- Email: [email protected]
Revised national TB control programme in India
ARTICLE IN PRESS Tuberculosis (2005) 85, 271–276
Tuberculosis http://intl.elsevierhealth.com/journals/tube
Revised national TB control programme in India L.S. Chauhana,, J. Tonsingb a
Ministry of Health and Family Welfare, 522 C Wing, Nirman Bhawan, New Delhi 110 011, India 533 C Wing, Nirman Bhawan, New Delhi 110 011, India
b
KEYWORDS Tuberculosis; DOTS; Programme implementation; RNTCP; India
Summary The Revised National TB Control Programme (RNTCP), an application in India of the Directly Observed Treatment, Short Course (DOTS) strategy to control TB is being implemented in the country since 1997. The goal of the RNTCP is 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 Since 1999, achievements of the RNTCP have largely determined the global DOTS progress. It has been cited as the fastest expansion in the history of DOTS and in terms of patients being treated, it is the largest programme in the world. More than 50-fold expansion in RNTCP coverage has occurred since 1998 thus making DOTS accessible to more than 83% of the country’s population. Quality of services has been maintained during this rapid expansion. As a result, the proportion of sputum positive cases confirmed in the laboratory is on par with international standards. By September 2005, the programme has initiated more than 3.5 million patients on treatment, thus saving over 600,000 additional lives. In 2003, new sputum positive case detection rate of 69% was achieved against target of at least 70% and treatment success rate of 86% has been achieved above the target of 85% Aggressive steps are being taken to meet global TB control targets by covering the entire country with RNTCP by 2005. Despite these achievements, there are many challenges for the RNTCP. Implementing DOTS in a diverse and large country, maintaining the quality of services during rapid expansion phase, decentralization of programme management to the states and, widening the reach of the programme to reach all sections of the society are some of the major challenges. & 2005 Elsevier Ltd. All rights reserved.
Background Corresponding author. Ministry of Health and Family Welfare,
523 C Wing, Nirman Bhawan, New Delhi 110 011, India. Tel./fax: +91 11 2301 8126. E-mail addresses: [email protected] (L.S. Chauhan), [email protected] (J. Tonsing).
Tuberculosis (TB) remains one of the most pressing health problems of India. Every year, India has 1.8 million new cases of TB of which 0.8 million are new smear positive. About 417,000 deaths occur each year which amounts to more than 1000
1472-9792/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.tube.2005.08.003
ARTICLE IN PRESS 272
L.S. Chauhan, J. Tonsing
patients dying from TB every day.1 The emergence and spread of HIV and drug-resistant TB threaten to further complicate the TB situation in the country. Besides the disease burden, TB also causes an enormous socio-economic burden. Each year, more than 300,000 children leave school permanently because of their parents’ TB, and more than 100,000 women are rejected by their families on account of TB. TB costs India more than $300 million annually in direct costs alone, of which more than $100 million is incurred in the form of debt by patients and their families.2
Revised National TB Control Programme (RNTCP) pilots began in few sites. Having proved both its technical and operational feasibility, a soft loan of US $ 142 million was negotiated with the World Bank and the RNTCP was formally launched in the country in 1997.
Goal and objectives The goal of the RNTCP is to decrease mortality and morbidity due to TB, and to interrupt the chain of transmission in order that TB is no longer a major public health problem in India. The objectives of the RNTCP, set to conform to the targets for global TB control are:
RNTCP
The joint review of the National Tuberculosis Programme (NTP) in 1992, undertaken by the Government of India (GoI) and the World Health Organisation (WHO), found that despite the existence of the NTP for 30 years, no impact had been made on the control of TB in India.3 Following the review recommendations, the GoI developed a revised strategy incorporating the internationally recommended directly observed treatment, short course (DOTS) strategy for TB control,4 and in 1993
At least 85% cure of new smear positive pulmonary TB (NSP) patients; and at least 70% detection of new smear positive pulmonary TB cases existing in the community.5
Major features RNTCP is integrated with the general health care delivery systems in the States. Organization of services for the revised approach has been discussed elsewhere.6 A salient feature of the RNTCP 1200
P r ojected expansion
1000
906 Sept ’ 2004 800
600
400 Covered by Programme
200
Figure 1 Multiyear DOTS expansion plan for India. 30th September 2004.
