16.2 National Tuberculosis Elimination Programme & NVBDCP

National Tuberculosis Elimination Programme & NVBDCP

National health programs form a substantial portion of the UPSC Combined Medical Services (CMS) Community Medicine paper. Programmatic targets, diagnostic algorithms, therapeutic regimens, and operational guidelines under the National Tuberculosis Elimination Programme (NTEP) and National Vector Borne Disease Control Programme (NVBDCP) are examined extensively.

1. National Tuberculosis Elimination Programme (NTEP)

In 2020, India renamed the RNTCP to the National Tuberculosis Elimination Programme (NTEP), signaling a strategic shift from tuberculosis control to elimination by 2025 (5 years ahead of the Sustainable Development Goal [SDG] global target of 2030).

Strategic Pillars: The DTPB Framework

• Detect: Find all cases (active and passive case finding) with upfront rapid molecular diagnostics.
• Treat: Initiate 100% of notified TB patients on appropriate, daily fixed-dose combination (FDC) anti-TB regimens with digital adherence monitoring.
• Prevent: Scale up Tuberculosis Preventive Treatment (TPT) among contacts, airborne infection control, and BCG vaccination.
• Build: Strengthen health systems, multi-sectoral partnerships, civil society engagement, and political commitment.

NTEP Upfront Diagnostic Pathway

NTEP has phased out sputum smear microscopy as the primary diagnostic tool in favor of upfront rapid molecular testing (NAAT) for all presumptive TB cases:

• CBNAAT (Cartridge-Based Nucleic Acid Amplification Test / GeneXpert): Automated real-time PCR assay that simultaneously detects M. tuberculosis complex DNA and mutations conferring Rifampicin resistance (rpoB gene) within 2 hours.
• Truenat: Microchip-based real-time PCR developed in India; portable, battery-operated, suitable for peripheral PHCs.
• Universal Drug Susceptibility Testing (Universal DST): Every diagnosed TB patient undergoes DST for Rifampicin upfront. If Rifampicin resistance is detected, specimens undergo Line Probe Assay (LPA) or Liquid Culture DST (MGIT 960) for second-line drugs (Fluoroquinolones, Bedaquiline, Linezolid).

NTEP Treatment Regimens for Drug-Susceptible TB (DS-TB)

NTEP utilizes daily Fixed-Dose Combinations (FDCs) packaged in blister packs based on weight bands, administered under direct observation / digital support:

Note: Pyrazinamide is stopped during CP. If a patient remains sputum-positive at the end of IP (2 months), CP is started without extension, and sputum is sent for NAAT / Line Probe Assay to rule out drug resistance.

Drug-Resistant TB (DR-TB) Definitions & Regimens

• Rifampicin Resistant TB (RR-TB): Resistance to Rifampicin detected by NAAT or liquid culture, with or without resistance to other drugs.
• Multidrug Resistant TB (MDR-TB): Resistance to at least Isoniazid (H) and Rifampicin (R).
• Extensively Drug-Resistant TB (XDR-TB): MDR-TB plus resistance to any Fluoroquinolone (Levofloxacin or Moxifloxacin) AND at least one Group A drug (Bedaquiline or Linezolid).
• BPaLM Regimen: Modern 6-month fully oral regimen for MDR/RR-TB comprising Bedaquiline, Pretomanid, Linezolid, and Moxifloxacin.

Patient Support & Digital Platforms

• Nikshay Portal: Web-based notification and patient management database. Mandatory for both public and private health facilities.
• Nikshay Poshan Yojana: Direct Benefit Transfer (DBT) scheme providing ₹500 per month to all registered TB patients throughout anti-TB treatment duration for nutritional support.
• Tuberculosis Preventive Treatment (TPT): Recommended for all household contact children <5 years, HIV-infected individuals, and household contacts ≥5 years with positive TST/IGRA after ruling out active TB. Regimen: Isoniazid daily for 6 months (6H) or Isoniazid + Rifapentine weekly for 12 weeks (3HP).

