Modifications in the Revised National Tuberculosis Control Program


IntroductionTop


In India, the National Tuberculosis Control Program was initially launched in the year 1962 to counter tuberculosis (TB). The program was subsequently modified to the Revised National Tuberculosis Control Program (RNTCP) in 1992, owing to the multiple concerns in the diagnostic/treatment/administrative aspects of the implementation of the program. [1] However, this program has been revised in multiple fronts over the years to reduce the morbidity and mortality associated with the disease. The aim of the study is to explore the recent developments in the RNTCP in order to accomplish universal access to TB care.


India: Distribution of the disease


Considering the global distribution, magnitude of the problem, serious impact on the quality of life, and high mortality rates, TB in today's world is the biggest public health disease of an infectious nature. [1] The Global Tuberculosis Report - 2012, released by the World Health Organization (WHO) has revealed that in the year 2011 alone, 11.7 million new cases of TB have been reported worldwide, of which India contributed to almost one-quarter of the cases. [1] Further, India also contributes to almost 60% of the multidrug resistant (MDR) TB cases reported worldwide, along with Russia and China. [1]


Newer developments in the program


The RNTCP has been geographically scaled-up and revised on multiple fronts based on the epidemiology of disease (viz. distribution/determinants/magnitude), infield practical experience, WHO's and international agency's recommendations, and on the successful implementation of different strategies in the high burden countries. [2],[3] Refinement in the program has been observed in different areas such as.


Strengthening the diagnostic setup


Imposing a ban on serological tests in reaching a diagnosis of TB, [4] progression from solid culture to liquid culture and then to line probe assay and cartridge-based nucleic acid amplification test (CBNAAT) in diagnosing drug resistant TB, [5],[6] proposal to start more National Reference Laboratories (NRLs) to reduce the burden on the existing NRLs, strengthening and capacity building of the existing Designated Microscopy Centers (DMCs)/Intermediate Reference Laboratories (IRLs), [2] launching of project LIGHT (LED Fluorescent Microscopy in Gaining TB Cases in High Workload Teaching Hospitals) in high workload settings (>25 slides per day) in 200 medical colleges, [7] development of standard operating procedures for culture and drug susceptibility testing (DST), [8] framing of guidelines for facilitating accreditation of laboratories for culture and DST, [8] formulating technical specifications for laboratory consumables required for DMCs/IRLs and for culture sensitivity for IRLs. [8]


Treatment options in adult and pediatric TB


Withdrawal of category III treatment regimen on account of poor effectiveness, [2] provision of quality assured and interrupted supply of drugs with the help of strict inventory control and maintenance of buffer stocks at different levels (viz. directly observed treatment, short course (DOTS) center, TB unit, district TB center, and state drug store), [2],[9] alterations in treatment of pediatric TB (viz proposing six weight bands instead of previous four namely - 6-8/9-12/13-16/17-20/21-24/25-30 kg, ensuring availability of pestle and mortars at the DOT center, an increase in the dose of isoniazid chemoprophylaxis from 5 mg/kg body weight to 10 mg/kg body weight), [2] amendments in the weight bands of MDR-TB treatment (viz. proposing five weight bands contrary to the previous three weight bands - <16/16-25/26-45/46-70/>70 kg), [10] and introduction of guidelines for storage of second line anti-TB drugs. [11]


Involving medical colleges


Medical colleges have a critical role to play in the diagnostic/therapeutic aspect of the program. [10] In order to streamline the contribution of different medical colleges/clinicians/faculties, all the medical colleges (government or private) have been directed to form a medical college core committee to overview the functioning of RNTCP and to conduct regular meetings. [10] In addition to facilitate operational research and thesis, RNTCP has revised financial norms such as an increase in the thesis grant from Rs. 20,000 to Rs. 30,000. [11]Other initiatives, such as organization of continuous medical education/quiz competitions/training sessions for faculties and students about TB, encouraging teachers to plan visits to the district TB center/DMCs/DOTS center for undergraduate students. [10] RNTCP has also increased the number of conferences that a state can organize with the aid of medical college to four per year, with a financial assistance of Rs. 4 lakh each. [11] The vision is that each of the medical college should adopt one district and plan for conducting sensitization sessions for the community/private medical practitioners (PMPs), facilitate TB notification, and encourage PMPs to become a DOT provider. [10],[12]


Fostering the private sector


RNTCP has proposed nine different schemes to encourage the involvement of private sector namely-Treatment adherence scheme, Sputum collection centre scheme, Sputum transport scheme, DMC scheme - A and B, Laboratory technician scheme, Culture and DST scheme, Advocacy, communication and social mobilization (ACSM) scheme, TB-human immunodeficiency virus (HIV) scheme, and slum scheme. [10] Involvement of private sector in the RNTCP has been looked upon as the most crucial component in reducing the burden of the disease, as almost 70% of the patients avail the services of private health sector for their complaints. [13] In addition, RNTCP program managers have tried to develop strong bonds with Indian Medical Associations/Indian Pharmacist Association, etc., for extending the gamut of services to the different stakeholders. The program is committed to organize training and retraining sessions for the PMPs and other healthcare providers. [2],[9],[10]


