Lok Sabha Question No. 972 (UNSTARRED), answered on 2016-07-22
Subject: Cases of TB and MDR-TB
Ministry: HEALTH AND FAMILY WELFARE
Asked by: KUNWAR SARVESH  KUMAR

## GOVERNMENT OF INDIA MINISTRY OF HEALTH AND FAMILY WELFARE DEPARTMENT OF HEALTH AND FAMILY WELFARE

LOK SABHA UNSTARRED  QUESTION NO. 972 TO BE ANSWERED ON 22 ND JULY, 2016

## CASES OF TB AND MDR - TB

## 972. KUNWAR SARVESH KUMAR:

Will the Minister of HEALTH AND FAMILY WELFARE be pleased to state:

- (a)  the  number  of  cases  of  Tuberculosis  (TB)  and  Multi - Drug  Resistant  TB  (MDRTB)  and attributable deaths reported in the country during each of the last three years and the cu State/UT - wise;
- (b)  the  st eps  taken/proposed  to  be  taken  by  the  Government  for  identification,  detection treatment of TB/MDR - TB cases along with the funds allocated and utilised therefor during said period, State/UT - wise;
- (c) whether the Government has set any target to c ontrol and eliminate tuberculosis, if so, the details thereof and the action plan drawn by the Government for the purpose, State/UT - wise;
- (d)  whether  as  per  the  findings  of  a  latest  study,  use  of  Xpert  molecular  test  as diagnostic  test  for  TB in  public  health  facilities  increased  the  rate  of  notification  of  T rifampicin resistant TB cases in the country; and
- (e) if so, the details thereof along with the corrective measures being taken by the Governm include the same in country's TB control programme?

## ANSWER THE MINISTER OF STATE IN THE MINISTRY OF HEALTH AND FAMILY WELFARE (SHRI FAGGAN SINGH KULASTE )

- (a): The details of the number of Tuberculosis (TB) and Multi - Drug Res stant TB (MDRTB) and deaths reported in the country during the last three years and the current year, State under RNTCP is annexed (Annexure -I,II,III,IV).
- (b): Government of India, a long with State Governments, has been implementing the Revised National Tuberculosis Control Programme in the country which since 2005 is under the aegi the National Health Mission. The goal of the programme is to attain universal access to quality assured diagnosis and treatment of tuberculosis.

Under  the  programme,      more  than  13000  designated  microscopy  centres  have  been established for quality diagnosis of TB. Treatment for drug sensitive TB is provided th network  of  DOT  Centres  whe re  a  dedicated  box  containing  complete  course  of  treatment  is available  for  each  patient.  Most  government  hospitals,  Community  Health  Centres  (CHC Primary Health Centres (PHC), Sub Centres (SC) function as DOT centres. In addition NGO Private  Practitio ners  (PPs)  involved  under  the  RNTCP,  community  volunteers,  Anganwadi workers, women self - help groups etc. also function as DOT providers/DOT Centres. Drugs are provided under direct observation and the patients are monitored to facilitate adherenc completion of treatment.

Programmatic Management of Drug Resistant TB (PMDT) Services under RNTCP were initiated in India from year 2007 and the entire country was covered by 2013. Diagnosis o Resistant TB is conducted through quality assured drug susceptibility testing at 65 Culture and Drug Susceptibility Testing (C & DST) laboratories, in addition to availability of rapid m tests  like  Line  Probe  Assay  (LPA)  and  Cartridge  Based  Nucleic  Acid  Amplification  Te (CBNAAT).

The programme also addresses co - morbidities with TB.  TB was made notifiable vide Government Order No Z28015/2/2012 - TB dated 7th May 2012. A case based web based online application  'Nikshay'  has  been  implemented  to  improve  surveillance  and  facilitate  case notification.

