on 31 st October, 2012. Revised National TB Control Programme - - PowerPoint PPT Presentation

Review Meeting-Mission Directors, NRHM

States & UTs

• n

31st October, 2012. Revised National TB Control Programme (RNTCP)

RNTCP - Components of DOTS Strategy

(Directly Observed Treatment- Shortcourse)

• Political commitment
• Diagnosis by microscopy
• Adequate supply of Short Course

drugs

• Directly Observed Treatment
• Accountability

TB Register

RNTCP – Goal and Objectives

• Goal

– 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.

• Objectives:

– To achieve and maintain a case detection of at least 70%

• f new sputum positive TB patients

– To achieve and maintain a cure rate of at least 85% in newly detected smear positive cases

Moving towards Universal Access i.e. detection of 90% of all estimated TB cases (including Drug Resistant & HIV-TB) in the community and successful treatment of at least 90% of the TB patients registered.

State-wise New Sputum Positive Case Detection Rate & Treatment Success Rate

State-wise Performance (2011) New Smear Positive Case Detection Rate (NSP CDR)

Performance States

Good (NSP CDR >= 70%) (15 states/UTs) A &N , AP, Arunachal Pradesh, Chandigarh, Delhi, Gujarat, HP, Jharkhand, Meghalaya, Nagaland, Rajasthan, Sikkim, UP, Puducherry Moderate (NSP CDR 50 - 70%) (18 states/UTs) Chhattisgarh, D & N Haveli, Goa, Haryana, J&K, Karnataka, Kerala, MP, Maharashtra, Manipur, Mizoram, Orissa, TN, Tripura, Uttarakhand, Punjab, Assam, West Bengal Poor (NSP CDR < 50%) (3 states/Uts) Bihar, Daman and Diu, Lakshadweep

State-wise Performance (2010) New Smear Positive Treatment Success Rate (NSP TSR)

Performance States

Good (NSP TSR >= 85%) (27 states/UTs) AP, Arunachal Pradesh, Chandigarh, Delhi, Gujarat, HP, Jharkhand, Nagaland, Rajasthan, UP, Puducherry, Chhattisgarh, Haryana, J&K, MP, Maharashtra, Manipur, Mizoram, Orissa, TN, Tripura, Uttarakhand, Punjab, West Bengal, Bihar, Daman and Diu, Lakshadweep. Poor (NSP TSR < 85%) (8 states/Uts) Sikkim, D & N Haveli, Karnataka, A &N , Assam, Meghalaya, Goa, Kerala,

27 States/UTs have shown a decline/no improvement in New TB Case Detection in 2011 v/s 2010

Relatively better performing States

New TB Case Detection during 2011 v/s 2010

States/UTs

• No. of

Districts

• No. of Districts with NSP Case

Detection Rate (2011) >=70% 50-70% <50%

A&N Islands 1 1 Andhra Pradesh 24 19 4 1 Arunachal Pradesh 14 8 5 1 Assam 24 6 8 10 Bihar 38 2 12 24 Chandigarh 1 1 Chhattisgarh 16 3 7 6 D & N Haveli 1 1 Daman & Diu 2 2 Delhi 25 17 8 Goa 2 2 Gujarat 30 18 10 2 Haryana 21 8 11 2 Himachal Pradesh 12 4 4 4 Jammu & Kashmir 14 6 6 2 Jharkhand 24 11 11 2 Karnataka 31 13 16 2 Kerala 14 3 5 6

States/UTs

• No. of

Districts

• No. of Districts with NSP Case

Detection Rate (2011) >=70% 50-70% <50%

Lakshadweep 1 1 Madhya Pradesh 50 15 17 18 Maharashtra 55 11 27 17 Manipur 9 3 4 2 Meghalaya 7 2 1 4 Mizoram 8 5 2 1 Nagaland 11 3 4 4 Orissa 31 9 15 7 Puducherry 1 1 Punjab 20 9 10 1 Rajasthan 33 21 10 2 Sikkim 4 1 3 Tamil Nadu 31 5 19 7 Tripura 4 2 2 Uttar Pradesh 71 34 36 1 Uttarakhand 13 6 6 1 West Bengal 19 3 8 8 Grand Total 662 252 274 136

