REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Tuberculosis, well known as TB, Yakshma, Kshaya of Tapedik in the community is a disease known since ages and referred as " Rajyakshma" or "Rajrog" in the ancient Indian medical literatures. It mainly affects lungs, but can affect any part of body. Little was known about the Pathogenesis and communicability of the disease before the 18th century.
The world changed on the evening of 24th March 1882, when German physician Robert Koch, working over decades onto the disease, read his paper in the Physiological Society of Germany in Berlin. He stated 1 /7th of all human being in world die of Tuberculosis. It is an infectious disease caused by bacteria and gave details about the presence of bacilli in the sputum of infected patient.
Tuberculosis (TB) is a disease caused by bacteria called as Mycobacterium Tuberculosis. TB spreads through droplet infection. As no drug or combinations of drugs were effective against TB till middle of the 20th century, the main line of treatment was good food, open air and dry climate in sanatoria. Streptomycin, the first antibiotic which showed anti- Tuberculosis effect, was discovered in 1943 by Dr. Selman A Waksmam, later a series of antibiotics viz. Isoniazid, PAS, Pyrazinamide, Ethambutol, Thiaciteazone and Rifampicin were discovered and were used in the TB treatment and are still in use. The latest molecule which has shown promising effect against TB bacilli is 'Bedaquiline'.
Despite of all these developments till today, Tuberculosis is still a major public health problem. Every day more than 900 people die of TB (2 people per 3min die due to TB in our country). High mortality especially among socio-economically productive age group causes huge economic losses to the society and country.
The Tuberculosis (TB) burden in India is staggering. About 40% of the adult population of the country is estimated to be infected with Mycobacterium Tuberculosis. Every year nearly 2.2 million new TB cases occur, of which nearly 0.8 million are infectious (Smear positive pulmonary). Once infected, an individual has on average a 10% life-time risk of developing TB disease. India has more people with active TB Disease than any other country in the world accounting for 26% of the global TB Burden. Also, an estimated 2.34 million individuals in India are now living with HIV/AIDS. With HIV Infection to active disease, the potential impact of the HIV epidemic on TB control in India is large.
National TB Control Programme
(NTP) was implemented from 1962 to 1998. However, it had limited success with only 30-40% treatment completion rate amongst patients put on treatment. Government of India started Revised National Tuberculosis Programme (RNTCP) with Directly Observed Treatment – Short Course (DOTS) strategy, since 1998.
India's TB control programme is on track as far as reduction in disease burden is concerned. There is 42% reduction in TB mortality rate by 2015 as compared to 1990 level. Similarly there is 51% reduction in TB prevalence rate by 2015 as compared to 1990 level.
In the 12th 5 year plan, the programme has entered an ambitious National strategic plan (NSP) with a theme of "Universal Access" for quality diagnosis and treatment for all TB patients in the community with a target of "Reaching the Unreached". This envisages early and complete detection of all TB, including the vulnerable and marginalized population and greater engagement with private sector.
It is estimated that 2.8 percent of new TB patients in India and 15 percent of those previously treated are estimated to have drug-resistant TB. However, the last survey for MDR-TB was conducted in 2009 and these estimates may no longer be applicable. National Drug Resistant Survey is currently underway to estimate the DRTB burden. Extensively drug-resistant (XDR) TB has been identified in 105 countries, including India; on an average, among those with MDR-TB globally, 9.7 percent are estimated to have XDR-TB.
The Standards for Tuberculosis Care in India (STCI) is developed, published and disseminated by the Central TB Division (CTD), Government of India, in 2014. These standards apply to all health care providers in the country, both public and private, and establish a common yardstick for TB management.
The END TB STRATEGY has a
Vision: A "Tuberculosis free India – achieving universal access, by provision of quality diagnosis and treatment for all Tuberculosis patients in the community".
Goal: To decrease the morbidity and mortality by early diagnosis and early treatment of all Tuberculosis cases, thereby cutting the chain of transmission.
Objectives: "Universal Access to TB Care"
Tuberculosis in Karnataka
Revised National Tuberculosis Control Program was implemented in the State from 1998 and the entire State was covered in 2004.More than 65,000 TB patients put on treatment annually in Karnataka TB control program itself. Rough estimates suggest another 40,000 TB patients being put on treatment in private setting. Nearly 7000 TB patients die and default with in RNTCP every year. This is causing a concern as RNTCP is aiming at Universal Access and Zero TB deaths as a part of End TB Strategy. Karnataka is one of the high HIV-TB burden states. The death and default in the State is addressed aggressively. The total default rate which was 10% in 2009 is reduced to 7 % in 2015 and death rates have decreased from 8% in 2009 to 6% in 2015 despite high HIV – TB burden. The success rates of TB treatment have improved from 80% in 2008 to 83.5% in 2014.
