Fullscreen

  • DR-TB HIV Coordinator: General Concepts in Adherence Management

    Fullscreen

    • TB Treatment Adherence

      Content

      Tuberculosis(TB) is curable if patients are treated with effective, uninterrupted anti-tuberculous treatment. Treatment adherence is critical for curing individual patients, controlling the spread of infection in the community, and minimizing the development of drug resistance.

      Adherence to treatment means that a patient follows the recommended course of treatment by taking all the prescribed medications for the entire length of time, as necessary. In other words, “right dose for the right duration”.

      In Drug Sensitive Tuberculosis(DSTB), a TB patient completes 168 doses of TB treatment and adheres to TB treatment.


       

    • Importance of Treatment adherence

      Content

      Adherence to tuberculosis(TB) treatment is important for promoting individual and public health. Poor adherence to TB treatment results in:

      • More individual suffering and death,
      • Costly treatment as treatment regimens lengthen and
      • Increases the risk for Drug Resistant Tuberculosis

       

      Proper treatment of all forms of TB is critical to reducing individual morbidity and mortality and to interrupting transmission among family and community members.


       

    • Recording and Monitoring Adherence

      Content

      Recording of Treatment Adherence can be done as

      • Manually by DOT/Health Care Provider in TB Treatment Card of a patient.
      • Self-reported by Patient using digital tools for reporting adherence using 99 DOTS and MERM technologies.

       

      Monitoring Treatment Adherence:

      All TB patients should be monitored to assess their response to TB treatment. Nikshay Adherence calendar has a colour legend for various doses taken by a patient

       

      Figure: Sample Nikshay Adherence Calendar in web and Mobile App

       

      COLOUR LEGEND DOSE DESCRIPTION
        Treatment Start /End Denotes Treatment start and End Date
        Digitally Reported Dose Denotes that the patient has successfully called the Toll Free Number displayed on the envelope
        Manually Reported Dose Indicates that the staff has marked manually confirmed dose for the day
        Unreported Dose Indicates that there was no call event received on Nikshay for that day
        Manually Reported Missed Dose Indicates that the staff has marked a manually confirmed missed dose for the day
        Digitally Reported(From Shared Phone Number) Indicates that the patient has been calling from a shaed number(A mobile number that is common for more than one patient)
      DSTB Paper Treatment Card

      Figure: DSTB Treatment Card (Paper)
       

    • Digital Adherence Monitoring Technologies

      Content

      99DOTS is a low-cost digital adherence technology built-in Nikshay that uses inexpensive packaging(envelopes or stickers) with medication that enables people taking medication to engage with their treatment daily. This packaging, distributed to TB patients taking medications, has a hidden number behind perforated flaps on the external envelope; in some cases, the number may be fixed outside the medication blister or pill bottle. This number can be a toll-free number that can be called to register daily adherence or a code sent by SMS, USSD, or other communication channels. Calling or messaging the number is free!

      Figure: 99 DOTS Envelope

       

      MERM: The Medication Event Reminder Monitor(MERM) is a digital pillbox that provides daily pill-taking reminders and facilitates remote monitoring of medication adherence. This system provides visual and audible reminders for both daily dosing and refill,.transmits this data to a server so that healthcare providers can remotely visualize patients’ dosing histories to support enhanced adherence counselling. 

       

      Figure: MERM Box

       


       

    • Directly Observed Treatment

      Content

      Directly observed treatment (DOT) is one of the key elements of the DOTS strategy. In DOT, an observer (health worker or trained community volunteer, or trained family member for selected patients) watches and supports the patient intaking their drugs. Direct observation ensures treatment adherence with the right drugs, in right doses for the right duration.

       

    • Treatment Support

      Content

      A person affected by TB requires support throughout the course of treatment and beyond that. The support to a TB patient is essential to ensure that s/he completes the treatment without affecting her/his quality of life (QoL). Keeping the patient as the central figure in the continuum of care, and ensuring social and personal circumstances are supportive (not only meeting immediate requirements of medical treatment) is the key to treatment support.

