“NATIONAL TUBERCULOSIS

ELIMINATION PROGRAM”
(NTEP)
M O D E R AT O R : D R . V I N O D C H AYA L P R E S E N T E D B Y: D R . PA R M E E T S I N G H
PROFESSOR PG RESIDENT 1 ST YEAR
D E P T. O F C O M M U N I T Y M E D I C I N E D E P T. O F C O M M U N I T Y M E D I C I N E
P G I M S , R O H TA K P G I M S , R O H TA K
 What is Tuberculosis?
Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium
tuberculosis (MTB) which generally affects the lungs, but can also affect other parts
of the body
Risk factors:
o Malnutrition o Overcrowding
o Diabetes o Inadequate
o HIV infection ventilation
o Poor immunity o Enclosed living/
o Severe kidney disease
working conditions
o Other lung diseases
o Occupational risks
e.g. silicosis
o Substance abuse etc.

One patient with infectious pulmonary TB if

untreated can infect 10-15 persons in a year
TB Burden- Global v/s India
Estimates of TB Burden Global India % of
(2021) (Million) Global

Incidence TB cases 10.6 3 Million 28.3%

Mortality of TB 1.4 494,000 35.3%

Incidence HIV TB 0.7 54,000 7.7%

Mortality of HIV-TB 0.18 11,000 5.9%

MDR-TB 0.45 119,000 26.4%

Children with TB 1.1 356,000 32.4%

CASE DEFINITIONS
 CASE DEFINITIONS
Bacteriologically TB diagnosed in a biological specimen by smear microscopy, culture or a WHO-
confirmed TB endorsed rapid molecular test and adopted by NTEP such as Xpert
MTB/RIF®/Truenat®

Clinically diagnosed TB
• A presumptive TB patient who is not Bacteriologically confirmed, but diagnosed
with active TB by a clinician on the basis of X-ray, histopathology or clinical signs
with a decision to treat the patient with a full course of Anti-TB treatment.
• In children, this is based on the presence of abnormalities consistent with TB on
radiography, history of exposure to an infectious case, evidence of TB infection
(positive TST) & clinical findings suggestive of TB in the event of negative or
unavailable microbiological results

Bacteriologically confirmed or clinically diagnosed cases of TB are also classified according to:
– anatomical site of disease
– history of previous treatment
– drug resistance
 Classification by H/O previous TB treatment
New case TB patient who has never had treatment for TB or has taken anti-TB drugs for less than one month.

Previously treated Received 1 month or more of anti-TB drugs from any source in the past.
patients

Recurrent TB case TB Patient previously declared as successfully treated (cured/treatment completed) and is subsequently
found to be microbiologically confirmed TB case.

Treatment After Those patients who have previously been treated for TB and whose treatment failed at the end of their
failure most recent course of treatment.

Treatment after lost TB patient previously treated for TB for 1 month or more and was declared lost to follow-up in their most
to follow-up recent course of treatment and subsequently found microbiologically confirmed TB case.

Other previously Those who have previously been treated for TB but who cannot be classified into any of the above
treated patients classification.

Transferred in TB patient who has been received for treatment in a Tuberculosis Unit, after starting treatment in
another TB unit where she/he has been registered is considered as a case of transferred in.
 Sustainable Development Goals (SDG)

Vision: A world free of TB

Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB Epidemic (<10 cases per 100,000 population)

TARGETS
INDICATORS
SDG 2030
Reduction in number of TB deaths
compared with 2015 (%) 90%
Reduction in TB incidence (new case) rate
compared with 2015 (%) 80%
TB-affected families facing catastrophic
expenditures due to TB (%) Zero
 End TB Strategy

• In 2014, the World Health Assembly

endorsed a new, bold plan called “The
End TB Strategy”.
• The vision is “A world free of TB - Zero
TB deaths, Zero TB disease, and Zero
TB suffering”.
• The goal is to end the global TB
epidemic (<10 cases per 100,000).
Delhi End TB Summit 13 March
2018, To END TB By 2025
TB Elimination Strategy
VISION – A world FREE of TB

