Tuberculosis continues to be major public health problem throughout the world, more so in developing countries and India in particular. India has the largest number of cases of TB and around one-fourth of the world TB cases are in India. Every year there are approximately two million (2.2 million) new cases of TB (incidence) occur in the country. To tackle this problem, Govt. of India introduced and launched the Revised National TB control Programme or RNTCP in 1992-93 replacing the earlier NTP, and this is now the largest and fastest growing public Health Program not only in India but also in the world today.
RNTPC
The goals of RNTCP are to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India. The objectives are to achieve and maintain a case detection of at least 70% of new sputum positive TB patients and to achieve and maintain a cure rate of at least 85% in newly detected smear positive cases. Further, the program has made its national strategic plan (2012-17) with new goals to decrease mortality and morbidity due to TB and stop transmission of infection until TB ceases to be a major public health problem in India in line with the Millennium Development Goals and Stop-TB partnership targets. The new objectives are to achieve 90% notification rate for all forms to TB cases, to achieve 90% success rate for all new and 85% for re-treatment cases, to significantly improve the successful outcomes of treatment of Drug Resistant TB Cases, to achieve decreased morbidity & mortality of HIV associated TB and to improve outcomes of TB care in the private sector.
DOTS
The basic strategy is DOTS (Directly Observed treatment – short course) through which treatment completion is ensured. Diagnosis and treatment is provided free of cost to all individuals. The program operates through 3644 Tuberculosis Units (TUs) and 13,306 designated microscopy centres (DMCs) throughout the country. So far under the programme, and since implementation > 60 million TB suspects have been examined, > 17 million patients have been placed on treatment and > 3 million lives have been saved. India’s TB control programme is on track as far as reduction in disease burden is concerned. There is 42% reduction in TB mortality rate by 2012 as compared to 1990 level. Similarly there is 51% reduction in TB prevalence rate by 2012 as compared to 1990 level.
ACSM
The program has a well-defined ACSM (Advocacy, communication, and social mobilization) strategy based on Communication needs, Target Groups and Communication tools/Media options to reach target groups. Roles and responsibilities are defined at the central, state and district level. The ACSM strategy is modified for addressing newer initiatives like MDR- TB and TB HIV co-infection and is supported under the project Axshaya wherein 374 districts in 23 states are involved.
TB-HIV
Other strategies of RNTCP include TB-HIV management in collaboration with NACO. It is a well-known fact that TB is more common in HIV cases and is one of the most common causes of infection and mortality. TB patients are regularly tested for HIV and vice versa. Patient with this dual infection receive co-trimoxazole chemoprophylaxis. Both anti-TB drugs as well as antiretroviral drug therapy are given to patients with both infections and disease. CB-NAAT (Cartridge-based nucleic acid amplification) test is done in priority basis to detect TB in Presumptive TB cases among People living with HIV / AIDS in all CB-NAAT sites. Pilot projects are operating in 30 sites in five high burden states (Tamilnadu, Karnataka, Telengana, Andhra Pradesh and Maharashtra).
Paediatric TB
Paediatric tuberculosis is also covered by the program which is unique in the world. About 6-7% of all TB cases occur in children as per the program reports. Revised Paediatric TB Guidelines have been released, wherein a newer diagnostic algorithm was developed with newer six weight bands are available according to the weight of the child, there is provision for flexibility in extending intensive and continuation phase for selected conditions, also increased dose for INH chemoprophylaxis is given to these cases. Drug resistant TB in children has some inherent problems like difficult to diagnose, getting an appropriate sample for testing, and clinical diagnosis predominates without laboratory confirmation. Treatment in these situations is challenging. Paediatric formulations of treating these MDR-TB cases in children are not available in the market. Administering drugs by crushing & breaking to meet body weight requirements affects bio-availability. Monitoring progress on treatment is also difficult. Malnutrition, co-morbidity, adverse drug reactions adds on to the challenge of treatment adherence. Also there are other issues like availability of expertise to manage paediatric MDR TB is limited. Some of the initiatives taken are the establishment of CB NAAT labs at Delhi, Chennai, Kolkata and Hyderabad, identification of key hospitals and private clinics catering to pediatric populations and establish referral network for pediatric, identification of Engaging more number of pediatricians for referrals and sensitization meeting for identified key personnel.
