DR-TB HIV Coordinator: Public Health Actions

Nutrition constitutes an important part of TB Treatment. Undernutrition increases the risk of Tuberculosis (TB), and in turn, TB can lead to malnutrition. It has been demonstrated that undernutrition is a risk factor for progression from TB infection to active TB disease, and undernutrition at the time of diagnosis of active TB is a predictor of increased risk of death and TB relapse. There is, as yet, little evidence showing that additional nutrition support improves TB-specific outcomes, but low body mass index, as well as lack of adequate weight gain during TB treatment, are associated with an increased risk of TB relapse and death.

The following table illustrates the effect of undernutrition on outcomes in TB.

Effects on disease	Increased severity of disease Increased risk of death
Effects on treatment	Delayed sputum conversion Risk factor for drug-induced hepatotoxicity Malabsorption of rifampicin Reversion of positive cultures in Multidrug-resistant (MDR) -TB
Effects on long-term outcomes	Increased rate of relapse
Effects on contacts	Increased incidence in undernourished contacts

 

The basic recommendations to address the nutritional needs of TB patients are discussed below.

1. Conducting an initial nutrition assessment of TB patients with further monitoring
2. Providing ongoing counselling for patients on their nutritional status; Diet for TB patients starting treatment should include: cereals (maize, rice, sorghum, millets, etc.), pulses (peas, beans, lentils, etc.), oil, sugar, salt, animal products (canned fish, beef and cheese, dried fish), and dried skimmed milk
3. Managing severe acute malnutrition according to national guidelines and WHO recommendations
4. Managing moderate undernutrition for TB patients who fail to regain normal Body Mass Index (BMI) after two months of TB treatment or appear to lose weight during TB treatment and evaluating for proper treatment adherence and other comorbidities. If indicated, these patients should be provided with locally available nutrient-rich or fortified supplementary foods.
5. Special categories of TB patients, such as:

• Children who are less than 5 years of age should be managed as any other children with moderate undernutrition.
• Pregnant women with active TB and patients with MDR-TB should be provided with locally available nutrient-rich or fortified supplementary foods.

     6. Micronutrient supplementation for all pregnant women as well as lactating women with active TB. These women should be provided with iron and folic acid and other vitamin and minerals to complement their maternal micronutrient needs. In situations when calcium intake is low, calcium supplementation is recommended as part of antenatal care.

To achieve the above objectives, the guidelines for nutrition for TB patients are available and a mobile application (N-TB) is available for decision-making on nutritional support for TB patients.            

Improving nutritional status at a population level is important for TB prevention which should be part of broader actions on social determinants. All efforts should be made to link TB patients for nutritional support which can be done through the existing public distribution system, local self-government or Non-governmental Organisations (NGOs)or donor agencies or through the corporate sector under Corporate Social Responsibility (CSR).

 

Resources

• Guideline: Nutritional Care and Support for Patients with Tuberculosis, WHO, 2013.
• Guidance Document: Nutritional Care and Support for Patients with Tuberculosis in India, MoHFW, WHO, CTD, 2017.
• Training Modules (1-4) For Programme Managers & Medical Officer NTEP, CTD, WHO, MoHFW, 2020.
• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, MoHFW, WHO, 2021.

 

Assessment

Question 1	Answer 1	Answer 2	Answer 3	Answer 4	Correct Answer	Correct Explanation	Page id	Part of Pre-Test	Part of Post-Test
Undernutrition doesn’t affect the outcomes of TB.	True	False			2	Undernutrition affects the outcomes of TB in terms of treatment.

Who can provide Psychosocial support?

Family Members, Peer groups, treatment support groups, TB Champions, Community Health Volunteers(CHVs) and NGOs can provide psychosocial support to TB patients and their families by:

 

• Building a strong sense of community
• Helping the patients to contact a health worker or visit a health facility
• Providing treatment support to take their drugs and finish their treatment. Family members, community-based volunteers and workers can be trained as treatment supporters by NGOs
• Facilitating patients to access DBT for nutritional support under NPY
• Helping TB patients with comorbidities to visit the referral facility for treatment
• Treatment adherence support through peer support and education and individual follow up
• Home-based palliative care for TB
• Awareness generation, providing right information, behaviour change communication and community mobilisation for reducing stigma and discrimination
• Facilitating patients to join yoga/meditation/exercise groups once the active phase is over
• Facilitating and arranging rehabilitative services for problems/disabilities in TB patients
• Social and livelihood support
• Food supplementation
• Income-generation activities(NGO can start or facilitate patients to join activities like candle making, making festival-related goods)
• Sensitising PRIs to engage TB patients(who can work) through the Mahatma Gandhi National Rural Employment Guarantee Scheme(MGNREGS)

Substance use has been one of the major reasons for non-adherence to TB treatment and therefore, the National TB Elimination Programme (NTEP) has implemented several initiatives for control and de-addiction of substance use in association with various other health programmes like the National Tobacco Control Programme (NTCP), Drug De-Addiction Programme (DDAP), etc.

