[Draft] Trainer's guide for the Course for MO-PHI on NTEP

1. 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
2. Progression to TB disease exists as a continuum, with two distinct stages (infection and disease)

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.

1. India's commitment to ENDING TB 5 years ahead of global Targets
2. The PHI is a the 5th level in NTEP hierarchy; the only one responsible for actual service delivery. 
3. The MO-PHI is the leader and program manager at this level for the population catered to by the PHI. 

1. Discuss: Can a medical college be a PHI? Answer is yes.
2. 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]

1. Ni-kshay is the information system of the TB program
2. It has different interfaces for various stakeholders ranging from Patient's to program managers
3. The various stages in a person's care identified in Ni-kshay and the actions to be performed at each stage by which stakeholder.

1. Highlight the various steps in case finding from screening to confirmation of diagnosis.
2. The policy of and definitions bidirectional screening and UDST. 

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]

1. Rapid Molecular Test as a highly sensitive tool for diagnosis of TB
2. Three tier hierarchy (NRL, IRL, Service Labs- NAAT/ C&DST /Microscopy)
3. Role of Sputum/ Specimen Collection and Transportation Centre

1. Good quality sputum being mucopurulent, early morning sample.
2. 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.

1. ACF is conducted in vulnerable populations to detect cases early. Vulnerable population mapping is the first step in the ACF campaign.
2. ACF is conducted to find cases early directly from the community.
3. Yield of ACF is depends on the sensitivity of the screening and diagnostic Technology / algorithm used.

"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?

1. The process of treatment starts from initiation to the end of long-term follow-up
2. Treatment initiation consists of pre-treatment counseling and testing, prescription and dispensation.
3. Patient Transfer and its implications.

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.

1. 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.
2. 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.
3. Monthly Clinical Follow-up and end IP and CP are required during treatment. Post treatment 6monthly follow-up is required for two years.
4. 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

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? 

1. Treatment support is a range of measures taken by a Treatment Supporter to ensure that the client completes treatment successfully. 
2. This includes adherence support, monitoring and referral for ADR, followup-support.

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

1. 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. 
2. 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.

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.

1. 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.

1. AIC measures need be taken by individuals, and as protocols and interventions at Health Facilities.

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

1. 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
2. These include actions including contact tracing and investigation and actions for prevention of TB.

1. People with TB have various needs and require support to get a diagnosis, completing their treatment successfully and even during post treatment. 
2. 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
3. MO needs to ensure that people with TB receive those supports.

1. 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
2. Gender differences and inequalities play a significant role in how people of all gender access and receive healthcare services.

1. For the purpose of monitoring information in Ni-kshay is available as registers for each service.
2. 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.