05
05 3Q
05
04
04
04
04
03
03
03
03
02
02
Quarter & Year * Projected population based on 2001 census.
2Q
1Q
4Q
3Q
2Q
1Q
4Q
3Q
2Q
1Q
4Q
3Q
02
01
01
01
02
2Q
1Q
4Q
3Q
00
00
00
01
2Q
1Q
4Q
3Q
2Q
1Q
00
0
population coverage * with DOTS (in millions) *
Total Population 1111
ARTICLE IN PRESS Revised national TB control programme in India is the release of funds to state and district societies which are non-governmental organizations (registered charities) rather than to state and district governments. Direct release of funds to these societies has ensured availability of funds for TB control activities and flexibility in fund utilization. Other major features include modular training to ensure a uniform standard of training throughout the country and remove subjectivity of the trainer; use of diagnostic and treatment algorithms; and ensuring an uninterrupted drug supply through the use patient wise boxes which contain requirement of drugs for the entire duration of treatment. In addition, the RNTCP creates a subdistrict level TB Unit (TU) for every 500,000 population which is manned by a special cadre of dedicated TB supervisory staff for the exclusive purpose of supervision and monitoring of TB control activities. Cohort wise analysis of the patients put on treatment is undertaken and published every quarter.5 More than 90% of the districts/reporting units submit their quarterly report electronically on time. The programme also has its own website featuring information related to RNTCP and the Performance Reports.
273
Achievements Expansion Large-scale implementation of the programme began in 1998, by September 2004, the RNTCP had expanded to cover 83% of the country—906 million populations in 521 districts. Figure 1 shows the progress in DOTS implementation in the country so far and expansion plans for the future. The RNTCP has expanded more than 50-fold since 1998 and continues to expand at a rapid rate, covering 10–15 million additional population every month. Global progress in DOTS expansion since 1999 has been largely determined by the achievements of the RNTCP. In 1999, the Indian expansion of RNTCP accounted for one-third, and in 2000 and 2001 for over half, of the global increase in DOTS coverage.7–9 The expansion of the RNTCP has been recognized as the fastest expansion of any DOTS programme in the world, even whilst still maintaining the quality of services provided.10 It is planned that by 2005, nation-wide coverage under RNTCP will have been achieved.
1000
316,026 300000
900 Total patients treated Population coverage (in millions)
800 700
200000
600 500
150000 237615
400
Total patients treated
Population covered (millions)
250000
100000
300 200
50000 100 0 I/9 8 III /9 8 I/9 9 III /9 9 I/0 0 III /0 0 I/0 1 III /0 1 I/0 2 III /0 2 I/0 3 III /0 3 I/0 4
7
/9 7 III
I/9
6
/9 6 III
I/9
5
/9 5 III
I/9
/9 4 III
I/9
4
0
Quarter/Year
Figure 2 Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter. January 1994–June 2004.
ARTICLE IN PRESS 274
L.S. Chauhan, J. Tonsing
Performance Figure 2 shows that along with the increase in population coverage, the number of patients put on treatment has increased concomitantly. In the quarter of April–June 2004, more than 100,000 patients were initiated on DOTS treatment each month—more than any other country in the world. By June 2005, the programme had initiated more than 3 million patients on treatment which increased to over 3.5 million patients by September
2005. Considering that 18 lives are saved for every hundred patients treated under the RNTCP, this has resulted in the saving of over 600,000 additional lives.11 The annualized new smear-positive case detection and treatment success rates in the DOTS areas between 1999 and June 2004, is shown in Fig. 3. Treatment success has been consistently high and in recent quarters exceeded the global target of 85%. Case detection in the DOTS areas show a rising trend with a seasonal variation, and has now
100% 90% 80% 70% 60% 50% 40% 30% 20% Annualised New S+ve CDR
Success rate
10%
19 99 Q 19 1 99 Q 19 2 99 Q 19 3 99 Q 20 4 00 Q 20 1 00 Q 20 2 00 Q 20 3 00 Q 20 4 01 Q 20 1 01 Q 20 2 01 Q 20 3 01 Q 20 4 02 Q 20 1 02 Q 20 2 02 Q 20 3 02 Q 20 4 03 Q 20 1 03 Q 20 2 03 Q 20 3 03 Q 20 4 04 Q 20 1 04 Q 2
0%
Figure 3 Annualized new smear-positive case detection rate and treatment success rate in DOTS areas. January 1999–June 2004.
