Course on TB Free Workplace interventions

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Resources

• Global Tuberculosis Report, 2020; Geneva: World Health Organization, 2020
• Training Modules (1-4) for Programme Managers and Medical Officers India: Central TB Division, MoHFW, Government of India,July 2020

TB is one of the top burdensome infectious diseases in India. It is estimated that, around 1/4th (26%) of the world's TB cases are in India, translating to about 30 Lakhs new TB cases emerging each year (TB incidence). Against this estimated incidence the National TB Elimination program reported around 19 lakh new and relapse cases in the year 2021.

An estimated 5 Lakhs deaths occur due to TB each year in the country, translating to about 1 case of TB death every one-two minutes. Compared to this, there are only about 60 thousand deaths due to HIV and about 77 deaths due to Malaria each year.

TB diagnosis and treatment services although provided free of cost in the public sector, the cost of accessing these services and related loss of wages drive the affected people with poverty (catastrophic costs). TB also has a huge impact on the world's and the country's economy because of loss of workdays (100 million workdays per year).

Assessment

Resources:

• ^*WHO Global TB Report 2021
• ^{^}Status of National AIDS Response
• ^$PIB MOHFW

TB is caused due to the infection by a bacterium called Mycobacterium tuberculosis.

It often affects the lungs, and in such cases it is called Pulmonary Tuberculosis. But, it can affect almost any part of the body (except the hair and the nails), in which it is known as Extra-Pulmonary Tuberculosis.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

Determinants are any characteristics that affect the health of a patient.

TB can affect anyone but it is more prevalent in some communities which are vulnerable to TB disease due to various factors which are mentioned below:

Increased exposure of TB due to where they live or work

• prisoners
• slum dwellers
• miners
• hospital visitors
• healthcare workers

Limited access to Quality TB services

• Migrant workers
• Women in settings with gender disparity,
• Children
• Physically challenged
• Transgender population
• Tribal and population living in hard to reach areas
• Refugees or internally displaced people
• Illegal miners and undocumented migrants

Increased risk because of biological or behavioural factors that compromise immune functions in people who:

• People who live with HIV
• have diabetes or silicosis
• undergo immunosuppressive therapy
• are undernourished
• use tobacco
• suffer from alcohol use disorders.
• inject drugs 

Tuberculosis is transmitted mainly through the air via droplet nuclei generated when a TB patient coughs or sneezes. 

It is estimated that every sputum smear-positive patient spreads the infection to 10 – 15 persons annually, if untreated..

Figure: Transmission of TB bacteria through air via droplet

Resources:

• Technical and Operational Guidelines for TB Control in India 2016
• WHO - Fact sheet details on Tuberculosis

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Active TB disease has 4 major symptoms (the 4 Symptom complex). Presence of any one of these symptoms without any other reason warrants evaluation for TB. These are:

Figure: Signs and Symptoms of TB

People affected with TB may experience other symptoms as well. These may be based on the site that is affected with TB or other more non-specific symptoms of an infection. The physician or doctor would evaluate these symptoms in view of diagnosis of TB.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

After exposure to infective droplets containing M.TB, only a small proportion gets infected and further progresses to active TB disease.

• Majority of those that get infected persist in a stage of clinical latency known as TB infection (previously known as Latent TB infection). They do not have TB disease and do not show any symptoms of TB and no evidence of any TB related changes on chest X-ray.
• A small proportion of those with prior infection may progress to active TB disease due to various environmental/ agent/ host factors.

Figure: Flow chart for TB disease progression

Resources:

• Understanding delayed T-Cell Priming, Lung Recruitment, and AirwayLuminal T-Cell Responses in Host defence against Pulmonary Tuberculosis

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• TB Infection (or previously known as Latent TB infection) is a stage in between uninfected and having active TB. In this stage the person has no symptoms and can only be identified using laboratory tests.

• The vast majority of infected people may never develop TB disease. However, to achieve TB elimination, it is important to treat TB infection in people at risk of developing active TB disease.

• It is a state of persistent immune response to stimulation by Mycobacterium tuberculosis antigens with no evidence of clinically manifested active TB.

• There is no single acceptable/reliable test for direct identification of Mycobacterium tuberculosis infection in humans. Tuberculin Skin Test (TST) and Interferon-gamma release assay (IGRA) are commonly used tests for identifying TB infection.

Resources:

• Latent Tuberculosis Infection Guideline

• Guideline for Programmatic Management of Tuberculosis Preventive Treatment in India

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

• The National Tuberculosis Elimination Program (NTEP) is the public health initiative of the Government of India that organizes the country’s Tuberculosis Elimination efforts. 
• NTEP is a centrally sponsored scheme being implemented under the aegis of the National Health Mission with resources sharing between the State Governments and the Central Government.
• The program provides various free of cost, quality tuberculosis diagnosis and treatment services across the country.

