Annexures

The list of the annexures is available here. The different items may be accessed by clicking on the individual items.

Guide for Course-coordinators on LMS
Cadre-wise Trainers' manual for different courses.

Abhimanyu Mon, 16/01/2023 - 13:49

Guide for Course-coordinator on LMS

The Course coordinator's guide can be accessed here:

Course Coordinator guide_Updated_11Nov.pdf (1.31 MB)

WIP

The role of course coordinator is of paramount importance for training the TB workforce using the modernized training system. S/he needs to coordinate with different stakeholders for smooth conduction of training.

For eg. Coordination with the trainer/facilitator for his/her availability for taking the training.
Coordination with ECHO relationship manager for the ECHO-zoom links for webinar. He needs to perform

Login to the platform:

Step 1: Open Swasth e-Gurukul | Spreading Knowledge Faster (swasth-egurukul.in)) on your browser window. (https://cms. swasth-egurukul.in)

Step 2: Enter your login credentials (Provided to you during your training). The dashboard page will open in the browser window.

Scheduling the course on Swasth-eGurukul:
1. Click on ‘Schedule a course’ and the tab will open which requires certain fields:

I. The field needs to be filled meticulously:
1. Course name: to be selected from the drop down menu. Select ‘Course Name’ for the target audience
2. Rename selected course name as ‘<Full State Name> State Health Volunteers training on NTEP <Month Year>’. For eg. Uttar Pradesh State Health Volunteers training on NTEP July 2021

3. Start Date: to be selected from the calendar. Date may be selected 2-3 days before the scheduled date of course starting. This will enable participants to complete enrolment, access and complete pre-test.
4. End date: to be selected from the calendar that pops up after clicking the field. The end date will be based on the number of days the course is expected to run.
5. Stage type: The frequency of sessions may be adjusted here. In Health Volunteers course it is recommended that the stage type is kept as Daily. On the basis of the stage type (daily/weekly/monthly) and the number of corresponding intervals between the start-date and the end-date, there will be a related number of stages available for dividing the course sessions into. Eg if the start date is 1/2/2021 and end date is 28/2/2021, corresponding to 28 days; setting stage type as daily will give 28 stages, and setting stage type as weekly will give 4 stages.
6. Certificate: The certificate for the course needs to be chosen from the list of templates available from the drop down menu.
7. State: This field helps filtering the training aspirants from a particular state. The registered trainees from the selected state will be able to join the course.
8. Moderator: From the drop-down menu, facilitator/trainer needs to be selected. One or multiple facilitator may be selected for the same course but for different sessions.
The facilitators are registered by the Project-admin and login credentials are created for them. After this, their names are included in the drop down menu.

The filled up fields appears like this (image below):
II.The next important step is setting the stages in which course needs to scheduled. Only on this particular date and chronology the course will become live on portal.
All the stages (at the level of chapters) needs to be set individually.
The dates and facilitator may be changed as per the training plan. Once the date is changed for a particular session inside a stage, all the dates for the subsequent sections changes automatically and is set to be after that date.(image below)

After clicking ‘Schedule’ the course scheduling progress tab opens. It may take while to schedule the course. Do not stop or refresh your browser window during this process.(image below)

Admitting trainees to a course:
1. On opening this tab, the course list is available. The course coordinator needs to click the course s/he has scheduled and the list of people who have enrolled for the course will be displayed.
2. The course-coordinator need to approve the trainees who have been shortlisted for this particular course (on the basis of training plan) and may disapprove the rest/non-qualified enrolees.(image below)

Scheduling webinars:
Webinars need to be scheduled inside the course for various virtual sessions that the participants need to join. The Course Coordinator needs to get in touch with the corresponding ECHO relationship manager to create the ECHO Meeting link.
1. The webinars are scheduled for the instructor to train the participants virtually using the ECHO-zoom link. The fields name is to be entered in a standardised manner.
2. Course: To be selected form the drop down menu. The course which has scheduled by the course-coordinator should be selected as the choice here.
3. Webinar title: The webinar to be titled in standardised manner as: Course name - Day 0 and so on. Eg. Uttar Pradesh State Health Volunteers training on NTEP July 2021 - Day0, Uttar Pradesh State Health Volunteers training on NTEP July 2021 - Day 1, etc.
4. Starting date and time:
a. The webinar may be scheduled on or after the start date of the course.
b. A webinar Day 0 may be planned as an ice-breaker session to establish rapport between and the trainer and the trainees and to explain the participants the structure of the training and to share other relevant details.
c. Upon scheduling the enrolled trainees will get the webinar link. The trainees also receive a reminder email from LMS on the day of webinar. The link will also be sent to the facilitators The trainees and facilitators may click the link and access the zoom meeting.
5. Duration of meeting: To be entered in minutes
6. Facilitator: It has to be selected from the drop down menu from the list of facilitators already added by project admin.
7. Use meeting licence: It has to be changed to “External” and the Echo zoom link provided by the ECHO relationship manager for the specific webinar needs to be entered here.
8. Webinar enrolment limit: By default, it has been set to 500. But, it may be changed depending on number of participants expected to join the webinar. After entering all these details, on clicking the ‘schedule’ button, the webinar is scheduled. (image below):

9. After scheduling, the tab displays the number of participants enrolled for course. The participants enrolled and approved for the course automatically becomes the recipient of webinar link. The course coordinator may see the list and status of webinar scheduled by him under the tab- ‘my webinars’(Image below)

Discussion board
It may be used by the trainees and trainer alike to post queries and respond to the comments and
queries. (Image below)

Monitoring the progress of Training
Training report: This tab gives the summary of scheduled courses. It also gives the overall summary
of the course progress, like how many trainees have enrolled for course, how many have started the
training, how many have completed the training, feedback received, etc. (Image below):

On clicking the course, the detailed training report of all the trainees opens. The course-coordinator
can see the progress of each trainee- the enrolment date, trainee’s progress on course, etc. This is
particularly helpful in reaching out to those trainees who are facing difficulty with the training.
(Image below):

Abhimanyu Mon, 16/01/2023 - 13:53

Trainers' Guide for Health Volunteers Course

Trainees

The targeted trainees for this course are generally those persons at the community level who would be interacting with the population for the purpose of on-ground TB activities related to awareness, screening and Treatment Support. These may include:

ASHA Workers
Volunteers from NGOs, Community Representatives/ Youth Volunteers
TB Champions / Survivors/ Family Members
Workplace Representatives who volunteer for becoming focus for TB Services
Educators/ Teachers from Schools and Colleges

Trainers

The following cadres are supposed to be trained to become trainers on this course.

STS
TB HV
MO-PHI
MPHW/ Block Coordinators (NHM trainers)
DPC/ PPM Co-ordinators
NGO coordinators/ Supervisors
Representatives from Private/ Corporate sector

The capacity of these trainers to conduct the training for health volunteers will be in-built into their training and is considered as one of their essential competencies.

Training Methods

Teaching and discussing the course content using the standardised training content available on the NTEP approved LMS (such as Swasth-eGurukul). This training may use blended training delivery methods that are appropriate to the local context. This would include a mix of the following options

Training Premises
1. In-person
2. virtual
Mode of delivery
1. Facilitator led
2. Self learning
3. Demonstrations
4. practical exercises.

In the blended mode, an instructor-led session should be conducted for each chapter. Simultaneously the trainees would go through the content available online themselves according to the schedule. Trainees need to attempt the quizzes after each chapter/module.

At the end of each chapter/session the trainer/ facilitator should summarise the key messages of the chapter by engaging trainees through questions and discussions. The discussion should focus on aspects related to the competencies listed below. These sessions should also help the trainees to clarify doubts and queries.

For the training areas which require hand-holding of trainees like to perform actual processes such as filling of forms, counselling/ addressing stigma, screening, sample collection, adherence monitoring, a demonstration/ role play mode may be adopted.

The duration of training content including discussions/ demonstrations/ role play, pre/post training assessments, is expected to be completed 6 hours. The course coordinator may schedule the course in multiple sessions totaling to this duration as appropriate.

Pre-training Preparation

Before starting a batch of training, the following preparations need to be completed.

Creation/ confirmation/ Issue of Ni-kshay Usernames to the Health Volunteers
Preparation of Props (Drug Blister packs, PWB, Specimen collection container, falcon tube, Specimen carry bags, IEC Materials)

Chapter wise Trainers notes

The course is divided into three modules, with a total of 12 chapters, each with specific learning and training objectives in alignment with the competencies of the person.
The different scenarios and probes for the conversation and discussion have been covered in details at relevant sections. Three standard role plays have also been incorporated at the end of each module in the training course.

Session	Activity	Duration
Session-1 (Introduction)	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.	5 mins
Pre-test assessment	Note: This is Mandatory before proceeding with course content	10 mins
Module 1. Basics of TB and NTEP (120 mins)
Chapter 1: Tuberculosis	Emphasis points during the session burden of TB Disease in terms of new cases, deaths and suffering the causative bacteria mode of transmission, progression to TB disease and the difference between TB infection and active TB disease. 4 major symptoms of Pulmonary TB and how to enquire about these symptoms. Types of TB disease on the basis of sites of TB disease. The various sites of EPTB may be mentioned and explained in local language/context. 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.	30 mins
Chapter 2: NTEP	Emphasis points during the session The goals of NTEP. The TB Unit and its significance and the HR posted there. The TB case classification in NTEP The TB patient care cascade and their interaction with the health system. The role of the health volunteer and Treatment Supporter in NTEP 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.	15 mins
Chapter 3-TB diagnosis and Case Finding	Emphasis points during the session Identifying Presumptive Pulmonary TB using the 4 Symptom complex of TB Process of referral for testing and specimen collection and transport. Discuss the video on the sputum collection. 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.	15 mins
Chapter 4: Nikshay & Treatment Supporter	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 How they will enroll cases, request for test, and add sample details on Ni-kshay. Post Session Activity: 1. The Nikshay Mobile app may be demonstrated.	20 mins
Role play #1:	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	10 mins
Quiz #1	The participants need to attempt the quiz based on training content covered in Module 1. Participants should complete the quiz before moving on to Module 2. This is a pre-requisite for final certificate	10 mins
Module 2: Treatment Support and Monitoring of TB Patient (90 mins)
Chapter 5- 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 DR-TB and the factors that lead to development of DR-TB. 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.) Explain the TB Infection and two therapies for TB Prevention Post session activity: Have a practical demo of the drug formulations (blister packs/ pouches/ FDCs) of an Adult and paediatric DSTB Treatment regimen. The participants may be asked to enumerate common ADRs to first/ second-line anti-TB treatment and subsequent action by Health Volunteer. May ask about the options for TPT regimen	40 mins
Chapter 6- Treatment Adherence	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)	30 mins
Role play #2:	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	10 mins
Quiz #2	The participants need to attempt the quiz based on training content covered in Module 2. Participants should complete the quiz before moving on to Module 3. This is a pre-requisite for final certificate	10mins
Module 3: Patient Support (120 mins)
Chapter 7 - Public Health Action	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 Volunteers 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	25 mins
Chapter 8: TB Arogya Sathi Application	Emphasis points during the session Explain the trainees about the TB Arogya Sathi Application, its multilingual interface, various information available in it and how TB patients can use it to mark their adherence in it and see their DBT status in the 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.	20 mins
Chapter 9- Counselling	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 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	20 mins
Chapter 10- Social inclusion and wellness activity	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	20 mins
Chapter 11: Community Engagement	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. Explain the role of HVs in Community engagement. Post Session activity Ask the participants, in what ways the TB Champions help the TB patients	20 mins
Chapter 12: Linkages to Social Support Scheme	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	10 mins
Role play #3:	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	15 mins
Quiz #3: Post - Test	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	10 mins

Roles and responsibilities of Key Stakeholders

Please refer to the general roles of various stakeholders for training of Health Volunteers (click here).

Apart from these general roles, the state NHM has an important role to play in the training of Health Volunteers, especially those who are ASHAs in the state. The state NHM needs to ensure that all the ASHAs are being trained on TB and NTEP as per the standard training content. The state ASHA cell at the NHM, should ensure that the following steps are being taken:

Support STDC/ STC in planning the training and inclusion in PIP
Prepare and share the list of ASHA’s in the prescribed format with the respective STDC Team
Guide and provide directives to the respective District/ Blocks to deploy ASHA’s along with concerned supervisors to ensure active participation.

nitin.solanki Tue, 27/09/2022 - 17:21

Competencies of the Health Volunteer

The following nine competencies are important to a health volunteer -

Sr No	Competency	Description/ activities pertaining to the said competency	Assessment of competency
1	Talk about TB	Provide correct information about TB to anybody that (a) It is curable, (b)symptoms of TB, (c) Diagnostic services available in the health facilities, (d) Prevention of TB (Ventilation, Cough etiquette, TB Preventive Therapy)	1. Observe the health volunteers talking about TB during home visits
2	Screen for TB using the 4 symptom complex	Identify individuals with high vulnerability to develop TB/TB Infection. Screen them using 4 symptom complex and identify "presumptive TB." Identify individuals eligible for TB Preventive Therapy/ testing for TB Infection	1. Observe a health volunteer screening for TB during home visits
3	Refer for diagnosis to the nearest TB Testing Centre.	Counsel the people with presumptive TB/ eligible for TBI testing to visit the nearest health facility. Refer presumptive TB/those eligible to be tested for TBI to the nearest health facility. Document the same in Ni-kshay using the Treatment Supporter login credentials	1. Observe a referral process during the home visit, including recording of the information in Ni-kshay
4	Collect the sample from a presumptive TB and transport it to the testing facility	Educate the eligible regarding how to collect good quality sputum. While following Infection Prevention & Control measures, collect the samples, label and transport it.	1. Check with the laboratory regarding the quality of samples collected by the health volunteer
5	Provide Treatment adherence Support for TB Treatment and TPT*	Provide treatment adherence support to the persons affected with TB/ people taking TPT. Document the adherence in Ni-kshay using treatment supporter login credentials	1. Review Ni-kshay / Treatment cards for Adherence scores of presently linked patients 2. Interview patients to check the kind of support they received
6	Counsel people who are on TB treatment/TPT and their family*	Counsel people on treatment for TB/ preventive treatment regarding (a) treatment adherence,(b) nutrition, (c) ADR, (d)addressing stigma, (e) infection control measures, f) social welfare measures	1. Interview with health volunteers to understand the current practice.
7	Detect Adverse Drug Reactions and Refer them for timely for management*	Detect common ADRs among the people taking anti-TB treatment/ TPT. Refer them timely to a health facility for management of ADR	1. interview the linked patients regarding how ADR was managed for them.
8	Perform post-treatment follow-up*	Follow up the people who completed TB treatment/TPT every six months and screen them for TB disease	1. Check whether previously linked Treatment completed patients have all their post treatment follow up due completed.
9	Use Ni-kshay for performing the actions related to the above	Using Ni-kshay, screen, refer for testing, collect and dispatch samples, record and monitor treatment adherence, record ADR, view DBT statuses	Check ability to login, enrol and refer patients to health facilities, sample collection and transportation and also mark treatment adherence in Ni-kshay during patient visit.

The five (first four and last one) are core competencies of all volunteers while the remaining four (marked with *) are core competencies only if the volunteer acts/ intends to act as a treatment supporter.

The knowledge and training related to these competencies will be provided through the Course for Health Volunteers on NTEP and assessed through the pre and post-test assessments/ quizzes.

Competency assessment needs to be done periodically (once in two years) or at the time of registration or initiation of the treatment regimen.

Shahnawaz Thu, 09/05/2024 - 16:28

Trainers' Guide for LT (Microscopy & NAAT)

1. Introduction

The purpose of this document is to provide the course coordinators and trainers for the “Course for Lab Technicians (Microscopy & NAAT) on NTEP” guidance for planning and executing the training. The targeted trainees for this course would be:

● Laboratory technicians (Microscopy & NAAT) working under NTEP (program staff and General health system staff)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstrations/ practical exercises. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernised Training System, each State may decide to choose the approach which is most suitable for their State.

For virtual sessions, the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted at the end of each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

For the training areas which require hand-holding of trainees like demonstration of processes- Specimen collection and transportation, smear microscopy, Using different NAAT, patient workflow in Ni-kshay, maintaining Lab Supplies, etc in-person training sessions need to be conducted.

The training course content has modules and 56 chapters. Based on different modalities used for the training, the training delivery should take at least 45 hours.

For the purpose of assessment of trainees, a pre-test before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content. The certificates are auto generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

The training of LTs needs to be conducted at DTC where the required lab facilities are available.

The batch size for Physical Session should not be more than 7 participants and not more than 15 participants for virtual sessions.

2. Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	BASICS OF TB AND NTEP	EPIDEMIOLOGY AND BURDEN OF TB NTEP GENERAL CONCEPTS IN TB CARE IN INDIA TB AROGYA SATHI APP	Virtual	4
2	TB DIAGNOSIS AND CASE FINDING	DIAGNOSTIC TECHNOLOGIES DIGNOSTIC NETWORK AND HIERARCHY APPROACHES TO TB CASE FINDING TB CASE FINDING IN NTEP	Virtual	4
3	Specimen collection and Transportation	General concepts in specimen collection & transportation Packaging & dispatching sample to a C&DST lab	Physical	2
4	Smear Microscopy	Collection & Storage of Good Quality Specimen Sputum Smear Preparation Preparation of Staining solutions Staining Sputum Smear Reading Smear and Reporting Microscopy results Maintaining Supplies of Lab consumables at DMC	Physical	8
5	CBNAAT	CBNAAT as a Rapid Molecular Diagnostic tool Sample processing for CBNAAT CBNAAT Result Interpretation and recording. Troubleshooting in CBNAAT Maintenance of CBNAAT	Physical	8
6	Truenat	Truenat as a Rapid Molecular Diagnostic Test Specimen processing for Truenat Truenat result Interpretation and recording. Troubleshooting in Truenat Truenat Instrument maintenance and record keeping.	Physical	8
7	Ensuring Smooth functioning of Lab Services	Biomedical waste management in a microscopy lab Biomedical waste management in CBNAAT Lab Biomedical waste management in Truenat lab Record maintenance	Physical	2
8	Ensuring Quality Microscopy	General concepts in quality assurance External quality assurance	Physical	3
9	Infection Prevention and Control [IPC]	General concepts in IPC Airborne Infection Control	Virtual	1
10	TB TREATMENT, FOLLOW-UP AND PUBLIC HEALTH ACTIONS	GENERAL CONCEPTS IN TB TREATMENT TB TREATMENT INITIATION AND FOLLOW-UP TB PREVENTIVE TREATMENT PUBLIC HEALTH ACTION TB & Comorbidities and special situations TREATMENT ADHERENCE	Virtual	3
9	INTERACTING WITH PATIENTS	COUNSELLING FOR COLLECTING SPUTUM SPECIMEN COMMUNICATING RESULTS TO THE PATIENT COUNSELLING THE TB PATIENTS STIGMA, DISCRIMINATION AND GENDER SENSITIVITY	virtual	3

3. Trainers

For this course, following personnel may be appointed as the trainers

DTO
STLS

Eligibility -

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. They must possess strong knowledge about TB laboratories and related processes in NTEP. The Trainers should have completed the ‘Course for LT(Microscopy & NAAT) on NTEP’’. The Trainers should be well versed with the IT systems such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System) and Nik-shay. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training
The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (4 hours)
Chapter 1.1	TB & TB Epidemiology	Virtual Session (60 min)
Emphasis Points	Differences between TB Infection and active TB Disease TB has many determinants- behavioral, socio economic, biological Vulnerable population for TB Concepts of TB Notification Rate and TB Incidence Rate
Post Session Activity	The participants may be asked to (i) enumerate the various determinants of TB and (ii) difference between TB Infection and TB Disease Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022.. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment.and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2021? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.]
Chapter 1.2	NTEP	Virtual Session (45 min)
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institution (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up’. Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College be a PHI?’
Chapter 1.3	Integration of NTEP with Health System	Virtual Session (30 mins)
Emphasis Points	Need for integration of NTEP with the general health system & NHM and how that integration is envisioned.
Post Session Activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized’?
Chapter 1.4	Patient Management	Virtual Session (60 mins)
Emphasis Points	How the information of patients are managed through Ni-kshay (Enrollment, Request for Test).
Post Activity Session	Call two participants to demonstrate how they (1) enroll a subject and (2) request for Test in Ni-kshay Make all participants to view their task list in Ni-kshay and discuss how they are going to use the feature
Module 2	TB Diagnosis and Case Finding	Virtual Session (4 hours)
Chapter 2.1	Diagnostic Technologies	Virtual Session (30 min)
Emphasis Points	Names of different tests, their uses, advantages and disadvantages
Post Session Activity	Ask what are the advantages and disadvantages of FL- LPA over NAAT?
Chapter 2.2	Diagnostic Network & Hierarchy	Virtual Session (30 min)
Emphasis Points	Network and hierarchy of laboratories and their basic role
Post Session Activity	Ask “ how many sputum collection and transportation facilities are there in their concerned TU? Make one participant explain how it functions and what are the benefits out of it”?- Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel
Chapter 2.3	Approaches to TB Case Finding	Virtual Session (30 min)
Emphasis Points	Differentiate between screening and testing. The three approaches may be discussed by giving suitable examples to fit into the three scenarios
Post Session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 2.4	TB Case Finding in NTEP	Virtual Session (30 min)
Emphasis Points	Diagnostic algorithm for Pulmonary TB- Role of Chest X ray as a screening tool and the need to complete the diagnostic algorithm. Classification of TB on the basis of site,diagnosis, drug resistance
Post Session Activity	Discuss: “What proportion of presumptive TB patients in your TU completes the diagnostic algorithm? What are the implications if the people are not completing the diagnostic algorithm?”
Chapter 2.5	Active Case Finding Campaign	Virtual Session(45 mins)
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post Session Activity	Discuss how they monitor the ACF in their TU against ‘Cascade of Care? What are the measures they undertake to prevent the leaks in ‘’Cascade of care’’?

Module 3: Specimen collection and transportation Virtual Session		(Physical Session: 2 hour)
Chapter 3.1	General concepts in SCT	Virtual (45 mins)
Emphasis Points	Need for transportation of specimen. Modes of transportation employed. The Process of Sputum collection Requirement for Cold chain The different items may be shown.
Post Session Activity	The participants may be asked to identify different items and the specification- Eg Thermocol box size, falcon tube size, etc.
Chapter 3.2	Packaging and dispatching a sample to a C&DST lab	Virtual (45 mins)
Emphasis Points	Triple layer packaging, cold/cool chain; specimen transport carriers-technical specifications and labeling; dispatch of samples-Ni-kshay
Post Session Activity	One participant may be asked to add test request(dispatching the sample to CDST lab) in Ni-kshay Few participants may be asked to demonstrate the triple layer packaging on negative sample/distilled water.

