Transcript Document
Current Challenges of the Revised National TB Control Programme (RNTCP) in India
31 st Annual conference of IAPSM PGIMER: 28 th February 2004 Dr LS Chauhan Deputy Director General (TB)
Directorate General of Health Services Ministry of Health & Family Welfare Nirman Bhawan, New Delhi 110 011
TB Burden, RNTCP and its achievements
TB Burden, India (2001)
- Nearly one third of the global TB burden
Annually:*
• Total new cases • New smear-positive cases • TB deaths 1.8 million 795,000 417,000
Daily:
• > 20,000 people become infected • More than 5,000 people develop TB • More than 1,000 people die
Source: provisional WHO estimates Sept 2003
Status of TB control in India
• • • • • • •
1950s-60s: 1962:
Important TB research National TB Programme
1992:
Programme Review- only 30% of patients diagnosed and only 30% of those treated successfully
1993:
RNTCP pilots the DOTS strategy
1998:
Rapid scale-up begins
2000: 2003:
> 30% of country covered under RNTCP >75% of country covered by DOTS
RNTCP: Goal & Objectives
Goal
To decrease mortality and morbidity due to TB, and to interrupt the chain of transmission in order that TB is no longer a major public health problem in India
Objectives
To cure at least 85% of new smear positive pulmonary cases; and To detect at least 70% of estimated new smear positive cases existing in the community, after achieving the first objective
India RNTCP (DOTS) implementation status by district, 31 st Jan 2004
Implementing Appraisal done Ready for appraisal Preparing
Type of districts / reporting units No. of districts / reporting units
445
Population as per 2001 Census Projected population (in million) *
770 814 Implementing Appraisal done Ready for appraisal 19 5 26 8 28 8 Preparing 162 223
*
2004 projected population based on 2001 census.
239
Summary : RNTCP Achievements 1
• Fastest expansion in the world – 10-15 million million additional population covered each month – >40 fold expansion of DOTS in past 4.5 yrs – 2nd largest programme in the world • > 80,000 patients placed on treatment every month • Treatment success rate more than 85% More than 8 out of 10 patients successfully treated Treatment success rates have tripled from 25% to 85% –TB death rates have been cut 7-fold from 29% to 4%
To date nearly 2.8 million patients placed on treatment
– more than 500,000 additional lives saved
Summary : RNTCP achievements 2
• To achieve the above – Sound training materials developed for all categories of staff – > 300 000 health workers trained – > 7,700 Microscopy centres established • Evaluation findings: – Well established logistic system – 99% patients received free drugs and free microscopy services – Published data at Central level reflects the programme activities in the field – Highly economical costing < US$ 5 cents per capita
RNTCP: Thrust areas & challenges
DOTS expansion, India (1993-2005)
1200 1000 800 600 400 200 0 IV /9 3 II/ 94 IV /9 4 II/ 95 IV /9 5 II/ 96 IV /9 6 II/ 97 IV /9 7 II/ 98 IV /9 8 II/ 99 IV /9 9 II/ 00 IV /0 0
Quarter/Year
II/ 01 IV /0 1 II/ 02 IV /0 2 II/ 03 IV /0 3 II/ 04 IV /0 4 II/ 05 IV /0 5 Country population Actual DOTS coverage Planned DOTS coverage
TB/HIV Coordination
• Action plan for TB/HIV collaboration developed and initiated in 6 high HIV burden states • Sensitization/training of key policy makers, programme staff and other partners undertaken • HIV/TB training manuals, treatment guidelines for TB among HIV-positive patients developed & disseminated • Referral linkages between VCTC and MCs established: as a result, 7000 HIV+ individuals put on DOTS.
• TB/HIV coordination activities being expanded to 8 other States in the near future
Public-private mix (PPM)
• • Ongoing efforts to involve all providers of care Guidelines for private practitioners (PPs) and NGOs developed • • >3000 PPs involved Over 50 corporate sector establishments engaged – Tea Garden hospitals in West Bengal, Nilgiris in TN – Sugar mill in Meerut, Uttar Pradesh – Eastern coal fields in Bardhaman • • 750 NGOs involved Documentation of existing PPM projects (e.g., Kannur, Thane, Pune, tea gardens etc.) initiated
Promising results seen from evaluation of existing PPM projects
Medical Colleges & Hospitals
• • • • • • Consensus workshop organized to define structure and process for effective involvement of medical colleges in RNTCP 7 nodal centres identified 1 National, 5 Zonal Task Forces established.
19/23 States have formed State task forces 131 Medical colleges implementing DOTS Action plans developed and participation of medical colleges sought in: – – – – Providing RNTCP services Training and teaching of RNTCP Advocacy for RNTCP Operational research
Contribution from Medical Colleges hospitals: an example
• • • • In Gujarat, medical colleges contributed to over 11% of the chest symptomatics examined for sputum microscopy. Most of the colleges referred > 2% of their new adult OPD patients for sputum microscopy 543 patients were started on treatment in medical college DOT centres alone. Medical colleges played a particularly important role in managing complicated cases of TB and in the diagnosis and management of Extra Pulmonary TB patients.
Pediatric TB
• • • • Practical problems associated with diagnosis & treatment of pediatric cases under RNTCP – difficulty in obtaining sputum, organizing drug in the form of combipacks in patient wise-boxes, linked to the child’s weight, monitoring issues Present guidelines of Indian Academy of Pediatrics not consistent with the RNTCP guidelines Ongoing consultations to formulate guidelines for diagnosis & Rx of Pediatric TB under RNTCP Consensus has been reached that DOTS is the recommended strategy for Pediatric TB and intermittent SCC given under DOT should be used in children
Operational Research
• • • • • Two central co-ordination committees established National research agenda developed and widely disseminated - www.tbcindia.org
Important centrally funded projects completed – – – National Annual Risk of TB Infection Drug Resistance Surveillance Utilization of RNTCP services by marginalized groups Relevant operational research projects ongoing at central institutes, other setups Research proposals for funding invited
• • • • • • •
Information, Education and Communication (IEC)
Mass Media agency hired at the national level Baseline KAP study undertaken Workshops conducted at national and regional levels to review IEC plans and existing materials TV spots, radio jingles and TB logo produced IEC materials, flip charts distributed to states Revision of TBC India website initiated Communication for Behavioural Impact (COMBI), initiated as a pilot project in Kerala
Summary : RNTCP Challenges
1
• • • Implementing DOTS in a large country like India Expansion to cover entire country whilst maintaining quality.
Maintain treatment success rates and increase case detection rate to meet global targets by 2005 • Strengthening inter-sectoral collaboration: – NACO for TB/HIV coordination • Build/strengthen partnerships: Medical colleges, NGOs, PPs, ESIS, Railways, TB hospitals etc • Mobilize community participation
Summary : RNTCP Challenges
2
• • • • • Strengthen State capacity for decentralized management Strengthen ongoing and refresher training Improve quality of implementation in urban areas Further intensify IEC activities Address issues related to: – Pediatric TB – Extra Pulmonary TB • Ongoing operational research to continuously improve on the programme
Conclusion
DOTS is the BEST strategy we have for controlling TB now AND