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NTEP National Tuberculosis Elimination Programme India guidelines 2025
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NTEP - National Tuberculosis Elimination Programme
Background and Evolution
India's national TB control effort has evolved through three major phases:
| Year | Programme |
|---|---|
| 1962 | National Tuberculosis Programme (NTP) launched |
| 1993 | Revised National TB Control Programme (RNTCP) - adopted DOTS strategy |
| 2020 | RNTCP renamed to NTEP - reflecting elimination goal |
The NTP (1962) had unacceptably low treatment success rates with high death and default rates, and the spread of MDR-TB worsened the situation. In 1993, the Government of India revitalized TB control with international assistance and introduced RNTCP based on the DOTS (Directly Observed Treatment Short-course) strategy - the most cost-effective approach at the time.
In 2020, in alignment with the global END TB Strategy, RNTCP was renamed NTEP to reflect India's ambition to eliminate TB by 2025 - five years ahead of the global target of 2030. - Park's Textbook of Preventive and Social Medicine
Vision and Targets
- Goal: Eliminate TB in India by 2025 (SDG 3)
- Compared to 2015 baseline, by 2025:
- 80% reduction in TB incidence
- 90% reduction in TB mortality
- 0% patients facing catastrophic expenditure due to TB
These align with the WHO END TB Strategy and SDG targets.
National Strategic Plan (NSP) 2017-2025 / 2020-2025
Driven by the DTPB framework (also written as Detect-Treat-Prevent-Build):
1. DETECT
- Active Case Finding (ACF): TB Mukt Bharat campaign for awareness and early case finding
- Community screening
- Institutional screening
- Engagement of private sector providers
- Upfront NAAT (Nucleic Acid Amplification Testing) for diagnosis
- X-ray-based mass screening in high-burden districts
2. TREAT
- Daily fixed-dose combination (FDC) regimens replacing thrice-weekly regimens
- Nikshay Poshan Yojana (NPY): Direct benefit transfer of Rs. 500/month for nutritional support
- Private sector engagement under PMTBMBA (Pradhan Mantri TB Mukt Bharat Abhiyan)
- Drug-resistant TB management (MDR-TB, XDR-TB)
- DR-TB Centres: 20-30 bedded tertiary care facilities (147 established by 2017), one per ~10 million population
3. PREVENT
- TB Preventive Therapy (TPT): For household contacts and vulnerable groups (HIV patients, malnourished individuals, etc.)
- Contact tracing in high-risk areas
- Addressing social determinants through multi-sectoral approach
- Airborne infection control measures
4. BUILD
- Strengthening health systems
- Engaging private providers
- Community involvement
- Data systems (Nikshay - national TB notification system)
- Financial support via World Bank, GFATM, DFID
Diagnostic Framework under NTEP
- Sputum smear microscopy (still backbone in peripheral centres)
- CBNAAT/Xpert MTB-RIF: Upfront molecular testing for rapid diagnosis and rifampicin resistance detection
- Culture and Drug Sensitivity Testing (DST)
- TrueNat machines at district level
- TRUNAT / LPA (Line Probe Assay): For detecting MDR-TB
Treatment Regimens
Drug-Sensitive TB (DS-TB):
- New cases (Cat I): 2HRZE / 4HRE (Intensive phase 2 months + Continuation phase 4 months)
- Previously treated (Cat II): 2HRZES / 1HRZE / 5HRE (now being phased out in favor of individualized regimens)
- FDC tablets color-coded: Red for Category I, Blue for Category II
Drug-Resistant TB (DR-TB):
- Services initiated in 2007 (Gujarat & Maharashtra), scaled nationally by March 2013
- MDR-TB prevalence (DRS 2014-2016): 2.84% in new cases, 11.60% in retreatment cases
- Managed by state PMDT (Programmatic Management of Drug-resistant TB) Committees
Programme Structure
National level: Central TB Division (CTD), DGHS, Ministry of Health and Family Welfare sets policy and technical guidelines
State level: State TB Officer (STO) - planning, implementation, monitoring
District level: District TB Centre (DTC) headed by District TB Officer (DTO)
Peripheral level: TB Units (TU) covering ~500,000 population; Designated Microscopy Centres (DMC) covering ~100,000 population
