Tuberculosis – VOICE OF PEOPLE

INTRODUCTION

• TB is the most ancient disease.

• It has been referred in the vedas and ayurvedic samhitas.

• It is caused by mycobacterium tuberculosis.

• In India, 1stopen air sanatorium was founded in 1906.

• TB survey- (1939) 1stintroduction of BCG Vaccine (1948) under Dr FRIMODT MOLLER.

• 1st TB dispensary introduced in bombay on 1917.

• India became member of International Union Against Tuberculosis (IUAT) in 1929.

Incident in India (2016)

Estimates of TB burden, 2016

Mortality (excludes HIV+TB)

Mortality (HIV+TB only)

Incidence (Includes HIV+TB)

Incidence (MDR/TT-TB)

Rate (Per 100 000 population)

32 (24-40)

0.92(0.5-1.5)

6.6(4.3-9.4)

11(7.2-15))

National Tuberculosis Programme (NTP) is in operation since 1962. However the treated success was low and death and default rate remain high and spread of multidrug resistance tuberculosis strain was further threatening to worsen the situation.

In view of this, 1992 GOI along with WHO and SIDA reviewed the situation in INDIA and came up with following conclusion: 1) NTP though technically sound, suffered from marginal weakness. 2) Inadequate funding. 3) Over reliance on X-RAY for diagnosis. 4) Frequent interrupted supply of drugs. 5) Low rate of TREATMENT COMPLETION. In 1993, in order to overcome these RNTCP started with the assistance from international agencies and adopted the internationally recommended DIRECT OBSERVED SHORT COURSE (DOTS) therapy with a target of achieving at least 85% of cure rate of infectious cases through DOTS, involving peripheral health functionaries and augmentation of case finding through quality sputum microscopy to detect at least 70% of estimated cases. The revised strategy was introduced in our country in phased manner, like PILOT PHASE- i, PILOT PHASE-ii, PILOT Phase- iii etc.

In 2006, STOP TB strategy was introduced with:

VISION: A TB FREE WORLD.
GOAL: Dramatically reduce global burden of TB by 2015 in line MILLENIUM DEVELOPMENT GOALS and stop TB Partnership targets.

STRATEGY:

1) To pursue high-quality DOTS expansion and enhancement.

2) Address TB/HIV, MDR TB, the need of poor and the vulnerable population.

3) Contribute to health system, strengthening base of primary health care.

4) Engage all care provider’s.

5) Empower people with and the community through partnership.

6) Enable and promote research.

In 2014, STOP TB strategy was introduced with: VISION: A TB free World with Zero death, disease and suffering with TB. GOAL: End of global tuberculosis epidemic. INDICATORS:

1) 95% reduction of TB 2035 in number of death as compared with 2015.

2) 90% reduction in TB incidence rate as compared to 2015.

3) ZERO TB affected families facing catastrophic cost due to TTB by 2035.

NATIONAL REFERENCE LABORATORY:

-NRLs works closely with IRLs, monitors and supervise the IRL staff in EQA, culture, and DST, LPA, and EPA CBNAAT activities.

-Three microbiologist.

-Four laboratory technicians.

-The NRL microbiologists and laboratories supervisor/technicians.

-Quality improvement workshop.

IMMEDIATE REFERANCE LABORATORY:

-The function of IRL are supervision and monitoring of EQA activities, microbacterial culture and DST and drug resistance surveillance in selected state.

-Technical training to laboratory technicians and senior TB laboratory supervisor.

-IRL undertakes on site evaluation (districts in the state).

DESIGNATED MICROSCOPY CENTRE (DMC):

• DMC which serves a population of around 100000

• The quality assurance activities include:

• -onsite evaluation

• -Panel testing

• -Random blinded rechecking

• Culture and DST laboratory

• In addition to IRLs,

• Microbiology department of Medical colleges

• 64 C and DST laboratories

• Solid Culture certifications: 45.

• Line probe assay: Rapid diagnosis of MDR-TB by LPA.

• Expanding CBNAAT service: The time to diagnosis of TB and drug resistant TB has been significantly reduced with the availability of CBNAAT which is rapid molecular assay to detect M.TUBERCULOSIS and RIFAMPICIN resistance. The test is fully automated and provide result in two hours. Currently there are 21 machines.

TB Diagnostic

• Smear microscopy for acid fast bacilli.

• -sputum smear stained with ZN staining

• -Fluorescence stains and examined under direct or indirect microscopy with or without LED.

• 2. Culture -solid media -liquid media

• -Rapid diagnostic molecular test.

• -Conventional PCR based line probe assay for MTB complex.

• -Real-time PCR based nucleic acid amplification test NAAT for MTB complex.

• 4.Radiography

• 5.Tuberculin skin test.

TB Diagnostic Algorhytm

• Adult
• Peadiatric

STANDARD DRUG REGIMEN

• New Case
• Intensive Phase -2 months of HRZE
• Continuation Phase -5 Months HRE

PEADIATRIC DRUG DOSE

DOSE

NEW INITIATIVE:

1) NIKSHAY -TB surveillance using case based web IT system.
-Central TB division in collaboration with National Informatics Centre.
-Launched in May 2012.
-TB patient registration and details of diagnosis, DOT provider, HIV status, follow up, contact tracing, outcomes.
-Details of solid liquid culture and DST, LPA, CBNAAT details.
-DR-TB patient registration.
-Referral and transfer of patients.
-Private health facility registration and TB notification.
-Mobile application for TB notification.
-SMS alert to patient on registration.
-SMS alert to programme officer,
-Automated period report.
-Case finding.
-Sputum conservation.
-Treatment outcome.
2) -According to Government of India notification dated 7th May 2012, it is mandatory for all healthcare providers to notify every new TB case to local authorities.
3) -BAN on TB SEROLOGY

NEWER INITIATIVE:

1) Daily regimen for paediatric TB.
2) Daily regimen in all forms of TB in 5 states.
3) Daily regimen for TB/HIV co-infected patients across country.
4) Pilots for universal access to TB.
5) Bedaquilline conditional access programme.
6) Drug resistance surveillance under RNTCP.

TB-HIV COORDINATION:

· Dedicated human resources, integration of surveillance, joint monitoring and evaluation, capacity building and operational research.

Activities as follows:

• Intensified TB case finding has been extended to all ART centres.
• HIV testing of TB patients is now routine through provider initiated testing and counselling.
• Free HIV care at centre.
• Policy decisions has been taken by National Technical Working Group on TB/HIV collaborative activities to extend coverage of whole blood finger prick HIV screening test at all DMC without stand alone.
• Provide initiated HIV testing and counselling among presumptive TB cases is now policy.
• Intensified case finding activities to be specifically mentioned among HIV infected pregnant women and children living with HIV.
• The National AIDS Control programme and RNTCP have taken a policy decision to adopt ISONIAZIDE PROPHYLAXIS THERAPY as a strength of prevention of TB among PLHIV. The implementation will be in phased manner.
• RNTCP has prioritized presumptive TB cases among People Living with HIV (PLHIV) for diagnosis of TB and REFAMPICIN resistance with rapid diagnostic tools having high sensitivity.