NATIONAL

TUBERCULOSIS
ELIMINATION
PROGRAMME
Dr.Manoj Kumar
Department of community medicine
 Introduction
• Mycobacterium Tuberculli
• 56% world incidence in 5 countries.(India,china,Pakistan,philipines,Indonesia).
• World TB day- 24 march
• TB bacilli was discovered by Robert Koch(1982)
 Epidemiological facts

• Global population infected asymptomatically with TB : 33%

• 1 case of infectious pulmonary TB can infect :10-15 persons per year
• Majority of cases, global : > 15 years adults(90%)
• Country with highest no. of cases :India
• Male : Female ratio : 1.7 : 1
• Country with highest number of MDR – TB cases : India(24%)
• Treatment success rate : 82%(TB),77%(HIV-TB),55%(MDR TB),34%(XDR TB)
 TB situation in India

• Country with highest TB burden in world :India

• Infected with TB(Mantoux positive) : 2 out of 5 Indians (40%)
• Annual risk of becoming infected with TB : 1.5%
• Lifetime risk of disease among infected : 10%
• Indian developing TB everyday :5000
• Incidence of TB : 167 per 100000 population
• Prevalence of TB : 195 per 100000 population
 Epidemiological indices for TB

1.Incidence of TB infection(annual incidence rate, annual risk of infection-ARI):

• percentage of population under study who will be newly infected with TB among
non-infected in 1 year.
Express attacking force of TB in community
In developing countries 1% ARI corresponds to : 50 SS +ve cases per 100000
general population
2.Incidence of disease: percentage of new TB cases per 1000 population
Reveals trend of problem including impact of control measures.
Sputum smear examination(AFB) is a reliable method for estimation
3.Prevalence of disease or case rate : percentage of individuals whose sputum is
positive for TB bacilli on microscopic examination
Best available practical index to estimate case load in community
 Epidemiology
• Causative agent : M. Tuberculosis
• Source of infection :
Human cases
Bovine milk
• Period of communicability : infective as long as cases remain untreated
• MOT-Droplet infection
• IP : 4 – 12 weeks average
 EVOLUTION OF NTEP
• 1939: The TB Association of India (TAI) established to develop standard methods for
managing TB and to develop model training institutions

• 1946: Bhore Committee

• Wide gap between TB patients and number of beds

• TB clinic in every district and mobile clinics in rural areas.

• 1951: BCG Campaign

• 1962 : National TB control Programme

• 1997: RNTCP
EVOLUTION OF NTEP- cntd..
• 2006: DOTS

• 2007: DOTS Plus (PMDT), Joint TB/HIV Collaboration

• 2012: NSP 2012- 2017 Mandatory TB notification, Nikshay, CBNAAT, integration of

programme with NHM

• 2013: PMDT nation-wide coverage

• 2016: Daily weight bandwise FDC based DSTB regimen

• 2017: Newer drug containing regimen ( such as bedaquiline)

EVOLUTION OF NTEP- cntd..

• 2018: Universal DST (for Rifampicin)

• 2020: RNTCP to NTEP

• 2021: TB Mukt Bharat Abhiyan

NTEP- GOAL AND OBJECTIVES
• Goal- To achieve a rapid decline in burden of TB, morbidity and mortality while
working towards elimination of TB in India by 2025

• Vision- TB free India with zero deaths, disease and poverty due to TB

• Objectives

• To achieve 90% notification of all TB cases

• To achieve 90% success rate for new, 85% for retreatment cases

• To significantly improve successful outcomes of DRTB cases

• To achieve decreased morbidity and mortality of HIV associated TB

• To improve the outcomes of TB care in the private sector

National Strategic Plan (2017-
2025)
• Vision: TB free India with zero deaths, disease, and poverty due to TB
• Goal: To achieve a rapid decline in burden of TB, morbidity, &
mortality, & to achieve the SDG of 80% reduction in incidence & 90%
reduction in deaths by 2025.
• Strategic pillars: build- prevent- detect- treat
 NTEP Strategies
DETECT TREAT PREVENT BUILD