Module 4: Smear microscopy: Physical Session (8 hours )
Chapter 4.1	Collecting and storage of good quality specimen	Physical (45 mins)
Emphasis Points	Necessary steps in accepting request for TB test; Explain spot and morning samples, necessary steps during specimen receipt at laboratory, storage
Post Session Activity	Role play to collect two specimens-patient education, dispensing sputum cup, labelling etc.
Chapter 4.2	Sputum smear preparation	Physical (60 mins)
Emphasis Points	Steps involved and their details; Do’s and Don’t to be highlighted at each step Emphasis to be given to prepare smear within 6 inches of burning spirit lamp and using other AIC measures (Direction of airflow, position of exhaust fan with respect to working station.
Post Session Activity	May ask the different trainees to enumerate the different steps involved in Smear Microscopy. May ask the details of individual steps from different participants. Demonstrate good smears, smear thickness to visualize print through it
Chapter 4.3	Staining sputum smear	Physical (60 mins)
Emphasis Points	Describe staining process-ZN, FM; properties of well stained slide-ZN/FM, importance of quality stains and staining process
Post Session Activity	Demonstrate the well stained slides-ZN/FM (dark room)

Chapter 4.4	Reading smear and reporting microscopy results	Physical (45 mins)
Emphasis Points	Steps involved; focusing slides, different objective lens, paper based reporting in Lab register Digital reporting in Ni-kshay Diagnostic Module
Post Session Activity	Worksheets to demonstrate and fill paper-based records; Demonstration on Ni-shay Diagnostic Module(Demo) May ask one of the participant to generate the DMC register
Chapter 4.5	Maintenance of microscope	Physical (30 mins)
Emphasis Points	Elaborate why storage is essential, steps in cleaning, storage and maintenance of microscope, AMC, troubleshooting.
Post Session Activity	Demonstrate cleaning of the microscope May also ask some of the participants to demonstrate the handling and storage of microscope. May also ask the participants about the different problems encountered while handling the microscope and other participants about the causes and the other set of participants about the solutions/ways to fix.
Chapter 4.6	Maintaining Supplies of Lab Consumables at DMC; Consumables required at DMC.		Physical (60 mins)
Emphasis Points	Elaborate on consumables requires for sputum collection, slide preparation, staining and examination; stock registers; Technical specifications; Indenting supplies; Preparation of stains-ZN and FM
Post Session activity	Exercise on inventory management for laboratory consumables Some participants may be asked to prepare the reagents following the instruction of the trainer. The stock register may be shown and some participants may be asked to explain the information fields.

Practical Exercise

The practical exercise should include the demonstration by the trainer first and then practical demonstration by the trainees should follow.

Formation of batches: Depending on the availability of infrastructure (Like Size of the room/lab, availability of microscopes, availability of Truenat/CBNAAT machines and the modules therein).

Planning of exercise- The exercise should suitably be planned well in advance involving the lab technicians and other trainers.

Setting of training hall/Lab-

The Laboratory should be suitably equipped to demonstrate the various equipment, consumables. Requirement of equipment, supplies, reagents, samples, etc should be communicated to the lab incharge beforehand and same should be arranged before the start of the training.
The unnecessary items should be removed from the workstation before the training session.
The biosafety precautions should be followed meticulously during the demonstration. The spill management kit, etc should be In place to deal with any contingencies.

Workflow:

Smear Microscopy:

CBNAAT:

Truenat:

Module 5: CBNAAT (Virtual session XX min)
Chapter 5.1	CBNAAT as a rapid molecular diagnostic tool
Emphasis Points	Key components of CBNAAT, process overview of CBNAAT consumables required; in-built controls, other CBNAAT tests
Post Session Activity	The CBNAAT machine may be demonstrated. The participants may be asked to name and identify the different parts of the CBNAAT machine The participants may be asked to identify the different consumables and ways to handle it. May ask the different tests that can be conducted using the CBNAAT equipment
Chapter 5.2	Sample processing for CBNAAT
Emphasis Points	Importance of complete sample liquefaction; processing for EP samples
Post Session Activity	Demonstration of sample processing CBNAAT cartridge loading may be demonstrated to the participants.
Chapter 5.3	CBNAAT result interpretation and recording
Emphasis Points	Visualization of results; Interpretation; Non-conclusive results-retesting procedure; Recording of results in paper based register and in Ni-kshay
Post Session Activity	Discussion on need for new sample/use of left over sample for retesting
Chapter 5.4	Troubleshooting in CBNAAT
Emphasis Points	Interfering substances, Troubleshooting-errors, invalids, hardware problems, test failure without error codes; data backup should be discussed
Post Session Activity	Discuss what troubleshooting is possible in the lab and when technical support is required from the vendor
Chapter 5.5	Maintenance of CBNAAT
Emphasis Points	Need for maintenance, frequency, materials required
Post Session Activity	Prepare and fill log for daily, monthly maintenance

Module 6: Truenat (Virtual session XX min)
Chapter 6.1	Truenat as a rapid molecular diagnostic test
Emphasis Points	Context setting and the relevance of the technology. Emphasis that it is an indigenous technology and focus of programme to adopt this technology Components of Truenat workstation, consumables required, process overview, inbuilt controls Storage conditions of the consumables also need to be discussed
Post Session Activity	The different components may be shown and the importance of each part/component may be discussed Exercise on forecasting laboratory consumables The participants may also be asked to explain the Truenat cartridge and importance of different chambers
Chapter 6.2	Specimen processing for Truenat
Emphasis Points	Importance of cleaning the workstation daily before and after starting the work Importance of sample pre-treatment, liquefaction, processing EP TB samples; DNA extraction; Amplification and Detection importance of complete liquefaction emphasis on critical steps in DNA extraction
Post Session Activity	One participant may be asked to demonstrate the cleaning the workstation(Unidirectional cleaning) Demonstrate the different steps involved in the specimen processing; Discussion with the participants about the Dos and Donts during the specimen processing
Chapter 6.3	Testing using the Truenat
Emphasis points	The different processes should be explained after unloading the cartridge, using autoanalyzer for MTB testing, handling elute, testing for Rif resistance. Emphasis should be on the best practices.
Post session Activity	The test can be demonstrated using the negative sample and participants should be given the opportunity to handle the equipment under the guidance and supervision of the trainer.
Chapter 6.4	Truenat result interpretation and recording.
Emphasis Points	Result visualization and interpretation; Recording-paper based & Ni-kshay
Post Session Activity	How to retrieve test results should be demonstrated. Discussion on need for new sample/use of leftover sample for retesting
Chapter 6.5	Troubleshooting in Truenat
Emphasis Points	Interfering substances, Troubleshooting-errors with Trueprep and Truelab; error classification, test failure without error codes
Post Session Activity	Discuss what troubleshooting is possible in the lab and when technical support is required from the vendor
Chapter 6.6	Truenat instrument maintenance and record keeping.
Emphasis Points	Need for maintenance, frequency, materials required; data backup.
Post Session Activity	Prepare and fill log for daily, weekly, monthly maintenance.

Module 7	ENSURING SMOOTH FUNCTIONING OF LAB SERVICES
Chapter 7.1	BIOMEDICAL WASTE MANAGEMENT IN A MICROSCOPY LAB
Emphasis point	Segregation of biomedical waste based on color coding of bins What components should be discarded in which bag Preparation and Use of disinfectants for different purposes
Post Session activity	Based on discussion, participants should be asked to prepare the line list of all the items to be disposed and the ideal way to dispose it Exercise on preparation of laboratory disinfectants
Chapter 7.2	Biomedical waste management in a NAAT lab
Emphasis Points	Biosafety requirement; waste collection, disinfection and disposal
Post Session Activity	Based on discussion, participants should be asked to prepare the line list of all the items to be disposed and the ideal way to dispose it- disinfectant type, duration, etc

Module 8: ENSURING QUALITY TB LAB SERVICES AT TDCS (Virtual session XX min)
Chapter 8.1	General concepts in quality assurance
Emphasis Points	Need for quality, implication of false positives and false negatives, storage of slides, outline of QA processes
Post Session Activity	Ask audience about issues and correction actions taken to maintain quality; List Good Laboratory Practices
Chapter 8.2	External Quality Assurance
Emphasis Points	OSE, RBRC,
Post Session Activity

Module 9: Infection prevention and control (IPC) Virtual Session (xx min)
Chapter 9.1	General concepts in IPC
Emphasis Points	Need for IPC; standard precautions, IPC at a DMC and at NAAT sites
Post Session Activity	Demonstration of Respiratory hygiene Demonstration of Hand hygiene A virtual audit of cleaning practices in the lab can be carried out whether the good practices are followed in the participants lab or not
Chapter 9.2	Airborne infection control
Emphasis Points	Importance of AIC in TB laboratory, hierarchy of controls
Post Session Activity	Demonstrate ventilation as AIC measure Ask participants what administrative measures are taken at their centre for AIC and what actions they may take. They may be asked for some commitment and timelines to follow that.

Module 10: TB treatment and care (Virtual session XX min)
Chapter 10.1	General concepts in TB treatment
Emphasis Points	The treatment phases and significance of positive results for microscopy at the follow up testing The importance of counseling for treatment initiation and follow up testing should be emphasized Why testing is important after end of IP and CP and other follow up testing Follow up-including long term follow up and the importance
Post Session Activity	Discussion on need for long term follow up Important components of counseling a TB patient for follow-up testing
Chapter 10.2	ADR
Emphasis Points	Identification of some common ADRs due to anti-TB drugs
Post Session Activity	The participants may be asked to enlist the different ADRs
Chapter 10.3	DS-TB Treatment and care
Emphasis points	FDCs used for the treatment Schedule for followup and end of treatment testing and significance
Post session activity	May clear the doubts/queries of the participants
Chapter 10.4	DR-TB Treatment
Emphasis points	What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post Session activity	Ask participants for doubts and help them clear those doubts
Chapter 10.5	Adherence to TB Treatment
Emphasis points	Importance of Adherence monitoring Different adherence recording and monitoring technologies
Post session activity	May also ask the participants about the adherence recording in Nikshay and Tb Arogya Sathi Application
Chapter 10.6	Treatment Support
Emphasis Points	Meaning of Treatment support Significance of Treatment support Plan Treatment Supporter to a Tb patient Nutritional support and counseling Support for de addiction Free TB Services for TB patient
Post-session Activity	Assigning a Treatment supporter to a patient in Niskahy may be demonstrated The participants may be asked to find the nearest de-addiction facilities located to their place
Chapter 10.7	TB and comorbidities
Emphasis Points	Bi directional screening for TB-HIV, TB-Diabetes Need for screening for tobacco and alcohol use among people with TB Nutritional assessment for people with TB. Need for and mechanism of Linkages of people with comorbidity (HIV, Diabetes, Malnutrition, Tobacco and alcoholism)
Post Session activity	Ask the participants to describe the existing mechanism at their TU to screen TB among the people visiting ICTC centers - how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement. Ask the participant to describe how diabetes testing is done among people with TB in their TU? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Chapter 10.8	TB preventive therapy
Emphasis Points	Eligible people for TPT Testing for TBI Steps for Ruling out active TB before initiating TPT Adherence monitoring and treatment support for those on TPT
Post Session Activity	Discussions on target population and risk groups

Module 11: PUBLIC HEALTH ACTION
Chapter 11.1	Public Health Actions for TB
Emphasis Points	Why Public Health actions Public Health actions taken after TB notification Define contact tracing and contact investigation. TB education for community Counselling the TB patients and their family. Dos and Don'ts
Post Session Activity	May ask any participant to enumerate the PHA May ask participant what do they understand by a specific PHA and its importance May ask the participant for what to counsel at different phases of patient care i.e Pre-treatment, during treatment and post treatment A small role play or conversation to discuss about DOs and don'ts of patient counselling

Module 12: SUPPLY CHAIN MANAGEMENT
Chapter 12.1	SUPPLY CHAIN MANAGEMENT IN NTEP
Emphasis Points	Meaning and significance Broad Principles of SCM Flow of Supplies in NTEP Procurement, its types GeM, Direct procurement, floating tender in GeM, Buffer stock, storage norms Nikshay Aushadhi Indenting Receipt of Supplies
Post Session Activity	May ask any participant to enumerate the the broad principles in SCM May also ask one participant to show how indenting and receipt of supplies is carried out in Nikshay Aushadhi
Chapter 12.2	MAINTAINING SUPPLIES OF LAB CONSUMABLES AT TDC
Emphasis Points	Lab Consumables Consumables required at DMC Consumables required at NAAT laboratories Stock register and stock assessment at DMC
Post Session Activity	May ask one participant to show how they are updating the stock register.

Module 13: Supervision, Monitoring and Evaluation
Chapter 13.1	Supervision
Emphasis Points	Meaning of Supervision Objectives of Supervision Supportive Supervision Role of different stakeholders in Supervision at the TU level Role of STLS at the DMC Monitoring and Evaluation of NAAT labs Quality indicators of CBNAAT and Truenat lab
Post Session Activity

Module 14	Private Sector Engagement
Chapter 14.1	General Concepts
Emphasis Points	Why private sector engagement is important and what is the Vision of NTEP on private sector engagement Explain PPSAs, Direct Option for engagement. Explain STEPS Emphasis on various options under partnership options Regulations of Mandatory TB Notification and Schedule H1
Post Session Activity	Recollect Standards of TB Care in India and emphasize that the vision of NTEP with regard to private sector engagement is to ensure STCI to all patients. The choice of where to take treatment remains with the patient. Emphasize that more than the private sector, it is the NTEP who wants to engage with the private sector to ensure that all patients reaching them receive STCI. Tell that TU is a population and ensuring STCI to all cases emerging from that population is the responsibility of STS. STS can engage the private sector to minimize his/her workload. Ask each of the participants to think what model suits for private sector engagement in their TU and why Discuss how information from schedule H1 could be used? (Clue: Most crucial field in the schedule H1 register is the name of the provider who prescribed it. Information from Schedule H1 register could be used to Identify the provider prescribing the anti TB drugs and prioritize for engagement, Identify missing TB cases)
Module 15	ACSM and Community Engagement
Chapter 15.1	General Concepts in ACSM
Emphasis Points	Differentiate clearly among Advocacy, Communication and Social Mobilization Common approaches for ACSM for TB Elimination
Post Session Activity
Chapter 15.2	Guidelines and Protocols for ACSM activities
Emphasis Points	Organising Community Meetings, Peer group interventions, ACSM activities in schools
Post Session Activity	Discuss experiences form 1-2 participants regarding organizing community meetings
Chapter 15.3	Community Engagement
Emphasis Points	LSGs and their role in TB Elimination TB Forums and what they can do What role can TB Champions play?
Post Session Activity	Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.

Abhimanyu Wed, 15/03/2023 - 11:48

Competencies of the Lab Technician (LT)

The following competencies are important to a LT

Competency

Description/ activities pertaining to the said competency

Assessment of competency

Conduct laboratory tests for TB	Perform laboratory tests like AFB smear microscopy(ZN, FM), and NAAT (CBNAAT/ TruNAAT) as per NTEP guidelines Receive the sample in Ni-kshay/LIMS Record the test results in Ni-kshay/ LIMS	1. Direct observation of LT performing the tests 2. Assess as a part of QA (OSE/RBRC) results
Educate the individuals on collecting good quality sputum	Educate the clients on how to collect good quality sputum (where to collect, quantity desired, when to collect and how to collect)	1. Observe the demonstration by the LT where they educate people on the process of collecting good quality sputum.
Suggest appropriate tests to eligible individuals to detect TB/DR-TB/TBI	Encourage bi-directional screening for TB among high risk individuals like people living with HIV, diabetes, COVID-19, etc. Identify presumptive TB , Presumptive DR-TB Identify individuals eligible for TBI testing Suggest NAAT/LPA/CDST to people diagnosed with TB to detect DR-TB based on diagnostic algorithm Suggest appropriate diagnostic tests, based on diagnostic algorithm Request for Test through Ni-kshay	1. Interview with LT to identify the current practices 2. Observe the actual process while being in lab
Communicate the results properly to the beneficiaries	Communicate results properly to the health team -Communicate results properly to the person underwent the test	1. Interview with medical officer & STS to check the communication skill of LT
Pack the samples with triple layer and co-ordinate transportation to referral laboratories	Perform triple layer packing, labelling and coordinate transportation of samples	1. Observe the packing process while being at laboratory 2. Interview with referral laboratory to check the quality of packing done by the particular LT
Co-ordinate for making a diagnosis and initiating a person diagnosed with TB on treatment	Coordinate with medical officer to establish the diagnosis of TB Coordinate with STS to initiate prescribed regimen of TB treatment.	1. Interview with LT to identify the current practices 2. Interview with MO and STS to check LT's ability in coordination
Train paramedical staff/ community volunteers on sample collection, packaging and transport of sputum samples.	Train paramedical staff/ community volunteers on sample collection, packaging and transport of sputa samples.	1. Interview with volunteers to check LT's ability to train
Follow Standard Infection control Procedures, and Dispose off the laboratory waste as per bio-medical waste management protocols	Adherence to infection control procedures (handwashing, glove use, use of PPE, airborne infection control practices, etc) Ensure proper segregation, appropriate use of disinfectants, processing and disposal of lab waste material as per BMW management protocols	1. Direct observation of practices during duties, (good laboratory practices) 2. check methods of BMW management in laboratory
Raise the request for laboratory consumable stock replenishment	Monitor consumption trends and reagents/ supplies stock nearing expiry Coordinate with STLS for raising refill request. Update stock register/ indent register	1. Review of indents
Receive the lab consumable stock to designated TB detection center (TDC)	Carefully review issue voucher from STLS for details of supplies, expiry, etc. Follow First Expiry First Out (FEFO) principle while stocking and using the reagent/ consumable stocks, Update the relevant records	1. Review stock register in Ni-kshay Aushadhi
Maintain reports and registers as per NTEP requirements	Update in Ni-kshay details of beneficiaries who underwent testing Download and maintain laboratory register from Ni-kshay Maintain Quality Control Records(QCP/QCN checking records)	1. Check Ni-kshay Test records and extracted Laboratory Register for correctness, completeness and timeliness
Appropriately store consumables, slides, samples and equipment	Maintenance of Microscope/ CBNAAT/ TruNaat Slide storage for QA Storage of Biological specimen

Shahnawaz Tue, 28/05/2024 - 11:44

Trainers' Guide for Pharmacists (SDS & DDS)

Introduction

The purpose of this document is to provide the course coordinators and trainers for the “Course for Pharmacists and storekeepers in NTEP” guidance for planning and executing the training. The targeted trainees for this course would be:

State Drug Stores Pharmacists cum storekeepers
District Drug Stores Pharmacists

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstrations/ practical exercises. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernised Training System, each State Office may decide to choose the approach which is most suitable for their State.

For virtual sessions, the trainees will be going through the online content, and attempt quizzes after each chapter. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts of the training participants.

For the training areas which require handholding of trainees like demonstration of processes- like filling of forms, verification of supplies, stacking, etc. in-person training sessions need to be conducted.

Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB & TB Epidemiology NTEP Diagnostic Technologies Approaches to TB Case Finding TB Case Finding in NTEP	Virtual	3 hrs
2	TB Treatment	General concepts in TB Treatment DS-TB Treatment and care DR-TB Treatment and care Shorter Oral Bedaquiline containing MDR/RR-TB Regimen Longer Oral M/XDR-TB Regimen Isoniazid (H) Mono/Poly DR-TB Regimen TB Infection treatment and care Newer anti-TB Drugs in NTEP TB-Comorbidities and special situations General Concepts in Adherence Management	Virtual	3 hrs
3	General concepts and Principles of SCM in NTEP	Key Concepts and Principles in SCM Drugs and consumables in NTEP Stores in NTEP Patient-wise Boxes Information Systems in NTEP SCM Roles and responsibilities in SCM	Virtual	3 hrs (Includes 1 hr of Demonstration)
4	Inventory Management in NTEP	Overview of Inventory management in NTEP Indenting and receipt Issue and consumption Reporting of Stocks Expiry Management Stocking NTEP drugs in Private sector	Physical	6 hrs (Includes 3 hrs of Demonstration)
5	Procurement in NTEP	Key concepts in Procurement Procurement Processes Government e-Marketplace [GeM]	Physical	2 hrs (Includes 1 hr of Demonstration)
6	Logistics and Distribution of Drugs and consumables	Flow of Supplies Packaging Return and Reconstitution Transportation	Physical	4 hrs (Includes 2 hr of Demonstration)
7	Supervision, Monitoring and Evaluation and QA	Quality Assurance of Drugs Monitoring of sub-stores Store Visits Physical Verification Evaluation of Stores and Stocks	Physical	3 hrs (Includes 2 hr of Demonstration)

Trainers

For this course, following personnel may be appointed as the trainers

SDS Pharmacists
DDS Pharmacists (select)
DTO (select)
MO - STDC
MO - STC
WHO-consultants

Eligibility -

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. They must possess strong knowledge about Supply Chain Management and related processes in NTEP. The Trainers should have completed the ‘Course for Pharmacists’. The Trainers should be well versed with the IT systems such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System), Nikshay and Nikshay Aushadhi. The Trainers need to go through the Chapter- wise Training Guide for this Course.

The training of pharmacists of District and TU level to be conducted at state level.

It is recommended that the trainers are appointed from all regions of the State, so that subsequent refresher training can be conducted locally by these trainers.