NTEP has also included referral services to de-addiction facilities for TB patients as a part of the ‘Standards for TB Care in India (STCI)'.

 

Deaddiction Services and Linkages

1. Brief substance use counselling during the pre-treatment, treatment initiation and regular follow-up counselling sessions by the trained NTEP staff.
2. Referral to National Tobacco Quitline provides telephonic counselling via the toll-free number in English and Hindi languages 8 a.m. to 8 p.m. between Tuesday to Sunday.
3. Referral to mCessation Programme provides evidence-based behavioural change Short Text Messages (SMSs) in English and Hindi languages on mobile phones, which include health information on tobacco use hazards, tips on quitting, and encouragement for those attempting to do so.
4. Referral to nearest Tobacco cessation clinics/ centres in the government facilities.
5. Referral under the Drug De-Addiction Programme (DDAP) wherein affordable, easily accessible and evidence-based treatment for all substance use disorders are provided through the government health care facilities of the Ministry of Health and Family Welfare, viz., All India Institute of Medical Sciences (AIIMS), New Delhi; Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh; National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bengaluru; Dr Ram Manohar Lohia (RML) Hospital, New Delhi; AIIMS, Bhubaneswar; and Central Institute of Psychiatry (CIP), Ranchi.

 

Resources

• National Strategic Plan 2017-2025 for TB Elimination in India, MoHFW, India, 2017.
• National Framework for Joint TB-tobacco Collaborative Activities, MoHFW, India, 2017.

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 service does the National Tobacco Quitline provide?	Telephonic counselling	Face-to-face counselling	None of the above	Both 1 & 2	1	National Tobacco Quitline: Telephonic counselling via the toll-free number in English and Hindi languages.	​	Yes	Yes

Eliminating the catastrophic expenditure on TB patients and their families has been an important goal of the World Health Organisation's (WHO’s) END TB strategy.

The National TB Elimination Programme (NTEP) has also attempted the same through various partnerships and one of the action plans under this strategy was to provide transport allowance to cover the TB treatment-related travel costs of the TB patients as well as their attendants.

Travel cost for Drug-resistant TB (DR-TB) patients

• Travel costs are reimbursed for DR-TB patients travelling to District or Nodal DR-TB Centre for initiation/ follow-ups/ adverse reaction management during the treatment, along with one accompanying person/ attendant.
• The reimbursement is as per actual cost per visit through public transport with a limit of up to Rs. 400 per visit within the district and up to Rs. 1000 per visit for outside district travel.

Travel cost for TB Patients in tribal/ hilly/ difficult areas

• TB Patients from tribal /hilly/difficult areas are provided with an aggregate amount of Rs. 750 as transport allowance to cover patients and the attendants' travel costs.
• Rs. 750 as a one-time payment at the time of noti­fication.

Travel cost for Presumptive TB patients to visit District TB Centres (DTC)/ collection centres for testing

• Presumptive TB patients travelling to DTC/ collection centre are reimbursed as per actual cost with public transport.

Resources

• Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, 2021, CTD, MoHFW, India.
• Direct Benefi­t Transfer Manual for National Tuberculosis Elimination Programme. Central TB Division, Ministry of Health & Family Welfare, India, 2021.

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Post-test​
How much amount is provided as transport allowance to tribal/ hilly area patients and their attendants during their TB treatment	Rs.250	Rs.500	Rs.750	Rs.1000	3	Rs. 750 is provided as transport allowance to Tribal/ hilly area patients and their attendants during their TB treatment.	​	Yes	Yes

Nikshay Poshan Yojana (NPY) is one of the four initiative-based support schemes which provides financial support to TB patients for their nutrition. A financial incentive of Rs. 500 per month will be provided to patients on anti-TB treatment till the completion of treatment.

• All TB patients who are registered/ notified (from both public/ private sectors) on the Nikshay Portal on or after 1^st April 2018 are beneficiaries of the scheme.
• The incentive is paid in cash and will be deposited to the Aadhaar enabled bank account of the patient. In the case of paediatric TB patients, money will be deposited in parents'/ guardians’ accounts.
• The first instalment of Rs. 1000 total for the first 2 months is expected to be disbursed immediately after starting treatment. To ensure treatment adherence, after the first instalment, the conditionality of follow-up examination is applicable.
• Each month of treatment extension, Rs. 500 will be transferred to the patient's DBT account, till the treatment is continued.
• In some states, where the incentive is transferred in-kind, they should provide food baskets with a total value not less than the corresponding eligible benefit.