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Resources

• Training Modules (1-4) for Programme Managers and Medical Officers; New Delhi, India: Central TB Division, MoHFW, Government of India, July 2020
• India TB Report 2021

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Tuberculosis (TB) unit (TU) is the sub-district level supervisory unit of National TB Elimination Program with the following organogram:

Figure: Organogram of a TB Unit

(PHI: Peripheral Health Institution)

TUs are based mainly on National Health Mission (NHM) health blocks with the aim of aligning with the NHM Block Programme Management Unit (BPMU) for optimum resource utilization and appropriate monitoring.

The TUs have been created based on a population of 1 per 2,00,000 (range 1.5 – 2.5 lakh) for rural and urban populations and 1 per 1,00,000 (0.75 – 1.25 lakh) population in hilly/tribal/difficult areas.

The TU consists of a designated Medical Officer-Tuberculosis Control (MO-TC), as well as one full-time supervisory staff - Senior Treatment Supervisor (STS). However, one Senior TB Laboratory Supervisor (STLS) will be there in every 5 lakh population (one per 2.5 lakh population for tribal/hilly/difficult areas), mostly covering 2-3 TUs.

TB Unit manages the provision of TB services (Diagnosis, Treatment, Prevention, etc.) and programme management in the assigned geographical area. 

Resources

• RNTCP Technical and Operational Guidelines for TB Control in India 2016.
• Training Modules (1-4) for Programme Managers & Medical Officers, 2020.

Those who are suspected of having TB disease are first screened for symptoms like cough and fever for more than 2 weeks, blood stained sputum and weight-loss. If found positive on screening, then TB patients are referred for testing to the nearest health facility. If diagnosed with TB, then they are subsequently initiated on treatment. The TB patients initiated on treatment are regularly monitored with the help of field staff or digital interventions like 99DOTS and MERM (Medication Event Reminder Monitor) technology. NTEP staff also ensures that the TB patients are regularly followed up on monthly basis till their treatment completion.

Figure: Patient Flow

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Daily Regimen is prescribed for TB patients, where patients need to consume the medicine daily.

Daily Regimen comprises of the first line Anti TB drugs, based on

• Age: Adult/Paediatric
• Weight of the patient: Weight Bands

Age: Based on the age, patients are categorized into

• Adults: Patient's age should be 19 years or more.
• Paediatrics: Patient's age up to 18 years and weight less than 39 Kgs

Weight Bands: 

• Treatment dosage is based on the TB patient’s weight.
• A weight band category is defined for Adult and Paediatric patients separately and medicines are issued based on that weight category.

TB cases are generally classified on the basis of previous history of TB treatment into New and previously treated cases.

New case - A TB patient who has never had treatment for TB or has taken anti-TB drugs for less than one month is considered as a new case. 

Previously treated patients have received 1 month or more of anti-TB drugs in the past. They could be further classified as:

• Recurrent TB case - A TB patient previously declared as successfully treated (cured/treatment completed) and is subsequently found to be microbiologically confirmed TB case is a recurrent TB case. 
• Treatment After failure patients are those who have previously been treated for TB and whose treatment failed at the end of their most recent course of treatment.  
• Treatment after loss to follow-up - A TB patient previously treated for TB for 1 month or more and was declared lost to follow-up in their most recent course of treatment and subsequently found microbiologically confirmed TB case 
• Other previously treated patients are those who have previously been treated for TB but whose outcome after their most recent course of treatment is unknown or undocumented. 

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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Health Volunteers/ Treatment Supporters are often the regular point of contact for a TB patient in the community. They support the TB patient during the entire episode of TB and ensure complete diagnosis and treatment. The next points of contact are with the MPHWs who periodically visit the patients to ensure specific delivery of services.  

The Peripheral HeaIth Institution (PHI) is the nearest accessible health facility where the patient can access   a physician/ doctor for diagnosis and treatment services. These are often in the form of a Primary Health Centre, but can also be higher level institutions such as medical colleges and private health facilities that are most accessible to/ preferred by the patient. The PHI may also host a drug store/ pharmacy from where the patient's medicines would be dispensed.

Other health facilities with diagnostic services such as DMCs, NAAT Sites and C&DST Labs may be accessed by the patient or by their biological specimen being collected and transported to the corresponding laboratory. Other higher order health institutions such as DRTB Centres may also be accessed by the patient on referral. 

The District TB Centre, TB Unit and its staff provide programmatic support and supervision indirectly through the PHI. At times the National Call Centre may contact the patient for providing specific information, or for collecting feedback on quality of service delivery.

Figure: Stakeholders interacting with HVs

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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Health Volunteers

• are members of the communities where they work,
• are supported by the health system but not necessarily a part of its organization,
• and have shorter training than professional workers”

Figure: Role of Health Volunteers

Resources:

• https://www.who.int/hrh/documents/community_health_workers.pdf

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Presumptive TB case refers to a patient who presents with symptoms or signs suggestive of TB disease (previously known as a TB suspect) and where further diagnostic workup including bacteriological investigation is required.

