Revised National Tuberculosis Control

Program (RNTCP)

Presenters

Masiya DebbarmaNaorem Kriyalaxmi Devi

N. Chingei PhemNevedita Das

Introduction

Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis which was discovered by Robert Koch

Also known as “Koch’s Bacillus”

The most common organ involved is lung(>80%) but it can involve any organ of the human body (except hair and nails)

It usually affects human in the age group of 15 to 59 yrs

Robert Koch

Classification of TBTB

Pulmonary (85-90%) Extra-pulmonary (10-15%)

Sputum Positive TB (Those who have bacteria in sputum)

Sputum Negative TB (Those who do not have bacteria in sputum)

Lymph NodesJointsGenitourinary tractSpinal tractIntestines

Symptoms of TB

Most common symptom of TB • Cough for 2 weeks or more Other symptoms of TB are:• Fever, especially evening rise• Pain in the chest• Loss of weight• Loss of appetite• Coughing up blood-stained sputum• Shortness of breath,• Tiredness

How TB Spreads ?

• Those who have Tuberculosis of the lungs are the ones who can spread the disease to others

• When these infectious people cough, sneeze, talk or spit, they can spread TB bacteria into the air in the form of tiny droplets

• When these droplets are inhaled by a healthy person he/she can get infected with tuberculosis

A sputum positive TB patient can infect 10-15 persons in a year

When to Suspect TB

TB should be suspected in anyone with cough for 2 weeks or more

These persons should have sputum examination in the nearest Microscopy Centre at the earliest

TB-HIV co-infection

TB is the most common opportunistic infection amongst HIV infected individuals

An HIV infected person newly infected with TB has 10-30 times higher chances of developing TB than those without HIV

In India, 55-60% of AIDS cases reported had TB and TB is one of the leading causes of death in “People Living with HIV AIDS” (PLHA)

Every TB patient should be referred to ICTC for HIV status and vice versa

Risk of infection About two persons infected in every 3 seconds

About 50% are sputum smear positive and are infectious

TB infected person will have a 10% lifetime risk of developing tuberculosis

Infection of TB is 60 times more common in HIV +ve people than Non-HIV +ve

Diabetes, malignancy, smoking tobacco, malnutrition and alcohol abuse also increase the risk of progression from infection to disease

2 out of every 5 Indians are infected with TB bacillus

BURDEN OF DISEASE

WORLD:

TB continues to be one of the most important public

health problems worldwide

In 2014, an estimated 9.6 million people developed TB

and 1.5 million died from the disease, 400,000 of whom

were HIV positive

Worldwide the proportion of new cases with MDR-TB

was 3.3% in 2014, whereas those for previously treated

cases was 20.0%

Of the estimated 9.6 million people who developed TB in 2014, more than half (58%) were in South-East Asia and Western Pacific regions and a further one quarter (28%) were in African region

India, China and Indonesia alone accounted for 23%, 10% and 10% of total cases respectively

In 2014, an estimated 3.2 million cases were women

An estimated 510,000 women died as a result of TB, more than 1/3rd of whom were HIV positive

Globally, about 1.1 million new cases and 130,000 deaths occur annually due to TB among children

(Global TB report 2015)

INDIA Accounts for nearly 1/4th of the global burden of TB Around 2.2 million develop TB in 2013-14. During the

same period, 0.27 million people died due to TB Everyday about 20,000 people become infected, 5000

develop TB and more than 1000 die due to the disease In simple terms, 2 persons become sputum +ve for TB and

almost 1 person is killed every minute due to the disease ( WHO 2007)

The proportion of new cases with MDR-TB was 2.2% in 2014, whereas those for previously treated cases was 15.0%

Brief History of Tuberculosis (TB)- 1865 Jean-Antoine Villemin: confirmed

that TB is contagious- Robert Koch:

- 1882: Isolated and cultured M. Tuberculosis(24th March)

- 1890: Announced the discovery of tuberculin

- Developed staining methods used to identify the bacteria

- 1905: Received Nobel Prize

Visualization of M. tuberculosis using the Ziehl-Neelsen stain

• Bacteriologist Paul Ehrlich developed Ziehl-Neelsen staining

• Before 1940– Sanatorium approach, good food, rest & fresh air

• 1948– Introduction of BCG vaccination

• 1950s-60s:– Antibiotics available

Background History of RNTCP– 1906- First open air TB sanatorium founded in

India– 1939- TB association of India

- expert advice on the development of standard methods to deal with the disease;

- setting up model institutions for training TB

workers; - education of the public regarding preventive measures;

- conceived the idea of domiciliary Rx of TB in 1940

• 1946- Bhore Committee recommended to the GOI, setting up

TB clinics in the districts and mobile TB clinics in rural areas.