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted ( virtual/ Physical/ In-person)
The estimated time to complete the content
The key messages that a trainer should emphasise upon, while delivering the training
The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (90 min)
Chapter 1.1			TB & TB Epidemiology		Virtual Session (26 min)
Emphasis Points
Post Session Activity			The participants may be asked to raise their doubts/questions. The participants may be asked to unmute themselves and may be asked to enumerate the various determinants of TB, difference between TB Infection and TB Disease etc.
Chapter 1.2			NTEP		Virtual Session (34 min)
Emphasis Points			Different institutions may be explained and discussed with respect to its coverage geographically, its organogram, the functions that particular institution is carrying out.
Post Session Activity			The institution from which participants have come may be explained in detail and its relationship with other institutions. (e.g. District level functionaries may be asked about their relation with the state level and TU level institutions) The stages in TB patient’s care cycle may be elaborated as a story with special emphasis on long term post-treatment follow-up
Chapter 1.3			Diagnostic Technologies		Virtual Session (16 min)
Emphasis Points			Names of different tests, their significance in Diagnostic algorithm
Post Session Activity			The consumables required for different diagnostic technologies may also be mentioned here briefly to make it more relevant for the trainees
Chapter 1.4			Approaches to TB Case Finding		Virtual Session (6 min)
Emphasis Points			The three approaches may be discussed by giving suitable egs to fit into the three scenarios The different case definition may be mentioned.
Post Session Activity			The participants may be given the scenarios like visit to HIV Clinic, ANC Clinic, Covid clinic, OPD visit to a tertiary hospital, etc
Module 2			TB Treatment		Virtual Session (203 min)
Chapter 7.1			General concepts in TB Treatment		Virtual Session (45 min)
Emphasis Points			The other formats like Tb Treatment Card and NTEP ID card may also be shown and the different fields along with the significance may be discussed The transfer of patients on Ni-kshay also demonstrated and the impact of this transfer on the patients on the trainees may be asked first and discussed in detail The importance of monitoring the transfer of the patient should also be explained
Post Session Activity			The FDCs may be shown to the trainees over camera, (Various regimens and packaging should also be shown to them on their physical visits for training) The wrongly filled treatment cards may also be shown and discussed.
Chapter 2.2			DS-TB Treatment and care		Virtual Session (10 min)
Emphasis Points			Explain the basis of categorization of regimen i.e. age and weigt Explain the significance of weight measurement of patient on every follow-up visit Explain the importance of weight change and changes in regimen required. The weight bands may be explained and subsequent increase in dosage required. The importance should be given on the fact that weight change of the patient requires change in drug dosages and hence the practice of one time dispensation of medicines for the complete course or the complete phase should be discouraged The ADRs due to DS-TB treatment may be explained and when should one seek medical attention. It should be explained to the participants that not each patient will develop ADRs and tolerance develops for the drugs with due course of treatment and when should patient seek medical care.
Post Session Activity			The participants may be asked to enumerate the ADRs and when to seek medical care Some participants may also be asked – how to counsel the patient about the ADRs
Chapter 2.3			DR-TB Treatment and care		Virtual Session (20 min)
Emphasis Points			The meaning of DR-TB should be explained emphasizing on the fact that that once a patient develops DR-TB, he’ll be transmitting the DR-TB to the community. The different factors that lead to development of drug resistance should be explained. The role of incomplete and inadequate treatment should be emphasized connecting it to the importance of monthly follow-up and weight monitoring. It should again be emphasized that the practice of one-time dispensation of DS-TB drug to be discouraged. The different types of drug resistance may be explained with the different regimens available. The need for creation of different PWBs should be explained here. The MERM and its importance should be explained.
Post Session Activity
Chapter 2.4			Shorter Oral Bedaquiline-containing MDR/RR-TB Regimen		Virtual Session (14 min)
Emphasis Points			The salient features of regimen, its composition, the weight bands, the duration and some common ADRs of the regimen may be explained. The action to be followed after ADRs identification, whom to contact need to be explained.
Post Session Activity			The regimen may be shown to the participants- over the camera The composition of regimen and duration may be asked
Chapter 2.5			Longer Oral M/XDR-TB Regimen		Virtual Session (10 min)
Emphasis Points			The salient features of regimen, its composition, the weight bands, the duration and some common ADRs of the regimen may be explained. The action to be followed after ADRs identification, whom to contact need to be explained.
Post Session Activity			The regimen may be shown to the participants- over the camera The composition of regimen and duration may be asked
Chapter 2.6			Isoniazid (H) Mono/Poly DR-TB Regimen		Virtual Session (5 min)
Emphasis Points			The salient features of regimen, its composition, the weight bands, the duration and some common ADRs of the regimen may be explained. The action to be followed after ADRs identification, whom to contact need to be explained.
Post Session Activity			The regimen may be shown to the participants- over the camera The composition of regimen and duration may be asked
Chapter 2.7			TB Infection treatment and care		Virtual Session (14 min)
Emphasis Points			The TB infection may be explained here. The different tests available for TB infection testing may be mentioned here. The two regimens should be explained.
Post Session Activity			The regimen may be shown to the participants- over the camera. The composition of regimen and duration may be asked.
Chapter 2.8			TB-Comorbidities and special situations		Virtual Session (26 min)
Emphasis Points			Various Comorbidities and special situations like Pregnancy and lactation may be enlisted. The significance and impact of having these comorbidities to a TB patient should be explained. Bidirectional screening and its importance for HIV, Diabetes, COVID should be explained.
Post Session Activity			The details of the facilities for alcohol cessation and tobacco cessation may be shared with the participants.
Chapter 2.9			General Concepts in Adherence Management		Virtual Session (48 min)
Emphasis Points			What is adherence, importance of adherence, their role in adherence management, different ways of recording adherence- 3 ways(on Treatment Card by TS/STS, Self-reporting (99DOTS, MERM, TB Arogya Sathi), in Ni-kshay by TS, STS), How to assign TS and role of TS
Post Session Activity			Demonstration of the following at the end of the session: TB Arogya Sathi app and adherence recording Ni-kshay and adherence recording
Module 3: General concepts and Principles of SCM in NTEP Virtual Session (114 min)
Chapter 3.1		Key Concepts and Principles in SCM			Virtual Session (33 min)
Emphasis Points		Explain the flow of supplies through different tiers in SCM various types of drugs with emphasis on Minimum & Maximum stock, Buffer stock and its significance. May be explained by giving suitable examples from the local context and stories. Situational examples and past experiences to be shared, explain the various stocks like lost in transit, quarantine, substandard etc. The drug distribution flow and Stock types may be explained through a storyline (i.e. Some quantity of stock was transferred to State- in the transit some got damaged, some was quarantined for testing, and so on Identification of short expiry drugs and broad principles of management of Short expiry drugs. Outline the principle of FEFO and its scenario-based usage Indicating the various stocking points along with the purpose of respective stores.
Post Session Activity		The participants may be asked about the significance of SCM in their own words to check their understanding and their role clearly in the SCM To ask what will happen if SCM is not maintained efficiently Situational based examples for different types of stocks may be asked
Chapter 3.2		Drugs and consumables in NTEP			Virtual Session (14 min)
Emphasis Points		The different drugs and consumables handled by different stores may be shown over the camera or the images of the commodities may be flashed These supplies should be arranged beforehand by the trainer and should be present on the demonstration table The lab consumables handled by the respective store (by the trainees) and the importance of maintaining the efficient supplies of lab consumables The consequences of poor SCM of lab consumables should also be explained
Post Session Activity		Different Drugs and consumables may be shown over camera/physically The participants may be asked to identify the different supplies by asking them to unmute themselves Various registers and forms may also be displayed and brief intro about it may also be mentioned.
Chapter 3.3		Stores in NTEP			Virtual Session (14 min)
Emphasis Points		Different stores at State, district, TB, PHI may be explained ( Covering its geographical coverage, the infrastructure requirements, HRs posted there and the functions carried out by the respective stores.
Post Session Activity		The trainees may be asked about the existing gaps in stores with respect to stores infra, and the gaps in functioning of stores which are under their jurisdiction
Chapter 3.4		Patient-wise Boxes			Virtual Session (29 min)
Emphasis Points
Post Session Activity
Chapter 3.5		Information Systems in NTEP SCM			Virtual Session (10 min)
Emphasis Points		Ni-kshay Aushadhi and its significance, Detailed discussion on the Dashboard and various reports available in the Ni-kshay Aushadhi
Post Session Activity		Demonstration of the demo version of the portal and the navigation through it to discuss the different dashboard and its significance, generation of different reports Data to be fetched from Dashboard / various reports of Ni-kshay to be shown and participants may be asked to give their observation
Chapter 3.6		Roles and responsibilities in SCM			Virtual Session (14 min)
Emphasis Points		Explain the roles and responsibilities of different HR involved associating it with the functions of the stores Explain the importance and role of Pharmacists in NTEP emphasis on SCM, stock-keeping, and expiry management and use of Ni-kshay Aushadhi
Post Session Activity		Some of the participants may be asked to enumerate the roles of the position they are holding
Module 4: Inventory Management in NTEP Physical Session (125 min)
Chapter 4.1		Overview of Inventory management in NTEP			Physical Session (8 min)
Emphasis Points		Explain about the concept and the significance of it. discuss the process involved therein and significance of each step and also associate it with their role (trainees role in inventory management) discuss the different stocking norms at different levels and importance of it (norms at a particular level and why)
Post Session Activity		Different scenarios from daily life may asked to shared Essentials for Robust Supply Chain Situational questions may be asked to participants
Chapter 4.2		Indenting and receipt			Physical Session (24 min)
Emphasis Points		Types of method to be explained (Quarterly/ ADR along with its significance The different process involved in Indenting of supplies should be explained in detail giving example of drugs or any other supplies. Various sources of receipt to be indicated along with the purpose of them Steps to be followed physically to be explained The storytelling methodology may be adopted - where to request supply, supplies come from where, what to do in receipt of supplies and how to record the process in Nikshay Aushadhi Step wise procedure in Ni-kshay Aushadhi for receipt to be shown
Post Session Activity		Demonstration of the indenting in Ni-kshay Aushadhi, The processes of requesting supplies in Ni-kshay Aushadhi. The recording of receipt of supplies from different stores should be demonstrated in Ni-kshay Aushadhi. After the Module all the process should be demonstrated to the participants on live supplies- like checking for documents, inspection, check for damaged stocks, acknowledgement , followed by documenting in Ni-kshay Aushadhi (recording and reporting) for the said supplies.
Chapter 4.3		Issue and consumption			Physical Session (48 min)
Emphasis Points		Various sources to explained Essential steps required to be taken up by the Pharmacist upon the issue of Various methods for issue of drugs to be explained, with emphasis on the scenarios where these methods to be used
Post Session Activity		Demonstration of the issuing of supplies in Ni-kshay Aushadhi, The processes of issuing supplies in Ni-kshay Aushadhi. The recording of issue of supplies to different stores should be demonstrated in Ni-kshay Aushadhi. After the Module all the process should be demonstrated to the participants on live supplies- like checking for documents, inspection, check for damaged stocks, acknowledgement, followed by documenting in Ni-kshay Aushadhi (recording and reporting) for the said supplies. The same demonstrations to be made for issue of supplies as well. The drug dispensation module may be demonstrated to the participants (in real-time while dispensing the medicines to the patient at the PHI)
Chapter 4.4		Reporting of Stocks			Physical Session (13 min)
Emphasis Points		Importance of forecasting and follow-up actions following forecasting. Data for forecasting to be discussed with focus on the which data and from which date to be considered the need of forecasting may also be emphasized by giving the national perspective like that will happen if forecasting goes wrong and how to different levels forecast the supplies of different commodities and the factors affecting it.
Post Session Activity		Explain the participant about the consequences of not forecasting and doing it incorrectly. The participants should have clarity about the process and their role in making the process efficient Hypothetically situation (excess stock, shortage and short expiry) to be created and data of stock, expiry, consumption to be given and participant may be asked to forecast the requirement for 12moths.
Chapter 4.5		Expiry Management			Physical Session (19 min)
Emphasis Points		The end to end process- like what's expiry, how to identify expiry supplies, shelf-life of different supplies, forecasting of expiry drugs, reporting it and the follow-up actions to forecasting of expiry drugs including the scientific disposal of expiry drugs may be explained.
Post Session Activity		the participants may be asked to enumerate the different steps and the consequences if any of the step is not done efficiently. Demonstration of whole process in Nikshay Aushadhi
Chapter 4.6		Stocking NTEP drugs in Private sector			Physical Session (13 min)
Emphasis Points		Importance of stocking drugs in private sector to be explained
Post Session Activity		Participants may be sked to share their methods currently being sued for stocking and recording of drugs in private sector
Module 5: Procurement in NTEP Physical Session (39 min)
Chapter 5.1		Key concepts in Procurement			Physical Session (13 min)
Emphasis Points		Procurement – Goods, Works and Services Types of Procurement
Post Session Activity		Participants to be asked to explain procurement of goods, works and services with examples clearly set out the differences between them
Chapter 5.2		Procurement Processes			Physical Session (8 min)
Emphasis Points		Type and Process of procurement to be explained
Post Session Activity		Following the types of procurements (direct, tender, single source / sole etc, situation to be provided and participants may be asked which process to be followed and also asked to indicate the process from end to end.
Chapter 5.3		Government e-Marketplace [GeM]			Physical Session (18 min)
Emphasis Points		the GeM, its significance and the processes involved
Post Session Activity		Demonstration of GeM and the different processes involved for the supplies at the participants level if any. Participants may be asked to explain upon the methods of evaluation, custom bids, various different options available under the GEM
Module 6: Logistics and Distribution of Drugs and consumables Physical Session (89 min)
Chapter 6.1	Flow of Supplies			Physical Session (23 min)
Emphasis Points	Explain the difference in flow of DS-TB drugs and flow of DR-TB Drugs, flow of Bdq and Dlm need to be explained separately. Flow of supplies of CBNAAT cartridges and Truenat chips may be explained in state-specific context.
Post Session Activity	The participants may be asked to discuss the issues they are facing in the supplies and solutions may be suggested.
Chapter 6.2	Packaging			Physical Session (35 min)
Emphasis Points	The importance of packaging, specifications, labelling requirement, packaging instructions, preparation of PWB for different regimens and its recording in Nikshay Aushadhi should come out clearly.
Post Session Activity	The different PWBs (physically) may be shown to the participants along with the constituents (with attention on the details of specification of boxes, labelling of boxes). The recording of the whole process in Nikshay Aushadhi (PWB prep in real-time may also be demonstrated)
Chapter 6.3	Return and Reconstitution			Physical Session (18 min)
Emphasis Points	The overview of the process and importance of it.
Post Session Activity	Participants may be asked about the circumstances when return and reconstitution is carried out Demonstrate the entire process in Nikshay Aushadhi Situational Questions may be asked about Bdq and Dlm return and reconstitution.( Eg 10 Bdq tablets need to be returned- the process of return and reconstitution may be discussed) Some participants may share their experiences with respect to this process, the challenges they have faced and solutions may be suggested.
Chapter 6.4	Transportation			Physical Session (13 min)
Emphasis Points
Post Session Activity	The transportation facility available at the store may be demonstrated and the best practices may be discussed with the participants
Module 7	Supervision, Monitoring and Evaluation and QA			Physical Session (76 min)
Chapter 7.1	Quality Assurance of Drugs			Physical Session (33 min)
Emphasis Points	Type of Quality Assurance (Pre Dispatch / Post dispatch) Step to be followed for collection of sample for testing and in case of repeat testing Explain the process of recording the sample collection in Ni-kshay Aushadhi
Post Session Activity	The drug collection process for testing may be demonstrated to the participants. ( One batch of any drug and take out 10 strips for testing and packing. The remaining drugs need to be put in quarantine. Demo on Ni-kshay Aushadhi to record the transaction
Chapter 7.2	Monitoring of sub-stores			Physical Session (10 min)
Emphasis Points	Explain the significance of Monitoring and why it is reuired Different types of Monitoring methods to be explained with examples
Post Session Activity	Different groups may be formed, and the groups may be asked to do analysis of the reports, performance of sub-stores through Nikshay Aushadhi. The sample reports will be provided by the facilitator. The reports prepared may be reviewed jointly and follow-up actions may be discussed.
Chapter 7.3	Store Visits and Physical Verification			Physical Session (15 min)
Emphasis Points	Key points to be considered while visiting a store Post Visit, what steps to be taken What steps to be followed for conducting Physical verification and at what Intervals Importance of recording of physical verification
Post Session Activity	For store visit and Physical verification, the two demonstrations may be clubbed as a single exercise. The batch may be divided into subgroups (not more than 5) and may visit different stores (SDS, DDS, TU, PHI). The participants may be asked to fill the checklist. After the visit, the checklists filled by different trainees may be evaluated and discussed. Team to propose recommendation An Audit Trail may also be undertaken by the team, one batch to be selected from SDS (preferably issued to district almost 5-6 months back). Team to visit said district and to check upon the date of receipt, documentation and to check in which district it was issued. Then team to visit said TU and again take out the trail of same batch and figure out the PHI. Similarly visit said PHI and check. Afteward, team to enlist the observations and propose recommendation if required
Chapter 7.4	Physical Verification[SS1]			Physical Session (13 min)
Emphasis Points	What steps to be followed for conducting Physical verification and at what Intervals Importance of recording of physical verification
Post Session Activity	The site may be visited and the different processes may be explained.
Chapter 7.5	Evaluation of Stores and Stocks[SS2]			Physical Session (5 min)
Emphasis Points
Post Session Activity

Abhimanyu Fri, 07/10/2022 - 13:17

Competencies of the Pharmacists

The following competencies are essential to a Pharmacists

Competency	Description/ activities pertaining to the said competency	Assessment of competency
Prepare the forecast/ indent requirement for various supplies	Reconcile the existing stock of supplies by triangulating the records and actual stock (including own store and sub-stores/ dependent stores) Compute the "estimated consumption months" of particular actual quantity (units) of stock based on consumption patterns, units of conversion/ computation, etc. Estimate the requirement based on ongoing trends, anticipated changes in consumption patterns, and programme stocking guidelines for maintaining adequate stocks at different levels Prepare and submit the request/intend as per forecast in the respective recording template	1. Check indent request form and Drug Requisition modules in Ni-kshay Aushadhi
Prepare the procurement request for drugs and other supplies	Review forecast estimates of supplies permitted for local procurement. Secure information about necessary approvals (including records of proceedings/ ROP), Technical specifications of supplies intended for procurement, Submit procurement request to appropriate authority in follow-up with forecast plans Contribute in preparation of procurement documents - including "bid/ tender document" (request for quotes/ proposals) based on programme specifications, and respective applicable guidelines (NTEP and State Governments), "bid evaluation report", "purchase orders", etc.	1. Check records of procurement documents namely "Tender/ bid documents", "Bid Evaluation Report", "Purchase Order", "Bill of Supplies", etc.
Issue the stock of supplies to sub stores	Review indent requests from sub stores -Check available stock and (forecasted requirements from other indenting units) -Follow First Expiry First Out (FEFO) principle while stocking and issuing the stocks -Updating the relevant records (physical & digital)	1. Review records of stock register and respective modules in Ni-kshay Aushadhi
Receive the stock of supplies in the store	Review the "issue receipt" and "actual stock to be received" for the details like quantity, types of supplies, expiry, etc. -Updating the relevant records (physical & digital copies) and stocking the received supplies as per FEFO principle.	1. Review records of stock register and respective modules in Ni-kshay Aushadhi
Maintain the physical stock of supplies as per programme guidelines in their respective store	Update Ni-kshay Aushadhi and stock register. Identify separate stocking areas/ shelves for respective supplies. Physical stocking of supplies based on "First Expiry First Out/ Last Expiry First In" principle of stocking	1. Reviewing records of reconciliation of stock register and physical stock and Ni-kshay Aushadhi 2. Verify the store for stocking arrangements
Conduct periodic physical stock verification	Assist store in-charge for planning and executing the periodic physical stock verification (PSV) activity as per programme guidelines. Review physical stocks as against the respective updated records . Document and communicate the findings and actionable recommendations of PSV to relevant stakeholders	1. Review records of Physical Stock Verification (PSV) Report
Dispose off the expired stock as per programme guidelines	Periodically (at least monthly) identify and label the expired stock of supplies at the store. Stock the EXPIRED stock of supplies separately from main/ non-expired supplies. Reconcile stocks (types and quantities of various supplies) to be disposed off with various permissible disposal methods like burning/ burial/ handing over to bio-medical waste handlers - vendors/ condemnation and auctioning, etc. Reconcile the records of expired stocks and prepare disposing off request for approval from competent authority. Contribute in "disposing off" process as a key committee member	1. Review records of Physical Stock Verification report, disposal (write-off) report, etc. 2. Interview with pharmacist to understand the current practices
Perform supportive Supervision at health facility/TU/District level	Plan and conduct supportive supervisory visits to sub-stores for need-based agenda (e.g., ensuring availability of adequate stocks, maintenance of stores and records, adherence to standard operating procedures, etc.). Provide timely and actionable feedback to sub-stores. Review actions taken with an intention to improve quality of services	1. Review of Supervisory Register at health facility 2. Review Feedbacks (referrable mails/ letters) to districts/TU/ Health facility
Conduct the trainings on the supply chain management in NTEP	Conduct trainings on Course for Pharmacists in NTEP -Conduct trainings on supply chain management for all cadres	1. Interview with trainees trained by pharmacist 2. Interview with the pharmacists to understand current practices
Counsel people affected with TB/families	Educate the patient and family about dosage, duration, frequency of medications prescribed for DS-TB/DR-TB/ TBI. Counsel them regarding treatment adherence and adverse drug reactions during the treatment	1. Interview patients to check pharmacist's ability to counsel

Shahnawaz Fri, 10/05/2024 - 12:57

Trainers' Guide for STS Course

Introduction

The purpose of this document is to provide the course coordinators and trainers for the ‘Course for STS in NTEP’ guidance for planning and executing the training. The targeted trainees for this course would be:

Senior Treatment Supervisor (STS)
Tuberculosis Health visitor (TB-HV)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstration and role plays. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernized Training System, each State Office may decide to choose the approach which is most suitable for their State.

The training of STS to be conducted at State/Regional level preferably at the STDC. The batch size for Physical Session/Virtual Sessions should not be more than 25.

For virtual sessions, the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

For the training areas which require hand-holding of trainees like demonstration of processes- like patient management in Ni-kshay, filling of various forms, Adherence Management tools, recording information on Public Health action, use of NI-kshay Aushadhi, etc in-person training sessions need to be conducted.

The training course content has 11 modules and 43 chapters. Based on different modalities used for the training, the training delivery should take at least 40 hours.

For the purpose of assessment of trainees, a pretest before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content. The certificates are auto-generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB & TB Epidemiology NTEP Integration of NTEP with Health System	Virtual	4
2	TB Diagnosis and Case finding	TB Case Finding in NTEP Diagnostic Technologies Diagnostic Network and Hierarchy Approaches to TB Case Finding Active Case Finding Campaign	Virtual	4
3	TB Treatment and care	General concepts in TB Treatment DS-TB Treatment and care DR-TB Treatment and care TB Infection treatment and care TB-Comorbidities and special situations	Virtual	4
4	Adherence Management	Patient Management General Concepts in Adherence Management Adherence Support Adherence recording 99 DOTS Medication Event Reminder Monitor(MERM) Adherence Monitoring and follow-up Action	Physical	4
5	Public Health Action	Patient Support TB Arogya Sathi Application Contact Investigation Counseling and education AIC	Physical	4
6	DBT	General Concepts Processes in DBT	Physical	4
7	Supervision, Monitoring and Evaluation	Supervision Program Monitoring Indicators Monitoring	Physical	4
	Supply Chain Management in NTEP	General concepts in SCM Stocking Norms General Processes involved in SCM	Physical	4
9	Private sector Engagement	Overview of Private Sector Engagement Models for Private Sector engagement Partnership Options Regulations TB Mukt Panchayat Initiative	Virtual	2
10	ACSM and Community Engagement	General Concepts in ACSM Guidelines and Protocols for ACSM activities Community Engagement TB Champion Social Inclusion and wellness activities Engaging Family care givers Pradhan Mantri TB Mukt Bharat Abhiyan		3
11	Training the Health Volunteers and Treatment Supporters			3

Trainers

For this course, following personnel may be appointed as the trainers:

MO - STDC
MO - STC
WHO-consultants
DTO (select)
SDS/DDS Pharmacists (Select)- for Supply chain and drug distribution module.

Trainer Eligibility

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. The Trainers should have completed the ‘Course for STS’ and they must possess strong knowledge about the NTEP and the various processes related to patient workflow, Niskahy and Niskahy Aushadhi. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure.

The Trainers should be well versed with the IT systems, for video conferencing (such as Zoom), Learning Management System (such as Swasth-eGurukul), Ni-kshay and Ni-kshay Aushadhi.

