NTEP: Programmatic Management of TB in India

Key Points:-

• The current national programme for the control of TB in India is NTEP (National Tuberculosis Elimination Program) launched in January 2020
• The First Nation Programme for the Control of Tuberculosis was NTP (National Tuberculosis control Programme) started in 1962. NTP was replaced by RNTCP in 1997 and RNTCP was replaced with NTEP in January 2020
• With the goal to achieve Sustainable Development Goals (SDGs) related to TB by 2025, five years ahead of the global targets, India has implemented a National Strategic Plan (NSP 2017-2025) having 4 pillars: DETECT, TREAT, PREVENT and BUILD (DTPB)
• World Health Assembly in 2014 endorsed the END TB strategy with a vision of TB free world and zero death, disease and suffering from Tuberculosis by 2035
• The latest targets for India by 2025 are: 90% Reduction in death, an 80% reduction in TB incidence and Reducing the expenditure to ZERO in families affected with TB (taking 2015 as the base year)

When We talk about the National Programme for Tuberculosis in India, we came across a number of terms like NTP, RNTCP, NTEP, STOP TB strategy, END TB Strategy, Nikshay mitra, National strategic plan NSP 2017-25, etc. 

We shall look into these topics and try to establish the relationships among them so as to get a clear picture and don’t get confused with these names.

The Current Program for Control of TB in India

National Tuberculosis Elimination Programme (NTEP) is the current name of the national programme to combat Tuberculosis in India.

There has been a long history of programmatic management of tuberculosis in India which stats with NTP in the year 1962. 

NTP

The first national programme to control tuberculosis was started in 1962 as NTP (National Tuberculosis Control Programme). Under NTP self-administered dosing was followed (there was no direct supervision over the patient to know whether the patient was taking medicine as per schedule or not). Though NTP created extensive infrastructure for TB control and spread awareness of TB. it suffered a number of issues like:-

• Inadequate funding
• Frequent interruption of supplies of drugs
• Low rates of treatment completion
• Other managerial weaknesses.

In the view of above shortcomings, NTP was replaced with RNTCP (Revised National  TB Control Programme) in 1997.

RNTCP

In 1997, RNTCP (Revised National Tuberculosis Control Programme) was launched as a National programme. It adopted the internationally recommended cost-effective and most systematic approach named DOTS (Directly Observed Treatment Short-course) strategy (practised in over 200 countries). DOTS has 5 key components:-

1. Political and administrative commitment (support in terms of finance and human resources)
2. Good quality diagnosis (primarily by using sputum smear microscopy and other microbiological tools)
3. Uninterrupted supply of Quality Drugs
4. DOT- Directly observed treatment (patients take medicine in the presence of a treatment supporter)
5. Systematic monitoring and accountability

In addition to DOTS, other changes introduced in RNTCP were:

• Establishment of a TB unit (sub-district supervisory unit) with Dedicated RNTCP supervisors (STS, STLS)
• Decentralization of diagnostic and treatment services.

*STS_ senior treatment supervisor, STLS- senior TB Laboratory supervisor.

RNTCP implementation made it possible to achieve the global benchmarks of TB case detection and Treatment success rates.

STOP TB strategy

In the year 2006 WHO (World Health Organization) released the STOP TB strategy to achieve the global TB-related MDGs by 2015.

The vision of the STOP TB strategy was:

• World free of TB

Objectives were:

• Achieve universal access to high-quality diagnosis and patient-centred treatment
• Reduce the human suffering and socioeconomic burden associated with TB
• Protect poor and vulnerable populations from TB, TB/HIV and multidrug-resistant TB
• Support the development of new tools and enable their timely and effective use

Targets were:-

• Halt and begin the reversal of the incidence of tuberculosis
• Targets linked to the MDGs and endorsed by Stop TB Partnership:
  • Reduce the prevalence and deaths due to TB by 50% by 2015 (relative to 1990)
  • Eliminate TB as a public health problem by 2050 ( less than 1 case per million population )

Millennium Development Goals (MDGs) are now replaced with the SDGs (Sustainable Development Goals). 

NSP (National Strategic Plan) 2012-17

National strategic plans are the plans designed by the government to achieve the specific objectives of a programme or policy. It usually involves the relocation of resources for a certain time period.

