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Innovative Approach is essential for TB Control in India

Innovative Approach is essential for TB Control in India. T Jacob John FNA Ahmedabad 6 September 2013. Evolution of TB control ideology. Independence  free spirit and idealism ICMR, MMR, Mantoux = TB widely prevalent 1962: autonomous decision : to Control TB

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Innovative Approach is essential for TB Control in India

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  1. Innovative Approach is essential for TB Control in India T Jacob John FNA Ahmedabad 6 September 2013

  2. Evolution of TB control ideology • Independence  free spirit and idealism • ICMR, MMR, Mantoux = TB widely prevalent • 1962: autonomous decision: to Control TB • Leaders were great; ‘State’ was unenthusiastic • 1978 World Bank opposed Primary Health Care and preached Selective Disease Control (Vertical) • 1990-93 autonomy rejected, ‘do as told’ prevailed • India lost will to control TB

  3. 2012: 50 Yrs of National TB Control Project • Late 1950s: nation-wide TB survey (tuberculin tests + mass miniature radiography = High prevalence • 1962: Mass BCG, Lab, Trial/NTI/TRC/PPP treatment • BCG was believed to protect against MTb infection • Treatment was humanitarian service • BCG Trial: reports of 1979 & 1999  no protection • 1990: Evaluation = TB control was failure • Revised NTCP with DOTS: 1993  2006

  4. National TB control began in 1962; revised in 1992; country-wide coverage reached in 2006; quarterly No. treated range~375,000; no evidence of decline 4

  5. TB is No. 1 public health problem among all infectious diseases • 17% global population carries 26% TB burden • 1000 deaths/day: biggest single cause of deaths • Large proportion (60%) latently infected with MTb • 50 years of Gov. efforts have not controlled TB

  6. What do we understand by Control? • Establish a TB control project? Vote Yes/No • Prevent all deaths due to TB? ” • Protocol-based anti-TB treatment (DOTS) ” • Any other thoughts?

  7. RNTCPDefinition of TB control • Revised National TB Control Project (RNTCP) defines it as 85% cure among 70% cases of lung TB • Effective cure = 59.5% [Is this enough to prevent transmission of TB bacilli to others?] Yes/No • When does one becomes “infectious” in relation to 3 weeks of cough as TB symptom?

  8. Epidemiologic definition of control • Human mastery over Pathogens: Control; elimination; eradication; extinction • Epidemiological definition: Control = reduction of incidence to pre-set level in target time interval • So, my own definition of TB control = Annual 5% reduction of MTb infection • Requirements: Base lineand annual monitoring

  9. Why should we control TB? • So, I pose the question: Do we want to control TB? • If Yes, why? [desire? Motivation? Policy?] • Please jot down reasons why • Will see if they justify priority for TB control

  10. Reasons why we should control TB • Humanitarian reasons – mitigate suffering • Human Rights – Everyone’s Right to live without TB • Socio-economic reasons: 1. Poverty alleviation requires TB control 2. Healthy adults produce greater wealth 3. National annual loss = $ 23.7 billion 4. Raise Human Development Index

  11. Gaps in RNTCP Policy • Control is defined as reduction of incidence to pre-defined level in stipulated time period • Goal of RNTCP = 70% case detection; 85% cure • Common sense = inadequate for “control” • TB “Control” definition avoided in Policy • Cure rate equals lives saved – successful • RNTCP is mortality reduction by DOTS, not TB control

  12. Major Gaps in TB control • Major Policy Gaps • Major Funding Gaps • Major Gaps in Project Design • Major Gaps in Project Implementation • Major Gaps in Partnering Healthcare Enterprise • Major Gaps in People’s Participation

  13. Gaps defined • Loss 23.7 billion $; RNTCP budget 200 million • Need ~100% case capture if control is the goal • 3 wks cough is too late for reduction in infection • Only 50% captured in DOTS: PPP non-functional • Public participation grossly inadequate • RNTCP must be re-engineered

  14. AIDS Control design was indigenous • 3 critical elements: public participation; multiple interventions; denominator-based data • RNTCP design by TB experts unfamiliar with Indian conditions and ID epidemiology • Did Western (& Indian) experts think India is: incapable of multiple interventions against TB? Incapable of denominator-based monitoring? Incapable of achieving public participation?

  15. How should we control TB? What is the opposite of Innovation? Imitation, improvisation? Innovate only when we need to solve problem ourselves Lessons from AIDS control

  16. The Way Forward nationally: 1 • Control target must be defined with objective monitoring methods included • Eg. 5% annual reduction of new infections • Monitoring tool = PPD survey and ARTI • Another target = 5% annual reduction of childhood TB for which all childhood TB must be counted John TJ. Tuberculosis control: detect and treat infection in children. Indian Pediatr 2008; 45: 261-264 John TJ, John SM. Paradigm shift for control of tuberculosis in high prevalence countries. Trop Med Int Health 2009; 14 : 1-3

  17. The Way Forward: 2 • Maximise passive surveillance through PPP and ensure case notification • Assist private sector with diagnostic technology • Improve diagnosis, detect infection early • Capture drug resistance early for 2nd line Rx • Help counseling & follow up of all patients • Social/economic support for those in dire need

  18. The Way Forward: 3 • The public should be well informed: innovative approaches needed • Multiple channels to be used – middle school and older could be taught – repeat annually • We have “Handwriting competition” and “Project handkerchief” • We have designed a rainbow ribbon as symbol of solidarity with the TB affected

  19. Way forward in Vellore (under design) • Introduce all known interventions except improving housing • Network all likeminded civil society partners (Rotary Clubs and other NGOs) for sustained efforts  public IEC/behaviour change • Network all private healthcare centres to promptly report TB and apply scientific treatment norm (re-establish NATHI model) • Help Dt TB officer capture all cases through PPP and contact tracing • Enable all sputum specimens to be rapidly tested for reliable diagnosis including drug resistance – with CMC participation • Expedite treatment of drug resistant cases • Address childhood TB, now neglected in RNTCP • Introduce monitoring mechanisms: ARTI annual monitoring; pediatric TB burden

  20. Rotary Club of Vellore:Supporting and supplementing Revised National TB Control Project

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