[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)

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

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)

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

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)

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

Public Health Action

Patient Support
Contact tracing and investigation
Counselling
TB Arogya Sathi App

Physical

TB Prevention

Physical

Direct Benefit Transfer in NTEP

General Concepts in DBT
Processes in DBT
Monitoring of DBT

Physical

Financial management and Planning

Overview of PIP
Needs assessment for Planning.
Preparing a PIP
Implementing the Plan
Financial expenditure and accounting

Physical

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

Partnerships, Corporate and Multisectoral engagement

General concepts in Partnership and MSE
Models of Partnership
Establishing Partnership
Multisectoral Engagement
Medical Colleges and NTEP

Physical

ACSM and Community Engagement

ACSM
ACSM Activities
Social Inclusion and wellness activities
Community Engagement
PM TB Mukt Bharat Campaign

Physical

Supervision, Monitoring and Evaluation

Supervision

Monitoring

Programme Monitoring and Reviews

Physical

Training and capacity development

Physical

Trainers

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

National trainers from National Institutes

National Consultants- Central TB Division

Trainers from select STDCs (identified by Central TB Division)

Select WHO consultants (from States)

Consultants (partner Organisations)

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 Program Managers’ and they must possess strong knowledge about the NTEP and the various processes related to patient workflow, Ni-ksahay and Ni-kshay 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 such as, Zoom (for video conferencing), Swasthya-eGurukul (Learning Management System), 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 (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 Virtual Session ( hours)
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: 1.1.1-Find the incidence of TB in India in preceding year. Please mention the source also. 1.1.2-What was the no of TB notifications in India for year 2021. Please mention the source that you used. Why incidence is not same as notification? 1.1.3-Download the notification register (Q1-2023) of your district. 1.1.4-What are the Columns headings available in the register? 1.1.5-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 be a PHI?’ Assignments: 1.2.1-Enumerate the 4 pillars/strategies mentioned in NSP (2017-2025). 1.2.2-Elaboorate 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	General introduction of the information available around NTEP
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	hours)
Chapter 2.1	Diagnostic Technologies and Lab Network
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? Ask “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 organised to the lab to understand and discuss the following: 1) Microscopy Centre: The following should be discussed: a) Slide preparation, Storage of slides b) Lab Register c) Selection of slides for EQA & RBRC b) Notification Register c) Stock Register d) Quality Control (QC) slides e) Flow of pt and samples from OPD to MC and to CBAAT facility. Select few entries in the lab register and validate it with information in Ni-kshay. 2) NAAT Facility a) The CBNAAT process overview b) DOs and Don'ts while doing CBNAAT c) Result entry in Ni-kshay 3) Turnaround time for the labs
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 District Drug Store DR-TB centre/ward Treatment Centre (PHI) Patient flow should be explained. 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 The following should be discussed during the visit: storage of drugs ideal storage conditions (including logbook for temp and humidity Registers (Stock, etc) maintained at DDS Processes being followed at DDS (receipt and supply to sub-centres) - Both physical and in Ni-kshay Aushadhi. DR-TB centre/DR-TB ward The following should be discussed by the facilitator during the visit: Interview with the 1-2 patients. Pre-treatment evaluation the checklist for DR-TB centre (Annex 22, PMDT guidelines 2021) The DR-TB committee records The checklist for DR-TB wards
Module 5	TB and comorbidity management
Chapter 5.1	TB and HIV
Emphasis Popints	Bidirectional screening for TB-HIV
	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
	Bidirectional screening for TB-Diabetes
	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



Chapter 7.2	TB Preventive Treatment


Chapter 8.1	General Concepts in DBT


Chapter 8.2	Processes in DBT


Chapter 8.3	Monitoring of DBT


Module	Financial management and Planning
Chapter 9.1	Overview of PIP


Chapter 9.2	Needs assessment for Planning

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

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