Ch 09: Role of LTs and related stakeholders in TB Care

The major duties and responsibilities of the Laboratory Technician at the Designated Microscopy Centre (DMC) are to: ​

 

1. Follow the standard operating procedures for sample collection, sputum smear microscopy​ and Nucleic Acid Amplification Test (NAAT)
2. Maintain the Tuberculosis (TB) Laboratory Register and early submission of the results to the medical officer managing the patient, which should also be updated in the Nikshay online portal in real-time
3. Coordinate with other staff to ensure that presumptive TB cases and symptomatic contacts of TB patients receive sputum containers with the necessary instructions to undergo sputum examination/NAAT
4. Assist the medical officer of the peripheral health institution (MO-PHI) in the identification of presumptive drug-resistant TB patients and ensure the collection and transportation of sputum specimens for NAAT/culture and drug susceptibility test according to the guidelines
5. Organize and supervise the disposal practices of contaminated lab material as detailed in the Laboratory Manual
6. Assist the Senior Tuberculosis Laboratory Supervisor (STLS) in the implementation of the National Tuberculosis Elimination Programme (NTEP) Lab Quality Assurance
7. Assist in the implementation of new TB diagnostic tools in NTEP
8. Facilitate change management with respect to use of Information and Communications Technology (ICT) and Nikshay tool for concerned data entry, validation, and its use for public health actions
9. Any other jobs assigned by the reporting officer

​

Resources

 

• DO letter - TOR and need norms for NTEP staff, 2021.
• Training Module (1-4) for Program Managers and Medical Officer, NTEP, MoHFW, 2020.

​

Kindly provide your valuable feedback on the page to the link provided HERE

The Medical Officer Designated Microscopy Centre (MO-DMC) at a Primary Health Facility is appointed from the General Health System. The MO-DMC is responsible for activities at DMC under the National TB Elimination Programme (NTEP).

Key Responsibilities of MO-DMC include

1. Screening and diagnosis

·        Clinical examination of all TB cases should be done by the MO. 

·        The MO should screen/refer:

o   All identified presumptive pulmonary TB cases for sputum smear microscopy, chest X-ray and presumptive Extra-pulmonary Tuberculosis (EPTB) cases for appropriate investigations

o   Presumptive TB cases with a negative sputum result to be referred for chest X-ray, followed by Cartridge-based Nucleic Acid Amplification Test (CBNAAT) as per diagnostic algorithm to ensure no TB case is missed

o   All diagnosed TB patients for Nucleic Acid Amplification Test (NAAT) for early diagnosis of resistance to Rifampicin (Rif)

o   All Rif-sensitive TB patients for first-line LPA testing

o   All presumptive TB patients for HIV testing

o   All diagnosed TB patients for HIV testing

o   HIV positive patients for TB by four symptom complex screening

o   All HIV positive TB patients to Antiretroviral Therapy (ART) centre for initiation of ART and Co-trimoxazole Prophylaxis Therapy (CPT).

2. Treatment initiation, follow up and treatment outcome

·        The MO should fill the original treatment card with details of treatment regimen according to weight-band and Drug Susceptibility Testing (DST) pattern.

·        It is the responsibility of the MO to ensure that all the diagnosed smear-positive patients start treatment or are referred for treatment.

o   All patients who are sensitive to Isoniazid (H) & Rifampicin (R) and all patients whose H & R status is not known should be initiated on first line anti-TB treatment.

·        The MO is responsible for clinically following-up the patient once in a month to:

o   Identify any ADR early

o   Assess clinical improvement

o   Support follow-up by laboratory investigations, whenever necessary

o   Control comorbid conditions like HIV and diabetes by appropriate treatment

o   Screen all patients for presence of symptoms of TB at the end of 6th, 12th, 18th and 24th month after completion of treatment and do a sputum culture in the presence of symptoms to diagnose recurrent TB.

3. Recording, reporting and TB notification

·        The NTEP Request Form for examination of biological specimens should be filled up completely by the MO.

·        The MO should coordinate with the STLS to ensure that tuberculosis-related laboratory services are properly performed and recorded by the laboratory technician.

·        Results recorded in the laboratory register, treatment cards and the TB Notification Register should be verified and ensured that they are consistent.

·        The MO should maintain TB Notification Register for patients diagnosed and transferred-in.

·        The MO should ensure that the treatment details are entered in Nikshay immediately.

·        Detailed description of symptoms and signs of ADRs to anti-TB drug should be recorded in TB Treatment Card by the MO.

·        The treatment outcome has to be recorded on the Treatment Card, Nikshay and the TB Notification register within one month of the event. Declaration of the treatment outcome has to be decided upon and signed with date by the MO.

·        The MO should ensure updating of Notification Register and Nikshay entry by the designated staff:

o   If any smear-positive patients are not entered in the TB Notification Register and are on treatment

o   For patients who have not been put on treatment after tracing them and putting them on treatment immediately

o   After collecting the bank account details of the patient for Direct Benefit Transfer of Nikshay Poshan Yojana.