NSP 2012-17 was envisaged with the vision of a TB-free India. The goal was to achieve universal access to quality TB diagnosis and treatment for all TB patients.

Objectives of NSP 2012-17 were:

• 90% notification rate for all cases of TB
• 90% success rate for all new cases and 85% for retreatment cases.
• Improving the proportion of successful outcomes among DR-TB patients
• Decreasing morbidity and mortality in patients coinfected with HIV and TB
• Improving outcomes of patients taking treatment from the private sector

NTEP- Current National Programme in Action in India

RNTCP programme was revitalized and reorganized into the National Tuberculosis elimination program(NTEP) in January 2020.

The Government of India implemented the National TB Elimination Programme (NTEP) under the aegis of the National Health Mission (NHM). With the goal to achieve Sustainable Development Goals (SDGs) related to TB by 2025, 5 years ahead of the global targets, the programme has implemented a National Strategic Plan (NSP 2017-2025)

NSP (National Strategic Plan) 2017-25

Vision:–

TB-free India with zero death, disease and poverty due to TB (similar to the END TB strategy)

Goal:- 

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

Objectives: –

• Early diagnosis of TB patients, prompt treatment
• To engage with the patients seeking care in the private sector.
• Prevention strategies like active case finding and contact tracing 
• Airborne infection control.
• Multi-sectoral response for addressing social determinants.

Strategic pillars:-

In NSP 2017-25 there are 4 strategic pillars namely Detect, Treat, Prevent, and Build (DTPB)

1. Detect:- scaling-up and decentralizing Molecular Diagnosis, private sector involvement, vulnerability mapping and Active case finding
2. Treat:- universal daily regimens for treatment, adherence monitoring to treatment, free drugs to all, eliminating the catastrophic cost by linking patients to social welfare schemes including nutritional support
3. Prevent:- testing and treating LTBI, airborne infection control measures at health facilities, addressing social determinants of TB (using an inter-sectoral approach)
4. Build:- political commitment, IEC, capacity building, human resource development, multisectoral collaboration (avoid duplication ), surveillance.

Indicators and targets:-

There are 4 impact indicators and 10 outcome indicators along their targets for 2020, 2023, and 2025. find details in the pdf given below.

Please note that NSP 2017-25 and NTEP are not different things. NSP is a policy document that lays the strategies and directions on how to achieve the desired goal and NTEP is the name of the programmer that executes the same on the ground.

END TB Strategy

While the STOP TB Strategy cured millions of patients and saved lives it disappointed in reducing the incidence (occurrence of NEW cases in a population over a specified period of time) of TB. In the view of above limitation, the World Health Assembly endorsed a new plan- END TB Strategy in 2014. 

The Vision of END TB Strategy:–

A world free of TB. Zero death, disease or suffering due to TB

The Goal of END TB Strategy:–

Ending Tuberculosis Epidemic

Indicators of END TB Strategy:–

• 95% reduction in the number of TB deaths by 2035 (compared with 2015)
• 90% reduction in TB incidence by 2035 rate (compared with 2015)

• Reducing catastrophic costs to Zero by 2035 in families affected by tuberculosis

Principles of END TB Strategy

• Government commitment and accountability, with monitoring and evaluation
• Protection and promotion of human rights, ethics and equity
• Adaptation of the strategy and targets at the country level, with global collaboration (the personalized plan of each country to achieve the indicators)
• Strong coalition with civil society organizations and communities (making it a mass movement, involving all the stakeholders)

Pillars and components

1. Integrated, patient-centred care and prevention
   • Early Diagnosis and universal drug-susceptibility testing(UDST), along with screening of contacts and high-risk groups for TB or TBI.
   • Treatment of all people with tuberculosis including drug-resistant tuberculosis(DR-TB), and patient support.
   • Collaborative tuberculosis/HIV activities, and management of co-morbidities.
   • Preventive treatment of persons at high risk, and vaccination against tuberculosis.
2. Bold policies and supportive systems
   • Political commitment with adequate resources for tuberculosis care and prevention.
   • Engagement of communities, civil society organizations, and public and private care providers.
   • Universal health coverage policy, and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control.
   • Social protection, poverty alleviation and actions on other determinants of tuberculosis.
3. Intensified research and innovation
   • Discovery, development and rapid uptake of new tools, interventions and strategies.
   • Research to optimize implementation and impact, and promote innovations.

