Programmes

National Tuberculosis Elimination Programme (NTEP)

RNTCP (Revised National Tuberculosis Control Programme)Tuberculosis (TB) is an infectious disease caused by Mycobacterium Tuberculosis bacteria. It spreads through air when a person suffering from tuberculosis cough, sneeze or spit. TB remains to be major public health problem in India. TB control efforts are initiated countrywide since 1962 with inception of National TB Control Programme. The programme was reviewed and revised strategy was pilot tested in 1993. The Revised National TB Control Programme (RNTCP) was launched in 1997 with implementation of Directly Observed Treatment, Short Course Strategy, Programme is further renamed as National Tuberculosis Elimination Programme in the year 2020 by Central TB Division, Government of India, DOTS strategy is based on five components:

  • Political and administrative commitment
  • Good quality diagnosis, primarily by sputum smear microscopy
  • Uninterrupted supply of quality drugs
  • Directly observed treatment (DOT)
  • Systematic monitoring and accountability

Vision, Goals and Targets

This plan proposes strategies to reduce TB burden in the state by 2025 in line with the global End TB targets and Sustainable Development Goal’s to attain the vision of a TB-free Gujarat.

VISION:

TB-Free Gujarat with zero deaths, disease and poverty due to tuberculosis

GOAL:

To achieve a rapid decline in burden of TB, morbidity and mortality while working towards elimination of TB in state by 2025.

The main areas of focus are private sector engagement, strengthen public sector notification, TB case-finding among key populations (socially vulnerable and clinically high risk), Improvement in the success rate, newer drugs and regimen implementation and reduce catastrophic cost to patient.

Vision Statement

A) Administrative and Political commitment, community awareness and participation

An effective NTEP advocacy, social mobilization and communication strategy shall be in place, in order to maintain high visibility of TB and NTEP amongst policy makers, opinion leaders and community, and hence sustain long-term political and administrative commitment and greater community involvement to NTEP.

Advocacy and communication will be central and integral part of the TB Project. Communication plan will be directed towards scaling up the current level of communication activities. Good mass media campaign requires substantial resources. Mass media creates supportive and enabling environment for grass roots level participatory processes. Community media approach is very effective for facilitating participation and community empowerment.

B) Provision of Services:

1. Human Resource Development:

The vision is to have available at all times, adequate numbers of staff at the different levels of the health system, who have the skills, knowledge and attitudes (in other words are competent) necessary to successfully implement and sustain TB control activities, based on the DOTS strategy, including the implementation of new and revised strategies and tools.

The programme will have an overall HRD plan, of which training would be the core component, to address the issues of maintaining adequate manpower to carry out programme activities with a good level of proficiency and efficiency. It is planned to have an activity based budgeting and reporting system, which will report on and allow for monitoring of HRD.

The training plan will endeavour to minimize delay in the training of newly placed staff. As budgeting will be activity based. Training will hone the skills and shape the attitudes for desired competence in each category of staff. For human resource development to deliver results, empowerment of staff and ownership of the programme at all levels is necessary and it is envisaged that sufficient political and administrative commitment will be cultivated at the state level to ensure this aspect.

2. Diagnostic Facilities:

The vision is to have in place at the earliest date possible, a state-wide network of NTEP quality assured designated sputum smear microscopy laboratories which will provide appropriate, available, affordable and accessible diagnostic services for presumptive TB cases.

The programme plans to utilize the state health infrastructure optimally to provide affordable and quality assured microscopic services. The programme will have provision for the supply of quality reagents and equipment’s to the Laboratory network. The programme will have an in-built routine system for sputum microscopy external quality assessment (EQA), and for supervision and monitoring of the diagnostic systems by the Senior Treatment Laboratory Supervisor (STLS) locally and by the intermediate (State level).

State has also implemented universal DST to all TB cases through CBNAAT. TRUNNAT (Newer diagnostic facility) pilot is ongoing. At those centres where sputum microscopy may not be readily accessible, the programme will endeavour to provide access for hard-to-reach populations, wherein, and based on need, sputum collection and transport networks will be set-up. The programme will also foster partnerships with private, NGO and other sectors, and Medical colleges to guarantee the even wider availability of NTEP diagnostic services and to cultivate professional acceptance of the programme’s diagnostic algorithms amongst the wider medical fraternity.

