NEW VISION FOR TB CONTROL
- DR. PRAPULLA CHANDRA
India has highest TB burden
6%
5%
5%
4%
3%
3%2%
2%
2%
1%1%
IndiaOtherSouth Africa IndonesiaPakistanBangladeshdPhilippinesEthiopiaDR CongoMyanmarNigeriaMozambiqueRussian FederationVietnamKenyaBrazil
23%
10%
10%
Data source: Global TB Report 2016, WHO
Global annual incidence = 10.4 millionIndia annual incidence = 2.84 million
TB Burden Global India
Incidence TB
104 lakh 28.4 lakh
Mortality of TB *
14 lakh 4.8 lakh
Incidence HIV TB
12 lakh 1.13lakh
Mortality of HIV-TB *
4.0 lakh 37,000
MDR-TB 5. 8 lakh 1.3 lakh
National Strategic Plan for TB Control2012-2017
Universal Access to quality TB diagnosis and treatment for all TB patients in the community
Vision
Goal
A TB FREE INDIA
Objectives
Early and improved diagnosis(90%)Access to high-quality treatment(90%)
Scale-up access to effective DR TB treatment
Decrease the morbidity andMortality in HIV TB
Extend RNTCP services to patients in Private Sector
Evolving Strategies – Case Finding
Passive
Intensified
Active
ZN & LED
Microscopy
Radiology
Molecular
diagnostics
Culture & DST
Linkages
Co morbiditi
es
Key Populati
ons
Slums
Migrants
Communities
Evolution in TB Diagnosis• LED microscopy.• MODS-Microscopic Observation Drug Susceptibility • LPA refinement for smear negative MDR TB suspects• Rapid Identification of species by strip speciation test• Breathalyzer screening test• First generation loop mediated isothermal
amplification technology platform (LAMP)• Urinary Lipo-arabinomannan (LAM) or any other
antigen detection tests• Rapid automated 2nd and 3rd generation NAATs for first
and second line DST
PREVIOUS RECOMMENDATIONS :• Commercial molecular line probe assays for 1st-line anti-TB drugs:
For use at central/regional reference laboratory level for rapid detection of rifampicin (alone or with isoniazid) resistance. Suitable for use on smearpositive specimens or culture isolates.
• NOT recommended for 2nd line drugs.
Automated NAAT(GeneXpert / Xpert MTB/RIF)
• Result in 90m• M TB – Y / N• Rif res – Y / N• 70% additional
yield in smear negative TB
15Gokulam 21-03-2014
PREVIOUS RECOMMENDATIONS• LAMP NOT recommended for use due to insufficient data.
URINARY LAM TEST• Detection of lipoarabinomannan (a lipopolysaccharide
component of MTB cellwall) antigen in urine.• Single clinical visit, results in ½ hr.• sensitivity is 28.2 %• But sensitivity increases to 66.7% when CD4 cell count <50• In HIV pts, LAM + Smear microscopy increases sensitivity
comparable to GeneXpert MTB/RIF .
BREATHALYZER TEST• Uses optical detection technology with fluorometry.• The collection tube was designed to collect aerosols and
particles coughed out by the patient.• Result can be obtained in 10min.• Sensitivity is 74% and specificity is 79%
- TECHNICAL OPERATIONAL GUIDELINES FOR TB CONTROL IN INDIA 2016
25
Current views leading to change in regime to daily regime• High rates of “relapse” in RNTCP ~ 12 - 15%• Incidence rates remain high
26
Himachal PradeshSikkimBihar MaharashtraKerala
Daily Regimen implementation in 104 districts
Total population -2690 Lakh
28
MAIN CHANGES IN 2016 UPDATE• A shorter MDR-tb treatment regimen under specific
conditions.• Medicines used in the MDR tb treatment regimens are now
regrouped differently.• MDR-tb treatment is recommended for all pts of RR-TB
regardless of confirmation of isoniazid resistance.• Clarithromycin and other macrolides are no longer included
in the treatment of MDR-tb.
Earlier WHO classification of anti TB drugs Group Drugs
Group 1. First line oral drugs Isoniazid, RifampicinEthambutol, PyrazinamideRifabutin, Rifapentine
Group 2. Injectable anti-TB drugs Streptomycin (First line)Kanamycin, Amikacin, Capreomycin
Group 3. Fluoroquinolones Ofloxacin, LevofloxacinMoxifloxacin
Group 4. Oral bacteriostatic second-line anti-TB drugs
Ethionamide, ProthionamideCycloserine, TerizidonePara-aminosalicylic acid
Group 5. Anti-TB drugs with limiteddata on efficacy and/or long termsafety in the treatment of drug-resistantTB
BedaquilineDelamanidLinezolidClofazimineAmoxicillin/ clavulanateImipenem/cilastatin; MeropenemHigh-dose isoniazidThioacetazoneClarithromycin
• The shorter MDR-TB treatment regimens were standardized in content and duration and split into two distinct parts.
