REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME

National Tuberculosis programme (1962) – disadvantages/ problems

a. Managerial weakness
b. Inadequate funding
c. High reliance on C- Xray for Dx
d. Freq interrupted supplies of drugs
e. Low rates of treatment completion

In order to overcome the above lacunae RNTCP was formulated and the following happened

(i) Political and administrative commitment to ensure provision of organized and comprehensive
TB control services
(ii) Smear microscopy for reliable and early diagnosis was introduced in a decentralized manner in
the general health services
(iii) DOTS was adopted to increase the treatment completion rate
(iv) Supply of drugs strengthened to provide assured supply that meets requirement

RNTCP was built on already established infrastructure of NTP

Objectives of RNTCP

a. Achievement if at least 85% cure rate of cases of infectious tuberculosis through DOTS and
involving peripheral health functionaries
b. Augmentation of case finding through quality sputum microscopy to detect at least 70% of
estimated cases

Since March 2006 RNTCP covers the whole country. Currently RNTCP II phase is running.

Aims of RNTCP Phase II

(i) Consolidate the gains made to date

(ii) Widen services in terms of activities and access and to sustain the achievements
(iii) Provide standardized treatment and diagnostic facilities to all TB patients irrespective of the
health care facility from which they seek treatment
(iv) Improve access to marginalized groups – urban slum dwellers, tribal

DOTS – 5 components

a. Political will and administrative commitment

b. Diagnosis by quality assured sputum smear microscopy
c. Adequate supply of quality assured short-course chemotherapy drugs
d. Directly observed treatment
e. Systematic monitoring and accountability
STOP TB Strategy

In 2006 WHO announced STOP TB strategy and the same was adopted by RNTCP.

Components- 1. Pursuing quality DOTS- expansion and enhancement

2. Addressing TB/HIV and MDR-TB

3. Engaging all care providers

4. Empowering patients and communities

5. Enabling and promoting research (diagnostic, treatment, vaccine)

Initiatives taken by RNTCP under STOP TB are-:

a. Developing and piloting - ‘National Airborne Infection Control Guidelines’

b. Developing and piloting – ‘Practical Approach to Lung Health’

ORGANISATION – RNTCP

State wise-

State TB office State TB officer

State TB training and demonstration center Director
(STDC)
District TB center District TB officer
Tuberculosis unit Medical officer of TB control
Senior TB laboratory supervisor
Senior Treatment supervisor

Microscopy centers, Treatment centers

DOTS providers

LABORATORY NETWROK

Quality assured laboratory services: RNTCP aims to-:

(i) Consolidate lab network into a well-organized one where there will be defined hierarchy for
carrying out sputum microscopy
(ii) External quality assessment (ESA)
Quality assurance activities include

(i) On-site evaluation

(ii) Panel testing
(iii) Random blinded rechecking

The various labs are as follows

a. National reference laboratories: 6 in number. Monitor and supervise Intermediate reference

laboratories’ (IRL) activities and train the IRL staff in ESA, Culture and Drug Sensitivity Testing
(C&DST).
3 microbiologists and 4 lab technicians are provided to NRL for monitoring and supervision of
lab activities. They visit their assigned state for 2-3 days at least once a year for on-site
evaluation.

b. Intermediate Reference laboratories (IRL): One among the STDC/public health lab/ medical
college lab has been designated as IRL. Functions of IRL-:
(i) Supervision and monitoring of EQA activities, C&DST of mycobacterium, drug
resistance surveillance (DRS- selected states)
(ii) Ensuring proficiency of staff in smear microscopy bear training dist. and sub-dist. lab
technicians and senior TB lab supervisor
(iii) On-site evaluation and panel testing to each dist. at least once a year
c. Designated Microscopy center: The peripheral laboratory under RNTCP catering to pop. of
100,000 ( 50,000 in hilly areas or tribal areas).
d. Culture and Drug sensitivity testing (C&DST) labs: RNTCP also involves the microbiology
department of medical colleges for-:
(i) Providing diagnosis for drug resistance TB
(ii) Diagnosis of extra pulmonary TB
(iii) Research

These C&DST labs can provide one among solid culture certification, liquid culture certification,
line probe assay (LPA) or Second Line DST.(Hierarchy of TB labs pg. 428)
RNTCP endorsed TB diagnostics

a. Smear microscopy for acid fast bacilli

(i) Sputum smear stained with Zeihl-Neelsen staining
(ii) Fluorescent stains and examined under direct or indirect microscopy with or without LED
b. Culture
(i) Solid media (LJ)
(ii) Liquid media (middle-brook) using manual semiautomatic or automatic machines eg
BACTEC, MGIT
c. Rapid diagnostic molecular test
(i) Conventional PCR based LPA for MTB complex
(ii) RT-PCR based NAAT for MTB complex- GeneXpert
 New Initiatives under RNTCP