TOWARDS

ZERO ZERO ZERO

DEATHS DISEASE SUFFERING
Global Plans Target
Rule of 90
• Reach at least 90% of all people with TB and start
appropriate therapy.
• Reach at least 90% of key population (most
vulnerable, underserved, high risk)
• Achieve at least 90% treatment success (through
affordable treatment, complete and correct, and
social support)
TB Free India
India has committed to End TB by
2025, 5 years ahead of the global
SDG target

Prime Minister of India launched TB

Free India campaign at ‘Delhi End TB
Summit’ on 13th March, 2018

The campaign calls for a social

movement focused on patient-
centric and holistic care driven by
integrated actions for TB Free India
 Evolution of NTEP in India
2021 2020
TB Mukt Bharat Abhiyaan on World TB Day In January 2020, GoI revised RNTCP to National TB
Elimination Program (NTEP) in line with Ending TB by
2025

2019
2017 – 25 TB Harega Desh Jeetega Campaign
National Strategic Plan - II (2017 – 25)
Patient centric care for TB elimination 2012 -17
National Strategic Plan-I (2012 -17)
Mandatory notification of TB,
Rapid Molecular testing,
Active Case Finding (ACF) and
2005 – 11 integration of the program with National Health Mission
Second phase of RNTCP – Pan India coverage and
improved quality and scale up of services
2007 – Programmatic Management of Drug Resistant TB
1997
GoI revised NTP to RNTCP – introduction of DOTS (Directly
Observed Treatment Short course)
1993
WHO declares TB as a global emergency
1962
Govt. of India launched the National TB Program and set
up District TB Centres
 National Strategic Plan (2017 - 2025)
The National Strategic Plan (NSP) envisages that the TB patient must not be seen as passive
recipient of care but an equal stakeholder in provision and enhancement of quality services

Find all TB cases

Prevent the emergence of TB through quality
in susceptible populations assured Diagnostics
and stop catastrophic with an emphasis on
expenditure due to reaching every TB
TB by all patient in the private
Detect
Prevent
Build
Treat
Detect
Prevent
sector
Build
Treat
Build & strengthen
supportive systems Treat all TB cases
including enabling policies, with high quality
empowered institutions anti TB drugs
& human resources
National Strategic Plan (2017-25)

Multi-
sectoral
response Active
Community
Engagement
Case
Finding

TB
Preventive
Measures Strategies Co-
morbidities

ICT Tools for Private

adherence sector
and engagement
monitoring Drug
Resistant
TB
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 ORGANIZATION STRUCTURE OF NTEP
MINISTRY OF HEALTH AND FAMILY WELFARE
SUPPORTING FACILITIES
CENTRAL TB DIVISON
National Institutes(3)
STATE TB CELL
National Reference Laboratories(6) 37 STATES/UTs

DISTRICT TB CENTRE; 767 Districts

Intermediate Reference Laboratories(34)
TB UNIT
State TB Training and Demonstration Centre(26) ONE PER 1.5-2.5 LAKH POPULATION

Culture and DST Laboratories (87) DESIGNATED MICROSCOPY CENTRE

50,000 TO 1 LAKH POPULATION
Nodal DR-TB Centre (173)s
PERIPHERAL HEALTH INSTITUTE
CBNAAT Laboratories(3165)
 Key Services