• The first was an intensive phase of four months (extended up to a maximum of six months in case of lack of sputum smear conversion) and included the following drugs: gatifloxacin (or moxifloxacin), kanamycin, prothionamide, clofazimine, high-dose isoniazid, pyrazinamide and ethambutol.
• This was followed by a continuation phase of five months with the following medicines:
• gatifloxacin (or moxifloxacin), clofazimine, pyrazinamide and ethambutol.
Introduction of Bedaquiline BDQ-CAP (Conditional access programme)
• Six sites identified to roll out BDQ CAP
• Guidelines have been prepared
• National Training of trainers(TOT) done at NTI Bangalore in Jan 2016
• BDQ CAP rolled out in six pilot sites in 2016.
Rajasthan
Gujarat
MaharashtraOrissa
Karnataka
Madhya Pradesh
Bihar
Uttar Pradesh
Jammu & Kashmir
Tamil Nadu
Assam
Telangana
Chhattisgarh
Andhra Pradesh
Jharkhand
Punjab
West B engal
Kerala
Haryana
Himachal Pradesh
Manipur
Mizoram
Andaman & Nicobar
Daman & Diu
UttarakhandSikkim
Arunachal Pradesh
Nagaland
Tripura
TB-HIV Collaborative Activities
TB – HIV co-morbidity
Status 2015• 79% TB patients know their HIV status• 92% TB HIV patients are receiving ART• 93% TBHIV patients receiving CPT
3 I’s• Intensified case finding (ICF)• Isoniazid preventive therapy (IPT)• Infection control for Tuberculosis (IC)
Intensified TB case finding and treatment at high burden Anti-Retroviral Therapy (ART) centres
Single window service delivery for TB & HIV
Intensified case finding TB diagnosis through CBNAAT Daily Regimen Better management of side
effects- Pharmacovigilance Use of newer technology for
treatment monitoring Isoniazid Preventive Therapy Air Borne Infection control
Progress so far 45419 PLHIV tested for TB 6389 diagnosed as TB 185 diagnosed as Rif
Resistance 6073 put on Daily Anti TB
treatment 149 Rif /R put on CAT IV
Country-wide expansion by 2nd October 2016
ISONIAZID PREVENTIVT THERAPY
Reaching the unreached
Groups• Socially vulnerable• Clinically high risk
Screening TB patients for DMTertiary Care Centers
Screening DM patients for TB Tertiary Care Centers
DM Patients screened for TB DM Patients diagnosed as TB
(68%)
(13%)
TB –Diabetes and Tobacco Collaborative Activities
TB-DM• A national collaborative workshop was
held between RNTCP and NPCDCS• The joint framework aims at reduction in
morbidity and mortality by doing bi-directional screening, early detection and prompt management of DM and TB.
• Activities to improve diagnosis and management of DM among TB pts :
-Screening of all registered TB pts for DM -DM management among TB ptsTB among DM patients : - intensified detection of active TB among DM pts -TB infection control measures -TB treatment and management in comorbid pts
TB AND TOBACCO
TB AND TOBACCO• Main intervention will be counselling of tobacco users at TB
facilities and referral of tobacco users coming at Tobacco Cessation Centre to DMC for TB screening.
VACCINES
INDEX TB Guidelines 2016• New guidelines
developed for management of Extra pulmonary TB by Central TB Division , AIIMS, New Delhi , WHO and GHA
• Dissemination Workshop held on 09th July 2016 at AIIMS New Delhi
• Dissemination and further develop a training module
SKELETAL TB
NOTIFICATION OF TB CASES
NIKSHAYCase Based Web Based TB Notification System
Developed & powered by CTD & NIC
TB Notification (private)
Laboratory Single-PP clinic Multi-Hospital0
10000
20000
30000
40000
50000
60000
70000
3 420 10273563 4732
1803
24226
29395
12620
56101
64908
24875
38571
51879
Before 2012 2012 20132014 2015
Total 3.2 lakh till date
Source: Global TB Report 2015, WHO, Geneva
Missed Call Server
Missed Call
Missed call List
Call Center Agent
Agent call to Patient
Server
Patie
nt
Feed
back
Patie
nt Fe
edba
ck
upda
ted t
o Ser
ver
Patient Category wise List
Information about diagnosis
General information TB
Adverse drug reactions due to TB drugs
Missed Call Campaign
Information about treatment facilities
Missed call server will be linked with NIKSHAY platform
DTO
Web based Monitoring for DR TB patients
e-Smart
Electronic Surveillance and Management of Drug Resistant Tuberculosis System
- An innovative approach towards better patient management
Vision: A world free of TB Zero TB deaths, Zero TB disease, and Zero TB suffering
Goal: End the Global TB epidemic
Vision, goal, targets, milestones
(2,2 million)
(2.2 lakh)
Global TB projections to 2035 compared with current trends
Next Seminar on WEDNESDAY 26/10/16
MEDIASTINUM by DR. SATISH & NON-INVASIVE VENTILATION by DR. SANDEEP