entire country by 2012
Recording of HIV status in TB records in these states
Early start of ART in eligible HIV+ve TB patients (2 wks following start of TB treatment; TB patients with CD4 <350/cc eligible for ART); also recording in TB records in these states
Decentralized provision of CPT to all HIV+ve TB patients in these states
Intensified TB case finding at ICTCs, ART centres & CCCs
Priority accorded to airborne infection control in ART centres

14. WHO-recommended TB/HIV interventions
Indian TB/HIV
Activities
Ongoing
Ongoing at VCTC; ART
Pilot testing
Guidelines in preparation
Collaborative TB/HIV activities jointly implemented by RNTCP and NACP in India include all the TB/HIV interventions recommended by WHO.
Ongoing (ICTCs)
Ongoing (NACO)
Ongoing
Ongoing (NACO ART centres) 14

15. MDR-TB….1 Recently implemented change in MDR-TB suspect definition
“any patient who fails a Cat I or III treatment regimen or any Cat II patient who remains smear positive at the end of the fourth month of treatment or later”
Future change of MDR-TB suspect definition planned to include all smear +ve retreatment cases
Elimination of exclusion criteria (pregnancy, pediatric age-group, H/o SL ATT) for DOTS-Plus
National DOTS-Plus committee has recommended
A Cat-V regimen for XDR-TB
To treat Rif mono-resistance with Cat-IV
Replace ofloxacin with levofloxacin in Cat-IV regimen

16. MDR-TB….2 Newer rapid diagnostics
Molecular technology based DST (Line Probe Assay)
Advantages: rapid (result in 2 days), high throughput
Status: Validation phase over; demonstration phase to start in Aug 2009
43 labs with LPA planned (these labs will also have solid media DST)
Automated liquid culture
In 33 out of the 43 labs liquid culture systems planned

17. PPM New PPM schemes implemented Additional scheme on:
TB/HIV for high HIV risk population
Purchase of DST services from private accredited labs
Sputum collection and transportation

18. Other changes
Operational research: New operational research agenda and guidelines (can be downloaded from
RNTCP OR agenda 2009.pdf
RNTCP OR guidelines March2009.pdf
Airborne infection control guidelines being developed

19. Change is also happening in RNTCP policy

20. Thanks