 Presumptive TB can be categorized into

1. Presumptive Pulmonary TB (P TB) - Symptoms are directly related to lungs (Cough, hemoptysis)

2. Presumptive Extra Pulmonary TB (EP TB) - Symptoms/ signs are specific to an extra pulmonary site (example: Lymph node swelling)

3. Presumptive Pediatric TB - Symptoms of TB in young children are more difficult to identify and can be more general (fever, weight loss) 

Resources:

• Technical and Operational Guidelines for TB Control in India 2016
• Definitions and reporting framework for tuberculosis

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Pulmonary TB(PTB) is primarily involves lungs. Screening should be done for the following symptoms:

Figure: Signs and Symptoms of active TB

Regular screening of Presumptive TB cases with unexplained cough of any duration should be done and checked for:

• History of close contact with known active TB case 

• Whether the patient has developed Presumptive/confirmed extrapulmonary TB(EPTB)

• High-risk groups: PL HIV, Diabetics, Malnourished, Cancer patients, patients on immunosuppressive therapy or steroids

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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National Tuberculosis Elimination Programme (NTEP) strives for all presumptive TB patients to be microbiologically confirmed. Under NTEP, the acceptable methods for microbiological diagnosis of TB are: 

Rapid diagnostic molecular test: Rapid molecular tests that use techniques like NAAT are very specific. They amplify the genomic material in the patient sample and hence enhances detection

• Nucleic Acid Amplification Test (NAAT) e.g., GeneXpert, TrueNat

  

  Figure: Genxpert Machine for CBNAAT

  

  Figure:  Truenat Machine

• Line Probe Assay

For laboratory diagnosis of TB, different biological specimens are used.

Pulmonary TB: Sputum sample is used. Sputum is a thick fluid produced in the lungs and in the adjacent airways. Normally, a spot sample and a fresh morning sample is preferred for the bacteriological examination of sputum.

Extra Pulmonary TB:

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

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Presumptive TB patients attending the TB Diagnostic centre (TDC) will be referred for sputum examination at the same facility. The patients are given the sputum container with laboratory serial number written on its side. The patient is:

Figure: Sputum Collection Process

• Provided with the labelled sputum cups and demonstrated how to open and close the container.
• Given a labelled container with instructions to cough out sputum into the container early in the morning after rinsing the mouth with water. This is the early morning specimen. This is labelled as Specimen ‘b’.
• Ensure collection of sputum samples in an open, well-ventilated area designated for this purpose.
• Given a sputum container with instructions to collect an early morning specimen and go with the sputum specimen to the TDC(if the health facility is not a TDC) where the spot specimen can be collected. If the patient cannot travel to the TDC, then the spot specimen could be collected at the nearest health facility or sputum collection centre and transported to the TDC.

Video: Process of sputum collection 

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

• Community Health Volunteers play a significant role in increasing awareness regarding the burden of TB and the importance of preventing it and regularly screening the population.
• Community Health Volunteers should use the various platforms in the communities, such as the PRI meetings, school meetings etc., for spreading the information on TB. Using such media, the Community Health Volunteers should focus on building community awareness to improve the patients' health-seeking behaviour.

• Community Health Volunteers should screen the vulnerable population for Tuberculosis during the Active Case Finding Campaign. Positive TB suspects identified should then be referred for testing, post which, if diagnosed with TB, should be initiated on treatment.
• Community Health Volunteers should also ensure that those TB patients initiated on treatment adhere to the treatment.
• Community Health Volunteers should also record the population screened; sputum examined cases, diagnosed cases and patients initiated on treatment.
• Community Health Volunteers should also confirm the patient's address in their respective locality for correct patient identification.

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As TB is an airborne infection, TB bacteria are released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by taking simple precautions:

Figure: Measures for control and prevention of tuberculosis

TB Preventive Treatment(TPT) also has a very important role in prevention of TB. Presently, household contacts of sputum-positive TB patients are given TPT upon confirmation of TB infection and ruling our active Tuberculosis.

Resources:

• Technical and Operational Guidelines for TB Control in India 2016

Nikshay is an Integrated ICT system for TB patient management and care in India. Nikshay was launched in 2012 and since then, various improvements have been made in the system.

Nikshay provides-

• A Unified interface for public and private sector health care providers
• Different types of Logins such as State, District, TU, PHI, Staff logins, Private providers, Chemist, Labs and PPSA/JEET Logins
• Integration of all adherence technologies such as 99DOTS and MERM
• Unified DSTB and DRTB data entry forms
• Mobile friendly website with mobile app

Nikshay is accessible either via web browser(https://Nikshay.in ) or mobile App called ‘Nikshay’ that can be downloaded from Google Play Store(Android).

