RevisedNationalTuberculosis

ControlProgramme
(RNTCP)

Dr.NAVPREET
AssistantProf.,Deptt.ofCommunityMedicine
GMCHChandigarh

ProblemStatementofTBinIndia
India accounts for nearly 1/4th of global burden of TB
(2010).
Mortality: 26per1lacpopulation.
Prevalence(old+newcases):256per1lacpopulation.
Incidence(newcasesonly):185per1lacpopulation.

MillenniumDevelopmentGoals
Goal 6: Combat HIV/AIDS, malaria and other
diseases
Target 8: By 2015, to have halted and begun to
reverse the incidence of malaria and other major
diseases
Indicator 23: between 1990 and 2015 to halve
prevalenceofTBdiseaseanddeathsduetoTB
Indicator24:todetect70%ofnewinfectiouscasesand
tosuccessfully treat 85% of detected sputum positive
patients

EvolutionofTBControlinIndia
1950s60s ImportantTBresearchatTRCandNTI
1962

NationalTBProgramme(NTP)

1992

ProgrammeReview
only30%ofpatientsdiagnosed;
ofthese,only30%treatedsuccessfully

1993

RNTCP pilotbegan

1998

RNTCPscaleup

2000

>30%ofcountrycovered

2004

>80%ofcountrycovered

2006

EntirecountrycoveredbyRNTCP

NationalTuberculosisControl
Programme
NTCPwasstartedin1962withaimtodetectcasesat
theearliest&treatthem.
However,
Treatmentsuccessrate
:unacceptablylow
Death&defaultrate :high

NeedForRevisedStartegy
in 1992, nation wise review was conducted with
assistanceofSIDA&WHO.

NTPsufferedfrommanagerialweakness
Inadequatefunding
OverrelianceonXraysfordiagnosis
Frequentinterruptedsuppliesofdrugs
Lowratesoftreatmentcompletion.

In 1993, GoI decided to give a new thrust by

revitalizingNTP.
RNTCPthusformulated

RevisedNational TuberculosisControlProgramme
ObjectivesofRNTCP:
1. To achieve and maintain a cure rate of at least 85%
amongnewlydetectedinfectious(newsputumsmear
positive)cases
2.Toachieveandmaintaindetectionofatleast70%of
suchcasesinthepopulation.

Revisedstrategy:
1. Augmentation of organizational support at centre
andstatelevel.
2. Usesputumtestingasprimarymethodofdiagnosis
3. Standardizedtreatmentregimen
4. Ensuringregular,uninterruptedsupplyofdrugs
5. Emphasis on training, IEC, operational research &
NGOinvolvement.
6. Increasedbudgetoutlay

ComponentsofDOTS:
1. Political will ensures financial support and
sustainability.
2. Case detection with the help of quality assured
sputumsmearmicroscopy.
3. Regularanduninterruptedsupplyofdrugs
patientwiseboxes

4. Directlyobservedtreatment
directobservationwhilepatientisgettingtreatment.

5. Systemicmonitoringandaccountability.

StructureofRNTCPatStatelevel
State TB Cell

Nodal point for

TB control

District TB Centre

One/ 5 lakh (2.5

lakh in hilly/
difficult/ tribal area)

Tuberculosis Unit

One/ lakh (0.5 lakh

in hilly/ difficult/
tribal area)

Microscopy Centre

DOT Centre

STO, Deputy STO

MO, Accountant,
IEC Officer, SA, DEO

DTO, MO-DTC, LT,

DEO, Driver

MO-TC
STS, STLS

MO, LT

DOT Provider MPW,

NGO, PP, Comm Vol

RecommendationoftheRNTCPNationalLaboratory
Committee(Oct2008)
Strongly recommended that RNTCP changes diagnostic
criteriaofSmear+vePTBasbelow:
TB suspect is any person with cough for 2 weeks, or
more
Number of specimen required for diagnosis is 2, with
oneofthembeingamorningsputum
One specimen positive out of the two is enough to
declareapatientasSm+PTB

Basisofchanges
The revised definition of a new sputum smear
positivepulmonaryTBcaseisbasedonthepresence
ofatleastoneacidfastbacillus(AFB)inatleastone
sputum sample in countries with a well functioning
EQAsystem.
The reduction of the number of specimens to be
examined for screening of TB cases from three to
two, in places where workload is very high and
humanresourcesarelimited.

RevisedCategories
Treatmen Typeofpatient
tgroups

Regimen
Intensive Continuation
phase(IP) phase(CP)
4
New
Newsputumsmearpositive 2
(CatI)
Newsputumsmearnegative H3R3Z3E3 H3R3
Newextrapulmonary
Newothers
5
2
Previously Smearpositiverelapse
H3R3Z3E3 H3R3E3
Smearpositivefailure
treated
S3/
Smearpositivetreatment
(CatII)
1
afterdefault
H3R3Z3E3
Others

QualityAssurance
RNTCPLabnetworkhasthreelevels:
NationalReferenceLaboratories
NTIBangalore
TRCChennai
LRSNewDelhi

