INTRODUCTION

Tuberculosis is an infectious
disease caused by a bacterium
Mycobacterium tuberculin spread
through air by an infected person. TB is
most prevalent in India compared to
other developing countries due to HIV
infection, low socioeconomic status and
unhygienic living conditions
 About 0.5 million people die of TB
every year . To control tuberculosis
NATIONAL TUBERCULOSIS
PROGRAMME [NTP] has been in
operation since 1962
 OBJECTIVES OF NTP
 LONG TERM OBJECTIVES:
 To reduce TB in the community to that

level when it causes to be a public

health problem i.e.
*when one case infects less than
one new person annually
*the prevalence of infection in age
group below 14 is brought down to less
than 1
OPERATIONAL/SHORT TERM OBJECTIVE:
*To detect maximum number of TB
cases among the outpatient attending any
hospital with symptoms of TB an treat
them effectively
*To vaccinate newborns and infants
with BCG
*To undertake the above objectives in
an integrated manner through all the
existing health institutions in the country
 DISTRICT TUBERCULOSIS
PROGRAMME
 NTP operates through DTP which is the
backbone of NTP
 Over 600 TB clinics have been set up in the

country out of which 390 have been

upgraded as DISTRICT TUBERCULOSIS
CENTRE [DTC]
 DTC is the nucleus of DTP

 The function of DTC is to plan, organize

and implement DTP in entire district

 The health institutions available for
inclusion in DTP are government
general hospitals and community
health centres,TB clinics
 Only such peripheral health

institutions [PHI’s] are selected for

implementation of the program
which are under the charge of
qualified medical officers these are
called implement able PHI’s
 The activities of DTC inclde case finding
and treatment. The treatment is free and is
offered on domiciliary bases from all
health institution
 It is organized in such a manner that
patients are expected to collect drugs
once a month on fixed dates from the
nearest treatment centers .When the
patient fails to collect his drug on the due
date a letter is written to him [first action]
and in event of no response for 7 days
a home visit is paid [second action] by the
health staff
 ACTIVITIES OF DTC
 Case finding and case holding
 Microscopic examination of sputum

 Radiological examination

 BCG vaccination

 Monitoring and evaluation

 Supervision and follow up

 Involvement of PHC, subcentres and

private practitioners
 ORGANIZATION OF DTP
A DTP consists of 1 DTC and on an
average 50 PHI’s
To implement the DTP a specially trained
team of key program personnel is posted
at each DTC .The team is trained at
national TB institute, Bangalore for a
period of 13 weeks. The team consists of
 1 district TB officer

 1second medical officer

 2 lab technician

 2 treatment organizer or health visitor

 1 X-ray technician
 1 non-medical team leader

 1 statistical assistant

 1 pharmacist

Not only PHI’s but also cadres of health

workers and MPW’s are all involved in
the program of case detection treatment
NTP is a centrally sponsored scheme. Anti
TB drugs for free treatment are being
supplied to TB clinics run by state Govt’s
on 50-50 basis between central and state
 REVISED NATIONAL TB
CONTROL PROGRAM
 The Govt of India, WHO and world bank

together reviewed the NTP in the year

1992. Based on this a revised strategy for
NTP was evolved. The salient features of
this strategy are
* achievement of at least 85% cure rate
of infectious cases through supervised
short course chemotherapy involving
health functionaries
 * augmentation of case finding
activities through quality sputum
microscopy to detect at least 70% of cases
*Involvement of
NGO’s, information, education,
communication and research
Under RNTCP case finding is not pursued.
Case finding is passive. Patients
presenting themselves with symptoms
suspicious of TB are screened through 3
sputum smear examinations. Such
microscopic examination is done in
designated RNTCP MICROSCOPY
CENTRE
CRITERIA OF DIAGNOSIS
AND INITIATION OF
TREATMENT
 Cough for 3 weeks or more