Figure: Nikshay Login Pages

Figure: Nikshay Home Page

After login in Nikshay, using the login credential shared by NTEP Health Staff, Treatment Supporter will be able to access the following button:

• New Enrolment: Allows to enrol new cases in Nikshay
• Search Patient: Allows to search for patients that are mapped to him /her, using Patient Name, Nikshay ID and Old Nikshay ID
• Add Patient Test: Allows to add tests for all the patients.
• Diagnosis Pending: View the list of the patients that are pending for diagnosis
• Not on Treatment: View the list of the patients that are diagnosed but pending to be initiated on treatment
• On Treatment Patients: Gives the list of on treatment patients
• Outcome assigned: Gives the list of the patients that have completed their treatment
• Training Material; Access the training content available on Nikshay
• Patient Summary: Gives a brief overview on the Presumptive cases registered, Diagnosed and patients that are initiated on treatment
• Task List: Allows to view the list of pending activities pertaining to adherence, Treatment Outcome and Bank details missing for mapped patient
• Latest Updates: New updates of features that are released on Nikshay

TB Aarogya Sathi empowers Citizens(including TB Patients under NTEP) and to serve as a Direct interface with the healthcare system. The App is aimed at augmenting the initiatives of the Central TB Division, Government of India in proactively increasing awareness among the citizens and ensuring availability of free and quality assured drugs and diagnostics to all citizens in the country.

Citizens using the TB Aarogya Sathi App will have access to common FAQs regarding TB, Information on the symptoms of TB and Side effects of Anti TB drugs. Using the app, any user will be able to find the closest health facilities that can assist in diagnosis of TB.

Patients registered with Nikshay will have access to the Adherence, Treatment Progress and DBT Details.

Citizen:

• Informative Content available for all Citizens using the App(no login required to access this content)
  • Information on TB 
  • Symptoms of TB
  • Side Effects of TB
  • Health Facility Search
  • BMI Assessment
  • Nikshay Sampark Helpline
  • Motivational Videos
  • Nutritional Advice

Patient:

• Patients registered in Nikshay get access to additional information(after login)
  • Adherence Details
  • Treatment Progress Details
  • DBT Details

TB Aarogya Sathi App is available in Google play store and can be download using this QR Code

Figure: TB Aarogya Sathi Application snapshot

Public Health Action is conducted under the NTEP programme to support and prevent further health complications among TB patients after diagnosis.

Figure: Various activities under Public Health Action

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

Interaction with the patients and their families is crucial to gauge a patient's understanding of the disease he/she is suffering from and the course of treatment to be followed.

Aspects to be considered during a Home visit:

• First home visit should be completed within 7 days of the patient's diagnosis.
• Patients who have Adverse Drug Reaction(i.e. ADR) / interrupted treatment /Loss to follow up /Repeat episode, interrupted the treatment should be given preference and would be preferable if the In-charge of the health facility accompany the team during home visit.

Figure: Precautionary measures to be advised to patient during home visit

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.

• Screening for four symptom complex for TB and refer for testing
• Support for treatment adherence
  • By self-monitoring
  • Patient /family counselling
  • Peer group support meetings
• Counselling of TB Patients
  • ​To report Adverse Drug Reaction(ADR), if any
  • Adhere to the treatment and ensure treatment completion
  • Regular monthly follows up during treatment
• Nutritional support
  • Supporting the patients in getting linked with existing nutritional supplementation schemes
• Socio economic support
  • Profiling of patients to determine eligibility for the scheme
  • Support to file application for socio-economic schemes
  • Collaboration with non-governmental sources
  • Community engagement
• Promotion of other Health programmes.

TB Aarogya Sathi empowers Citizens(including TB Patients under NTEP) and to serve as a Direct interface with the healthcare system. The App is aimed at augmenting the initiatives of the Central TB Division, Government of India in proactively increasing awareness among the citizens and ensuring availability of free and quality assured drugs and diagnostics to all citizens in the country.

Citizens using the TB Aarogya Sathi App will have access to common FAQs regarding TB, Information on the symptoms of TB and Side effects of Anti TB drugs. Using the app, any user will be able to find the closest health facilities that can assist in diagnosis of TB.

Patients registered with Nikshay will have access to the Adherence, Treatment Progress and DBT Details.

Citizen:

• Informative Content available for all Citizens using the App(no login required to access this content)
  • Information on TB 
  • Symptoms of TB
  • Side Effects of TB
  • Health Facility Search
  • BMI Assessment
  • Nikshay Sampark Helpline
  • Motivational Videos
  • Nutritional Advice

Patient:

• Patients registered in Nikshay get access to additional information(after login)
  • Adherence Details
  • Treatment Progress Details
  • DBT Details

TB Aarogya Sathi App is available in Google play store and can be download using this QR Code

Figure: TB Aarogya Sathi Application snapshot

Video: Download the Tb Arogya Sathi App and Steps to Login

Video: Health Facilities

Video: Summary and Treatment Progress View

Video: Adherence Details and DBT Details View

Video: DBT Details View

Video: Adding bank details in the Arogya Sath App

Video: Symptom Checker-Overview

Video: Screening for Self and Others

Video: Post enrolment follow-up cycle in Nikshay

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.,

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, the 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

Stigma is when someone sees you in a negative way.