States/UTs Total no. of Districts

• No. of Districts with NSP Treatment

Success Rate (2010) >=85% 75-85% <75%

A&N Islands 1 1 Andhra Pradesh 24 23 1 Arunachal Pradesh 14 9 4 1 Assam 24 7 15 2 Bihar 38 29 9 Chandigarh 1 1 Chhattisgarh 16 10 5 1 D & N Haveli 1 1 Daman & Diu 2 2 Delhi 25 12 12 1 Goa 2 1 1 Gujarat 30 28 2 Haryana 21 14 7 Himachal Pradesh 12 12 Jammu & Kashmir 14 13 1 Jharkhand 24 19 5 Karnataka 31 9 21 1 Kerala 14 3 11

States/UTs

• No. of

Districts

• No. of Districts with NSP Treatment

Success Rate (2010) >=85% 75-85% <75%

Lakshadweep 1 1 Madhya Pradesh 50 46 4 Maharashtra 55 30 23 2 Manipur 9 8 1 Meghalaya 7 4 2 1 Mizoram 8 5 3 Nagaland 11 11 Orissa 31 23 7 1 Puducherry 1 1 Punjab 20 18 2 Rajasthan 33 33 Sikkim 4 2 1 1 Tamil Nadu 31 20 11 Tripura 4 3 1 Uttar Pradesh 71 68 3 Uttarakhand 13 11 2 West Bengal 19 10 9 Grand Total 662 485 166 11

Uttar Pradesh: District-wise Annual New Smear Positive Case Detection Rate in 2011

Uttar Pradesh: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Madhya Pradesh: District-wise Annual New Smear Positive Case Detection Rate in 2011

Madhya Pradesh: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Bihar: District-wise Annual New Smear Positive Case Detection Rate in 2011

Bihar: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Maharashtra: District-wise Annual New Smear Positive Case Detection Rate in 2011

Maharashtra: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Tamil Nadu: District-wise Annual New Smear Positive Case Detection Rate in 2011

Tamil Nadu: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Orissa: District-wise Annual New Smear Positive Case Detection Rate in 2011

Orissa: District-wise Annual New Smear Positive Treatment Success Rate in 2010

Punjab: District-wise Annual New Smear Positive Case Detection Rate in 2011

Punjab: District-wise Annual New Smear Positive Treatment Success Rate in 2010

% Population with access to PMDT services

1 % - 25 % 26 % - 50 % 51 % - 75 % 76 % - 99 % 100 %

Meghalaya Tripura Goa Dam an & Diu Chandigarh

Rajas than Gujarat Maharas htra Oriss a Madhya Prades h Bihar Uttar Pradesh Karnataka Andhra Pradesh Jam m u & Kas hm ir Assam Chhatis garh Tam il Nadu Punjab Jhark hand W est Bengal Kerala Haryana Uttaranc hal Arunachal Pradesh Himac hal Pradesh Manipur Mizoram Nagaland Sikk im A&N Is lands D&N H aveli Lak shadweep

Delhi

• PMDT Services

introduced in Aug 2007

• All 35 State/UTs have

introduced PMDT services of which 25 have achieved complete geographical coverage

• 901 million (73%) pop

have access to services across 527 districts

• 74 DR-TB Centers are

functional (70% in Medical Colleges)

Status of PMDT Services (Oct ’12)

DR TB Centres

A&N Islands Arunachal Pradesh

Chandigarh D&N Haveli Daman & Diu

Goa Karnataka Lakshadweep Meghalaya Mizoram Nagaland

Pondicherry

Sikkim Tripura Haryana Delhi Gujarat Andhra Pradesh Assam Manipur Punjab Kerala West Bengal Jammu & Kashmir Himachal Pradesh Rajasthan Maharashtra Tamil Nadu Orissa Madhya Pradesh Chhatisgarh Uttar Pradesh Uttaranchal Jharkhand Bihar