% Cases detected of total estimated for India .
80%
70% Target 70% 60%
50%
40%
30%
20%
10%
0% 1999
2000
2001
2002
2003 Year
2004
2005
2006
Figure 4 Progress towards target of 70% case detection.
2007
9019 10,820 1918 9490 38,814 69,877 11,670 13,311 8714 50,797 24,878 32,269 127,725 5095 1512 24,187 15,624 98,147 1403 89,617 75,860 2068 89,826 906,472
109 117 10 94 149 502 131 63
112 489 324 449 1008 25 19 268 154 594 6 634 864 20 829
7754
Grand total
132
102 117 77 113 130 202 81 140 106 165 245 141 124 105 111
109 92 199 101 261 139 150 212
142 173
Annual total detection rate
358,496
3532 21,625 10,861 12,687 46,257 1451 657 11,703 5831 37,459 443 34,768 31,937 827 38,866
3863 4201 702 3543 11,325 26,471 4330 4902
38,702 779
New S+ve cases initiated on treatment
52
41 49 34 44 47 58 35 69 39 63 77 55 52 42 48
47 36 73 38 76 52 55 78
61 68
69%
55% 66% 45% 55% 59% 77% 47% 91% 41% 79% 82% 73% 55% 44% 64%
62% 48% 77% 47% 80% 66% 57% 82%
81% 91%
Annual new S+ve detection rate per 100,000 (%)
0.8
1.0 0.7 0.6 0.9 0.9 1.3 0.5 0.6 0.7 0.8 0.7 0.9 0.8 0.7 0.7
0.8 1.1 0.6 1.1 0.8 0.6 0.8 0.6
0.9 0.8
Ratio of new S ve to new S+ve patients
90
86
93 84 89 83 85 85 87 85 87 87 86 86 89 95 85
86 89 79 81 81 84 80 88
84 93 89 87 88 91 86 92 96 88 90 87 90 89 84 88 88 91 90 92 87 96 89
85 81
Cure rate of new S+ve patients (%)
89 90
3 months conversion rate of new S+ve patients (%)
87
93 85 89 85 86 88 87 87 87 88 87 87 90 95 86
88 92 80 82 82 84 82 89
87 82
Success rate of new S+ve patients (%)
Notes: (1) Case detection rate (CDR) is calculated using person-year method and to account for districts which started implementation during 2003, data is included only for full quarter implementation. (2) Projected population of 2003, based on Census 2001, is used for CDR calculation. (3) Estimated total new-smear positive cases adjusted for available data on Annual Risk of TB Infection (ARTI) for each zone. Thus, estimated new smear-positive cases for North Zone (Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu & Kashmir, Punjab, Uttar Pradesh, Uttaranchal) is 95/lakh; East Zone (Andaman & Nicobar, Arunachal Pradesh, Assam, Bihar, Jharkhand, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Sikkim, Tripura, West Bengal) is 75/lakh; South Zone (Andhra Pradesh, Karnataka, Kerala, Lakshwadeep, Pondicherry, Tamil Nadu) is 75/lakh and West Zone (Chattisgarh, Dadra & Nagar Haveli, Daman & Diu, Goa, Gujarat, Madhya Pradesh, Maharashtra, Rajasthan) is 80/lakh. (4) Values in black are below or above RNTCP targets.
89,511 1978
742 11
Population covered Total cases initiated on in 100,000 by treatment 31.12.03
Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhatisgarh Delhi Gujarat Haryana Himachal Pradesh Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Uttar Pradesh Uttaranchal West Bengal
State
Table 1 RNTCP annual summary—2003. Performance of states case finding (2003), smear conversion (4th quarter 2002 and quarters 1–3, 2003) and treatment outcomes (2002).
