rntcp: dots expansion and plans for dots-plus central tuberculosis division directorate general of...
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RNTCP: DOTS Expansion and plans for DOTS-Plus
Central Tuberculosis DivisionDirectorate General of Health Services
Ministry of Health & Family WelfareGovernment of India
Status of DOTS expansion
Plans for DOTS-Plus
Contents
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.ImplementingAppraisal doneReady for appraisalPreparing
2 3 7 6 1 5
0
100
200
300
400
500
600
700
800
900
1000
I/94
III/9
4I/9
5III
/95
I/96
III/9
6I/9
7III
/97
I/98
III/9
8I/9
9III
/99
I/00
III/0
0I/0
1III
/01
I/02
III/0
2I/0
3III
/03
I/04
III/0
4
Quarter/Year
Po
pu
lati
on
co
ve
red
(m
illio
ns
)
0
50000
100000
150000
200000
250000
300000
To
tal p
ati
en
ts t
rea
ted
Total patients treatedPopulation coverage(in millions)
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
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Annualised New S+ve CDR Success rate
Case detection (New S+ve) and treatment success in DOTS areas, 1999-2004 *
•Population projected from 2001 census•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)
State-wise Case-detection and treatment success rates in RNTCP areas for 2004/2003Case-detection and treatment success rates in RNTCP areas for 2004/2003
70%
75%
80%
85%
90%
95%
100%
40% 50% 60% 70% 80% 90% 100%Case detection
Suc
cess
rat
e
Target Zone
Bihar
Andhra Pr.
HaryanaManipur
MizoramDelhi
Gujarat
Arunachal Pr.
SikkimRajasthan
Chandigarh
2004
W Bengal
Tamil Nadu Himachal Pr.
Orissa
Karnataka
Madhya Pr.
Uttaranchal
Jharkhand
Maharashtra
Chhatisgarh
Punjab
Nagaland
Assam
Kerala
Uttar Pr.
Meghalaya
2000
2002
2001
2003
Treatment outcome of New Smear Positive patients in 2003
Cure, 84.9%
Died, 4.7%
Failure, 2.5%
Defaulted, 6.2%
Trans out, 0.3%
Completed1%
n=358,196
14%
35%
24%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Orissa
Chhatis
garh
Kerala
Tamil
Nadu
Bihar
Jam
mu &
Kas
hmir
West
Ben
gal
Jhar
khan
d
Tripura
Andhra
Pra
desh
Maha
rash
tra
Assam
India
Tota
l
Karnat
aka
Mizo
ram
Uttar P
rade
sh
Chandig
arh
Madh
ya Pra
desh
Mani
pur
Pondiche
rry
Sikki
m
Punjab
Goa
Megh
alaya
Nagaland
Arunac
hal P
rades
h
Haryan
a
Himach
al Pra
desh
Rajast
han
Delhi
Uttara
nchal
Gujara
t
India: percentage of re-treatment cases out of all smear positive cases, 2004
Treatment outcome of Retreatment patients excluding ‘Others’ in 2003
Failure, 6%Cured,
66%
Transferred out, 0.6%
Defaulted, 15%
Completed, 4%
Died, 8%
n=112,304
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
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 2009-10 Requires a planned and phased programme of capacity
building of such an IRL network
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
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
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
2005-06 2 Gujarat and Maharashtra 100 -
2006-07 5 (+2) Delhi, Kerala, Rajasthan, Tamil Nadu & W Bengal (plus Andhra Pradesh and Orissa under GFATM R4)
450 550
2007-08 7 Chandigarh, Chhattisgarh, Harayana, Himachal, Jharkhand, Karnataka and Uttaranchal
1250 1700
2008-09 5 Assam, Goa, Madhya Pradesh, Punjab and UP
2350 3600
2009-10 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.
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
THANK YOU
Multiyear DOTS expansion plan for India *31st March 2005
Total Population 1111
* Projected population based on 2001 census.
0
200
400
600
800
1000
1200
Quarter/Year
Po
pu
lati
on
in
mil
lio
n .
Country population Actual DOTS coverage Planned DOTS coverage
0%
10%
20%
30%
40%
50%
60%
70%
80%
1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
% C
ases
det
ecte
d o
f to
tal e
stim
ated
fo
r In
dia
.
Target 70%
Progress Towards 70% Case Detection Target*
•Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report)
RNTCP Treatment Regimen
Category I
New smear-positive; seriously ill smear negative; seriously ill extrapulmonary, New TB case with known HIV positive status
2 H3R3Z3E3 / 4 H3R3
Category II
Previously treated smear-positive (relapse, failure, treatment after default)
2 H3R3Z3E3S3 / 1 H3R3Z3E3 /
5 H3R3E3
Category III New smear-negative; and extrapulmonary, not seriously ill
2 H3R3Z3 / 4 H3R3
All treatment thrice weekly. Cat I and Cat II extended onemonth if smear+ at end of initial intensive phase.
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