Figure: Aims of Nikshay Poshan Yojana

The health volunteer/ Treatment supporter, Multi-purpose Health worker in-charge, or the Senior Treatment Supervisor (STS), are responsible to collect the bank details of the patient from the field level and enter it on the Ni-kshay.

 

Resources

Nutritional Support DBT Scheme Details, CTD.

Direct Benefi­t Transfer Manual for National Tuberculosis Elimination Programme, CTD, 2020.

Guidelines for Programmatic Management of Drug-resistant TB in India, 2021.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
Only patients seeking treatment in public hospitals are eligible for Nikshay Poshan Yojana.	True	False			2	All patients who are receiving treatment from both public and private sectors and are notified on the Nikshay platform are eligible to receive the benefit.

 

In the National Sample Survey Office (NSSO) 68th round 2011-2012, India was reported to have the highest out-of-pocket expense on healthcare, of which over 67% was spent on drugs. Recognising the importance of essential drugs being available and accessible to the general public, the Ministry of Health & Family Welfare, Govt. of India, implemented the Free Drugs Service Initiative (FDSI) under the National Health Mission (NHM) in 2015.

Objectives

• To ensure that a set of essential drugs is made available free of cost to all those who access public health care facilities.
• To reduce the Out-of-Pocket Expenses (OOPE) of patients to support their treatment and adherence to medication.

Under this initiative, provision for obtaining free of cost essential medicines is made available through public health facilities under the National Health Mission at Primary Health Centres (PHCs), Community Health Centres (CHCs), Sub Divisional Hospitals (SDH) and District Hospitals (DHs).

Under this scheme, National TB Elimination Programme (NTEP) recommended Fixed-Dose Combination (FDC) anti-TB medicines are also available for both paediatric and adult TB patients. While most of these medicines are procured centrally, few loose drugs, especially for prophylaxis, are allowed to be procured at the state or district level at times when central supply is short. 

NHM has dedicated funding for free drugs, and various levels, including Peripheral Health Institutions (PHI), are allotted preset budgets under this scheme. PHIs are supposed to procure essential drugs which are not supplied by the government-owned "General Medical Stores" from this budget. Although most of the drugs are readily provided to the PHIs, some subsidiary drugs and supplements, which are required in TB care, can be made available under this scheme. For example drugs required to treat minor adverse drug reactions, vitamins, protein supplements, expectorants, antitussives, etc. 

 

Resources

• Operational Guidelines - Free Drugs Service Initiative, MoHFW, GoI.

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

• Essential Medicine List for SHC & PHC Level, Ayushman Bharat - Health and Wellness Centre, 2020.

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct Answer	Correct explanation
To reduce the Out-of-Pocket Expenses (OOPE) of patients.	True	False			1	Free drug service initiative under NHM aims to reduce the Out-of-Pocket Expenses (OOPE) of patients.

 

Figure: Components of Ayushman Bharat Yojana

Pradhan Mantri Jan Arogya Yojana (PM-JAY) is one of the two key components of the Ayushman Bharat Yojana launched by the Government of India as part of the National Health Policy 2017. It is one significant step toward achieving Universal Health Coverage (UHC) and Sustainable Development Goal - 3 (SDG3): Good health and well-being.

Aim

To provide health protection cover to poor and vulnerable families against financial risk arising from catastrophic health episodes.

Provisions

• Financial protection (Swasthya Suraksha) to 10.74 crore poor, deprived rural families and identified occupational categories of urban workers’ families as per the latest Socio-Economic Caste Census (SECC) data (approx. 50 crore beneficiaries). It will offer a benefit cover of Rs. 5,00,000 per family per year (on a family floater basis).
• Cover medical and hospitalisation expenses for almost all secondary care and most of the tertiary care procedures. PM-JAY has defined 1,350 medical packages covering surgery, medical and daycare treatments, including medicines, diagnostics and transport.
• To ensure that nobody is left out (especially girl child, women, children and the elderly), there will be no cap on family size and age.
• Cashless & paperless at public hospitals and empanelled private hospitals.
• Beneficiaries are not required to pay any charges for hospitalisation expenses.
• Benefit also includes pre and post-hospitalisation expenses.
• The scheme is entitlement based; the beneficiary is decided based on the family being figured in the SECC database.