• 1947- GOI established a TB division under DGHS in the

MoH, Planning and execution of anti-TB activities were

greatly facilitated by this Division.

• 1951- Mass BCG vaccination campaign covering 65 million

children in collaboration with IUAT

• 165 million tuberculin tests were administered to find the

prevalence of TB in India

• 1955-58 - National Sample Survey conducted under ICMR to find the magnitude of TB problem in India

• 1956- TRC established in Chennai

- Proved the efficacy of domiciliary Rx for TB with chemotherapy

• 1959- National TB Institute (NTI) established in Bangalore by GoI, with the active cooperation of the WHO, to develop a TB control programme

• 1962- National TB Control Program(NTCP) startedManagerial weakness, lack of supervisionPoor quality of sputum microscopyMultiplicity of treatment regimensPoor organizational set-up Inadequate fundingOver dependence on X-ray for diagnosisFrequent interrupted supplies of drugsLow rate of treatment completion (30% only)

• 1992- Programme Review showed - only 30% of patients diagnosed and only 30% of them treated successfully

• 1993- WHO Declared TB as a global emergency, RNTCP was initiated applying the principles of DOTS as a pilot project

• 1997- RNTCP started as a national programme

• 1998- Massive RNTCP expansion began, RNTCP Ist phase (1998-2005)

• 1998 September- RNTCP Implemented in Imphal District, Manipur RNTCP programme covered the State from 21st Jan 2002

Early 2000 - 135 million population covered; Monitoring Mission conducted

Sept 2003 - 741 million population covered; Monitoring Mission appreciates rapid expansion and overall quality

End 2005- 97% population covered; next 5-year plan approved with additional activities, such as DOTS-Plus

March 2006- The entire country covered by DOTS

Oct 2006 - RNTCP phase II started for 5 years ( to Sep’11)

2007 - New sputum + case detection was 70% and treatment

success rate was 86%

2007 - DOTS plus services for management of MDR-TB

patients have been rolled out in the states of Gujarat and

Maharashtra

2009: Prevalence of all forms of TB ↓ from 338 per 100,000

population (1990) to 249 per 100,000 population and TB

mortality in the country ↓ from over 42 per 100,000

population in 1990 to 23 per 100,000 population (WHO

global TB report 2010)

May 2012- Notification of TB is made mandatory by GOI

Revised National Tuberculosis Control Programme

o The National TB Programme (NTP) was started in 1962 for TB control in India. This programme was not able to give expected results in India

o The NTP was reviewed in 1992

o As a result of the review and pilot studies in 1993, the DOTS strategy was adopted in India under the Revised National TB control Programme - RNTCP

o The programme was implemented in a phase manner and by 24th March 2006, the entire country was covered under the programme

GoalThe goal of RNTCP is to decrease the mortality and morbidity due to tuberculosis and cut down the chain of transmission of infection until TB ceases to be a public health problem

ObjectivesTo achieve and maintain:o Cure rate of at least 90% among newly detected smear

positive (infectious) pulmonary TB cases ando Case detection of at least 85% of the expected new smear

positive PTB cases in the community

Organisational structure of RNTCPCentral TB Division, DGHS,

MoH&FWDeputy Director General-TB

State TB Cell

District TB Centre

Tuberculosis Unit

DMC

DOTS Centre

National Institutes(NTI, TRC, LRS, JALMA)

National Lab Committee, National TWG for TB-HIV, National DOTS Plus Committee, NTF for medical colleges, National OR Committee