ARTICLE IN PRESS
Revised national TB control programme in India 275
ARTICLE IN PRESS 276 crossed the global target of 70%. Figure 4 shows the percentage of cases detected out of the total estimated cases for the country. Had India continued expansion and increase in case detection at the same rate as prior to 2002 then the target of 70% case detection would not have been met until after 2006. With the accelerated increase since 2002, the global target is expected to be achieved by 2005. Table 1 presents the performance of the States of the country in terms of case finding, smear conversion and treatment outcomes during the year 2003. Overall, the new sputum positive case detection rate in 2003 was 69% against the target of at least 70%, with the treatment success rate of 86% surpassing the 85% target. Compared to the previous National TB Programme, treatment success rates under the RNTCP have tripled from 25% to 86%. The proportion of sputum positive cases confirmed in the laboratory are double that of the previous programme and is on par with international standards.10
L.S. Chauhan, J. Tonsing
Challenges Despite these achievements, there are many challenges for the RNTCP at this juncture. The quality of TB services provided by RNTCP needs to be maintained, whilst continuing to rapidly expand RNTCP to cover the entire country. Partnership with the huge network of health care providers outside the health ministry will need to be further strengthened. The programme has to meet the special requirements of urban areas, slums and migratory populations, tribals and other marginalized communities, HIV+ve TB patients and pediatric TB patients. Though the focus now is on rapid expansion of DOTS to prevent multi-drug resistant TB (MDR-TB), in the long run, the programme will require to have a provision for the management of MDR-TB. In addition, the programme will have to continue for many years to come before achieving control of TB in India. Continued decentralization of programme management to the states, ensuring financial support for the RNTCP, and mobilizing community participation in TB control are other challenges that the programme will have to ensure for its sustainability.
Partnerships Alongside maintaining and improving the core services of the programme, RNTCP has implemented many new initiatives and have forged partnerships with many other health providers other than the traditional public health services. Starting with a public–private TB mix (PPM) pilot site in Hyderabad in 1995, the programme has recognized the need to partner with the non-governmental organization (NGO) and private health care providers. The RNTCP is one of the few DOTS programmes in the world to have official published guidelines for the involvement of NGOs (2001) and private practitioners (2002).11 Over 750 NGOs, 3000 private practitioners and 80 corporate health facilities are involved in RNTCP activities. One hundred and sixty-six out of the 213 medical colleges located in DOTS implementing areas have established a DOTS centre.11 These colleges also train the future generations of doctors in their institutes on RNTCP, advocate on behalf of RNTCP and are being involved to undertake relevant operational research for the programme.
References 1. World Health Organization (WHO). Global tuberculosis control. WHO report 2004. Geneva: WHO; 2004. 2. Ramachandran R, Balasubramaniam R, Muniyandia M, et al. Socio-economic impact of TB on patients and family in India. Int J Tuberc Lung Dis 1999;3:869–77. 3. World Health Organisation (WHO). Tuberculosis programme review—India, 1992. Geneva: WHO; 1992. 4. World Health Organisation (WHO). Framework for effective tuberculosis control. WHO/TB/94.179. Geneva: WHO; 1994. 5. Central TB Division (CTD). Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Revised National Tuberculosis Control Programme. Operational guidelines for tuberculosis control. Delhi: CTD; 1997. 6. Khatri GR. DOTS progress in India: 1995–2002. Tuberculosis 2003;83:30–4. 7. World Health Organization (WHO). Global tuberculosis control. WHO report 2001. Geneva: WHO; 2001. 8. World Health Organization (WHO). Global tuberculosis control. WHO report 2002. Geneva: WHO; 2002. 9. World Health Organization (WHO). Global tuberculosis control. WHO report 2003. Geneva: WHO; 2003. 10. World Health Organization (WHO). Joint tuberculosis programme review. September 2003. New Delhi: WHO; 2004. 11. www.tbcindia.org. Accessed 7/12/04.
