[Draft] Trainer's guide for the Course for MO-PHI on NTEP

[Draft] Trainer's guide for the Course for MO-PHI on NTEP

Introduction

Targeted Trainees: Medical Officer- PHI includes generally all Medical Officers placed at Government Health facilities at primary, secondary and tertiary levels. This does not include Medical Officers that have specified roles in the NTEP program, such as Medical Officers at, District / Nodal DRTB-Centres, Medical Colleges, MO-TC. 

Qualified Trainers: Trainers may be other Medical Officers at the District Level or above that are prior identified by State such as DTOs, MO-TCs who are in-turn trained on their cadre's corresponding course on NTEP. 

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. The Trainers should have completed their own cadre-wise course, thorough with this trainers guide and must possess strong knowledge about the NTEP, and the various processes related to patient workflow and Ni-kshay. The Trainers should be well versed with the supporting IT systems such as those for video conferencing (Zoom/ Teams/ Google meet), Learning Management System (Swasth-eGurukul), Ni-kshay, etc. 

Mode of Training: Training may be provided by utilizing the blended approach where a mix of training methods and modes may be used to execute the training. 

Training Institution: The training of MO-PHI is to be organized by the District TB Centre. 

Recommended Batch size: 25.

Training Duration: The training course content has 4 modules with a total of 18 chapters. A trainee needs to complete this course in about a total 16 hours. The Module wise breakup is provided below

Sr.

Module

Duration
1 Basics of TB and NTEP 2hrs 
2 Case Finding and Diagnosis 3hrs
3 TB Treatment and Management 7hrs
4 Program Management and Programmatic actions 4hrs

Chapter wise detailed instructions for Trainers

Module 1: Basics of TB and NTEP
Chapter 1.1 TB & TB Epidemiology Mode: Self Learning
Emphasis Points
  1. TB is an important public health problem for India and accelerating progress toward the END TB Targets (2015-2035) is a priority for the country
  2. Progression to TB disease exists as a continuum, with two distinct stages (infection and disease)
Post Session Activity

Ak trainees: "Compare and discuss the prevalence of TB in your state and India"

Refer to : National TB Prevalence survey 2019-2021 report, page 68 https://tbcindia.gov.in/WriteReadData/l892s/25032022161020NATBPSReport.pdf

If there are other state specific estimates, discuss that.
Chapter 1.2 NTEP Mode: Self Learning
Emphasis Points
  1. India's commitment to ENDING TB 5 years ahead of global Targets
  2. The PHI is a the 5th level in NTEP hierarchy; the only one responsible for actual service delivery. 
  3. The MO-PHI is the leader and program manager at this level for the population catered to by the PHI. 
Post Session Activity
  1. Discuss: Can a medical college be a PHI? Answer is yes.
  2. Ask one of the trainees to clarify what India is trying to achieve by 2025?  India has committed to prepone the SDGs related to Ending TB five years ahead. Tell them that 'Ending TB'' is different from ''Eliminating TB'' [Refer to https://ntep.in/node/115/CP-indias-commitment-end-tb]
Chapter 1.3 Information Systems in NTEP Mode: Self Learning
Emphasis Points
  1. Ni-kshay is the information system of the TB program
  2. It has different interfaces for various stakeholders ranging from Patient's to program managers
  3. The various stages in a person's care identified in Ni-kshay and the actions to be performed at each stage by which stakeholder.
Post Session Activity Request all trainees to log into Ni-kshay using their institution's login credentials. Ask them to list various modules they are seeing on the page after logging in.  
Module 2: Case Finding and Diagnosis
Chapter 2.1  General Concepts in TB Case Finding  Mode: Self Learning
Emphasis Points
  1. Highlight the various steps in case finding from screening to confirmation of diagnosis.
  2. The policy of and definitions bidirectional screening and UDST. 
Post Session Activity

Ask a few trainees: 'If you refer 10 individuals with TB symptoms for testing from the OPD, what proportion will actually undergo testing?" 

Ask a follow up question: "How do you know that the number is correct?" 