Discrimination is when someone treats you in a negative way.

TB patients face various forms of stigma and discrimination in the community

Figure: Stigma towards TB Patients in the community

At Individual Level

• Lack of self-esteem and confidence
• Increased sense of emotional isolation, feeling of guilt and anxiety
• Physical as well as financial debilitation
• People, more often women, are forced to leave their homes
• Concealing symptoms and hesitancy in seeking medical care making disease management more difficult
• Delayed diagnosis, interrupted treatment that can lead to further transmission and DRTB
• Vulnerability increases, can lead to suicidal thoughts due to isolation and shame

At Family and Community Levels

• Loss of household earnings
• Exposure of caregivers to the risk of infection that lowers productivity and cycle of poverty further gets perpetuated
• Isolation and stigmatization of infected persons often by people of their community
• Deep-rooted lack of knowledge and misconceptions among the affected and infected within their cultural and religious environment
• Loss of status and negative impact on those with the disease, their caregivers, family, friends and communities
• Perceived and internalized stigma of the community due to socio-cultural values that TB is punishment for sins or transgression

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”

Community engagement is a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes.

Mobilize communities to engage them in TB care and to increase ownership of the Programme by communities.

Why Community Engagement?

Figure: Importance of Community Engagement

Community-based TB activities are conducted outside the premises of formal health facilities (e.g. hospitals and clinics) in community-based structures (e.g. schools and places of worship) and homesteads. Community health workers and community volunteers carry out community-based TB activities. Both can be supported by nongovernmental organizations and/or the government.

Community Engagement is a cost effective intervention to improve health service coverage and deliver accessible and people-centered integrated care.

Figure: Importance of Community Engagement

A TB Champion is a person who has been affected by TB and successfully completed the treatment.

TB Champions, in their capacity as survivors, are role models and can provide valuable support to those with TB and their families.

Figure: Roles of TB Champion

Community Health Volunteers should identify TB Champions and engage them to provide their support to the patient in activities like:

Figure: Help to TB Patients by Community Health Volunteers

Involve TB Champions: Community Health Volunteers should play a key role in the following aspects

• Identification from TB survivors in the community
• Training in various aspects of TB and role of TB Champions in NTEP activities
• Mentoring and grooming for providing support to TB patients as peer counsellors
• Supporting the formation & functioning of survivor-led networks at various levels
• Recognition and facilitation for good work on occasions like “International TB Day Celebration.”

Engaging community structures at village level: Community Health Volunteers should engage the community for the following:

• Active Case Finding
• TB awareness generation
• Stigma reduction
• Support for TB patients

Psychosocial Support to TB Patients: 

• Offer words of encouragement,  alleviate anxiety and create awareness.
• Promote kindness, solidarity, compassion; offer to talk to family & community members.
• Connect TB patients to TB community network, TB survivors.
• Have a gender-sensitive approach and ensure gender equality.
• Provide guidance on supportive interventions(e.g., refer to mental health helplines, share information on videos/resources available on MoHFW’s website).
• Choose words carefully while referring to those affected; form treatment support groups.
• Avoid using words like cases, victims, transmitters and suspects.
• Share key messages to prevent stigma; conduct stigma reduction interventions.

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

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.

What’s inside:

Read this page to learn how TB is a threat to the nation's economy and the role of workplaces in reducing the burden of TB 

Tuberculosis (TB) is one of the top ten deadliest diseases known to mankind and India is accountable for 26% of all TB cases and 31% of all TB-related deaths worldwide.

• TB control and prevention faces daunting challenges in India. A significant proportion of the population is undernourished, which weakens immunity and drives.
• 83% of TB cases come from the most productive age group of 15-60 years in India.
• The public and private sectors in India employ 470 million workers, of which around 80% are from the unorganized sector . [Unlike the organized sector, unorganized sector may not have access to formal mechanisms of regular health check up, insurance etc.]
• It is estimated that around 170 million work days are annually lost due to TB.

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Source:

Global tuberculosis report 2020: executive summary. Geneva: World Health Organization; 2020  * India TB Report 2021

Periodic Labour Force Survey (PLFS) by the National Sample Survey Organization Ministry of Statistics & Programe Implementation, 2017 – 2018

What’s inside:

Read this page to know; how TB could impact the organization & why TB Free workplace is important.

Absenteeism & Productivity Loss related to TB in workplace and its implications:

The success of industries is closely linked to the health and prosperity of the community of workers, services, contractors and consumers. However, India’s response from industries, and business organizations to TB remains minimal and requires scaling up.

