NATIONAL TUBERCULOSIS ELIMINATION PROGRAMME (NTEP) - Park's Textbook of Preventive and Social Medicine

HISTORICAL BACKGROUND

• Park's Textbook of Preventive and Social Medicine, p. 482

OBJECTIVES OF RNTCP (basis for NTEP)

1. Achievement of at least 85% cure rate of infectious cases of tuberculosis through DOTS involving peripheral health functionaries.
2. Augmentation of case finding through quality sputum microscopy to detect at least 70% of estimated cases.

DOTS STRATEGY - FIVE MAIN COMPONENTS (Initial)

1. Political will and administrative commitment
2. Diagnosis by quality assured sputum smear microscopy
3. Adequate supply of quality assured short course chemotherapy drugs
4. Directly observed treatment
5. Systematic monitoring and accountability

STOP TB STRATEGY (WHO, 2006 - adopted by RNTCP)

• Pursuing quality DOTS - expansion and enhancement
• Addressing TB/HIV and MDR-TB
• Contributing to health system strengthening
• Engaging all care providers
• Empowering patients and communities
• Enabling and promoting research (diagnosis, treatment, vaccine)

NTEP ORGANOGRAM - FIVE LEVELS

1. National Level

• Central TB Division (CTD) manages the National TB Control Programme under AS&DG (RNTCP & NACO) through Deputy Director General TB (DDG TB).
• CTD is supported by National TB Institute (NTI), Bengaluru, and six National Reference Laboratories (NRLs):
  • NTI, Bengaluru
  • NIRT (National Institute for Research in Tuberculosis), Chennai
  • NITRD (National Institute of Tuberculosis and Respiratory Diseases), Delhi
  • JALMA Institute for Leprosy, Agra
  • Regional Medical Research Centre, Bhubaneshwar
  • BMHRC, Bhopal
• NIRT Chennai is a Supra National Reference Lab (SNRL) for WHO for the South East Asia Region.

2. State Level

• State Tuberculosis Officer (STO) - full-time, trained at national level, based at State TB Cell (STC).
• Responsible for planning, training, supervising and monitoring in all districts.
• Supported by State TB Training and Demonstration Centre (STDC) - with three units: training unit, supervision and monitoring unit, and an Intermediate Reference Laboratory (IRL).
• Each state has one State Drug Store (SDS) for each 5 crore of population.

3. District Level

• District Tuberculosis Centre (DTC) is the nodal point for TB control activities.
• District Tuberculosis Officer (DTO) - full-time, trained at national level.
• The Chief District Health Officer (CDHO)/Civil Surgeon is responsible for all medical and public health activities including TB control.

4. Sub-District Level (Tuberculosis Unit Level)

• Tuberculosis Unit (TU) - the major organizational change in NTEP.
• Population norms:
  • 1 TU per 2,00,000 (range 1.5-2.5 lakh) for rural/urban areas
  • 1 TU per 1,00,000 (0.75-1.25 lakh) for hilly/tribal/difficult areas
• TU comprises:
  • Medical Officer - TB Control (MO-TC) - designated Medical Officer
  • Senior Treatment Supervisor (STS) - full-time supervisory staff
  • Senior TB Laboratory Supervisor (STLS) - 1 per 5 lakh population (1 per 2.5 lakh for tribal/hilly areas)
• Provision for additional STS if >300 TB cases registered in public sector annually OR >50 private health establishments registered in NIKSHAY.

5. Peripheral Health Institutions (PHIs)

• For the purpose of NTEP, a PHI is a health facility manned by at least a medical officer.
• Includes dispensaries, PHCs, CHCs, referral hospitals.

NTEP ENDORSED TB DIAGNOSTICS

1. Smear microscopy for acid fast bacilli
   • Ziehl-Neelsen staining; or
   • Fluorescence stains with direct/indirect microscopy with or without LED
2. Culture
   • Solid (Lowenstein Jensen) media; or
   • Liquid media (Middle Brook) using Bactec, MGIT, etc.
3. Rapid diagnostic molecular test
   • Conventional PCR based Line Probe Assay (LPA) for MTB complex; or
   • Real-time PCR based Nucleic Acid Amplification Test (NAAT), e.g., GeneXpert (CBNAAT/Xpert MTB/RIF)
4. Radiography where available
5. Tuberculin skin test

• Park's Textbook of Preventive and Social Medicine, p. 484

NEW INITIATIVES UNDER NTEP

1. NIKSHAY - TB Surveillance System

• Developed by Central TB Division in collaboration with National Informatics Centre.
• The word NIKSHAY is a combination of two Hindi words NI + KSHAY, meaning eradication of TB.
• Launched in May 2012; it is a case-based, web-based IT system.