       

      Figure: Key Components of Treatment Support

       

      Resources

      National Strategic Plan for Tuberculosis Elimination 2017–2025, RNTCP, 2017.

      A Patient-centred Approach to TB Care, WHO, 2018.

       

      Assessment

      Question​ 

      Answer 1​ 

      Answer 2​ 

      Answer 3​ 

      Answer 4​ 

      Correct answer​ 

      Correct explanation​ 

      DOT is the only treatment support provided to TB patients.

      True

      False

       

       

      2

      Ensuring social and personal circumstances are supportive for treatment adherence and not just medical requirement is the key to treatment support.

       

    • Treatment supporter to TB Patient

      Content

      A Treatment Supporter can be any person such as a Medical Officer, MPWs, community volunteers working with the program etc. Even a patient’s relative or family member can be a Treatment Supporter.

       

      As per NTEP guidelines, salaried NTEP/General Health System staff may also be assigned as treatment supporters for a patient.  However, they will not be eligible for any honorarium.

       

      A patient can only be linked to one treatment supporter at a time in Nikshay.


       

    • Assigning a TS

      Content

      At treatment initiation a suitable Treatment Supporter has to be identified and assigned to the Patient.

      How to identify a Treatment supporter for a patient 

      • The Treatment Supporter has to be acceptable and accessible to the patient and accountable to the health system.
      • Should be identified in mutual consultation with the patient and provider, during pre-treatment evaluation.
      • The Treatment Supporter can either be a healthcare worker, community worker/ volunteer, private practitioner or family member.
      • Should be able to receive training on drug administration, adherence monitoring, ADR referrals etc., and perform these functions. 

      Assigning a Treatment Supporter to a Patient 

      Once the Treatment Supporter is identified, the patient records (Ni-kshay & treatment card) have to be updated by assigning the treatment supporter (prior registration in Ni-kshay is a pre-requisite) to the patient. See the steps below to assign a Treatment Supporter to the episode of a patient.

      Treatment Supporters are eligible to receive the Treatment Supporters Honorarium as a Direct Benefit Transfer. However, to receive the DBT he/she should not be a salaried government employee.

      NOTE:

      1. Only one Treatment Supporter can be assigned to an episode with status "OnTreatment" of the patient
      2. Treatment Supporters can be assigned by both the current PHI/ TU user.
      3. If required, a Treatment Supporter can be removed/ replaced by another Treatment Supporter anytime during the treatment.

       

      Steps to assign a Treatment Supporter

      Figure: Steps to Assign a Treatment Supporter in Ni-kshay

      AssignTrSuppNi-kshay

      Figure: Screenshot Assigning a Treatment Supporter in Ni-kshay

       

      Resources

       

      Assessment

      Question​ Answer 1​ Answer 2​ Answer 3​ Answer 4​ Correct answer​ Correct explanation​ Page id​ Part of Pre-test​ Part of Post-test​
      When should a treatment supporter be identified assigned to a patient episode ? While declaring treatment outcomes Any time while the patient is on treatment At treatment initiation When the patient is transferred 2

      Treatment Supporters are to be identified and assigned to a patient at the time of treatment initiation.

      Treatment Supporters can be assigned or re-assigned anytime during treatment, but this is in-case it has not been assigned before 

      		 ​ Yes Yes
      A TB-HV acting as a Treatment Supporter can receive the Treatment Supporters Honorarium. TRUE FALSE     2 TB HV is a Salaried Government Employee and hence cannot receive the Treatment Supporters Honorarium.   Yes Yes
      To assign a Treatment Supporter to a patient, which of the following are True? The Treatment Supporter needs to be registered on Ni-kshay The Treatment Supporter should be acceptable to the patient Should be able to record and monitor adherence, ADR, administer drugs, refer to the nearest Health Facility All of the above 4 Treatment Supporter needs to fulfill all the mentioned criteria.      