STO, MO, Epidemiologist,DEO etc

State TB Training and Demonstration Centre/SDS/IRL

DTO, MO-DTC, Support staff etcNodal centre for TB control in the district

MO-TC, STS, STLS1 per 5 lakh population, 1 per 2.5 lakh in tribal, hilly and difficult areas

1 per 1 lakh population, 1 per 0.5 lakh in tribal, hilly and difficult areas

MO, LT

HW, ASHA, AWW, PPs,NGO, Comm vol etc

Unique features of RNTCP

• District TB Control Society• Modular training• Patient wise boxes• Sub-district level supervisory staff (STS, STLS) for

treatment & microscopy • Robust reporting and recording system

FUNDING

• 100 % central government sponsored

• The program is assisted by World bank and The Department for International Development (DFID)

• Other supporting agencies areo Global TB Drug Facility(GDF)

o Global Fund to Fight AIDS, TB, Malaria(GFATM)

o United States Agency for International Development(USAID)

o Danish International Development Agency (DANIDA)

Strategies

o Case finding and Diagnostics- Use of sputum testing as the primary method of diagnosis

o Patient friendly treatment services and ensuring a regular, uninterrupted supply of drugs up to the most peripheral level-DOTS

o Scale-up of Programmatic Management of Drug Resistance –TB (PMDT)

o Scale -up of Joint TB-HIV Collaborative Activities

o Integration with Health Systems

Strategies

Engagement of Private Sector Human Resource Development Advocacy, Communication and Social Mobilization

(ACSM)Monitoring and Evaluation, Surveillance and Impact

AssessmentOperational research to inform TB Control policy and

practice

Strategies

1. Case finding and Diagnostics: Early identification of all infectious TB cases Improved integration with the general health system and

leverage field staff for home-based case finding Improve communication and outreach Screening clinically & socially vulnerable risk groups for

TB Develop improved sputum collection and transportation

systems

Strategies

Deployment of higher-sensitivity diagnostic tests for TB suspects (and incorporate new tests) & decentralized DST services

Catch patients already diagnosed through notification from all sources

Improved referral for treatment mechanisms, and deployment of Laboratory & Private Provider notification

Strategies

2. Patient friendly treatment services: DOTS strategy Promptly and appropriately treating TB, increasingly

guided by DSTMaking DOTS more patient friendly through ↑

communitization of DOT pilot incentives/offsets for patient costs to help patients

complete treatment and better monitoring through IT Improving partnerships between public and private

sector

Strategies

3. Scale-up of Programmatic Management of Drug

Resistance –TB (PMDT):Developing network of C&DST Laboratories &

Strengthening of Reference LaboratoriesDecentralized DST at district level for early MDR

detection Improved information system for PMDT

Implementation• Case finding- by passive surveillance on patient with

symptoms of

i) Persistent cough for 2weeks or more.

ii) Haemoptysis

iii) Night sweats

iv) Evening rise of temperature

v) Chest pain

In lab.-

i) Sputum collection for diagnosis

ii) Radiography

iii) Tuberculin test

• Diagnosis of TB

Sputum examination is the best method to diagnose TB

• Pulmonary TB diagnosis can be confirmed by sputum examination. Two sputum samples are collected over one/two consecutive days

• If the health facility is a DMC, spot sample is collected immediately and the patient is given a sputum container to collect early morning sample & brought to the lab

• Alternatively the patient can be asked to collect a morning sample and go to a DMC where a spot sample can be taken

• In case the patient is not able to reach a DMC, both samples - morning and spot, can be collected and transported

• The sputum samples are subjected to microscopy examination as early as possible

• A patient is diagnosed positive if one or both the samples is positive for bacteria

• If the bacteria are not visible in any sputum sample, the patient is negative and should be referred to a medical officer for further evaluation

• TB of other organs is diagnosed by a medical officer

RNTCP revised diagnostic algorithm (2009)

Note: RNTCP has separate diagnostic algorithm for pediatric pulmonary TB and common forms of extra-pulmonary TB

DOTS Directly Observed Treatment Short Course

Directly observed treatment (DOT) is one element of the DOTS strategy

An observer watches and helps the patient swallow the tablets

Direct observation ensures treatment for the entire course• with the right

drugs• in the right doses• at the right

intervals

Directly Observed Treatment

Components of DOTS

DOTS is a systemic strategy to control TB diseases. It has the following 5 components -