• Diagnose all cases • Quality • Decentralised

• Passive, assured case
intensified and Prevention of…
treatment management
active case finding • New infections
• ADR • Integration
• UDST(universal • Resistance
drug sensitivity management • Private sector
• Death
testing) • New regimens involvement
• Mandatory • Daily regimen • Multi sectoral
notification
• PTFU engagement 13
PREVENT
• Prevent new infections
• Early diagnosis and treatment
• Airborne infection control
• Prevent active breakdown of infection to disease
• Vulnerability reduction (Eg. Nutrition, management of co-morbidities)
• Management of LTBI
• Prevent emergence of resistance to drugs
• Ensure quality of treatment and adherence
• DST guided treatment
• Prevent Death
• Early diagnosis, comorbidity management
DETECT

• Diagnose all TB cases including DRTB

• Passive and active case finding

• Establishing quality assured laboratory network

• Universal and extended DST

• Notification of all cases

• Mandatory notification

• Surveillance system
 Treat

• Daily Regimen
Treatment • Shorter Regimen
• Newer Drugs
• IT Enabled Adherence
Support
Patient Centric Care • Comorbidity
management
• Financial incentives
Reduce Out-of-pocket •
Direct Benefit Transfer
Expenditure
 Treatment Adherence
99 DOT Smart box

Directly Observed Treatment

Health facility
Community treatment
supporter Call centre Human interaction
ICT based adherence
99 DOT
Self reporting (Call Centre)
SMS Reminder
Pill counting Social Support
IT enabled adherence monitoring

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DEFINITION
CLASSIFICATION OF TB
BASED ON MICROBIOLOGICAL CONFIRMATION:
• Microbiologically confirmed TB
• Clinically Diagnosed TB
BASED ON ANATOMICAL SITE INVOLVEMENT:
• Pulmonary tuberculosis (PTB)
• Extra Pulmonary tuberculosis (EPTB)
BASED ON PREVIOUS TB TREATMENT HISTORY:
• New TB Patient
• Previously Treated TB
- Recurrent TB patient
- Treatment after failure
- Treatment after lost to follow-up
- Transferred in: A TB paitent who has been received in a TB unit after having
registered in another TB unit treatment
 Classification based on drug
resistance
• Mono – resistant(MR):A TB patient, who is resistant to one 1st line anti-
TB drug only.
• poly – drug resistant : A TB patient is resistant to more than one 1st line
anti TB drug. Other than Rifampicin
• Rifampicin resistant(RR): A TB patient ,who is resistant to rifampicin
with or without resistance to other drugs.Paitents who have rifampicin
resistance, should be managed as if they are an MDR TB case.
• MDR:A TB patient, who is resistant to both isoniazid & rifampicin.
• XDR:A MDR TB patient who is additionally resistant to a
fluroquinolone(ofloxacin,levofloxacin,moxifloxacin)
DIAGNOSIS OF TB
A. Smear Microscopy C. Rapid molecular tests:
• Zeihl-Neelsen Staining • Line Probe Assay for MTB
B. Culture: complex and detection of drug
resistance (FL& SL LPA)
• Solid (Lowenstein Jensen) media
• Nucleic Acid Amplification
• Automated Liquid culture Test(CBNAAT/Truenat)
systems e.g. BACTEC MGIT 960,
BacT Alert or Versatrek etc. Supportive tools: Chest X-ray and
radiological tests, TST,other blood
tests, Histopathology, etc..
Diagnostic algorithm for Drug
Sensitive TB
Diagnostic algorithm for Extra-
pulmonary TB
 Treatment Regimens
Type of TB Type of regimen Duration and Drugs
Drug
2 months H, R, Z, E
susceptible DS-TB regimen
4 months H, R, E
TB
H mono/poly H mono/poly 6 months Lfx, R, E, Z
DR-TB DR-TB regimen
(4-6) Bdq (6 m), Lfx, Cfz, Z, E,
Shorter oral BDQ containing H
MDR / RR regimen
and XDR-TB (5) Lfx, Cfz, Z, E
Longer oral BDQ containing (18-20) Lfx Bdq (6 month or longer)
regimen Lzd# Cfz Cs
6 H (6 months daily INH
monotherapy)
3 HP (3 months weekly dose of
TB TB Preventive treatment
HP – 12
6 Lfx (6 dose)
months Lfx in contacts
Infection ofRMDR/RR
4 (4 months daily R in
contacts of H Res)
3RH (3 months daily RH -2FDC)
 Extension of treatment in mono/poly DR TB regimens