Urban TB Control
Although RNTCP is being implemented in every part of country either through the State government or through the local self- government wherever there is a separate health system in corporations, focus is given for urban TB control. Exclusive resources for urban areas included in RNTCP in terms of TB health visitors for every 1 lakh aggregate urban population, additional funding norms in ACSM in urban areas, Urban / pubic private mix Coordinators, NGO/Private Practitioner (PP) schemes are specially oriented with urban areas. These provisions are made because there are inadequate diagnostics, insufficient treatment facilities, enormous, unregulated, distinctly divided private sector, intense transmission due to congregate settings/poor Airborne Infection control (AIC) measures and poor TB risk perception and inadequate efforts for advocacy and social mobilization. Through themission mode Slum TB Control, there are provisions for identification of high risk wards, line listing of all health care providers segregated by AYUSH and others, house to house survey for active case finding and training of all health care providers in Standards for TB care in India.
Drug-resistant TB (DR-TB)
India is world’s highest MDR-TB burden country with 64,000 cases emerging annually in notified Pulmonary TB cases. To get an exact picture national drug resistance survey underway since July 2014. Diagnosis and treatment of MDR TB and XDR TB (Extensively drug resistant TB) are difficult, costly, takes minimum of 2 years of treatment and the drugs have a lot of side effects. The program manages these cases through PMDT (Programmatic management of Drug resistant TB). The program (earlier known as DOTS-PLUS) was started in July 2007 and is now available throughout the country. Under this all investigations and treatment are provided free. At present the country has 58 Culture and Drug Susceptibility Testing (DST) Laboratories. There are 122 DR-TB Centers mainly in Medical Colleges and other larger hospitals. There are 50 Linked DR-TB Centers and 89 CB-NAAT (X’pert) Sites to give quick diagnosis within 2 hours. So far over 15, 000 cases of MDR TB are undergoing treatment or are being treated. Newer initiatives in this area include formation of Expert Committee on Regulation of newer anti-TB drug e.g. bedaquiline study, counselling project to enhance treatment adherence among DR-TB patients and piloting of DST Guided Treatment in selected districts.
Others
The cases are now registered through Nikshay, a case Based Web Based recording and reporting system. TB now is a notifiable disease under Government notification and the Govt. of India has banned the use of serology in the diagnosis of TB. The program is trying to bring all private sectors through case notification, persuading the private sector to follow standardized treatment guidelines.
Medical college faculty, who are academicians are seldom directly involved in the implementation of national public health programmes. More than a decade ago for the first time in the global history of tuberculosis (TB) control, medical colleges of India are involved in the Revised National TB Control Programme (RNTCP) of Government of India (GOI). Till the time involvement of medical colleges in the RNTCP was conceived, the interaction between the academicians in the medical colleges and the Programme managers was sparse and on many occasions discordant. The young doctors in training seldom got an opportunity to practice what was preached to them. As a result, the facilities available under the RNTCP were seldom utilized to the full extent possible. Keeping in mind the needs of the country, a future “5-Star” doctor who would take up the responsibilities as a care provider, decision maker, communicator, community leader, and a manager was visualized and such a future doctor would not only serve the patients and the community but would also gain their respect.
A substantial proportion of patients with TB are managed at medical colleges across the country. From the TB control point of view, medical colleges, in both the government and private sectors are recognized to occupy a key position with a unique potential for involvement with the RNTCP. To widen access and improving the quality of TB services, involvement of medical colleges and their hospitals is of paramount importance. Being tertiary care medical centres, large numbers of patients seek care from the medical colleges. In addition, the role of medical college faculty in TB control as key opinion leaders and role models for practicing physicians and as teachers imparting knowledge, skills and shaping the attitude of medical students cannot be underestimated. There is a pressing need for all medical colleges to advocate and practice DOTS strategy which provides the best opportunity for cure of TB patients. In addition, medical colleges have the diagnostic facilities for extra-pulmonary TB (EPTB), human immunodeficiency virus (HIV)-TB co-infection, multidrug-resistant TB and extensively drug-resistant TB (M/XDR-TB). Recognizing the potential of involving medical colleges in TB control a decade ago, the RNTCP of GOI, for the first time in the world conceived and implemented the unique experiment of involving the academicians who constitute the faculty in the public health programme for TB control. A mechanism of National, Zonal and State level Task Forces was conceived for the involvement of medical colleges, wherein the sole responsibility of participation of medical colleges in DOTS strategy lies with the faculty of medical colleges, which perhaps made them more responsive.
The involvement of medical colleges in TB control envisaged and successfully implemented by the RNTCP for more than a decade in India is an extraordinary effort. The Task Force mechanism has entrusted the responsibility to medical colleges to ensure their effective contribution to the efforts of GOI in TB control. The successful amalgamation of the public health approach and the expertise of academicians has immensely benefited the RNTCP and TB control in India and facilitated the emergence of the “future doctor” from among the medical students.
# March 24th is World Tuberculosis Day
