Tuberculosis Programme - Orrisa PCS Exam Notes

Tuberculosis Programme

TB was declared as a global health emergency in 1993. In the same year, India established the RNTCP as a small pilot project. This project was scaled up nationwide between 1998–2006.
The overall vision of RNTCP is “A TB free India”—a situation in which TB is no longer a major public health problem.
Over the last 15 years, the RNTCP became one of India’s largest and greatest public health achievements.
By 2006, decentralized basic TB control services had been established nationwide. In 2006–11, in its second phase RNTCP sought to improve the quality and reach of services, and reach global case detection and cure targets.
These targets were achieved by 2007-08, and from 2006–10 alone more than 27 million chest symptomatic have been examined and 6 million treated.
In the process, the programme implemented activities effectively, delivering Rs. 1545 crores (as of March 2012) expenditure against Rs.1447 crores planned expenditure in the 11th five year plan. There is compelling evidence that the tide has turned for TB.
The burden of TB has begun to fall, and there are now fewer TB-related deaths each year than the year before.
Despite these achievements, undiagnosed and mistreated cases continue to drive the epidemic such that TB remains an enormous public health problem for India. In 2011 alone an estimated 1.2 million TB cases occurred, and 60,000 people died of TB – nearly 165 deaths per day. Nearly 1 in 6 deaths among adults aged 15–49 are due to TB. More adult women die of TB every year than from peri-partum complications or HIV/AIDS. TB remains the leading cause of illness and death among persons living with HIV/AIDS. Nearly 100,000 cases of serious multidrug resistant TB (MDR-TB) are estimated to occur in the country every year, mostly attributable to prior inadequate treatment, and each MDR TB case costs more than Rs 1 lakh to diagnose and treat. TB affects anyone, but predominantly the poor and marginalized, perpetuating poverty through health and economic shocks to families least able to cope.

History of TB Control:

Despite the National TB Programme (NTP) being in existence since 1962, no appreciable change in the epidemiological situation of TB in the country had been observed. The HIV-AIDS epidemic and the spread of multi-drug resistance TB were threatening to further worsen the situation. In view of this, in 1992, GOI, with WHO and SIDA reviewed the TB situation and identified the following limitations:

NTP, was managerially weak
Inadequate funding for program activities
Over-reliance on x-ray for diagnosis
Frequently interrupted drug supply
Low rates of treatment compliance

In order to overcome these limitations, in 1993 the GoI decided to reenergize the NTP, with assistance from international agencies.

The Revised National TB Control Programme

The Revised National TB Control Programme (RNTCP) thus formulated, adopted the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, as the most systematic and cost-effective approach for TB control in India. Political and administrative commitment, to ensure the provision of organised and comprehensive TB control services was obtained. Adoption of smear microscopy for reliable and early diagnosis was introduced in the general health services. DOTS was adopted as a strategy for provision of treatment to increase the treatment completion rates.
The supply of drugs was also strengthened to meet the requirements of the system.
The key objectives of the RNTCP were to achieve and maintain at least 85 per cent cure rate among the new smear-positive cases initiated on treatment, and thereafter a case detection rate of at least 70 per cent of such cases

RNTCP (Revised National TB Control Programme Growth) & Innovations:

The RNTCP built on the infrastructure and systems built through the NTP. A key focus area was strengthening the recording and reporting systems.
An addition to the RNTCP was the establishment of a subdistrict supervisory unit, known as a TU (Tuberculosis Unit), with dedicated RNTCP supervisors. This led to decentralization of both diagnostic and treatment services, with treatment given under the support of DOT providers.
The quality of diagnosis of TB patients under RNTCP improved by giving the highest priority to the provision of quality assured sputum smear microscopy services.
Another key innovation under RNTCP has been the development of Patient-Wise Boxes, which contain the full course of treatment for an individual patient.
This ensures that treatment of that patient cannot be interrupted due to a lack of drugs. The RNTCP has effectively decentralized supervision via the sub-district TB Units, with in-built systems for monitoring and evaluation.

RNTCP (The Revised National TB Control Programme) II

RNTCP II was developed based on the lessons learnt from the implementation of the programme over a 12-year period (1993-2005).
RNTCP II was designed to consolidate the gains achieved in RNTCP I and to initiate services to address TB/HIV, MDR-TB and extend RNTCP to private sector.
Systematic research and evidence building to inform the programme for better design was also an important component of the programme. The emerging needs of Advocacy, Communication and Social Mobilization were addressed in the new phase.
The challenges imposed by the structures under NRHM were also taken into account for RNTCP II.
Since 2007, the programme has been consistently achieving a treatment success rate of >85% and a NSP case detection rate (CDR) of >70%.
In 2011, RNTCP achieved the NSP CDR of 72% and treatment success rate of 88%, which is in line with the global targets for TB control.

Monitoring, supervision and evaluation:

The RNTCP’s ‘Supervision and Monitoring strategy’ includes detailed guidelines, tools and indicators for monitoring the performance from the PHI level to the national level.
The quality programme implementation is ensured by frequent Internal and external evaluations.
The programme is focusing on the reduction in the default rates among all new and re-treatment cases.
Quality assured sputum smear microscopy facilities are available nationwide through about 13,000 sputum microscopy laboratories in the health system.
As a result, chest symptomatic examined has increased from 397 to 642 per 100,000 population per annum over the last 10 years.
Quality assured anti-TB drugs for the full course of treatment are provided to the patients through patient wise boxes.
Decentralized treatment is provided through a network of more than 6,40,000 DOTS providers, to provide treatment to the patients as near to their home as possible

National Strategic Plan 2012-17/ The National Strategic Plan for TB Control 2012-17 (NSP-RNTCP)

The vision of the Government of India is for a “TB-free India” with reduction of the burden of the disease until it is no longer a major public health problem.
To achieve this vision, the programme has now adopted the new objective of Universal Access for quality diagnosis and treatment for all TB patients in the community.
This entails sustaining the achievements of the programme to date, and extending the reach and quality of services to all persons diagnosed with TB.
With the GOI vision as a long term guide, the programme defined objectives for 2012–2017 are:

To ensure early and improved diagnosis of all TB patients including drug resistant and HIV-associated TB
To provide access to high-quality treatment for all diagnosed cases of TB
To scale-up access to effective treatment for drug-resistant TB
To decrease the morbidity and mortality of HIV-associated TB
To extend RNTCP services to patients diagnosed and treated in the private sector.

Thrust areas and Strategies

Strengthening and improving the quality of basic DOTS services
Further strengthening and aligning with health system under NRHM
Deploying improved rapid diagnostics to the field level
Expanding efforts to engage all care providers
Strengthening urban TB Control
Expanding diagnosis and treatment of drug resistant TB
Improving communication, outreach, and social mobilization
Promoting research for development and implementation of improved tools and strategies

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