2. National Vector Borne Disease Control Programme (NVBDCP)

NVBDCP is an umbrella program for the prevention and control of 6 major vector-borne diseases in India:

1. Malaria
2. Dengue
3. Chikungunya
4. Japanese Encephalitis (JE)
5. Kala-azar (Visceral Leishmaniasis)
6. Lymphatic Filariasis

A. Malaria Elimination Strategy (NFME 2016–2030)

India aims for zero indigenous malaria cases by 2030. Districts are stratified based on API:

• Category 0 (Prevention of Re-introduction): 0 cases.
• Category 1 (Elimination Phase): API < 1 per 1,000 population.
• Category 2 (Pre-elimination Phase): API 1 to 2 per 1,000 population.
• Category 3 (Intensified Control Phase): API ≥ 2 per 1,000 population.

Anti-Vector Measures under NVBDCP

• Indoor Residual Spraying (IRS): Applied to indoor wall surfaces where mosquitoes rest. Carried out in high-risk areas (API ≥ 2). Insecticides used: Synthetic Pyrethroids (Alphacypermethrin, Deltamethrin), Malathion (5%), or DDT (50% WP). Minimum 2 rounds required during transmission season, achieving >85% room coverage.
• Long-Lasting Insecticidal Nets (LLINs): Impregnated with pyrethroids (e.g., Deltamethrin, Permethrin) bound to synthetic fibers. Effective for 3 years or 20 washes without re-treatment. Distributed free of charge in areas with API ≥ 1.
• Biological Control: Introduction of larvicidal fish—Gambusia affinis (top feeding minnow) and Poecilia reticulata (guppy)—into slow-flowing streams, wells, and large water bodies. Chemical larviciding uses Temephos (Abate) or Bacillus thuringiensis israelensis (Bti).

B. Kala-azar (Visceral Leishmaniasis) Elimination Programme

• Agent: Leishmania donovani (protozoan parasite).
• Vector: Phlebotomus argentipes (Sandfly). Breeds in moist, organic-rich soil, cracks in mud walls, and cattle sheds. Extremely small size (1.5–3.5 mm).
• Endemic Focus: Bihar, Jharkhand, West Bengal, and Eastern Uttar Pradesh.
• Elimination Target: <1 case per 10,000 population at the Block level.
• Diagnostic Tool: rK39 Immunochromatographic Rapid Diagnostic Test (detects antibodies against 39-amino-acid recombinant leishmanial antigen).
• First-Line Treatment: Single intravenous infusion of Liposomal Amphotericin B (10 mg/kg).
• Vector Control: 2 rounds of Indoor Residual Spraying (IRS) with Synthetic Pyrethroids (Deltamethrin) up to a height of 6 feet on indoor wall surfaces.

C. Lymphatic Filariasis Elimination Programme

• Agent in India: Wuchereria bancrofti (99% of Indian cases) and Brugia malayi (1%, localized to coastal Kerala/Odisha).
• Vector: Culex quinquefasciatus (breeds in dirty, polluted, stagnant water, sewage, and cesspools).
• Elimination Target: Microfilaria (Mf) rate < 1% in endemic districts.
• Mass Drug Administration (MDA) Strategy:
  • Triple Drug Therapy (IDA Regimen): Administered once annually in target endemic districts to all individuals aged ≥2 years (excluding pregnant women and critically ill):
    1. Ivermectin: 200 µg/kg body weight (height-based dosing chart).
    2. Diethylcarbamazine (DEC): 6 mg/kg body weight.
    3. Albendazole: 400 mg fixed single dose.
• Morbidity Management & Disability Prevention (MMDP): Foot hygiene, anti-fungal cream, and limb elevation for Lymphedema; hydrocelectomy for Hydrocele cases.

D. Japanese Encephalitis (JE) Control Strategy

• Agent: Flavivirus.
• Vector: Culex tritaeniorhynchus and Culex vishnui group. Breeds extensively in paddy fields and flooded vegetated water bodies.
• Amplifier Host: Pigs and wild water birds (herons, egrets). Humans are dead-end hosts.
• Vaccination: SA-14-14-2 (live attenuated cell-culture derived vaccine) under the Universal Immunization Programme. 2 doses: Dose 1 at 9 completed months (along with MR-1) and Dose 2 at 16–24 months.