Trainers' Guide for CHO/MPW-PHI Course on NTEP

Introduction and Overview of course    
(The course structure should be explained that there are 3 modules and modules are further divided into chapters)

NOTE: This session may be used as an ice-breaking session and to establish a rapport with the participants. It may also be emphasized here the importance of pre-test, quizzes and post-test assessment to successfully finish the course and obtain the certificate.

Emphasis points during the session

• Burden of TB Disease in terms of new cases, deaths and suffering
• The causative bacteria  
• Mode of transmission, risk factors for TB Disease, progression to TB disease
• 4 major symptoms of Pulmonary TB and how to enquire about these symptoms.
• The difference between TB infection and active TB disease.
• General Principles for Prevention of TB
  
  Post Session activity:  
• Facilitator may ask the audience one after the other "50-Year-old ASHA died due to TB. Why did she die?". Write responses on board and classify them into biological, behavioural, socio-economic and occupational determinants.
• Trainees may be asked about difference between TB infection and active TB disease.
• Ask any one trainee to enumerate the 4 symptoms and may ask other trainees to explain the meaning of each symptom.

Emphasis points during the session

• The goals of NTEP.
• The TB Unit and its significance and the HR posted there.
• The TB patient care cascade and their interaction with the health system.
• The role of the CHO in NTEP
• The Role of the CHO in TB prevention
• Post Session Activity:  
• Ask the participants to enumerate and various stages of TB patient care ecosystem and what all activities are carried out in each of the stage.

Emphasis points during the session

•  Types of TB disease on the basis of sites of TB disease, on the basis of diagnosis, on the basis of drug resistance. The various sites of EPTB may be mentioned and explained in local language/context.
• Identifying Presumptive Pulmonary TB using the 4 Symptom complex of TB 
• Process of referral for testing and specimen collection and transport.
• Discuss briefly about the different tests available for diagnosis of TB.
• Discuss the video on the sputum collection.
• Discuss in brief the approaches to TB case finding.

Post Session Activity:  

• Ask the participants to enumerate the 4 chief symptoms of PTB and explain each of the symptom.
• May ask one of the participants to demonstrate how they would refer a case and sample for testing.
• Ask the participants about the dos and don'ts regarding sputum collection.

Emphasis points during the session

• Nikshay portal and various features available in it which are relevant to treatment-supporters.
• Explain the trainees the pre-requisites and process to get themselves registered on Nikshay platform  
   

Post Session Activity:  
1.    The Nikshay Mobile app may be demonstrated.

Emphasis points during the session

• TB Arogya Sathi Application and steps to download it. Discuss the two UI- citizen centric and patient centric.
• Discuss how to look for the nearest health facility providing different services related to TB care.
• Discuss how to screen self and others using the TB Arogya Sathi- screening tool. Also explain that facility for self-enrolment is available using this tool.
• Discuss how to access the patient UI- after login using the Patient ID and the details available under that login- Treatment details, adherence details and DBT details.
• Discuss how patient can mark and monitor adherence in Ni-kshay using the patient UI on TB Arogya Sathi Application.
• Discuss how patients can enter/modify the DBT details using the Patient UI on TB Arogya Sathi application.
   

Post Session Activity:  

• The TB Arogya Sathi App may be demonstrated to participants or videos can be displayed at the end of session.
• The use of TB Screening tool in TB Arogya Sathi app may be demonstrated and the utility of this tool in enrolment of presumptive TB. 
• Participants may be asked to demonstrate the use of application and clear their doubts.

Emphasis points during the session

• Discuss the overview of patient management workflow in Ni-kshay
• Discuss the different processes- Enrolment with complete demographic details (with importance of each field), Deduplication, adding a test request, entering specimen details, patient management and Task list on Ni-kshay.

Post Session Activity:  
1.    The above-mentioned functionalities should be demonstrated and few of the participants should be asked to do different data entries in demo Ni-kshay version.

URL: demo.nikshay.in

Username: tbu-kadha01

Password: Test@123

A short role play with the trainees to explain the process of screening and case finding, identifying the presumptive cases, and referring them to the nearest DMC for TB diagnosis. The trainer may act as the case/patient and one participant may act as an ASHA.

Scenario Brief

• On a routine community visit, ASHA came to know about Ashish who works in a brick kiln on daily wages. Ashish has been coughing and unexplained weight-loss for more than a month. He’s also reluctant to get tested and is relying on a nearby Pharmacist to get a cure for his long-standing cough issues.

Probes:

• Identification of vulnerable population
• Enquiring about the chief symptoms of Pulmonary TB and signs and symptoms of EPTB (with constitutional symptoms life fever, night sweats and weight loss)
• Information about nearest testing facilities and process of sputum collection
• Provision for free diagnostic and treatment services and patient support for TB patients.
• Educating the patients and family about the signs and symptoms of TB disease and addressing their doubts and concerns.
• How the enrolment, referral for testing and sample is collected and transported through Ni-kshay

Emphasis points during the session

• Explain about the first line anti TB Drugs
• Discuss about the treatment phases in TB treatment.
• Discuss about the FDCs used in NTEP and the advantages.
• Discuss about the various TB drug regimens.

Post session activity:

• Have a practical demo of the drug formulations (blister packs/ pouches/ FDCs) of an Adult and paediatric DSTB Treatment regimen.