1. Free diagnosis and treatment for TB patient

2. Public health action- contact tracing, testing for
co-morbidities etc.
3. Treatment adherence support
4. Nutrition assistance to TB patients (DBT-
Nikshay Poshan Yojana)
5. Preventive measures
 Strengthening Case Finding in the Public Sector
ACTIVE APPROACH TO CASE FINDING
PASSIVE APPROACH TO CASE FINDING
Chest X Ray:
Clinically diagnosed TB
increased from 8.8 lakhs in
2017 to 12.7 lakhs in 2019
Revised Diagnostic
Algorithm for TB: Increase
in DR-TB cases from 38,000
in 2017 to 66,000 in 2019
Upfront Rapid Molecular
Testing: Increased from
5.23 lakhs upfront tests in
2017 (16% yield) to 11.34
lakhs in 2019 (17% yield)
Intensive Case Finding in Health
facilities- Screening for TB
among:
-DM patients increased from
11.5 L in 2018 to ~20 L in 2019
- ICTC/ART referrals increased
from 3.35 L in 2017 to 3.94 L in
2019
Active Case Finding in vulnerable
population: from 5.5 crore
population screened in 2017 to
28 crores screened in 2019. Yield
increasing from ~27,000 to
~63,000 TB patients.
Leveraging Outreach of other
Healthcare Programmes: 8.3
lakhs referrals from Health &
Wellness Centres .
Strengthening Case Finding in the Private Sector

Schedule H1 Implementation: The number of

chemists registered in Nikshay increased from
15221 in 2017 to over 43000 chemists notifying
20,609 TB cases in 2019.

77% Increase
Mandatory Notification of TB: Gazette in private
notification issued in March 2018; Provisions sector
of Sections 269 and 270 of the Indian Penal notification
Code (IPC) in 2019 from 3.8
lakhs in 2017
to 6.8 lakhs in
2019.
Patient Provider Support Agency through JEET
and Domestic Resources: From 48 PPSAs in 2017
to 220 PPSAs in 2019 and 266 PPSAs in 2020.
Public Health Measures
(PHA)
• Counselling of patients and family Successful treatment
outcome
members
• Contact investigation
• Chemoprophylaxis Monthly clinical follow-
• HIV testing up

• Blood sugar testing

• Drug Susceptibility testing Treatment support to
• Ni-kshay Poshan Yojana benefit patient & monitoring

• Follow up
• Adherence support Drug strips handed over
• Treatment outcome reporting to treatment supporter

Suitable treatment
support method to be
decided

Treatment to be
prescribed by a Doctor
 Treat
• Daily Regimen
Treatment • Shorter Regimen
• Newer Drugs
• IT Enabled Adherence
Support
Patient Centric Care • Comorbidity
management
• Financial incentives
Reduce Out-of-pocket •
Direct Benefit Transfer
Expenditure
 Treatment Regimens
Type of TB Type of regimen Duration and Drugs
Drug susceptible 2 months H, R, Z, E
DS-TB regimen
TB 4 months H, R, E
H mono/poly DR- H mono/poly 6 months Lfx, R, E, Z
TB DR-TB regimen

Shorter oral BDQ containing (4-6) Bdq (6 m), Lfx, Cfz, Z, E, Hh, Eto
MDR / RR and regimen (5) Lfx, Cfz, Z, E
XDR-TB
Longer oral BDQ containing regimen (18-20) Lfx Bdq (6 month or longer) Lzd# Cfz Cs

6 H (6 months daily INH monotherapy)

3 HP (3 months weekly dose of HP – 12
dose)
TB Infection TB Preventive treatment 6 Lfx (6 months Lfx in contacts of MDR/RR
4 R (4 months daily R in contacts of H Res
3RH (3 months daily RH -2FDC)
 Pyridoxine in TB Regimen
It is given to prevent INH related neuropathy due to Vitamin B6 deficiency.

Following are the conditions where the possibility of developing neuropathy when
given INH without Pyridoxine is high:
1)Alcoholics
2)Malnourished persons
3)Pregnant and lactating women
4)Patients with conditions such as chronic renal failure, diabetes
5)HIV infection
Hence, simultaneous monitoring for neuro and hepatotoxicity is advised if given
INH.
 Treatment Adherence
99 DOT Smart box

Directly Observed Treatment

Health facility
Community treatment supporter
Family DOT Call centre Human interaction
ICT based adherence
99 DOT
MERM (Pill box)
Self reporting (Call Centre, IVRS)
SMS Reminder Social Support