Key Initiatives Under NTEP
| Initiative | Details |
|---|---|
| Nikshay | National web-based notification and patient management system |
| Nikshay Poshan Yojana | Rs. 500/month nutritional support via DBT |
| PMTBMBA | Pradhan Mantri TB Mukt Bharat Abhiyan - private sector involvement |
| 100 Days Campaign (Dec 2024 - Mar 2025) | Targeted campaign in high-burden districts: X-ray + NAAT screening, TPT, death audits |
| TB Mukt Bharat | Awareness campaign for early case detection |
| Ni-kshay Mitra | Community/corporate adoption of TB patients for support |
India's TB Burden
- India accounts for approximately 26% of global TB cases (highest burden country)
- TB is predominantly a disease of the poor - affecting migrant labourers, slum dwellers, marginalized populations
- A significant proportion of the economic burden is due to loss of life rather than morbidity
- 32% increase in drug-resistant TB cases has been a major challenge
Financial Support
NTEP is supported by:
- World Bank
- DFID (Department for International Development)
- WHO
- Global TB Drug Facility (GDF)
- Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
Source: Park's Textbook of Preventive and Social Medicine; NTEP - PIB India; Maharashtra PHD - NTEP
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NTEP India latest clinical guidelines protocols 2024 2025 tuberculosis treatment
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NTEP India tuberculosis treatment guidelines
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NTEP 2024 BPaLM regimen drug resistant TB India Central TB Division guidelines
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tuberculosis India treatment guidelines drug resistant 2024 2025
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https://www.pib.gov.in/PressReleasePage.aspx?PRID=2244661&re…
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India TB report 2025 Central TB Division NTEP new treatment protocols extrapulmonary TPT
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PMID: 39718911
Here is a comprehensive synthesis of the latest NTEP clinical guidelines and protocols as of 2025-2026:
NTEP - Latest Clinical Guidelines & Protocols (2024-2026)
Key Source Documents
- India TB Report 2024/2025 - Central TB Division, MoHFW, GoI
- Technical & Operational Guidelines for Management of Drug-Resistant TB in India (CTD, 2024)
- National Guidelines for Management of Drug Resistant TB (2024)
- NTI Annual Report 2024-25 - National Tuberculosis Institute, Bengaluru
- WHO Global TB Report 2025 (referenced for India data)
1. Drug-Sensitive TB (DS-TB) Treatment
Current NTEP Standard Regimen (Official National Guideline)
6-month regimen: 2HRZE / 4HR(E)
- Intensive phase (2 months): Isoniazid (H) + Rifampicin (R) + Pyrazinamide (Z) + Ethambutol (E)
- Continuation phase (4 months): Isoniazid (H) + Rifampicin (R) [+/- Ethambutol]
- Administered as daily fixed-dose combinations (FDC) - color coded (red for new, blue for retreatment)
Important note: The WHO-recommended 4-month regimen (2HPMZ / 2HPM - incorporating Moxifloxacin + Rifapentine) has been evaluated through the SHINE and TB-PRACTECAL trials and shown non-inferiority. However, as of 2026, NTEP has NOT yet formally adopted the 4-month regimen - it remains under evaluation in India. The 6-month 2HRZE/4HRE remains the official NTEP guideline. (source)
2. Drug-Resistant TB (DR-TB) - Major 2024 Protocol Update
NEW: BPaLM Regimen (Bedaquiline + Pretomanid + Linezolid + Moxifloxacin)
This is the biggest recent NTEP update, formalized in the Technical & Operational Guidelines for DR-TB Management 2024:
| Feature | BPaLM |
|---|---|
| Drugs | Bedaquiline (B) + Pretomanid (Pa) + Linezolid (Lzd) + Moxifloxacin (M) |
| Duration | 6 months (down from 18-24 months) |
| Indication | MDR-TB / RR-TB (Rifampicin-resistant) |
| Patients started | >15,000 MDR/RR-TB patients enrolled under NTEP |
| Treatment success | ~88% in studies; 76% in TB-PRACTECAL vs 51% with older injectable regimens |
| Key advantage | Injectable-free, shorter duration, safer adverse effect profile |
BPaL (without Moxifloxacin) is used for pre-XDR-TB and XDR-TB.