4. Monitoring and supervision

·        Every week, the MO of the DMC should review the TB Laboratory Register to ensure that correct number of sputum smear examinations (two per presumptive TB case) are being performed for diagnosis.

·        The MO of the DMC should cross-check the results of the sputum examination in the TB Register with that of TB Laboratory Register and the TB Treatment Card.

·        The MO of the DMC should check the Tuberculosis Laboratory Register to make sure that all the columns have been completed.

o   The MO of DMC is responsible for determining the amount of reagents and consumables the DMC needs every month.

o   The MO should ensure uninterrupted supply of drugs; monitor monthly replenishment of stock to treatment supporter if drugs are not already
given and update in drug stock register and in Nikshay Aushadhi through designated staff.

·        The District TB Officer (DTO) conducts Random Blinded Rechecking (RBRC) of sputum smear microscopy and gives feedback and corrective actions to Lab technicians through MO-DMC.

 

Resources

Training Modules for Programme Managers and Medical Officers.

 

Assessment

 

Question

Answer 1

Answer 2

Answer 3

Answer 4

Correct answer

Correct explanation

Page id

Part of Pre-test

Part of Post-test

What are the key duties of a Medical Officer at DMC?

Screening and diagnosis

Advocacy and support to private practitioners

Treatment initiation, follow-up, treatment outcome

All the above

4

The Medical Officer (MO) at the DMC is responsible for screening, diagnosis, treatment initiation, follow-up, treatment outcome, monitoring and supervision, recording, reporting, TB notification, advocacy and support to private practitioners.

 

Yes

Yes

Peripheral Health Care Workers (PHWs) including Community Health Officer (CHO), Auxiliary Nurse Midwife (ANM) and Multi-purpose health worker (MPHW) are central to primary health care and service delivery. They play important an role in TB care at Peripheral Health Institutes (PHIs) and Designated Microscopy Centres (DMCs).

Their responsibilities include:

1. Vulnerable population mapping: vulnerability assessment and mapping of vulnerable population (diabetic patients, patients on immunosuppressants, alcoholics and smokers etc) in communities is done by PHWs.

 

2. Screening and referral for testing:

PHWs are involved in:

- screening of household/workplace contacts and other contacts of TB patients as eligible in the local context

- periodic active case finding among identified vulnerable population for TB/Latent TB Infection

- referring presumptive TB patients promptly to the nearest microscopy or molecular laboratory through laboratory request forms

- registration of referred cases in Nikshay as presumptive TB patient

- providing sputum container to persons with symptoms of TB and counselling for collection of good quality sputum in the morning

- sample packaging and transport to TB laboratories for testing

- follow-up sputum examination

CHO is responsible to ensure availability of adequate sputum collection containers (sputum cups and falcon tubes), logistics for sample packaging and transportation.

 

3. Treatment initiation: It is the responsibility of the PHWs in coordination with NTEP staff to organize and ensure treatment initiation for the patient. They decide upon a convenient location for drug administration, identification of treatment supporter and supply of drugs to treatment supporter

 

4. Coordinating treatment support:

- PHWs act as a treatment supporter or identify treatment supporter who is accessible and acceptable to the patient to provide TB treatment

- support for adherence to treatment and monitoring of TB patients at the community level

- update the original treatment card at the PHI on a fortnightly basis and Nikshay entries in coordination with NTEP staff

 

5. Ensuring public health action: 

The PHW visits the house of the patient within a week of TB diagnosis to:

- verify the residential address so that in case of interruption, retrieval action can be taken

- counsel the patient and family members regarding the disease, treatment and its adherence

- screening of contacts, providing TB Preventive Therapy (TPT) to all eligible

- advise patient on balanced diet, taking the food they can afford and also about nutritional support systems available for the eligible patients

- collect the bank account number of the patient or one of the household members; or facilitate getting the bank account opened, if not having one

- mobilize/refer for HIV testing

- sample collection and transportation for Dug Susceptibility Testing 

 

6. Awareness generation/advocacy in community

PHWs generate awareness/advocacy in the community. The activities include:

- awareness on health promotion and health seeking behaviour

- awareness on symptoms of TB, good cough etiquettes, available services for screening, diagnosis and treatment of TB

- awareness on patient support and benefit schemes including Nikshay Poshan Yojana

- mobilize community, community leaders (religious leaders, school principals, women’s Self-Help Groups, etc) and Panchayati Raj Institution (PRI) members for TB sensitization activities

- identify TB survivors to volunteer for the community engagement activities 

Resource

 

Training Modules for Programme Managers and Medical Officers, Central TB Division, MoHFW 2020

 

Assessment

 

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
What is the key role of the Peripheral Healthcare Worker?	Vulnerable population mapping	Home visits, counselling and contact tracing	Awareness generation/ advocacy in community	All of the above	4	Peripheral Healthcare Workers' (PHW) role is in vulnerable population mapping, screening and referral for testing, treatment initiation, coordinating treatment support, ensuring public health action, and awareness generation/ advocacy in the community.		Yes	Yes

The Senior TB Laboratory Supervisor (STLS) is the person responsible for monitoring the day-to-day activities of all the microscopy centres and nucleic acid amplification test (NAAT) sites and is thus essential to the success of the National TB Elimination Programme (NTEP). They also ensure the quality of TB diagnostic services.