TRC

A

NDTC AIIMS-2

RNTCP Culture & DST Labs Network (October, 2012)

LRS NTI JALMA

Med Col / NGO / Private Labs (Certified) IRL (Certified ) IRL (Under Process) Med Col / NGO / Private Labs (Under Certification ) National Reference Labs

Gurgaon

By Technology

• Solid culture:35
• LPA: 31
• Liquid Culture:10

Certified : N=44

• 30 / 43 RNTCP

supported labs

• 14 Additional

SLDST - 3 NRLs

Critical Gaps for PMDT by States

• 1. State PMDT Committee meetings not held regularly
• 2. Slow scale up of PMDT services in few states with limited access
• UP (15%), BI (38%), CG (44%), TR (47%), MP (54%), HP (58%), AS (56%), HR

(63%), JH (68%)

• 3. Laboratory capacity limited
• PB (0), HP (0), JK (0), UP (2), WB (2), KA (2), RJ (2), BI (1)
• 4. Deficit of DR TB Centers against norm (1/10million population) with

service gaps

• UP (2/20), BI (1/11), MP (2/8), TN (3/7), WB (4/9), AS (1/3), HR (1/3), CG

(1/2)

• 5. High % of confirmed MDR TB Cases not put on treatment in 2012
• WB (48%), MH (40%), RJ (28%), HP (35%), HR (28%), GU (27%)

Action Points (1)

• Strengthening the quality of basic DOTS services

– Ensure sanctioned posts are filled and all staff trained. – Ensure availability of quality diagnostic and treatment services. – Ensure availability of free X-Ray services linked with all facilities. – Ensure quality drug supply for first-line, 2nd line ATT drugs and antibiotics. – Bringing services closer to the community with the help of ANM, MPW, ASHA.

• Strengthening supervision and monitoring

– Use COMPOSITE INDICATORS – Implement Focused Action Plan in Under-performing Districts – Use of online case-based reporting system for data entry.

• Identifying areas with low suspect examination and

prioritize case finding

Action Points (2)

• Promoting community screening of suspects and

referral.

• TB diagnosis and treatment facilities at all Nutritional

Rehabilitation Centers (NRCs).

• Referral linkages for diagnosis of EP-TB cases.
• Focused attention for Urban areas.
• Expanding efforts to engage all care providers.

– Innovative approaches to engage the private sector. – Need based involvement with accountability. – Timely payment of dues.

• Active case finding in high risk population TB-HIV,

TB-Diabetes.

Action Points for PMDT - (1)

• 1. State PMDT Committee meetings to be held every quarter

to review progress and address local challenges

• 2. Expedite 100% coverage to PMDT services in the states by

Dec ’12

• Complete – establishment of DR-TB centers, Labs and

Drug Stores upgrades, Staffing & Trainings, Central Appraisals in remaining districts

• 3. Expedite lab capacity enhancement to enable move

towards universal DST

• Complete – Civil works, equipment installation & AMC,

power backup, HR, proficiency testing in various technologies in all remaining labs in the states.

Action Points for PMDT – (2)

• 4. Expedite scale up of DR TB Centres (norm @ 1/10

million population)

• Upgrade for airborne infection control, provide

nurses and ward attendants

• Free beds, investigations, ancillary drugs, food etc.
• 5. Improve coordination b/w labs, districts, field staff and

DR TB centre for prompt treatment of confirmed MDR TB cases in the states

RNTCP - Newer Initiatives

All States/UTs need to ensure all

• ut

efforts towards implementation of – 1. TB Notification Order dated 7th May 2012. 2. Patient-wise data entry in “Nikshay” for all TB cases detected with effect from 1st January 2012 (Case Based Web Based Recording & Reporting System). 3. The Gazette Notification dated 7th June 2012 on the banning the import, manufacture, sale, distribution and use of “ All Serological Tests for TB Diagnosis”. 4. Enforcement of Schedule H – All ANTI-TB drugs are under Schedule H (i.e. should be sold only on the prescription of registered medical practitioner).