Ask a follow up question: "What could be done to ensure that 100% of the clients referred are tested?" [ Getting information of all individuals with presumed TB either in Ni-kshay or other methods, specimen collection and transportation to prevent the leaks in cascade of care, monitoring the results against the line list of individuals with presumed TB]
Chapter 2.2 Diagnostic Technologies and Lab Network Mode: Self Learning
Emphasis Points
  1. Rapid Molecular Test as a highly sensitive tool for diagnosis of TB
  2. Three tier hierarchy (NRL, IRL, Service Labs- NAAT/ C&DST /Microscopy)
  3. Role of Sputum/ Specimen Collection and Transportation Centre
Post Session Activity Arrange a Visit to (a) Microscopy Centre and understand the External Quality Assurance activities (RBRC, OSE) happening (b) CB NAAT facility and observe the testing process (c) TrueNAT facility and observe the testing process
Chapter 2.3  Diagnostic Specimen Mode: Self Learning
Emphasis Points
  1. Good quality sputum being mucopurulent, early morning sample.
  2. Patient TAT is monitored by the Programme. It includes processes from specimen collection to reporting the test result and is longer than the time taken to perform a test.
Post Session Activity Discuss: What is the Turn Around Time for various tests in your institution? How is that compared against the benchmark? How could we reduce it further?
Chapter 2.4  Active Case Finding Campaign Mode: Self / virtual instructor led
Emphasis Points
  1. ACF is conducted in vulnerable populations to detect cases early. Vulnerable population mapping is the first step in the ACF campaign.
  2. ACF is conducted to find cases early directly from the community.
  3. Yield of ACF is depends on the sensitivity of the screening and diagnostic Technology / algorithm used.
Post Session Activity

"A medical officer was reviewing the ACF data done in their field area. Total individuals mapped for ACF were 10,000; total individuals screened using TB symptoms were 8000. Out of them 400 were found to have TB symptoms. 200 underwent testing and 20 were diagnosed as TB, all were initiated on treatment"

Provide them the scenario. Ask them to comment on the data. 

Discuss: Where is the biggest leaks in cascade? (significant leak in people with TB symptoms not underwent a test). What measures will you take as  MO-PHI to minimize the gap?
Module 3: TB Treatment and Management
Chapter 3.1 General Concepts in TB Treatment  Mode: Self / virtual instructor led
Emphasis Points
  1. The process of treatment starts from initiation to the end of long-term follow-up
  2. Treatment initiation consists of pre-treatment counseling and testing, prescription and dispensation.
  3. Patient Transfer and its implications.
Post Session Activity

Physically check the Fixed Dose Combinations available in the program [4 FDC, 3 FDC, Pediatric drugs]

Perform treatment initiation, and outcome declaration in demo version of Ni-kshay  and restart a case to reinitiate the case on a new episode.
Chapter 3.2  TB Treatment and Care Mode: Self / virtual instructor led
Emphasis Points
  1. DSTB Treatment comprises 4 drugs given as weight band-wise FDCs in two phases. H Mono Poly Regimen consists of 4 Drugs given for 6-9 months.
  2. Regimen for H/ Mono Poly has INH of the DSTB regimen replaced with Lfx and the entire duration of 6 months has all 4 drugs.
  3. Monthly Clinical Follow-up and end IP and CP are required during treatment. Post treatment 6monthly follow-up is required for two years.
  4. Treatment outcomes are declared when the person terminates treatment and in cases of successful treatment (completed/ cured) the patient needs to be followed up for 2 years, every 6 months
Post Session Activity

A 30-year-old female with 66 Kg, newly diagnosed to have drug sensitive pulmonary TB.  

1. What pre-treatment evaluation will you advise before initiating the client on treatment?

2. Initiate and the treatment and prescribe the treatment on the demo version of Ni-kshay

3. Schedule clinical and laboratory follow-up for the client. What all will you will assess when she comes for the follow up? 
Chapter 3.3  Treatment Support  Mode: Self / virtual instructor led
Emphasis Points
  1. Treatment support is a range of measures taken by a Treatment Supporter to ensure that the client completes treatment successfully. 
  2. This includes adherence support, monitoring and referral for ADR, followup-support.
Post Session Activity

Discuss: How do you generally assign treatment supporter to your patient? Is that in consultation with the patient?