    • Treatment Support Groups

      Content

      Treatment Support Groups play an important role in providing treatment support to TB patients. It has been envisioned as a non-statutory body of socially responsible citizens and volunteers to provide social support to TB patients. This group goes beyond just providing treatment-related support as it also helps the community in accessing information, free and quality services and linkage to social welfare programmes without compromising confidentiality and respecting the dignity of the patient.

      A good treatment support group creates a conducive environment for TB patients to access complete care without experiencing stigma and incurring out-of-pocket expenditures.

       

      Figure: Schematic representation of the concept of treatment support groups.

       

      Treatment Support Group (TSG): Example from Kerala

      The initiative in the Pathanamthitta district of Kerala demonstrated that treatment support groups helped in minimising the loss-to-follow-up cases and better treatment outcomes. The group supported the patients in accessing information, free and quality services and social welfare programmes, thereby empowering the patients to complete the treatment successfully.

      Resources

      National Strategic Plan for Tuberculosis Elimination 2017–2025, RNTCP, 2017.

      Guidance Document for the Peoples’ Movement Against Tuberculosis in Kerala, Kerala TB Elimination Mission, 2017.

       

      Assessment

      Question​  Answer 1​  Answer 2​  Answer 3​  Answer 4​  Correct answer​  Correct explanation​ 
      What is a treatment support group? A group of treatment supporters in the community A group of TB patients in the community A non-statutory body of citizens and volunteers to provide social support to TB patients All of the above 3 A treatment support group is a non-statutory body of citizens and volunteers to provide social support to TB patients.

       

  • DR-TB HIV Coordinator: Adherence Support

    Fullscreen

    • Recording manual doses in Nikshay

      Content

      Manual recording of Adherence in Nikshay:

      in Nikshay, Adherence can only be recorded only if there is corresponding dispensation being issued to a Patient 

      Figure: Steps to record manual dose in Nikshay

       

      Recording in Patient Treatment Card:

       

      Figure: Filled Treatment card for TB Patient

       


       

  • DR-TB HIV Coordinator: 99 DOTS

    Fullscreen

    • 99 DOTS- Envelopes

      Content

       

      The 99DOTS product consists of customised envelopes (see Figure 1) that fit around the tuberculosis medication blister pack distributed to patients. 

      Figure 1: 99DOTS Envelope

       

      Universal Envelopes (Figure 2): Each adult patient gets the same sleeve, regardless of their weight band.

      These are new envelopes that are currently being introduced by the program. Weight band wise envelopes will be used while the stock lasts, but new requirements by the state will be fulfilled by providing universal envelopes.

      There are 2 types of these envelopes: 1 envelope for IP: Intensive Phase, and 1 envelope for CP: Continuation Phase, for both Macleods and Lupin Fixed-dose Combinations (FDCs). These envelopes are only to be used for adult patients on anti-TB treatment using FDCs.

      Figure 3: Universal 99DOTS Envelopes

      Using the Universal Envelope

      • The counsellor/ pharmacist/ treatment supporter write the number of pills per day the patient should take on the envelope.
      • Every day, the patient will take the prescribed number of pills and reveal 1, 2, or 3 hidden phone numbers. The patient calls any one of the numbers they reveal that day.
      • The patient should start at pill 1 and move in sequence (1,2,3…28), completing each column, and starting from the top of each row.
      • The district should always have sufficient stock, which can be calculated as:
        • Number of IP strips = Number of IP envelopes + some buffer
        • Number of CP strips = Number of CP envelopes + some buffer

      Advantages of the Universal Envelopes

      • There is no need to estimate the requirements of weight band wise envelopes.
      • Less space is required to store the envelopes.
      • Stock-outs of envelopes for a particular weight band will not occur.
      • It is easy for patients to follow the top to down arrow mark pattern while dispensing and ingesting medicines.
      • Counselling time and dispensing time by pharmacists reduce per patient, thus increasing efficiency.