TB in Workplace impacts the organization by: Employees may lose 3 – 4 months of work on an average if they are affected by TB. 

• Lost man hours 
• Disruption in workflow 
• Weeks and months of absenteeism 
• Lowered productivity.

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The industries could also incur indirect costs due to, consequent recruitment and training.

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Why TB Free workplaces are important?; Challenges & opportunities:

• Workers spend most of their time at workplaces
• Difficult for the program to reach workers
• Workplaces play a vital role in creating TB awareness and providing necessary support for treatment completion
• Workplaces can promote zero stigma related to TB

What’s inside:

Read this page to learn how stigma & discrimination due to TB can lead to late diagnosis, disease spread and decrease the health & wellbeing of an employee affected with active TB disease.

TB related Stigma & Discrimination at workplaces, and Wage Loss affecting the Employee

People affected by TB lose jobs, go into debt and face considerable stigma from their families, community and employers. Thus, the impact of TB on individuals is often all- encompassing, affecting not only physical health, but also social, economic, and psychological well-being.

If the employer & co-workers are showing stigma and discrimination to the employee diagnosed with TB, it can cause:

• Loss of employment
• Lower Income

Added to the social consequences such as:

• Ostracism from family and community
• Divorce
• Loss of housing
• Depression, Higher levels of anxiety
• Lower Life Satisfaction

Since TB affects the economically productive age group, the social consequences mentioned above will be huge.

Many employees are migrants at their place of work and may be dependent on the employer, and on co-workers, for health care needs.

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To initiate and complete treatment successfully, and to prevent the spread of the disease in the community, TB patients and their families need the understanding, empathy, and support of employers and co-workers.

Four principles to prevent or reduce consequences of stigma:

1. People diagnosed with TB and those who are close to them are able to live and acess TB services without being judged.

2. People in the social circle / members of the community of the person diagnosed with TB do not fear TB but are assured that it is a treatable disease, and that their support of persons with TB will result in early and better recovery, and thus prevent its transmission to others.

3. Community influencers contribute to fostering of safe and acceptable environments towards people diagnosed by TB and thier close contacts.

4. Healthcare providers and health influencers adopt standards for TB care and their capacity in using stigma-mitigating soft-skills and language is built.

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Steps you can take to avoid stigma and discrimination against TB in your community and workplace:

1. Providing awareness:
   1. Against fear of TB.
   2. Regarding the curability of the disease
   3. Need of avoiding stigma and discrimination.
   4. On advantages of early diagnosis and need of treatment adherence
2. Advocating for undergoing periodic TB screening 
3. Providing extensive psycological, economical and nutritional support to TB patients and their family
4. Ensuring that your workplace is having a policy or guidelines against stigma and discrimination especially related to TB and HIV.  

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Recommendations for the employer:

• Conduct periodic health screening camps specifically for TB in your workplace
• Ensure HR support to employee diagnosed with TB by providing sick leave / paid leave during the treatment period.
• Allot flexible work hours during the recovering period. Consider provision of work from home if the circumstances allow.
• Introduce “TB FREE WORKPLACE” policy in your organization

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TB transmission in Workplaces

What’s inside:

Read this page to learn how TB spreads inside your workplace 

Introduction:

The global spread ofCovid-19 has highlighted the need for implementing standard infection control precautions and to improve preparedness for pandemic respiratory infections. Preparedness means having infection control activities already in place; many of the same infection control activities will help contain TB as well.

Although this chapter focuses on TB as the prototypical airborne disease, the principles also apply to other respiratory infections.  

Dynamics of TB Spread:

The following must be known in order to fully understand TB transmission.

TB is infectious only when it occurs in the lungs or larynx (thought). TB that occurs elsewhere in the body is usually not infectious, unless the person also has TB in the lungs or larynx at the same time.

Tuberculosis is transmitted mainly through the air via droplet nuclei generated when a TB patient coughs or sneezes. 

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Why TB & Workplace ?:

An employee will be spending an average of 8Hrs / day (48 hrs / week) in their work spaces making them vulnerable for contracting diseases like TB and making them a challenging population for the programme (National TB Elimination Program) to reach.

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Added to all of these, Low BMI, Accessibility to Healthcare, Malnutrition, Smoking, Alcoholism and Tobacco usage can also make a person vulnerable to TB.

What’s inside:

Read this page to find out what steps can be taken to tackle the spread of TB and other airborne infections in the workplace (such as COVID-19, Influenza A H1N1, etc.)

Measures for tackling spread of Airborne Infections (TB, Covid-19, Influenza A H1N1, etc.) inside the organization:

Majorly two line of activities are recommended in controlling spread of Air Borne infection inside a work place:

1. Administrative Control
2. Environmental Control

Administrative Control Strategies:

The main objective of this strategy is to reduce the exposure to diseases like TB inside the workplace by:

1. Reduce the delay in diagnosis so that a person with active TB disease or any airborne infections will not spread the disease inside the workplace. 
2. Reducing airborne transmission of disease to other workers / employees by facilitating continues - awareness, early diagnosis and treatment support activities.    