Discuss: How many treatment supporters are in your area? What do you think about the quality of treatment support they provide? Share some experiences
Chapter 3.4  Adherence Management  Mode: Self / virtual instructor led
Emphasis Points
  1. Adherence is recorded daily in the Ni-kshay as an action by the person on treatment themselves (through the TB Aarogya Sathi Application/ by DAT) or by the Treatment Supporter. 
  2. Adherence is monitored by all levels of program hierarchy through Ni-kshay using adherence register and adherence dashboards. Based on monitoring retrieval action is to be taken daily by the Treatment Supporter, if unsuccessful, it is to be reported to the corresponding STS for further action/ support.
Post Session Activity

On the demo version of Ni-kshay, Mark adherence for a person on TB Treatment; 5 days as manually reported as taken and 5 days as manually reported as missed. 

Login to Ni-kshay using your institutional credentials. Comment on the treatment adherence pattern of the patients under anti-TB treatment in your area.
Chapter 3.5  TB and comorbid conditions Mode: Self / virtual instructor led
Emphasis Points
  1. Comorbid conditions require TB services to actively refer for comorbidity screening and management, especially Diabetes and HIV. Similarly people with Diabetes and HIV need to be regularly screened for TB.
Post Session Activity Discuss: How many people with diabetes are visiting your institution on a month? Are they all been screened for TB? Share your experiences related to screening for TB among the people with diabetes. How could we ensure that all people with diabetes reaching a health facility are screened for TB?
Chapter 3.6  Infection Prevention & Control  Mode: Self / virtual instructor led
Emphasis Points
  1. AIC measures need be taken by individuals, and as protocols and interventions at Health Facilities.
Post Session Activity Discuss: What are the various administrative measures for air borne infection control in your institutions?  Is it adequate? Is there a scope for improvement?
Chapter 3.7  TB Preventive Therapy Mode: Self / virtual instructor led
Emphasis Points

TB Preventive Therapy is permitted only after ruling out TB

TB preventive therapy is available for people at high risk of TB but is not currently diseased, such as contacts and PLHIV
Post Session Activity Discuss: What proportion of eligible contacts in your area are initiated on TPT? Out of those whom you initiated, what proportion completes the TPT?   What needs to be done to improve the situation
Module 4: Program Management and Programmatic actions
Chapter 4.1  Public Health Actions Mode: Self / virtual instructor led
Emphasis Points
  1. Public Health Actions include a set of actions to support and prevent further health complications and limit social and economical impairment to people with TB and prevent spread of TB in the household and community
  2. These include actions including contact tracing and investigation and actions for prevention of TB.
Post Session Activity Discuss: What are the some of the communication practices towards a person affected with TB  you wish to see changed from your colleagues/staff of your health facility?
Chapter 4.2  Patient Support Mode: Self / virtual instructor led
Emphasis Points
  1. People with TB have various needs and require support to get a diagnosis, completing their treatment successfully and even during post treatment. 
  2. Treatment and Patient support include all measures that are taken by the health system and community to support an individual suffering from TB to successfully complete treatment and return them as functional members of society
  3. MO needs to ensure that people with TB receive those supports.
Post Session Activity Discuss: How should we support a person with TB with alcohol use disorder? Share your experiences related to your team's support in managing such clients.
Chapter 4.3  Social Inclusion and wellness activities  Mode: Self / virtual instructor led
Emphasis Points
  1. Stigma and discrimination towards people with TB exists and these have a significant negative impact on the individual as well as the efforts to end TB
  2. Gender differences and inequalities play a significant role in how people of all gender access and receive healthcare services.
Post Session Activity Discuss: Do you think gender inequality in TB care  exists in your area? As a MO-PHI, what can you do to address the same?
Chapter 4.4 Programme Monitoring Mode: Self / virtual instructor led
Emphasis Points
  1. For the purpose of monitoring information in Ni-kshay is available as registers for each service.
  2. MO-PHIs need to weekly review progress toward end-outcomes patient-wise in each register and direct field staff to take necessary actions for the same.  
Post Session Activity Discuss: Is the Panchayat/Local Body where your health facility is located progressing towards ending TB? Discuss using data.
Abhimanyu

