1. RNTCP: DOTS Expansion and plans for DOTS-Plus
Central Tuberculosis Division
Directorate General of Health Services
Ministry of Health & Family Welfare
Government of India

2. Status of DOTS expansion Plans for DOTS-Plus
Contents
Status of DOTS expansion Plans for DOTS-Plus

3. India: DOTS Implementation Status by District, 31st Mar 2005
Type of districts / reporting units
No. of districts / reporting units
Projected population (in million) *
Implementing
563
1001
Appraisal done 17 27
Ready for appraisal 8 14
Preparing 44 68
* 2005 projected population based on 2001 census.

4. significant cohort of 1.2 million TB patients initiated on DOTS
Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter
In 2004, a globally
significant cohort of 1.2 million
TB patients initiated on DOTS
Yearly total population projected from 2001 census.

5. Case detection (New S+ve) and treatment success
in DOTS areas, *
Treatment success has recently exceeded the global target of 85%
Case Detection in DOTS areas has recently attained global target of 70%
Population projected from 2001 census
Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

6. State-wise Case-detection and treatment success rates in RNTCP areas for 2004/2003

7. Treatment outcome of New Smear Positive patients in 2003

8. India: percentage of re-treatment cases
out of all smear positive cases, 2004

9. Treatment outcome of Retreatment patients excluding ‘Others’ in 2003

10. Plans for DOTS-Plus
RNTCP regimens highly effective, with low failure rates (2% in CAT I , 6% in CAT II cases)
However issue of PTB patients who remain positive following a fully supervised CAT II regimen, has previously not been well addressed by the RNTCP
Although these cases represent a small minority of overall caseload of TB patients, they constitute an on-going problem for RNTCP managers, both from an epidemiological and human rights viewpoint
Now that RNTCP is well established in 90% of the country, it is timely to develop services to address the needs of this group of patients

11. Plans for DOTS-Plus (…2)
MDR-TB is a laboratory diagnosis, NOT a clinical one
Hence quality assured culture and DST lab facilities must be available
For RNTCP to provide MDR-TB treatment, RNTCP will start establishing network of state-level IRLs
Aim is to have 1 such state-level IRL in each large state by
Requires a planned and phased programme of capacity building of such an IRL network

12. Plans for DOTS-Plus (…3)
RNTCP views treatment of MDR-TB patients as a “standard of care” issue
Recognizing that MDR-TB treatment is complex, treatment will follow the international DOTS Plus guidelines and will be done only in designated RNTCP DOTS Plus sites:
sites will be in a limited number of highly specialized centres, at least 1 in each large state;
sites will have ready access to an RNTCP accredited IRL;
will have adequate number of qualified staff available to manage patients;
use standardized second-line drug regimens given under daily DOT and with standardized follow-up protocols;
systems in place to deliver ambulatory DOT after an initial short period of in-patient care to stabilise patient on the second-line drug regimen; and
with a logistics system and standardized MIS in place

13. Plans for DOTS-Plus (…4)
Activities to be undertaken for DOTS Plus:
Formation of a national level MDR-TB / DOTS Plus Committee;
Develop national management guidelines for treatment of MDR-TB cases and DOTS Plus;
Establish procurement mechanism for second-line drugs, including systems for quality assurance of the drugs;
Identify sites for DOTS Plus; and
Enrol MDR-TB patients for treatment
DOTS Plus sites will be initiated in a phased manner similar to that for establishment of state-level IRL network, and sites will be geographically linked to the establishment of the IRLs
By 2010, plan is for 24 DOTS Plus sites, with the capacity to annually enroll 5,000 new MDR-TB cases for treatment
Planned to enroll first 100 cases in Gujarat and Maharashtra in early 2006

14. Nos. of DOTS Plus sites initiated Location of new DOTS Plus sites
Year
Nos. of DOTS Plus sites initiated
Location of new DOTS Plus sites
Annual nos. of new MDR-TB patients put on Rx *
Annual total nos. of MDR-TB patients on treatment 2
Gujarat and Maharashtra
100 -
5 (+2)
Delhi, Kerala, Rajasthan, Tamil Nadu & W Bengal (plus Andhra Pradesh and Orissa under GFATM R4)
450
550 7
Chandigarh, Chhattisgarh, Harayana, Himachal, Jharkhand, Karnataka and Uttaranchal
1250
1700 5
Assam, Goa, Madhya Pradesh, Punjab and UP
2350
3600 3
Bihar, J&K and Manipur
3450
5800
Total
22 (+2)
22 (+2) states
7600 (+1100)
In 1st Year of a new DOTS Plus site, 50 new patients enrolled per site for treatment. In 2nd Year, 100 patients enrolled. From 3rd Year onwards, 200 new patients enrolled for treatment annually in each DOTS Plus site.

15. Summary Rapid expansion – nearly 90% covered; 100% by end 2005
Case detection and treatment success meeting global targets within DOTS areas
Next 5-year plan includes, DRS and DOTS-Plus
Challenges for DOTS-Plus include laboratory capacity at State level, procurement of drugs, in-hospital care and follow-up/monitoring of patients, and a system for daily DOT

16. THANK YOU

17. Multiyear DOTS expansion plan for India *
31st March 2005
Total Population 1111
Yearly total population projected from 2001 census.
* Projected population based on 2001 census.

18. Progress Towards 70% Case Detection Target*
Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)

19. RNTCP Treatment Regimen
All treatment thrice weekly. Cat I and Cat II extended one
month if smear+ at end of initial intensive phase.