1. Political and administrative commitment

2. Good quality diagnosis, primarily by sputum smear

microscopy

3. Uninterrupted supply of quality drugs

4. Directly observed treatment (DOT)

5. Systemic monitoring and accountability

DOTS

1- Intensive Phase(IP):- Intensive phase is of 2 to 3 months duration Patient swallow medicine under the observation of a

health worker during IP Medicines are taken 3 times a week on alternate

days If the sputum is negative for bacteria after IP,

continuation phase is started

Directly Observed Treatment Short CourseThere are two phases in DOTS treatment

DOTS

2. Continuation Phase• This phase is of 4 or 5 months duration• The patient is provided with a weekly blister pack to take

home• The medicines from the blister pack are taken on

alternate days, three times a week and in the remaining days, Vitamin tablets are taken

• The first dose of the weekly blister pack is taken under direct observation of the health worker

• Empty blister packs are collected to ensure that the medicines are taken at home by the patient

Directly Observed Treatment Short Course

Treatment Regimens

Category ofTreatment Type of Patient Regimen

Category I All new pulmonary (smear-positive andnegative), extra pulmonary and ‘others’ TB patients.

2H3R3Z3E3+ 4H3R3

Category II TB patients who have had more than one month anti-tuberculosis treatment previously

Relapse , Failure, Treatment After Default ,Others

2H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3

NEW CATEGORY

The medicine box of this category-Red

Treatment

Box contains 2 packets of IP & CP

It contains 24 blister doses for 2 months IP

It contains 18 weekly combipack doses for 4 months CP

All medicines of the blister pack have to be taken under observation, thrice weekly on alternate days

1st dose of this combipack should be swallowed by patient under direct observation The remaining medicines are taken home by patient & taken thrice weekly on alternate days Vitamin tablets in the combipack are taken on remaining days

Towards A World Free From TB…

NEW CATEGORY

• Patient is sent for follow up sputum examination after 22 blister in the IP. The 23rd and 24th blisters should be taken as per the scheduled time

• If the follow up examination is negative after the IP, the patient is put on Continuous phase as per the schedule

• After 2 months in the CP (8 weekly strips) and at the end of the treatment (17th weekly strip), follow up sputum examination is done

NEW CATEGORY

• If the follow up sputum examination after the IP is positive, the IP is extended for 1 month(12 blisters strip). Sputum examinations is done again at the end of this phase (11th blister strip)

• If the follow up sputum examination is positive after the extended phase, CP is started irrespective of the sputum result

Previously Treated Category

Medicine box of this category - Blue

Treatment

Box contains 2 packets of IP & CP

Contains 36 blisters for 3 months & 24 injection

Contains 22 weekly combipacks for 5 month CP

All medicines of the blister to be taken thrice weekly on alternate days under direct observation and Injection also on the same days

1st dose of the weekly combipack should be swallowed by patient under direct observation Remaining part of combipack is taken home by the patients and taken on alternate days Vitamin tablets are taken in the remaining days

Previously Treated

• Patient is sent for follow up sputum examination after 34 blister strips in the IP. The 35th and 36th blisters strips should be taken as per the scheduled time

• If the follow up examination is negative after the IP, the patient is put on Continuous phase as per the schedule

• After 2 months in the CP (8 weekly strips) and at the end of the treatment (21st weekly strip), follow up sputum examination is done

Previously Treated

• If the follow up sputum examination after the IP is positive, the IP is extended for 1 month(12 blisters strip). Sputum examinations is done again at the end of this phase (11th blister strip)

• If the follow up sputum examination is positive after the extended phase, CP is started irrespective of the sputum result

ANTI-TUBERCULAR DRUGS

Medication Drug action Dose(Thrice a week)***

Dose in children(mg/kg)

Isoniazid Bactericidal 600 mg 10-15

Rifampicin Bactericidal 450 mg* 10

Pyrazinamide Bactericidal 1500 mg 30-35

Ethambutol Bacteriostatic 1200 mg 20-25

Streptomycin Bactericidal 0.75 g** 15

* Patients who weigh 60 kg or more at the start of treatment are given an extra 150mg dose of Rifampicin

** Patients over 50 years of age are given 0.5g of streptomycin*** Adult patients weighing <30kg receive drugs in patients-

wise from the weight band suggested for pediatric patients

CURED• Initially sputum smear-positive patient who has completed

treatment and had negative sputum smears, on two occasions, one of which was at the end of treatment

TREATMENT COMPLETED• Sputum smear-positive patient who has completed treatment,

with negative smears at the end of the intensive phase but none at the end of treatment.