Competencies of MO-PHI

Competencies of MO-PHI
# Competency Description/ activities pertaining to the said competency Assessment methods
1 Diagnose TB Correctly and completely based on NTEP guidelines/Standards of TB Care in India - Identify individuals vulnerable to develop TB disease and TB Infection. 
- Screen for TB using 4 symptom complex and Chest X ray and identify presumptive TB 
- Prescribe appropriate diagnostic test to diagnose TB/ EP-TB, DR-TB, paediatric TB and TB Infection to the eligible based on NTEP guidelines/ Standards of TB Care in India 
- Enroll a person in Ni-kshay and request for Test through Ni-kshay based on NTEP Diagnostic algorithms and requirements for UDST 
- Enter the diagnosis details of clinically diagnosed TB in Ni-kshay
- Implement Intensified Case Finding in the Facility 		 1. Verification of case records in Ni-kshay to check whether correct tests are prescribed and the diagnosis is complete including testing for drug resistance 2. Interview with Medical Officer to understand his/her practice in relation to diagnosis of TB and adherence to diagnostic algorithm and request appropriate tests.
3. Assess OPD referral rates of presumptive TB Cases and random prescription audits for referral for TB Testing of presumptive TB Cases
4. Interviews with people affected with TB under care of the MO to check whether cases are diagnosed completely based on referral for testing and test results.
5. Review of Test Request (Referral for testing) Registers to check for appropriate referral of patients or their samples for higher diagnostic tests which are not available in the current health facility.
2 Prescribe and initiate TB treatment to a person diagnosed as TB/ TBI - Check reports of various laboratory and radiological investigations and interpret the results to make a diagnosis of TB or TB Infection and decision to treat based on microbiological or radiological evidences or on clinical judgement
-Classify the TB disease based on site of disease, DST results and history of anti-TB treatment.
- Prescribe appropriate regimen to treat people affected with DS-TB, H Mono/Poly TB, TB Infection based on NTEP guidelines/ Standards of TB Care in India according to weight bands for adult and paediatricsx
-Identify an appropriate treatment supporter in consultation with the person affected with TB
- Evaluate & advise for indoor admissions based on differrentiated TB care model
- Modify regime (based on laboratory results and clinical examination, special conditions such as TB in pregnancy, renal impairment, adverse events following anti-TB treatment, liver functions impairment etc.) based on program guidelines 
-Document the treatment initiation and details of prescription in Ni-kshay		 1. Verification of case records and treatment card in Ni-kshay to check whether correct regimens are prescribed 
2. Interview with Medical Officer to understand current prescription practices 
3. Interview with patients under care of MO and assess whether right regimen are prescribed
4. Review of Ni-kshay module for differentiated TB care which is updated for all the patients for the TB unit
3 Perform pre-during-and post-treatment evaluation of people affected with TB/DR-TB/TB Infection, as per programme guidelines/ STCI - Cousel for Perform or coordinate for pre-treatment evaluation of people affected with DS-TB/ DR-TB/ TB Infection 
- Conduct periodic clinical follow up and prescribe appropriate laboratory follow-up for people on treatment for DS-TB/DR-TB/TB Infection
- Prescribe and arrange for post treatment follow-up investigations as per programme guidelines 
- Document all evaluation details in Ni-kshay  		 1. Verification of case records in Ni-kshay/ Treatment cards or prescriptions to check whether all evaluations are done correctly 
2. Interview with Medical Officer to understand current practice of pre-during-post evaluations 3. Interview with patient/beneficiaries under the MO's care to check whether all evaluations are done correctly
4. Review Status of post Treatment followup in cases notified in Nikshay for the past year
4 Identify and manage Adverse Drug Reactions due to anti-TB drugs   - Screen for adverse drug reactions to anti-TB drugs among people on treatment 
-Detect and grade ADRs due to anti-TB treatment 
-Evaluate adverse reactions of anti-TB medicines and manage them appropriatly based on NTEP guidelines 
-Counsel people affected with TB/TBI about nature, consequences of ADRs and changes in treatment rehimen to address the ADRs
- Document the ADRs on Ni-kshay  		 1. Verification of case records in Ni-kshay and treatment records to see ADR's were identified and managed 
2. Interview with Medical Officer to understand the practices related to ADR identification and management including referral to higher centres
3. Interview with patient/beneficiaries under MO's care to understand whether ADRs are identified and managed properly
5 Transfer persons affected with TB/DR-TB, to higher center/ nearest health facility for appropriate management, correctly and timely - Identify the need for referral of people affected with TB for availaing various services 