RNTC P strategy is multi - pronged and includes, inter alia, the following :

- strengthening and improving quality of basic DOTS services
- addressing TB HIV co - infection, other co - morbidities and MDR - TB
- engaging with care providers both in the public and the priva te sector
- targeted intervention in the vulnerable population and strengthening urban TB control
- integrating newer molecular diagnostics for TB  in the health system for early diagn MDR TB
- introducing newer anti - tuberculosis drug, Bedaquiline
- expansion of Programmatic Management of Drug Resistant Tuberculosis  (PMDT) services
- aligning the Tuberculosis Units with Block Units under National Health Mission (NHM) rationalizing  the  available  resources  and  integration  of  TB  services  in  the  genera l  health system
- leveraging  of  Information  Communication  Technology  (ICT)  for  TB  notification  and strengthening of monitoring.
- The details of funds allocated and utilized are placed at Annexure - V.

(c):   The targets have been defined as per the Sustainabl e Development Goal for 2030, which aims in reducing morality rate by 90% and TB incidence rate by 80% as compared to 201 Targets  for  End  TB  Strategy  for  2035  which  aims  in  reducing  mortality  rate  by  95%, incidence rate by 90% as compared to 2015 and n o TB affected families face catastrophic costs due to TB by 2020.

(d) & (e):   In a study undertaken to assess the impact of up - front Xpert MTB/RIF testing on detection of pulmonary tuberculosis and rifampicin - resistant cases of pulmonary TB in India, it was found that introduction of Xpert MTB/RIF as initial diagnostic test for TB in public facilities significantly increased case notification rates of all bacteriologically confi rifampicin resistant TB case notification. Under  the  RNTCP,  Cartridge  Based  Nucleic  Acid Amplification  Test  (CBNAAT)  or  Xpert  molecular  test  is  used  for  testing  patients presumptive  Drug  resistant  Tuberculosis  (DRTB)  and  Tuberculosis  preferentially  in population such as PLHIV, children and extra - pulmonary TB. The data available with the TB control programme suggested its value addition.  The programme has 628 CBNAAT machines across the country.

|   S No | State/UTs            | 2013          | 2014          | 2015          | Upto March 2016   |
|--------|----------------------|---------------|---------------|---------------|-------------------|
|      1 | Andaman & Nicobar    | 738           | 756           | 584           | 127               |
|      2 | Andhra Pradesh       | 103707        | 88638         | 61758         | 16552             |
|      3 | Arunachal Pradesh    | 2500          | 2691          | 2748          | 599               |
|      4 | Assam                | 35624         | 38317         | 38014         | 8761              |
|      5 | Bihar                | 67020         | 67991         | 64928         | 16067             |
|      6 | Chandigarh           | 2890          | 2869          | 3143          | 743               |
|      7 | Chhattisgarh         | 25889         | 28864         | 29950         | 7663              |
|      8 | Dadar & Nagar Haveli | 411           | 450           | 487           | 139               |
|      9 | Daman & Diu          | 742           | 279           | 284           | 90                |
|     10 | Delhi                | 50727         | 54037         | 55260         | 15253             |
|     11 | Goa                  | 1778          | 1660          | 1599          | 426               |
|     12 | Gujarat              | 74086         | 77395         | 82585         | 22096             |
|     13 | Haryana              | 38104         | 39498         | 40913         | 9717              |
|     14 | Himachal Pradesh     | 13691         | 14441         | 14333         | 3449              |
|     15 | Jammu & Kashmir      | 11038         | 10243         | 9873          | 2484              |
|     16 | Jharkhand            | 34941         | 35907         | 34792         | 8417              |
|     17 | Karnataka            | 61446         | 61328         | 59932         | 15453             |
|     18 | Kerala               | 24204         | 23439         | 22785         | 5458              |
|     19 | Lakshadweep          | 23            | 27            | 40            | 15                |
|     20 | Madhya Pradesh       | 92420         | 100034        | 103108        | 24430             |
|     21 | Maharashtra          | 137237        | 135465        | 130874        | 32925             |
|     22 | Manipur              | 2329          | 2198          | 1881          | 427               |
|     23 | Meghalaya            | 5002          | 4944          | 4674          | 1011              |
|     24 | Mizoram              | 2005          | 1993          | 2088          | 531               |
|     25 | Nagaland             | 3339          | 3298          | 3316          | 759               |
|     26 | Orissa               | 45269         | 45777         | 45814         | 11696             |
|     27 | Pondicherry          | 1458          | 1409          | 1288          | 369               |
|     28 | Punjab               | 37258         | 38152         | 38625         | 9397              |
|     29 | Rajasthan            | 94698         | 94908         | 90296         | 21900             |
|     30 | Sikkim               | 1637          | 1630          | 1400          | 379               |
|     31 | Tamil Nadu           | 80407         | 84570         | 80543         | 21227             |
|     32 | Telangana            | -             | 18655*        | 39498         | 10028             |
|     33 | Tripura              | 2540          | 2507          | 7394          | 563               |
|     34 | Uttar Pradesh        | 256733        | 255364        | 246589        | 64497             |
|     35 | Uttarakhand          | 13700         | 14429         | 14317         | 3477              |
|     36 | West Bengal TOTAL    | 90423 1416014 | 89819 1443942 | 87468 1423181 | 21086 358211      |