Karnataka is currently implementing RNTCP's National Strategic Plan 2012-'17 with goal of Universal Access to Quality Diagnosis and Treatment for all TB patients in the community. For administrative feasibility, state is divided into 31 District TB Centres (DTC). 31 DTCs are divided into 188 TB Units (TU) one for every 2.5 lakh population. Selected PHCs have been up-graded as DMCs including 46 medical colleges and facilities in private sector, there are a total of 688 DMCs providing sputum microscopy services across the state.
The Joint Director TB is responsible for planning, training, supervising and monitoring of the program as per the guidelines of the state health society and central TB division. At the district level, the district TB officer is responsible for implementing the TB control program. He is also responsible for involvement of other sectors in RNTCP. At the sub district level, the Tuberculosis Unit (TU) is the nodal point for TB control activities. The TU consists of designated medical officer- Tuberculosis control who does RNTCP work in addition to other responsibilities. There are two full time RNTCP contractual supervisory staff exclusively for tuberculosis work – a senior TB treatment supervisor (STS) and a senior TB laboratory supervisor (STLS).Apart from this the program supports the districts by providing contractual medial officers to medical colleges, laboratory technicians , TB health visitors in urban areas, statistical assistants for DR-TB centres, district program coordinators, PPM coordinators, DR-TB centre, counsellors, senior DOTS Plus TB HIV supervisors and accountants. Currently, 1007 contractual employees are working for TB control across the state. State TB cell under "Karnataka State Health and Family Welfare Society – TB control Programme" and 31 districts TB centres under "District Health Society – TB control programme" have been established to supervise and monitor the implementation of this programme effectively.
The TB control program in Karnataka recognizes the need of targeting special populations. TB control program in Karnataka has identified special populations and has planned target interventions. The target interventions include active surveillance in these populations' and utilizing genotypic methods for the diagnosis TB and if resistant TB.
TB Notification and Nikshay Registration:
Tuberculosis is a notifiable disease. All providers must notify TB patients including public and private providers through "NIKSHAY" which is a case based web based application for TB patient's registration. This software was launched in May 2012 and it is disseminated to all districts. There is a significant response from private providers. 10038 health facilities have been registered on NIKSHAY and out of which 361 health facilities are notifying TB cases. A total of 9267 TB cases have been notified from private sector so far.
(i.e., TB among the population aged less than 14 years) has always been accorded high priority by Revised National Tuberculosis Control Programme
(RNTCP). In our state screening of TB among SAM children is of high priority. To overcome the delay and to augment the diagnosis of pediatric TB, 34 gene Xpert machines are placed at district level. There are exclusive pediatric drugs with different weight bands, which helps in successful outcomes.
Programmatic management of drug resistant TB aims at diagnosis, treatment and follow-up of patients with drug resistant TB. For the diagnosis of DRTB, two dedicated mycobacteriology laboratories are established, one is Intermediate Reference laboratory at Bangalore and other is CDST laboratory at KIMS Hubli. Both the laboratories are certified by government of India
(CTD) to perform both genotypic and phenotypic tests. The third one is being established at RIMS Raichur. The diagnosis, treatment and follow up of the patient is done free of cost. The cost of treating MDR patients is 2-6 lakh rupees which is provided free to the patients. Currently, more than 25,000 patient samples are tested for MDR-TB and 2500 MDR patients are getting free treatment.
The Xpert MTB/RIF is a cartridge-based, automated diagnostic test that can identify Mycobacterium tuberculosis (MTB) DNA and resistance to rifampicin (RIF) by nucleic acid amplification technique
(NAAT). Results are obtained from unprocessed sputum samples in 90 minutes, with minimal biohazard and very little technical training required. The state has 26 gene Xpert machines which are placed at the district level and at places where there is high HIV-TB burden thereby ensuring early quality diagnosis and management happens to these patients.
The following innovations stand out in programme strengthening in Karnataka state they are:
- Joint TB HIV visits to districts involving officials from KSAPS and State TB Centre for monitoring TB HIV collaborative activities.
- Provider initiated TB suspects testing for HIV.
- Designing of formats for reporting HIV TB collaborative activities.
