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Module 1: Basics of TB and NTEP Virtual Session (4 hours)
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Chapter 1.1
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TB & TB Epidemiology
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Virtual Session (60 min)
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Emphasis Points
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- 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
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Post Session Activity
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- 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.]
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Chapter 1.2
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NTEP
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Virtual Session (45 min)
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Emphasis Points
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- 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
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Post Session Activity
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- 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?’
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Chapter 1.3
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Integration of NTEP with Health System
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Virtual Session(30 mins)
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Emphasis Points
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- Need for integration of NTEP with the general health system & NHM and how that integration is envisioned .
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Post Session Activity
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- Discuss - "What are the opportunities available to NTEP through Health & Wellness Centers? How could that be materialized”’
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Chapter 1.4
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Patient Management
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Virtual Session (60 mins)
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Emphasis Points
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How the information of patients are managed through Ni-kshay (Enrollment, Request for Test).
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Post Activity Session
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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
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Module 2
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TB Diagnosis and Case Finding
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Virtual Session (4 hours)
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Chapter 2.1
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Diagnostic Technologies
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Virtual Session (30 min)
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Emphasis Points
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- Names of different tests,their uses, advantages and disadvantages
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Post Session Activity
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- Ask what are the advantages and disadvantages of FL- LPA over NAAT?
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Chapter 2.2
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Diagnostic Network & Hierarchy
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Virtual Session (30 min)
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Emphasis Points
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- Network and hierarchy of laboratories and their basic role
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Post Session Activity
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- 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
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Chapter 2.3
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Approaches to TB Case Finding
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Virtual Session (30 min)
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Emphasis Points
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- Differentiate between screening and testing.
- The three approaches may be discussed by giving suitable examples to fit into the three scenarios
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Post Session Activity
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- 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
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Chapter 2.4
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TB Case Finding in NTEP
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Virtual Session (30 min)
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Emphasis Points
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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
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Post Session Activity
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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?”
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Chapter 2.5
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Active Case Finding Campaign
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Virtual Session(45 mins)
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Emphasis Points
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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.
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Post Session Activity
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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’’?
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Module 3: TB Treatment and care Virtual Session (4 hours)
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Chapter 3.1
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- General Concepts in TB Treatment
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Virtual Session (60 mins)
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Emphasis Points
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- It's an overview chapter explaining the concepts- Fixed Dose Combination, Intensive & Continuation Phase.
- Process of Treatment Initiation and Transfer of patients
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Post Session Activity
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- Request two participants to demonstrate in Demo Ni-kshay the ‘Transfer’ of patients using (i) Push and (ii) Pull methods.
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Chapter 3.2
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DS-TB Treatment and Care
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Virtual Session ( 30 mins)
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Emphasis Points
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- 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
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Post Session Activity
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- 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.
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Chapter 3.3
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DR-TB Treatment and care
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Virtual Session (30 mins)
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Emphasis Points
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- What is UDST?
- Classification of DR-TB?
- Regimens available for DR-TB?
- Levels of facilities where treatment needs to be initiated.
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Post Session Activity
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- Ask participants for doubts and help them clear those doubts
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CHapter 3.4
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Different DR-TB Regimens
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Virtual Session (15 mins)
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Emphasis points
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- Different regimens, constituents and duration
- ADRs due to different regimens
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Chapter 3.4
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- TB Infection treatment and care
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Virtual Session (30 min)
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Emphasis Points
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- 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
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Post Session Activity
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- Role Play- Counseling for TPT
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Chapter 3.5
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- TB Co-morbidity and special situations
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Virtual Session (30 min)
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Emphasis Points
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- 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)
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Post Session Activity
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- 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.
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Module 4: Adherence Management Physical Session (4 hours)
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Chapter 4.1
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General concepts in Adherence management
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Physical Session (60 mins)
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Emphasis Points
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- 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 ?
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Post Session Activity
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- Ask one participant to demonstrate how they register treatment supporter in Ni-kshay
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Chapter 4.2
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Physical Session (60 mins)
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Emphasis Points
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- Imparting skills to Record adherence in Ni-kshay- Demonstrate the recording of adherence in Ni-kshay.
- Recording adherence using TB Arogya Sathi Application
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Post Session Activity
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- Call one participant and ask to demonstrate recording adherence using TB Arogya Sathi Application
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Chapter 4.3
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Chapter: 99 DOTS
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Physical Session (30 mins)
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Emphasis Points
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- 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)
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Post Session Activity
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- 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.
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CHapter 4.4
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Chapter: MERM
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Physical Session (30 mins)
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- 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
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- One/more participants may be asked to demonstrate this in Ni-kshay(Demo)
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Chapter 4.4
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Chapter: Monitoring of adherence
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Physical Session (60 mins)
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Emphasis Points
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Participants need to be empowered to use adherence summary dashboards and interpret the indicators.