 

Roles of STLS at the DMC

1. Program management

The STLS is responsible for ensuring that microscopy services in the district are well organized and the locations of the designated microscopy centres (DMCs) are known to all the medical officers in all peripheral health institutions (MO-PHI).

The STLS also ensures that there are:

• Uninterrupted staffing of DMCs, including coverage for laboratory technicians (LTs) that might be on leave, so that there is regular and uninterrupted availability of smear examination at the DMC.
• Uninterrupted supply of reagents and logistics required for the microscopy.
• Quality assurance and accuracy guarantee for the microscopic activities carried out.
• Regular training and continuing education of LTs.

The STLS reports to the district TB officer (DTO) in collaboration with the senior treatment supervisor (STS) regarding implementation, quality control (QC), supervision and management of laboratory supplies.

 

2. Monitor documentation related to microscopy

STLS ensures that all documentation related to sputum smear examinations is accurate and reports of examinations are given to the treating physician promptly. This includes:

• Each LT has a TB lab register which is filled completely and accurately.
• LTs understand the importance of limiting administrative errors (for example, keeping the sputum specimens with the proper lab forms for sputum examination and slides) and accurately recording the results of sputum smear examinations.
• LTs keep examined slides for review and on-site evaluation (OSE) visit by the STLS.
• There is an accurate recording of the results of the sputum smear examination.

STLS must explain to LTs that patients are diagnosed and placed on appropriate treatment regimens based on the smear results.

 

3. Ensure appropriate number and schedule of sputum examinations

• Presumptive TB persons should have their sputum examined the correct number of times for tubercle bacilli, at least 2 sputum samples should be examined.
• Follow-up cases should have 2 sputum samples examined and should be done according to the follow-up schedule.
   

4. Perform laboratory QC

This is done via OSE visits. The visit includes a comprehensive assessment of the laboratory safety including infection control measures; conditions of the equipment, adequacy of supplies as well as the technical components of acid-fast bacilli (AFB) smear microscopy employing a simple “Yes” and “No” checklist.

• The STLS visits every DMC under their supervision at least once every 4 weeks, and more often if possible.
• During these visits, at least 5 positive and 5 negative slides must be re-checked by the STLS.
• Staff at the DMC is supervised, evaluated and trained during these visits.
• The STLS maintains a diary, recording the details of these field visits.

At the end of each QC visit, detailed feedback is given by the STLS for continuous internal quality improvements. The STLS also ensures that centres maintain proper storage and transport of sputum specimens, the safety of lab staff and the maintenance of microscopes.

5. Waste disposal checks: STLS ensures that contaminated material is disposed of safely to ensure infection control. Sputum containers with sputum must either be incinerated, disinfected and autoclaved, or burnt in a pit and the burnt material buried.

6. Maintain an adequate supply of all materials necessary for microscopic examination

The STLS ensures that LTs have an adequate supply of reagents, sputum containers, slides and other materials including boxes for storing slides. This includes:

• Calculating the required volume of material (slides, sputum containers, etc.) required.
• Ordering supplies during the first week of the quarter to ensure uninterrupted supply at all DMCs.
• Distribution of sputum containers to all sputum collection centres/ DMCs in the area.
• Estimating and ensuring maintenance of adequate reserve stock at DMCs.

 

Resources

• NTEP Training Modules 1-4 for Programme Managers & Medical Officers, 2020.
• Module for Senior Tuberculosis Laboratory Supervisors, NTEP, 1999.
• Module for Laboratory Technicians, NTEP, 2005.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
What is the role of the STLS in the DMC?	Conduct an on-site evaluation visit.	Make sure that LTs fill the TB lab register properly.	Ensure adequate supply of lab material, like slides, at the DMC.	All of the above	4	The STLS conducts an on-site evaluation visit at the DMC, ensures proper documentation of smear results and ensures an adequate supply of lab materials at the DMC.	​	Yes	Yes
How often should the STLS visit the DMC?	Every 2 weeks	Every month	Every quarter	Every 6 months	2	The STLS visits every DMC under their supervision at least once every 4 weeks, and more often if possible.		Yes	Yes

At a DMC, the STS primarily ensures that 

1. All patient services from enrolment to outcomes for a TB patient are completed optimally. This is done by monitoring information submitted by the DMC such as referral for testing, no of people tested, no of people diagnosed with TB, initiated on treatment. 

2. All the patients started on treatment are tested promptly using the appropriate follow-up testing schedule( i.e. at the end of IP and CP). 

3. Maintain profile of the DMC in the Nikshay such as tagging the PHI as DMC, name of contact person and other particulars

4. Ensure data quality in the various records, both in physical and electronic records. This includes patient data, referral data and testing data.