Following, are the activities recommended under administrative control strategies:

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Environmental Control:

Environmental control majorly includes ventilation (natural and mechanical), installation of easily accessible hand wash areas / hand sanitisation dispensing units inside the facility.

Environmental controls work on the basic principle of dilution of infectious particles through real or ‘effective’ air exchange. In the case of ventilation, that dilution occurs through the introduction of fresh, uninfected air and the removal of infected air.

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Types of ventilation: 

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Any of the above ventilations if appropriatly placed can ensure air exchange inside the closed space and can prevent Air Borne infections like TB to a large extend.

High-risk occupational areas / workplaces like cotton mills, glass, chemical manufacturing, healthcare settings, and weaving industries require adequate ventilation systems because workers spend time indoors exposed to harmful substances for their respiratory systems, which can in turn make them susceptible to tuberculosis.

However, all workplaces shall ensure prevention of overcrowding and adequate ventilation in indoor settings for prevention and control of airborne infections such as TB, Covid-19, etc.

In addition to ventilation measures, hand sanitizer and mask dispensing units should be installed at easily accessible areas.

What’s inside:

Read this Chapter to learn - What a TB Free Workplace means and how to implement TB Free workplace.

Page: 1 What is a TB Free Workplace?

An Overview: ‘TB Free Workplace’ is an organization with adequate model and policies for prevention and control of TB by integrating awareness, health education and service delivery with existing systems, structures and resources, and by taking cognisance of their business agendas thus by reducing the burden of TB inside the organization.

A TB Free Workplace will have supportive environment and provisions where employees including contractual workers:

• Have easy access to information and services on TB and employees/ worker feel confident to utilize these services;
• Periodic Intensive Case Finding, workers having active TB is identified early and is put on treatment;
• Provisions are in place to support treatment adherence with job security;
• There is no discrimination either based on real or perceived TB status of workers;
• Favourable policy/guidelines are in place to protect rights of TB patients and
• No or Low TB incidence among workers are being report in last one year.

The goal is to implement a comprehensive program on TB prevention and care inside the organization.

Industries can help India's TB outcomes by enabling access to early detection, diagnosis, and high-quality care and treatment services by investing in the health of their own workforce.

Key activities for implementing TB Free workplace:

• Setting up Workplace committee or nominating a focal point 
• Training of master trainers followed by implimenting training on TB to all the employees through the master traininers
• Awareness Generation by circulating communication materials on TB
• Organizing periodic screening for TB
• Facilitating treatment support to identified TB patients, ensuring all the TB patients are put on treatment
• Counselling services for treatment adherence and linkages with government
• Monitoring, Documentation and Reporting
• TB in HR induction

The image below will provide a 360⁰ view of how a TB free workplace should be:

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Read this page to know about the TB Free workplace commitee

Forming a TB Free workplace committee

TB Free workplace committee (Recommendations):

1.For Large scale organizations (with more than 500 employees) - 

Members: TB Free workplace committee is an internal committee formed with the following members:

• Chairperson of the organisation – Chair of the Committee
• Key administration staffs
• Head of HR department
• Medical Officer of the organization
• Representatives from employees
• District TB Officer as the invited member (if necessary)

In case if organization is having a Health committee, TB can be actively integrated into the existing system.

2. For Small scale organizations (less than 500 employees and not having a health commitee)-  Nominate an administrative staff for being the nodal officer, and periodic reporting of TB prevention and control activities that are carried out in the organization to the administrative board of the organization. 

Functions of the TB Free committee: A TB Free committee will be functioning as the pivot point for all the TB related activities of the organization such as:

• Forming and implementing a TB Free workplace policy.
• TB Awareness and Trainings supervision:
  
  • Ensuring TB awareness through the official communications (mails, messages, posters, and other means) to reach all its employees.
  • Identifying employee representatives as master trainers to educate peers on TB
  • Allocating schedules for trainings on TB to its workforce.
  • Workplace against TB related Stigma / Discrimination campaigns. 
• TB Screening and testing supervision:
  
  • Organizing TB screening and diagnosis camps periodically and ensuring the attendance of all its employees in the camp.
• ​​​​​​​TB Treatment & Nutrition support:
• Ensure patient is undertaking prompt treatment.
• Ensuring Zero Stigma and discrimination in the organization.
• Provision of nutrition support to employee from underprivileged category
• Ensure HR support to employee diagnosed with TB by providing sick leave / paid leave during the treatment period.
• Allot flexible work hours during the recovering period. Consider provision of work from home if the circumstances allow.​​​​​​​​​​​​​​​​​​​​​​​​​​​​
• Monitoring and evaluating the TB prevention and control activities.
• Human Resource department: Integrating TB in HR induction

Promoting treatment support groups for physiological support & ensuring zero stigma and discrimination inside the organization

Page 3: Checklist for a TB Free Work Place

The implementation of a checklist will be ensuring that all the TB prevention and control activities are being carried out at the workplace. Following is a TB Free work place checklist model:

TB work place policy by the Corporate Organizations:

Workplace policies should be developed in a participatory manner with the active involvement of senior management and representatives of workers.