      Resources:

      Assessment

      Question​ Answer 1​ Answer 2​ Answer 3​ Answer 4​ Correct answer​ Correct explanation​ Page id​ Part of Pre-test​ Part of Post-test​
      Which of the following is correct about 99DOTS envelopes? The envelopes have medicine inside them. The envelopes have hidden numbers that can be called by the patient. There are weight-band wise envelopes. All of the above 4 99DOTS envelopes have anti-TB medicines with hidden toll-free numbers that patients call. These envelopes can be weight-band wise or universal envelopes.      
      For weight-band wise 99DOTS envelopes, background colours differ for each weight band. True False     1 For weight-band wise 99DOTS envelopes, background colours differ for each weight band.      

       

       

    • 99 DOTS- Envelope Dispensing Process

      Content

      The 99DOTS (Directly Observed Treatment, Short-course) universal envelope is developed to avoid the complexity of weight band wise 99DOTS envelope.

      The overall dispensing process is easy and can be divided into these steps:

      1. The patient consumes 2, 3, 4, or 5 pills per day, as per the doctor's prescription.
      2. One or more toll-free numbers can be seen behind the pill flap after taking out the pills every day.
      3. The patient takes the pill.
      4. The patient calls any one of the toll-free numbers seen on that day.

      This call will be recorded as a consumed dose for the day.

      The dispensing process is outlined in the figure below.

       

      Figure: 99DOTS Universal envelope dispensing process

       

      Resources:

       

       

      Assessment

      Question​

      Answer 1​

      Answer 2​

      Answer 3​

      Answer 4​

      Correct answer​

      Correct explanation​

      Page id​

      Part of Pre-test​

      Part of Post-test​

      Which of the following is the 99DOTS universal envelope dispensing process?

      The patient calls the number on the envelope to ask for medicines.

      Pharmacist/ treatment supporter fills the number of pills to be taken – Patient opens the pill flap, takes the pills, and reveals the hidden number – Patient calls the toll-free number.

      The treatment supporter calls the medical officer to know how many pills to fill on the envelope – The pharmacist opens the pill flap to check that the medicine is in place.

      All of the above

      2

      The 99DOTS universal envelope dispensing process is: Pharmacist/ treatment supporter fills the number of pills to be taken – Patient opens the pill flap, takes the pills, and reveals the hidden number – Patient calls the toll-free number.

       

      		    

       

       

       

    • 99 DOTS- Initiating adherence monitoring of the patient

      Content

      Initiating adherence monitoring of the patient on 99DOTS (Directly Observed Treatment, Short-course) on Nikshay is done by the STS/ Health care provider initiating patient on treatment. 

      Registering a Patient

      It is the responsibility of the STS/ Health care provider initiating patient on treatment to register the patient on the Nikshay . S/he has to make sure to enter all the phone numbers of the patient and to keep them updated. They also add the complete address where the patient is currently residing, entering a landmark in the address field, if possible.

      Before adherence monitoring can be initiated on Nikshay, the patient’s status must show that they have positive test results and have started treatment on Nikshay. After entering a positive test result for a patient, treatment is started from the “Treatment Details” tab by clicking the “Start Treatment” button, as shown in Figure 1.

      Figure 1: Starting Treatment on Nikshay

       

      How to Select 99DOTS as the Adherence Technology?

      1. After entering the test details of the patient, click on the “Treatment Details” tab. 
      2. Under the “Adherence Monitoring” option, select “99DOTS” as the adherence technology and click “Start Treatment" (Figure 2).
      3. Once you click “Start Treatment” you will be able to see the adherence calendar of the patient under the “Adherence Tab”.

       

      Counselling Information to be given to the Patient when Initiating 99DOTS

      The counselling checklist to be followed by the National TB Elimination Programme (NTEP) staff when initiating patients on 99DOTS is shown in the table below.

       

      Resources:

       

       

      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 correct sequence for initiating 99DOTS adherence for a patient on Nikshay?

      For 99DOTS, there is no need to register the patient on Nikshay.

      Register the patient – Select adherence details – Enter the test results – Enter treatment details.

      Register patient name, phone number and address – Add test details – Start treatment – Select 99DOTS as the adherence mechanism – Click ‘Start treatment’ to view the adherence calendar.