Annexure-II State/UT wise TB deaths reported in the last three years and current year

| State             | 2012   | 2013   |   2014 |   2015# |
|-------------------|--------|--------|--------|---------|
| Andaman & Nicobar | 34     | 18     |     38 |       8 |
| Andhra Pradesh    | 5439   | 5169   |   3089 |     689 |
| Arunachal Pradesh | 65     | 67     |     68 |      24 |
| Assam             | 1648   | 1678   |   1759 |     412 |
| Bihar             | 2125   | 2139   |   1914 |     469 |
| Chandigarh        | 82     | 65     |     48 |      20 |
| Chhatisgarh       | 1085   | 782    |   1350 |     394 |
| D & N Haveli      | 12     | 15     |     18 |       5 |
| Daman & Diu       | 7      | 8      |      9 |       3 |
| Delhi             | 1241   | 1316   |   1281 |     340 |
| Goa               | 75     | 76     |     52 |      13 |
| Gujarat           | 3808   | 4094   |   4312 |    1174 |
| Haryana           | 1649   | 1628   |   1709 |     405 |
| Himachal Pradesh  | 521    | 518    |    537 |     141 |
| Jammu & Kashmir   | 337    | 303    |    292 |      75 |
| Jharkhand         | 1341   | 1332   |   1465 |     311 |
| Karnataka         | 4542   | 4356   |   4348 |    1013 |
| Kerala            | 1205   | 1158   |   1084 |     239 |
| Lakshadweep       | 1      | 1      |      2 |       0 |
| Madhya Pradesh    | 2966   | 3174   |   3574 |     932 |
| Maharashtra       | 7687   | 7716   |   7629 |    1814 |
| Manipur           | 72     | 73     |     75 |      19 |
| Meghalaya         | 213    | 202    |    190 |      46 |
| Mizoram           | 79     | 77     |     87 |      26 |
| Nagaland          | 91     | 201    |     77 |      17 |
| Orissa            | 2405   | 2332   |   2451 |     584 |
| Puducherry        | 78     | 66     |     64 |      15 |
| Punjab            | 1925   | 1678   |   1989 |     474 |
| Rajasthan         | 3592   | 3599   |   3428 |     877 |
| Sikkim            | 82     | 47     |    222 |       9 |
| Tamil Nadu        | 3865   | 4005   |   4095 |     997 |
| Telangana         | -      | -      |   2050 |     558 |
| Tripura           | 150    | 106    |    141 |      30 |
| Uttar Pradesh     | 7866   | 7946   |   8736 |    2386 |
| Uttarakhand       | 552    | 500    |    537 |     132 |
| West Bengal       | 5047   | 5184   |   4506 |    1063 |
| Total             | 61887  | 61629  |  63226 |   15714 |

Under RNTCP, TB Patient who died during the course of treatment regardless of cause is declared as 'Died'

#Treatment outcomes of patients registered as drug sensitive TB under RNTCP are reported 13-15 months after initiation of treatment, hence data upto 2015 has been provided upto March 2015.

