National TB Elimination Program (India): Difference between revisions

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RNTCP or the Revised National Tuberculosis Control Program is the State-run Tuberculosis Control Initiative of the Government of India. It incorporates the principles of Directly observed treatment-Shortcourse (DOTS) - the global TB control strategy of the World Health Organization . The program provides, free of cost, quality Anti-Tubercular drugs across the country through the numerous Primary Health Centres and the growing numbers of the private-sector DOTS-providers

File:DOTS logo English.jpg

DOTS Logo

History

Need for a Revised Strategy - India has had an on-going National TB Program, NTP since 1962. In 1992, the Government of India, together with the World Health Organization (WHO) and Swedish International Development Agency (SIDA), reviewed the National TB Program, and concluded that it suffered from the following

managerial weakness,
inadequate funding,
over-reliance on x-ray,
non-standard treatment regimens,
low rates of treatment completion, and
lack of systematic information on treatment outcomes.

Program reviews showed that only 30% of estimated tuberculosis patients were diagnosed and only 30% of those were treated successfully.

Based on the findings and recommendations of the review in 1992, the GOI evolved a revised strategy and launched the Revised National TB Control Programme (RNTCP) in the country.

Started on a pilot project in 1993, the strategy proved both its technical and operational feasibility. A soft loan of US $ 142 million was negotiated with the World Bank in December 1996 and the credit agreement was signed with IDA in May 1997.

Launch, Expansion and Coverage

The Revised National Tuberculosis Control Programme (RNTCP), based on the DOTS strategy, began as a pilot in 1993 and was launched as a national program in 1997. Rapid RNTCP expansion began in late 1998.

By the end of 2000, 30%of the country’s population was covered
By the end of 2002, 50%of the country’s population was covered under the RNTCP
By the end of 2003, 778 million population was covered
By the end of 2004, the coverage reached to 997 million
By December 2005, around 97% (about 1080 million) of the population had been covered
By 24th March 2006, the entire country was covered under DOTS covering 1114 million people.

Components of RNTCP

The Directly observed treatment, Short-course DOTS strategy along with the other ingrediants of the Stop TB Partnership are implemented as a comprehensive package for TB control.

The five principal components of DOTS are

Political and administrative commitment
Case detection by Sputum Smear Microscopy
Uninterrupted supply of good quality anti-TB drugs
Standardized treatment regimens with directly observed treatment for at least the first two months
Systematic monitoring and accountability

Diagnosis of Pulmonary TB under RNTCP

Diagnosis is made primarily based on Sputum Smear Examination. X-rays play a secondary role in the standard diagnostic Algorithm for pulmonary tuberculosis

Sputum Smear Microscopy using the Ziehl-Neelsen staining technique is used as the standard case-finding tool. Three sputum samples are collected over two days (as spot-morning-spot) from Chest Symptomatics to arrive at the diagnosis. In addition to the test's high specificity, the use of three samples ensures that the diagnostic procedure has a high (>99%) test Sensitivity also.

As a national health program, RNTCP pays more attention to the sputum-positive pulmonary tuberculosis patients (who are likely to spread the disease in the community) than people with other, non-pulmonary forms of the disease.

Treatment Categories and Drug Regimens

Standardized Treatment Regimens are one of the pillars of the DOTS strategy

Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin are the primary Antitubercular drugs used. Most DOTS regimens have thrice-weekly schedules and typically last for 6 to 8 months, with an initial Intensive phase and a Continuation phase.

Based on the Nature/severity of the disease and the Patients' exposure to previous anti-tubercular treatments, RNTCP classifies tuberculosis patients in to three Treatment Categories.

Category I	Category II	Category III
New sputum smear-positive Seriously ill sputum smear-negative Seriously ill extra-pulmonary	Sputum smear-positive Relapse Sputum smear-positive Failure Sputum smear-positive Treatment after default	New sputum smear-negative, not seriously ill New extra-pulmonary, not seriously ill
2H₃R₃Z₃E₃ + 4H₃R₃	2H₃R₃Z₃E₃S₃ + 1H₃R₃Z₃E₃ + 5H₃R₃E₃	2H₃R₃Z₃ + 4H₃R₃
2 months Intensive phase + 4 months continuation phase Four drugs at Thrice-weekly Schedule	3 months Intensive phase + 5 months continuation phase Five drugs at Thrice-weekly Schedule	2 months Intensive phase + 4 months continuation phase Two drugs at Thrice-weekly Schedule

H: Isoniazid (600 mg), R: Rifampicin (450 mg), Z: Pyrazinamide (1500 mg), E: Ethambutol (1200 mg), S: Streptomycin (750 mg)

PPP - Public Private Patrnership under RNTCP

In India, a sizeble proportion of the people with symptoms suggestive of Pulmonary Tuberculosis approach the private sector for their immediate health care needs. There is need for regularizing the varied anti-tubercular treatment regimens used by General Practioconers and other private sector players.

Second Phase of RNTCP

In the first phase of RNTCP (1998-2005), the programme’s focus was on ensuring expansion of quality DOTS services to the entire country. The future holds a different set of challenges including MDR TB and HIV/TB

The RNTCP has now entered its second phase in which the programme aims to firstly consolidate the gains made to date, to widen services both in terms of activities and access, and to sustain the achievements. These needs to be done in order to achieve the TB-related targets set by the Millennium Development Goals for 2015 and to achieve TB control in the longer term.

External links

TBC-RNTCP Tuberculosis Control India's Homepage on RNTCP

TRC Chennai Tuberculosis Research Center, Chennai

NTI Bangalore The National Tuberculosis Institute, Bangalore

StopTB The Stop Tuberculosis Initiative Website

History of TB Control in India

WHO Page on TB WHO's Global TB Programme

Reference

What is DOTS? A guide to Understanding the WHO-recommended TB Control Strategy -1999

RNTCP at a Glance

Tuberculosis Control in India

RNTCP Annual Report, 2007 Status Reports 2007

@@ Line 47: / Line 47: @@
 Diagnosis is made primarily based on '''Sputum Smear Examination'''. X-rays play a secondary role in the standard '''diagnostic [[Algorithm]] for [[pulmonary tuberculosis]]'''
-Sputum Smear Microscopy using the '''[[Ziehl-Neelsen stain]]ing''' technique is used as the standard case-finding tool. '''Three sputum samples''' are collected over two days (as spot-morning-spot) from '''Chest Symptomatics''' to arrive at the diagnosis. The use of three samples ensures that the diagnostic procedure has a high (>99%) [[Sensitivity ]]
+Sputum Smear Microscopy using the '''[[Ziehl-Neelsen stain]]ing''' technique is used as the standard case-finding tool. '''Three sputum samples''' are collected over two days (as spot-morning-spot) from '''Chest Symptomatics''' to arrive at the diagnosis. In addition to the test's high [[specificity]], the use of three samples ensures that the diagnostic procedure has a high (>99%) test [[Sensitivity ]] also.
 As a national health program, RNTCP pays more attention to the '''sputum-positive''' '''[[pulmonary tuberculosis]]''' patients (who are likely to spread the disease in the community) than people with other, non-pulmonary forms of the disease.