      None of the above

      3

      The correct sequence for initiating 99DOTS adherence for a patient on Nikshay is: Register patient name, phone number and address – Add test details – Start treatment – Select 99DOTS as the adherence mechanism – Click ‘Start treatment’ to view the adherence calendar.

      ​

      Yes

      Yes

       

       

    • 99 DOTS- Self Reporting Adherence

      Content

       

       

      Self-reporting adherence by dispensing pills and calling toll-free numbers

      When patients dispense pills, they break through perforated flaps on the back of the envelope, revealing a hidden, unpredictable phone number.

      Patients use an ordinary phone (usually their own or a relative’s) to place a free call to this number, which a computer answers, says “Thank You”, and hangs up.

      Important information to tell patients about calling the toll-free number:

      • Make a free call (from a mobile or landline phone) on any one of the toll-free numbers revealed every day.
      • Don’t add ‘0’ or ’91’ before the toll-free number.
      • The call can be made with no balance and from any city and anytime (no roaming charges).
      • A call for a day’s medication must be made on the same day.
      • Make calls only from the phone (mobile/ landline) numbers given to the centre (and registered on Nikshay).
      • Do not cut the call till you hear “Thank You”.

      From this simple interaction — the combination of the patient’s registered caller ID on Nikshay and the sequence of unpredictable numbers that they call over time — healthcare workers can monitor when pills were dispensed and likely taken.

      In addition to this mechanism for self-reporting adherence, 99DOTS also supplies supporting Information, Communication and Technology (ICT) tools (Nikshay, 99DOTS platform) for health workers, enabling them to efficiently monitor and respond to any missed doses.

      If a patient does not call 99DOTS on any given day, they receive an escalating series of dosage reminders. First, an automated SMS message is sent. If additional doses are missed, the patient can expect a personal outreach from a health worker, either via a phone call or a home visit.

       

      Resources:

      Assessment

      Question​

      Answer 1​

      Answer 2​

      Answer 3​

      Answer 4​

      Correct answer​

      Correct explanation​

      Page id​

      Part of Pre-test​

      Part of Post-test​

      99DOTS is a digital adherence technology that allows for self-reporting adherence by the patient.

      True

      False

       

       

      1

      99DOTS is a digital adherence technology that allows for self-reporting adherence by the patient.

       

      		    

       

       

       

    • 99 DOTS- Troubleshooting

      Content

      Whenever a patient calls a toll-free line on the 99DOTS (Directly Observed Treatment, Short Course) envelope, they should have the following experience:

      • The call is answered immediately.
      • A brief "thank you" message is played.
      • The call hangs up automatically.

      In total, the call is less than two seconds long. After this sequence, the Nikshay adherence dashboard will be updated with the adherence details.

      Patients may sometimes face issues with the toll-free lines. In such cases, the healthcare worker must try to understand the challenge and help the patient to resolve the issue. The table below shows common issues with the toll-free lines and their solutions.

      Issues

      Solutions

      The patient dials the toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red.
      • Ask the patient to give a missed call to your phone. Check that it is the same number that is registered in Nikshay. If there is a data entry error in the registered phone number, correct the number in Nikshay.
      • The patient might also have a dual SIM phone or another alternative phone number. If another number is being used by the patient, add the number in Nikshay.

      The patient dials the toll-free number but hears an out-of-service voice message.
      • Visit the patient and check the balance in the pre-paid phone connection.
      • If it is negative, the call cannot be made.
      • The call can be made with zero or more balance in pre-paid connections.
      • In post-paid connections, if the bill is not paid, the patient cannot dial the toll-free number.

      The patient dials the toll-free number but hears “Please check the number”, “Invalid number”, or “Number not in use” voice messages.
      • Ask the patient to dial the number.
      • Check that they are dialling the entire number, without adding ‘0’, ‘91’, or ‘+91’ and they should not cut the call till they hear “Thank You”.

      The patient says that their pre-paid balance is deducted after dialling the toll-free number.
      • Ask the patient to make a toll-free call.
      • Check the balance SMS they receive. The last call charge will show as Rs.0.00 and the total balance will also be shown.