• Sputum smear-negative TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment.

• Extra-pulmonary TB patient who has received a full course of treatment and has not become smear-positive during or at the end of treatment

Treatment Outcomes

• DIED– Patient who died during the course of treatment

regardless of cause• FAILURE– Any TB patient who is smear positive at 5 months or

more after starting treatment.• Default– A patient who has not taken anti-TB drugs for 2 months

or more consecutively after starting treatment.• Transferred out– A patient who has been transferred to another

Tuberculosis Unit/ District and his/ her treatment result (outcome) is not known.

WHO definitions of TB cases recommended for use since March 2013

• Bacteriologically confirmed case of TB: A patient from whom a biological specimen is positive by smear microscopy, culture or WHO-approved rapid diagnostic test (such as Xpert MTB/RIF)

• Clinically diagnosed case of TB: A patient who does not fulfil the criteria for bacteriologically confirmed TB but has been diagnosed with active TB by a clinician or other medical practitioner who has decided to give the patient a full course of TB treatment

• Case of pulmonary TB: Any bacteriologically confirmed or clinically diagnosed case of TB involving the lung parenchyma or the tracheobronchial tree. Miliary TB is classified as pulmonary TB because there are lesions in the lungs. Tuberculous intra-thoracic lymphadenopathy (mediastinal and/or hilar) or tuberculous pleural effusion, without radiographic abnormalities in the lungs, constitute a case of extrapulmonary TB. A patient with both pulmonary and extrapulmonary TB should be classified as a case of pulmonary TB.

• Case of extrapulmonary TB: Any bacteriologically confirmed or clinically diagnosed case of TB involving organs other than the lungs, e.g. abdomen, genitourinary tract, joints and bones, lymph nodes, meninges, pleura, skin

• New case of TB: A patient who has never been treated for TB or has taken anti-TB drugs for less than one month

• Retreatment case of TB: A patient who has been treated for one month or more with anti-TB drugs in the past.

Retreatment cases are further classified by the outcome of their most recent course of treatment into four categories.

1. Relapse patients have previously been treated for TB, were declared cured or treatment completed at the end of their most recent course of treatment, and are now diagnosed with a recurrent episode of TB (either a true relapse or a new episode of TB caused by reinfection)

2. Treatment after failure patients have previously been treated for TB and their most recent course of treatment failed i.e. they had a positive sputum smear or culture result at month 5 or later during treatment

3. Treatment after loss to follow-up patients have previously been treated for TB and were declared ‘lost to follow-up’ at the end of their most recent course of treatment

4. Other previously treated patients are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented

DOTS Plus ?

• DOTS programme that add components for MDR-TB

diagnosis, management and treatment

Drug resistant TB

Causes of drug resistance

Programme related -Poor treatment

Drug related - Poor drugs

Patient related - Poor drug intake by the patient

Scientific basis of drug resistance Genetic Mutation in bacteria due to continuous exposure to low

concentration of drugs

Methods of Sputum C&DST• Solid Culture – ( LJ Method)

-2-3 months – Used both for diagnosis & follow up

• Liquid Culture: - 2-4 weeks for diagnosis - only used for diagnosis• LPA – Line Probe Assay (Molecular test)– 3 days for diagnosis– Only used for diagnosis

• CBNAAT (Cartridge Based Nucleic Acid Amplification Test)- can diagnose TB and Rifampicin resistance within 2 hours