Benefits for the Health Care System of the Country

• Helps to achieve UHC and SDG.
• Ensures improved access and affordability of quality secondary and tertiary care services through a combination of public hospitals and well-measured strategic purchasing of services in health care deficit areas from private care providers, especially the not-for-profit providers.
• Significantly reduces out-of-pocket expenditure for hospitalisation. Mitigates financial risk arising out of catastrophic health episodes and consequent impoverishment for poor and vulnerable families.
• Acts as a steward, align the growth of the private sector with public health goals.
• Promotes the use of evidence-based health care and cost control for improved health outcomes.
• Strengthens public health care systems through the infusion of insurance revenues.
• Enables the creation of new health infrastructure in rural, remote and under-served areas.
• Increases health expenditure by the government as a percentage of Gross Domestic Product (GDP).

Resource

• National Health Portal

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of Pre-test	Part of Post-test
PM-JAY benefits can be redeemed only from government hospitals.	True	False			2	PM-JAY provides cashless & paperless benefits at public hospitals and empanelled private hospitals. It ensures improved access and affordability of quality secondary and tertiary care services through a combination of public hospitals and well-measured strategic purchasing of services in health care deficit areas from private care providers, especially not-for-profit providers.		Yes	Yes

Contact tracing is a process to identify people who are  at a high risk of developing TB due to their contact with a known TB case.

The aim of contact tracing is to find other people with TB disease and those infected with TB

All close contacts, especially household contacts of a Pulmonary TB patient, should be screened for TB. 

In paediatric TB patients, reverse contact tracing for the search of any active TB case in the child's household must be undertaken.

Particular attention should be paid to contacts with the highest susceptibility to TB infection.

Figure: Contacts to be Prioritized for contact TB screening

 

Index TB patient: Initially identified person of any age with new or recurrent TB in a specific household or other comparable settings in which others may have been exposed. The Index TB patient is the person on whom a contact investigation is centred, but is not necessarily the source/ primary case.

Contact: Any individual who was exposed to a person with active TB disease

Household Contact (HHC): Person who shared the same enclosed living space as the index TB patient for one or more nights or for frequent or extended daytime periods during the three months before the start of current TB treatment.

Close contact: Person who is not in the household but shared an enclosed space, such as at a social gathering, workplace or facility, for extended periods during the day with the index TB patient during the three months before the commencement of the current TB treatment episode. 

Contact tracing: Contact tracing is the process of listing out all the contacts (household contacts and close contacts) of the index TB patient. Contact tracing has to be done for all Index TB cases, whether pulmonary (sputum positive or negative) or Extra-pulmonary (EPTB). As per the current policy, it is compulsory to trace household contacts but it is desirable to trace other close contacts (workplace, social gathering etc) also. 

Why Contact Tracing  is done: Contact tracing is followed by contact investigation to identify active TB cases and Tuberculosis Preventive Treatment (TPT) beneficiaries.

Contact investigation: This is a systematic process for identifying previously undiagnosed people with TB disease and TB infection, among the contacts of an index TB patient.

Conducting Contact Tracing and Contact Investigation

Once a new/ recurrent TB case is diagnosed (ideally within 1 week), a healthcare worker (usually the Multipurpose Worker (MPW) from the nearby public health facility visits/ tele calls the patient’s household, interviews the patient about his/her contacts in the household and other settings such as workplace or social gatherings. The contacts’ details are recorded in a standardised format and entered in Ni-kshay contact tracing module. Each contact's details enter the workflow as a presumptive TB case or TPT beneficiary.

The traced contacts are screened for TB using a symptom checklist and if found to have any symptoms suggestive of TB, they are tested using X-ray/ sputum microscopy/ Cartridge-based Nucleic Acid Amplification Test (CBNAAT) as required. 

 

Outcome of Contact Tracing and Contact Investigation

• Those contacts diagnosed with active TB are initiated TB treatment.
• As per the current policy, those HHC of sputum-positive Pulmonary TB (PTB), in whom active TB disease is ruled out, are considered for TB Preventive Therapy (TPT)

 

References

• Guidelines for Programmatic Management of TB Preventive Treatment in India, 2021.
• Technical and Operational Guidelines for Tuberculosis Control in India, 2016.

 

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 statements are true?	Contact tracing should always be followed by contact investigation.	Household contacts of Extrapulmonary TB are offered TPT.	The index case is always the primary source of infection in the household.	Contact tracing and investigation need to be done only during ACF campaigns.	1	2- Only HHC of Sputum positive PTB cases are offered TPT. 3 – The index case need not be the primary source of infection in the household. 4 – Contact tracing and investigation are to be done routinely for all TB cases. ACF campaigns are only an added measure.	​	Yes	Yes

Contact Tracing plays an important role in the detection of all those who are secondarily infected for proper diagnosis and prompt treatment. This process can be recorded and reported in Ni-kshay under the ‘contact tracing’ option. The process of recording contact tracing in Ni-kshay is given below.