## Annexure III

## MDR cases initiated on treatment under RNTCP (2013 - 2016)

| State             |   2013 |   2014 |   2015 |   2016 (till March) |
|-------------------|--------|--------|--------|---------------------|
| Andaman & Nicobar |     21 |     39 |     46 |                  16 |
| Andhra Pradesh    |    905 |    704 |    632 |                 214 |
| Arunachal Pradesh |    171 |    206 |    171 |                  59 |
| Assam             |    388 |    360 |    424 |                  66 |
| Bihar             |    551 |    978 |   1287 |                 319 |
| Chandigarh        |     43 |     44 |     36 |                  20 |
| Chhattisgarh      |    125 |    141 |    183 |                  39 |
| Delhi             |   1278 |   1572 |   1566 |                 397 |
| Goa               |     42 |     37 |     43 |                  13 |
| Gujarat           |   1660 |   1971 |   1860 |                 537 |
| Haryana           |    505 |    561 |    659 |                 146 |
| Himachal Pradesh  |    248 |    236 |    192 |                  40 |
| Jammu & Kashmir   |    130 |     97 |     97 |                  22 |
| Jharkhand         |    257 |    225 |    206 |                  50 |
| Karnataka         |    717 |    733 |    938 |                 205 |
| Kerala            |    223 |    199 |    180 |                  41 |
| Madhya Pradesh    |    814 |   1126 |   1278 |                 193 |
| Maharashtra       |   4687 |   5072 |   5878 |                1685 |
| Manipur           |     56 |     38 |     35 |                  14 |
| Meghalaya         |    134 |    204 |    189 |                  53 |
| Mizoram           |     29 |     47 |     47 |                   7 |
| Nagaland          |     77 |     76 |     63 |                  11 |
| Orissa            |    206 |    244 |    262 |                  55 |
| Puducherry        |     18 |     28 |     13 |                   2 |
| Punjab            |    463 |    436 |    446 |                 122 |
| Rajasthan         |   1822 |   1681 |   1728 |                 384 |
| Sikkim            |    226 |    242 |    203 |                  63 |
| Tamil Nadu        |   1287 |   1164 |   1031 |                 293 |
| Telangana         |    720 |    769 |    728 |                 141 |
| Tripura           |     10 |     14 |     16 |                   3 |
| Uttar Pradesh     |   1859 |   2799 |   4663 |                1128 |
| Uttarakhand       |    182 |    281 |    303 |                  49 |
| West Bengal       |   1288 |   1798 |   1563 |                 398 |
| Grand Total       |  21142 |  24122 |  26966 |                6785 |

## MDR cases died and reported under RNTCP (2013 - 2015)

| State             | 2013   |   2014 |   2015# |
|-------------------|--------|--------|---------|
| Andaman & Nicobar | --     |      5 |       6 |
| Andhra Pradesh    | 67     |    108 |     236 |
| Arunachal Pradesh | --     |      7 |       8 |
| Assam             | --     |     55 |      69 |
| Bihar             | --     |    113 |      84 |
| Chandigarh        | --     |      5 |      11 |
| Chhattisgarh      | --     |     27 |      18 |
| Delhi             | 66     |    162 |     270 |
| Goa               | --     |      8 |       6 |
| Gujarat           | 173    |    295 |     386 |
| Haryana           | 17     |     87 |      93 |
| Himachal Pradesh  | 7      |     21 |      37 |
| Jammu & Kashmir   | --     |     13 |      19 |
| Jharkhand         | 4      |     19 |      49 |
| Karnataka         | --     |    129 |     120 |
| Kerala            | 16     |     27 |      39 |
| Madhya Pradesh    | --     |    179 |     129 |
| Maharashtra       | 75     |    768 |    1008 |
| Manipur           | --     |      2 |       4 |
| Meghalaya         | --     |     26 |      26 |
| Mizoram           | --     |      6 |       5 |
| Nagaland          | --     |      6 |      10 |
| Orissa            | 7      |     25 |      20 |
| Puducherry        | 1      |     11 |       4 |
| Punjab            | --     |     83 |      88 |
| Rajasthan         | 44     |    281 |     497 |
| Sikkim            | --     |     21 |      16 |
| Tamil Nadu        | 39     |    170 |     311 |
| Telangana         | --     |    140 |     134 |
| Tripura           | --     |      2 |       3 |
| Uttar Pradesh     | 7      |    469 |     202 |
| Uttarakhand       | --     |     32 |      22 |
| West Bengal       | 46     |    193 |     176 |
| Grand Total       | 569    |   3495 |    4106 |