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training
The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (4 hours)
Chapter 1.1	TB & TB Epidemiology	Virtual Session (60 min)
Emphasis Points	Differences between TB Infection and active TB Disease TB has many determinants- behavioral, socio economic, biological Vulnerable population for TB Concepts of TB Notification Rate and TB Incidence Rate
Post Session Activity	The participants may be asked to (i) enumerate the various determinants of TB and (ii) difference between TB Infection and TB Disease Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022.. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment.and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2022? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.]
Chapter 1.2	NTEP	Virtual Session (45 min)
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institutions (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up’ Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College be a PHI?’
Chapter 1.3	Integration of NTEP with Health System	Virtual Session(30 mins)
Emphasis Points	Need for integration of NTEP with the general health system & NHM and how that integration is envisioned .
Post Session Activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized”’
Module 2	TB Diagnosis and Case Finding	Virtual Session (4 hours)
Chapter 2.1	Diagnostic Technologies	Virtual Session (30 min)
Emphasis Points	Names of different tests,their uses, advantages and disadvantages
Post Session Activity	Ask what are the advantages and disadvantages of FL- LPA over NAAT?
Chapter 2.2	Diagnostic Network & Hierarchy	Virtual Session (30 min)
Emphasis Points	Network and hierarchy of laboratories and their basic role
Post Session Activity	Ask “ how many sputum collection and transportation facilities are there in their concerned TU? Make one participant explain how it functions and what are the benefits out of it”?- Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel
Chapter 2.3	Approaches to TB Case Finding	Virtual Session (30 min)
Emphasis Points	Differentiate between screening and testing. The three approaches may be discussed by giving suitable examples to fit into the three scenarios
Post Session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 2.4	TB Case Finding in NTEP	Virtual Session (30 min)
Emphasis Points	Diagnostic algorithm for Pulmonary TB- Role of Chest X ray as a screening tool and the need to complete the diagnostic algorithm. Classification of TB on the basis of site,diagnosis, drug resistance
Post Session Activity	Discuss: “What proportion of presumptive TB patients in your TU completes the diagnostic algorithm? What are the implications if the people are not completing the diagnostic algorithm?”
Chapter 2.5	Active Case Finding Campaign	Virtual Session(45 mins)
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post Session Activity	Discuss how they monitor the ACF in their TU against ‘Cascade of Care? What are the measures they undertake to prevent the leaks in ‘’Cascade of care’’?
Module 3:	TB Treatment and care	Virtual Session (4 hours)
Chapter 3.1	General Concepts in TB Treatment	Virtual Session (60 mins)
Emphasis Points	It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase. Process of Treatment Initiation and Transfer of patients
Post Session Activity	Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
Chapter 3.2	DS-TB Treatment and Care	Virtual Session ( 30 mins)
Emphasis Points	Regimen and dose of drugs for managing DS-TB for adults and pediatric group and weight bands available Display all FDCs in NTEP and ensure the participants could identify all information related to it Common adverse events of anti-TB drugs
Post Session Activity	Call one participant and ask to explain the step by step process for initiating treatment to a 50 Kg old adult diagnosed with pulmonary TB (Rif Sensitive). Write down all the steps in a flip chart/chatbox/Virtual whiteboard. Ask other members to comment on the missed steps and the order of steps. Call a second participant and ask to explain the follow up for the same patient.
Chapter 3.3	DR-TB Treatment and care	Virtual Session (30 mins)
Emphasis Points	What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post Session Activity	Ask participants for doubts and help them clear those doubts.

Chapter 3.4	Different DR-TB Regimens	Virtual Session (15 mins)
Emphasis points	Different regimens, constituents and duration ADRs due to different regimens	Virtual Session (15 mins)
Chapter 3.4	TB Infection treatment and care	Virtual Session (30 min)
Emphasis Points	Eligible people for TPT Testing for TPT Steps for Ruling out active TB before initiating TPT Adherence monitoring and treatment support for those on TPT
Post Session Activity	Role Play- Counseling for TPT
Chapter 3.5	TB Co-morbidity and special situations	Virtual Session (30 min)
Emphasis Points	Bidirectional screening for TB-HIV, TB-Diabetes Need for screening for tobacco and alcohol use among people with TB Nutritional assessment for people with TB. Need for and mechanism of Linkages of people with comorbidity (HIV, Diabetes, Malnutrition, Tobacco and alcoholism)
Post Session Activity	Ask the participants to describe the existing mechanism at their TU to screen TB among the people visiting ICTC centers - how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement. Ask the participant to describe how diabetes testing is done among people with TB in their TU? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Module 4:	Adherence Management	Physical Session (4 hours)
Chapter 4.1	Patient Management	Virtual Session (60 mins)
Emphasis Points	How the information of patients is managed through Ni-kshay (Enrollment, Request for Test).
Post Activity Session	Call two participants to demonstrate how they (1) enroll a subject and (2) request for Test in Ni-kshay Make all participants to view their task list in Ni-kshay and discuss how they are going to use the feature
Chapter 4.2	General concepts in Adherence management	Physical Session (60 mins)
Emphasis Points	This is an overview chapter where participants need to understand the (i) General Concepts in Adherence Management such as why adherence monitoring and treatment support is important, (ii) what are the various supports required by a person with TB during TB treatment and (iii) various ways of providing those supports and (iv) various ways to monitor treatment adherence?
Post Session Activity	Ask one participant to demonstrate how they register treatment supporter in Ni-kshay
Chapter 4.3	Adherence Support	Physical Session (60 mins)
Emphasis Points	Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay. Recording adherence using TB Arogya Sathi Application
Post Session Activity	Call one participant and ask to demonstrate recording adherence using TB Arogya Sathi Application
Chapter 4.4	Chapter: 99 DOTS	Physical Session (30 mins)
Emphasis Points	Need to have 99 DOTS Envelops for this sessions. Explain step by step process of adherence monitoring using 99 DOTS (Choosing the envelope, educating the person with TB on 99DOTS, linking it with Ni-kshay, administering the first dose, troubleshooting)
Post Session Activity	Give the following scenarios and ask them to troubleshoot\ Scenario 1: One of their patients complained that she used to dial the toll-free number every day and used to hear “Thank You” also. But when you check, the Nikshay dashboard is still showing red. Scenario 2: One of your clients with TB called you and told you that his call is not going to the ‘toll free’ number because of ‘insufficient’ balance.
Chapter 4.5	Chapter: MERM	Physical Session (30 mins)
	Need to have a MERM device for demonstration. Battery assembly may be explained and the different scenarios to troubleshoot should be explained. The process flow in Ni-kshay(registering the device, setting the alarm and refill time) should be explained to the participants.
	One/more participants may be asked to demonstrate this in Ni-kshay(Demo)
Chapter 4.6	Chapter: Monitoring of adherence	Physical Session (60 mins)
Emphasis Points	Participants need to be empowered to use adherence summary dashboards and interpret the indicators.
Post Session Activity	Request everybody to open their adherence dashboards and comment on their % of 'Average Adherence' of all patients on treatment. Request all participants to open their adherence task list and ask their plans based on the task list
Module 5:	Public Health Action	Physical Session (4 hours)
Chapter 5.1	Patient Support	Physical Session (60 min)
Emphasis Points	Various kinds of support the TB patient needs (nutritional support, psycho social support, support for deaddiction, travel support) and how STS could help in offering the same
Post Session Activity	Give a scenario: A 62 year old woman from a Tribal community affected with TB. Ask all participants to list out all the Government schemes/initiatives which can support her during the treatment period? Write down all schemes in a flip chart/Chatbox/Virtual board
Chapter 5.3	Contact Investigation	Physical Session (60 mins)
Emphasis Points	Step by step process for contact investigations Discuss the steps to record the contact tracing in Ni-kshay
Post Session Activity	Ask one of the participants how contact investigations are happening in his/her TU (Coverage, Quality, Periodicity, Challenges). Ask one/more participants to demonstrate the process in Ni-kshay(Demo)
Chapter 5.4	Counselling and Education	Physical Session (60 mins)
Emphasis Points	Basic principles of counselling (DOs and DONTs) Points to be included while counselling of a person with TB
Post Session Activity	Ask participants to comment on the following statements made by STS while counselling a person with TB “I have already informed all people who came to your shop that you are having TB”. (Clue: It's a breach of confidentiality. It should have been discussed with the person with TB first. The person with TB should have been empowered to disclose it to others if required) “If you are not taking the medicines properly, you will definitely die”. (Clue: It's a coercive/threatening language and should be avoided) “Because you were a smoker and alcoholic, you got TB” (Clue: It's a blame on the person and should be avoided)
Module 6:	DBT	Physical Session (4 hours)
Chapter 6.1	General Concepts in DBT	60 mins
Emphasis Points	This is an overview chapter. Various DBT schemes for people affected with TB Various stakeholders while processing DBT (Beneficiary, Maker, Checker) PFMS
Post Session Activity	Re-emphasise the concepts - Maker & Checker; Ni-kshay & PFMS.
Chapter 6.2	Processes in DBT	150 mins
Emphasis Points	Explain beneficiary registration, benefit process & benefit approval. Processing incentives for NP, private provider, treatment supporter, tribal TB Calculation of benefits DBT reports & registers in Ni-kshay
Post Session Activity	Make every participant open their DBT benefit register and beneficiary register and comment on performance.
Module 7	Supervision, Monitoring & Evaluation	Physical (4 hours)
Chapter 7.1	Supervision	60 minutes
Emphasis Points	General Concepts of Supervision and basis tenants of a good supervisory process Supervisory Protocols for STS Supervisory roles of MO-TC & DTO at TU
Post Session Activity	Reemphasise the concept of supportive supervision. Get feedback on how some of them plan to change their supervision plan.
Chapter 7.2	Program Monitoring Indicators	120 minutes
Emphasis Points	Nine program monitoring indicators - definitions, how to calculate the indicators, how to interpret the indicators. How to perform a root cause analysis- (1) drill down to the problem using data, (2) perform a person, place, time analysis, (3) explore for potential reasons of low performance through interviews.
Post Session Activity	Assignment: Each participant needs to calculate any 3 indicators in their TU based on real time data and interpret those indicators. For one of the low performing indicators, they need to do a root cause analysis and come up with potential solutions. Every participant needs to submit an assignment based on this.
Module 8	Supply Chain Management	Physical (4 hours)
Chapter 8.1	General Concepts	60 mins
Emphasis Points	General Concepts of SCM Principles of SCM Drug distribution flow Nikshay Aushadhi
Post Session Activity	Ask for any doubts from the participants and clarify the same.
Chapter 8.2	Stocking Norms	30 mins
Emphasis Points	Buffer stocks and storage norms
Post Session Activity	Reinforce the concepts of buffer stock and storage norms.
Chapter 8.3	Supply chain process	150 mins
Emphasis Points	Indenting, Receipt Storage of drugs
Post Session Activity	Request one participant to demonstrate drug indenting through Ni-kshay aushadhi
Chapter 8.4	Drug dispensation Module	30 mins
Emphasis Points	Dispensation of drug using Ni-kshay, adding filling and returning dispensation
Post Session Activity	Request one participant to demonstrate the Ni-kshay dispensation module.
Module 9	Multisectoral Sector Engagement	Virtual (2 hours)
Chapter 9.1	General Concepts	30 mins
Emphasis Points	Why private sector engagement is important and what is the Vision of NTEP on private sector engagement.
Post Session Activity	Recollect Standards of TB Care in India and emphasize that the vision of NTEP with regard to private sector engagement is to ensure STCI to all patients. The choice of where to take treatment remains with the patient. Emphasize that more than the private sector, it is the NTEP who wants to engage with the private sector to ensure that all patients reaching them receive STCI. Tell that TU is a population and ensuring STCI to all cases emerging from that population is the responsibility of STS. STS can engage the private sector to minimize his/her workload.
Chapter 9.2	Models of Private Sector Engagement	60 mins
Emphasis Points	Explain PPSAs, Direct Option for engagement. Explain STEPS
Post Session Activity	Ask each of the participants to think what model suits for private sector engagement in their TU and why.
Chapter 9.3	Partnership Guidelines	30 mins
Emphasis Points	Emphasis on various options under partnership options
Post Session Activity	Discuss what all partnership options are currently existing in their TUs and what would they want to have.
Chapter 9.4	Regulations	30 mins
Emphasis Points	Regulations of Mandatory TB Notification and Schedule H1
Post Session Activity	Discuss how information from schedule H1 could be used? (Clue: Most crucial field in the schedule H1 register is the name of the provider who prescribed it. Information from Schedule H1 register could be used to Identify the provider prescribing the anti TB drugs and prioritize for engagement, Identify missing TB cases)
Module 10	ACSM and Community Engagement	Physical (3 hours)
Chapter 10.1	General Concepts in ACSM	60 mins
Emphasis Points	Differentiate clearly among Advocacy, Communication and Social Mobilization Common approaches for ACSM for TB Elimination
Post Session Activity
Chapter 10.3	Protocols for ACSM activities	60 mins
Emphasis Points	Organising Community Meetings, Peer group interventions, ACSM activities in schools
Post Session Activity	Discuss experiences form 1-2 participants regarding organizing community meetings
Chapter 10.4	Community Engagement	60 mins
Emphasis Points	LSGs and their role in TB Elimination TB Forums and what they can do What role can TB Champions play?
Post Session Activity	Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.

Abhimanyu Sun, 26/02/2023 - 22:33

Competencies of the Senior Treatment Supervisor (STS)

The following competencies are essential to a STS

Competency	Description/ activities pertaining to the said competency	Assessment of competency
Suggest appropriate test to eligible individuals to detect TB/DR-TB/TBI	Identify individuals vulnerable to develop TB disease. Identify individuals eligible for TPT/ testing for TBI - Screen for TB using 4 symptom complex and identify presumptive TB. Prescribe appropriate diagnostic test to diagnose TB, DR-TB and TB Infection to the eligible based on NTEP guidelines. Enroll a person in Ni-kshay and request for Test through Ni-kshay	Verification of case records in Ni-kshay to check whether correct tests are prescribed and the diagnosis is complete including testing for drug resistance Interview with STS to understand his/her practice in relation to diagnosis of TB Interviews with people affected with TB/TBI under care of the STS to check whether they are diagnosed completely.
Coordinate to initiate treatment for a person diagnosed with TB/ TBI or those eligible for TPT	Check the reports of various laboratory investigations and coordinate with medical officer to establish the diagnosis of TB/ TB Infection . Classify the TB disease based on site of disease, DST results and history of ant-TB treatment.. Co-ordinate to identify an appropriate treatment supporter and health facility in consultation with the medical officer, field staff and beneficiary. Document the treatment initiation and details of prescription in Ni-kshay -To conduct home visit for initial counselling	Verification of case records in Ni-kshay to check whether correct regimens are prescribed Interview with patients under care of STS to check whether treatment initiation is as per NTEP guidelines
Counsel the people with presumptive TB or people affecetd with DS-TB/DR-TB/ TBI and their family	Counsel the people with presumptive TB/ people affected with TB/TBI on: Early and complete Diagnosis of TB, correct and complete Treatment of TB, Treatment Adherence, Air borne Infection Control, Contact Investigation, TB Preventive Therapy, Co-morbidity management, Adverse Drug Reactions and Social welfare measures	Interview with people affected with TB/TBI to check STS's ability to counsel
Transfer out/in a person affected with TB to to ensure continuum of care	Successfully refer out a person with TB to higher center/ nearest health facility for ensuring continuum of care -Accept the referred in patients and co-ordinate to provide care. Request for transfer in of treatment records for ensuring continuum of care when ever required -Document the referral in Ni-kshay. Coordinate with respective program staff for continuation of treatment post referral out	Verify Transfer Module in Ni-kshay to check success of referrals
Conduct the trainings for health volunteers and treatment supporters	Maintain the list of treatment supporters in Ni-kshay -Train- the health volunteers and treatment supporters using the cadre wise training course	Interview with treatment supporters to check STS'S ability to train
Perform DBT maker functions	Co-ordinate to Feed bank details of benificiaries for Ni-Kshay Poshan Yojana, Incentives to informers and private providers, treatment supporters and tribal TUs. Verify bank details and initiate payment process. Trouble shoot any issues at maker level related to non-payment of benifits to the eligible. Monitor DBT using dashboard and registers, identify the list of people for which the benefits were not paid and thrive to process the payment timely	Review of DBT indicators in Ni-kshay
Plan and conduct Active TB case Finding (ACF) campaigns in respective geographies	Perform vulnerability mapping to identify vulnerable populations/ individuals - Identify and train pool of community volunteers, ASHAs, on active TB case finding campaign Prepare team wise daily micro-plan/ calendar of ACF activities including plan for door to door visit, sample collection and transportation to linked TB laboratories Monitor the process and provide supportive supervision to ensure quality of services and prevent leaks in cascade of care -Coordinate for reporting the data on Ni-Kshay on ACF modules	Review Ni-kshay ACF data, review micro plans and ACF documents
Organize Treatment Adherence Support and other support to the person taking anti-TB treatment	Coordinate with persons affected by TB and concerned field staff (TB-Health Visitor, ASHA, ANM, etc.) for identification of the nearest health facility and arranging a treatment supporter Identify, train and maintain a pool of treatment supporters Counsel people affected with TB about various choices of directly observed treatment (DOT) options - like treatment supporter, 99DOTS, MERM, etc. and arrange for option of patients choice as per feasibility Co-ordinate for recording of Realtime adherence either by treatment supporter or MPHW/CHO in Ni-kshay or by the beneficiary directly through 'Arogya Sathi App' Link the eligible beneficiaries with Ni-kshay Mitra for addressing the essential unmet needs including nutrition, co-morbidity management, infection control, rehabilitation and palliative care	Interview with people affected with TB regarding the support received
Monitor the treatment adherence of people on anti-TB treatment and initiate timely retrieval actions	Monitor treatment adherence records on Ni-ksay on a day to day basis -Identify people who have missed doses Investigate reasons for missed doses and trouble shoot -Initiate timely retrieval actions wherever required	Review Ni-kshay adherence calendars Interview with treatment supporters and patients who missed doses
Co-ordinate to ensure all public health actions for all diagnosed TB patients in the geography	Co-ordinate with the primary health care team and treatment supporters to ensure that the people affected with TB and their families are offered all public health actions including contact investigations, TB Preventive Therapy, Infection control counselling, treatment adherence support, linkages to social welfare schemes and universal drug susceptibility testing and post treatment follow up Record the details of public health action in Ni-kshay	Review of Ni-kshay records to check timeliness and completeness of Public health actions Interviews with people affected with TB to check about public health actions
Conduct "advocacy" to improve access to TB care at local level	Identify local issues (community & health facility level) affecting TB care efforts -Maintain list of key people to target for political advocacy (PRI leaders) and list of prominent key opinion leaders (KOL), Ni-kshay Mitras, Private Providers - Identify and engage Ni-Kshay Mitra and link the to program and beneficiaries Identify and train local TB Champions, Ni-Kshay Mitra, etc.	Check for any results of advocacy in terms of commitment from Local Government, engagement of private providers, engagement of community
Engage Community for Ending TB in the locality	Maintain a database of TB Champions Train TB Champions Ensure their voices are heard in all important meetings Discuss TB in meetings like Jan Arogya Samiti (JAS), Mahila Arogya Samiti (MAS), Village Health Sanitation, Nutrition Committee (VHSNC), etc. and appeal for inclusion of TB case finding and stigma alleviation activities to be integrated in general health related outreach activities Organize community meetings and patient provider meetings Organise activities at schools, workplaces to mobilize community for health behaviour Conduct awareness about TB in community	Interview with PRI leaders, civil society leaders, TB Champions and the staff. Review of documents of community engagement activities
Engage Private Sector for TB Care	Identify and map key providers (private hospitals, practitioners, AYUSH, chemists, traditional healers, laboratories) Advocate with key players for following Standards of TB Care in India Support the providers in ensuring STCI to their clients by providing information, providing drugs diagnostics and public health actions based on need Strengthen surveillance by ensuring timely notification and outcome data from private sector Identify patients not notified and their providers through information from Schedule H1 Co-ordinate with agencies working for private sector engagement to achieve the expected outcome Liase with professional organizations like IMA, IAP, AHPI ect for engaging their members in NTEP activities	1. Interview with private providers for STS's ability to engage them 2. Interview with STS for understanding the current practices 3. Verify Ni-kshay records for health facility registration and data from private sector
Periodically update Health Facility registration in respective geographical territory	To update Ni-kshay profile section of all health facilities in allocated geographical territory (services, GIS location, contact details, names, bank details, etc.) To identify new health facility and register as new health facility (public sector & private sector) on Nikshay, as per classification and programme guidance	1. Check Ni-kshay the details of health facility
Raise a request for drug stock replenishment at particular health facility	To monitor adherence to stocking norms and identify health facility for impending stockouts or with drug stock nearing expiry and assist respective PHI drug store to raise refill request. Coordinate with TU/ DTC drug store pharmacist for issuance of relevant drug stock as per request	1. Review indent and issue register of Ni-Kshay Aushadhi
Assist Medical Officer- In Charge/ MO-TC/ Block MO to monitor the NTEP in the concerned area	Use Ni-kshay dashboards and other program records, and interpret key performance indicators of NTEP in the facility/geography -Perform time, place, person analysis and identify areas for improvement ` Assist MO in Monitoring the input and process indicators related to the output/outcome indicator and suggest corrective actions - Conduct supportive supervision and help in building capacity of treatment supporters with an intention to improve quality of services. Assist Medical Officer in providing timely and actionable feedback to health sub-centers and reporting field staff (ANM, ASHA, TB-HV, STS, STLS, MPW, HA, etc.) Support the staff in taking the corrective actions leading to an improvement in quality of services"	1. Interview with Medical Officer in Charge/MOTC to check STS's ability in supporting monitoring 2. Verification of review meeting minutes & documentation of feedbacks provided

Shahnawaz Fri, 10/05/2024 - 14:39

Trainers' Guide for STLS Course

1. Introduction

The purpose of this document is to provide the course coordinators and trainers for the “Course for STLS in NTEP” guidance for planning and executing the training. The targeted trainees for this course would be:

● Senior TB Laboratory Supervisors

For the training areas which require handholding of trainees like demonstration of processes- Specimen collection and transportation, smear microscopy, using different NAAT, patient workflow in Ni-kshay, maintaining Lab Supplies, etc in-person training sessions need to be conducted.

The training course content has 15 modules and 56 chapters. Based on different modalities used for the training, the training delivery should take 60 hours (including demonstrations)

The training of STLS needs to be conducted at STDC/IRL where all the lab facilities are available.

The batch size for Physical Session should not be more than 7 participants and not more than 25 participants for virtual sessions.

2. Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB & TB Epidemiology NTEP Integration of NTEP with Health System	Virtual	4
2	TB Diagnosis and case finding in NTEP	TB Case Finding in NTEP Diagnostic Technologies Diagnostic Network and Hierarchy Approaches to TB Case Finding Active Case Finding Campaign	Virtual	4
3	Specimen collection and Transportation	General concepts in specimen collection & transportation Packaging & dispatching sample to a C&DST lab	Physical	2
4	Smear Microscopy	Collection & Storage of Good Quality Specimen Sputum Smear Preparation Preparation of Staining solutions Staining Sputum Smear Reading Smear and Reporting Microscopy results	Physical	8
5	CBNAAT	CBNAAT as a Rapid Molecular Diagnostic tool Sample processing for CBNAAT CBNAAT Result Interpretation and recording Troubleshooting in CBNAAT Maintenance of CBNAAT	Physical	8
6	Truenat	Truenat as a Rapid Molecular Diagnostic Test Specimen processing for Truenat Truenat result Interpretation and recording Troubleshooting in Truenat Truenat Instrument maintenance and record keeping	Physical	8
7	Ensuring Smooth functioning of Lab Services	Biomedical waste management in a microscopy lab Biomedical waste management in CBNAAT Lab Biomedical waste management in Truenat lab Record maintenance	Physical	3
8	Ensuring Quality TB lab services at TDCs	General concepts in quality assurance External quality assurance	Physical	3
9	Infection Prevention and Control [IPC]	General concepts in IPC Airborne Infection Control	Virtual	2
10	TB Treatment and care	Concepts in TB Treatment Patient Management Adverse Drug Reactions with anti-TB Drugs Documentation of Treatment Extra Pulmonary TB (EPTB) Drug Sensitive TB (DS-TB) Drug Resistant TB (DR-TB) Follow up of TB patients. Adherence monitoring Treatment Support TB & Comorbidities and special situations TB Preventive Treatment	Virtual	6
9	Public Health Action	Public health actions for TB	virtual	1
11	Supply Chain Management	Supply Chain Management in NTEP Maintaining Supplies of Lab consumables at TDC	Virtual	2
12	Supervision, Monitoring & Evaluation	Supportive supervision Evaluation	Virtual	2
13	Private sector Engagement	Private sector engagement in NTEP	Virtual	2
14	ACSM	Advocacy, Communication & Social Mobilization in NTEP Community engagement in NTEP	Virtual	2
15	Training	Training the Lab Technicians		2

3. Trainers

For this course, following personnel may be appointed as the trainers

STDC- Medical Officers
IRL Microbiologist
EQA Microbiologist
NRL Microbiologist
WHO consultants

Eligibility -

Trainers are selected based on their ability to conduct training in an interactive and interesting manner. They must possess strong knowledge about TB laboratories and related processes in NTEP. The Trainers should have completed the ‘Course for STLS on NTEP’’. The Trainers should be well versed with the IT systems such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System) and Nik-shay. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure

Chapter wise detailed instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training
The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP Virtual Session (4 hours)
Chapter 1.1	TB & TB Epidemiology	Virtual Session (60 min)
Emphasis Points	Differences between TB Infection and active TB Disease TB has many determinants- behavioral, socio economic, biological Vulnerable population for TB Concepts of TB Notification Rate and TB Incidence Rate
Post Session Activity	The participants may be asked to (i) enumerate the various determinants of TB and (ii) difference between TB Infection and TB Disease Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022.. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment.and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2021? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.]
Chapter 1.2	NTEP	Virtual Session (45 min)
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institution (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up’. Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College be a PHI?’
Chapter 1.3	Integration of NTEP with Health System	Virtual Session (30 mins)
Emphasis Points	Need for integration of NTEP with the general health system & NHM and how that integration is envisioned.
Post Session Activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized’?
Chapter 1.4	Patient Management	Virtual Session (60 mins)
Emphasis Points	How the information of patients are managed through Ni-kshay (Enrollment, Request for Test).
Post Activity Session	Call two participants to demonstrate how they (1) enroll a subject and (2) request for Test in Ni-kshay Make all participants to view their task list in Ni-kshay and discuss how they are going to use the feature
Module 2	TB Diagnosis and Case Finding	Virtual Session (4 hours)
Chapter 2.1	Diagnostic Technologies	Virtual Session (30 min)
Emphasis Points	Names of different tests, their uses, advantages and disadvantages
Post Session Activity	Ask what are the advantages and disadvantages of FL- LPA over NAAT?
Chapter 2.2	Diagnostic Network & Hierarchy	Virtual Session (30 min)
Emphasis Points	Network and hierarchy of laboratories and their basic role
Post Session Activity	Ask “ how many sputum collection and transportation facilities are there in their concerned TU? Make one participant explain how it functions and what are the benefits out of it”?- Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel
Chapter 2.3	Approaches to TB Case Finding	Virtual Session (30 min)
Emphasis Points	Differentiate between screening and testing. The three approaches may be discussed by giving suitable examples to fit into the three scenarios
Post Session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 2.4	TB Case Finding in NTEP	Virtual Session (30 min)
Emphasis Points	Diagnostic algorithm for Pulmonary TB- Role of Chest X ray as a screening tool and the need to complete the diagnostic algorithm. Classification of TB on the basis of site,diagnosis, drug resistance
Post Session Activity	Discuss: “What proportion of presumptive TB patients in your TU completes the diagnostic algorithm? What are the implications if the people are not completing the diagnostic algorithm?”
Chapter 2.5	Active Case Finding Campaign	Virtual Session (45 mins)
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post Session Activity	Discuss how they monitor the ACF in their TU against ‘Cascade of Care? What are the measures they undertake to prevent the leaks in ‘’Cascade of care’’?

Module 3: Specimen collection and transportation Virtual Session		(Physical Session: 2 hour)
Chapter 3.1	General concepts in SCT	Physical (45 mins)
Emphasis Points	Need for transportation of specimen. Modes of transportation employed. The Process of Sputum collection Requirement for Cold chain The different items may be shown.
Post Session Activity	The participants may be asked to identify different items and the specification- Eg Thermocol box size, falcon tube size, etc.
Chapter 3.2	Packaging and dispatching a sample to a C&DST lab	Virtual (45 mins)
Emphasis Points	Triple layer packaging, cold/cool chain; specimen transport carriers-technical specifications and labeling; dispatch of samples-Ni-kshay
Post Session Activity	One participant may be asked to add test request(dispatching the sample to CDST lab) in Ni-kshay Few participants may be asked to demonstrate the triple layer packaging on negative sample/distilled water.

Module 4: Smear microscopy:		Physical Session (8 hours )
Chapter 4.1	Collecting and storage of good quality specimen	Physical (60 mins)
Emphasis Points	Necessary steps in accepting request for TB test; Explain spot and morning samples, necessary steps during specimen receipt at laboratory, storage
Post Session Activity	Role play for collection of sputum sample (Probes- Collect two specimens, patient education, dispensing sputum cup, labelling etc.)
Chapter 4.2	Sputum smear preparation	Physical (60 mins)
Emphasis Points	Steps involved and their details; Do’s and Don’t to be highlighted at each step Emphasis to be given to prepare smear within 6 inches of burning spirit lamp and using other AIC measures (Direction of airflow, position of exhaust fan with respect to working station.
Post Session Activity	May ask the different trainees to enumerate the different steps involved in Smear Microscopy. May ask the details of individual steps from different participants. Demonstrate good smears, smear thickness to visualize print through it
Chapter 4.3	Staining sputum smear	Physical (60 mins)
Emphasis Points	Describe staining process-ZN, FM; properties of well stained slide-ZN/FM, importance of quality stains and staining process.
Post Session Activity	Demonstrate the well stained slides-ZN/FM (dark room)

Chapter 4.4	Reading smear and reporting microscopy results	Physical (60 mins)
Emphasis Points	Steps involved, focusing slides, Use of Different objective lens, Paper based reporting in Lab register. Digital reporting in Ni-kshay Diagnostic Module
Post Session Activity	Worksheets to demonstrate and fill paper-based records. Demonstration on Ni-shay Diagnostic Module (Demo) May ask one of the participants to generate the DMC register.
Chapter 4.5	Maintenance of microscope	Physical (30 mins)
Emphasis Points	Elaborate why storage is essential, steps in cleaning, storage and maintenance of microscope, AMC, troubleshooting.
Post Session Activity	Demonstrate cleaning of the microscope May also ask some of the participants to demonstrate the handling and storage of microscope. May also ask the participants about the different problems encountered while handling the microscope and other participants about the causes and the other set of participants about the solutions/ways to fix.

Practical Exercise

The practical exercise should include the demonstration by the trainer first and then practical demonstration by the trainees should follow.

Formation of batches: Depending on the availability of infrastructure (Like Size of the room/lab, availability of microscopes, availability of Truenat/CBNAAT machines and the modules therein).

Planning of exercise- The exercise should suitably be planned well in advance involving the lab technicians and other trainers.

Setting of training hall/Lab-

The Laboratory should be suitably equipped to demonstrate the various equipment, consumables. Requirement of equipment, supplies, reagents, samples, etc should be communicated to the lab incharge beforehand and same should be arranged before the start of the training.
The unnecessary items should be removed from the workstation before the training session.
The biosafety precautions should be followed meticulously during the demonstration. The spill management kit, etc should be in place to deal with any contingencies.

Workflow:

Smear Microscopy:

The batch of trainees after theoretical discussion and demonstration of various items, equipment and reagents should be taken to lab with strict instructions to maintain all biosafety and IPC measures (including PPEs)

They may be allotted individual workspaces (with samples, broom sticks, spirit lamps, etc) and may start the practical exercises under the supervision of trainers.

Not more than 3 trainees should be supervised by one trainer at a time.

CBNAAT:

Truenat:

Module 5: CBNAAT		(Physical Session: 08 hours)
Chapter 5.1	CBNAAT as a rapid molecular diagnostic tool	Physical (60 mins)
Emphasis Points	Key components of CBNAAT, process overview of CBNAAT consumables required; in-built controls, other CBNAAT tests
Post Session Activity	The CBNAAT machine may be demonstrated. The participants may be asked to name and identify the different parts of the CBNAAT machine. The participants may be asked to identify the different consumables and ways to handle it. May ask the different tests that can be conducted using the CBNAAT equipment.
Chapter 5.2	Sample processing for CBNAA	Physical (60 mins)
Emphasis Points	Importance of complete sample liquefaction; processing for EP samples
Post Session Activity	Demonstration of sample processing CBNAAT cartridge loading may be demonstrated to the participants (with emphasis on DOs and Donts)
Chapter 5.3	CBNAAT result interpretation and recording.	Physical (60 mins)
Emphasis Points	Visualization of results; Interpretation of results Non-conclusive results-retesting procedure. Recording of results in Ni-kshay Recording of results in paper-based register
Post Session Activity	Discussion on need for new sample/use of left over sample for retesting. may ask one of the participants to demonstrate Recording of results in Ni-kshay
Chapter 5.4	Troubleshooting in CBNAAT	Physical (30 mins)
Emphasis Points	Interfering substances, Troubleshooting-errors, invalids, hardware problems, test failure without error codes; data backup should be discussed
Post Session Activity	Discuss what troubleshooting is possible in the lab and when technical support is required from the vendor
Chapter 5.5	Maintenance of CBNAAT	Physical (60 mins)
Emphasis Points	Need for maintenance, frequency, materials required.
Post Session Activity	Prepare and fill log for daily, monthly maintenance.
	Practical Exercise on CBNAAT		Physical (180 mins)

Module 6: Truenat		(Physical Session: 08 hours)
Chapter 6.1	Truenat as a rapid molecular diagnostic test	Physical (45 mins)
Emphasis Points	Context setting and the relevance of the technology. Emphasis that it is an indigenous technology and focus of programme to adopt this technology Components of Truenat workstation, consumables required, process overview, inbuilt controls Storage conditions of the consumables also need to be discussed
Post Session Activity	The different components may be shown and the importance of each part/component may be discussed Exercise on forecasting laboratory consumables The participants may also be asked to explain the Truenat cartridge and importance of different chambers
Chapter 6.2	Specimen processing for Truenat	Physical (60 mins)
Emphasis Points	Importance of cleaning the workstation daily before and after starting the work Importance of sample pre-treatment, liquefaction, processing EP TB samples; DNA extraction; Amplification and Detection importance of complete liquefaction emphasis on critical steps in DNA extraction
Post Session Activity	One participant may be asked to demonstrate the cleaning the workstation(Unidirectional cleaning) Demonstrate the different steps involved in the specimen processing; Discussion with the participants about the Dos and Donts during the specimen processing
Chapter 6.3	Testing using the Truenat	Physical (60 mins)
Emphasis points	The different processes should be explained after unloading the cartridge, using autoanalyzer for MTB testing, handling elute, testing for Rif resistance. Emphasis should be on the best practices.
Post session Activity	The test can be demonstrated using the negative sample and participants should be given the opportunity to handle the equipment under the guidance and supervision of the trainer.
Chapter 6.4	Truenat result interpretation and recording.	Physical (60 mins)
Emphasis Points	Result visualization and interpretation; Recording-paper based & Ni-kshay
Post Session Activity	How to retrieve test results should be demonstrated. Discussion on need for new sample/use of leftover sample for retesting
Chapter 6.5	Troubleshooting in Truenat	Physical (30 mins)
Emphasis Points	Interfering substances, Troubleshooting-errors with Trueprep and Truelab; error classification, test failure without error codes
Post Session Activity	Discuss what troubleshooting is possible in the lab and when technical support is required from the vendor
Chapter 6.6	Truenat instrument maintenance and record keeping.	Physical (30 mins)
Emphasis Points	Need for maintenance, frequency, materials required; data backup.
Post Session Activity	Prepare and fill log for daily, weekly, monthly maintenance.
	Practical Exercises on Truenat		Duration: 3 hours

Module 7	ENSURING SMOOTH FUNCTIONING OF LAB SERVICES	Physical Session (3 hours)
Chapter 7.1	Maintaining Supplies of Lab Consumables at DMC; Consumables required at DMC.	Physical (60 mins)
Emphasis Points	Elaborate on consumables requires for sputum collection, slide preparation, staining and examination; stock registers; Technical specifications; Indenting supplies; Preparation of stains-ZN and FM.
Post Session activity	Exercise on inventory management for laboratory consumables Some participants may be asked to prepare the reagents following the instruction of the trainer. The stock register may be shown and some participants may be asked to explain the information fields.
Chapter 7.2	BIOMEDICAL WASTE MANAGEMENT IN A MICROSCOPY LAB	Physical (60 mins)
Emphasis point	Segregation of biomedical waste based on color coding of bins What components should be discarded in which bag Preparation and Use of disinfectants for different purposes
Post Session activity	Based on discussion, participants should be asked to prepare the line list of all the items to be disposed and the ideal way to dispose it Exercise on preparation of laboratory disinfectants
Chapter 7.3	Biomedical waste management in a NAAT lab	Physical (60 mins)
Emphasis Points	Biosafety requirement; waste collection, disinfection and disposal
Post Session Activity	Based on discussion, participants should be asked to prepare the line list of all the items to be disposed and the ideal way to dispose it- disinfectant type, duration, etc

Module 8: ENSURING QUALITY TB LAB SERVICES AT TDCS		Physical Session (3 hours)
Chapter 8.1	General concepts in quality assurance	Physical (60 mins)
Emphasis Points	Need for quality, implication of false positives and false negatives, storage of slides, outline of QA processes
Post Session Activity	Ask audience about issues and correction actions taken to maintain quality; List Good Laboratory Practices
Chapter 8.2	External Quality Assurance	Physical (60 mins)
Emphasis Points	OSE, RBRC,
Post Session Activity
Chapter 8.3	External Quality Assurance for NAAT	Physical (60 mins)
Emphasis Points	Panel testing
Post Session Activity	Envelopes and the content of the envelopes (received from NTI) may be shown. Demonstrate on EQANAAT portal- how the information has to be shared.

Module 9: Infection prevention and control (IPC)		Virtual Session (2 hours)
Chapter 9.1	General concepts in IPC	virtual (60 mins)
Emphasis Points	Need for IPC; standard precautions, IPC at a DMC and at NAAT sites
Post Session Activity	Demonstration of Respiratory hygiene Demonstration of Hand hygiene A virtual audit of cleaning practices in the lab can be carried out whether the good practices are followed in the participants lab or not
Chapter 9.2	Airborne infection control	virtual (60 mins)
Emphasis Points	Importance of AIC in TB laboratory, hierarchy of controls
Post Session Activity	Demonstrate ventilation as AIC measure Ask participants what administrative measures are taken at their centre for AIC and what actions they may take. They may be asked for some commitment and timelines to follow that.

Module 10: TB treatment and care		Virtual Session (6 hours)
Chapter 10.1	General concepts in TB treatment	Virtual (60 mins)
Emphasis Points	The treatment phases and significance of positive results for microscopy at the follow up testing The importance of counseling for treatment initiation and follow up testing should be emphasized Why testing is important after end of IP and CP and other follow up testing Follow up-including long term follow up and the importance
Post Session Activity	Discussion on need for long term follow up Important components of counseling a TB patient for follow-up testing
Chapter 10.2	ADR	Virtual (30 mins)
Emphasis Points	Identification of some common ADRs due to anti-TB drugs
Post Session Activity	The participants may be asked to enlist the different ADRs
Chapter 10.3	DS-TB Treatment and care	Virtual (30 mins)
Emphasis points	FDCs used for the treatment Schedule for followup and end of treatment testing and significance
Post session activity	May clear the doubts/queries of the participants
Chapter 10.4	DR-TB Treatment	Virtual (30 mins)
Emphasis points	What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post Session activity	Ask participants for doubts and help them clear those doubts
Chapter 10.5	Adherence to TB Treatment	Virtual (30 mins)
Emphasis points	Importance of Adherence monitoring Different adherence recording and monitoring technologies
Post session activity	May also ask the participants about the adherence recording in Nikshay and Tb Arogya Sathi Application
Chapter 10.6	Treatment Support	Virtual (30 mins)
Emphasis Points	Meaning of Treatment support Significance of Treatment support Plan Treatment Supporter to a Tb patient Nutritional support and counseling Support for de addiction Free TB Services for TB patient
Post-session Activity	The participants may be asked to find the nearest de-addiction facilities located to their place.
Chapter 10.7	TB and comorbidities	Virtual (30 mins)
Emphasis Points	Bi directional screening for TB-HIV, TB-Diabetes Need for screening for tobacco and alcohol use among people with TB Nutritional assessment for people with TB. Need for and mechanism of Linkages of people with comorbidity (HIV, Diabetes, Malnutrition, Tobacco and alcoholism)
Post Session activity	Ask the participants to describe the existing mechanism at their TU to screen TB among the people visiting ICTC centers - how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement. Ask the participant to describe how diabetes testing is done among people with TB in their TU? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Chapter 10.8	TB preventive therapy	Virtual (30 mins)
Emphasis Points	Eligible people for TPT Testing for TBI Steps for Ruling out active TB before initiating TPT Adherence monitoring and treatment support for those on TPT
Post Session Activity	Discussions on target population and risk groups

Module 11: PUBLIC HEALTH ACTION		Virtual (1 hour)
Chapter 11.1	Public Health Actions for TB	virtual (60 mins)
Emphasis Points	Why Public Health actions Public Health actions taken after TB notification Define contact tracing and contact investigation. TB education for community Counselling the TB patients and their family. Dos and Don'ts for Tb pateint couonseling
Post Session Activity	May ask any participant to enumerate the PHA May ask participant what do they understand by a specific PHA and its importance May ask the participant for what to counsel at different phases of patient care i.e Pre-treatment, during treatment and post treatment A small role play or conversation to discuss about DOs and don'ts of patient counselling

Module 12: SUPPLY CHAIN MANAGEMENT		Virtual (2 hours)
Chapter 12.1	SUPPLY CHAIN MANAGEMENT IN NTEP	Virtual (60 mins)
Emphasis Points	Meaning and significance Broad Principles of SCM Flow of Supplies in NTEP Procurement, its types GeM, Direct procurement, floating tender in GeM, Buffer stock, storage norms Nikshay Aushadhi Indenting Receipt of Supplies
Post Session Activity	May ask any participant to enumerate the the broad principles in SCM May also ask one participant to show how indenting and receipt of supplies is carried out in Nikshay Aushadhi
Chapter 12.2	MAINTAINING SUPPLIES OF LAB CONSUMABLES AT TDC	Virtual ( 60 mins)
Emphasis Points	Lab Consumables Consumables required at DMC Consumables required at NAAT laboratories Stock register and stock assessment at DMC
Post Session Activity	May ask one participant to show how they are updating the stock register

Module 13: Supervision, Monitoring and Evaluation (Virtual Session: 2 hours)
Chapter 13.1	Supervision	Virtual (120 mins)
Emphasis Points	Meaning of Supervision Objectives of Supervision Supportive Supervision Role of different stakeholders in Supervision at the TU level Role of STLS at the DMC Monitoring and Evaluation of NAAT labs Quality indicators of CBNAAT and Truenat lab
Post Session Activity

Module 14	Private Sector Engagement	Virtual Session ( 2 hours)
Chapter 14.1	General Concepts	Virtual (60 mins)
Emphasis Points	Why private sector engagement is important and what is the Vision of NTEP on private sector engagement. Explain PPSAs, Direct Option for engagement. Explain STEPS Emphasis on various options under partnership options Regulations of Mandatory TB Notification and Schedule H1
Post Session Activity	Recollect Standards of TB Care in India and emphasize that the vision of NTEP with regard to private sector engagement is to ensure STCI to all patients. The choice of where to take treatment remains with the patient. Emphasize that more than the private sector, it is the NTEP who wants to engage with the private sector to ensure that all patients reaching them receive STCI. Tell that TU is a population and ensuring STCI to all cases emerging from that population is the responsibility of STS. STS can engage the private sector to minimize his/her workload. Ask each of the participants to think what model suits for private sector engagement in their TU and why Discuss how information from schedule H1 could be used? (Clue: Most crucial field in the schedule H1 register is the name of the provider who prescribed it. Information from Schedule H1 register could be used to Identify the provider prescribing the anti TB drugs and prioritize for engagement, Identify missing TB cases)
Module 15	ACSM and Community Engagement	Virtual Session (2 hour)
Chapter 15.1	General Concepts in ACSM	Virtual (60 mins)
Emphasis Points	Differentiate clearly among Advocacy, Communication and Social Mobilization Common approaches for ACSM for TB Elimination
Post Session Activity
Chapter 15.2	Guidelines and Protocols for ACSM activities	Virtual Session (30 mins)
Emphasis Points	Organising Community Meetings, Peer group interventions, ACSM activities in schools
Post Session Activity	Discuss experiences form 1-2 participants regarding organizing community meetings
Chapter 15.3	Community Engagement	Virtual (30 mins)
Emphasis Points	LSGs and their role in TB Elimination TB Forums and what they can do What role can TB Champions play?
Post Session Activity	Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.

Abhimanyu Sun, 26/02/2023 - 22:37

Competencies of the STLS

The following competencies are essential to an STLS.