3 sputum smears

2 or 3 +ve 1 +ve 3-ves

 3 or 2 +ves

Smear +ve TB

Anti TB treatment
 1 +ve

X-ray

+ve -ve

Smear +ve TB Non TB

Anti TB treatment
 3 -ves
Antibiotics for 1-2 weeks
Symptoms persists
X-ray

-ve for TB +ve for TB

Smear +ve TB
Non TB
Anti TB treatment
All patients are provided short course
chemotherapy free of charge. All the
drugs are administered under direct
supervision called DIRECT OBSERVED
THERAPY SHORT COURSE [DOTS
 DOTS
DOTS is a strategy to ensure cure by
providing the most effective medicine and
confirming that it is taken
DOTS is a community based TB treatment
and care strategy that combines the
benefits of supervised treatment and
benefits of community based care and
support
• DOTS regimen recommended a short
course regimens for 6 months for newly
diagnosed patient
• It starts with an intensive phase of 4 drugs
[isoniazid, rifampicin, pyrazinamide,
ethambutol] for 2 months followed by
continuation phase of
[rifampicin,isoniazid] for 4 months all
given under DOT
• When DOTS is not feasible
through out the treatment periods
the dots strategy recommends
continuation phase for 6 months
i.e. total 8 months of treatment
 DOSAGE OF DRUGS
*ETHAMBUTOL-800mg E
*ISONIAZID-300mg H
*RIFAMPICIN-450mg R
*PYRAZINAMIDE-1.5g Z
*STREPTOMYCIN-0.75mg S
TREATMENT CATEGORIES
IN DOTS CHEMOTHERAPY
C TYPE OF PATIENT REG
A IMEN
T
New sputum smear +ve 2[HRZ
E]3
Seriously ill sputum smear
4[HR]3
1 –ve
Seriously ill extra pulmonary
C TYPE OF PATIENT REG
A IMEN
T
Sputum smear +ve relapse 2[HRZ
ES]3
Sputum smear +ve failure 1[HRZ
E]3
2 5[HRE]
Sputum smear +ve treatment 3
after default
C TYPE OF PATIENT REG
A IMEN
T
Sputum smear –ve not 2[HRZ]
seriously ill 3

3 Extra pulmonary not

4[HR]3
seriously ill
 HOW DOTS IS GIVEN
In DOTS, during intensive phase of
treatment a health worker or other trained
person watches as the patient swallows
the drug in his presence. During
continuation phase, the patient is issued
medicine for one week in a multiblister
combipack, of which the first dose is
swallowed by the patient in the presence
of health worker or trained person..
 The consumption of medicine in
the continuation phase is also
checked by return of empty
multiblister combipack, when the
patient comes to collect medicine
for the next week. The drugs are
provided in patient wise boxes
 5 ESSENTIAL COMPONENTS OF
DOTS
 POLITICAL COMMITMENT WITH

INCREASED AND SUSTAINED

FINANCING:
*Clear and sustained political commitment
by national government is crucial
*adequate funding is essential. Current
resources are inadequate and further
effort is required to mobilize domestic as
well as international resources
 CASE DETECTION THROUGH
QUALITY ASSURED
BACTERIOLOGY:
*Bacteriology remains the good method
of TB case detection first using sputum
microscopy and then culture and
sensitivity test
*a wide network of properly equipped lab
with trained personnel is necessary to
ensure access to quality assured sputum
smear microscopy
 STANDARDISED TREATMENT WITH
SUPERVISION AND PATIENT
SUPPORT:
*The mainstay of TB control is organizing
and administering treatment across the
country for all adult and pediatric TB cases
*Services of TB cases should identify
factors that make patient interrupt or stop
treatment
*DOTS helps patient to take drugs
regularly and complete treatment, thus
achieving cure and preventing
development of drug resistance
*supervision may be under taken at a health
facility, in the work place, in community
or at home.
*locally appropriate measures should be
undertaken to identify and address
physical, financial, social and cultural
barrier
AN EFFECTIVE DRUG SUPPLY AND
MANAGEMANT:
*An uninterrupted and sustained supply of
quality assured anti TB drug is basis for
TB control
*A reliable system of distribution of all
essential anti TB drug to all health facility
should be in place and drugs should be
provided free of cost for the patients
*The TB recording and reporting system is
designed to provide information needed
to plan distribute and maintain adequate
stock of drugs
MONITORING AND EVALUATION
SYSTEM AND IMPACT
MEASUREMENT:
*Establishment of reliable monitoring and
evaluation system with regular
communication between the central and
peripheral levels of health system is vital.
This requires standardized recording of
individual patient data [name, address
etc.] of sputum positive case in district
TB index
 ADVANTAGES OF DOTS
 DOTS produces cure rates up to 95%
even in poorest countries
 DOTS prevent new infections by

curing infectious patients completely

 Prevent multi drug resistance by

ensuring full course of treatment

 This strategy has proven successful

through out the world

 Patients need not be hospitalized
 Dots prolong survival of HIV infected TB

patients
 DOTS helps more than double accuracy

of diagnosis of TB
 A DOT is cheap