Overview of the Presentation

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2 Overview of the Presentation Definitions(TBCase, MDR-TB & XDR-TB) Global Tuberculosis (TB,HIV/TB,MDR & XDR)Scenario & Trend Risk factor for TB Natural history of TB Types of TB & Trends of Extra Pulmonary TB RNTCP-Goals, Objectives, & Achievements Contribution of Medical institutions in TB Control Challenges Future Plans

3 Definition of TB case (Operational) A patient diagnosed with at least one sputum specimen positive for acid fast bacilli, or Culture-positive for Mycobacterium tuberculosis, or RNTCP endorsed Rapid Diagnostic molecular test positive for tuberculosis OR A patient diagnosed clinically as a case of tuberculosis, without microbiologic confirmation, and initiated on anti-tb drugs. Source: Ministry of Health and Family Welfare, Govt of India.

4 Definition of MDR / XDR MDR-TB is defined as resistance to isoniazid and rifampicin, with or without resistance to other anti-tb drugs from an accredited RNTCP Laboratory XDR-TB is defined as resistance to at least Isoniazid and Rifampicin (i.e. MDR-TB) with resistance to any of the fluoroquinolones and any one of the second-line injectable drugs (amikacin, kanamycin, or capreomycin).

5 TB cases Globally (2011) 15% Total New TB cases In the 22 high burden countries China India South africa 50% 24% Indonesia All other countries 6% 5% Annual Global TB Report 2012-RNTCP India ranks 1st

6 TB Prevalence 6% TB Incidence 5% Other 6% Other Bangladesh 46% 26% China 25% Bangladesh China India Indonesia 12% 54% 11% Pakistan 5% Global TB Report % India South africa

7 TB Mortality Cases 7% EPTB Cases (Extra pulmonary TB) Ehiopia Other 6% 6% Bangladesh 41% China 28% DR Congo 30% India India South Africa 55% Pakistan Indonesia 7% 4% 5% Annual Global TB Report % 5% All Other countries

8 Tuberculosis (TB) cases in India from 1999 to 2011

9 TB HIV Cases 3% Other 28% DR Congo India 30% Mozambique Uganda Zimbabwe Brazil 3% Ethiopia Kenya 4% 8% 5% 3% 9% Global TB Report % 4% South Africa UR Tanzania

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12 HIV on TB Incidence & TB Deaths(2008)

13 MDR TB Cases 7% 13% 33% India Kazakhstan Russian Federation South Africa Ukraine 23% 7% 17% Global Tuberculosis report 2012 Other countries

14 India ICMR Study MDR-TB initial Drug resistance:0.6% - 3.2% MDR-TB Acquired Drug resistance: 6% - 30%

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16 Annual multi-drug resistance (MDR) cases reported in India along with prevalence rate of TB noti-fied. Numbers above the bars indicate total number of cases of MDR-TB reported each year. Numbers above the red line notifies the estimated total TB cases reported each year.

17 Number of XDR-TB patients reported under RNTCP 0% AMONG NEW CASES % AMONG RETREATMENT CASES No of Patients Source: Annual report on TB (till sept)

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19 Natural History of untreated smear + TB over a 5-8 year period 60-70% case-fatality rate for smear positive cases, majority within the first 18 months (50%-60% case-fatality rate, all forms) 30% self-cu e ate eve t to uiescent TB 20% chronic excretor rate For each untreated smear+ case, new infections/year can be expected

20 Risk factors for TB Risk factor Category Risk factors Biomedical HIV infection, diabètes, Tobacco, malnutrition, silicosis, malignancy Environmental Socioeconomic indoor air pollution, ventilation crowding, urbanization, migration, poverty Diabetes accounts for 14.8% of all tuberculosis 20.8% of smear-positive TB & 4.85% of the incident TB cases in India were HIV-positive.

21 Risk Factors for the Development of Active Tuberculosis Among Persons Infected with Mycobacterium Tuberculosis Risk Factor Estimated increased risk of active tuberculosis persons infected with Mycobacterium tuberculosis Acquired immunodeficiency syndrome Human immunodeficiency virus infections Other Immuno-compromising conditions* Recentness of infection (<2 years) 15.0 Age of contact (< 5 years and >60 years) For example, diabetes mellitus type 1, renal failure, carcinoma of the head or neck, iatrogenic immuno-suppression

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23 Causes of inadequate treatment which can lead to drug resistance TB Providers/ Programmes: Inadequate regimens Absence of guidelines or inappropriate guidelines Non-compliance with guidelines Inadequate training of health staff No monitoring of treatment Poorly organized or funded TB control programmes Drugs:Inadequate supply/quality Non-availability of certain drugs (stockouts or delivery disruptions) Poor quality Poor storage conditions Wrong dosages or combination Patients:Inadequate drug intake Poor adherence (or poor DOT) Lack of information Non-availability of free drugs Adverse drug reactions Social and economic barriers Malabsorption Substance abuse disorders

24 Communicability : patients are infective as long as they remain untreated. Effective treatment reduces infectivity by 90% within 48 hours

25 Incubation period Ranges from 3 6 weeks Depends on closeness of contacts Extent of the disease Sputum positivity of the source case Host parasite relationship May be weeks, o ths, or years

26 Relative proportion of various forms of TB in immunocompetent (a) and HIV-infected individuals (b) a

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28 The Goal and Objectives of the RNTCP-1st phase Goal: Decrease mortality and morbidity due to TB cut transmission until TB ceases to be a major public health problem in India. Objectives: 85% cure rate 70% case detection rate

29 Directly Observed Treatment, Short Course (DOTS) The success of DOTS depends on five components: - Political commitment - Good quality sputum microscopy - Directly observed treatment - Uninterrupted supply of good quality drugs, and - Accountability.