CAT IV – MDR TBINITIAL INTENSIVE PHASE :6- 9 months• Tab. Pyrazinamide• Tab Ethionamide• Tab. Ethambutol• Cap Cycloserine• Tab Ofloxacin• Inj. KanamycinCONTINUATION PHASE :18 months• Tab Ethionamide• Tab Ofloxacin• Tab Ethambutol• Cap Cycloserine

DOT – 6 days a Week

Sunday – Unsupervised Oral Medicines

Inj Kanamycin OMITTED

CAT V- XDR TB

XDR TB- MDR TB+ Resistant to Second line injectable Anti TB drug & Fluroquinolone

The Intensive Phase (6-12 months) will consist of 7 drugs Capreomycin (Cm), PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav

The Continuation Phase (18 months) will consist of 6 drugs

PAS, Moxifloxacin (Mfx), High dose-INH, Clofazimine, Linezolid, and Amoxyclav

• Preventive chemotherapy with isoniazid (H) 10mg/kg body weight daily for 6 months is administered to all the children aged 6 years and below who are in contact with smear positive pulmonary TB case

PROPHYLAXIS

TB-HIV collaborative activities

Specific TB-HIV collaborative activities undertaken are:Establishment/Strengthening NACP-RNTCP co-

ordination mechanisms at national, state and district levelScaling up of intensified TB/HIV package of services

across the country Joint M&E including standardized reporting shared

between the two programmesTraining of the programme and field staff on HIV/TBTB and HIV service delivery co-ordination

Offer of HIV testing to TB patients Intensified TB case finding at ICTCs & ART Linking of HIV-infected TB patients to NACP for HIV care

and support and to RNTCP for TB treatment Provision of Co-trimoxazole Prophylactic Treatment (CPT)

for HIV infected TB patients Involvement of NGOs/CBOs and affected communities

working with NACP and RNTCP for all activities on TB/HIV collaboration

Operational research to improve the implementation and impact of TB/HIV collaborative activities

Public Private Partnership Intensified Public Private Mix Project is being undertaken with

IMA in 16 states and with CBCI-CARD(catholic bishop

conference of india-coalition for AIDS & related disease)

Several organizations and Projects like Programme for

Appropriate Technology in Health (PATH), The Union,

Foundation for Innovative New Diagnostics (FIND), Improving

Health Behavior Project (IHBP), World Vision India etc are

actively involved in the programme

At present 2,708 NGOs collaborations and 13,311 private

practitioners are involved in the programmes in different

schemes

Monitoring and Evaluation

Structure of RNTCP laboratory network

• 3 tier systemNational Reference Labs (NRL): 6 NRLs at present

1. Tuberculosis Research Centre (TRC), Chennai

2. National TB Institute, Bangalore

3. LRS Institute of TB and Respiratory Diseases, New Delhi and

4. JALMA Institute, Agra

5. Regional Medical Research Centre, Bhubaneswar and

6. Bhopal Memorial Hospital and Research Centre, Bhopal

Intermediate Reference Labs: At State TB Training and Demonstration Centres (STDCs)

Designated Microscopy Centres (DMCs): At the periphery

Each NRL will supervise sputum microscopy EQA of states designated under them

The NRL will ensure proficiency of RNTCP staff for carrying out good quality diagnosis by providing technical training to the STOs, STDC Directors, Microbiologists and Lab Technicians of States

The states will designate 1 IRLs in the STDC or Medical Colleges or in any Public Health Laboratory of the State

The designated IRL will conduct sputum microscopy EQA for the state and occasionally for a neighbouring state or union territory

The IRL will provide technical training to district and sub-district technicians and STLS

Sputum microscopy diagnostic services under

RNTCP are provided by DMCs established for every

1 lakh population (50,000 population in tribal, hilly

and remote areas)

In addition, the DMCs are also established at Medical

Colleges, Corporate hospitals, ESI, Railways, NGOs,

large private hospitals and other major hospitals

Quality Assurance (QA) for smear microscopy: It includes

1. Internal Quality Control (IQC)

2. External Quality Assessment ((EQA)

3. Quality Improvement (QI)

Internal Quality Control (IQC): It’s a systematic internal monitoring of working practices It includes technical procedures, checking instruments,

quality of new batches of staining solution, smear preparation, grading etc

External Quality Assessment (EQA): A process to assess laboratory performance. It includes