IntermediateReferenceLaboratories
Statelevel

NetworkofDesignatedMicroscopyCenters(>11,000)
Includesmicroscopycentersinmedicalcolleges
OneDMCcoversapopulationofabout1lakh
Providequalityassuredacidfastsputumsmearmicroscopy
services

RNTCPExternalQualityAssessment
Components
Paneltesting
Onsiteevaluation
Randomblindedrecheckingofroutineslides

ExternalQualityAssessmentactivitiesofRNTCP

ReportingProcedure

HIV&TB
HIV coinfection strongest known risk factor for the
progressionoflatentTBinfectiontoactiveTBdisease
Estimated710%annualriskofreactivation,with60%lifetime
risk (cf. 10% lifetime risk in TB infected, nonHIV infected
individual)
Conversely, TB amongst the most common causes of
morbidityandmortalityinpeoplelivingwithHIV/AIDS
Immune response to TB bacilli increases HIV replication
leadingtoarapidprogressionofHIVdisease
Optimal access to DOTS will significantly reduce morbidity
andmortalityinPLWHA

TB/HIVcollaborativeactivities
TB/HIV Action Plan implemented by RNTCP and NACP
jointly,focusingon:
Trainingofserviceproviders
Servicedeliverylinkages(ICTCRNTCPCrossreferrals)
Monitoring
Information,Education,andCommunication
Implementationstarted:
in 2001, in 6 high HIV prevalent States (population 311
million)
expanded in 2004, to 8 additional States (population 323
million)

TB/HIVcollaboratingactivities
National, State and District level coordination committees to
monitorlinkages
Guidelinesandtrainingmaterialdevelopedjointly
OngoingtrainingofstaffonTB/HIV
Crossreferral between ICTC and DOTS services developed,
pilotedandimplemented
InvolvementofNGOsandPPs
CollaborativeIECactivities
Jointmonitoringofactivities

TreatmentofTBinHIV
TBcanbesuccessfullytreatedeveninHIVinfectedpts.
But,cannotalonepreventpeoplefromdyingofAIDS
InadditiontoTBtreatment,ARTandCPTneededforthose
eligible
DOTSisthetreatmentofchoice
IntermittentSCCiseffective
NationalpolicyistoprovideRNTCPCatItonewcasesand
CatIItoretreatmentcases
Higher relapse rates have been observed especially in those
treatedwithnonRifampicincontainingregimen
Whethertruerelapseorreinfection?
DruginteractionsbetweenRifampicinandARVs
National policy is to start ART after completing antiTB
treatment, or modify ART by replacing Nevirapine with
EfavirenzforthedurationofTBtreatment

LikelyimpactofHIVonTBinIndia?
ScenariowithoutRNTCP
HIV would increase TB prevalence (by 1%), incidence (by
12%), and mortality rates (by 33%) between 1990 and
2015
ScenariowithRNTCP
Expect substantial reductions in prevalence (by 68%),
incidence(by41%),andmortality(by39%)between1990
and2015

Nationally, RNTCP should be able to reverse the increases in TB burden

duetoHIVbut,toensurethatTBmortalityisreducedby50%or moreby
2015, HIVinfected TB patients should be provided with antiretroviral
therapyinadditiontotherecommendedtreatmentforTB

PediatricTuberculosis
RelatedtoadultTB
Canoccuratanyage

Diseasedevelopswithinoneyearofinfection
Younger,earlier= disseminated

PTB:EPTB::55:45

PTBpaucibacillary,usuallyspneg

TreatmentofPediatricTB
DOTS
Categorization SAME
Dosesperkgbodyweight
Drugs to be made available as combipacks in patient wise
boxes, linked to child's weight ( 610kg,1117kg, 1825kg,26
30kg)
PWB beingmadeavailable
PC13yellow(610kg)
PC14orange(1117kg)
Prolongationpouches
Pink(1825kg)
Gray(2630kg)

MDRTBandDOTSPlus
MDRTBisalabdiagnosis,NOTaclinicalone
MDRTBlevelsoflessthan1%to3%innewcasesandof12%
inretreatmentcases.
EmergenceofresistancetoRifampicin inonly2%ofpatients,
despite a high level (8%) of initial resistance to Isoniazid,
eitheraloneorincombinationwithotherantiTB
Quality assured laboratory facility for culture and Drug
SusceptibilityTestmustbeavailable(NB:2 4monthsdelay
beforeDSTresultsseen)

 RNTCPCatIVtreatmentisa24monthstandardized2ndline
regimengivenunderdailyDOT:
6KmOfxEtoCsZE/18OfxEtoCsE
MDRTBpatientadmittedtoindoorfacilityatDOTSPlussite
forupto1monthfor:
pretreatmentassessment;
initiationofCategoryIVtreatmentafterdecisionofDOTS
Plussitecommittee;
monitoringtolerancetotreatmentregimen;
counselingandhealtheducationtopatientandfamily;
developinglinkagestodistrictservices;and
contacttracing

AchievementsofRNTCP

Treatmentsuccessrate:25%(1998)to88%(2010)
Deathrate:29%(1998)to4%(2010)
662DTCs
2,698TUs
13,039DMCs
1,971NGOs
>10,894Privatepractitioner
297Medicalcolleges
>13,000peripherallaboratories

Thanks.