 

Process Overview

Detailed Step-wise Procedure

 

Step 1: Login to the Ni-kshay ecosystem and enter the patient ID for which the contact tracing details are being recorded.

Step 2: Click on the ‘Contact tracing’ tab to reach the contact tracing window.

 

Step 3: Click on the 'Edit' tab and fill in the relevant information in the fields provided.

 

 

Step 4: Once the details are entered, click on the ‘update’ tab present at the upper right corner of the window to finish the process. A message will be displayed by the system once the details are updated successfully.

 

 

Step 5: Once the details are updated successfully, an option to add the contact will appear at the upper right corner of the contact tracing window. This option can be used to add contacts as Beneficiaries (Presumptive TB/ TB Preventive Treatment (TPT) beneficiaries) in the system.

 

 

Step 6: Selecting the 'Add contact' tab will take the user to the enrollment window. The process of entering information in this window is similar to adding a New presumptive TB case in Ni-kshay, except that the option of “Contact of Known TB Patient” is automatically selected for the field “Key Population”.

Once the contact is added as a beneficiary (Presumptive TB/ TPT beneficiary) in the system, the contact details can be seen in the contact tracing tab.

Video: Recording Contact tracing in Ni-kshay (Web)

 

 

Video: Recording Contact tracing in Ni-kshay (Mobile App)

 

Resources

• Contact Tracing, Ni-kshay Knowledhge Base, Ni-kshay Zendesk.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​	Page id​	Part of Pre-test​	Part of Pre-test​
Contact tracing plays an important role in the detection of all those who are secondarily infected.	False	True			2	Contact tracing plays an important role in the detection of all those who are secondarily infected for proper diagnosis and prompt treatment.		Yes	Yes

Awareness should be generated in the community for promoting various health programmes, health seeking behaviours, screening of TB cases etc. by involving and sensitizing community influencers including PRI members and treatment support groups.

Figure: Activities for awareness generation in community

 

Confidential dialogue between a health care provider and a patient that helps a patient to define his/her feelings, cope with stress, and to make informed decisions regarding treatment.

The patient should be counselled at all the three phases i.e.,

Pre-treatment counselling` About TB disease and treatment Air borne infection control Need for adherence Public Health Actions Identification of adverse events Tobacco /Alcohol cessations Identification of comorbidities

During Treatment Counselling Importance of Adherence Identification of adverse events Importance of timely follow ups Public Health Actions Tobacco /Alcohol cessations Management of comorbidities

Post treatment Counselling Testing at the end of treatment. Long term follow up Tobacco /Alcohol cessations

Objectives of TB Counselling:

• Prevention of TB transmission.
• Provision of emotional support to TB patients.
• Motivation of TB clients to complete treatment.
• Helping patients make their own informed decisions about their behaviour and supporting them in carrying out their decisions.

Figure: Characteristics of effective counselling

 

Do’s

• Active listening, emphatic gestures and expressions
• Ensure the confidentiality of the conversation done with the patient
• Ensure Minimum interruption during the conversation with patient
• Ensuring availability of IEC materials such as posters, videos, pamphlets etc. to dispel myths and misconceptions.

Don'ts

• Do not use any negative stereotypes
• Do not have any physical wall or glass between patient and yourself
• Do not breach the trust and confidentiality of the TB patient
• Do not make threats or use coercive language
• Do not exaggerate dangers or risk of TB
• Do not blame or shame TB patients

 

Nutritional Counselling begins with the nutritional assessment of TB patients by

• Nutritional Status: Assessing the height, weight and BMI of the TB patient

• Diet and Preference food for TB patients

• Current appetite and food intake of TB patients

 

Based on the nutritional assessment, following information can be conveyed to TB Patients

• Patients with TB should be encouraged to have frequent food intake in the form of three meals and three snacks.

• Attempts should be made to increase the energy and protein content in the meals and snacks without increasing its volume.

• The addition of oil, butter or ghee to the chapati or rice can increase the energy content of the diet.

• Pulses in other forms, e.g. sprouts, roasted Chana, groundnuts, can be taken as snacks in either fried or in roasted form. Milk and eggs to be included in the diet.

• The use of easily available nutritious foods based on vegetarian/non-vegetarian preferences of the patients must be emphasized.

• Information about NFSA (National Food Security Act) and Poshan abhiyan should be given.

Figure: Healthy diet for TB Patients

 

Resources:

• Guidance Document: Nutritional care and support for patients with Tuberculosis in India

 

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Providing health education and counselling to each Drug-resistant TB (DR-TB) patient is an essential step in the management of DR-TB patients. 