Pill counting
IT enabled adherence monitoring

26
 Direct Benefit Transfer (DBT) schemes

1. Honorarium to Treatment Supporters – For provision of treatment support to

TB patients (Adherence, ADR monitoring, counselling @Rs.1000/- to
Rs.5000/-)
2. Patient Support to Tribal TB Patients (Financial Patient Support @Rs750/-)
3. Nutritional Support to All TB patients (Financial Support to Patients
@Rs.500/-month)
4. Incentives to Private Providers (Rs.500/- for Notification & Rs.500/- for
reporting of Treatment Outcome
5. Incentives to Informant (Rs. 500/- is given on diagnosis of TB among referrals
from community to public sector health facility)
Prevent
Air borne infection control
measures
Strengthen Contact
Investigation
Preventive treatment in high
risk groups
Manage Latent TB Infection
Address determinants of
disease
 CASCADE OF TB CASE FINDING AND TPT
The aim is to reduce TB burden Target Population
and transmission.
Rule out active TB
In the cascade of care approach,
No signs/
o Reach out to all target Presumptive TB
symptoms of TB
population who are at-risk of
developing TB disease Active TB ruled Test for TB infection
TB confirmed (as per policy)
out
o Screened for TB disease and
o Provide TPT after ruling out TB Start TB Evaluate for TPT
treatment
disease
Start TPT
Systematic follow-
up
Systematic follow-
up
29
 Tests For TB Infection

Currently recommended and available tests for TBI-

Both tests measure immune sensitization
1. Tuberculin Skin Test (TST) and
(type IV or delayed-type II hypersensitivity)
2. Interferon- Gamma Release Assay (IGRA) to mycobacterial protein antigens that
occurs following infection by M.tb

A diagnosis of TBI needs to be complemented by a negative test outcome for

TB disease, through clinical evaluation, chest radiography and examination of
sputum or another suitable specimen if symptomatic, as per NTEP diagnostic
algorithm.

30
 ALGORITHM FOR TB SCREENING AND TPT
HIV positive Household contact Other risk group 3

Any symptom1 of Symptomatic?2

current cough or fever or weight loss or
night sweats
YES NO

NO YES <5 years 5 years +

Investigate for active TB

No active TB TST or IGRA

Preventive treatment
Positive or unavailable Negative
contraindicated?4

Abnormal
YES NO CXR6
Normal or
unavailable
Defer preventive Give preventive treatment5
treatment

Follow-up for active TB as necessary, even for patients who have completed preventive treatment
31
 TB PREVENTIVE TREATMENT
a. Expanded eligible group Target population Target population
including children >5 • People living with HIV (+ ART)
years, adolescents and o Adults and children >12 months
• 6-months daily isoniazid (6H)
adult HHC of o Infants <12 months with HIV in contact
with active TB • 3-month weekly Isoniazid and
pulmonary* TB patients Rifapentine (3HP) in persons
notified in Nikshay from • HHC below 5 years of pulmonary* TB older than 2 years
public and private patients
sector
(*bacteriologically • HHC 5 years and above of pulmonary* TB • 3-month weekly Isoniazid and
patients# Rifapentine (3HP)
confirmed pulmonary
TB patients will be • 6-months daily isoniazid (6H)
prioritized for • Children/adult on immunosuppressive • 3-month weekly Isoniazid
enumeration of the therapy, silicosis, anti-TNF treatment, and Rifapentine (3HP)
target population) dialysis, transplantation • 6-months daily isoniazid (6H)
b. other risk groups
32
 CONTRAINDICATIONS OF TPT
Active TB disease (absolute)
Acute or chronic hepatitis
Concurrent use of other hepatotoxic medications (such as nevirapine)
Regular and heavy alcohol consumption
Signs and symptoms of peripheral neuropathy like persistent tingling, numbness
and burning sensation in the limbs
Allergy or known hypersensitivity to any drugs being considered for TPT
• Pregnancy or a previous history of TB are not contraindications for TPT

33
 Multi-sectoral Engagement
TB care services in Socio-economic
health support &
infrastructure Empowerment
Infection
Prevention Information
Education
Address Communication
Determinants
Corporate
Prevention and
Care at Work Place Social
Responsibility