NIKSHAY (Case Based Web Based Recording & Reporting System)

35

Current Status of funds and Expenditure

& Status of AR / UC (2011-12)

Sl. No. Name of the State/ UT Budget Allocatio n (ROP) Unspent Fund as

• n

01.04.20 12 Funds Released by MoHFW/ GOI (2012-13) till now Total funds available with States / UTs Statement

• f

Expenditu re (SOE) upto 30.09.2012 % of exp to availab le fund Status of Audit Report for the year 2011-12 (1) (2) (3) (4) (5) (6) = (4) + (5) (7) (8) (9) 1 Andhra Pradesh 2733.31 515.85 1612.50 2128.35 899.96 42.28 Received 2 Andaman & Nicobar 51.89 5.22 33.70 38.92 15.46 39.72 Awaited 3 Arunachal Pradesh 396.52 5.23 297.39 302.62 178.79 59.08 Received but to be Revised 4 Assam 1088.95 22.91 802.94 825.85 426.75 51.67 Awaited 5 Bihar 2486.62 563.32 1722.51 2285.83 286.21 12.52 Awaited 6 Chandigarh 86.83 14.61 57.33 71.94 45.26 62.91 Awaited 7 Chattisgarh 1050.90 470.84 317.34 788.18 118.89 15.08 Awaited 8 D & N Haveli 40.74 4.91 25.65 30.56 3.77 12.34 Received 9 Daman & Diu 25.88 12.87 8.45 21.32 2.66 12.48 Awaited

36

Sl. No. Name of the State/ UT Budget Allocatio n (ROP) Unspent Fund as

• n

01.04.20 12 Funds Released by MoHFW /GOI (2012-13) till now Total funds available with States / UTs Stateme nt of Expend iture (SOE) upto 30.09.20 12 % of exp to availa ble fund Status of Audit Report for the year 2011-12 (1) (2) (3) (4) (5) (6) = (4) + (5) (7) (8) (9) 10 Delhi 947.40 91.45 619.10 710.55 39.59 5.57 Awaited 11 Goa 68.59 8.25 43.19 51.44 30.46 59.21 Awaited 12 Gujarat 1318.95 15.37 973.84 989.21 905.86 91.57 Received 13 Haryana 883.25 72.58 589.86 662.44 257.08 38.81 Awaited 14 Himachal Pradesh 346.28 14.46 259.71 274.17 193.92 70.73 Received but to be Revised 15 Jammu & Kashmir 557.35 121.48 249.46 370.94 124.00 33.43 Received 16 Jharkhand 1270.98 205.87 743.73 949.60 346.68 36.51 Awaited 17 Karnataka 1548.05 275.49 846.68 1122.17 693.52 61.80 Awaited 18 Kerala 735.50 202.80 387.56 590.36 387.50 65.64 Awaited

Current Status of funds and Expenditure & Status of AR / UC (2011-12)

37

Current Status of funds and Expenditure & Status of AR / UC (2011-12)

Sl. No. Name of the State/ UT Budget Allocatio n (ROP) Unspent Fund as

• n

01.04.20 12 Funds Released by MoHFW/ GOI (2012-13) till now Total funds available with States / UTs Statement

• f

Expenditu re (SOE) upto 30.09.2012 % of exp to availabl e fund Status of Audit Report for the year 2011-12 (1) (2) (3) (4) (5) (6) = (4) + (5) (7) (8) (9) 19 Lakshadweep 22.19 6.76 10.43 17.19 4.83 28.10 Received 20 Madhya Pradesh 1472.48 333.04 746.78 1079.82 660.20 61.14 Received but to be Revised 21 Maharashtra 3744.12 441.00 2155.93 2596.93 1518.55 58.47 Received but to be Revised 22 Manipur 330.91 29.74 218.44 248.18 34.00 13.70 Received 23 Meghalaya 243.62 38.07 138.24 176.31 101.61 57.63 Received but to be Revised 24 Mizoram 278.63 1.07 181.71 182.78 120.08 65.70 Received 25 Nagaland 305.30 10.77 218.07 228.84 8.77 3.83 Received 26 Orissa 1458.95 425.79 668.42 1094.21 177.18 16.19 Awaited 27 Puducherry 106.48 16.56 60.43 76.99 21.14 27.46 Received

