India

India has more new tuberculosis (TB) cases annually than any other country, ranking first among the 22 high-burden TB countries worldwide, according to the World Health Organization’s (WHO’s) Global TB Report 2008. TB remains one of the leading infectious causes of mortality in India, causing more than 325,000 deaths in 2006. There were more than 1.9 million new TB cases in India in 2006, representing more than 21 percent of all TB cases worldwide. The estimated incidence rate in 2006 was 168 new cases per 100,000 population. India began the Revised National Tuberculosis Control Program (RNTCP) with DOTS (directly observed treatment, short course) implementation in 1997. DOTS coverage increased from 30 percent in 2000 to 100 percent in 2006, and the case detection rate increased from 12 to 64 percent during the same period. India’s challenges are to sustain and improve the quality of DOTS, expand services to manage multidrug-resistant (MDR) TB, and develop stronger links between TB and HIV/AIDS services and control activities. The RNTCP recently introduced MDR-TB services as part of routine program activities. Successful implementation will depend however on the capacity of laboratories for diagnosis and a reliable supply of second-line drugs for treatment. According to WHO, there were more than 110,000 cases of MDR-TB in 2006, half of which occurred among new TB cases. This represents more than 20 percent of the global burden. Extensively drugresistant (XDR) TB was first reported in India in July 2007, and MDR-TB and XDR-TB are potential threats to TB control activities in the country.

USAID Approach and Key Activities

To address the TB epidemic, India has rapidly expanded the RNTCP. Between 2000 and 2005, USAID funding for TB programming in India averaged $3.5 million per year and increased to $4.7 million in fiscal year (FY) 2007. USAID supports state-level capacity building for TB control, including training TB personnel on diagnosis, treatment, and laboratory protocols. It strengthens the laboratory network’s capacity to diagnose TB and identify drug-resistant strains of TB through enhanced capability for myco-bacterial culture and drug susceptibility testing. USAID is also strengthening advocacy and communication through establishment of a national-level, multisectoral partnership dedicated to TB control. At the community level, USAID is engaging and empowering communities to have a greater role in TB control and care through improved knowledge and participation. USAID’s assistance includes the following activities and interventions:

• Enhancing national-level planning, monitoring, and supervisory capacity
• Supporting education of health personnel in all aspects of DOTS, policy reform, and advocacy
• Strengthening TB surveillance and upgrading laboratory capacity for drugresistant TB diagnosis and quality assurance for smear microscopy
• Improving TB drug management
• Updating national strategies and plans formulated to address the challenges of MDR-TB and TB-HIV/AIDS
• Strengthening the technical capacity of RNTCP, leading to sustained quality of DOTS services and improved access to diagnosis and treatment, including management of MDR-TB and HIV care
• Enhancing private sector involvement in RNTCP
• Building capacity in TB-HIV/AIDS activities and operations research
• Strengthening advocacy and communication and mobilizing communities through local nongovernmental organizations’ networks
• Facilitating the engagement of more than 260 medical colleges through support to six medical college task forces that provide services to the RNTCP services and incorporate DOTS in their academic curricula
• Supporting the WHO/Tuberculosis Research Centre (ICMR) collaborative Model DOTS Project and provides technical assistance to ICMR

USAID Program Achievements

USAID’s program has contributed to substantial improvements in human and infrastructure capacities to implement DOTS. Achievements have included the following:

• Expanded DOTS implementation to cover 24 million people in the north Indian state of Haryana
• Enabled Haryana to exceed targets for cure rates and register more than 13,000 new smear positive pulmonary TB patients for treatment in FY07
• Established and equipped the state-level Intermediate Reference Laboratory for conducting TB culture and drug susceptibility testing in Haryana and established more than 200 microscopy centers in Haryana
• Facilitated establishment of a functional state TB office and 19 district TB centers with district- and subdistrict-level drug stores in Haryana
• Catalyzed the successful involvement of the medical colleges in the RNTCP by facilitating the creation of a task force mechanism and by supporting the meetings of the national task force and of the five zonal task forces
• Supported studies on biological and behavioral risk factors, community surveillance, pediatric TB, suspect TB identification, diagnostic algorithms, and MDR-TB management, which resulted in improvements to national TB policies and guidelines
• Supported applied and operational TB research at the ICMR
• Supported a WHO staff to provide technical assistance to RNTCP, specifically in policy and technical guideline development, and to monitor the proposed activities supported by USAID
• Supported a proportion of the WHO network of field consultants to provide technical assistance to RNTCP for the implementation and monitoring of the core RNTCP activities in the states and districts

Note: DOTS treatment success rate for 2006 will be reported in the 2009 global report. Source: Global Tuberculosis Control: Surveillance, planning, financing:WHO Report 2008.

Partnerships

USAID partners in TB control include the Indian Government’s RNTCP, the Indian Clinical Epidemiology Network, the Indian Medical Association, the RNTCP’s Medical College task forces and individual medical colleges, and the WHO Stop TB unit. WHO leads the technical collaboration of external partners. In addition to USAID, other key donors include the World Bank and the U.K. Department for International Development. India has received four grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria. The most recent grant (Round 6) was approved in June 2007 for $26.3 million for consolidating and scaling up RNTCP interventions in three states of India, which have a combined population of more than 62 million, along with a publicprivate collaboration project via the Indian Medical Association.

January 2009

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Related Links

• USAID Overview of India