RNTCP - MD SEMINAR RNTCP Dr Gaurav Didi GLOBAL& INDIAN SCENARIO In 2002 estimated 8.8 million new cases of TB globally In 3.9 million sputum

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Unformatted text preview: MD SEMINAR RNTCP Dr. Gaurav Didi GLOBAL & INDIAN SCENARIO In 2002 estimated 8.8 million new cases of TB, globally In 3.9 million sputum smear positive, 3.9 One fifth of the global TB cases in India One 1.8 million new cases every year 1.8 0.8 million smear-positive cases 0.8 smear4 lakh deaths occur from TB every year. lakh Every Day, in India Every more than 5000 develop TB disease more than 1000 people die of TB (2 deaths every 3 minutes) TB kills more adults in India than any other infectious TB disease. Peak incidence in economically productive age group of Peak 15-60 years. 15- 1 TUBERCULOSIS CONTROL IN INDIA National TB Control Programme (NTP) National 1962 RNTCP – 1993 RNTCP NTP NTP Launched in 1962 Launched District tuberculosis control programme District Managerial weakness Managerial Over reliance on x ray Over 30% cases diagnosed 30% Of them 30% completing treatment Of Non standardized treatment Non Lack of report on outcome Lack 2 LAUNCH OF RNTCP Failure of NTP Failure GOI – WHO revised strategy for control of GOI TB in India RNTCP application of WHO – DOTS RNTCP launched in 1993 CHALLENGES FOR RNTCP The general health service often does not function optimally. A large and mostly unregulated private sector large provides a substantial proportion of outpatient care, and this care is of inconsistent quality. The level of socioeconomic development can The have a major effect on program performance. Ensuring the quality of drugs is difficult. Ensuring 3 OBJECTIVES OF RNTCP Primary aim – achieve a cure rate of 85% of new Primary sputum smear positive patients. RNTCP shifts the responsibility for cure from the RNTCP patient to the health system 70% detection of new sputum smear positive 70% cases – but only if the cure rate of already detected patients is > 85% DOTS – 5 COMPONENTS Political and administrative commitment Political Good quality diagnosis, primarily by Good sputum smear microscopy Uninterrupted supply of good quality drugs Uninterrupted Directly observed treatment (DOT) Directly Systematic monitoring and accountability Systematic 4 STRUCTURE OF RNTCP Central TB Division Central State level State District level District Sub-district level Sub Tuberculosis Unit (TU) Medical Officer-Tuberculosis Control (MO-TC) Senior Treatment Supervisor (STS) Senior TB Laboratory Supervisor (STLS) STRUCTURE OF RNTCP STRUCTURE Designated Microscopy Centre Designated Tertiary / Secondary level health care institutions Block PHCs / other equivalent institutions Caters to a population of 1 lakh (0.5 lakh in hilly, tribal and difficult areas) 60 -100 new adult outpatient attendance per day The laboratory technician must be examining an average of at least 3 – 5 smears and not more than 20 – 25 smears per day. 5 DIAGNOSIS The most common symptom of pulmonary TB is The persistent cough, usually with expectoration 2-3% of new adult outpatients in a general health facility 10% of TB suspects are expected to have 10% sputum smear positive pulmonary TB Three sputum specimens Three SPOT - EARLY MORNING - SPOT. SPOT 6 SPUTUM EXAMINATION TREATMENT Factors that determine the regimen Disease classification Disease Type of case Type Sputum result Sputum Severity of illness Severity History of previous treatment History 7 DISEASE CLASSIFICATION Pulmonary tuberculosis Pulmonary a. Smear-positive patient SmearA patient with at least 2 initial sputum smear patient examinations positive for AFB Or: one sputum positive for AFB and radiographic Or: abnormalities Or: one sputum positive for AFB and culture positive for Or: M. tuberculosis. b. Smear-negative patient SmearSymptoms suggestive of TB with at least 3 sputum Symptoms examinations negative for AFB, and radiographic abnormalities consistent with active pulmonary TB as determined by the treating MO, followed by a decision to treat the patient with a full course of anti-TB therapy; antiOr: culture positive for M. tuberculosis but sputum smear Or: examinations negative DISEASE CLASSIFICATION DISEASE Seriously ill smear-negative PTB Miliary TB Miliary Extensive parenchymal infiltration Extensive Co-infection with HIV Co Pulmonary disease with cavitations Pulmonary All forms of pediatric sputum smear negative All pulmonary TB except primary complex 8 DISEASE CLASSIFICATION Extra Pulmonary Tuberculosis This includes TB of organs other than the lungs. This Patients who have both pulmonary and extra-pulmonary Patients extraTB are classified as having pulmonary tuberculosis. TYPES OF PATIENTS TYPES New: A TB patient who has never had treatment New: for TB or one who has taken anti-TB drugs for less than one month. Relapse: A TB patient who was declared cured Relapse: or treatment completed by a physician, but who reports back to the health service and is now found to be sputum smear-positive. Treatment after default: A TB patient who Treatment received anti-TB treatment for one month or more from any source and returns to treatment after having defaulted, i.e., not taken anti-TB drugs consecutively for two months or more, and who is found to be sputum smear-positive. 9 TYPES OF PATIENTS Failure: Any TB patient who is smear-positive at Failure: 5 months or more after starting treatment. Failure also includes a patient who was treated with Category III regimen but who becomes smear-positive during treatment. Transferred in: A TB patient who has been Transferred received for treatment in one Tuberculosis Unit, after starting treatment in another unit (TU) where (s)he has been registered Chronic: A TB patient who remains smear Chronic: positive after completing a re-treatment regimen. Others: TB patients who do not fit into the Others: above mentioned types. Reasons for putting a patient in this type must be specified. ESSENTIAL ANTITUBERCULAR DRUGS DRUGS Essential drug (abbreviation) weekly isoniazid (H) isoniazid rifampicin (R) pyrazinamide (Z) streptomycin (S) ethambutol (E) thioacetazone (T) Daily Daily 5 (4–6) (4– 10 (8–12) (8– 25 (20–30) (20– 15 (12–18) (12– 15 (15-20) (152.5 Recommended dosage (dose range) in mg/kg 3 times 10 (8–12) (8– 10 (8–12) (8– 35 (30–40) (30– 15 (12–18) (12– 30 (20-35) (20NA 10 RATIONALE OF TREATMENT 3 main properties of anti-TB drugs: Bactericidal activity Bactericidal Sterilizing activity Sterilizing Ability to prevent resistance Ability RATIONALE OF TREATMENT Intermittent use – rationale: Equally efficacious in intermittent dosing Equally Facilitates observation Facilitates Reduces costs and convenience Reduces “Lag period” phenomenon 11 RATIONALE OF TREATMENT RATIONALE Intensive Phase (IP) Rapid killing of bacilli. Shorter duration of infectiousness (≤ 2 weeks) Rapid smear conversion (80% – 90%) after 2 to 3 months of treatment. Each dose in this phase should be directly observed Continuation Phase (CP) Eliminates most residual bacilli Reduces failures and relapses. Low numbers of bacilli and less chance of drug resistant mutants. CATEGORIES OF TREATMENT 12 Patients in Categories I and II who have a Patients positive sputum smear at the end of the initial intensive phase receive an additional month of intensive phase treatment Patients who weigh 60 kg or more receive Patients additional rifampicin 150 mg. Patients who are more than 50 years old receive Patients streptomycin 500 mg. Patients who weigh less than 30 kg, receive Patients drugs as per body weight. FOLLOW UP EXAMINATION 13 TREATMENT OUTCOME Cured: Initially sputum smear-positive patient who has Cured: smearcompleted treatment and had negative sputum smears, on at least two occasions, one of which was at the end of treatment. Treatment Completed: A sputum smear-positive patient Treatment smearwho has completed treatment, with negative smears at the end of IP but none at the end of treatment, OR OR A sputum smear-negative patient who has received a full sputum smearcourse of treatment and has not become smear-positive smearduring or at the end of treatment, OR OR An EP TB patient who has received a full course of An treatment