1 On-Site Evaluation (OSE): Conducted at least once a month by STLS to the DMCs Once a year by STDC/IRL lab supervisors to DTCs and TUs Once a year by lab supervisors of NRLs to STDCs/IRLs

2 Panel testing: This determine whether a lab technician can adequately

perform AFB smear microscopy This method evaluate individual performance in staining

and reading

Panel testing is not performed as a routine in the DMCs

3 Random Blinded Re-Checking (RBRC) of routine slides: It’s a process of re-reading a statistically valid sample of

slides from a laboratory to assess whether that laboratory has an acceptable level of performance

Performed once a month for every DMCs

Quality Improvement (QI): A process by which all components of smear microscopy

diagnostic services are carefully analyzed with the aim of looking for ways to permanently remove obstacles to success

Technical and managerial indicators for case finding and management

Indicator NormProportion of symptomatic patients who are smear

positive8-12%

Two smears taken from suspect cases 100%

Percent of smear positive among new TB cases >50%

Proportion of new smear positive patients found in the lab register being on treatment

>95%

Proportion of new smear positive cases placed on DOTS (within seven days of diagnosis)

>90%

Sputum conversion for new smear positive cases at three months

>90%

Percent of new smear positive patients who are cured >85%

Improving TB surveillance by transitioning to case based web based recording and reporting

(Nikshay)

• This ICT(information communication technology)

application (Nikshay) was launced on 15th May 2012 by

NIC(national informatics centre) (HQ) and Central TB

Division

• The data entry of the individual TB cases is being done at

the block level DEOs(data entry operator) of NHM

• The system has been extended to include drug resistant

TB cases, online referral and transfer of patients

Achievements RNTCP has been recognized for the fastest expansion

of DOTS in the world During the year 2009 DOTS treatment success Rate

was 87% Diagnostic facilities have been established in >13000

labs/ DMC throughout the country RNTCP has successfully involved 297 medical colleges

,over 1971 NGOs,10,984 private practitioners and over 150 corporate private sector health units

Quality Assurance protocol for smear microscopy has

been implemented in all the states

662 DTC, 2,698 TB units, >13000 DMC are

functioning

About 140 internal evaluations conducted in 2007

> 60,0000 Dots Provider

38287 MDR TB suspects examined till the end of 2011,

and 10267 MDR-TB patients diagnosed in 2011

6994 have been put on treatment

Programme performanceIndicator Norm Achievement

Annual case detection rate 135/lakh pop.

176/lakh pop.

Annual new sputum positive case detection rate

70% 72%

% of smear positives among total new pulmonary TB cases

50% 62%

Proportion of new smear positive cases placed on DOTS within 7 days of diagnosis

>90% 88%

New sputum positive conversion rate at 3 months

>90% 90%

Cure rate >85% 87%Default rate <5% 6%Death rate <5% 4%

Source: MOHFW. RNTCP. Annual report 2013-14. Central TB Division, MOHFW, GOI, TB India 2012 status report. Central TB Division, TB India 2014, RNTCP Annual Status Report.

MANIPUR TB case detected 30,895 (1998-2008) Treated successfully – 28,072 (1998-2008) No. of patients put on DOTS - 2061( 2008 ) (2011 )Manipur 27-lakhs, suspects examined- 13083 ;No of Smear positive patients Diagnosed – 1360; Total patients registered for treatment- 3080;Annual total case notification rate- 113;Annual new smear positive case notification rate -39 ; Annual new smear negative case notification Rate 30; Annual new extra pulmonary case notification rate -25

Recommendations• Strengthening and improving the quality of basic DOTS

services• Further strengthening and alignment with health system

under NRHM• Deploying improved rapid diagnosis at the field level• Expand efforts to engage all care providers• Strengthen urban TB Control• Expand diagnosis and treatment of drug resistant TB• Improve communication and outreach• Promote research for development an implementation of

improved tools and strategies

• Govt of India had declared Tuberculosis as a

notifiable disease on 7th May 2012. All public and

private health providers shall notify TB cases

diagnosed and/or treated by them to the nodal officers

for TB notification

Thank you