Key principles for developing a workplace policy:

• Recognition of TB as workplace issue
• Bipartite approach (working with management and worker’s representatives)
• Gender equality       
• Protection of the rights of workers
• Non-discrimination
• Confidentiality  
• Continuation of employment
• Prevention
• Treatment, care and support

Benefit of an ideal TB Free workplace policy:

• Commitment to corporate action
• Guarantees adherence to pertinent national laws and regulations on TB care
• States a standard of behaviour for all employees (whether infected or not);
• Provides guidance to supervisors and managers;
• Enables workers diagnosed with TB to understand the support and care they will receive, increasing the likelihood that they will adhere to the appropriate treatment.
• Helps to control the spread of TB in the workplace
• Assists the organization in planning for TB prevention and control, which ultimately results in cost savings.

Models of TB Free Workplace policies:

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 Policies and Guidelines related to TB in Workplace:

From the Government and the ILO :

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TB Free Workplace Strategies Developed by the International Labour Organization (ILO) in partnership with The Union. (2017) (Click here for link) 

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Policy framework released by Ministry of Labour & Employment, Govt. of India (2019).Refer: Policy_Framework_MoLE2019

Supporting an employee diagnosed with TB

What’s inside:

Read this Chapter to learn how an organization can support an employee diagnosed with active TB.

Expressing Solidarity with the TB diagnosed employee

The employers are advised to provide a supportive environment for the TB diagnosed employees by documenting the organisation’s approach on managing TB at the workplace.

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Ensuring a safe workplace:

• Maintain confidentiality
• No tolerance to stigma and discrimination
• Promote peer employees support activities for TB diagnosed employee
• Contact Tracing for identifying cases if any other employees are having TB

Sick leave and flexible workhours:

TB treatment always involves extended sick leave & the intensive phase of the treatment lasts around 2 months

• HR policy needs to be sensitive to the treatment period.
• Work from home for possible cases depending on the health of the employee
• Considering provision of flexible work hours

Support for continuity of Treatment:

TB treatment lasts for minimum of 6 months, and in most cases the employee can join back to work in and around 2 months. The work place shall ensure the employee is continuing the treatment till the completion of the prescribed course.

Return to work:

The organization shall have a clear return to work policy for avoiding:

• Possible anxiety of employee under treatment as well as other employees
• Prevention of hiding of TB or other air borne infection symptoms

The return to work shall be linked to the medical certification that the employee is no longer infectious.

What’s inside:

Read this page to learn how nutrition is linked to TB

TB Nutrition and workplace :

• Under nutrition is a proven risk factor for progression of latent TB into active TB.
• Especially in the context of India, where both women and men in the country are found to be suffering from high levels of moderate to severe malnutrition.
• In the patients with active TB, absence of nutritional support results in a vicious cycle of worsening disease and undernutrition, which can be detrimental and even fatal.
• Undernutrition has also been associated with malabsorption of key anti-TB drugs.

Evidence suggests that nutritional interventions are associated with:

• Better outcomes in TB patients including reduced mortality
• Improved weight gain and body composition
• Earlier stop of infectivity
• Improved effect of key drugs
• Improved functional status and adherence to therapy

Ensuring proper nitrition to the employee diagnosed with TB will be an adequate measure for supporting him / her in recovering from the disease.

Support through provision of Nutrition Kits to underprivileged TB diagnosed Employees /  Patients :

Thus, if the organization if can support the underprivileged TB patients / Employees diagnosed (and family if possible) with TB with Nutrition Kit, the chances of recovery from the disease will be high.

Composition of Nutrition Kits:

Nutrition support could cost around: Rs.1500 (Rs.2500) / patient (Family) / month.

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Supports for TB patient from the Government

The government of India, through the National TB Elimination Programme (NTEP) is providing following support for all the patients diagnosed with TB irrespective of his or her economic status:

• Free of cost Diagnostic Services
  • CB NAAT / True NAAT
  • Liquid Culture & DST (Selected samples)

• Free of cost Treatment
  • TB medications
  • Prophylaxis
• Direct Benefit Transfer (DBT) – Rs.500 / month for all TB patients during treatment period through bank accounts.

• Adherence Support – To prevent drop out during treatment period
• Public Heath Actions- Retrieval, Contact Investigation / tracing
• Support for TB Notification in NIKSHAY portal of the NTEP
• Training and Capacity building for anyone willing to volunteer.