[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
Chapter 8.1	General Concepts in DBT
Emphasis Points
Post-session Activity
Chapter 8.2	Processes in DBT
Emphasis Points
Post-session Activity
Chapter 8.3	Monitoring of DBT
Emphasis Points
Post-session Activity
Module	Financial management and Planning
Chapter 9.1	Overview of PIP
Emphasis Points
Post-session Activity
Chapter 9.2	Needs assessment for Planning
Emphasis Points
Post-session Activity

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