 

It is important to consider the long duration of treatment and the multitude of factors that may influence the overall treatment continuation and success. 

 

The treatment duration of any DR-TB regimen is long enough for the patient who needs multiple sessions of counselling, preferably more frequently in the initial phase of treatment. 

 

Counselling during treatment offers an opportunity to explore and address past and present difficulties faced by patients. The National TB Elimination Programme (NTEP) provides a counsellor at every Nodal DR-TB Centre (NDR-TBC). 

 

All counsellors and healthcare workers in the health system should know the key points of counselling for DR-TB patients, which include: 

• Confidentiality and informed decision-making process
• Information on the nature and duration of treatment 
• Possible changes in the regimen based on the additional investigations carried out
• Importance of adherence to treatment and the need for complete and regular treatment 
• Consequences of irregular or premature cessation of treatment
• Possible side effects of the drugs
• Mechanism of infection transmission
• Cough etiquette

​ 

The counsellors are expected to maintain the counsellor register for recording the information related to counselling services provided under NTEP.

 

Resources

 

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.
• WHO Training Modules for the Syndromic Management Sexually Transmitted Diseases, 2nd Edition, Module 5: Educating and Counselling the Patient, 2007.
• Technical and Operational Guidelines for TB in India, 2016.
• Central TB Division, MoHFW, GOI - Training Modules (1-4) for Programme Managers & Medical Officers, NTEP, 2020.

 

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During the treatment of Drug-resistant TB (DR-TB) patients, there are some important points that patients and caregivers must be counselled on. 

 

The table below shows all the aspects of DR-TB counselling that must be covered by health workers.

 

Table: DR-TB Counselling Tool; Source: PMDT Guidelines, March 2021, p232.

DR-TB COUNSELLING TOOL COMPONENTS	DETAILS
1. Greeting and Introduction: Build rapport in order to establish an effective relationship	Greet the patient and introduce yourself; establish boundaries by describing your role clearly Collect basic demographic details  Ensure that all the information shared or discussed will be kept confidential Inform patients of free diagnosis and free treatment under National TB Elimination Programme (NTEP)
2. Education: Assess and provide correct and updated information	Provide basic information on TB and discuss about the symptoms of TB Differentiate between drug-sensitive-TB and drug- resistant TB Explain about the diagnosis of DR-TB Explain about the DR-TB treatment regimen, duration, side effects and importance of adherence to the regimens Assess and arrange available support systems for adherence Addressing stigma and discrimination
3. Importance of Cough Hygiene and Airborne Infection Control (AIC) at Home	Discuss about the contagious nature of TB Inform about the correct cough hygiene and safe disposal of sputum Provide information on the use of mask/ handkerchief Explain that wet mopping is advisable
4. Importance of Nutritious and High-protein Diet	Assess food habits Advise the patient based on socio-cultural and economic background Consider underlying comorbidities while advising on diet (e.g., diabetes, hypertension)
5. Nikshay Poshan Yojana: Inform about social welfare schemes	Link the patient with Nikshay Poshan Yojana and other social welfare schemes
6. Other Important Aspects of Counselling	De-addiction counselling Sexual and reproductive health Addressing mental health Family/ caregiver counselling

 

Resources

 

• Guidelines for Programmatic Management of Drug-resistant Tuberculosis in India, March 2021.

 

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

The Drug-resistant TB (DR-TB) counselling register is a format developed for documenting information about the patient's treatment-related and psycho-social status as observed by the counsellor during the course of the treatment and counselling services provided from the time of diagnosis till the post-treatment follow-up period.

This register is maintained in all the District DR-TB Centres (DDR-TBCs) where the DR-TB counsellors are placed and are recognised as Annexure 13 under the Programmatic Management of Drug-resistant Tuberculosis (PMDT).

Figure: DR-TB Counselling Register; Source: Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, 2021, CTD, MoHFW, India.

The DR-TB counsellor is expected to update and maintain the counselling register on a regular basis.

The DR-TB counselling register requires the counsellors to fill in the following information about the patients. 

• District, Block, and Health facility from where the patient is receiving DR-TB treatment
• Patient’s DR-TB diagnosis date, type of DR-TB, Ni-kshay id - Episode id
• Name and mobile number of the patient’s treatment supporter
• Observations during the counselling session as applicable related to the psycho-social aspects, and treatment adherence (i.e., for pre-treatment counselling, initial home visit counselling, follow-up counselling)
• Reason for treatment interruption/ lost to follow-up along with details on the retrieval status of the patient

 

Importance

• Documenting the counselling sessions in an appropriate manner helps the counsellors to record the observations and take corrective actions wherever required.
• This register can further be used to tailor future counselling sessions in a way that contributes to treatment adherence by the patients.
• The counselling register also acts as a guide for the counsellor to refer the patients for psychiatric treatment whenever required.