Under RNTCP, MDR-TB Patients who died during the course of treatment regardless of cause is declared as 'Died'

#Treatment outcomes of patients registered as MDR TB under RNTCP are reported 31-33 months after patients in the respective cohort started treatment, hence patients started on treatment upto 2012 and reported in 2015 has been provided.

In 2013, a few states have not reported death in MDR-TB because, services of MDR-TB was not initiated in these states in 2010.

## Annexure IV

## Revised National TB Control Programme

## State wise Allocation and Utilisation (cash and kind)

(Rs. In lakhs)

|             |                         | 2013- 14   | 2013- 14    | 2014- 15   | 2014- 15    | 2015- 16   | 2015- 16    | 2016- 17*   | 2016- 17*   |
|-------------|-------------------------|------------|-------------|------------|-------------|------------|-------------|-------------|-------------|
| Sl.No. Name | of the State / UT       | Allocation | Expenditure | Allocation | Expenditure | Allocation | Expenditure | Allocation  | Expenditure |
| 1           | Andhra Pradesh          | 4907.34    | 3785.90     | 2861.96    | 2308.49     | 2200.34    | 2002.85     | 2194.68     | 376.80      |
| 2           | Andaman & Nicobar       | 87.15      | 59.49       | 87.15      | 88.34       | 90.90      | 110.86      | 90.90       | 3.54        |
| 3           | Arunachal Pradesh       | 565.36     | 451.14      | 565.36     | 580.95      | 552.32     | 585.22      | 564.48      | 43.91       |
| 4           | Assam                   | 4303.74    | 1505.54     | 4303.74    | 1549.79     | 2527.13    | 2622.95     | 2776.33     | 116.86      |
| 5           | Bihar                   | 4094.59    | 1729.66     | 4094.59    | 2589.91     | 2963.81    | 2757.19     | 2962.00     | 126.26      |
| 6           | Chandigarh              | 154.54     | 145.24      | 154.54     | 140.70      | 156.14     | 144.07      | 156.14      | 10.00       |
| 7           | Chattisgarh             | 1440.60    | 1183.97     | 1440.6     | 1540.53     | 1401.08    | 1587.32     | 1398.15     | 54.37       |
| 8           | D & N Haveli            | 68.05      | 48.83       | 68.05      | 50.68       | 72.03      | 67.59       | 72.03       |             |
| 9           | Daman & Diu             | 43.47      | 20.61       | 43.47      | 21.77       | 45.98      | 43.21       | 45.98       |             |
| 10          | Delhi                   | 1820.02    | 1325.35     | 1820.02    | 1350.22     | 1705.12    | 1605.19     | 1018.43     | 109.73      |
| 11          | Goa                     | 116.34     | 118.82      | 116.34     | 104.74      | 127.78     | 105.25      | 127.61      | 11.10       |
| 12          | Gujarat                 | 4857.52    | 6217.91     | 4857.52    | 4698.01     | 3298.04    | 5056.34     | 3282.10     | 739.11      |
| 13          | Haryana                 | 1292.26    | 796.49      | 1292.26    | 1419.57     | 1207.93    | 1093.27     | 1204.96     | 197.70      |
| 14          | Himachal Pradesh        | 581.22     | 532.05      | 581.22     | 515.31      | 837.57     | 834.98      | 833.82      | 96.37       |
| 15          | Jammu & Kashmir         | 943.43     | 644.8       | 943.43     | 552.05      | 1038.26    | 892.45      | 1036.78     | 40.87       |
| 16          | Jharkhand               | 1783.56    | 899.72      | 1783.56    | 1583.85     | 1512.16    | 1302.31     | 1511.23     | 61.80       |