• Master management
• User details
• TB patient registration with details of diagnosis, DOT provider, HIV status, follow-up, contact tracing, outcomes
• Details of solid/liquid culture, DST, LPA, CBNAAT
• DR-TB patient registration with details
• Referral and transfer of patients
• Private health facility registration and TB notification
• Mobile application for TB notification
• SMS alerts to patients on registration
• SMS alerts to programme officers
• Automated periodic reports: (a) Case finding, (b) Sputum conversion, (c) Treatment outcome
• IT enabled adherence tools like 99 DOTS for HIV-TB patients
• Park's Textbook of Preventive and Social Medicine, p. 484

2. TB Notification (Mandatory)

• Government of India notification dated 7th May 2012 - it is now mandatory for all healthcare providers to notify every TB case to:
  • District Health Officer / Chief Medical Officer
  • Municipal Health Officer
• Format: every month in a given format
• Applicable to all care providers (public and private)

3. Ban on TB Serology

• Serological tests have poor specificity and may reflect remote infection rather than active disease.
• Their import, manufacturing, sale, distribution, and use is banned by the Government of India.

4. Direct Benefit Transfer (DBT) Schemes

• Direct beneficiary transfer systems established by linking TB patients reported in NIKSHAY with AADHAAR and PEMS to effectively deliver benefits to TB patients and their providers.

NIKSHAY POSHAN YOJANA

• Under the NSP 2017-2025, one of the key strategies is "Addressing social determinants including nutrition".
• The NSP target explicitly states: "Proportion of notified TB patients receiving financial support through Direct Benefit Transfers (DBT)" - Target: 80-90%.
• The goal is that 0% patients should have catastrophic expenditure due to TB (NSP target).
• The programme links TB patients in NIKSHAY with AADHAAR to deliver financial benefits directly to TB patients.

• Rs. 500 per month is provided to every notified TB patient as nutritional support through Direct Benefit Transfer (DBT) into their bank account.
• This is for the entire duration of treatment (both DS-TB and DR-TB patients).
• The patient must be registered on the NIKSHAY portal to receive the benefit.
• Aims to address nutritional deficiency and reduce catastrophic costs to TB patients and families.
• Part of the NSP 2017-2025 goal of ending TB by 2025 (5 years ahead of SDG target).
• Park's Textbook of Preventive and Social Medicine, p. 484-488

NATIONAL STRATEGIC PLAN (NSP) 2017-2025 FOR TB ELIMINATION

Main Objectives:

1. Find all DS-TB and DR-TB cases - especially from private providers and high-risk populations.
2. Initiate and sustain all patients on appropriate anti-TB treatment with patient-friendly systems and social support.
3. Prevent emergence of TB in susceptible populations.
4. Build and strengthen enabling policies, empowered institutions, human resources, and financial resources.

Key Strategies:

• Private sector engagement
• Active case finding
• Drug resistant TB case management
• Addressing social determinants including nutrition (where Nikshay Poshan Yojana fits)
• Robust surveillance system
• Community engagement and multi-sectoral approach

Four Strategic Pillars - DTPB:

Expected Targets (NSP 2017-2025):

FINANCIAL RESOURCES FOR NTEP

• World Bank and DFID via WHO
• Global TB Drug Facility (GDF)
• Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM)
• USAID and DANIDA
• Government of India provides 100% grant-in-aid to states/UTs, besides free drugs.

TB-HIV COORDINATION

• Collaborative efforts began in 2001.
• RNTCP has prioritized presumptive TB cases among People Living with HIV (PLHIV) for diagnosis using rapid diagnostic tools with high sensitivity (e.g., Xpert MTB/RIF).

SUMMARY TABLE: KEY NTEP FACTS FOR EXAM