38

Current Status of funds and Expenditure & Status of AR / UC (2011-12)

Sl. No. Name of the State/ UT Budget Allocation (ROP) Unspent Fund as on 01.04.2012 Funds Released by MoHFW/GOI (2012-13) till now Total funds available with States / Uts Statement

• f

Expenditur e (SOE) up to 30.09.2012 % of exp to availa ble fund Status of Audit Report for the year 2011-12 (1) (2) (3) (4) (5) (6) = (4) + (5) (7) (8) (9) 28 Punjab 627.47 69.05 401.55 470.60 191.08 40.60 Awaited 29 Rajasthan 1216.44 448.31 464.02 912.33 486.50 53.33 Awaited 30 Sikkim 162.01 2.42 95.73 98.15 42.85 43.66 Received 31 Tamilnadu 1425.65 71.71 737.26 808.97 238.95 29.54 Awaited 32 Tripura 194.07 6.78 118.94 125.72 22.36 17.79 Awaited 33 Uttar Pradesh 4411.44 166.71 0.00 166.71 125.55 75.31 Awaited 34 Uttrakhand 501.40 75.25 300.80 376.05 213.91 56.88 Received but to be Revised 35 West Bengal 1707.64 351.56 929.17 1280.73 405.68 31.68 Awaited Total 33846.79 5118.10 17036.86 22154.96 9329.60 42.11 SOE received for the quarter ending June 2012 only. Shows less than 20 expenditure.

www.tbcindia.nic.in

Assam – District wise Annual New Smear Positive Case Detection Rate, 2011 (in %age)

Assam – District wise Annual New Smear Positive Treatment Success Rate, 2010 (in %age)

Jharkhand – District wise Annual New Smear Positive Case Detection Rate, 2011 (in %age)

Jharkhand – District wise Annual New Smear Positive Treatment Success Rate, 2010 (in %age)

West Bengal – District wise Annual New Smear Positive Case Detection Rate, 2011 (in %age)

West Bengal – District wise Annual New Smear Positive Treatment Success Rate, 2010 (in %age)

Chhattisgarh – District wise Annual New Smear Positive Case Detection Rate, 2011 (in %age)

Chhattisgarh – District wise Annual New Smear Positive Treatment Success Rate, 2010 (in %age)

Karnataka – District wise Annual New Smear Positive Case Detection Rate, 2011 (in %age)

Karnataka – District wise Annual New Smear Positive Treatment Success Rate, 2010 (in %age)

Action Points (3)

• Improving communication and outreach.

– focused strategies, targeting hard-to-reach groups. – innovative communications strategies to generate demand from patients, and – improving cooperation from the private sector.

• State and District TB-HIV Coordination Committee

Meetings not being conducted regularly in many States/Districts, the frequency of which should be ensured.

Airborne Infection Control – (1)

• National Guidelines for Airborne Infection Control in

Health Care and Other settings developed and disseminated (available on www.tbcindia.nic.in ) that covers

• Managerial responsibilities at State, District and Facility

level

• Administrative, Environmental & Engineering, Personal

Protective Controls

• Infection control measures at congregate and

community level

• Prioritized implementation across DR TB Centres and

TB C-DST Laboratories.

Airborne Infection Control – (2)

• Pilot implementation to assess operational feasibility

underway at 35 health care facilities (Primary to Tertiary care including 10 ART centres) in 3 states (GU, AP, WB)

• Pilot results will guide refinement of the national

guidelines

• Future scale up of the guidelines implementation

proposed through integration with NRHM, NCDC & NIHFW with technical support from CTD in

• Capacity building of state teams
• Integration as a chapter in the Infection Control

Plans and Strategies of Health care facilities.