Tuberculosis http://intl.elsevierhealth.com/journals/tube
Revised national TB control programme in India L.S. Chauhana,, J. Tonsingb a
Ministry of Health and Family Welfare, 522 C Wing, Nirman Bhawan, New Delhi 110 011, India 533 C Wing, Nirman Bhawan, New Delhi 110 011, India
b
KEYWORDS Tuberculosis; DOTS; Programme implementation; RNTCP; India
Summary The Revised National TB Control Programme (RNTCP), an application in India of the Directly Observed Treatment, Short Course (DOTS) strategy to control TB is being implemented in the country since 1997. The goal of the RNTCP is 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 Since 1999, achievements of the RNTCP have largely determined the global DOTS progress. It has been cited as the fastest expansion in the history of DOTS and in terms of patients being treated, it is the largest programme in the world. More than 50-fold expansion in RNTCP coverage has occurred since 1998 thus making DOTS accessible to more than 83% of the country’s population. Quality of services has been maintained during this rapid expansion. As a result, the proportion of sputum positive cases confirmed in the laboratory is on par with international standards. By September 2005, the programme has initiated more than 3.5 million patients on treatment, thus saving over 600,000 additional lives. In 2003, new sputum positive case detection rate of 69% was achieved against target of at least 70% and treatment success rate of 86% has been achieved above the target of 85% Aggressive steps are being taken to meet global TB control targets by covering the entire country with RNTCP by 2005. Despite these achievements, there are many challenges for the RNTCP. Implementing DOTS in a diverse and large country, maintaining the quality of services during rapid expansion phase, decentralization of programme management to the states and, widening the reach of the programme to reach all sections of the society are some of the major challenges. & 2005 Elsevier Ltd. All rights reserved.
Background Corresponding author. Ministry of Health and Family Welfare,
523 C Wing, Nirman Bhawan, New Delhi 110 011, India. Tel./fax: +91 11 2301 8126. E-mail addresses: [email protected] (L.S. Chauhan), [email protected] (J. Tonsing).
Tuberculosis (TB) remains one of the most pressing health problems of India. Every year, India has 1.8 million new cases of TB of which 0.8 million are new smear positive. About 417,000 deaths occur each year which amounts to more than 1000
1472-9792/$ - see front matter & 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.tube.2005.08.003
ARTICLE IN PRESS 272
L.S. Chauhan, J. Tonsing
patients dying from TB every day.1 The emergence and spread of HIV and drug-resistant TB threaten to further complicate the TB situation in the country. Besides the disease burden, TB also causes an enormous socio-economic burden. Each year, more than 300,000 children leave school permanently because of their parents’ TB, and more than 100,000 women are rejected by their families on account of TB. TB costs India more than $300 million annually in direct costs alone, of which more than $100 million is incurred in the form of debt by patients and their families.2
Revised National TB Control Programme (RNTCP) pilots began in few sites. Having proved both its technical and operational feasibility, a soft loan of US $ 142 million was negotiated with the World Bank and the RNTCP was formally launched in the country in 1997.
Goal and objectives The goal of the RNTCP is to decrease mortality and morbidity due to TB, and to interrupt the chain of transmission in order that TB is no longer a major public health problem in India. The objectives of the RNTCP, set to conform to the targets for global TB control are:
RNTCP
The joint review of the National Tuberculosis Programme (NTP) in 1992, undertaken by the Government of India (GoI) and the World Health Organisation (WHO), found that despite the existence of the NTP for 30 years, no impact had been made on the control of TB in India.3 Following the review recommendations, the GoI developed a revised strategy incorporating the internationally recommended directly observed treatment, short course (DOTS) strategy for TB control,4 and in 1993
At least 85% cure of new smear positive pulmonary TB (NSP) patients; and at least 70% detection of new smear positive pulmonary TB cases existing in the community.5
Major features RNTCP is integrated with the general health care delivery systems in the States. Organization of services for the revised approach has been discussed elsewhere.6 A salient feature of the RNTCP 1200
P r ojected expansion
1000
906 Sept ’ 2004 800
600
400 Covered by Programme
200
Figure 1 Multiyear DOTS expansion plan for India. 30th September 2004.
05
05 3Q
05
04
04
04
04
03
03
03
03
02
02
Quarter & Year * Projected population based on 2001 census.