Competency	Description/ activities pertaining to the said competency	Assessment of competency
Conduct laboratory tests for TB	Perform laboratory tests like AFB smear microscopy (ZN, FM) and NAAT (CBNAAT/ TruNAAT) as per NTEP guidelines Receive the sample in Ni-kshay/LIMS Record the test results in Ni-kshay/ LIMS	Direct observation of STLS performing the tests Verify at DTC regarding error rates of STLS' during RBRC process/Panel Testing.
Conduct On Site Evaluation (OSE) for Quality Assurance in TB laboratories	Plan & conduct On site Evaluation (OSE) visits for Quality Assurance in all TDCs Document the details of OSE and provide action-oriented feedback Advocate at various levels to ensure that the actions are taken as per the feedback provided	1. Review OSE reports & actions taken against the recommendations 2. Interview LT to understand STLS' ability in performing OSE
Manage supply chain of lab consumables in TU.	Monitor and identify health facilities with laboratory consumable stock nearing expiry and assist respective lab technicians to raise refill request Review indent requests from labs, take stock of available stock, and (forecasted requirements from other indenting units) follow the First Expiry First Out (FEFO) principle while stocking and issuing consumable stocks, updating the relevant records (physical). Review forecast estimates of supplies permitted for local procurement Coordinate with DTC store pharmacist for issuance of relevant consumable stock as per request	1. Interview STLS' to check the current practices 2. Review the stock register, intend register, issue register 3. Interview LT's regarding stock outs
Prepare chemical reagents for AFB staining	Prepare batches of laboratory chemical reagents (5% Phenol, etc.) Prepare QC slides Record batch wise and expiry wise quantities in stock register Update receipts/ issues of respective stocks on stock register	1. Direct observation of stain preparation 2. Direct observation at various laboratories regarding practices regarding chemical reagents
Conduct Random Blinded Random Rechecking (RBRC) activity	Collect RBRC sample slides from respective TB detection centers Read the given slides (blinded and from another TB Unit/ STLS) and fill Annexure C. Assist DTO/ MO-DTC in verification and finalization of RBRC final report. Investigate errors and submit reports Do Umpire reading of discordance slide when designated as Umpire	1. Check RBRC reports (annexures B,C,D) and errors investigation reports 2. Interview with STSL to understand the current practices 3. Interview with LTs to check STLS's ability in conducting RBRC
Conduct the trainings for LTs	Contribute in training needs assessment/ planning of respective training calendar at district level for LTs Train LT's based on the curriculum provided by NTEP	1. Check Training Management Information System, training plan and training reports 2. Interview with LTs to check STLS' ability in training
Establish sample collection and transportation system in respective areas	Map various TB testing technologies in respective health facilities Identify specimen collection centers based on need Identify transportation mechanism Train the team to collect, package in triple layer and transport samples Monitor and assure quality of the specimen collection & transportation system	1.Interview with STLS to understand the current practices 2.Review the plan for specimen collection & transportation 3.Observe current practices in the geography
Periodically update the Health Facility registration in respective geographical territory	Update Ni-kshay profile section of all health facilities classified as laboratories in allocated geographical territory (services, GIS location, contact details, names, bank details, etc.) Add/ register new laboratory facility on Ni-kshay	1. Review health facility status in Ni-kshay
Plan and conduct Active TB case Finding (ACF) campaigns in respective geographies	Perform mapping of vulnerable populations/ individuals Identify and train pool of community volunteers, ASHAs, on active TB case finding campaign Prepare team wise daily micro-plan/ calendar of ACF activities including plan for door-to-door visits, sample collection and transportation to linked TB laboratories Monitor the process and provide supportive supervision to ensure quality of services and prevent leaks in cascade of care Coordinate for reporting the data on Ni-Kshay on ACF modules	1. Review Ni-kshay ACF data, review micro-plans and ACF documents
Reporting and Monitoring of Laboratory performance under the geography	Monitor performance and quality of testing at TDCs under the assigned geography Reporting monthly lab indicators for NAAT and TDCs Support the DTO and MO-TC for taking necessary actions to maintain and improve laboratory performance	Check ability to access Ni-kshay records and calculate laboratory performance indicators Check previously reported Monthly indicators for NAAT and TDC Discuss with DTO in ability of STLS to monitor lab performance and suggest action points

Shahnawaz Fri, 10/05/2024 - 15:12

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

Introduction

The purpose of this document is to provide the course coordinators and trainers for the “Course for CHO/MPW-PHI on NTEP” guidance for planning and executing the training. The targeted trainees for this course would be:

Community Health Officers (Stationed at AB-HWCs)
Multi-purpose workers (stationed at PHI)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstrations/ practical exercises. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the NTEP Training System, each State may decide to choose the approach which is most suitable for their State.

For virtual sessions, the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session may also be conducted at the end of each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

For the training areas which require handholding of trainees like demonstration of processes- Counselling about Specimen collection, patient workflow in Ni-kshay, etc. in-person training sessions need to be conducted.

The training course content has 3 modules and 16 chapters. Based on different modalities used for the training, the training delivery should take at least 8 hours.

The training of CHOs/MPWs needs to be conducted at DTC/Block level wherever adequate facilities are available.

The batch size for in-person Session should not be more than 15 participants and not more than 30 participants for virtual sessions.

Pre-training Preparation

Before starting a batch of training, the following preparations need to be completed.

Creation of Nikshay Usernames to the Community Health Officers
Preparation of Props (Drug Blister packs, PWB, Specimen collection container, falcon tube, Specimen carry bags, IEC Materials, etc.)

Chapter wise Trainers notes

The course is divided into three modules, with a total of 16 chapters, each with specific learning and training objectives in alignment with the competencies of the person.
The different scenarios and probes for the conversation and discussion have been covered in details at relevant sections. Three standard role plays have also been incorporated at the end of each module in the training course.

Session	Activity	Duration
Session-1 (Introduction)	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.	5 mins
Pre-test assessment	Note: This is Mandatory before proceeding with course content	10 mins
Module 1. Basics of TB and NTEP (180 mins)
Chapter 1: Tuberculosis	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.	30 mins
Chapter 2: NTEP	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.	15 mins
Chapter 3-TB diagnosis and Case Finding	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.	15 mins
Chapter 4: Nikshay & Treatment Supporter	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.	20 mins
Chapter 5: TB Arogya Sathi Application	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.	30 mins
Chapter 6: Patient Management in Ni-kshay	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	60 mins
Role play #1:	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	10 mins
Quiz #1	The participants need to attempt the quiz based on training content covered in Module 1. Participants should complete the quiz before moving on to Module 2. This is a pre-requisite for final certificate	10 mins
Module 2: TB Treatment and Monitoring (150 mins)
Chapter 7- General Concepts in TB treatment	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.	30 mins
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	30 mins
Chapter 9: DR-TB treatment and care	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	20 mins
Chapter 10: Treatment Adherence	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)	30 mins
Role play #2:	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	30 mins
Quiz #2	The participants need to attempt the quiz based on training content covered in Module 2. Participants should complete the quiz before moving on to Module 3. This is a pre-requisite for final certificate	10mins
Module 3: Patient Support (150 mins)
Chapter 11 - Public Health Action	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	30 mins
Chapter 12- Counselling	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. 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.	20 mins
Chapter 14- Social inclusion and wellness activity	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	20 mins
Chapter 15: Community Engagement	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.	20 mins
Chapter 16: Linkages to Social Support Scheme	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	20 mins
Role play #3:	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.	30 mins
Quiz #3: Post - Test	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	10 mins

Abhimanyu Mon, 10/04/2023 - 09:27

[Draft] Trainers' Guide for Program Manager's course

Introduction

The purpose of this document is to provide the course coordinators and trainers for the ‘Course for Program Managers in NTEP’ guidance for planning and executing the training. The targeted trainees for this course would be:

District Program Managers- District TB Officer (DTO)
State Program Managers- State TB Officer (STO)

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstration and role plays. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernized Training System, the training institute may decide to choose the approach which is most suitable for their trainees.

The training of DTOs is to be conducted at National Institutes (NITRD/NTI) or at select STDCs across country as decided by Central TB Division. The training of STOs is however be conducted at the national Institutes only.

The batch size for Physical Session/Virtual Sessions should not be more than 25.

Virtual sessions: the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

Physical/In-person Sessions: For the training areas which require hand-holding of trainees like demonstration of processes- like patient management in Ni-kshay, filling of various forms, Adherence Management tools, recording information on Public Health action, use of NI-kshay Aushadhi, etc in-person training sessions need to be conducted.

The training course content has 14 modules and 61 chapters. Based on different modalities used for the training, the training delivery should take at least 80 hours.

For the purpose of assessment of trainees, a pre-test before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content.

Some exercises have also been formulated to assess and reinforce the learnings of the trainees based on their job requirements. These exercise will be communicated to the trainees either before the beginning of in-person sessions and the solutions of which will be discussed during the physical sessions.
The other exercises will be given to trainees during the conduct of the training and will be discussed simultaneously.

The certificates are auto-generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB TB Epidemiology NTEP Approaches to S&M in NTEP Integration of NTEP with Health System Information Systems in NTEP	Self-Reading/Virtual	6
2	TB Laboratories and Diagnostic technologies in NTEP	Diagnostic Technologies and Lab Network TB Detection centres QA of TDC	Self-Reading/Virtual	6 (including Lab/Field visit)
3	TB Diagnosis and Case finding	TB Diagnosis and Case finding General Concepts in TB Case Finding Specimen collection and transportation Approaches to TB Case Finding Diagnostic Algorithms in NTEP Active Case Finding Campaign S&M for Case finding activities in NTEP	Physical	6
4	TB Treatment	Anti-TB Drug Formulations and regimens ADRs to ATT DS-TB Treatment and Care Treatment Initiation Treatment and post-treatment follow up Treatment Support Adherence Management	Physical	10(including field visit)
5	TB and comorbidity management	National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke [NPCDCS] TB and HIV TB and Diabetes TB and malnourishment TB and Substance Abuse TB and other comorbid conditions	Physical	3
6	Public Health Action	Patient Support Contact tracing and investigation Counselling TB Arogya Sathi App	Physical	4
7	TB Prevention	IPC TPT	Physical	4
8	Direct Benefit Transfer in NTEP	General Concepts in DBT Processes in DBT Monitoring of DBT	Physical	6
9	Financial management and Planning	Overview of PIP Needs assessment for Planning. Preparing a PIP Implementing the Plan Financial expenditure and accounting	Physical	3
10	Procurement, Supply Chain Management & Preventive Maintenance	General Concepts in SCM Information system for SCM in NTEP Processes in SCM Procurement in NTEP QA in SCM	Physical	6
11	Partnerships, Corporate and Multisectoral engagement	General concepts in Partnership and MSE Models of Partnership Establishing Partnership Multisectoral Engagement Medical Colleges and NTEP	Physical	4
12	ACSM and Community Engagement	ACSM ACSM Activities Social Inclusion and wellness activities Community Engagement PM TB Mukt Bharat Campaign	Physical	4
13	Supervision, Monitoring and Evaluation	Supervision Monitoring Programme Reviews and Evaluation	Physical	4
14	Training and capacity development	Training and capacity development	Physical	3

Trainers:

For this course, personnel that have been trained and certified by Central TB Division for conducting this course at national level may only act as trainers. These may include personnel from Central TB Division, National Institutes, Technical Partner Organizations, STDCs and Medical Colleges. Central TB Division will maintain the latest list of certified trainers and need to be referred to before conducting the training.

Trainers are selected based on the following aspects

Ability to conduct training in an interactive and interesting manner.
Strong knowledge about the NTEP and the various processes related to patient workflow, Ni-ksahay and Ni-kshay Aushadhi; demonstrated by completing the entire question bank related to the modules they are certified to train.
Proficient in this Chapter- wise Training Guide.
Well versed with the IT systems such as, Zoom (for video conferencing), Swasth-eGurukul (Learning Management System), Ni-kshay and Ni-kshay Aushadhi.

Chapter wise instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (Self-reading/virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training

The activities which should be conducted at the end of each chapter / session to ensure learning effectiveness. This may include asking specific questions, demonstrating processes, discussing various forms and equipment. If any Module specific physical visits are required to be conducted, such details are also provided here.

Some exercises have also been provided with the relevant chapters that the trainees need to finish as the part of curriculum. The trainers should ensure that all the trainees finish these exercises individually and record it in appropriate response forms. All the exercise should be discussed by the trainers during the training.

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP
Chapter 1.1	TB & TB Epidemiology
Emphasis Points	1. Difference between Incidence and notification 2. Difference between Exposure to TB, infection and TB disease.
Post Session Activity	Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2022? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not, Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.] These exercises are to be given as assignments that trainees need to finish before start of 2nd module. Assignments: Find the incidence of TB in India in preceding year. Please mention the source . What was the no of TB notifications in India for year 2021. Please mention the source Why incidence is not same as notification? Download the notification register (Q1-2023) of your district. What are the Columns headings available in the register? What are the options available under the filters for the 4 columns- a) patient status, b) key population, c)basisOfDiagnosis_FinalInterpretation, d) Treatment Outcome
Chapter 1.2	NTEP
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institution (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up'. Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from. What does a TU actually mean?
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College/ IRL be a PHI?’[Clarify that any patient service delivery point will be a PHI, but program management units like STC, DTC, TU etc are not PHIs] Assignments: Enumerate the 4 pillars/strategies mentioned in NSP (2017-2025). Elaborate the build component with respect to your district.
Chapter 1.3	Approaches to S&M in NTEP
Emphasis Points	Discuss the importance of S&M. Emphasize that S&M of the different activities under NTEP will be discussed alongside the activity while discussing the content in the modules.
Post-session activity	Assignment: 1.3.1- Find the index score of your district using Nikshay for year 2022. 1.3.2.-FInd the areas where the performance of district is less than the state average.
Chapter 1.4	Integration of NTEP with Health System
Emphasis Points	Discuss the need for integration of NTEP with the general health system & NHM and how that integration is envisioned.
Post-session activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized? Assignments: 1.4.1-Write the organisation str of NTEP in your district. 1.4.2-Draw the district health system structure and how NTEP is integrated into it.
Chapter 1.5	Information Systems in NTEP
Emphasis Points	The Information system in NTEP is an ecosystem of three applications (Ni-kshay, Ni-kshay Aushadhi and Ni-kshay LIMS ) which interact with each other and with other external systems. Data from these systems may be viewed/ extracted for monitoring and review purposes from Ni-kshay Reports and Dashboards. Patients may access their health record from the Ni-kshay Arogya Saathi Application There may be other additional supporting applications provided by NTEP, states, National Institutes or by other partner organizations. Eg, TB Free Himachal, N-TB Application, ManageTBIndia,
Post-session Activity	1.5.1- Enlist the different stakeholders that are working with Nikshay and their specific roles in NI-kshay.
Module 2	TB Laboratories and Diagnostic technologies in NTEP
Chapter 2.1	Diagnostic Technologies and Lab Network
Emphasis Points	Names of different tests, their uses, advantages and disadvantages
Post-session Activity	Discuss: what are the advantages and disadvantages of FL- LPA over NAAT? Discuss “how many sputum collection and transportation facilities are there in their concerned district? Make one participant explain how it functions and what are the benefits out of it”? - Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel Assignment: 3.1.1Learn about the processes being followed in your district for sample transport from patient to TDC. 3.1.2Learn about the different processes being followed in Nikshay for the same- i.e. adding test request, sample details and entering results in Ni-kshay.
Chapter 2.2	TB detection Centres
Emphasis Points	Discuss the consumables required for the Microscopy, CBNAAT and Truenat
Post-session Activity	Assignments: A Lab-visit needs to be organised for participants to see the different processes involved for testing.
Chapter 2.3	Specimen collection and transportation
Emphasis Points	The need for SCT, importance of cool chain requirement. Discuss how the delays can be reduced to improve the TAT overall
Post Session Activity	May ask one of the participants to volunteer and demonstrate the different processes being followed in Nikshay for the same- i.e. adding test request, sample details and result updation in Ni-kshay.
Chapter 2.4	Quality Assurance of TDC
Emphasis Points	Explain the process involved in EQA of microscopy.
Post-session Activity	Lab Field visit: A field visit should be organized to a lab to understand and discuss the following: Microscopy Centre: The following should be discussed/ demonstrated: Slide preparation, Storage of slides Lab Register (Physical and Ni-kshay: what all records are being digitized) Selection of slides for EQA & RBRC Quality Control (QC) slides Flow of pt and samples from OPD to MC and to CBAAT facility. View the "My tests" page of the PHI login in Ni-kshay and review the status of tests in the last 1 month. Discuss the process of referring a patient for testing through Ni-kshay. NAAT Facility Discuss the CBNAAT process overview DOs and Don'ts while doing CBNAAT View the "My tests" page of the PHI login in Ni-kshay and review the status of tests in the last 1 month. 3) Obtain the Lab register from Nikshay and calculate the patient TurnAroundTime (referral to test reporting) for the lab and compare it with the Lab TurnAroundTime (Sample Receipt to Reporting)
Module 3	TB Diagnosis and Case finding
Chapter 3.1	General Concepts in TB Case Finding
Emphasis Points	Differentiate between screening and testing.
Post-session Activity
Chapter 3.2	Approaches to TB Case Finding
Emphasis Points	Clearly differentiate the difference between the three different approaches- Active, Passive and Intensified.
Post-session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 3.3	Diagnostic Algorithms in NTEP
Emphasis Points	Discuss how the algorithms to be read
Post-session Activity	Ask the participants to look at details of 5 TB patients from their district and see whether complete diagnostic algo has been followed or not.
Chapter 3.4	Active Case Finding Campaign
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post-session Activity	Discuss how ACF campaign is carried in participants district and how the activity can be carried out more effectively.
Chapter 3.5	S&M for Case finding activities in NTEP.
Emphasis Points	Discuss the TB index dashboard. Discuss the TB Notification dashboard,
Post-session Activity	The participants may be asked to access the TB index dashboard and TB notification dashboard from their logins and share their learnings with other audience.
Module 4	TB Treatment
Chapter 4.1	General Concepts in TB Treatment
Emphasis Points	It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase. Process of Treatment Initiation and Transfer of patients Follow-up - clinical and laboratory, assigning Treatment outcome and long-term follow-up.
Post-session Activity	Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
Chapter 4.2	ADRs to ATT
Emphasis Points	Discuss about the aDSM available in Ni-kshay , the importance and how it is carried out.
Post-session Activity	Ask one of the participants to demonstrate the adverse event module in Ni-kshay from reporting, management and outcome.
Chapter 4.3	DS-TB Treatment and Care
Emphasis Points	Regimen and dose of drugs for managing DS-TB for adults and paediatric group and weight bands available. Display all FDCs in NTEP and ensure the participants could identify all information related to it. Common adverse events of anti-TB drugs
Post-session Activity	Call one participant and ask to explain the step-by-step process for initiating treatment to a 50 Kg old adult diagnosed with pulmonary TB (Rif Sensitive). Write down all the steps in a flip chart/chatbox/Virtual whiteboard. Ask other members to comment on the missed steps and the order of steps. Call a second participant and ask to explain the follow up for the same patient.
Chapter 4.4	Overview of DR-TB
Emphasis Points	Explain: What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post-session Activity	Ask participants for doubts and help them clear those doubts.
Chapter 4.5	Isoniazid [H] Mono/Poly DR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session Activity	May ask the participant to look at 2 TB patients (outcome declared) on H Mono/poly DR-TB regimen whether the follow-up sputum examination was done timely or not.
Chapter	Shorter Oral Bedaquiline-containing MDR/RR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session activity	May ask participants to look at 2 TB patients (outcome declared) on shorter oral Bdq containing MDR/RR regimen whether all the relevant investigations for PTE and follow-up sputum examination were carried out timely.
Chapter	Longer Oral M/XDR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session activity	May ask participants to look at 1 TB patient (outcome declared) on longer oral M/XDR regimen whether all the relevant investigations for PTE and follow-up sputum examination were carried out timely.
Chapter 4.6	Treatment Support
Emphasis Points	Discuss the role of treatment supporter and how they can be registered in Nikshay, patient mapped.
Post-session Activity	Ask the participants to practice the registration of treatment supporter and subsequent mapping of patients to the treatment supporters in demo-version in Ni-kshay.
Chapter 4.7	Adherence Management
Emphasis Points	Discuss about the importance of adherence and how adherence is being reported, recorded and monitored through Ni-skahy. Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay. Recording adherence using TB Arogya Sathi Application Discuss about the Adherence dashboard.
Post-session Activity	One/more participants may be asked to record the adherence in Ni-kshay Request everybody to open their adherence dashboards and comment on their % of 'Average Adherence' of all patients on treatment. Request all participants to open their adherence task list and ask their plans based on the task list
Chapter	Monitoring of Treatment
Emphasis Points	Discuss the indicators used in monitoring the treatment- treatment initiation, outcome declaration.
Post-session activity	Exercise: Ask the participants to download the notification register for Q1-2023 and ask them to calculate the average delay in treatment initiation from date of diagnosis. Discuss how this delay can be minimised.
Field Activity	A 2nd field visit(Batch size- 5-7 participants) should be organised to the following Treatment Centre (PHI) Explain Patient flow at the centre: OPD visit (passive case finding) - registration/enrolment-> Visit to MO-> Specimen collection and transportation (spot and early morning samples) -> Pre-treatment counselling->Treatment initiation-> Dispensation-> Home visits->ADR identification and reporting-> Follow-up patient visits -> transfer of patient. The data entry points for recording the above processes in Ni-kshay and the relevant forms and registers to be maintained at the treatment centres. District Drug Store Discuss storage of drugs(ideal storage conditions), Processes being followed at DDS (inward and outward stocks) - Both physical and Ni-kshay Aushadhi Records and registers (including logbook for temp and humidity, Stock Registers, Intend/ Drug Request form, maintained at DDS DR-TB centre/ward Interview with the 1-2 patients and understand their journey from exposure to TB to current day. Pre-treatment evaluation processes Review and fill the checklist for DR-TB centre (Annex 22, PMDT guidelines 2021) The DR-TB committee meeting records The checklist for DR-TB wards
Module 5	TB and comorbidity management
Chapter 5.1	TB and HIV
Emphasis Points	Bidirectional screening for TB-HIV
Post-session activity	Ask the participants to describe the existing mechanism at their district to screen TB among the people visiting ICTC centres- how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement.
Chapter 5.2	TB and Diabetes
Emphasis Points	Bidirectional screening for TB-Diabetes
Post-session activity	Ask the participant to describe how diabetes testing is done among people with TB in their district? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Chapter	TB and malnourishment
Emphasis Point:	Discuss how malnourishment affects TB patient and role of Nutritional support in successful completion of treatment.
Chapter	TB and Substance Abuse
Emphasis Point:	Discuss how Alcohol and Tobacco Abuse affects TB and importance of linkage with the deaddiction centre.
Post Session Activity	The participants may be asked to list the de-addiction centres and tobacco-caseation centres.
Chapter	TB and other comorbid conditions