30 Second Phase of RNTCP ( ) All components of new STOP TB Strategy(DOTS+) are incorporated: 1. Pursue quality DOTS expansion and enhancement 2. Address TB-HIV, MDR-TB and other challenges 3. Contribute to Health system strengthening 4. Involve all health care providers 5. Engage people with TB, and affected communities 6. Enable and promote research

31 Changes in RNTCP policy on diagnosis of smear positive pulmonary TB 1. Number of sputum specimen required for diagnosis is One smear specimen positive out of the two is enough to declare a patient as Sm+ PTB 3. Definition of PTB suspect- any person with cough for 2 weeks, or more

32 Changes in RNTCP treatment Guidelines Discontinuation of Cat III regimen under RNTCP Further, these regimens will be called regimen for New (Category I) and Previously treated (Category II) cases.

33 Revised Categories Treatment Regimes Type of Patient Regimen Intensive Phase(IP) Continuation Phase(CP) New (Cat I) New Sputum smear-positive New Sputum smear-negative New Extra-pulmonary New Others 2(HRZE)3 4(HR)3 Previously Treated (Cat II) Smear-positive relapse Smear-positive failure Smear-positive treatment after default Others 2 (HRZES)3/ 1(HRZE)3 5(HRE)3 6 (9) Km, Ofx, Eto, Cs, Z, E 18 Ofx, Eto, Cs, E MDR-TB Cases(Cat IV)

34 C&DST-MDR-TB(Diagnosis) Andhra Pradesh State TB Demonstration & Training Centre, Irramnuma, Besides AP Chest Hospital, HYDERABAD Blue Peter Research Centre, Near TEC Building, Cherlapally, HYDERABAD DOTS PLUS sites(treatment) Hyderabad AP Chest Hospital, Hyderabad Guntur Govt.Fever Hospital

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36 Achievements of RNTCP

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38 Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, * 120% 110% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Annualised New S+ve CDR Success rate Population projected from 2001 census Estimated no. of NSP cases - 75/100,000 population per year (based on recent ARTI report) NTF Presentations for RNTCP Sensitization First edition 10 th Nov

39 Progress towards MDG s-india Indicator 23: between 1990 and 2015, to halve the prevalence of TB disease and deaths due to TB. per 1Lakh Population Prevalence (MDG-Target)

40 Progress towards MDG s-india Mortality Rate per 1Lakh Population (MDG-Target)

41 RNTCP-REVISED GOALS 12th Five year plan( ) Vision: "TB-free India Goal: Universal Access to quality TB diagnosis & treatment for all pulmonary & extra pulmonary TB patients including drug resistant and HIV associated TB.

42 RNTCP-REVISED OBJECTIVES 12th Five year plan( ) Objectives: To achieve 90% notification rate for all types of TB cases To achieve 90% success rate for all new and 85% for re-treatment cases To significantly improve the successful outcomes of treatment of Drug Resistant TB To achieve decreased morbidity and mortality of HIV associated TB To improve outcomes of TB care in the private sector

43 Contribution to referral of TB suspects (n=430908) Contribution to New smear case detection(n=35025) NGO NGO 3% 6% 1% 5% 5% Private 1% Corporate Corporate 23% 25% Medical colleges 57% 8% Private Govt.Other than Health Health Dept. Medical colleges 56% 10% Govt.Other than Health Health Dept. Contribution of Medical Institutions in TB Control

44 Contribution to DOT Provision(n=25833) Contribution to Treatment Success of NSP Case Reg.(n=26388) NGO NGO Private 8% 9% 1% 7% 71% 4% Private Corporate 8% 6% 3% Medical colleges Govt.Other than Health Health Dept. 10% 1% 72% Corporate Medical colleges Govt.Other than Health Health Dept. Contribution of Medical Institutions in TB Control

45 Chemoprophylaxis TB chemoprophylaxis with Isoniazid daily for a period of six months. This is regardless of BCG vaccination. Close contacts of MDR TB patients should receive careful clinical follow-up for a period of at least 2years. During this stage, no prophylactic treatment of MDR TB contacts is recommended.

46 Challenges

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49 References 1)WHO & AFMC Textbook of Public Health and Community Medicine, 1st edition, ) Textbook of Community Medicine by Dr.Sunder lal, 2nd edition, ) Park s Textbook of Preventive and Social Medicine by K.Park, 21st edition, ) TB Control of India, 5) Ministry of Health and family welfare, 6) World Health Organization(WHO) n/index.html

50 Thank you

51 Evaluation Define TB case Define MDR-TB Current case detection rate & cure rate for INDIA Treatment duration of New treatment regime Previous treatment regime Dots plus treatment regime

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