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
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.
www.tbcindia.nic.in
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).
15%
24%
6%
5%
50%
TB cases Globally (2011)
China
India
South africa
Indonesia
All other countries
Total New TB cases
In the 22 high burden countries
7100000
India ranks 1st
2200000
Annual Global TB Report 2012-RNTCP
46%
5%
12%
26%
6% 5%
TB Prevalence
Other
Bangladesh
China
India
Indonesia
Pakistan
54%
4%
11%
25%
6%
TB Incidence
Other
Bangladesh
China
India
South africa
Global TB Report 2012
41%
7%
5% 4%
30%
7% 6%
TB Mortality Cases
Other
Bangladesh
China
DR Congo
India
Indonesia
6%
28%
6% 5%
55%
EPTB Cases
(Extra pulmonary TB)
Ehiopia
India
South Africa
Pakistan
All Other
countries
Annual Global TB Report 2012
Tuberculosis (TB) cases in India from
1999 to 2011
28%
3%
4% 5%
3% 4%
3% 9%
8%
30%
3%
TB HIV Cases
Other
DR Congo
India
Mozambique
Uganda
Zimbabwe
Brazil
Ethiopia
Kenya
South Africa
UR Tanzania
Global TB Report 2012
HIV on TB Incidence & TB Deaths(2008)
7%
13%
23%
17%
7%
33%
MDR TB Cases
India
Kazakhstan
Russian Federation
South Africa
Ukraine
Other countries
Global Tuberculosis report 2012
MDR-TB initial Drug resistance:0.6% - 3.2%
MDR-TB Acquired Drug resistance: 6% - 30%
India – ICMR Study
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.
0
5
10
15
20
25
30
35
40
45
2008 2009 2010 2011(till sept)
4
29
43
36
No
of
Pa
tie
nts
Number of XDR-TB patients reported under RNTCP
Source: Annual report on TB 2011.
http://www.tbcindia.nic.in/pdfs/RNTCP
0% AMONG NEW CASES
0.5% AMONG RETREATMENT CASES
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, 10-14 new
infections/year can be expected
Risk factors for TB Risk factor Category Risk factors
Biomedical HIV infection, diabètes, Tobacco,
malnutrition, silicosis, malignancy
Environmental indoor air pollution, ventilation
Socioeconomic 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.
Risk Factors for the Development of Active
Tuberculosis Among Persons Infected with
Mycobacterium Tuberculosis
Estimated increased risk of active
Risk Factor tuberculosis persons infected
with Mycobacterium tuberculosis
Acquired immunodeficiency syndrome 170.0
Human immunodeficiency virus infections 113.0
Other Immuno-compromising conditions* 3.6 – 16.0
Recentness of infection (<2 years) 15.0
Age of contact (< 5 years and >60 years) 2.2 – 5.0
For example, diabetes mellitus type 1, renal failure, carcinoma of the head or neck, iatrogenic immuno-suppression
Causes of inadequate treatment which can lead to drug
resistance TB
Providers/ Programmes:
Inadequate regimens
Drugs:Inadequate supply/quality
Patients:Inadequate drug intake
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
Non-availability of
certain drugs (stock-
outs or delivery
disruptions)
Poor quality
Poor storage
conditions
Wrong dosages or combination
Poor adherence (or
poor DOT)
Lack of information
Non-availability of free
drugs
Adverse drug reactions
Social and economic
barriers
Malabsorption
Substance abuse disorders
Communicability :
• patients are infective as long as they remain
untreated.
• Effective treatment reduces infectivity by
90% within 48 hours
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…
Relative proportion of various forms of TB in immunocompetent (a) and HIV-infected individuals (b)
a
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
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.
Second Phase of RNTCP (2006-2011)
• 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
Changes in RNTCP policy on diagnosis of smear
positive pulmonary TB
1. Number of sputum specimen required for
diagnosis is 2.
2. 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
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.
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
MDR-TB Cases(Cat IV) 6 (9) Km, Ofx,
Eto, Cs , Z, E
18 Ofx, Eto,
Cs, E
C&DST-MDR-TB(Diagnosis)
Andhra Pradesh State TB Demonstration &
Training Centre, Irramnuma,
Besides AP Chest Hospital,
HYDERABAD-500 038.
Blue Peter Research Centre,
Near TEC Building,
Cherlapally,
HYDERABAD 501 301.
DOTS PLUS sites(Treatment)
Hyderabad AP Chest Hospital, Hyderabad
Guntur Govt.Fever Hospital
Achievements of RNTCP
NTF Presentations for RNTCP Sensitization First edition 10th Nov 06
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
110%
120%
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
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)
Annualized New Smear-Positive Case Detection Rate and Treatment Success Rate in DOTS Areas, India, 2000-2009*
Progress towards MDG’s-India
• Indicator 23: between 1990 and 2015, to
halve the prevalence of TB disease and deaths
due to TB.
459
256 230
0
100
200
300
400
500
1990 2010 2015(MDG-Target)
pe
r 1
Lak
h P
op
ula
tio
n
Prevalence
Progress towards MDG’s-India
39.1
29.4
19.5
0
5
10
15
20
25
30
35
40
45
1990 2010 2015(MDG-Target)
Ra
te p
er
1La
kh
Po
pu
lati
on
Mortality
RNTCP-REVISED GOALS 12th Five year plan(2012 – 2017)
• 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.
RNTCP-REVISED OBJECTIVES 12th Five year plan(2012 – 2017)
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
6%
3% 1%
25%
8%
57%
Contribution to referral of TB
suspects (n=430908)
NGO
Private
Corporate
Medical
colleges
Govt.Other
than Health
Health Dept.
5% 5%
1%
23%
10%
56%
Contribution to New smear
case detection(n=35025)
NGO
Private
Corporate
Medical
colleges
Govt.Other
than Health
Health Dept.
Contribution of Medical Institutions in TB Control
8% 9% 1%
7%
4% 71%
Contribution to DOT
Provision(n=25833)
NGO
Private
Corporate
Medical
colleges
Govt.Other
than Health
Health
Dept.
8% 10%
1%
6%
3%
72%
Contribution to Treatment
Success of NSP Case
Reg.(n=26388)
NGO
Private
Corporate
Medical
colleges
Govt.Other
than Health
Health
Dept.
Contribution of Medical Institutions in TB Control
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.
Challenges
References
1)WHO & AFMC Textbook of Public Health and Community
Medicine, 1st edition, 2009.
2) Textbook of Community Medicine by Dr.Sunder lal, 2nd
edition, 2009.
3) Park’s Textbook of Preventive and Social Medicine by K.Park, 21st edition, 2011.
4) TB Control of India, http://www.tbcindia.nic.in/
5) Ministry of Health and family welfare,
http://www.mohfw.nic.in/NRHM.htm
6) World Health Organization(WHO)
http://www.who.int/publications/guidelines/tuberculosis/e
n/index.html
Thank you
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