Total duration of mono-poly DR TB regimen is 6 months

Treatment may be extended to 9 months
• uncontrolled comorbidity
• extra-pulmonary TB
• if smear at the end of 4th month is found positive; based on smear
microscopy and clinical monitoring;
In CNS, skeletal and miliary TB, treatment may be given up to a year.
In patients who remain sputum smear positive at the end of 5-month
or later of treatment, the outcome will be declared as treatment
failure.
 Management of DR-TB patients with
Treatment Interruptions and Loss to
Follow up
All the missed doses during IP must be completed prior to switching the patient to CP.
Similarly all missed doses during CP must be administered prior to ending treatment.
Patients who interrupt treatment for less than one month during IP:
• Resume IP treatment, the duration of treatment will be extended to complete IP.

Patients who interrupt treatment for less than one month during CP:
• Resume CP treatment, the duration of treatment will be extended to complete the CP..

Patients who are Loss to Follow up (interrupt treatment continuously for one month or more)
and return back for treatment:
• Such patients will be given an outcome of “loss to follow up”.
• The patient would be subjected to repeat FL-SL LPA as per the diagnostic algorithm to restart
with appropriate DST guided regimen with or without newer drug for a fresh episode of
treatment.
 Missing Bedaquiline doses and reload after
interruption
Initial 2 weeks of BDQ course and returns to resume the treatment:

 If interruption is up to 7 days:
BDQ containing regimen will be continued to complete the doses and the duration of treatment will be
extended to complete IP..
 If interruption is more than 7 consecutive days
BDQ course will be re-loaded (started afresh) if returns within 1 month and a sputum sample will be
collected for culture.

3-24 weeks of BDQ course and returns to resume the treatment:

 If interruption is up to 1 month:
BDQ containing regimen will be continued to complete the doses
 If interruption is more than 1 months:
BDQ will be permanently discontinued. Such patients will be given an outcome of “Lost to follow up”
(LTFU) based on the duration of LTFU
 DSTB Regimen and duration

Type of TB Intensive Phase Continuation Phase

case
New (2) HRZE (4) HRE

Previously (2) HRZE (4) HRE

Treated

Provision for extension of CP by 12-24 weeks in certain

forms of TB like CNS TB, skeletal TB, disseminated TB
based on the clinical decision of the treating physician.

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Doses in Daily Regimen
Type of TB Case Doses in IP Doses in CP#

New 56 doses (8 weeks x 112 doses(16 weeks

7 days/week) or x 7 days/week) or
28*2 28*4

Previously treated 56 doses (8 weeks x 112 doses(16 weeks

7 days/week) or x 7 days/week) or
28*2 28*4

#CP can be extended by 12 to 24 weeks in certain forms like CNS TB, Skeletal TB
and Disseminated TB, based on clinical decision of the treating physician
 Pyridoxine in TB Regimen
It is given to prevent INH related neuropathy due to Vitamin B6 deficiency.

Following are the conditions where the possibility of developing neuropathy

when given INH without Pyridoxine is high:
1)Alcoholics
2)Malnourished persons
3)Pregnant and lactating women
4)Patients with conditions such as chronic renal failure, diabetes
5)HIV infection
Hence, simultaneous monitoring for neuro and hepatotoxicity is advised if given
INH.
 TB & COMORBIDITIES
Comorbidities cause

Weakening of the immune system.

Progression of TB infection to TB disease within a shorter time.

Increased Severity of TB illness.

Poor TB treatment outcome.

DOTS STRATEGY
• NTEP is strongly anchored on the DOTS strategy

• Five components for the DOTS strategy

• Political and administrative commitment

• Diagnosis by quality assured microbiological methods

• Uninterrupted supply of good quality drugs

• Observation of treatment (DOT)- right drug, right dose and right duration

• Systematic Monitoring and accountability

DBT schemes for TB patients
Thanks