-Refer the beneficiary following standard operations including documentation in Ni-kshay 
- Coordinate with respective program staff for continuation of care post referral 		 1. Verification of case records in Ni-kshay and treatment records to check whether referral is correct and timely
2. Interview with MO to understand the current prictise related to referral 
3. Interview patients/beneficiaries under MO's care to check whether referral is prompt 
6 Evaluate and mange person affected with TB for medical co-morbidities and conditions  - Screen people diagnosed with TB for co-morbidities like Diabetes, HIV, Malnutrition, COVID-19 and sustance abuse like Tobacco Use, Alcohol use
-Mange the co-morbidity and link them to appropriate services whereever required
- Document the co-morbidity status in Ni-kshay		 1. Verification of case records in Ni-kshay to check whether screening and management of co-morbidity are done as per guidelines
2. Interview MO to understand current practices regarding co-morbidity management
3. Interview beneficiaries/ patients under MO's care to check whether co-morbidities are screened and managed properly
7 Counsel the people with presumptive TB or people affecetd with DS-TB/DR-TB/ TBI and their family  - Counsel the people with persumptive TB/ people affected with TB/TBI on: Early and complete Diagnosis of TB, correct and complete Treatment of TB, Treatement Adherence, Air borne Infection Control, Contact Investigation, TB Preventive Therapy, Co-morbidty management, Adverse Drug Reactions and Social welfare measures 1. Interview with Medical Officer to understand current practises regarding counselling
2. Interview with patients/ beneficiaries to understand the quality of counselling received from MO
8 Ascertain treatment outcomes as per NTEP guidelines - Ascertain appropriate outcome of the prescribed treatment as per NTEP guidelines.
- Document treatment outcomes in Ni-kshay		 1. Verification of records in Ni-kshay to check whether outcome assigned are correct
2. Interview with people who had their outcome assigned to check whether the outcome assigned were correct
9 Monitor NTEP and perform supportive supervision in the health facility and in the population served by the health facility -Monitor the NTEP program at facility level and at the level of population served by the facilty, 
-Use Ni-kshay reports and other program reccords/registers, and supervise all services/ processes reach their logical conclusion. Incase of any difficulty inform higher program management (MOTU/ DTO) for further action. 
-Monitor the input and process indicators related to the output/outcome indicator and suggest corrective actions 
- Conduct supportive supervision and help in building capacity of nursing, paramedical and field staff with an intention to improve quality of services. 
- Provide timely and actionable feedback to health sub-centers and reporting field staff (ANM, ASHA, TB-HV, STS, STLS, MPW, CHO, etc.)
- Ensure the staff are supported in taking the actions leading to an improvement in quality of services		 1. Verification of review meeting minutes, documentation of feedbacks provided and supervisory registers to check qulaity of monitoring, review and supervision activities
2. Interview with MO to understand the current practises regard to Monitoring, Review and Supportive supervision
3. Interview with staff (ANM, ASHA, TB HV, STS, MPHW, CHO, Nurse, Pharamacist etc.) supervisied by MO to get an understanding about the quality of supportive supervision and review 
10 Advocacte with Local Government, Private providers and community for engaging them for TB Elimination activities in the field area of health facility  - Advocate with Local Government (Panchayat/ Municipality) to commit for Ending TB 
-Technically assist Local Government in planning and implimenting TB Elimination activities including fostering community ownership, decentralised surveillance, organising treatment support to needy, air borne infection control at household, community, hospitals and workplaces, intersectoral coordination with other line departments. -Advocate with and successfully engage private health delivery service providers to ensure citizens reaching them are receiving care as per the STCI -Conduct meetings like "patient provider meetings, TBHV-ASHA-ANM/MPHW-Treatment Supporter meetings, various committee meetings (Rogi Kalayan Samiti/ RKS, Jan Arogya Samiti/ JAS, Village Health Sanitation, and Nutrition Committee/ VHSNC, Mahila Arogya Samiti/ MAS, DRTB Center committee, Medical College Core-committee, District TB Forum, etc.), discuss the desired changes with related to TB Program and achieve the same.		 1. Check for any results of advocacy in terms of commitment from Local Government, engagement of private providers, engagement of community
2. Interview with private practitioners and Local Government leaders to get an understanding about the MO's competency
ManuMathew