Module 6	Public Health Action
Chapter 6.1	Patient Support
Emphasis Points	Various kinds of support the TB patient needs (nutritional support, psychosocial support, support for deaddiction, travel support) and how STS could help in offering the same
Post-session activity	Give a scenario: A 62 year old woman from a Tribal community affected with TB. Ask all participants to list out all the Government schemes/initiatives which can support her during the treatment period? Write down all schemes in a flip chart/Chatbox/Virtual board
Chapter 6.2	Contact tracing and investigation.
Emphasis Points	Discuss: Step by step process for contact investigations Discuss the steps to record the contact tracing in Ni-kshay
Post-session Activity	Ask one of the participants how contact investigations are happening in his/her district (Coverage, Quality, Periodicity, Challenges). Ask one/more participants to demonstrate the process in Ni-kshay(Demo)
Chapter 6.3	Counselling
Emphasis Points	Discuss: Basic principles of counselling (DOs and DONTs) Points to be included while counselling of a person with TB
Post-session Activity	Ask participants to comment on the following statements made by STS while counselling a person with TB “I have already informed all people who came to your shop that you are having TB”. (Clue: It's a breach of confidentiality. It should have been discussed with the person with TB first. The person with TB should have been empowered to disclose it to others if required) “If you are not taking the medicines properly, you will definitely die”. (Clue: It's a coercive/threatening language and should be avoided) “Because you were a smoker and alcoholic, you got TB” (Clue: It's a blame on the person and should be avoided)
Chapter 6.4	TB Arogya Sathi App
Emphasis Points	Discuss the various information available in TB Arogya Sathi Application- the two user interfaces (General Public and TB patient) The TB Screening tool How to locate the nearest health facility Accessing the treatment details (patient interface) Recording the adherence using the app Viewing the DBT benefits and statuses. Entering /modifying the bank details
Post-session Activity	The participants may be requested to do a screening test on themselves and check the working of the application.
Module 7	TB Prevention
Chapter 7.1	Infection Prevention and Control
Emphasis Points	Discuss the following: Need for IPC Airborne infection control and need for it. Administrative measures for ensuring AIC (particularly with respect to HFs). Ventilation as an AIC measure (focus on seating plan for Health care provider and people with symptoms, air-flow in labs providing TB detection/diagnostic servies) AIC practiced at Microscopy centres including the PPEs The need and ways for disinfection and Bio-medical waste management at the Health facilities the important roles various stakeholders are required to play emphasising more on their role.
Post-session Activity	May ask the participants to recollect the AIC practices being followed in DR-TB ward (part of field-visit) and enumerate it.
Chapter 7.2	TB Preventive Treatment
Emphasis Points	Discuss the following points: The eligibility for TPT The different regimens available The different approaches- Test & Treat and test only approach. Testing for TB infection- TST, IGRA and CyTB and interpretation of different test results Counselling for TBI testing and TPT Importance of adherence for TPT and its monitoring Management of missed doses in TPT course Outcome for TPT t Monitoring indicators for TPT
Post-session Activity	Ask the participants to download the Contact tracing register (for Q3-2022) and comment on the leakages in the cascade of care for TPT for your district.
Chapter 8.1	General Concepts in DBT
Emphasis Points	Discuss the following points: Different DBT schemes under NTEP- beneficiaries and benefits Different stakeholders for DBT and their roles & responsibilities Other state-specific social welfare schemes may also be discussed Ni-kshay Poshan Yojana- benefit and the eligibility conditions Tribal Support scheme Treatment Supporter- eligibility and Honorarium Financial incentives for Private provider and informants How to register the private Health facilities and processing of their benefits Discuss the generation of benefits in Ni-kshay Different scenerios where private facilities will be getting benfits
Post-session Activity
Chapter 8.2	Processes in DBT
Emphasis Points	Discuss the following points: Process of benefit processing in Ni-kshay Steps that need to be taken by DBT maker at TU level Steps that need to be taken by DBT checker at Distrcit level Process flow for DBT in PFMS Benefit processing and approval in PFMS Process to create DBT maker and checker accounts.
Post-session Activity
Chapter 8.3	Monitoring of DBT
Emphasis Points	Discuss the following points: the different registers- Benefit register, beneficiary register, benefit batch register. DBT troubleshooting at various levels- Beneficiary, Benefit, Maker, Banking, PFMS DBT dashboards DBT process Indicator dashboards
Post-session Activity	Ask the participants to open the dashboard for their particular district: and look at the information available in the funnel diagram. (Scheme: NPY and Notification cohort- previous two quarters)- Identify the level at which the delay is maximum and discuss what measures can be taken to reduce the delay). Ak them to try the beneficiary status and benefit status. The geographic view may also be discussed to assess the TU wise performance. May ask the participants to do the same exercise for other DBT schemes and ask them to explore the reasons. The participants may be asked to open the DBT process Indicators dashboard for their district and explore the different schemes and discuss the insights developed during the process.
Module	Financial management and Planning
Chapter 9.1	Overview of PIP
Emphasis Points	Discuss the following points: the general terms related to PIP The fund flow Role of DTO in PIP preparation
Post-session Activity	May ask the participants for any doubts/queries.
Chapter 9.2	Needs assessment for Planning
Emphasis Points	Discuss the following points: Identifying the gaps in known program indicators Needs assessment
Post-session Activity	May ask the participants to clear their doubts
Chapter 9.3	Preparing a PIP and Implementing the plan
Emphasis Points
Post-session activity	May give one PIP format to the participants and ask them to fill it for their district.
Chapter 9.4	Financial expenditure and accounting
Emphasis Points	Explain the following. The general principles of accounting Basics of account books and records and the maintenance Issue and receipt of vouchers Financial Audits
Post-session Activity
Module	Procurement, Supply Chain Management & Preventive Maintenance
Chapter	General Concepts in SCM
Emphasis Points	Explain the following concepts: Drug distribution flow Different stock types and its importance FEFO and its importance Different drugs and supplies under NTEP various stocking points in NTEP Drug stores at different levels- SDS, DDS, TU drug store and drug storage at PHI level (how drugs are stored and role of different stakeholders) Flow of different drugs in NTEP- DS-TB, DR-TB, Bdq, Dlm, Lab supplies. Expiry management and monitoring.
Post-session Activity
Chapter	Information system for SCM in NTEP
Emphasis Points	Discuss the following: Ni-kshay Aushadhi Different dashboards- State/district/Alert/Reports and features available at different levels.
Post-session Activity	Ask the participants to open their district dashboard and look at the alert dashboard and share the finding with other participants.
Chapter	Processes in NTEP
Emphasis Points	Discuss and demonstrate the participants the following processes: Indenting meaning and procedure for requesting the supplies from different levels Issue of supplies and recording in Ni-kshay Aushadhi Consumption of supplies at different levels Forecasting- meaning, importance and calculations. Expiry of drugs, forecasting and disposal PWB- types and preparation Process of return of drugs Reconstitution of Bdq bottle and recording in Ni-kshay
Post-session Activity	Ask the participant to demonstrate the following in demo version of Ni-kshay AUshadhi: Indenting of drugs from the TU store to district Issue of supplies to TU from the district Acknowledge the receipt of drugs at TU Dispatching of drugs in Ni-kshay Aushadhi: On request and without request Ask the participants to demonstrate the following in demo version of Nikshay Adding and Printing Dispensation Returning the dispensation Ask the participants to forecast the supplies (for DS-TB drugs) for next quarter on the basis of consumptions based in previous quarter in their district
Chapter	Procurement in NTEP
Emphasis Points	Explain the following points: Procurement- meaning and importance. Different types of procurement processes- Direct and tendering Government e-Marketplace - meaning and different processes involved.
Post-session Activity	The trainer may demonstrate them the processes involved in GeM using the demo version/live version using their login credentials.
Chapter	Quality Assurance in Supply Chain Management
Emphasis Points	Discuss the following points: Meaning and Processes involved in QA of drugs in NTEP Recording of QA of drugs in Ni-kshay AUshadhi Monitoring of drug stores Store visits in NTEP- checklist for store visits Physical verification of supplies and recording in Ni-kshay Aushadhi
Post-session Activity	Ask the participant to open demo Ni-kshay aushadhi and demonstrate the recording of Physical Stock verification, and QA of drugs
Module	Partnerships, Corporate and Multisectoral engagement
Chapter 10.1	General Concepts in Partnership and MSE
Emphasis Points	Discuss the following points: Vision of NTEP regarding private sector Engagement Importance of Private Sector Engagement and multisectoral engagement Stakeholders for Private Sector Engagement Steps for Engagement. Involvement of Pharmacist, Labs, Ayush Providers Regulatory provisions- H1 regulation, Mandatory notification
Post-session activity
Chapter 10.2	Models of Partnerships
Emphasis Points	Discuss the following- STEPS PPSA Direct Engagement
Post session activity.	May ask the participants to clear their doubts.
Chapter 10.3	Establishing the partnerships
Emphasis Points	Discuss the following: Guidance Document on Partnership- Overview Undertaking a needs assessment Mapping of the stakeholders- meaning and process Partnership Options- meaning and significance. Steps to engage a service delivery. Partnership options available to Private sector engagement Bundling approach- meaning and significance Contract- Meaning, Types: input-based, Output-based, Fee for service contract, Steps for executing a contract. Budgeting for Partnership options Performance matrix for partnerships Verification and validation of invoices
Post Session activity	The participants may clear their doubts.
	Multisectoral Engagement

Abhimanyu Mon, 11/09/2023 - 12:47

Competencies of the Program Managers (PM) at district level

The following competencies are important to a PM

Competency	Description/ activities pertaining to the said competency	Assessment of competency
Implement the NTEP in the district	Ensuring uninterrupted TB services in the district (case finding, treatment, prevention, monitoring, supervision and evaluation)	Assess the availability of TB services in the district Ability to sensitize and train the GHS staff, NTEP workforce, Private providers, Professional organisations (IMA, etc) Assess the implementation through NTEP performance indicators Take action in response to Action-oriented feedback Conduct PDSA cycle for identified issues.
Prepare Program Implementation Plan for NTEP	Identify interventions/solutions to local problems Prepare proposals for newer interventions Locally adapt the strategies of the NSP toward TB Elimination to the district/ state Prepare the annual PIP and budget of the district Implement activities as per Record of Proceedings (RoP)	1. Verify PIP. 2. Interview with the DTO to identify the current practices regarding planning
Monitor NTEP performance	Use Ni-kshay dashboard to monitor the program Compare the key performance indicators against expected and interpret Do time, place, person analysis and identify areas needing improvement in performance Perform root cause analysis with an intention to solve the identified issues Provide timely and actionable feedback to TUs and PHIs Prioritize themes and finalize agenda based for review meetings based on monitoring Conduct regular review meetings in a consultative mode to identify and solve issues Support staff in taking recommended actions and monitor the change in program performance due to the action Take actions and submit action taken reports to feedback received from state/national level	1. Verify action-oriented feedback provided by the program manager 2. Verify Minutes of review meeting to check the quality of review 3. Interview with the program manager to identify the current practices regarding monitoring
Perform Supportive Supervision	Prioritize geographies and themes for supervision based on monitoring Conduct supportive supervision to TB Detection Centers, health facilities, patient and staff interviews to solve problems, build capacity of staff and motivate them	1. Verify Supervisory reports to check the quality of supervisory visits 2. Interview with the program manager to understand the current practices
Mange supply chain and logistics	Forecasting the requirements of the district Manage procurements of supplies and timely availability of optimum stocks of drugs and consumables, vendor and Contract Management.	1. Interview with the DTOs to understand current practices 2. Verify records (Ni-kshay Aushadhi/Stock registers), Physical Stocks and contract records to check whether supply chain and logistics management are as per norms
Solve problems and improve the quality of program	Implement quality improvement measures using Plan-Do-Study-Act (PDSA) approach	1. Check documents and evaluate the field realities for number of problems systematically solved by the DTO
Manage the training and capacity building at the district.	Monitor and plan the trainings Train staff such as Medical Officers, Health Volunteers, CHO, MPHW, Civil Society Representatives Advocating for filling the vacant positions in their district Perform staff competency assessment	1. Review training plan and training reports 2. Interview with staff to assess the quality of training conducted by the district 3. Review the competency assessment performed by the DTO.
Manage NTEP funds of the district	Make expenditure as per RoP Monitor expenditure against RoP Document expenditure as per guidelines Perform checker functions on Ni-Kshay modules and ensure DBT payment disbursals	1. Review SOEs, account book, PFMS and check whether the program manager is able to perform this function as expected 2. Interview with the program manager to understand the current practices
Advocate for securing resources and commitment for TB Elimination activities		1. Check for any results of advocacy in terms of commitment from District Administration, District Health Administration, engagement of community 2. Check for the relevant meeting records
Engage Public (General Health System) and Private Healthcare Sector for TB Care	Identify and map key providers (private hospitals, medical colleges, Government HFs, Private practitioners, AYUSH facilities/practitioners, chemists, traditional healers, laboratories) for engagement Advocate with all providers for following Standards of TB Care in India/ latest NTEP Guidelines. Co-ordinate with agencies working for private sector engagement Liase with professional organizations like IMA, IAP, AHPI etc Co-ordinate with other Health Programmes for joint activities	1. Interview with private providers, Drug Inspector, Association leaders to check program manager's ability to engage them 2. Interview with the DTO for understanding the current practices
Engage Community for Ending TB	Conduct District TB Forum meetings Engaging the community including the TB Vijeta for providing the TB services.	1. Interview with PRI leaders, civil society leaders, TB Vijeta and the staff. 2. Review of documents of community engagement activities 3. Review the proportion of patients who are on receiving community support

Shahnawaz Tue, 28/05/2024 - 12:33

Trainers Guides for Cadre wise Courses

ManuMathew Wed, 18/09/2024 - 11:34

[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	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 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	India's commitment to ENDING TB 5 years ahead of global Targets The PHI is a the 5th level in NTEP hierarchy; the only one responsible for actual service delivery. The MO-PHI is the leader and program manager at this level for the population catered to by the PHI.
Post Session Activity	Discuss: Can a medical college be a PHI? Answer is yes. 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	Ni-kshay is the information system of the TB program It has different interfaces for various stakeholders ranging from Patient's to program managers 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	Highlight the various steps in case finding from screening to confirmation of diagnosis. 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	Rapid Molecular Test as a highly sensitive tool for diagnosis of TB Three tier hierarchy (NRL, IRL, Service Labs- NAAT/ C&DST /Microscopy) 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	Good quality sputum being mucopurulent, early morning sample. 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	ACF is conducted in vulnerable populations to detect cases early. Vulnerable population mapping is the first step in the ACF campaign. ACF is conducted to find cases early directly from the community. 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	The process of treatment starts from initiation to the end of long-term follow-up Treatment initiation consists of pre-treatment counseling and testing, prescription and dispensation. 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	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. 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. Monthly Clinical Follow-up and end IP and CP are required during treatment. Post treatment 6monthly follow-up is required for two years. 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	Treatment support is a range of measures taken by a Treatment Supporter to ensure that the client completes treatment successfully. 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	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. 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	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	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	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 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	People with TB have various needs and require support to get a diagnosis, completing their treatment successfully and even during post treatment. 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 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	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 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	For the purpose of monitoring information in Ni-kshay is available as registers for each service. 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 Fri, 07/06/2024 - 15:16

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 Sat, 27/07/2024 - 09:49

[Draft] Trainers Guide for Course for Senior DR-TB/TB-HIV Supervisor on NTEP

In Development

ManuMathew Mon, 22/07/2024 - 11:30

Competencies of Sr DR-TB/TB-HIV Supervisor

The following competencies are essential to a Sr DR-TB/TB-HIV Supervisor.

#	Competency	Description	Assessment Method
1	Monitor and coordinate for DST/DRT Testing for all Notified TB Cases	- Identify individuals pending various DST/ DRT tests from Notification Register/ Patient wise Lab register based on NTEP guidelines - Coordinate with various field staff to obtain samples and transport them to linked Laboratory and to obtain valid results, and ensure Patient TATs are within norms - Reinitiate new epsiodes and initiate request for Test through Ni-kshay	Evaluate knowledge, attitude, and practices based on a review of the status of DST/DRT Testing performance in the district.
2	Coordinate to initiate appropriate DRTB treatment by referral to relevant PHI and coordinate with field staff for patient support	- Check the reports of various laboratory investigations and coordinate to establish the diagnosis of DRTB - Refer a person with TB to the appropriate DRTB Centre/ ART Centre/ health facility for Clinical followup/ Treatment initiation and ensure appropriate HF Linkage in Ni-Akshay -Co-ordinate to identify an appropriate treatment supporter and health facility in consultation with the medical officer, field staff and beneficiary -Document the treatment initiation and details of prescription in Ni-kshay	1. Verification of case records in Ni-kshay to check whether correct regimens are prescribed when new diagnostic information is available 2. Interview with patients under care of the individual to check whether treatment initiation is as per NTEP guidelines
3	Counsel the people who are presumptive DRTB/ diagnosed with/ on treatment for, DR-TB and their family	Through home visits Counsel the people with presumptive DR-TB/ people diagnosed with or on treatment of DR-TB and TB-HIV on: -Early and complete Diagnosis of DRTB, correct and complete Treatment of DRTB, -Treatment Adherence, -Co-morbidity management including regular Treatment and follow-up with ART for PLHIV -Airborne Infection Control, -Contact Investigation, -TB Preventive Therapy for contacts, -Adverse Drug Reaction monitoring and management -Social welfare measures	1. Interview with people affected with TB/TBI to check STS's ability to counsel
4	Monitor the treatment adherence of people on DR-TB treatment and initiate timely retrieval actions	-Monitor treatment adherence records on Niksay on a day to day basis -Identify people who have missed doses -Investigate reasons for missed doses and trouble shoot -Initiate timely retrieval actions wherever required	1. Review Ni-kshay adherence calenders 2. Interview with treatment supporters and patients who missed doses
5	Coordinate timely Clinical and Laboratory follow-up of DR-TB patients according to NTEP Guidelines	Clinical Followup Laboratory Followup Treatment outcomes Long Term Post Treatment Outcomes	Review in Ni-kshay reports Interview with patients
6	Monitor Status of completion of comorbidity Testing for All notified TB patients	Coordinate with NTEP staff for timely completion of comorbidity testing	. Review in Ni-kshay reports and register
7	Monitor and Raise a request for drug stock and consumables replenishment at particular health facility	- To monitor adherence to stocking norms and identify health facility for impending stockouts or with drug stock nearing expiry and assist respective PHI drug store to raise refill request. - Coordinate with DTC/ State drug store pharmacist for issuance of relevant drug stock as per request	1. Review indent and issue register of Ni-Kshay Aushadhi
8	Support the DTO in organizing the District level Comorbidity Committees and ensure optimal performance of TB Comorbidity activities	-Prepare and maintain a directory of ICTCs, ART Centres, Community Care Centres, NCD clinics, private health facilities and NGOs working for HIV , in the district and collaborating NTEP Centres -Coordinating the meeting with relevant stakeholders and preparing action points -To oversee that action points are implemented	Interview with DTOs
9	Build capacity of District staff (STS/ TBHV, MPHW, TS/HV, CHO) on DR-TB Services	- Support in the training of Peripheral staff	1.Competency Assessment
10	Assist DTO to monitor the NTEP in the district	- Use Ni-kshay dashboards and other program reccords, and interpret key performance indicators of NTEP in the faility/geography -Perform time, place, person analysis and identify areas for improvement ` -Assist MO in Monitoring the input and process indicators related to the output/outcome indicator and suggest corrective actions - Conduct supportive supervision and help in building the capacity of treatemnet supporters with an intention to improve quality of services. - Assist Medical Officer in providing timely and actionable feedback to health sub-centers and reporting field staff (ANM, ASHA, TB-HV, STS, STLS, MPW, HA, etc.) - Support the staff in taking the corrective actions leading to an improvement in quality of services"	1. Interview with DTO/ MO-DTC to check ability in supporting monitoring 2. Verification of review meeting minutes & documentation of feedback provided

mayank.mittal@… Mon, 22/07/2024 - 11:30

[Draft] Trainers' Guide for Course for MO-TC on NTEP

Introduction

The purpose of this document is to provide the course coordinators and trainers for the ‘Course for Medical Officers- TB Control’ guidance for planning and executing the training. The targeted trainees for this course would be:

Medical Officers- TB Control

This training may be provided by utilizing the blended approach where a mix of training methods and modes will be used to deliver content. This would include either in-person/ virtual training or facilitator led/ Self learning/ demonstration and role plays. Training sessions which require hands-on training will be conducted only in a physical setting. Keeping in mind the aforesaid best practices of the Modernized Training System, the training institute may decide to choose the approach which is most suitable for their trainees.

The training of MO-TC is to be conducted at STDCs. The batch size for Physical Session/Virtual Sessions should not be more than 25.

Virtual sessions: the trainees will be going through the online content, and attempt quizzes after each module. An instructor-led session will also be conducted for each module. This will help the trainees for better clarification of contents and to address the queries and doubts.

Physical/In-person Sessions: For the training areas which require hand-holding of trainees like demonstration of processes- like patient management in Ni-kshay, filling of various forms, Adherence Management tools, recording information on Public Health action, use of NI-kshay Aushadhi, etc in-person training sessions need to be conducted.

The training course content has 13 modules and 53 chapters. Based on different modalities used for the training, the training delivery should take at least 60 hours.

For the purpose of assessment of trainees, a pre-test before the beginning of training, interim quizzes at the end of each module and a post-test at the end of training has been configured in the course content.

Some exercises have also been formulated to assess and reinforce the learnings of the trainees based on their job requirements. These exercise will be communicated to the trainees either before the beginning of in-person sessions and the solutions of which will be discussed during the physical sessions.
The other exercises will be given to trainees during the conduct of the training and will be discussed simultaneously.

The certificates are auto-generated for the trainees in their LMS account on successful completion of post-test and their performance in interim quizzes.

Training curriculum / Agenda

Sr.	Module	Chapters	Training Modality	Duration (Hrs)
1	Basics of TB and NTEP	TB TB Epidemiology NTEP Approaches to S&M in NTEP Integration of NTEP with Health System Information Systems in NTEP	Self-Reading/Virtual	6
2	TB Laboratories and Diagnostic technologies in NTEP	Diagnostic Technologies and Lab Network TB Detection centres Specimen collection and transportation Quality Assurance of TB Detection Centres	Self-Reading/Virtual	6 (including Lab/Field visit)
3	TB Diagnosis and Case finding	General Concepts in TB Case Finding Approaches to TB Case Finding Diagnostic Algorithms in NTEP Active Case Finding Campaign S&M for Case finding activities in NTEP	Physical	6
4	TB Treatment	General Concepts in TB Treatment DS-TB Treatment and Care Overview of DR-TB Treatment and care Isoniazid [H] Mono/Poly DR-TB Regimen Treatment Support Adherence Management ADRs to ATT Monitoring of Treatment	Physical	10(including field visit)
5	TB and comorbidity management	National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke [NPCDCS] TB and HIV TB and Diabetes TB and malnourishment TB and Substance Abuse TB and other comorbid conditions Monitoring the comorbidities	Physical	3
6	Public Health Action	Patient Support Contact tracing and investigation Counselling TB Arogya Sathi App	Physical	4
7	TB Prevention	Infection Prevention and Control TB Preventive therapy	Physical	4
8	Direct Benefit Transfer in NTEP	General Concepts in DBT Processes in DBT Monitoring of DBT	Physical	6
9	Procurement, Supply Chain Management & Preventive Maintenance	General Concepts in SCM Information system for SCM in NTEP Processes in SCM	Physical	6
10	Partnerships, Corporate and Multisectoral engagement	General concepts in Partnership and MSE TB Mukt Panchayat Initiatives Models of Partnership	Physical	4
11	ACSM and Community Engagement	ACSM Activities TB Champions PM TB Mukt Bharat Campaign Engaging Family Care Givers for Supporting Persons with TB	Physical	4
12	Supervision, Monitoring and Evaluation	Supervision Monitoring	Physical	4
13	Training and capacity development	Training and capacity development	Physical	3

Trainers:

For this course, following personnel may be appointed as the trainers:

MO - STDC
MO - STC
WHO-consultants
DTO (select)
SDS/DDS Pharmacists (Select)- for Supply chain and drug distribution module.

Trainer Eligibility

Trainers should have ability to conduct training in an interactive and interesting manner. The Trainers should have completed the ‘Course for MO-TC’ or Should have undergone training on 'Course for Program Managers in NTEP' and they must possess strong knowledge about the NTEP and the various processes related to patient workflow, Niskahy and Niskahy Aushadhi. The Trainers need to go through the Chapter- wise Training Guide for this Course, provided as an Annexure.

The Trainers should be well versed with the IT systems, for video conferencing (such as Zoom), Learning Management System (such as Swasth-eGurukul), Ni-kshay and Ni-kshay Aushadhi.