and has not become smear-positive during or smearat the end of treatment. TREATMENT OUTCOME Died: Patient who died during the course of treatment, Died: regardless of the cause of death. Failure: Any TB patient who is smear-positive at 5 Failure: smearmonths or more after starting treatment, OR OR A patient who was treated with Category III but who patient becomes smear-positive during treatment. smearDefaulted: A patient who has not taken anti-TB drugs for Defaulted: anti2 months or more consecutively after starting treatment. Transferred out: A patient who has been transferred to Transferred another TB Unit or district and for whom the treatment result (outcome) is not known. 14 QUALITY ASSURANCE An effective quality assurance (QA) An system for sputum smear microscopy is an integral part of RNTCP. QA is a total system consisting of QA Internal quality control(IQC), Internal Assessment of performance using external Assessment quality assessment (EQA) methods Continuous quality improvement (QI) of Continuous laboratory services. FEATURES UNIQUE TO RNTCP Public-private mix projects Private Practitioners (PPs) are the first “point Private of contact”; necessary to “partner” with NGOs and private health care providers. Officially prescribed guidelines for the Officially involvement of NGOs(2001) and private practitioners (2002). To date, 800 NGOs & 5,000 PPs involved in To RNTCP activities. 15 FEATURES UNIQUE TO RNTCP Involvement of other sectors Public sectors outside of the Health Public Departments e.g. Railways and ESI hospitals, Port hospitals. Medical Colleges - sheer number of TB Medical patients treated, role in teaching medical students and other practitioners FEATURES UNIQUE TO RNTCP Collaboration with National AIDS Control Programme Infection with HIV- risk factor for progression Infection to active TB among adults. Joint Action Plan between RNTCP and the Joint AIDS Programme implemented for collaborative activities (2001), initially in the 14 states of highest HIV prevalence, Indian J Tuberc 2005; 52: 1-4 Indian 1- 16 INDIAN EXPERIENCE OF DOTS More than doubles the accuracy of TB diagnosis More Cuts down TB deaths by seven fold Cuts Doubles the cure rate Doubles Reduces the incidence and prevalence of TB Reduces Helps in alleviating poverty by saving lives, Helps reducing the duration of illness and preventing new infectious cases Improves the quality of care and overcomes Improves stigma Prevents treatment failure and the emergence of Prevents MDRTB JIACM 2004; 5(2): 109-13 ACHIEVEMENTS OF RNTCP RNTCP 17 ACHIEVEMENTS OF RNTCP Over 100,000 patients being put on treatment each Over month, the RNTCP, in terms of patients treated, is the largest DOTS programme in the world. Full nation-wide coverage by 2005- the fastest Full nation2005expansion of any DOTS programme in the world, without any compromise on the quality of services provided In 2004, the case detection rate was 78% - 75% with In cure rate maintained at 85%, WHO targets met. 18 ACHIEVEMENTS OF RNTCP Over 3.5 million patients provided free diagnosis and Over treatment under the RNTCP. Resulted in over 6 lakh additional lives saved Resulted Indian J Tuberc 2005; 52: 1-4 1- CHALLENGES FOR RNTCP IN THE FUTURE Shortage of staff – rapid expansion – Shortage redistribution of current staff Upgradation of existing TB laboratories and Upgradation creation of new microscopy centres to strengthen the TB laboratory network Recent study – initial bacillary load can Recent influence sputum conversion rates and treatment outcome of new smear positive patients treated by DOTS. 19 Sputum conversion – 3+ were 62% & 81% Sputum at 2 & 3 months, 1+/2+ were 77% & 89% Cure rates 76% vs 85% Cure Failure rates 7.7% vs 4.5% Failure Indian J Chest Dis Allied Sci 2005 Treatment of MDR cases – DOTS PLUS – Treatment DRS surveys & establishment of quality assured culture & drug sensitivity testing (DST) lab facility in large states + provision of second line drugs for resistant cases 20 ...
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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