Revised National TB Control Program (RNTCP)

 

Introduction

·         India is the highest TB burden country in the world, accounting for nearly 27% of the global incidence¹.

·         The revised national TB Control program (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy, was launched in 1997 and expanded across the country in a phased manner.

·         RNTCP is the largest and the fastest expanding TB control program in the world.

·         In 2020, Govt. of India has renamed RNTCP as National Tuberculosis Elimination Program (NTEP). This is to achieve the sustainable development goal of ending TB in India by 2025².

 

Objectives

·         To achieve and maintain a TB treatment success rate of at least 85% among new sputum positive (NSP) patients. New sputum positive patients are those people who have never received TB treatment before, or who have taken TB drugs for less than a month with a positive result to a sputum test³.

·         To achieve and maintain detection of at least 70% of the estimated new sputum positive people in the community.

Secondary objectives

·         To reduce the incidence of, and mortality due to TB

·         To prevent further emergence of drug resistance and effectively manage drug-resistant TB cases

·         To improve outcomes among HIV-infected TB patients

·         To involve private sector recognizing their dominant presence in health care services.

Program implementation²

·         NTEP is implemented by the central TB division through the state TB cell (STDC).

·         Each district has a district TB center (DTC) to co-ordinate the activities.

·         Under the DTC the functioning unit is a tuberculosis unit (TU) which caters to 1.5 -2.5 lakh population.

·         The peripheral health institution (PHI) is a health unit manned by at least one medical officer and is called tuberculosis diagnostic center (formerly designated microscopy center).

Strategic component of NTEP²

·         Active case detection through laboratory methods including highly sensitive molecular methods.

·         Treatment of drug susceptible tuberculosis.

·         Treatment of latent TB infection.

·         Treatment of drug resistant TB.

·         Implementation of air borne infection control.

TB notification

·         To ensure proper TB diagnosis and case management, to reduce TB transmission and to address emergence and spread of drug resistant TB, it is essential to have complete information of all TB cases.

·         Healthcare providers should notify every TB case diagnosed or treated to local authorities.

·         This can be easily done through Nikshay, a case based web based platform.

Treatment guidelines

·         New TB cases are treated with daily regimen.

·         Intensive phase consists of 8 weeks of isoniazid, rifampicin, pyrazinamide and ethambutol as per 4 weight bands.

·         There is no need for extension of intensive phase.

·         Continuation phase consists of 16 weeks with 3 drugs. Pyrazinamide is stopped in this phase.

·         Regimen is (2) HRZE + (4) HRE in fixed dose combination where each tablet contain 75 mg of INH, 150 mg of Rifampicin, 400 mg of pyrazinamide and 275 mg of ethambutol.

·         Dose is 25-39 Kg -2 tablets, 40-54kg-3 tablets, 55-70 kg-4 tablets and more than 70 kg-5 tablets

Treatment of latent TB infection⁴

The treatment options are:

·         Isoniazid monotherapy for 6 months at a dose of 5 mg/kg in adults, and 10 mg/kg in children up to a maximum of 300 mg.

·         Rifampicin and isoniazid combination daily for 3 months (in children <15 years). Rifampicin is given at a dose of 10 mg/kg in adults and 15 mg/kg in children up to a maximum of 600 mg.

·         Rifapentine and isoniazid weekly for 3 months.  

Treatment of drug resistant TB

·         The standardized treatment for MDR TB is a 6-drug regimen, with an intensive phase of 6–9 months and a continuation phase of 18 months (Total duration is 24–27 months)

·         The six drugs used are kanamycin, levofloxacin, cycloserine, ethionamide, pyrazinamide, and ethambutol.

 

References

1.       GLOBAL TUBERCULOSIS REPORT 2019 downloaded from www.who.int/tb/data

2.       RNTCP gets name change, now called National Tuberculosis Elimination Program (NTEP)", 2020,  https://medicaldialogues.in/rntcp-gets-a-name-change-now-called-national-tuberculosis-elimination-program-ntep

3.       Mukherjee, A “Outcomes of different subgroups of smear-positive retreatment patients under RNTCP in rural West Bengal, India”, Rural and Remote Health www.ncbi.nlm.nih.gov/pubmed/19260766

4.       Latent Tuberculosis Infection: Updated and Consolidated Guidelines for Programmatic Management, Licence: CC BY-NC-SA 3.0 IGO. Geneva: World Health Organization; 2018.