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Post Session Activity
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- 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
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Module 5: Public Health Action Physical Session (4 hours)
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Chapter 5.1
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Patient Support
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Physical Session (60 min)
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Emphasis Points
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- 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
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Post Session Activity
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- 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
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Chapter 5.3
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Contact Investigation
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Physical Session (60 mins)
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Emphasis Points
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- Step by step process for contact investigations
- Discuss the steps to record the contact tracing in Ni-kshay
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Post Session Activity
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- 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 nikshay(Demo)
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Chapter 5.4
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Counseling and Education
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Physical Session ( 60 mins)
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Emphasis Points
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- Basic principles of counseling (DOs and DONTs)
- Points to be included while counseling of a person with TB
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Post Session Activity
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- Ask participants to comment on the following statements made by STS while counseling 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)
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Module 6
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DBT
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Physical Session(4 hours)
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Chapter 6.1
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General Concepts in DBT
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60 mins
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Emphasis Points
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This is an overview chapter.
- Various DBT schemes for people affected with TB
- Various stakeholders while processing DBT (Beneficiary, Maker, Checker)
- PFMS
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Post Session Activity
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- Re-emphasise the concepts - Maker & Checker; Ni-kshay & PFMS
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Chapter 6.2
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Processes in DBT
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150 mins
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Emphasis Points
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- 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
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Post Session Activity
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- Make every participant open their DBT benefit register and beneficiary register and comment on performance
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Module 7
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Supervision, Monitoring & Evaluation
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Physical ( 4 hours)
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Chapter 7.1
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Supervision
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60 minutes
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Emphasis Points
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- General Concepts of Supervision and basis tenants of a good supervisory process
- Supervisory Protocols for STS
- Supervisory roles of MO-TC & DTO at TU
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Post Session Activity
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- Reemphasise the concept of supportive supervision. Get feedback on how some of them plan to change their supervision plan.
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Chapter 7.2
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Program Monitoring Indicators
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120 minutes
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Emphasis Points
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- 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
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Post Session Activity
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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.
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Module 8
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Supply Chain Management
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Physical (4 hours)
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Chapter 8.1
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General Concepts
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60 mins
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Emphasis Points
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General Concepts of SCM
- Principles of SCM
- Drug distribution flow
- Nikshay Aushadhi
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Post Session Activity
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Ask for any doubts from the participants and clarify the same
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Chapter 8.2
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Stocking Norms
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30 mins
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Emphasis Points
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Buffer stocks and storage norms
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Post Session Activity
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Reinforce the concepts of buffer stock and storage norms
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Chapter 8.3
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Supply chain process
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150 mins
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Emphasis Points
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- Indenting, Receipt
- Storage of drugs
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Post Session Activity
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- Request one participant to demonstrate drug indenting through Ni-kshay aushadhi
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Chapter 8.4
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Drug dispensation Module
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30 mins
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Emphasis Points
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- Dispensation of drug using Ni-kshay, adding filling and returning dispensation
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Post Session Activity
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- Request one participant to demonstrate the Ni-kshay dispensation module
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Module 9
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Private Sector Engagement
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Virtual (2 hours)
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Chapter 9.1
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General Concepts
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30 mins
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Emphasis Points
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Why private sector engagement is important and what is the Vision of NTEP on private sector engagement
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Post Session Activity
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- 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.
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Chapter 9.2
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Models of Private Sector Engagement
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60 mins
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Emphasis Points
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Explain PPSAs, Direct Option for engagement
Explain STEPS
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Post Session Activity
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Ask each of the participants to think what model suits for private sector engagement in their TU and why
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Chapter 9.3
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Partnership Guidelines
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30 mins
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Emphasis Points
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Emphasis on various options under partnership options
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Post Session Activity
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Discuss what all partnership options are currently existing in their TUs and what would they want to have
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Chapter 9.4
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Regulations
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30 mins
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Emphasis Points
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Regulations of Mandatory TB Notification and Schedule H1
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Post Session Activity
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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)
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Module 10
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ACSM and Community Engagement
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Physical(3 hours)
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Chapter 10.1
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General Concepts in ACSM
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60 mins
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Emphasis Points
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- Differentiate clearly among Advocacy, Communication and Social Mobilization
- Common approaches for ACSM for TB Elimination
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Post Session Activity
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Chapter 10.3
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Guidelines and Protocols for ACSM activities
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60 mins
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Emphasis Points
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Organising Community Meetings, Peer group interventions, ACSM activities in schools
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Post Session Activity
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Discuss experiences form 1-2 participants regarding organizing community meetings
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Chapter 10.4
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Community Engagement
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60 mins
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Emphasis Points
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LSGs and their role in TB Elimination
TB Forums and what they can do
What role can TB Champions play?
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Post Session Activity
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Discuss what needs to be done to reduce stigma regarding TB in the community. Encourage everybody to discuss.
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