2Q
1Q
4Q
3Q
2Q
1Q
4Q
3Q
2Q
1Q
4Q
3Q
02
01
01
01
02
2Q
1Q
4Q
3Q
00
00
00
01
2Q
1Q
4Q
3Q
2Q
1Q
00
0
population coverage * with DOTS (in millions) *
Total Population 1111
ARTICLE IN PRESS Revised national TB control programme in India is the release of funds to state and district societies which are non-governmental organizations (registered charities) rather than to state and district governments. Direct release of funds to these societies has ensured availability of funds for TB control activities and flexibility in fund utilization. Other major features include modular training to ensure a uniform standard of training throughout the country and remove subjectivity of the trainer; use of diagnostic and treatment algorithms; and ensuring an uninterrupted drug supply through the use patient wise boxes which contain requirement of drugs for the entire duration of treatment. In addition, the RNTCP creates a subdistrict level TB Unit (TU) for every 500,000 population which is manned by a special cadre of dedicated TB supervisory staff for the exclusive purpose of supervision and monitoring of TB control activities. Cohort wise analysis of the patients put on treatment is undertaken and published every quarter.5 More than 90% of the districts/reporting units submit their quarterly report electronically on time. The programme also has its own website featuring information related to RNTCP and the Performance Reports.
273
Achievements Expansion Large-scale implementation of the programme began in 1998, by September 2004, the RNTCP had expanded to cover 83% of the country—906 million populations in 521 districts. Figure 1 shows the progress in DOTS implementation in the country so far and expansion plans for the future. The RNTCP has expanded more than 50-fold since 1998 and continues to expand at a rapid rate, covering 10–15 million additional population every month. Global progress in DOTS expansion since 1999 has been largely determined by the achievements of the RNTCP. In 1999, the Indian expansion of RNTCP accounted for one-third, and in 2000 and 2001 for over half, of the global increase in DOTS coverage.7–9 The expansion of the RNTCP has been recognized as the fastest expansion of any DOTS programme in the world, even whilst still maintaining the quality of services provided.10 It is planned that by 2005, nation-wide coverage under RNTCP will have been achieved.
1000
316,026 300000
900 Total patients treated Population coverage (in millions)
800 700
200000
600 500
150000 237615
400
Total patients treated
Population covered (millions)
250000
100000
300 200
50000 100 0 I/9 8 III /9 8 I/9 9 III /9 9 I/0 0 III /0 0 I/0 1 III /0 1 I/0 2 III /0 2 I/0 3 III /0 3 I/0 4
7
/9 7 III
I/9
6
/9 6 III
I/9
5
/9 5 III
I/9
/9 4 III
I/9
4
0
Quarter/Year
Figure 2 Population in India covered under DOTS and total tuberculosis patients put on treatment each quarter. January 1994–June 2004.
ARTICLE IN PRESS 274
L.S. Chauhan, J. Tonsing
Performance Figure 2 shows that along with the increase in population coverage, the number of patients put on treatment has increased concomitantly. In the quarter of April–June 2004, more than 100,000 patients were initiated on DOTS treatment each month—more than any other country in the world. By June 2005, the programme had initiated more than 3 million patients on treatment which increased to over 3.5 million patients by September
2005. Considering that 18 lives are saved for every hundred patients treated under the RNTCP, this has resulted in the saving of over 600,000 additional lives.11 The annualized new smear-positive case detection and treatment success rates in the DOTS areas between 1999 and June 2004, is shown in Fig. 3. Treatment success has been consistently high and in recent quarters exceeded the global target of 85%. Case detection in the DOTS areas show a rising trend with a seasonal variation, and has now
100% 90% 80% 70% 60% 50% 40% 30% 20% Annualised New S+ve CDR
Success rate
10%
19 99 Q 19 1 99 Q 19 2 99 Q 19 3 99 Q 20 4 00 Q 20 1 00 Q 20 2 00 Q 20 3 00 Q 20 4 01 Q 20 1 01 Q 20 2 01 Q 20 3 01 Q 20 4 02 Q 20 1 02 Q 20 2 02 Q 20 3 02 Q 20 4 03 Q 20 1 03 Q 20 2 03 Q 20 3 03 Q 20 4 04 Q 20 1 04 Q 2
0%
Figure 3 Annualized new smear-positive case detection rate and treatment success rate in DOTS areas. January 1999–June 2004.
