TB-Diabetes service delivery integration

Procedure for screening and referral of TB patients for diabetes

Screening intervention and diagnosis of diabetes

All TB patients who have been diagnosed and registered under NTEP are referred for screening for diabetes. Referral of TB patients for screening of diabetes and its recording and reporting is the responsibility of the PHI where TB treatment is initiated.

Screening for diabetes follows the guidelines stipulated by NPCDCS. Screening TB patients for diabetes should be conducted as early as possible after diagnosis of TB but can be done at any time during the course of TB treatment. TB patients will be initially screened with a random blood sugar (RBS) test using a glucometer. If the RBS is < 140 mg/dl, this is a normal result and no further tests need to be carried out. If the RBS is greater than or equal to 140 mg/dl, this might indicate an abnormal glucose state and there is a possibility of diabetes. The patient will be referred to the nearest NCD clinic for fasting blood glucose (FBG) test with NCD clinic referral slip. FBS value of greater than or equal to 126 mg/dl indicates diabetes.

As stipulated in the operational guidelines of NBCDCS The screening procedure and criteria for diagnosis of diabetes is summarized in Annexure 4 and the procedure for conducting the test is provided in Annexure 5 of the below guideline.

Who will do the blood glucose test?

The blood glucose testing will be done by a person designated and trained for the purpose at every PHI. Though, this could vary from site to site the following general principles would apply. Wherever NPCDCS is being implemented the Auxiliary Nurse Midwife (ANM) has been trained to use a glucometer and screen patients for diabetes. In case this mechanism is not available the laboratory technician working in the PHI will be trained to do the test. If a PHI does not have a laboratory technician, then either the staff nurse or any other staff designated by the MO-PHI will be trying to do the test.

Linkage of TB patients with diabetes for diabetes care management

In districts where NPCDCS is being implemented TB patients with diabetes or with a RBS greater than or equal to 140 mg/dl will be referred to the NCD clinic using an NPCDCS patient referral slip (Annexure 6) four definite diagnosis and management. A referral and feedback mechanism has been developed to enable timely exchange of information. Good cooperation and collaboration is needed to develop between two sets of staff working in the different service areas. The NPCDCS referral slip can be procured for PHI through NCD clinics. The procurement of the NCD referral step will be the responsibility of MO-PHI. The linkage flow chart is placed at Annexure 17. At districts where NPCDCS is not implemented TB patients should be referred to the nearest healthcare facility for further diagnosis and management of TB diabetes comorbidity.

Procedure for screening and referral of the diabetic patients for TB

Screening and referral of diabetic patients for TB

Four-symptoms complex screening for active TB in diabetes patient is to be done. Screening is expected to be carried out every time the patient visits the NCD clinic. Patients will be asked whether they are on TB treatment and if not they would be screened for four symptoms complex-

• cough that has persisted for more than two weeks
• fever of more than two weeks 
• experiencing of significant weight loss and 
• night sweat 

The screening results for TB are to be recorded in the patient NPCDCS Register given at Annexure 7 and will be reported in Form 3A (CHC NCD Clinics) and Form 4 (district NCD clinics) given in Annexure 8 and 9 respectively the response will be subsequently compiled in the reporting for profoma at the District NCD cell (Form 5A) and subsequently at the state NCD cell (Form 6) given in Annexure 10 and 11 respectively. All NCD clinics implement basic infection measures as stipulated in the NTEP guidelines The staff nurse and counselor at the NCD clinic will be responsible for implementing the infection control measures. The detailed guideline is given in Annexure 12.

Who will do the screening of TB symptoms complex?

All patients registered at the NCD clinic will be screened for the four-symptoms complex and will be referred to the nearest DMC or PHI with referral slip if found positive for any one or more of the symptoms. MO in charge of the NCD clinic will ensure regular screening of patients attending the NCD clinic. Staff nurse and counselor attending to the NCD patient will enquire about the TB symptoms complex and refer the patient. The staff nurse and councilor would be trained by the MO in charge to screen the TB symptoms complex.

Linkage of diabetic patients with TB or TB case management

After screening, patients with one or more symptoms of TB symptom complex will be referred to the nearest DMC/PHI for diagnosis of TB. A referral and feedback mechanism is developed to enable timely exchange of information The staff nurse or councilor will refer the patient with a NTEP laboratory request request form to the nearest TB detection centre for confirmation of TB disease. The form is provided in Annexure 13. The patients diagnosed with TB would be initiated on TB treatment by the TB clinic staff as per management guidelines stipulated in NTEP. The TB detection centre will return the results of the TB test to the NCD Clinic through the counterfoil of the laboratory request form with the patient. The NTEP laboratory request form for referring the patient from NCD clinics can be obtained from the nearest TB detection centre. The MO in charge of the NCD clinic will be responsible for obtaining the NTEP laboratory request form. The linkage flow chart is placed at an Annexure 17

Resources

• National Framework for Joint TB-Diabetes Collaborative Activities

Assessment