Current%20Challenges%20of%20the%20Revised%20National%20TB%20Control%20Programme%20(RNTCP)%20in%20India

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Current Challenges of the Revised National TB
Control Programme (RNTCP) in India
31st Annual conference of IAPSMPGIMER 28th
February 2004
Dr LS Chauhan Deputy Director General
(TB) Directorate General of Health
Services Ministry of Health Family
Welfare Nirman Bhawan, New Delhi 110 011
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TB Burden, RNTCP and its achievements

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TB Burden, India (2001)

• - Nearly one third of the global TB burden
• Annually
• Total new cases 1.8 million
• New smear-positive cases 795,000
• TB deaths 417,000
• Daily
• gt 20,000 people become infected
• More than 5,000 people develop TB
• More than 1,000 people die

Source provisional WHO estimates Sept 2003
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Status of TB control in India

• 1950s-60s Important TB research
• 1962 National TB Programme
• 1992 Programme Review- only 30 of patients
  diagnosed and only 30 of those treated
  successfully
• 1993 RNTCP pilots the DOTS strategy
• 1998 Rapid scale-up begins
• 2000 gt 30 of country covered under RNTCP
• 2003 gt75 of country covered by DOTS

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RNTCP Goal Objectives

• Goal
• To decrease mortality and morbidity due to TB,
  and to interrupt the chain of transmission in
  order that TB is no longer a major public health
  problem in India
• Objectives
• To cure at least 85 of new smear positive
  pulmonary cases and
• To detect at least 70 of estimated new smear
  positive cases existing in the community, after
  achieving the first objective

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India RNTCP (DOTS) implementation status by
district, 31st Jan 2004
Type of districts / reporting units No. of districts / reporting units Population as per 2001 Census Projected population (in million)
Implementing 445 770 814
Appraisal done 19 26 28
Ready for appraisal 5 8 8
Preparing 162 223 239
2004 projected population based on 2001 census. 2004 projected population based on 2001 census. 2004 projected population based on 2001 census. 2004 projected population based on 2001 census.
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Summary RNTCP Achievements 1

• Fastest expansion in the world
• 10-15 million million additional population
  covered each month
• gt40 fold expansion of DOTS in past 4.5 yrs
• 2nd largest programme in the world
• gt 80,000 patients placed on treatment every
  month
• Treatment success rate more than 85
• More than 8 out of 10 patients successfully
  treated
• Treatment success rates have tripled from 25 to
  85
• TB death rates have been cut 7-fold from 29 to
  4
• To date nearly 2.8 million patients placed on
  treatment
• more than 500,000 additional lives saved

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Summary RNTCP achievements 2

• To achieve the above
• Sound training materials developed for all
  categories of staff
• gt 300 000 health workers trained
• gt 7,700 Microscopy centres established
• Evaluation findings
• Well established logistic system
• 99 patients received free drugs and free
  microscopy
• services
• Published data at Central level reflects the
  programme
• activities in the field
• Highly economical costing lt US 5 cents per
  capita

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RNTCP Thrust areas challenges

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DOTS expansion, India (1993-2005)
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TB/HIV Coordination

• Action plan for TB/HIV collaboration developed
  and initiated in 6 high HIV burden states
• Sensitization/training of key policy makers,
  programme staff and other partners undertaken
• HIV/TB training manuals, treatment guidelines for
  TB among HIV-positive patients developed
  disseminated
• Referral linkages between VCTC and MCs
  established as a result, 7000 HIV individuals
  put on DOTS.
• TB/HIV coordination activities being expanded to
  8 other States in the near future

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Public-private mix (PPM)

• Ongoing efforts to involve all providers of care
• Guidelines for private practitioners (PPs) and
  NGOs developed
• gt3000 PPs involved
• Over 50 corporate sector establishments engaged
• Tea Garden hospitals in West Bengal, Nilgiris in
  TN
• Sugar mill in Meerut, Uttar Pradesh
• Eastern coal fields in Bardhaman
• 750 NGOs involved
• Documentation of existing PPM projects (e.g.,
  Kannur, Thane, Pune, tea gardens etc.) initiated
• Promising results seen from evaluation of
  existing PPM projects

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Medical Colleges Hospitals

• Consensus workshop organized to define structure
  and process for effective involvement of medical
  colleges in RNTCP
• 7 nodal centres identified
• 1 National, 5 Zonal Task Forces established.
• 19/23 States have formed State task forces
• 131 Medical colleges implementing DOTS
• Action plans developed and participation of
  medical colleges sought in
• Providing RNTCP services
• Training and teaching of RNTCP
• Advocacy for RNTCP
• Operational research

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Contribution from Medical Colleges hospitals an
example

• In Gujarat, medical colleges contributed to over
  11 of the chest symptomatics examined for sputum
  microscopy.
• Most of the colleges referred gt 2 of their new
  adult OPD patients for sputum microscopy
• 543 patients were started on treatment in medical
  college DOT centres alone.
• Medical colleges played a particularly important
  role in managing complicated cases of TB and in
  the diagnosis and management of Extra Pulmonary
  TB patients.

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Pediatric TB

• Practical problems associated with diagnosis
  treatment of pediatric cases under RNTCP
• difficulty in obtaining sputum, organizing drug
  in the form of combipacks in patient wise-boxes,
  linked to the childs weight, monitoring issues
• Present guidelines of Indian Academy of
  Pediatrics not consistent with the RNTCP
  guidelines
• Ongoing consultations to formulate guidelines for
  diagnosis Rx of Pediatric TB under RNTCP
• Consensus has been reached that DOTS is the
  recommended strategy for Pediatric TB and
  intermittent SCC given under DOT should be used
  in children

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Operational Research

• Two central co-ordination committees established
• National research agenda developed and widely
  disseminated - www.tbcindia.org
• Important centrally funded projects completed
• National Annual Risk of TB Infection
• Drug Resistance Surveillance
• Utilization of RNTCP services by marginalized
  groups
• Relevant operational research projects ongoing at
  central institutes, other setups
• Research proposals for funding invited

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Information, Education and Communication (IEC)

• Mass Media agency hired at the national level
• Baseline KAP study undertaken
• Workshops conducted at national and regional
  levels to review IEC plans and existing materials
  
• TV spots, radio jingles and TB logo produced
• IEC materials, flip charts distributed to states
• Revision of TBC India website initiated
• Communication for Behavioural Impact (COMBI),
  initiated as a pilot project in Kerala

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Summary RNTCP Challenges 1

• Implementing DOTS in a large country like India
• Expansion to cover entire country whilst
  maintaining quality.
• Maintain treatment success rates and increase
  case detection rate to meet global targets by
  2005
• Strengthening inter-sectoral collaboration
• NACO for TB/HIV coordination
• Build/strengthen partnerships Medical colleges,
  NGOs, PPs, ESIS, Railways, TB hospitals etc
• Mobilize community participation

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Summary RNTCP Challenges 2

• Strengthen State capacity for decentralized
  management
• Strengthen ongoing and refresher training
• Improve quality of implementation in urban areas
• Further intensify IEC activities
• Address issues related to
• Pediatric TB
• Extra Pulmonary TB
• Ongoing operational research to continuously
  improve on the programme

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Conclusion

• DOTS is the BEST strategy we have for controlling
  TB now
• AND
• The most contentious part of DOTS is to DO it

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THANK YOU