TB - A social problem & needs multi-sectoral approach

Inter-Ministerial Coordination
AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and
Homoeopathy)
• 1st meeting of National Technical Expert Group on NTEP-AYUSH Collaboration &
e-consultation of experts held
• 2nd draft of Policy Document and Joint Letter drafted

Railways
• Joint Working Group to be formed to monitor implementation

Defence
• Action Plan developed.
• 95 Ex- Servicemen Contributory Health Scheme (ECHS) Polyclinics registered in
Nikshay, remaining underway

Labour and Employment

• MoU signed in September 2020
 Community Engagement
TB Forums at the National, State
Transformation of TB survivors to TB and District level to provide a
platform for all stakeholders,
champions including the community, to voice
Capacity building and mentoring their views
programme
Engagement of existing community
groups like PRI, SHG, VHSNC, MAS,
Youth Club
Grievance redressal mechanism
Involvement of community
representatives in different forums
 Sub-National TB Free Certification
Claims awarded in 2020
Awarded
States and Union Territories (UTs) claim reduction in incidence Category
District State/UT
Verification carried out by third party – a research institute, WHO & public TB Free 1 1
health association Gold 1 0
Method of verification include a survey and secondary data analysis including Silver 4 0
drug sales Bronze 29 2
Total 35 3

Claims submission in 2021

Awarded
Category
District State/UT
Award Bronze Silver Gold TB Free TB Free 0 0
Gold 11 0
Criteria
(Incidence Silver 52 4
 20%  40%  60%  80%
decline) Bronze 138 6
Total 201 10
 Sub-National TB Free Certification – Award Status
Lakshdweep first TB free UT Claims awarded in 2020 States/UTs awarded claims
Awarded • TB Free – Lakshdweep
Category • Bronze – Kerala, Puducherry
District State/UT
• From Punjab- Fatehgarh Sahib,
TB Free 1 1
Kapurthala and Nawanshaher
Gold 1 0 (Bronze Award)
Silver 4 0
Bronze 29 2
Total 35 3
Badgaon first TB free district
States/UTs claims
Claims submission in 2021
• Silver – DNH &DD, Himachal
Claims Pradesh,
Category
District State/UT Kerala, Puducherry
TB Free 0 0 • Bronze – Gujarat, Jammu & Kashmir,
Gold 11 0 Karnataka, Ladakh, Sikkim,
Silver 52 4 Tripura
Bronze 138 6 Punjab- Faridkot, Ferozepur, Moga,
Total 201 10 Ropar and Tarn Taran (Bronze Award)
 Call Centre- Nikshay Sampark

 1800-11-6666 Counselling
 Outbound & Inbound Nikshay Treatment
Poshan Adherence
 Time – 7 to 11 Yojana
 Languages – 14
 100 call centre agents Grievance
Information Redressal
 Pan-India coverage
 Citizen – Patient - Providers
TB Follow
Notification Up
Policy Update in RNTCP, 2018
 Ni-kshay Mitra
Individual
Institution- School / College
NGO
Political Party
Others
◦ Elected Representatives
◦ BDO / DM
◦ Factories
◦ Corporates / industries
◦ Anyone
 Key Challenges
1. Under reporting and uncertain care of TB patients in private
sector

2. Reaching the unreached – Slums, Tribal, vulnerable

3. Drug Resistant TB

4. Co-morbidities – HIV, Diabetes

5. Undernutrition, overcrowding

6. Lack of awareness and poor health seeking behaviour lead

to delay in diagnosis
 Key Take Away
Improve TB notification rate Ensure mandatory TB notification from private sector
Active TB Case Finding to reach the unreached
Optimum utilization of CBNAAT machines
Expand Universal Drug Susceptibility Testing coverage
NIKSHAY Poshan Yojana to every TB patients
100% reporting through NIKSHAY
Collaboration with Line Ministries to tackle social determinants of TB
Community participation for TB Elimination
 Bending the Curve
Accelerating towards a TB free India
Thank You
Thank You