A 2025 study from a tertiary care center confirmed 88% treatment success and 82% sputum conversion in NTEP-enrolled BPaLM patients, with peripheral neuropathy (22%) and anemia (18%) as the most common adverse effects. (IJMEDPH 2025)
3. TB Preventive Therapy (TPT) - Expanded Protocol
NTEP has significantly expanded TPT scope beyond the earlier narrow indications:
Old policy: TPT for household contacts <5 years old and PLHIV only
New expanded TPT under NTEP 2024-25:
- All household contacts (any age) of pulmonary TB patients - eligible for screening and TPT
- Vulnerable groups: malnourished, diabetics, immunocompromised
- Regimens used:
- 6H (6 months of daily Isoniazid) - standard
- 3HP (3 months of weekly Isoniazid + Rifapentine) - shorter alternative
NTI conducted a national-level training on Guidelines for PMTPT (Programmatic Management of TB Preventive Therapy) in 2024-25 for rollout across states. (NTI Annual Report 2024-25)
4. Diagnostic Protocols - Current Standards
| Level | Diagnostic Tool | Notes |
|---|---|---|
| Peripheral | Sputum smear microscopy (ZN stain) | Basic screening |
| District | TrueNat / CBNAAT (Xpert MTB/RIF) | Upfront NAAT - mandatory for high-risk groups |
| Intermediate | LPA (Line Probe Assay) | For detecting H/R resistance |
| Reference | WGS (Whole Genome Sequencing) | Being rolled out at reference labs |
| Field campaigns | Portable X-ray + NAAT | Used in 100 Days Campaign, mobile vans |
Key policy: Upfront molecular testing (NAAT) is now mandated for all presumptive TB cases in the public sector - not just smear-positive patients.
Extrapulmonary TB (EPTB): A dedicated expert workshop was held at NTI in 2024-25 under CTD to frame new guidelines for management of EPTB under NTEP - these are expected to be released soon.
5. Special Populations Protocols
HIV-TB Co-infection
- Early ART initiation (within 2 weeks of TB treatment start in most cases)
- TPT with 6H for PLHIV who are TB-negative
- Cotrimoxazole preventive therapy continued
Pediatric TB
- Dedicated pediatric FDC formulations (weight-based dosing)
- SHINE trial data (shorter regimens for non-severe TB in children being evaluated)
- Contact tracing and TPT for child contacts <5 years - gaps identified in a 2026 study showing 65.5% of eligible pediatric contacts received no contact tracing (Cureus 2026, PMID study)
Diabetes + TB
- All TB patients screened for diabetes (bidirectional screening)
- Separate monitoring for blood glucose during anti-TB treatment
- Nutritional support under Nikshay Poshan Yojana
6. BCG Vaccination - New 2024 Initiative
From September 3, 2024: NTEP piloted an additional adult BCG dose (booster) for persons >18 years in 40 selected high-burden districts. By January 2025, over 15.58 lakh (1.558 million) adults vaccinated. This is a major programmatic innovation - adult BCG re-vaccination has not been standard globally. (Maharashtra PHD)
7. 100 Days Campaign (Dec 7, 2024 - Mar 24, 2025)
A high-intensity national campaign targeting highest-burden districts with:
- Upfront X-ray + NAAT for all screened individuals
-
20 crore (200 million) vulnerable persons screened
-
28 lakh (2.8 million) TB patients diagnosed (including 9 lakh asymptomatic)
- TB death audits conducted
- TPT for household contacts and vulnerable groups
- Bank seeding + NPY payment saturation
Treatment success rate rose to 90% under TB Mukt Bharat Abhiyan, surpassing the global average of 88%. (PIB India)
8. Programme Performance - WHO Global TB Report 2025
- New TB cases in India reduced by 21% from 2015-2024 - one of the fastest declines globally
- TB deaths reduced by 28% over the same period
- 46,118 Gram Panchayats certified TB-free for 2024
- India remains the highest-burden country but is on track toward targets
9. Identified Programmatic Gaps (2025 Evidence)
A 2025 Kerala evaluation (PMID: 39718911) of NTEP DR-TB management found:
- Only 69% of confirmed TB patients were tested for drug sensitivity
- Only 16% of staff were trained in recent DR-TB guidelines
- Only 30% of DR-TB patients received psychological assessment
- Contextual barriers: human resources, transport, financial gaps despite NPY support
- Recommendation: Establish dedicated district DR-TB treatment centres, dedicated clinical psychologists, and train all staff categories on 2024 guidelines
Official Reference Documents
| Document | Source |
|---|---|
| India TB Report 2024 | Central TB Division, MoHFW |
| Technical & Operational Guidelines for DR-TB (2024) | Central TB Division |
| NTI Annual Report 2024-25 | nti.gov.in |
| WHO Global TB Report 2025 | who.int |
| WHO Guidelines: TB & Undernutrition (Oct 2025) | who.int |
Summary of the biggest recent changes:
- BPaLM is now the standard regimen for MDR/RR-TB under NTEP (6 months, injectable-free)
- TPT expanded to all household contacts using 6H or 3HP
- Adult BCG booster piloted in 40 high-burden districts (2024)
- Upfront NAAT (TrueNat/CBNAAT) mandated across public sector
- EPTB guidelines being newly developed (workshop completed 2024-25)
- WHO 4-month DS-TB regimen not yet adopted by NTEP - 2HRZE/4HRE remains official
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