 

Resources

• Guidelines on Programmatic Management of Drug-resistant TB (PMDT) in India, 2021, CTD, MoHFW, India.

 

Assessment

Question	Answer 1	Answer 2	Answer 3	Answer 4	Correct answer	Correct explanation	Page id	Part of pre-test	Part of post-test
Who is responsible for writing the counselling register?	Patient	Nurse	District TB Officer	DR-TB Counsellor	4	The DR-TB counselling register is maintained in all the District DR TB Centres where the DR-TB counsellors are placed and are recognised as Annexure 13 under the Programmatic Management of Drug-resistant Tuberculosis (PMDT).		Yes	Yes

Direct Benefit Transfer (DBT) is a major initiative of Government of India (GoI) whereby any government subsidy or benefit is to be transferred directly into the beneficiary's bank accounts. Intermediary government agencies only manage the process of payments, without handling actutal money.

NTEP is one of the first health programmes in India to use a fully adopt DBT. It uses an end to end electronic system, to digitise beneficiary information and transfer monetary benefits. In NTEP to process benefits, two electronic systems are used, Ni-kshay (operated by NTEP) and PFMS (Public Finance Management System, operated by the Ministry of Finance). Ni-kshay enables Direct Benefit Transfer by digitizing the beneficiaries(bank account details of patients, treatment supporters and providers) and calculates of incentives/ benefits (eligible payment) and processes them for payment through PFMS under various schemes. The various schemes operational under NTEP are:

• Nikshay Poshan Yojana(NPY)
• Tribal Support Scheme
• Treatment supporter’s Honorarium
• Incentive for Notification and Outcome

• Beneficiary: These are the individuals who get benefits from payments under a particular scheme. E.g., all notified TB patients are beneficiaries under the Ni-kshay Poshan Yojana. An individual may be eligible for multiple payments under one scheme or may be eligible for multiple schemes. Only individuals with bank accounts will receive these benefits. Also, beneficiaries and their bank accounts need to be approved by a district-level authority to receive any of the benefits from Ni-kshay.
• Processing authorities: The DBT maker and checker are designated personnel in the health system for in processing benefits. They are responsible for the two levels of verification in Ni-kshay; confirming and approving each benefit under their jurisdiction. Both maker and checker are roles that are assigned to any personnel  in NTEP as decided by the District TB Officer. They perform their role through a special staff login in Ni-kshay with the designation “DBT Maker” or “DBT Checker,” created under the staff management module of Ni-kshay.
  1. DBT Maker: Maker acts at the TU level. All benefits created are assigned to the maker, who has to reconfirm the eligibility manually, update necessary details if required and send the benefit to the checker for approval.DBT maker is created by the District Tuberculosis Officer (DTO) upon request from the Medical Officer Tuberculosis Center (MOTC).
  2. DBT Checker: DBT checker acts at the district level. Checker is responsible for approving all beneficiaries under the district once it has been created by the DBT makers at TU levels. DBT checker role in Ni-kshay app is created by the State TB Officer (STO).

 

Resources

• Introduction to DBT, Ni-kshay Knowledge Base.
• https://tbcindia.gov.in/WriteReadData/NTEPTrainingModules5to9.pdf
• Direct Bene­t Transfer Manual for National Tuberculosis Elimination Programme; MoHFW, Government of India, 2020. 

 

Assessment

Question	Answer 1	Answer 2	Answer3	Answer 4	Correct Answer	Correct explanation
An individual is only eligible for a benefit under NTEP at one point in time.	True	False			2	An individual may be eligible for multiple payments under one scheme or may be eligible for multiple schemes.

 

 

There may be other Central or State government schemes and programmes that beneficiaries related to the TB program are eligible for, over and above the 4 schemes provided by the central government through NTEP. Some examples are:

• State Illness Relief Fund (can serve seriously ill TB patients)
• Chief Minister’s Farmers Security Scheme
• Nutritional Support to DR-TB Patients
• Sanjay Gandhi Niradhar Yojana
• Surakhaya Yojana
• Pridhar Parasar Yojana
• Scheme for treatment of critical disease for schedule caste/schedule Tribe and people below poverty line (BPL).
• Rastriya Swasthiya Bhima Yogana (RSBY) reimbursement for those TB patients who required hospitalisation
• Sudurvarti Sahayaks from CM's Sudurvarti Gram Yojana involved TB services

These schemes are paid through their respective payment processing channels and not through Ni-kshay.