Innovations/developments in the RNTCP


Since 2012, TB has been made a notifiable disease, which simply means that any case of TB diagnosed by any means has to be reported to the public health authorities. [14] Other initiatives such as formulation of standards for TB care in India; [15] launch of NIKSHAY software-a case-based web-based monitoring; [12] extension of TB-diabetes mellitus collaborative activities in 100 districts of country, every year under the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases, and Stroke; developing linkages with the Medical Council of India; [16] revision in the financial norms-for ACSM activities/honorarium to DOT providers; [10]involvement of school teachers and students in the ACSM activities; [10] conduction of regular state/zonal/national task force committee meetings; [10] strict implementation of the airborne infection control guidelines in health care institutions; [17] strengthening of the existing TB-HIV collaborative activities; [1],[2] conduction of regular training/sensitization sessions for program managers/PMPs/healthcare providers (viz. TB-health visitors/treatment organizers/paramedical staff of the primary health care centers) based on the community need assessment approach; [10] capacity building of the existing infrastructure and appointing different cadres of health workers for the sanctioned posts; [10] introduction of strategic document for supervision and monitoring for the assistance of the program managers; [11] and exploring the legal provisions to restrict over-the-counter sale of anti-TB drugs.


  ConclusionTop

To conclude, strengthening of the RNTCP program has been planned in a comprehensive manner and due attention has been given to encourage and actively involve all the stakeholders so that global vision to achieve universal access to TB care can be accomplished.


ReferencesTop

1.World Health Organization. Global Tuberculosis Control Report 2012. Geneva: WHO press; 2012.  Back to cited text no. 1
    
2.TBC India. Managing the RNTCP in your area-A training course (Modules 1-4). Available from: http://tbcindia.nic.in/documents.html[Last accessed on 2013 Sep 22].  Back to cited text no. 2
    
3.Verma R, Khanna P, Mehta B. Revised national tuberculosis control program in India: The need to strengthen. Int J Prev Med 2013;4:1-5.  Back to cited text no. 3
  Medknow Journal  
4.World Health Organization. Commercial serodiagnostic tests for diagnosis of tuberculosis, 2011. Geneva: WHO press; 2011.  Back to cited text no. 4
    
5.Albert H, Bwanga F, Mukkada S, Nyesiga B, Ademun JP, Lukyamuzi G, et al. Rapid screening of MDR-TB using molecular Line Probe Assay is feasible in Uganda. BMC Infect Dis 2010;10:41.  Back to cited text no. 5
    
6.RNTCP-FIND-WHO CBNAAT Project. Available from:http://www.finddiagnostics.org/export/sites/default/media/events/2012/pdf/Flyer_CBNAAT_India.pdf. [Last accessed on 2013 Sep 16].  Back to cited text no. 6
    
7.International Union against Tuberculosis and Lung Disease. Project LIGHT increases the number of TB cases diagnosed at test sites. Available from: http://www.theunion.org/index.php/en/newsroom/news/item/2350-project-light-increases-the-number-of-tb-cases-diagn osed-at-test-sites. [Last accessed on 2013 Sep 25].  Back to cited text no. 7
    
8.TBC India. Guidelines - Technical Specifications. Available from: http://www.tbc india.nic.in/documents.html [Last accessed on 2013 Sep 16].  Back to cited text no. 8
    
9.TBC India. Guidelines for PMDT in India, 2012. Available from: http://tbcindia.nic.in/documents.html [Last accessed on 2013 Sep 16].  Back to cited text no. 9
    
10.TBC India. Managing the RNTCP in your area-A training course (Modules 5-9). Available from: http://tbcindia.nic.in/documents.html[Last accessed on 2013 Sep 22].  Back to cited text no. 10
    
11.TBC India - Directorate of Health and Family Welfare. Guidelines: Programme Management; 2012. Available from: http://www.tbcin dia.nic.in/documents.html. [Last accessed on 2013 Sep 16].  Back to cited text no. 11
    
12.NIKSHAY. Available from: http://www.tbcindia.nic.in/ [Last accessed on 2013 Oct 08].  Back to cited text no. 12
    
13.Ministry of Health and Family Welfare. National family health survey (NFHS-3); 2005-06. Available from:http://www.measuredhs.com/pubs/pdf/SR128/SR128.pdf [Last accessed on 2013 Sep 16].  Back to cited text no. 13
    
14.Ministry of Health and Family Welfare. Guidance for TB notification in India; 2012. Available from:http://tbcindia.nic.in/pdfs/Guidance% 20tool%20 for%20TB%20notification%20in%20India%20-%20FINAL.pdf. [Last accessed on 2013 Sep 25].  Back to cited text no. 14
    
15.Express Healthcare Bureau. First national standards of TB care (STCI) released. Available from: http://health care.financial express.com/latest-updates/1925-first-national-standards-of-tb-care-stci-relea sed. [Last accessed on 2013 Sep 25].  Back to cited text no. 15
    
16.Operational guidelines-National programme for prevention and control of cancer, diabetes, cardiovascular diseases and stroke (NPCDCS), 2012. Available from: http://health.bih.nic.in/Docs/Guidelines/Guide lines-NPCDCS.pdf. [Last accessed on 2013 Sep 25].  Back to cited text no. 16
    
17.Ministry of health and family welfare. Guidelines on airborne infection control in healthcare and other settings. New Delhi, 2010. Available from: http://www.tbcindia.nic.in/pdfs/Guidelines_on_Air borne_Infection_Control_ April 2010 Provisional.pdf. [Last accessed on 2013 Sep 22].  Back to cited text no. 17



Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, Chennai, India
    

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