Chapter wise instructions for Trainers

The aim of providing chapter-wise detailed instructions provides the Trainers with the following:

Module-wise and Chapter-wise, modality that may be adopted (Self-reading/virtual/ Physical/ In-person)
The estimated time to complete the content.
The key messages that a trainer should emphasize upon, while delivering the training

This guiding document will also aid in bringing uniformity with respect to the content and quality of training conducted across the entire state and nation.

Module 1: Basics of TB and NTEP
Chapter 1.1	TB & TB Epidemiology
Emphasis Points	1. Difference between Incidence and notification 2. Difference between Exposure to TB, infection and TB disease.
Post Session Activity	Give an exercise to calculate the Notification rate of a TU. In a TU with a population of 2 lakhs, 100 TB cases were diagnosed and reported during the year 2022. A total of 90 people with TB were initiated on treatment, 5 died and 2 migrated before initiation of treatment and 3 could not be contacted at all. What is the annual TB notification rate for that TU in 2022? [ Answer: 50 per lakh] Discuss - Can we call the above obtained Notification figure as the incidence of TB in that TU? If not, Why? [Discussion Points: Notification and Incidence are not the same. Notification includes all diagnosed TB cases and reported to the system. It includes both new and previously treated cases. There may be cases diagnosed, but not reported. It is possible that there will be cases in the community not diagnosed at all.] These exercises are to be given as assignments that trainees need to finish before start of 2nd module. Assignments: Find the incidence of TB in India in preceding year. Please mention the source . What was the no of TB notifications in India for year 2021. Please mention the source Why incidence is not same as notification? Download the notification register (Q1-2023) of your district. What are the Columns headings available in the register? What are the options available under the filters for the 4 columns- a) patient status, b) key population, c)basisOfDiagnosis_FinalInterpretation, d) Treatment Outcome
Chapter 1.2	NTEP
Emphasis Points	Explain what India is committed to achieve in 2025 in relation to SDG related to ending TB. Clarify that the country has preponed the 2030 SDG targets related to ending TB to 2025. Organizational structure of NTEP with broad functions of each institution (state level and below) Different stages in the patient’s life cycle need to be explained in detail and emphasis on the concept of continuum of care from ‘presumptive TB to post treatment follow up'. Concepts of ‘’Standards of TB Care’’ as a minimum set of care that every citizen in India should receive irrespective of where he/she seeks care from. What does a TU actually mean?
Post Session Activity	Discuss- ‘What India is committed to achieve in 2025 in relation to ending TB?’’ [Clarify that the country is only trying to achieve the SDG goals related to Ending TB] Discuss- ‘Can Medical College/ IRL be a PHI?’[Clarify that any patient service delivery point will be a PHI, but program management units like STC, DTC, TU etc are not PHIs] Assignments: Enumerate the 4 pillars/strategies mentioned in NSP (2017-2025).
Chapter 1.3	Approaches to S&M in NTEP
Emphasis Points	Discuss the importance of S&M. Emphasize that S&M of the different activities under NTEP will be discussed alongside the activity while discussing the content in the modules.
Post-session activity	Assignment: 1.3.1- Find the index score of your district using Nikshay for year 2022. 1.3.2.-FInd the areas where the performance of district is less than the state average.
Chapter 1.4	Integration of NTEP with Health System
Emphasis Points	Discuss the need for integration of NTEP with the general health system & NHM and how that integration is envisioned.
Post-session activity	Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized? Assignments: 1.4.1-Write the organisation str of NTEP in your district.
Chapter 1.5	Information Systems in NTEP
Emphasis Points	The Information system in NTEP is an ecosystem of three applications (Ni-kshay, Ni-kshay Aushadhi and Ni-kshay LIMS ) which interact with each other and with other external systems. Data from these systems may be viewed/ extracted for monitoring and review purposes from Ni-kshay Reports and Dashboards. Patients may access their health record from the Ni-kshay Arogya Saathi Application There may be other additional supporting applications provided by NTEP, states, National Institutes or by other partner organizations. Eg, TB Free Himachal, N-TB Application, ManageTBIndia,
Post-session Activity	1.5.1- Enlist the different stakeholders that are working with Nikshay and their specific roles in NI-kshay.
Module 2	TB Laboratories and Diagnostic technologies in NTEP
Chapter 2.1	Diagnostic Technologies and Lab Network
Emphasis Points	Names of different tests, their uses, advantages and disadvantages
Post-session Activity	Discuss: what are the advantages and disadvantages of FL- LPA over NAAT? Discuss “how many sputum collection and transportation facilities are there in their concerned district? Make one participant explain how it functions and what are the benefits out of it”? - Bring out the following benefits (1) prevents leaks in cascade of care (reduce loss from presumptive TB identification to TB Testing) (2) minimizes patient inconveniences (3) minimize patient Turnaround Time (4) reduce out of pocket expenditure (5) helps in infection control as people with symptoms need not travel Assignment: 3.1.1Learn about the processes being followed in your district for sample transport from patient to TDC. 3.1.2Learn about the different processes being followed in Nikshay for the same- i.e. adding test request, sample details and entering results in Ni-kshay.
Chapter 2.2	TB detection Centres
Emphasis Points	Discuss the consumables required for the Microscopy, CBNAAT and Truenat
Post-session Activity	Assignments: A Lab-visit needs to be organised for participants to see the different processes involved for testing.
Chapter 2.3	Specimen collection and transportation
Emphasis Points	The need for SCT, importance of cool chain requirement. Discuss how the delays can be reduced to improve the TAT overall
Post Session Activity	May ask one of the participants to volunteer and demonstrate the different processes being followed in Nikshay for the same- i.e. adding test request, sample details and result updation in Ni-kshay.
Chapter 2.4	Quality Assurance of TDC
Emphasis Points	Explain the process involved in EQA of microscopy.
Post-session Activity	Lab Field visit: A field visit should be organized to a lab to understand and discuss the following: Microscopy Centre: The following should be discussed/ demonstrated: Slide preparation, Storage of slides Lab Register (Physical and Ni-kshay: what all records are being digitized) Selection of slides for EQA & RBRC Quality Control (QC) slides Flow of pt and samples from OPD to MC and to CBAAT facility. View the "My tests" page of the PHI login in Ni-kshay and review the status of tests in the last 1 month. Discuss the process of referring a patient for testing through Ni-kshay. NAAT Facility Discuss the CBNAAT process overview DOs and Don'ts while doing CBNAAT View the "My tests" page of the PHI login in Ni-kshay and review the status of tests in the last 1 month. 3) Obtain the Lab register from Nikshay and calculate the patient TurnAroundTime (referral to test reporting) for the lab and compare it with the Lab TurnAroundTime (Sample Receipt to Reporting)
Module 3	TB Diagnosis and Case finding
Chapter 3.1	General Concepts in TB Case Finding
Emphasis Points	Differentiate between screening and testing.
Post-session Activity
Chapter 3.2	Approaches to TB Case Finding
Emphasis Points	Clearly differentiate the difference between the three different approaches- Active, Passive and Intensified.
Post-session Activity	Discuss the following scenarios and ask the participants which case finding those are (i) Screening for active TB in a Diabetic Clinic & testing those who screened positive (ii) Screening for active TB in an elderly home & testing those who screened positive (iii) Screening for active TB in cancer wards & testing those who screened positive
Chapter 3.3	Diagnostic Algorithms in NTEP
Emphasis Points	Discuss how the algorithms to be read
Post-session Activity	Ask the participants to look at details of 5 TB patients from their TU and see whether complete diagnostic algo has been followed or not.
Chapter 3.4	Active Case Finding Campaign
Emphasis Points	Step by step process in planning and execution of an ACF campaign with special emphasis on identification of target population, need for micro planning and need to prevent the leaks in the cascade of care.
Post-session Activity	Discuss how ACF campaign is carried in participants geography and how the activity can be carried out more effectively.
Chapter 3.5	S&M for Case finding activities in NTEP.
Emphasis Points	Discuss the TB index dashboard. Discuss the TB Notification dashboard.
Post-session Activity	The participants may be asked to access the TB index dashboard and TB notification dashboard from their logins and share their learnings with other audience.
Module 4	TB Treatment
Chapter 4.1	General Concepts in TB Treatment
Emphasis Points	It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase. Process of Treatment Initiation and Transfer of patients Follow-up - clinical and laboratory, assigning Treatment outcome and long-term follow-up.
Post-session Activity	Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
Chapter 4.2	ADRs to ATT
Emphasis Points	Discuss about the aDSM available in Ni-kshay , the importance and how it is carried out.
Post-session Activity	Ask one of the participants to demonstrate the adverse event module in Ni-kshay from reporting, management and outcome.
Chapter 4.3	DS-TB Treatment and Care
Emphasis Points	Regimen and dose of drugs for managing DS-TB for adults and paediatric group and weight bands available. Display all FDCs in NTEP and ensure the participants could identify all information related to it. Common adverse events of anti-TB drugs
Post-session Activity	Call one participant and ask to explain the step-by-step process for initiating treatment to a 50 Kg old adult diagnosed with pulmonary TB (Rif Sensitive). Write down all the steps in a flip chart/chatbox/Virtual whiteboard. Ask other members to comment on the missed steps and the order of steps. Call a second participant and ask to explain the follow up for the same patient.
Chapter 4.4	Overview of DR-TB
Emphasis Points	Explain: What is UDST? Classification of DR-TB? Regimens available for DR-TB? Levels of facilities where treatment needs to be initiated.
Post-session Activity	Ask participants for doubts and help them clear those doubts.
Chapter 4.5	Isoniazid [H] Mono/Poly DR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session Activity	May ask the participant to look at 2 TB patients (outcome declared) on H Mono/poly DR-TB regimen whether the follow-up sputum examination was done timely or not.
Chapter	Shorter Oral Bedaquiline-containing MDR/RR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session activity	May ask participants to look at 2 TB patients (outcome declared) on shorter oral Bdq containing MDR/RR regimen whether all the relevant investigations for PTE and follow-up sputum examination were carried out timely.
Chapter	Longer Oral M/XDR-TB Regimen
Emphasis Points	Discuss the regimen composition and duration, inclusion-exclusion criterion, replacement sequence and the follow-up examination.
Post-session activity	May ask participants to look at 1 TB patient (outcome declared) on longer oral M/XDR regimen whether all the relevant investigations for PTE and follow-up sputum examination were carried out timely.
Chapter 4.6	Treatment Support
Emphasis Points	Discuss the role of treatment supporter and how they can be registered in Nikshay, patient mapped.
Post-session Activity	Ask the participants to practice the registration of treatment supporter and subsequent mapping of patients to the treatment supporters in demo-version in Ni-kshay.
Chapter 4.7	Adherence Management
Emphasis Points	Discuss about the importance of adherence and how adherence is being reported, recorded and monitored through Ni-skahy. Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay. Recording adherence using TB Arogya Sathi Application Discuss about the Adherence dashboard.
Post-session Activity	One/more participants may be asked to record the adherence in Ni-kshay Request everybody to open their adherence dashboards and comment on their % of 'Average Adherence' of all patients on treatment. Request all participants to open their adherence task list and ask their plans based on the task list
Chapter	Monitoring of Treatment
Emphasis Points	Discuss the indicators used in monitoring the treatment- treatment initiation, outcome declaration.
Post-session activity	Exercise: Ask the participants to download the notification register for Q1-2023 and ask them to calculate the average delay in treatment initiation from date of diagnosis. Discuss how this delay can be minimised.
Field Activity	A 2nd field visit(Batch size- 5-7 participants) should be organised to the following Treatment Centre (PHI) Explain Patient flow at the centre: OPD visit (passive case finding) - registration/enrolment-> Visit to MO-> Specimen collection and transportation (spot and early morning samples) -> Pre-treatment counselling->Treatment initiation-> Dispensation-> Home visits->ADR identification and reporting-> Follow-up patient visits -> transfer of patient. The data entry points for recording the above processes in Ni-kshay and the relevant forms and registers to be maintained at the treatment centres. Drug Store Discuss storage of drugs (ideal storage conditions), Processes being followed at the store (inward and outward stocks) - Both physical and Ni-kshay Aushadhi Records and registers (including logbook for temp and humidity, Stock Registers, Intend/ Drug Request form, maintained at the store
Module 5	TB and comorbidity management
Chapter 5.1	TB and HIV
Emphasis Points	Bidirectional screening for TB-HIV
Post-session activity	Ask the participants to describe the existing mechanism at their district to screen TB among the people visiting ICTC centres- how is the screening being done? How is it ensured that all those referred for testing have undergone testing? Discuss if there is any scope for improvement.
Chapter 5.2	TB and Diabetes
Emphasis Points	Bidirectional screening for TB-Diabetes
Post-session activity	Ask the participant to describe how diabetes testing is done among people with TB in their district? What are the steps if a person with TB is found to have diabetes? Who and how is diabetic control ensured for that person? Discuss if there are any ways to improve.
Chapter	TB and malnourishment
Emphasis Point:	Discuss how malnourishment affects TB patient and role of Nutritional support in successful completion of treatment.
Chapter	TB and Substance Abuse
Emphasis Point:	Discuss how Alcohol and Tobacco Abuse affects TB and importance of linkage with the deaddiction centre.
Post Session Activity	The participants may be asked to list the de-addiction centres and tobacco-caseation centres.
Chapter	TB and other comorbid conditions

Module 6	Public Health Action
Chapter 6.1	Patient Support
Emphasis Points	Various kinds of support the TB patient needs (nutritional support, psychosocial support, support for deaddiction, travel support) and how STS could help in offering the same
Post-session activity	Give a scenario: A 62-year-old woman from a Tribal community affected with TB. Ask all participants to list out all the Government schemes/initiatives which can support her during the treatment period? Write down all schemes in a flip chart/Chatbox/Virtual board
Chapter 6.2	Contact tracing and investigation.
Emphasis Points	Discuss: Step by step process for contact investigations Discuss the steps to record the contact tracing in Ni-kshay
Post-session Activity	Ask one of the participants how contact investigations are happening in his/her geography (Coverage, Quality, Periodicity, Challenges). Ask one/more participants to demonstrate the process in Ni-kshay(Demo)
Chapter 6.3	Counselling
Emphasis Points	Discuss: Basic principles of counselling (DOs and DONTs) Points to be included while counselling of a person with TB
Post-session Activity	Ask participants to comment on the following statements made by STS while counselling a person with TB “I have already informed all people who came to your shop that you are having TB”. (Clue: It's a breach of confidentiality. It should have been discussed with the person with TB first. The person with TB should have been empowered to disclose it to others if required) “If you are not taking the medicines properly, you will definitely die”. (Clue: It's a coercive/threatening language and should be avoided) “Because you were a smoker and alcoholic, you got TB” (Clue: It's a blame on the person and should be avoided)
Chapter 6.4	TB Arogya Sathi App
Emphasis Points	Discuss the various information available in TB Arogya Sathi Application- the two user interfaces (General Public and TB patient) The TB Screening tool How to locate the nearest health facility Accessing the treatment details (patient interface) Recording the adherence using the app Viewing the DBT benefits and statuses. Entering /modifying the bank details
Post-session Activity	The participants may be requested to do a screening test on themselves and check the working of the application.
Module 7	TB Prevention
Chapter 7.1	Infection Prevention and Control
Emphasis Points	Discuss the following: Need for IPC Airborne infection control and need for it. Administrative measures for ensuring AIC (particularly with respect to HFs). Ventilation as an AIC measure (focus on seating plan for Health care provider and people with symptoms, air-flow in labs providing TB detection/diagnostic servies) AIC practiced at Microscopy centres including the PPEs The need and ways for disinfection and Bio-medical waste management at the Health facilities the important roles various stakeholders are required to play emphasising more on their role.
Post-session Activity	May ask the participants to recollect the AIC practices being followed in DR-TB ward (part of field-visit) and enumerate it.
Chapter 7.2	TB Preventive Treatment
Emphasis Points	Discuss the following points: The eligibility for TPT The different regimens available The different approaches- Test & Treat and test only approach. Testing for TB infection- TST, IGRA and CyTB and interpretation of different test results Counselling for TBI testing and TPT Importance of adherence for TPT and its monitoring Management of missed doses in TPT course Outcome for TPT t Monitoring indicators for TPT
Post-session Activity	Ask the participants to download the Contact tracing register (for Q3-2022) and comment on the leakages in the cascade of care for TPT for your geography.
Chapter 8.1	General Concepts in DBT
Emphasis Points	Discuss the following points: Different DBT schemes under NTEP- beneficiaries and benefits Different stakeholders for DBT and their roles & responsibilities Other state-specific social welfare schemes may also be discussed Ni-kshay Poshan Yojana- benefit and the eligibility conditions Tribal Support scheme Treatment Supporter- eligibility and Honorarium Financial incentives for Private provider and informants How to register the private Health facilities and processing of their benefits Discuss the generation of benefits in Ni-kshay Different scenerios where private facilities will be getting benfits
Post-session Activity
Chapter 8.2	Processes in DBT
Emphasis Points	Discuss the following points: Process of benefit processing in Ni-kshay Steps that need to be taken by DBT maker at TU level Steps that need to be taken by DBT checker at Distrcit level Process flow for DBT in PFMS Benefit processing and approval in PFMS Process to create DBT maker and checker accounts.
Post-session Activity
Chapter 8.3	Monitoring of DBT
Emphasis Points	Discuss the following points: the different registers- Benefit register, beneficiary register, benefit batch register. DBT troubleshooting at various levels- Beneficiary, Benefit, Maker, Banking, PFMS DBT dashboards DBT process Indicator dashboards
Post-session Activity	Ask the participants to open the dashboard for their particular TU: and look at the information available in the funnel diagram. (Scheme: NPY and Notification cohort- previous two quarters)- Identify the level at which the delay is maximum and discuss what measures can be taken to reduce the delay). Ak them to try the beneficiary status and benefit status. The geographic view may also be discussed. May ask the participants to do the same exercise for other DBT schemes and ask them to explore the reasons. The participants may be asked to open the DBT process Indicators dashboard for their TU and explore the different schemes and discuss the insights developed during the process.
Module	Financial management and Planning
Chapter 9.1	Overview of PIP
Emphasis Points	Discuss the following points: the general terms related to PIP The fund flow
Post-session Activity	May ask the participants for any doubts/queries.
Chapter 9.2	Needs assessment for Planning
Emphasis Points	Discuss the following points: Identifying the gaps in known program indicators Needs assessment
Post-session Activity	May ask the participants to clear their doubts



Chapter 9.4	Financial expenditure and accounting
Emphasis Points	Explain the following. The general principles of accounting Basics of account books and records and the maintenance Issue and receipt of vouchers Financial Audits
Post-session Activity
Module	Procurement, Supply Chain Management & Preventive Maintenance
Chapter	General Concepts in SCM
Emphasis Points	Explain the following concepts: Drug distribution flow Different stock types and its importance FEFO and its importance Different drugs and supplies under NTEP various stocking points in NTEP Drug stores at different levels- SDS, DDS, TU drug store and drug storage at PHI level (how drugs are stored and role of different stakeholders) Flow of different drugs in NTEP- DS-TB, DR-TB, Bdq, Dlm, Lab supplies. Expiry management and monitoring.
Post-session Activity
Chapter	Information system for SCM in NTEP
Emphasis Points	Discuss the following: Ni-kshay Aushadhi Different dashboards- State/district/Alert/Reports and features available at different levels.
Post-session Activity	Ask the participants to open their TU dashboard and look at the alert dashboard and share the finding with other participants.
Chapter	Processes in NTEP
Emphasis Points	Discuss and demonstrate the participants the following processes: Indenting meaning and procedure for requesting the supplies from different levels Issue of supplies and recording in Ni-kshay Aushadhi Consumption of supplies at different levels Forecasting- meaning, importance and calculations. Expiry of drugs, forecasting and disposal PWB- types and preparation Process of return of drugs Reconstitution of Bdq bottle and recording in Ni-kshay
Post-session Activity	Ask the participant to demonstrate the following in demo version of Ni-kshay AUshadhi: Indenting of drugs from the TU store to district Issue of supplies to TU from the district Acknowledge the receipt of drugs at TU Issue of supplies ot the PHI from the TU Dispatching of drugs in Ni-kshay Aushadhi: On request and without request Ask the participants to demonstrate the following in demo version of Nikshay Adding and Printing Dispensation Returning the dispensation Ask the participants to forecast the supplies (for DS-TB drugs) for next quarter on the basis of consumptions based in previous quarter in their TU.



Chapter	Quality Assurance in Supply Chain Management
Emphasis Points	Discuss the following points: Meaning and Processes involved in QA of drugs in NTEP Recording of QA of drugs in Ni-kshay AUshadhi Monitoring of drug stores Store visits in NTEP- checklist for store visits Physical verification of supplies and recording in Ni-kshay Aushadhi
Post-session Activity	Ask the participant to open demo Ni-kshay aushadhi and demonstrate the recording of Physical Stock verification, and QA of drugs

Abhimanyu Fri, 08/03/2024 - 10:36

Competencies of the Medical Officers TB Centre- [MO-TC]

Following are the competencies required for a Medical Officer TC

Competency	Description/ activities pertaining to the said competency	Assessment of competency
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, pediatrics 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.
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 pediatrics Identify an appropriate treatment supporter in consultation with the person affected with TB Evaluate & advise for indoor admissions based on differentiated 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
Perform pre-during-and post-treatment evaluation of people affected with TB/DR-TB/TB Infection, as per programme guidelines/ STCI	Counsel 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 the Medical Officer to understand the current practice of pre-during-post evaluations 3. Interview with patients/beneficiaries under the MO's care to check whether all evaluations are done correctly 4. Review Status of post Treatment follow-up in cases notified in Ni-kshay for the past year
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 appropriately based on NTEP guidelines Counsel people affected with TB/TBI about nature, consequences of ADRs and changes in treatment regimen 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 centers 3. Interview with patients/beneficiaries under MO's care to understand whether ADRs are identified and managed properly
Refer correctly and timely, a person affected with TB/DR-TB, to higher center/ nearest health facility for appropriate management	Identify the need for referral of people affected with TB for availing 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 practice related to referral 3. Interview patients/beneficiaries under MO's care to check whether referral is prompt
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 substance abuse like Tobacco Use, Alcohol use Mange the co-morbidity and link them to appropriate services wherever 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
Counsel the people with presumptive TB or people affected with DS-TB/DR-TB/ TBI and their family	Counsel the people with presumptive TB/ people affected with TB/TBI on: Early and complete Diagnosis of TB, correct and complete Treatment of TB, Treatment Adherence, Air borne Infection Control, Contact Investigation, TB Preventive Therapy, Co-morbidity management, Adverse Drug Reactions and Social welfare measures	1. Interview with Medical Officer to understand current practices regarding counselling 2. Interview with patients/ beneficiaries to understand the quality of counselling received from MO
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
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 facility, Use Ni-kshay dashboards and other program records, and interpret key performance indicators of NTEP in the facility/geography Perform Care cascade and time/ place/ person analysis and identify areas for improvement 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 quality of monitoring, review and supervision activities 2. Interview with MO to understand the current practices regard to Monitoring, Review and Supportive supervision 3. Interview with staff (ANM, ASHA, TB HV, STS, MPHW, CHO, Nurse, Pharmacist etc.) supervised by MO to get an understanding about the quality of supportive supervision and review
Advocate 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 implementing TB Elimination activities including fostering community ownership, decentralized surveillance, organizing 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

Shahnawaz Tue, 28/05/2024 - 14:00