| 17          | Karnataka               | 3195.23    | 2122.1      | 3195.23    | 2683.65     | 3186.19    | 3591.43     | 3177.65     | 299.99      |
| 18          | Kerala                  | 1440.91    | 1621.39     | 1440.91    | 1253.73     | 1395.33    | 1056.88     | 1393.01     | 79.87       |
| 19          | Lakshadweep             | 35.39      | 15.54       | 35.39      | 8.33        | 37.95      | 27.31       | 37.95       |             |
| 20          | Madhya Pradesh          | 3081.84    | 2394.38     | 3081.84    | 3893.81     | 2880.71    | 3287.48     | 2878.14     | 171.70      |
| 21          | Maharashtra             | 6657.74    | 6918.98     | 6657.74    | 9695.28     | 8085.75    | 8058.82     | 8059.40     | 1754.45     |
| 22          | Manipur                 | 657.22     | 333.91      | 657.22     | 398.06      | 524.57     | 398.77      | 548.31      | 21.31       |
| 23          | Meghalaya               | 550.67     | 309.31      | 550.67     | 457.57      | 427.62     | 441.28      | 453.95      | 50.68       |
| 24          | Mizoram                 | 414.39     | 366.75      | 414.39     | 385.20      | 392.75     | 341.42      | 402.29      | 10.00       |
| 25          | Nagaland                | 596.41     | 310.51      | 596.41     | 364.14      | 460.49     | 445.42      | 477.38      | 24.20       |
| 26          | Orissa                  | 2141.81    | 1335.27     | 2141.81    | 1856.30     | 1991.54    | 2053.24     | 1986.79     | 93.75       |
| 27          | Puducherry              | 183.56     | 167.48      | 183.56     | 172.27      | 187.88     | 163.47      | 110.57      | 8.27        |
| 28          | Punjab                  | 1207.19    | 1240.91     | 1207.19    | 1511.48     | 1273.22    | 1135.85     | 1270.01     | 193.12      |
| 29          | Rajasthan               | 3653.38    | 2450.25     | 3653.38    | 3375.79     | 2792.23    | 2741.05     | 2781.23     | 732.10      |
| 30          | Sikkim                  | 242.98     | 199.75      | 242.98     | 428.77      | 426.92     | 442.29      | 474.88      | 68.12       |
| 31          | Tamilnadu               | 3131.84    | 2756.03     | 3131.84    | 3850.35     | 3367.31    | 4028.96     | 3353.00     | 587.99      |
| 32          | Tripura                 | 583.71     | 165.49      | 583.71     | 172.88      | 290.20     | 259.18      | 300.38      | 3.23        |
| 33          | Uttar Pradesh           | 7631.54    | 6374.47     | 7631.54    | 10785.86    | 7350.90    | 11610.11    | 7337.90     | 703.86      |
| 34          | Uttrakhand              | 661.14     | 570.64      | 661.14     | 852.15      | 651.62     | 930.21      | 650.44      | 78.64       |
| 35          | West Bengal             | 3834.82    | 3574.16     | 3834.82    | 3253.00     | 3187.70    | 3513.61     | 3183.10     | 307.48      |
| 36          | Telangana               |            |             | 2045.38    | 814.87      | 1672.53    | 2462.18     | 1667.00     | 298.14      |
|             | Total                   | 66960.96   | 52692.84    | 52692.84   | 61534.97    | 65308.40   | 61730.46    | 67800.01    | 16557.89    |
| (Jharkhand  | Releases to NGOs/ Study | 1754.04    | 516.51      | 1754.04    | 405.13      | 1000.00    |             | 1287.53     | 0.00        |
|             | HQ Expenditure          | 2300.00    | 439.92      | 2300.00    | 1605.69     | 2680.00    | 1372.07     | 2893.47     | 143.19      |
|             | Grand Total             | 71015.00   | 53649.27    | 71015.00   | 67319.22    | 64000.00   | 69172.08    | 64000.00    | 7618.51     |