3. Case Finding:

One of the major policy decision taken by NTEP is to change the focus of the NSP case detection objective of at least 70 % to the concept of universal access to good quality care for TB patients. There is now global consensus that the twin objectives of 70/85 alone is not enough to achieve adequate reduction of TB transmission and reduction in disease burden at the pace with which epidemiological impact is expected. Also, some studies suggest mortality remains higher than expected, including post TB treatment mortality. One of the major reasons for death in TB patients is late diagnosis.

Universal Access to TB Care:

All TB patients in the community (public and private sector) to have access to early, good quality diagnosis and treatment services in a manner that is affordable and convenient to the patient in time, place and person. All affected communities must have full access to TB prevention, care and treatment, including women, children, elderly, migrants, homeless people, alcoholic, prisoners & PLHIV.

Standards for TB care in India (STCI):

STCI is a widely accepted level of care that all practitioners, public and private, should apply in dealing with patients with tuberculosis or with symptoms and signs suggestive of tuberculosis. The key principles of STCI include the following: prompt and accurate diagnosis; use of standardized treatment regimens of proven accuracy; appropriate treatment support and supervision until cure; monitoring of the response to treatment, and essential public health responsibilities such as reporting on patients diagnosed and their treatment outcomes to national programmes.

4. Treatment of Drug Sensitive and Drug Resistant TB Patients:

The vision of the programme is to have at all times, sufficient quality assured fix drug combination daily regimen available at the appropriate levels to ensure that no patient has to delay initiation of their treatment, or interrupt treatment, due to the lack of drugs. Shorter MDR TB regimen, all oral longer regimen and newer drugs to eligible DRTB patient are also envisaged in the programme.

5. Treatment Delivery and Adherence Monitoring Strategy:

The vision is to have a state-wide network of treatment DOT providers to ensure delivery of DOTS is provided as close to the patient as possible.

The programme will venture to garner support of adequate staff and volunteers, who are committed and humane to deliver DOT, as per the recommended strategy. The vision is to further foster community participation in the DOT services and to implement it, the programme will endeavour to further streamline the drug distribution systems at sub-district level. The programme will attempt to reduce delays in treatment initiation for example by trying to decrease the average distance between a patient’s residence and their DOT center as far as it is logistically and programmatically feasible, Programme also wants to implement 99 DOTS, MERM box (ICT based monitoring system) & Family DOTS for bedridden and paediatric patients in the state in the year 2018

6. Patient support system

The vision of the programme is to have zero catastrophic cost to patient due to TB. The programme envisaged to give incentives to patient during treatment and to providers for case notification and ensure treatment adherence by patients.

C. Supervision, Monitoring and Evaluation:

To achieve the goal and objective of NTEP strategy future plan to strengthen supervision and monitoring and evaluation process as per guideline. Periodic programme assessment and review (by internal and external "evaluations”) at the district level would continue as existing guidelines, It is envisaged to evaluate program performance via periodic TB prevalence survey, the impact of the NTEP on the TB burden in Gujarat.

State Level
  • Standardized check list has been utilized to ensure supervision of all NTEP activities at District level
  • Quarterly review of NTEP at state level and Quarterly feedback to be given to all DDO / DTO / MOTC by principal secretary / Commissioner of Health & AD (PH).
  • Review of Regional Deputy Director and Chief District Health Officers and Civil surgeons by Additional Director Health Services on Performance bases during every month
  • Regular Internal Evaluation of Districts as per NTEP Guidelines.
  • For each District, Designated State Liaison Officer has been nominated and they are utilized for supervision & monitoring of all National Health Programme in their respective district
  • STDC plays main role in training component for NTEP, Technical Analysis and Evaluation of the Data, Strengthen Referral & Feedback Mechanism of all diagnose TB Patients, Drug & Logistic Management with timely forecasting
  • Intermediate Reference Laboratory from STDC, Ahmedabad has performed External Quality Assessment of district as per EQA guideline and also doing Diagnosis & Follow up of DR Patients will continue.
District Level

Bi-annually technical and financial review of NTEP program by collector through governing body meeting and by district development officer through executive committee meeting every quarter.

Monthly review of all MO PHI in every District.

TB Unit Level

Monitoring and supervision by MOTC at TU level under NTEP, Diagnostic services supervised by Senior Tuberculosis Laboratory Supervisor (STLS) and treatment services will supervise by Senior Treatment Supervisor (STS).

