Summary of changes in the RNTCP technical guidelines

Summary of changes in the RNTCP technical guidelines in 2008 -09 ZTF (South Zone) Workshop, Puducherry 27 -28 August 2009 Dr. K S Sachdev, CMO Central TB Division Directorate General of Health Services Ministry of Health & Family Welfare Nirman Bhavan, New Delhi

(Newer) COMPONENTS OF THE STOP TB STRATEGY • Pursue high-quality DOTS expansion and enhancement • Secure political commitment, with adequate and sustained financing • Ensure early case detection, and diagnosis through quality-assured bacteriology • Provide standardized treatment with supervision, and patient support • Ensure effective drug supply and management • Monitor and evaluate performance and impact

Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations • Scale-up collaborative TB/HIV activities • Scale-up prevention and management of multidrug-resistant TB (MDR-TB) • Address the needs of TB contacts, and of poor and vulnerable populations

Contribute to health system strengthening based on primary health care • Help improve health policies, human resource development, financing, supplies, service delivery and information • Strengthen infection control in health services, other congregate settings and households • Upgrade laboratory networks, and implement the Practical Approach to Lung Health (PAL) • Adapt successful approaches from other fields and sectors, and foster action on the social determinants of health

Engage all care providers • Involve all public, voluntary, corporate and private providers through Public-Private Mix (PPM) approaches • Promote use of the International Standards for Tuberculosis Care (ISTC)

Empower people with TB, and communities through partnership • Pursue advocacy, communication and social mobilization • Foster community participation in TB care • Promote use of the Patients' Charter for Tuberculosis Care

Enable and promote research • Conduct programme-based operational research, and introduce new tools into practice • Advocate for and participate in research to develop new diagnostics, drugs and vaccines

Diagnosis of TB • Change in the definition of PTB suspect - “Pulmonary TB suspect is any person with cough for 2 weeks, or more” • Change in the number of sputum samples required for diagnosis of PTB from 3 to 2 – Number of specimen required for diagnosis is 2, with one of them being a morning sputum – One specimen positive out of the two is enough to declare a patient as Sm+ PTB Based on WHO STAG recommendations and further evidence from India

Recording and reporting • Revised PM report for PHI, TU, District and State – – MDR-TB suspects TB/HIV Activities Revised PPM schemes Involvement of other sectors – ACSM (IEC) – Information on quality of DOTS for all smear positive TB patients (not just NSP cases) • New software phased in. Old software to be phased out in 2010

TB/HIV • Offer of VCT to all TB patients started in 9 states and planned to expand to the entire country by 2012 • Recording of HIV status in TB records in these states • Early start of ART in eligible HIV+ve TB patients (2 wks following start of TB treatment; TB patients with CD 4 <350/cc eligible for ART); also recording in TB records in these states • Decentralized provision of CPT to all HIV+ve TB patients in these states • Intensified TB case finding at ICTCs, ART centres & CCCs • Priority accorded to airborne infection control in ART centres

WHO-recommended TB/HIV interventions Indian TB/HIV Activities Ongoing Ongoing at VCTC; ART Pilot testing Guidelines in preparation Ongoing (ICTCs) Ongoing (NACO) Ongoing (NACO ART centres)

MDR-TB…. 1 • Recently implemented change in MDR-TB suspect definition – “any patient who fails a Cat I or III treatment regimen or any Cat II patient who remains smear positive at the end of the fourth month of treatment or later” • Future change of MDR-TB suspect definition planned to include all smear +ve retreatment cases • Elimination of exclusion criteria (pregnancy, pediatric age -group, H/o SL ATT) for DOTS-Plus • National DOTS-Plus committee has recommended – A Cat-V regimen for XDR-TB – To treat Rif mono-resistance with Cat-IV – Replace ofloxacin with levofloxacin in Cat-IV regimen

MDR-TB…. 2 • Newer rapid diagnostics – Molecular technology based DST (Line Probe Assay) • Advantages: rapid (result in 2 days), high throughput • Status: Validation phase over; demonstration phase to start in Aug 2009 • 43 labs with LPA planned (these labs will also have solid media DST) – Automated liquid culture • In 33 out of the 43 labs liquid culture systems planned

PPM • New PPM schemes implemented • Additional scheme on: – TB/HIV for high HIV risk population – Purchase of DST services from private accredited labs – Sputum collection and transportation

Other changes • Operational research: New operational research agenda and guidelines (can be downloaded from www. tbcindia. org) – RNTCP OR agenda 2009. pdf – RNTCP OR guidelines March 2009. pdf • Airborne infection control guidelines being developed

Change is also happening in RNTCP policy

Thanks