Reaching the Target

• To reach the targets set out in the End TB Strategy, the annual decline in global TB incidence rates must first accelerate from 2% per year in 2015 to 10% per year by 2025
• Secondly, the proportion of people with TB who die from the disease (the case-fatality ratio) needs to decline from a projected 15% in 2015 to 6.5% by 2025. These declines in deaths and incidence by 2025 while ambitious are feasible with existing tools complemented by universal health coverage and social protection
• To sustain progress beyond 2025 and achieve the SDGs 2030 and End TB 2035 targets, additional tools must be available by 2025.
  • a new vaccine that is effective pre- and post-exposure
  • safer and more effective treatment for latent TB infection 
  • better diagnostics 
  • safer and easier treatment including shorter drug regimens for TB disease

For all these things investments in research and development are required.

Miscellaneous Topics:

99DOTS

99DOTS is a low-cost approach for monitoring and improving TB medication adherence. it supplements the existing DOTS.

Using 99DOTS, each anti-TB blister pack is put into an envelope, which includes hidden phone numbers that are visible only when doses are dispensed. After taking daily medication, patients make a free call to the hidden phone number, yielding high confidence that the dose is “in hand” and has been taken.

99DOTS patients receive a series of daily reminders (via SMS and automated calls). Missed doses trigger SMS notifications to care providers, who follow up with personal, phone-based counselling

Yes! We Can End TB!

it is the theme of World Tuberculosis Day for the year 2023. World TB Day is celebrated on 24^th March every year. On 24th March 1882 Rober Koch discovered the cause of Tuberculosis.

The theme of World TB Day 2023 – Yes! We can end TB! – aims to inspire hope and encourage high-level leadership, increased investments, faster uptake of new WHO recommendations, adoption of innovations, accelerated action and multisectoral collaboration to combat the TB epidemic⁷. 

TB Harega Desh Jeetega

Union Minister for Health and Family Welfare of that time launched the new TB Harega Desh Jeetega Campaign on 19^th September 2019⁹.

its three strong pillars include:

1. Clinical approach
2. Public health component
3. Active community participation

The new TB campaign aims to improve and expand the reach of TB care services across the country. Other supporting elements of the campaign comprise private sector engagement, patient support, and political and administrative commitment at all levels. 

Pradhan Mantri TB Mukt Bharat Abhiyan

The President of India, Smt Droupadi Murmu virtually launched the Pradhan Mantri TB Mukt Bharat Abhiyaan on September 9, 2022¹¹. This Abhiyaan aims to ensure the linkage of all TB patients on treatment with a Ni-kshay Mitra for providing community support¹⁰.

Nikshay Mitra

As the name suggests one can adopt one or more TB patients after obtaining the written consent of the concerned patient. the one who adopts the patient is called Nikshay Mitra. Nikshay Mitra can be any individual, institution, NGO, corporation, cooperative society etc. These NIkshay Mitra not only provide a nutrition basket to the concerned patient but also provide much-needed psycho-social support.

NI-KSHAY

NI-KSHAY-(Ni=End, Kshay=TB) is the web-enabled patient management system for TB control under the National Tuberculosis Elimination Programme (NTEP). It is developed and maintained by the Central TB Division (CTD), Ministry of Health and Family Welfare, Government of India, in collaboration with the National Informatics Centre (NIC), and the World Health Organization Country Office for India.

Ni-kshay is used by health establishments at various levels across the country both in the public and private sectors to:

• register cases of TB
• order various types of tests from Labs across the nation
• record treatment details
• monitor treatment adherence
• transfer cases between care providers

It also functions as the National TB Surveillance System and enables reporting of various surveillance data to the Government of India¹².

Nikshay Poshan Yojana (Nutritional Support to TB patients)

it is a scheme to provide Nutritional Support to TB patients. It was started on 1st April 2018. the financial incentive of 500 RS per month is provided for the nutritional supplementation of patients during his/her treatment. all notified TB patients are the beneficiaries of this scheme. this scheme is being implemented all over India.

more details can be accessed in the pdf.

Nikshay Sampark

The toll-free helpline number for any support on ”Nikshay portal” is 1800-11-6666 (Ni-kshay sampark)