1. All TB patients notified on or continues treatment after 1st April 2018 including all existing TB patients under treatment are eligible to receive incentives.
2. For availing DBT scheme benefits under NTEP Programme, TB patients have to provide their bank details to the nearest NTEP Health facility.
3. The patient must be registered\notified on the NIKSHAY portal.
4. Each beneficiary can be linked to unique savings bank account belonging to him/her. Beneficiaries without bank accounts need to be facilitated to open bank accounts in any bank as convenient.
5. If a Beneficiary does not have a bank account and is unable to open a new bank account, his/her relative’s bank account may be used(immediate family member such as parents, spouse, siblings).
6. If a relative’s bank account is used, written consent should be taken from beneficiary.
7. If a bank account has already been used for another beneficiary, it cannot be re-used for another beneficiary. If a new Bank account needs to be opened, it’s easy to open a zero-balance account with Indian Post Payments Bank.

 

Special provisions have been made in the tribal, hilly and difficult to reach areas of the country under the National TB Elimination Programme (NTEP) to expand diagnosis and treatment centres, improve access for TB patients and coverage of TB services.

To provide access to diagnosis and treatment centres for people in the tribal areas, NTEP has initiated transport support for TB patients in notified tribal areas from the year 2019.
 

Transport support is available for patients receiving treatment from both the private and public sectors.

This is a one-time benefit of Rs. 750, provided to a TB patient notified from a health facility registered under a TB Unit (TU) that is flagged as “Tribal TU” on Nikshay to be eligible for this transport support.

To receive the benefit, the patient should be identified as unique by the Nikshay system or approved by the District TB Officer (DTO).

 

Resources

Direct Benefi­t Transfer Manual for National Tuberculosis Elimination Programme, CTD, 2020.

Guidelines for Programmatic Management of Drug-resistant TB in India, 2021.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
TB patients in tribal areas are eligible for transport support for every visit to the nearest health facility.	True	False			2	Transport support for TB patients is a one-time benefit for a notified TB patient registered under Tribal TU.

 

 

Treatment supporters are eligible for Honorarium at the end of TB patients treatment, only if the patient's treatment outcome has been declared either as "Cured “or "Treatment Complete".

 

The eligible amount of honorarium is

• Rs. 1,000 for DSTB Patients and for
• Rs. 5,000 for DRTB patients. 

 

These benefit amount are processed through Nikshay and below are the prerequisite conditions that needs to be met in Nikshay, for generating incentive

• Treatment supporter should be registered and enabled for receiving honorarium from Nikshay.
• Bank details of Treatment supporter should be submitted to the nearest NTEP health facility staff.
• In Nikshay, this is the only scheme where benefits are generated manually by TU users - STS
• Nikshay will allow NTEP TU users to generate benefits, only if
  • ​Treatment Outcome has been declared as "Cured “or "Treatment Complete"
  • Patient duplication status should be Unique i.e. Nikshay marks the patient duplicate based on Gender and Mobile Number
• For DSTB patient, one benefit of maximum amount of Rs. 1,000 can be created if outcome is updated as “Cured” or “Treatment Completed
• For DR TB patients two benefits can be generated in Nikshay:
  • First benefit of maximum amount Rs. 2,000 can be created at end IP - Intensive Phase (i.e. Initiation Date + 6 months)
  • Second benefit of maximum amount Rs. 3,000 can be created if Outcome is updated as “Cured” or “Treatment Completed”

Private health providers are an inevitable part of the TB treatment and support in the country. These private providers include:

• Practitioner / Clinic etc. (Single)
• Hospital/ Clinic/ Nursing Home etc. (Multi)
• Laboratories
• Chemists

 

To improve complete reporting and ensure support care for patients in the private sector, the facilities will receive an incentive of:

• Rs 500 as Informant or Notification Incentive
• Rs. 500 for Outcome declaration

For patients seeking healthcare from a facility in a different district, Nikshay enables the feature of linking a health facility (HF) in addition to the current HF. This enables the private facilities to enter treatment outcomes and become eligible for the incentive.

Private health providers are also eligible for treatment supporter incentives of Rs. 1000 for DS-TB patients and Rs 5000 for each DR-TB patient for ensuring support for the entire course of treatment.

Resources

Guidelines for Programmatic Management of Drug-resistant TB in India, 2021.

 

Assessment

Question​	Answer 1​	Answer 2​	Answer 3​	Answer 4​	Correct answer​	Correct explanation​
What incentive does a private sector facility receive for every TB patient notified?	Rs. 1000	Rs. 700	Rs.500	Rs. 250	3	A private facility will receive an incentive of Rs. 500 for every TB patient notified.