% Cases detected of total estimated for India .
80%
70% Target 70% 60%
50%
40%
30%
20%
10%
0% 1999
2000
2001
2002
2003 Year
2004
2005
2006
Figure 4 Progress towards target of 70% case detection.
2007
9019 10,820 1918 9490 38,814 69,877 11,670 13,311 8714 50,797 24,878 32,269 127,725 5095 1512 24,187 15,624 98,147 1403 89,617 75,860 2068 89,826 906,472
109 117 10 94 149 502 131 63
112 489 324 449 1008 25 19 268 154 594 6 634 864 20 829
7754
Grand total
132
102 117 77 113 130 202 81 140 106 165 245 141 124 105 111
109 92 199 101 261 139 150 212
142 173
Annual total detection rate
358,496
3532 21,625 10,861 12,687 46,257 1451 657 11,703 5831 37,459 443 34,768 31,937 827 38,866
3863 4201 702 3543 11,325 26,471 4330 4902
38,702 779
New S+ve cases initiated on treatment
52
41 49 34 44 47 58 35 69 39 63 77 55 52 42 48
47 36 73 38 76 52 55 78
61 68
69%
55% 66% 45% 55% 59% 77% 47% 91% 41% 79% 82% 73% 55% 44% 64%
62% 48% 77% 47% 80% 66% 57% 82%
81% 91%
Annual new S+ve detection rate per 100,000 (%)
0.8
1.0 0.7 0.6 0.9 0.9 1.3 0.5 0.6 0.7 0.8 0.7 0.9 0.8 0.7 0.7
0.8 1.1 0.6 1.1 0.8 0.6 0.8 0.6
0.9 0.8
Ratio of new S ve to new S+ve patients
90
86
93 84 89 83 85 85 87 85 87 87 86 86 89 95 85
86 89 79 81 81 84 80 88
84 93 89 87 88 91 86 92 96 88 90 87 90 89 84 88 88 91 90 92 87 96 89
85 81
Cure rate of new S+ve patients (%)
89 90
3 months conversion rate of new S+ve patients (%)
87
93 85 89 85 86 88 87 87 87 88 87 87 90 95 86
88 92 80 82 82 84 82 89
87 82
Success rate of new S+ve patients (%)
Notes: (1) Case detection rate (CDR) is calculated using person-year method and to account for districts which started implementation during 2003, data is included only for full quarter implementation. (2) Projected population of 2003, based on Census 2001, is used for CDR calculation. (3) Estimated total new-smear positive cases adjusted for available data on Annual Risk of TB Infection (ARTI) for each zone. Thus, estimated new smear-positive cases for North Zone (Chandigarh, Delhi, Haryana, Himachal Pradesh, Jammu & Kashmir, Punjab, Uttar Pradesh, Uttaranchal) is 95/lakh; East Zone (Andaman & Nicobar, Arunachal Pradesh, Assam, Bihar, Jharkhand, Manipur, Meghalaya, Mizoram, Nagaland, Orissa, Sikkim, Tripura, West Bengal) is 75/lakh; South Zone (Andhra Pradesh, Karnataka, Kerala, Lakshwadeep, Pondicherry, Tamil Nadu) is 75/lakh and West Zone (Chattisgarh, Dadra & Nagar Haveli, Daman & Diu, Goa, Gujarat, Madhya Pradesh, Maharashtra, Rajasthan) is 80/lakh. (4) Values in black are below or above RNTCP targets.
89,511 1978
742 11
Population covered Total cases initiated on in 100,000 by treatment 31.12.03
Andhra Pradesh Arunachal Pradesh Assam Bihar Chandigarh Chhatisgarh Delhi Gujarat Haryana Himachal Pradesh Jharkhand Karnataka Kerala Madhya Pradesh Maharashtra Manipur Nagaland Orissa Punjab Rajasthan Sikkim Tamil Nadu Uttar Pradesh Uttaranchal West Bengal
State
Table 1 RNTCP annual summary—2003. Performance of states case finding (2003), smear conversion (4th quarter 2002 and quarters 1–3, 2003) and treatment outcomes (2002).