- Micro planning (TU wise analysis) for identifying low performing TUs and planning focused interventions.
- Guiding tool for ACSM activities.
- Twitter (KA STATE TB CENTER) and Facebook (Tuberculosis control in Karnataka) accounts for State TB Centre.
- Involvement of field general health staff for pulmonary TB suspect referral.
- Incentives for ASHAs for sputum sample transportation in difficult to reach areas in some districts.
- Utilization of ophthalmic camps organised by NGO (Muslim forum) for creating TB awareness.
- Focused DTOs review.
- Drugs stock exercises done in all districts.
- Group SMS IDs created for DTOs, MOTCs, STS and STLS in WAY2SMS.
- A telephone Care-line (called "Mitra") was piloted under the SHOPS initiative in Karnataka. Kavin Corporation in Bangalore, supported by IKP Knowledge Park, piloted a telephone based patient-tracking and adherence promoting system for RNTCP patients in Bangalore.
- Involving 104 services for TB care.
TBHIV collaborative activities. – The RNTCP programme closely collaborates with AIDS control programme at state and district level for early diagnosis, follow up and treatment of HIV infected TB patients. The TB HIV collaborative services includes:
PITC (provider initiated testing and counselling) for presumptive TB patients.
2. Offering HIV testing for the all TB patients.
3. Providing CB NAAT testing for all the presumptive TB and presumptive MDR TB cases for all the symptomatic HIV infected patients.
4. Linking all HIV infected TB patients to ART centres.
5. Providing ART to all HIV infected TB patients irrespective of their CD4 counts.
6. Providing Cotrimaxozole preventive therapy (CPT) to all HIV infected TB patients.
THE END TB STRATEGY
The estimated number of Tuberculosis cases each year is slowly declining by an average of 2% and the world is on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015. However, TB remains one of the world's deadliest communicable diseases. To accelerate the decline of annual global TB incidence and the case fatality ratio within target period WHO has developed a post – 2015 global TB strategy (the End TB Strategy). The global strategy and target for Tuberculosis prevention, care and control after 2015 has been endorsed by the all member sates at the 67th World Health assembly 2014.
To reach the targets set out end TB strategy, the annual decline in Global TB incidence rates must first accelerate from an average of 2% per year in 2015 to 10% per year 2025. Secondly, the proportion of people with TB who die from the diseases (The case fatality ratio) needs to decline from a projected 15% in 2015 to 6.5% by 2025. These declines in deaths and incidence by 2025 although ambitions, but are feasible with existing tools complimented by universal health average and social protection.
The overall goal of the strategy is to end the global TB Epidemic, with corresponding 2035 targets of a 95% reduction in TB deaths and a 90% reduction in TB incidence (Both compared with 2015). The strategy also includes a target of zero catastrophic costs for TB effected families by 2020.
The following are the version, goals and targets set in the end TB strategy in the line with the United Nations post-2015 development agenda named "Sustainable Developed Goals" (SDGs) to be developed for 2013 including TB proposed to be part of the agenda and goals.
1. Government stewardship and accountability, with monitoring and evaluation.
2. Strong coalition with civil society organizations and communities.
3. Protection and promotion of human rights, ethics and equity.
4. Adaptation of the strategy and targets at country level, with global collaboration.
PILLARS AND COMPONENTS:
1. INTEGRATED, PATIENT- CENTRED CARE AND PREVENTION
A. Early diagnosis of TB Including universal drug susceptibility testing; and systematic screening of contacts and high-risk groups.
B. Treatment of all people with TB including drug- resistant TB; and patient support.
C. Collaborative TB/HIV activities and management of comorbidities.
D. Preventive treatment of persons at high-risk; and vaccination against Tb.
2. BOLD POLICIES AND SUPPORTIVE SYSTEMS
A. Political commitment with adequate resources for TB care and prevention.
B. Engagement of communities, civil society organizations, and public and private care providers.
C. Universal Health Coverage policy and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control.
D. Social protection, poverty alleviation and actions on other determinants of TB.
3. Intensified research and innovations
A. Discovery, development and rapid up take of new tools, interventions and strategies
B. Research to optimise implementation and impact, and promote innovations.
END TB STRATEGY
VISION, GOAL AND TARGETS
A world free of TB
Zero deaths, diseases and suffering due to TB
End the global TB epidemic
Milestones for 2025:
75% reduction in TB deaths (compared with 2015)
reduction in TB incidence rate
[<55/100,000(compared with 2015)]
No affected families face catastrophic costs due to TB.