Chapter 8: DS-TB Treatment and care

Emphasis points during the session

• Explain Drug Sensitive Tuberculosis and the treatment phases.
• Describe the treatment regimen for Drug-Sensitive TB (DS-TB) – Adult FDC & Paediatric formulations.
• Explain the patient flow for DSTB Treatment
• Explain the various Adverse drug reactions and their management.
• Explain the follow-up of TB patient on DS-TB treatment.
• Explain about the treatment outcomes of the patient on DS-TB treatment.

Post session activity:

• The participants may be asked to enumerate common ADRs to first anti-TB treatment and subsequent action by the CHO/MPW

Emphasis points during the session

• Explain the DR-TB and the factors that lead to development of DR-TB.
• Explain about the screening process for DR-TB
• Discuss the different regimens available for DR-TB treatment.

• Explain the Adverse Drug Reactions to drugs used in DR-TB Treatment and its identification, management and timely referral to health facility. (It may also be emphasized here that the DR-TB treatment is more complex and involves more toxic drugs, hence ADRs are more frequent and there is need to identify the ADRs early and manage these at nearest health facilities/referral centre to N/DDR-TB centre.)

  Post session activity:

• The participants may be asked to enumerate common ADRs to first anti-TB treatment and subsequent action by the CHO/MPW

Emphasis points during the session

• The meaning and importance of Treatment Adherence.
• The various options available to record patient adherence.
• Monitoring of adherence in Nikshay
• The recording of adherence and missed dose in Nikshay portal.
• The role of Health Volunteers in TB Treatment and care.

Post session activity:

• One-two participants may be asked about how they enquire about adherence to TB patients. 
• Adherence recording and monitoring can be demonstrated through Nikshay app or through videos)

Scenario 1: Mr Ashish who is diagnosed with TB has been initiated on first-line ATT. He was hesitant to start treatment after learning about his TB disease. He lives in an over-crowded chawl with poor hygiene.  
ASHA visits him on Day-5 after his treatment initiation. She speaks to him and convinces him to continue the treatment. She further discovers that Ghanshyam (father of Ashish) who has diabetes is also living in the same household.

Probes: 
1. Whether DBT has been initiated or not 
2. Identification of ADR. (The different ADRs may be explained and enquired about) 
3. Importance of adherence 
4. Contact tracing also needs to be carried out 
5. TPT and its eligibility. 
6. Counselling about TB to Ashish and his family. 
7. The need to control blood sugar of Ghanshyam 

Scenario: 2: ASHA visits Ashish’s house after 7 weeks after his treatment initiation. He is now feeling healthy. His TB symptoms have subsided and he has gained weight. He is now thinking about taking up some construction work in some far off place in Mumbai.

Probes  
• Identification of ADRs if any 
• Change in weight and accordingly change in dosages. 
• Importance of follow-up at DMC for end of IP lab investigation. 
• The option of transferring the treatment centre for TB care and management.  
• Importance of adhering to the ongoing treatment and recording it electronically.

Key message at the end of role play : 
In the form of summary and important areas to be covered while visiting a patient after his treatment initiation. Need to take healthy food and even if they feel healthy, they shouldn’t stop the treatment

Emphasis points during the session

• The concept of Public Health action
• Various components of PHA carried out under NTEP for a diagnosed TB patient
• The contact tracing and investigation carried out for TB patient under NTEP
• Tasks are carried out by Health Staff on home visit to a TB patient.
• The meaning of Treatment Supporter and who qualifies to be TS to a TB patient

Post Session activity

• Ask the participants to enumerate the 6 public health actions that are carried out after the TB Notification
• Ask other participants to explain each of the PHAs

• Explain the importance of TB awareness generation in community and how it is carried out in community
• Describe counselling for TB patients, at what stages it is carried out and what components are explained during different stages of TB treatment and care
• Explain Do's and Don'ts for Patient Communication
• Explain Nutritional Counselling and its importance related to TB patients

Post Session activity.

1. Give the participants different scenarios (Like pre-treatment/During treatment/post-treatment) and Ask the different participants about the components of counselling at different scenarios.

• Explain about the Stigma and discrimination faced by TB patients and its adverse effects at individual level and community level.
• Explain the gender aspects of TB and hoe to address gender inequalities.
• Explain about various wellness activities meant for TB patients

• Explain the meaning of community engagement and its importance in TB care.
• Explain about the various strategies of Community engagement in NTEP
• Explain about the TB champions.

Post Session activity

• Ask the participants, in what ways the TB Champions help the TB patients.

• Explain the meaning of DBT
• Explain the DBT schemes in NTEP including NPY, Tribal SS, TS honarium and incentives for notifications and outcomes
• Explain the various criteria for availing DBT Scheme benefits under NPY

Scenario: 

A newly diagnosed TB patient initiated on treatment comes to his hometown for home based care and treatment. ASHA worker visits his home to verify his address and upon enquiring with neighbours she learnt that Ashish is being stigmatised for contracting TB and his family is being discriminated against. Now ASHA has to give correct information regarding TB to the neighbourhood.

Probes:  
Correct information about TB  
Appreciation for Ashish to initiate the treatment early.  
Motivating the community to support Ashish and his family.  
Counselling to Ashish and his family to prevent TB infection.  
Complete PHA  
Precautions to be taken while visiting a TB patient’s home.

All module content will be covered in this quiz. 

Completion of this final quiz successfully, along with the two quizzes in-between the course is mandatory for certificate generation