1. REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
RNTCP

4. Introduction: 
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…

5. A 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.

6. Facts about TB:
One third of the world's population is affected by TB
Every year eight million people become sick with TB; of these 95 percent are in the developing world
26 percent of the avoidable adult deaths in the developing world are due to TB
40 percent of the world's TB cases lives in WHO's South-East Asia region
TB kills 2-3 million people each year; nearly 1 million deaths take place in South-East Asia
TB causes more deaths than AIDS, malaria and diarrhoea combined
TB kills more women than all cases of maternal mortality put together
TB is the leading infectious killer of people living with HIV/AIDS
More than 100,000 children die from TB every year
Up to 50 million people are likely to be infected with drug-resistant TB.

7. The 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.

8. Reason 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 disease
Non availability of trained staff

9. Revised strategy: Augmentation of organizational support
Increased budgetary outlay
Use of sputum as a primary method of diagnosis
Standardize treatment regimens
Augmentation of the peripheral level supervision
Ensuring a regular, uninterrupted supply of drugs up to the periphery health unit
Emphasis 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

11. PROGRAM
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

12. RNTCP-TARGET IN INDIA
million population in 190 districts were covered
million should be covered
2005- the whole country should be covered

13. SUCCESS OF RNTCP
“Instigating effective treatment regimens in a way that improves patient adherence is vital to tackling the global resurgence of tuberculosis”

14. RNTCP
ACTION PLAN

15. GOAL
To extend the RNTCP to cover the entire country by 2005

16. OBJECTIVE To cure 85% of the sputum positive cases
To detect 70% of the estimated cases of T.B

17. TARGET
Three million cases have to be treated and 1.5 million cases have to be cured.

18. STRATEGY
DOTS

19. DOTS

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

21. Components of DOTS
Case 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 volunteers
Systematic evaluation and monitoring
Political will

22. Treatment observes or Drug providers or Dots agent
Health inspectors
Pharmacists
Malaria field workers
Work place supervisors
Railway school teachers
SJAB personals
Cured patients
Wife of medical officers
Self help group volunteers
Mid-wife
Senior dressers
Multi purpose health workers
And H & FW personnel

23. TYPE OF TUBERCULOSIS PATIENT UNDER RNTCP
NEW CASE
RELAPSE
DEFAULTER
FAILURE CASE
CHRONIC CASE

25. CATEGORY I TREATMENT TYPE OF PATIENT New sputum positive
New sputum negative and seriously ill
New extra pulmonary seriously ill

26. CATEGORY - II TREATMENT
TYPE OF PATIENT
SPUTUM POSITIVE RELAPSE CASE
SPUTUM NEGATIVE RELAPSE OR FAILURE
SPUTUM POSITIVE TREATMENT AFTER DEFAULT

27. CATEGORY III TREATMENT
TYPE OF PATIENT
New sputum negative and not seriously ill
New extra pulmonary and not seriously ill

28. COLOUR OF BOXES AND QUANTITY OF DRUGS
RED COLOURED BOX
24 DOSES FOR TWO MONTHS OF INTENSIVE PHASE
18 CALENTERED WEEKLY MULTIBLISTER COMBI PACK FOR FOUR MONTHSOF CONTINUATION PHASE

29. COLOUR OF BOXES AND QUANTITY OF DRUGS
BLUE COLOURED BOX
36 DOSES FOR THREE MONTH OF INTENSIVE PHASE
22 CALENDERED WEEKLY MULTIBLISTER COMBI PACK FOR FIVE MONTHS OF CONTINUATION PHASE

30. COLOUR OF BOXES AND QUANTITY OF DRUGS
GREEN COLOURED BOX
24 DOSES FOR TWO MONTHS OF INTENSIVE PHASE
18 CALENTERED WEEKLY MULTIBLISTER COMBIBACK FOR FOUR MONTH OF CONTINUATION PHASE

31. MONITORING & EVALUATION
Sputum conversion rate
Cure rate

32. MONITORING 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…

33. MONITORING 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….

34. MONITORING 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…

35. MONITORING 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.

36. Sputum smear examination form Culture/sensitivity form
RECORDS AND REGISTER
Sputum smear examination form
Culture/sensitivity form
Laboratory register
TB register
Quarterly report form

37. THE STRATEGY FOR IMPROVING THE PERFORMANCE OF RNTCP PROGRAMME
Paramedical personnel to be nominated as DOTS agents
Motivation of the patients by Health Education
Early reporting
To create awareness about T.B
To take the treatment regularly, completely
To bring 3 consecutive day sputum for examination
To provide diagnostic and treatment facility in all sub- divisional, divisional and zonal hospitals
Contd..

38. THE 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.

39. CONCLUSION
Tuberculosis 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”.

40. FUTURE DIRECTION

41. The 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.