= 10 EXPAND TB SITES = 18 TU STUDY SITES

Pilot of Xpert-MTB-Rif (CB-NAAT) in India

• 10 CB-NAAT sites under EXPANDx

TB project to supplement the routine DST capacity

• RNTCP-WHO-FIND CB NAAT

assessing feasibility of introducing CBNAAT for TB suspects in RNTCP across 18 TU sites in 12 states from March 2012. Interim Results expected shortly and will be placed before National Technical Committee

• 950 CBNAAT machines planned

for every district and Medical College in India by 2017

Criteria A - 107 Criteria B - 167 Criteria C - 253

MDR TB Suspect Criteria in districts in India (Oct ’12)

A (All failures & cont) B (All S+ RT Reg & any FUS+) C (All S- RT & any HIV TB Case) Not implementing

DR TB Centre – Institutes commitments and Provisions from RNTCP

Requirement from Institute – It should be Tertiary Care Hospital – Separate card for Male & Female should be available – All the PMDT services (investigations and ancillary drugs for ADR) to be provided free of cost to the patient – Relevant specialties like Pulmonologist, Physician, Psychiatrist, Dermatologist & Gynaecologist etc. should be available – DR TB Centre Committee to be formed. – National Training of DR TB Centre Staff in PMDT (including Chairperson) – National AIC Guidelines to be implemented at the ward – Lab Investigation facility to be made available as per PMDT guidelines – Ancillary drugs to be provided as per DR TB Centre Committee`s advise – Management of Adverse Drug reactions as per PMDT Guidelines – Doctors and Nursing staff should be available from the institute – Records and Reports to be maintained for PMDT – Quarterly reports to be submitted electronically Provision from RNTCP – Remuneration of Sr. MO & SA for DR TB Centre –Training ,formats and registers for PMDT – Second Line Anti TB Drugs – Computer and Internet Facility

DR TB Centre at Government Institutes

• Medical Colleges located at a place where the state proposes to have a DR TB

Centre must be established in the Government Medical College Hospital under the auspices of Department of Pulmonary Medicine or Department of Medicine (if the former department does not exist).

• The above requirements for the institute must be mandatorily provided by the

Government Medical College / Institutes including free laboratory investigations and ancillary drug supply as part of their commitment for which no reimbursement will be available from the programme.

• Government medical colleges / institutes will be eligible for all the provisions from

RNTCP along with a one time provision of up to Rs.10 lacs for up-gradation of the ward to incorporate airborne infection control measures instead of the bed charges

DR TB Centre Scheme for NGOs/Private Hospital (Proposed)

• Private Hospitals and NGO Hospital should be considered at places where a

government medical college is not available to serve as DR TB Centre and the proposed scheme must be considered by the state in consultation with CTD.

• For Private/NGO institutes under MoU
• Reimbursement of laboratory investigations, ancillary drug support
• Bed Charges up to 800/day/patient (including consultant’s charges,

investigations, ancillary drugs and food)

• CTD may develop the Scheme for DR TB Centre in private institutes and seek

approval of the ministry before widely disseminating it.

• Till such time, the states health society can engage with Private hospitals on mutually

agreeable terms under an MoU under intimation of CTD.

Culture-DST Laboratory Scale-up Plan

• 43 laboratories being established & strengthened in the

public sector

– Enhanced sputum processing capacity (staff, centrifuges, BSC) – Solid culture and DST and Line Probe Assay (LPA) in all laboratories – Liquid culture in 33 laboratories

• Engaged private / medical college contractual lab services
• Revision of Laboratory Scale-up Plan being done by National

Laboratory Committee to address future needs

Source: RNTCP National Laboratory Scale-up Plan 2010, www.tbcindia.nic.in

Revised Laboratory Scale-up plan

• Technical Working Group formulating the revised

scale-up plan considering

– Technology (Solid, liquid and Molecular), – HR requirement at laboratories – Workload of diagnosis and follow up specimens

• Committee on Identification of two additional

NRLs

• Priority list of laboratory for Second line DST in

liquid culture based upon the performance and infrastructure