The requirements for moving towards state TB elimination plan have been integrated into the four strategic pillars of "Detect – Treat – Prevent – Build” (DTPB), aligned with RNTCP National Strategic Plan of 2017-2025.

Strategy

Structure of Strategy

Organization of NTEP services in Gujarat

  • The goal of TB control Programme is to decrease mortality and morbidity due to TB and cut transmission of infection until TB ceases to be a major public health problem in India.
  • Programme was launched in the state of Gujarat with implementation of pilot in two taluka of Mehsana district in 1993. By 2004, entire state was covered with implementation of DOTS strategy.
  • In, Gujarat, Joint Director (TB), under the guidance of the Additional Director Health & Commissioner Health, Medical Services and Medical Education, looks after the implementation of NTEP. There are a total of 306 TB Units in 33 districts and 3 Municipal Corporation (36 Reporting Units) and total of 1995 sanctioned Designated- Microscopy Centers and 60 CBNAAT site are working. 3 culture laboratory available in the state to diagnose DR-TB cases (IRL Ahmedabad, Culture lab. Jamnagar & Surat) Treatment is being provided through 40712 DOTS Providers. To implement NTEP each district has a District TB Centre, which monitors the program for the entire district. The district is further divided into sub-district i.e. Tuberculosis Unit (TU) at each Taluka.

Structure of NTEP

Structure of NTEP

TB-Comorbidities activities

Intensified TB-HIV package of services for TB/HIV Collaborative Activities are being implemented across the state since 2009.TB-HIV Collaborative activities are provided to all level of TB care settings. TB-HIV cross referral activities has been expanded through all ICTCs Centers in Gujarat, ART Centers and linked ART Centers at different medical colleges & district hospitals in the state. Diabetes screening is available in all PHI, All diagnosed TB patients screened for HIV and Diabetes and Tobacco and positive patients linked with appropriate care and services.

Public Private Partnership

29 medical colleges exist in the state and all are involved in NTEP. At each medical college, a Designated Microscopy Centre cum DOTS treatment Centre is established. The Grant-in-Aid non-governmental organizations, other NGOs, as well as private practitioners are being sensitized, encouraged and involved in programme. At present, there are total 58 NGOs are involved in the programme and more than 14,000 private health facility registered in Nikshay and more than 50,000 TB patients are notified every year from private health facility, Public heath action following notification initiated and extended services available in the programme are also delivered to privately notified TB cases.

Initiative taken by Gujarat state for the programme

Year Achievements
2005 First to Implement revised External Quality Assurance mechanism
2006 First to conduct Drug Resistance Survey to know the prevalence of MDR-TB
2007 First to implement DOTS Plus treatment for MDR TB patients and DOTS Plus ward at BJ Medical college Ahmedabad
2008 First to get certification for C & DST for State Level IRL at STDC Ahmedabad
First National level training centre for PMDT at STDC Ahmedabad
2009 First to implement TB-HIV intensified package in the country among moderate HIV prevalent State
2010 First in Pilot study on Air borne Infection Control guideline in Govt. & Private Health Care Sector
2010 First to Start TB-Tobacco Control pilot project in two Districts of Gujarat
2011 First in Country to conduct State specific Pulmonary TB Prevalence Survey
2012 First in country to establish State ACSM Quality Support Group
2013 First to get certification for 2nd line DST among state level laboratories
2014 First Pilot on free drug to TB patients accessing care from private practitioners
2015 Awarded for best performance of State NTEP at NHM National level at Shimla and Srinagar (Consecutive 2 years)
2016 Culture DST Laboratory initiated at Govt Medical College Surat
Bedaquiline Conditional Access Programme (BDQ-CAP) started in Ahmedabad DR-TB Site
2017 New TOG and Daily Regimen Implemented
Universal DST Started in entire state
2018
  • International STREAM-II Study initiated
  • Implementation of Shorter & MONO-H Regimen
  • Implementation of NIKSHAY Poshan Yojana (500 Rs. Per month to all notified TB patients for nutrition support)
2019 Implementation of All Oral regimen for DR-TB patients

Performance Report NTEP

RNTCP Guideline

RNTCP Modules

RNTCP TB-HIV Modules

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