1. Introduction of GeneXpert in 18 TB units in 12 states

2. Nikshay - TB surveillance using case based web based IT system : This software was launched in
May 2012 and has the following components-:
(i) Master management
(ii) User details
(iii) TB patient registration and details of DOT provider, HIV status, follow-up, contact
tracing outcomes.
(iv) Details of diagnostics like – solid/liquid culture, LPA, DST, CBNAAT(Cartridge based
nucleic acid amplification test)
(v) Drug resistant TB patients registration with details
(vi) Referral and transfer of TB patients
(vii) Private health facility registration and TB notification
(viii) SMS alerts to patients on registrations
(ix) SMS alerts to programme officer
(x) Automated periodic reports
(i) Case finding
(ii) Sputum conversion
(iii) Treatment outcomes
3. TB notification: It is essential to have complete information of all cases to-
(i) Ensure proper diagnosis and management of TB cases
(ii) Reduce the emergence and transmission of MDR TB

It is now mandatory for all healthcare providers to notify every TB case that they diagnose to
local authorities (district health officer/ chief medical officer of the district, Municipal health
officer) every month in a given format. (35,000 patients have been notified)

4. Ban on TB serology: serological tests are based on antibody response. Disadvantages are-:
(i) The response is highly variable and may reflect remote infection rather than active
disease
(ii) Poor specificity

The import manufacturing and sale are banned by the government of India

Initiation of Treatment

Under RNTCP active case finding is not pursued. Case finding is passive. Patients presenting with cough
for more than 2 weeks are screened through sputum smear examination

Sputum microscopy is done in RNTCP designated microscopy center which are located either in
PHC/CHC/Taluka hospital/TB dispensary. Each center has a skilled technician to ensure quality control.
Senior TB laboratory Supervisor is appointed for every 5 microscopy center- rechecks all the positive
slides and 10% of the negative slides (error in diagnosis is minimized)

Chance of detecting smear positive case with only one sputum sample is only 80%. Sputum smear
confirms the diagnosis, indicates the degree of infectivity and response to treatment.
DOTS- All patients are provided short-course chemotherapy free of cost.

- DOTS is a community based treatment and care strategy which combines the benefits of
supervised treatment with community support
- It ensures high cure rates through three components -:
(i) Appropriate medical treatment
(ii) Supervision and motivation by healthcare and non-health worker
(iii) Monitoring of disease status by health services
- DOTS is given through peripheral workers such as MPWs (multi-purpose workers), volunteers
such as teachers, aanganwadi workers, dais, ex-patients, social workers. They are known as
‘DOT Agents’ and paid an incentive of Rs. 150 per patient completing the treatment.
- Drug dispensing-:
(i) Drugs are packaged in blister packs and supplied in patient wise boxes containing full
course of treatment
(ii) Intensive Phase – each blister pack contains one-day’s treatment
Continuation phase- each blister pack contains 1weeks treatment
(iii) The combipacks for extension of intensive phase is supplies separately
(iv) The boxes are colored according to category- category I -> RED
Category II -> BLUE

Pediatric Tuberculosis

Drug resistance surveillance under RNTCP

RNTCP has taken steps to measure prevalence of drug resistance in TB because it is an indicator of
effectiveness of TB control activities.

The aim to is to determine the prevalence of drug resistance among new sputum smear positive PTB
patients and among previously treated sputum smear positive PTB patients

The prevalence of MTB is 2.2% in new cases and 15% in retreatment cases.

Programmatic Management of Drug Resistant TB

Implementations of the collaborative TB-HIV activities

1. Intensified TB case finding at ICTC and ART centers

2. HIV testing if TB patients through provider initiated testing and counselling
3. HIV-TB patients who are on protease inhibitors are getting rifabutin instead of rifampicin
4. Whole blood finger prick HIV testing at all DMCs without standalone ICTC or F-ICTC
5. Monitoring of case finding activities among HIV infected pregnant women and children living
with HIV
6. Isoniazid prophylaxis therapy for PLHIV
7. Diagnosis of TB and Rifampicin resistance will be done by Xpert MTB/RIF

TB in pregnancy
National Strategic plan(2012-2017)

For the 12th five year plan the following were the thrust areas identified

a. Improve quality of DOTS service

b. Strengthen health system under NRHM
c. Deploying improved rapid diagnosis at the field level
d. Expand efforts to engage all care providers
e. Strengthen urban TB control
f. Expand diagnosis and treatment of drug resistant TB
improve communication and outreach
g. Promote research for development of improved tools and strategies

Vision of Govt. of India: TB free India, reduction of the buren of TB to such an extent that it is no longer
a major public health problem

Objectives:

(i) Early detection and treatment of 90% of the estimated all type of TB cases
(ii) Successful treatment of atkeast 90% of new TB patients and 85% of previously treated TB
patients
(iii) Reduction in default rate of new TB cases to less than 5% and retreatment cases to less than
10%
(iv) Initial screening of all smear positive TB cases for drug resistance and providing MDR-TB
treatment services
(v) Offer HIV counselling and testing for all TB patients and linking HIV infected TB patients to
HIV care and support
(vi) Extend RNTCP support to patients treated in private sector

Targets

(i) D&T treatment of 87 lakh TB patients

(ii) D&T of at least 2lakh MDR-TB patients
(iii) Reduction in delay in diagnosis and treatment
(iv) Increase in access to services to marginalized and hard to reach groups, marginalized groups
and vulnerable groups

Financial Resources:

a. World Bank
b. Department of international development via WHO
c. Global TB drug facility
d. Global fund to fights AIDS TB Malaria
e. United States agency for international development
f. DANIDA

Govt. of India provides 100% grant-in-aid to implementing agencies, drugs free of cost