      The patient has very little or zero balance, dials the toll-free number and hears a long message regarding less or zero balance.

       
      • When the balance in the pre-paid connection is very little or zero, the patient might hear a long message from the telecom service provider.
      • Request the patient to wait for that voice message to end. On completion of this voice message, the toll-free number will be dialled, and the patient will hear “Thank You”.

      The patient dials the toll-free number but cannot hear anything or “Thank You” is not heard.
      • Request the patient to try multiple times.
      • At times, due to network congestion, the call may not go through, just like any other mobile number.
      • You can also try dialling the same toll-free number from your phone, to check that the toll-free line is working.

      The patient says that they are not able to connect to the toll-free lines after 1:00 PM or 3:00 PM.

       
      • The toll-free calls can be made till 11:59 PM for the current day’s dose. The timing restriction is only for the SMS alerts.
      • Educate the patient that if they do not call by 1:00 PM they will get an SMS reminder.
      • Even after that, if they do not call till 3:00 PM the staff will get an SMS alert.
      • They can still call after 3:00 PM till 11:59 PM. The moment they call, the dashboard will turn green.
      • It is only at 12:00 AM (midnight) that the dashboard turns red.

       

      Resources:

       

       

      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 should be done if a patient dials the 99DOTS toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red?

      Tell the patient that they lied as they did not take their medication.

      Check that there are no errors in the patient’s phone number on Nikshay.

      Check if the patient used an alternative number to call the toll-free line and register this dual line on Nikshay.

      Options 2 and 3

      4

      If a patient dials the 99DOTS toll-free number and hears “Thank You”, but the Nikshay dashboard is still showing red, then: Check that there are no errors in the patient’s phone number on Nikshay, also check if the patient used an alternative number to call the toll-free line and register this number on Nikshay.

       

      		    

       

       

  • DR-TB HIV Coordinator: MERM Boxes

    Fullscreen

  • DR-TB HIV Coordinator: Adherence Monitoring and Follow-up Actions

    Fullscreen

    • Adherence Summary Dashboard

      Content

      The Adherence Summary dashboard  is designed primarily for treatment supporters and field staff to help them monitor the day to day adherence statistics of their patients and incorporate necessary actions wherever required. This dashboard enables staff at district level hierarchies and below to view real-time adherence information of all patients on treatment.

      The adherence summary dashboard is available in both Ni-kshay web portal as well as the mobile application.

      879 (1)

       

      Figure 1: Adherence Summary Dashboard; Source: Ni-kshay Web Portal (L) and Ni-kshay Mobile Application (R)

       

      879 (2)

      Figure 2: Adherence Summary Dashboard; Source: Ni-kshay Web Portal

      879 (3)

       Figure 3: Adherence Summary Dashboard (contd.); Source: Ni-kshay Web Portal

      879 (4)

      Figure 4: Adherence Summary Dashboard; Source: Ni-kshay Mobile Application

      This dashboard provides a summary of the following:

      • The Number of Patients currently enrolled on various Digital Adherence Technologies (99DOTS, MERM, VOT)
      • Graph representing % of 'Average Adherence' of all patients on treatment
      • Graph representing the % 'Digital Adherence' of all patients on treatment
      • Real time update on the number of patients who have reported a dose (Digital + Manual) for the day and the number of patients who are yet to report a dose.
      • Adherence Task Lists: This tab gives information on the number and proportion (%) of treatment interrupting patients based on the no. of doses missed,  which helps the NTEP staff to undertake immediate actions to bring such patients back on treatment.

      Resources

      Assessment

      Question     Answer 1     Answer 2     Answer 3     Answer 4     Correct answer     Correct explanation     Page id     Part of Pre-test     Part of Post-test    
      Identify the correct statement from the options below  Adherence summary dashboard allows viewing only digital adherence of the patients Adherence summary dashboard allows viewing only average adherence of the patients Adherence summary dashboard allows viewing both digital and average adherence of the patients. None of the above 3 Adherence summary dashboard allows viewing both digital and average adherence of the patients.      Yes  Yes