ARTICLE IN PRESS
Revised national TB control programme in India 275
ARTICLE IN PRESS 276 crossed the global target of 70%. Figure 4 shows the percentage of cases detected out of the total estimated cases for the country. Had India continued expansion and increase in case detection at the same rate as prior to 2002 then the target of 70% case detection would not have been met until after 2006. With the accelerated increase since 2002, the global target is expected to be achieved by 2005. Table 1 presents the performance of the States of the country in terms of case finding, smear conversion and treatment outcomes during the year 2003. Overall, the new sputum positive case detection rate in 2003 was 69% against the target of at least 70%, with the treatment success rate of 86% surpassing the 85% target. Compared to the previous National TB Programme, treatment success rates under the RNTCP have tripled from 25% to 86%. The proportion of sputum positive cases confirmed in the laboratory are double that of the previous programme and is on par with international standards.10
L.S. Chauhan, J. Tonsing
Challenges Despite these achievements, there are many challenges for the RNTCP at this juncture. The quality of TB services provided by RNTCP needs to be maintained, whilst continuing to rapidly expand RNTCP to cover the entire country. Partnership with the huge network of health care providers outside the health ministry will need to be further strengthened. The programme has to meet the special requirements of urban areas, slums and migratory populations, tribals and other marginalized communities, HIV+ve TB patients and pediatric TB patients. Though the focus now is on rapid expansion of DOTS to prevent multi-drug resistant TB (MDR-TB), in the long run, the programme will require to have a provision for the management of MDR-TB. In addition, the programme will have to continue for many years to come before achieving control of TB in India. Continued decentralization of programme management to the states, ensuring financial support for the RNTCP, and mobilizing community participation in TB control are other challenges that the programme will have to ensure for its sustainability.
Partnerships Alongside maintaining and improving the core services of the programme, RNTCP has implemented many new initiatives and have forged partnerships with many other health providers other than the traditional public health services. Starting with a public–private TB mix (PPM) pilot site in Hyderabad in 1995, the programme has recognized the need to partner with the non-governmental organization (NGO) and private health care providers. The RNTCP is one of the few DOTS programmes in the world to have official published guidelines for the involvement of NGOs (2001) and private practitioners (2002).11 Over 750 NGOs, 3000 private practitioners and 80 corporate health facilities are involved in RNTCP activities. One hundred and sixty-six out of the 213 medical colleges located in DOTS implementing areas have established a DOTS centre.11 These colleges also train the future generations of doctors in their institutes on RNTCP, advocate on behalf of RNTCP and are being involved to undertake relevant operational research for the programme.
References 1. World Health Organization (WHO). Global tuberculosis control. WHO report 2004. Geneva: WHO; 2004. 2. Ramachandran R, Balasubramaniam R, Muniyandia M, et al. Socio-economic impact of TB on patients and family in India. Int J Tuberc Lung Dis 1999;3:869–77. 3. World Health Organisation (WHO). Tuberculosis programme review—India, 1992. Geneva: WHO; 1992. 4. World Health Organisation (WHO). Framework for effective tuberculosis control. WHO/TB/94.179. Geneva: WHO; 1994. 5. Central TB Division (CTD). Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. Revised National Tuberculosis Control Programme. Operational guidelines for tuberculosis control. Delhi: CTD; 1997. 6. Khatri GR. DOTS progress in India: 1995–2002. Tuberculosis 2003;83:30–4. 7. World Health Organization (WHO). Global tuberculosis control. WHO report 2001. Geneva: WHO; 2001. 8. World Health Organization (WHO). Global tuberculosis control. WHO report 2002. Geneva: WHO; 2002. 9. World Health Organization (WHO). Global tuberculosis control. WHO report 2003. Geneva: WHO; 2003. 10. World Health Organization (WHO). Joint tuberculosis programme review. September 2003. New Delhi: WHO; 2004. 11. www.tbcindia.org. Accessed 7/12/04.