Current Status: Tuberculosis in India Dr Ashwini Kalantri

1. Current Status: • Tuberculosis in India • Dr Ashwini Kalantri Moderator Dr BS Garg

2. History of TB Control in India • 1906 : Open air sanatorium in Ajmer • 1929 : King George V Thanksgiving Fund for TB control • 1939 : TB Association of India (TAI) • 1946 : Plan for TB Clinic in every district • 1955 - 58 : National survey by ICMR • 1959 : National TB Institute (NTI) to develop the national TB control programme.

3. History of TB Control in India • 1961 : NTP pilot tested in Andhra Pradesh • 1962 : NTP launched • 1978 : NTP covered 390 districts (81%) • 1983 : Short-course chemotherapy(compliance improved only marginally) • 1993 - 97 : DOTS pilot (RNTCP) • 1997 : RNTCP launched • 2007 : DOTS Plus (PMDT) for Drug resistant TB

4. The Stop TB Strategy • 2006 - 15 : Second Global Plan to Stop TB • Roadmap and budget to reach MDGs

5. Microscopy vs X-ray 98% 60% 50% False Positive True Positive 40% Specificity X-ray NTI, Bangalore, 1974

6. Sanatorium vs Domiciliary care A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.

7. The Revised National TB Control Programme • 100% centrally sponsored • Free of cost diagnosis and treatment with anti-TB drugs • 13,000+ microscopy centers • 4,00,000+ DOTS treatment centers • RNTCP an integral part if the NRHM

8. Components of DOTS • Political commitment • Diagnosis by microscopy • Adequate supply of the right drugs • Directly observed treatment • Accountability

9. Population Coverage and Patients Registered A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

10. RNTCP Objectives • To achieve 85% cure rate for the newly diagnosed sputum smear positive TB patients • To detect at least 70% of the new smear-positive patients

11. Treatment outcomes1994 to 2006 85 A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

12. UnfavourableTreatment Outcomes1994to 2006 A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

13. Prevalence A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010.

14. 3 vs 2 sputum samples

15. Revised National TB Control Programme Achievements

16. Achievements of RNTCP • Evaluated 55 million+ persons for TB • Initiated treatment for 15.8 million+ TB patients. • 2.8 million lives saved • TB/HIV services in 18 states • MDR-TB services in 132 districts • Successful medical college involvement • ARTI reduced from 1.5% to 1.1%

17. Achievements during 11th FYP

18. Objectives for the 12th FYP • Early detection and treatment of at least 90% of all type of TB cases • Reduction in default rate of new TB cases to less than 5% and re-treatment TB cases to less than 10% • Screening for drug-resistant TB and provision of treatment services for MDR-TB patients • HIV Counseling and testing for all TB patients • Extend RNTCP services to patients diagnosed and treated in the private sector.

19. Targets for the 12th FYP • Detection & treatment of about 87 lakh Tuberculosis patients during 12th FYP • Detection & treatment of at least 2 lakh MDR-TB patients during 12th FYP • Reduction in delay in diagnosis and treatment of alltypes of TB cases • Increase in access to services to marginalized and hard to reach populations and high risk and vulnerable groups

20. Economic Impact of TB • Each case of TB • US$ 12,235 • 4.1 DALYs • Each death due to TB • US$ 67,305 • 21.3 DALYs • 29.2 million DALYs and US$ 88.1 billion gained due to RNTCP

21. TUBERCULOSIS Current Status

23. Annual Incidence of TB

24. Estimated burden of TB in India

25. National ARTI survey RNTCP, Annual Status Report 2013

26. Annual New Smear Positive Case Detection Rate, 2012 RNTCP, Annual Status Report 2013

27. Cure Rate of New Smear Positive Cases, 2011 RNTCP, Annual Status Report 2013

28. Composite Indicators RNTCP, Annual Status Report 2013

29. Case Detection • RNTCP Designated Microscopy Center (DMC) • 2 Sputum smear examination (spot and morning) • ZN smear exam under bright field binocular microscopes • Drug resistant TB – solid/liquid culture DSTs • CBNAAT being used in 18 sites

30. Treatment • INH (H), Rifampicin(R), Pyrazinamide (Z), Ethambutol(E) and streptomycin (S) • Category I : 6 months • 2 months Intensive Phase: HRZE thrice weekly • 4 months Continuation Phase: HR • Category II : 8 months • 3 months Intensive Phase: 2 months HRZES and 1 month HRZE • 5 months Continuation Phase: HRE

31. Treatment • All doses of intensive phase and first dose of each week of continuation phase are given under supervision. • Follow-up sputum examination at the end of intensive phase, 2 months into the continuation phase and at the end of treatment

32. Drug Resistant TB • By 2015: DST for all smear positive cases • MGIMS, Sevagram certified for solid culture and DST. • Genexpert (CBNAAT) introduced in 12 TUs

33. Drug Resistant TB Treatment • For MDR-TB : Daily DOT includes (6-9m) Kanamycin, Levofloxacin, Cycloserine, Ethionamide, Pyrazinamide, Ethambutol / (18m) Levofloxacin, Cycloserine, Ethionamide, Ethambutol • For XDR-TB : (6-12m) Capreomycin, PAS, Moxifloxacin, High dose INH, Clofazimine, Linezolid, Amoxy- ClavulanicAcid / (18m) all the above drugs except Capreomycin

34. PMDT Services RNTCP, Annual Status Report 2013

35. TB/HIV • Latent TB  Active TB • 2001: TB/HIV collaboration • ICTC : Intensified TB case finding has been implemented nationwide at all HIV testing and ART centres • HIV testing of TB patients is now routine through provider initiated testing and counselling (PITC)

36. TB/HIV • 2012 : 56% TB patients screened, 5% positive • HIV-positive given free HIV care at the antiretroviral treatment (ART) centres • Policy decision taken expand coverage of whole blood finger prick HIV screening test at all DMC

37. TB and Diabetes • People with a weak immune system, as a result of chronic diseases such as diabetes, are at a higher risk of progressing from latent to active TB. • Diabetics have a 2-3 times higher risk of TB • 10% of TB cases globally are linked to Diabetes • Longer time of sputum conversion

38. TB and Diabetes • High chances of drug resistance, mortality and relapse • Good glycemic control in TB patients has better outcome • Policy to screen all TB patients for DM in the 100 districts where NPCDCS has been implemented

39. Childhood TB • The newer weight bands are 6-8 kg, 9-12 kg, 13-16 kg, 17-20 kg, 21-24 kg and 25-30 kg. • Chemoprophylaxis for children under 6 years: isoniazid (5mg/kg)for 6 months

40. Childhood TB • If sputum sample not available, alternative specimen (Gastric lavage, Induced sputum, bronco-alveolar lavage) should be collected under pediatric supervision. • Tuberculin skin test / Mantoux: 10 mm or more induration

41. Revised National TB Control Programme Newer initiatives

42. Notifiable Disease

43. www.nikshay.gov.in

44. Other Initiatives • Composite Indicator • Ban of sero-diagnostic tests • Availability of free quality assured anti-TB drugs through local chemists

45. References • A brief history of tuberculosis control in India. Geneva, Switzerland: World Health Organisation; 2010. • Revised National TB Control Program : Annual Status Report 2013. New Delhi: Central TB Division, 2013. • A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis in South India. Bull World Health Organ. 1959;21(1):51-144.